Exam 2

• almost three quarters 
• hot flashes, night sweats
• many report moderate to severe symptoms for a decade or longer

• may disrupt sleep
• cause mood changes, difficulty concentrating and impaired short term memory
• untreated: associated with higher healthcare costs and loss of work productivity

• systemic hormone threapy
• recommended for women with moderate to severe vasomotor symptoms
• benefits outweigh the risk if there are no contraindications

• women under 60 OR within 10 years of menopause onset without contraindications
• helps menopause hot flash and sleep disturbances and prevents bone loss for those at elevated risk

• hormone therapy and conjugated estrogen and bazedoxifine
• if contraindicated, SSRIs or SNRIs (PAXIL, EXCITALOPRAM, EFFEXOR, DESVENLAFAXINE) or GABAPENTIN can be used

NO, not recommended for this alone

• prasterone: non-estrogen
• dyspareunia happens bc of low estrogen
• brand name is interosa- contains prasterone aka DHEA

• an androgen, like testosterone
• helps integrity of skin, muscle and bone
• help maintain libido
• a remaining source of estrogens and androgens as estrogen levels naturally decrease
• in the body can be converted to estrogen and testosterone

• DHEA delivered directly to the vagina
• tissues will transform it to estrogen, estradiol
• allows natural production of estradiol WITHOUT a significant release of estrogens systemically into the blood

• Progesterone! bc of risk of endometrial cancer
• UNLESS they have had a hysterectomy, then they dont need it

Transdermal patch

no later than 10 years after menopause, or after age 60 bc pt at higher risk for cardiovascular events or worsening dementia

• increased breast cancer risk
• for this reason regimens should have cyclic rather than continuous progestogens
• use other formations than MPA (medroxy-progesterone acetate). Try bazedoxifene combined with conjugated estrogens

• needed to protect those with a uterus against endometrial cancer with estrogen
• micronized has a lesser effect on breast cancer risk than regular
• safest form of progesterone

• recommended over oral 
• low dose transdermal may have fewer risk
• less likely for thromboembolism, stroke and CAD

• shortest duration possible
• reassess and discuss risks beyond 5 years
• several years okay with women who dont have contraindications

• enjuvia
• ogen
• menest
• premarin
• brisdelle
• osphena
• estrase

• activella
• angeliq
• femhrt
• prempro

premphasee

prefest

• prometrium: micronized progesterone
• provera: medroxyprogesterone acitate

micronized is better

• divigel
• elestrin
• estrogel

evamist

• estrace
• premarin

• estring
• femring

• genitourinary syndrome of menopause
• sx genital, sexual and urinary
• dryness
• burning
• iritation
• lack of lubrication
• discomfort/pain
• impaired function
• urgency/frequency
• dysuria
• frequent UTI
• on exam: narrowing of vaginal opening, inflammation

• thinning of epithelial cells due to lack of estrogen
• less exfolation of cells
• less glycogen so therefore less lactic acid to keep pH down, so pH increases 
• decreased lactobacilli

no

• thinning of urethra and bladder
• also causes overactive bladder and urinary incontinence too
• due to decline in lactobacilli

• frail tissue in vagina and vulva: pale dry skin, loss ofelasticity and moisture
• inflammation, narrowing of vagina
• measure vaginal pH
• you will see external irritation
• internally: narrow shortened vagina and possible erytema

• no one test
• vaginal maturation index: someone with this puts out a lot of superficial cells meaning inflammation. done by specialty
• pH: >4.5 assuming no infection
• vaginal swab/screeening pcr, culture, wet mount: to rule out trich, yeast infection, and bv

many with this have chronic yeast infection that wont clear bc of lack of good bacteria in vagina

• seen with GSM
• but also with trich or yeast
• NOT seen with BV

• clear white or grey discharge with fishy odor
• no signs vaginal inflammation, no itching
• vulva unaffected

• discharge- white thick no odor
• itchy dryness dyspareunia
• vulvovaginal or cerfical inflammation, edema
• maybe dry white spots on vaginal wall or cracks in skin of vulva

• green-yellow frothy discharge
• dyspareunia, vaginal soreness, dysuria
• vaginal inflammation
• strawberry cervix

• chronic vaginal inflammation and itching
• confirmed with vulvar biopsy

• white lesions- may be hpv or other conditions
• biopsy

• choice depends on whether its related to sexual activity or not
• vaginal moisturizers: if unrelated to sexual activity
• lubricants: if related to sexual activity
• low dose transdermal estrogen or ospemifene: for women who dont want intravaginal options

• reduce friction
• can be used PRN- before sex ie
• dont treat underlying progressive disease
• no long term therapeutic effect

• water: latex safe, rarely causes irritation, but dries out fast
• petroleum: irriating to vagina, staining, not latex safe
• natural oil: safe unless peanut allergy. non irritating to vagina. stains
• silicone: nonirritating, long lasting, waterproof

• effects longer lasting than lubricants
• still dont affect underlying disease
• use every 1-3 days

irritating to vagina dont use on or in

astroglide

• replens
• ky

• when its bothering the woman- itching, cant have intercourse
• if pelvic organ prolapse or urinary incontenence- estrogen may improve

• avoid harsh perfume soap, detergent etc- contact dermatitis can happen
• avoid soap on inner vulva
• exercise care with warming and mentholated lubes and moisturizers
• cotton underwear

systemic estrogen therapy: vasomotor symptoms and can help GSM, but not always enough, they may need vaginal use

• ring: replace every 30 days
• vagifem tab/cream: use at night for 1-2 weeks every night, then go to maintenance 1-2 x per week

• reduces inflammation
• helps urinary symptoms
• ring can help chronic utis by using every 90 days

• 3-12 weeks
• if nothing, look to something better

• no, it does not go into their system
• but any vaginal spotting SHOULD BE CHECKED still

• women dont realize that vag estrogen doesnt go into system and therefore doesnt increase breast cancer risk
• arrange a 3 month follow up

yes

• only non low dose vaginal estrogen
• used for those with vaginal AND vasomotor symptems

• helps with pain during intercourse
• no estrogen
• if put in vagina- tissues transform it into weak estradiol

• complementary and alternative medicine
• stress management, massage, yoga, chiropractor, acupuncture, dietary supplements
• women view as normal natural and fewer adverse effects compared to Rx therapy
• most women try this first

• findings are low in quality evidence
• botanicals, black cohosh, vitamin e, red clover, omega 3s, exercise, anxiety control and paced breathing and acupuncture not backed

CBT and hypnosis have some evidence

• Selective estrogen receptor modulator (SERMs)
• block effect of estrogen in breast tissue and uterus, and enhance it in others (bone, liver, and uterus at times)
• may decrease risk of breast cancer in women on estrogen therapy
• selective to certain tissues
• similar effects to estrogen on bone, cholesterol and fat

• produce beneficial estrogen actions in certain tissues (bone, brain) and antagonistic in breast and endometrium (decr. risk for cancer)
• stimulate good things, and inhibit bad

• estrogen + SERM
• releives vasomotor symptoms and atrophy, and reduced bone resorption in women with uterus
• an alternative progestogen therapy for women averse to vaginal bleeding, breast tenderness, or altered mood
• prevents osteoporosis
• good for women who cant tolerater progesterone and estrogenn bc the SERM provides the protection, so no progesterone needed

• A serm
• helps with pain with intercourse
• does not stimulate endometrium
• oral
• thickens vaginal cells, decreases pH
• vaginal tissue improved preventing painful intercourse
• side effects: hot flash, vag discharge, muscle spasm

• at risk for VTE aterial thrombosis or stroke
• increases risk of these
• think with smoking, dvt history, hx hypercoagulation etc

• brisdelle
• SSRI for moderate to severe hotflashes
• 7.5mg
• only SSRI approved for vasomotor symptoms

• 75 mg
• not FDA approved for relief of vasomotor symptoms, but studies showed it

• clonidine 0.1mg
• gabapentin 600-900mg

• severity of symptoms #1
• quality of life
• info sources
• side effects
• beliefs
• media
• perception of HRT
• past physician experiences

• baseline breast cancer risk
• medical and family history to see contraindications
• quality of life- determines decision much of time
• is there a need for osteoporosis? hrt will meet 2 needs if so

• definitely: hot flashes/night sweats, vaginal dryness
• probably: poor sleep, adverse mood
• possibly/conflicting data: sexual dysfunction, incontinence, joint pain, brain fog, body composition changes, skin dryness

• there is an in creased risk after 3-5 years of continuous estrogen/progesterone therapy
• decreases after HT is stopped
• use gail model to assess individual BC risk

• both estrogen and e+p increase risk of clots
• increases with either type, but risk is rare in the 50-59 age group
• higer with oral than with patch

• risk: breast cancer, dvt, gallbladder disease (oral only), endometrial cancer (Reduced by progestin)
• benefit: releif/improvement of symptoms, higher qol, prevention of bone loss and colon cancer, improvement of mild-moderate depression

• lower with lower doses
• breast tenderness
• nausea
• bloating
• headache
• irregular vaginal bleeding/spotting
• edema
• dizziness
• mood changes

• active liver disease
• active or recent arterial thrombus
• current or past breast cancer
• known hypersensitivity
• known or suspected estrogen-sensitive malignant conditions
• active or previous history of DVT/PE
• undiagnosed genital bleeding
• untreated endometrial hyperplasia
• migraine with aura
• smoking
• suspected pregnancy
• active heart disease

• elevated breast cancer risk
• elevated risk of cvd (ie high lipids)
• migraine with aura
• gallbladder disease
• diabetes
• high triglycrides >400- use patch, doesnt elevate triglycerides

50%

yes, CDC recommends anyone diagnosed be re tested in 3 months

• an involuntary loss of urine in a sufficient amount or frequency to cause a social/health problem
• NOT a normal part of aging, menopause or pregnancy

• not asked
• emarassement

• Skin breakdown
• utis
• restriction of social activities, sexual avoidance, relationship stress
• feel unhygenic
• lost self esteem, depression
• social isolation- shame, fear, stress

• Immobility
• impaired cognition
• meds
• obesity
• low fluid intake
• constipation
• environmental barriers
• diabets
• stroke
• decreased estrogen
• smoking
• pregnancy
• pelvic floor trauma (vag delivery)
• hysterectomy
• menopause
• uti
• chronic cough

• common in older women
• causes incontinence symptoms
• cystocele- bladder drops into vagina
• rectocele- rectum drops out
• uterine prolapse- womb prolapses out vagina

• cholinergic or anticholinergic
• alpha blockers
• OTC allergy meds
• estrogen
• beta agonists (albuterol)
• sedatives
• muscle relaxants
• diuretics
• ACE inhibitors

• 1-2 at night
• every few hours

• decreased bladder capacity
• increased residual urine
• increased involuntary bladder contractions
• decreased outlet resistance
• decreased ability to inhibit contractions

• enlarged uterus
• muscles that support weakening
• childbirth injury
• irritatns/inflammation

• storage dysfunction: urge
• sphicnter dysfunction: stress
• both: mixed
• as long as bladder pressrue doesnt overcome pressure of urethra, continence is maintained

• theres a blockage
• uncommon in women
• seen with loss of bladder tone, obstruction or MS, diabetes, spinal nerve damage
• treatment is reveiw meds and drainage

• small bladder capacity, overactive bladder
• urine loss accompanied by urgency

• low resistance urethra
• urine loss resulting from sudden increased intraabdominal pressure

• stress: incontinence with increase intra abd pressure- ie cough
• urge: unable to make it to bathroom in time, overactive detrusor muscle

• post void residual
• amount of urine left in bladder after voiding
• measured with ultrasound or removing remaining urine with a cath and measuring
• 50mL is upper limit of normal, older adults 50-100, if over 100 deff overflow incontinence.

• consider if everything ruled out, urinary tract healthy
• think with decreased mobility or pain- cant get to the bathroom in time

• subset of urge incontinence
• frequency, urgency, and nocturia

• exclude transient/reversable cuases: uti, prolapse, neuro causes (stroke), meds, low estrogen in urethra causing inflammation
• send urine ua and culture
• ask pts for voiding diary, cotton swab test, cough stress test, PVR volume measurement
• cystoscopy (not primary care)

• helps identify U symptoms
• in last 3 months have you leaked urine, if yes move on

• all with this dx should have a bimanual pelvic exam, assessment of pelvic floor, and rectal exam
• 1 or 2 fingers to the first knuckle into the vagina and palpate at 5 and 7oclock- peace sign, have the woman contract pelvic floor muscles along fingers with as much force and as long as possible
• have cough or bear down to see if leakage or prolapse when they bear down
• if negative, have them stand
• can come in with full bladder for more accurate test

• writes when the leak, fluid intake, activities, urges
• do for 3 days, ahve them back

• done by obygn
• lubricate sterile qtip, insert inot bladder and withdraw slowly until resistance is felt
• measure of the angle helps identify the problem, more than 30 degress in stress incontinence

• urodynamic studies if complex condition by urology- most ppl dont need
• pain, hematuria, many comorbidities, obstructive voiding syndromes (ie retention) pelvic radiaiton, suspected fistula, pelvic organ prolapse beyond introitus, malignancy

• lifestyle changes, weight loss
• surgical periurethral injections/artificial urinary sphincter
• incontinance pessary

• lifestyle management, behavioral changes
• anticholinergic drugs
• neruomodulation-sacral stimulation implant or products/devices

• noninvasive behavioral
• devices/pharmacotherapy
• surgery (sling, urethropexy)

• pelvic floor muscle exercises
• weight loss (esp for stress)

• anticholinergic
• beta- agonissts (myrbetriq)
• onabotulinumtoxin A (otox
• intravaginal estrogen

neuromodulation - implanted sacral nerve stimulator

• alpha-agonists (pseudoephedrine, phenylephrine)
• duloxetine (cymbalta)

• sling: suburethral, pubovaginal, midurethral
• urethropexy: needle, retropubic or colposuspension
• perirutethral injections: of bullking agents

alpha blockers- tamsulosin

suprapubic catheter

• pelvic floor ex
• education
• scheduled toileting

• behavioral changes
• decreased caffeine
• toilet schedule
• limiteing evening and nighttime fluids
• pelvic floor muscle exercises
• lower bed/mattress to make it easire to get out of bed
• raised tolet seat/grab bars

squeeze pelvic muscle quickly hold 3 seconds and relax

• help ppl learn to do kegels
• put in vagina and weighted foam makes you do it

void only at scheduled times, can increase time between as you go

• not widely used, but can be better esp for older women
• limited evidence
• compress the bladder neck and urethra, thus decreaseing urine loss from stress incontinence
• stays in 1-2 months, pt comes in to have it change
• little contraindications, but check for ulceration

• high patient satisfaction but limited evidence
• associated with adverse effects- UTI and migration to bladder

• silicone tube with applicator
• urethral plug

• for urgency when bladder training hasnt helped
• no meds approved for Stress UI by FDA
• BEST therapy- combine behavioral and meds

• fesoterodine
• oxybutinin
• tolterodine
• trospium
• darifenacin (m2/m3 selective)
• solifenacin (m2/m3 selective) high selectivity for M3 muscarinic receptors

• avoid in the older adult in general unless no other option
• dementia, narrow angle glaucoma, GI obstruction/gastric retention (contraindication)
• short acting oxybutinin and tolterodine should be avoided in older adults0 higher anticholinergi side effects

• dry mouth 
• constipation
• dry or itchy eyes
• blurred vision
• dyspepsia
• uti
• impaired congnitive funciton

• onabotulinumtoxin A: into detrusor muscle
• collagen/carbin beads
• estrogen- intravaginally, but not FDA approved (estrogen only approved to treat GU syndrome of menoapuse/atrophic vagininits)

• DRIP
• D: delierium/derpession
• R: retention, restricted motility
• I: infection, inflammaiton, impactation
• P: pharm, polyuria from DM, pain

• low bone mass
• decreased bone strength
• fragility and susceptability to fracture

• 1 in 2
• higher incidence than DM, herat attack and BC
• MOST prevelant in post menopausal women

• in this order
• vertebrae, wrist, hip and pelvis

• pain
• decreased qol
• deformity
• mobility problems
• decreaased self care

50, down more from there

• low estrogen
• decreased activity of ostoblasts and excess activity of osteoclasts
• disruption of bone build up and resporption
• estrogen inhibits bone resorption and keeps osteoclasts down

• biggest: Rheumatoid arthritis, ankylosing spondylts
• Inherited....
• marfan syndrome
• hemochromatosis
• hypophasphatemia
• epidermolysis bullosa
• homocystinuria
• porphyria
• menkes syndrome
• osteogenesis imprefecta
• ehlers danlos syndrome
• glycogen storage disorders
• Other...
• immobilization
• preg
• lactation
• copd
• amylodosis
• glucocorticoids
• nutrition and gi...
• malnutrition
• malabsorption
• gastrectomy
• liver disease severe esp biliary cirrosis
• pernicious anemia
• endocrine...
• cushings
• hyperparathyroid
• DM I
• acromegaly
• adrenal insufficiency
• hypogonadal....
• turner
• klinefelter
• kallman
• hypothalmic ammenorhea
• hyperprolactinemia
• hematologic...
• multiple myeloma, lymphoma, luekimia
• mastocytosis
• hemophilia
• thalassemia

• postmenopausal: most common, due to decreased estrogen. bone loss 2-3$ per year. most common fracture: vertebral and distal forearm
• age related- 3rd decade of life starts slow decline. most common fracture hip and radius, females more. lose 0.5-1% per year

another cause, listed previously or med

• aluminum
• anticonvulsants
• etoh
• thyroxine
• depo provera- reversible after stopping
• glucocorticoids
• GnRH agonists
• heparin
• lithium

• femoral neck: most severe
• vertebrae: spontaneous compression fracutre- silent fracture- causes kypohosis and loss of height
• distal radius: colles fracture- fall and land on hand

• chronic pain
• height loss
• kyphosis
• decreased self esteem
• restrictive lung diseaes
• cosnstipation, abd pain
• depression

• personal history of fracture as adult
• hx fracture in 1st degree relative
• white
• female
• low body weight
• estrogen deficient- early menopause, bilateral ooperectomy, prolonged amenorrhea (>1year. ie anorexia)

also

• hx falls
• demenia
• etoh
• low clacium intake
• hypogonadism in men
• frail
• smoking

• all women over 50
• detailed history, physical exam and CLINICAL FRACUTRE risk assessment

• ask about
• early meno
• fam hx osto
• meds: sleep aid, opioid, nervous depressants, muscle relaxants, dehydration causing meds
• glucocorticoids, ppi, ssri

any of these would say do a DEXA sooner than 65

• kyphosis, spinal tenderness, bmi, ehight loss, signs low estrogen
• measure height annually with stadiometer (more accurate)
• look at gait for fall risk

• serum calcium 
• serum phosphorus
• alk phos
• PTH (if calcium high)- hyperparathyroid
• Vit D (osteomalacia)
• thyoroid (thyrotoxicosis)
• SPEP, UPEP (multiple myeloma)
• 24 hour urinary calcium or urine ca/creatinie (hyper/hypo calciuria)
• serum testosterone (hypogonadism)

• calculates 10 year probability of hip fracture or major osteoporitic fractures (spine, forearm, hip shoulders) in patients from several clinical risk factors
• can be used with or without bone density measurement of femoral neck
• risk factors; age, sex, weight, height, rpev fracture, current soking, glucocorticoids, rheum artrhitis, alcohol intake >3 units/day
• rec by USPSTF

• all women 65 and older
• women 50-64 with 10 year frax fracture risk of 9.3% or more
• persons with known fragility fracture or high risk med conditions should be screened regardless of frax risk

• t score
• orai

frax is most accurate

• lumbar spine and proximal femur both looked at
• lumbar may be impaired by scoliosis
• gold standard of bmd
• get a t score and aged matched Z score

ultrasound- inconsistent

• normal: -1 and over
• low bone mass (osteopenia): -1.0 - -2.5
• osteoporosis: below -2.5
• severe or established osteioporosis: t score at or below -2.5 with one or more fracutres

-2 or more used to view if an issue of secondary osteoporosis

• adults iwth fractures
• anyone with a condition like RA or glucocortigoids >5mg prednisone
• all over 65

no, its likely reversible when they stop

no uless risk

• t is gold standard
• z compares to women in the same age group, slightly different compared to younger women

use z score in young women, t score in older

q 1-2 years to determine no bone loss than q2 years after

can go longer if very few risk factors

• should be done in addition to dxa
• do in all women 70 and older and all men 80 and over if MBD t score at the spin,e hip, or femoral neck is -1 or less
• so women 65-69 or men 70-79 if t score -1.5 or less
• can do in postmenopausal women and men over 50 if... low trauma fracture during adulthood, historical height loss 4cm or more, prospective height loss 0.8 in, recent or ongoing longterm glucocorticoids

• femoral neck bone mineral density is preferred site
• youll get the spine reading, but fem neck best
• not valid if on treatment
• only hip bone density looked at
• not all risk factors included

• pts with low femoral neck BMD
• put in BMD data and pt history
• calculates a 10 year risk of major osteoporosis fracture and chances of hip fracutre

done through DEXA report and t score 2.5 or less

• helps you determine the actual risk to guide treatment
• if at -2.5 youll treat, but this is helpful if they have osteopenia and you want to know risk

• -2.5 or less, YES
• -1 to -2.5 yes if 10 year hip fracture on frax is > 3% or a major osteo facture risk is > 20%

• bone resorption inhibitors: caclium, estrogen, SERMs, biphosphonates (alendronate), calcitonin
• stimulators of bone formation: PTH, fluoride
• monoclonal antibody: prolia

• alendronate
• risendronate

denosumab (appropriate as initial therapy for pts at high risk of fracture)

teriparatide denosumab or zoledronic acid should be considered for patientes unable to use oral therapy if at esp high risk

• no prior fragility or moderate fracture risk: alendronate, risendronate, denosubmab or zoledronic acid
• prior fragility fracture or high fracture risk: denosumab, teriparatide, zolendronic acid

• oral biphosphonates (reduce resorption)
• oral: aldendronate weekly, or risedronate weekly/monthly
• nonoral: zoledronic acid once yearly IV

• raloxifene- only reduces risk of spine fractures, not others
• teriparatide- anabolic agent that builds bone, reserved for pts with severe osteoporosis or not responding to other treatments

• gi sied effects
• 61$ month
• compex dosing
• contraindicated in ESRD, need to adjust dose to cr clearance

NO increased risk of breast, uterine cancer or clot

osteoclasts

• if hypocalcemia is present
• if kidney function is poor (gfr <30-35)

• first thing in the morning (avoid gi issues)
• with 8oz water
• stay upright for 30 min
• seperate ca, al and mg meds by 4 hours

• >5 years
• osteonecrosis risk (jaw) - mostly cancer patients- exposed bone in maxilofacial region, can be asymptomatic for weeks and get swelling and inflammation eventually. you can see the jaw in the gum
• low trauma femur fracture

• more in asians, or glucocorticoid use
• can occur without trauma
• thigh pain
• takes longer to heal

• stop the biphosphonate after 5 years (zolendronate after 3 years)
• found the drugs still work after stoppped

• not for it only! only do if they have vasomotor symptoms
• need progesterone if uterus
• bone loss resumes after stopped

• antireabsorptive
• analgesic effect on bone pain
• nasal, sub q or IM
• inconsistent effects on bone density and fracutre risk

• for ppl very high risk 
• daily subq pth injections

• q3mo injection
• subq
• can cause hypocalcemia
• risk of femur fracture and osteoporosis

• prevention of osteoporosis by decreasing bone resorption
• raloxifine and bazedoxifine- reduce VERTEBRAL fracrue
• decreases risk of breast cancer, has risk of DVT
• best for PM women with osteoporosis who cant tolerate biphosphonates, no vasomotor symptoms or vte history and have high risk breast cancer

no

• calcium 1000-1200- diet better than pills
• vit d 800-1200 u day, serum should be 30 or more
• strength training
• weight bearing exercise
• no alcohol, no smoke
• measure with stadometer every year

• dairy, green leafy veggies, nuts
• supplements if cant get through diet, but not absorbed as well