Family Practice Program Info Accreditation Info Cultural & Linguistic Competency Resources Topics in Womens Health From the University of Oklahoma College of Medicines 17th Annual Primary Care Update Educational objectives The goal of this program is to improve management of pelvic bladder health and incontinence, and to review use of hormone replacement therapy (HRT) for treatment of menopausal symptoms. After hearing and assimilating this program, the clinician will be better able to: 1.Counsel patients about treatment options for pelvic organ prolapse. [L1] 2.Select treatment for stress incontinence, overactive blad der, and urge incontinence. [L1] 3.Discuss risks associated with mesh product removal. [L1] 4.Review findings of the Womens Health Initiative and Heart and Estrogen/Progestin Replacement Study. [L2] 5.Identify patients who may benefit from HRT. [L2] Faculty Disclosure In adherence to ACCME Standards for Commercial Support, Audio Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose. Pelvic Bladder Health and Incontinence Dena E. OLeary, MD, Assistant Professor, Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City Pelvic organ prolapse (POP): case presentation woman 70 yr of age referred for bulge in vagina noted on annual examination; bulge present for many years and slowly worsened over time; typically not bothersome, but worse with activity ( eg , lifting grandchildren); no voiding difficulties, pain, or defecatory dysfunction; treatment elective; surgery 11% lifetime risk for surgery for POP by 79 yr of age; ≈ 40% of postmenopausal women undergo surgery for POP; ≈ 400,000 surgeries performed per year in United States; POP most common indication for hysterectomy in women >50 yr of age; prevalence and risk factors true prevalence unknown; risk factors include age, parity, and connective tissue disorders Types of POP: cystocele herniation of bladder through anterior vagina; rectocele herniation of rectum through vagina; apical uterine or vaginal; often occurs in women who underwent hysterectomy; enterocele rarely seen on examination; herniation of small bowel through vagina; rectal prolapse herniation of bowel through anal canal Symptoms of POP: [Q1] pressure most common; patients may have pain, discharge, or bleeding; pressure only consistent symptom if prolapse extends beyond hymen; back and hip pain Baden-Walker staging of POP: 0 no prolapse; 1 descent halfway to hymen; 2 descent to hymen; 3 descent halfway past hymen; 4 maximal possible descent Treatment of POP: option to not treat unless patient has urinary retention; pessaries 1) space-filling pessaries; easily placed in office; well tolerated; avoid pessary with cube and string that may trap discharge; 2) support pessaries; ring pessary; incontinence pessary with knob supports urethra; cost ≈ $20; easily placed; most pessaries can remain in place for ≤3 mo without being removed; surgery most procedures do not include mesh; intervene if patient wants intervention; patients must be good candidates; refer patients with recurrent prolapse to, eg , urogynecologist Urinary incontinence: affects ≤35% of women; more often seen in women with hypertension and diabetes; ≈ 50% of women with urinary incontinence have stress incontinence, ≈ 20% have urge incontinence, and ≈ 30% have mixed incontinence (stress incontinence and urge incontinence) Stress incontinence: due to hypermobility and intrinsic sphincter deficiency (typically seen in women with history of radiation therapy); patients tend to leak larger amounts at lower volumes with less pressure; diagnosis largely based on history and physical examination; surgical candidates must demonstrate leakage on examination or on bladder testing; treatment conservative therapies include physical therapy and use of incontinence pessary; urethral bulking (minimally invasive office procedure; injection of bulking material in urethra under cystoscopic guidance); sling procedure; [Q2] no medical treatments available for stress incontinence; procedural treatments increase risk of worsening of overactive bladder (OAB) and urge incontinence (in patients with both urge and stress incontinence, address urge incontinence first) Overactive bladder: study ≈ 33 million individuals with OAB; 10.4% of population had OAB without urge incontinence; ≈ 6% had OAB with urge incontinence; risk factors include age; OAB and urge incontinence affect men and women at equal rates; clinical diagnosis; frequency ≥8 trips to toilet in 24 hr; urgency sudden strong desire to urinate; nocturia ≥2 visits to toilet during sleeping hours; important to distinguish from poor sleeping habits Treatment: [Q3] behavioral modification standard baseline treatment of OAB and urge incontinence; fluid management avoid drinking 2 hr before bed; avoid bladder irritants ( eg , caffeine, tobacco, chocolate, carbonated beverages, spicy foods); concentrated urine can irritate bladder (recommend 6 8-oz glasses of water per day); physical therapy focuses on urge suppression (patients taught to stop, sit, and contract pelvic floor muscles; patients should distract themselves and wait before walking calmly to toilet; difficult without help of physical therapist); timed voiding; medications anticholinergics mainstay of therapy; oxybutynin (Ditropan, Oxytrol, Urotrol) and tolterodine (Detrol) have no organ specificity and lead to many side effects ( eg , dry mouth, constipation); solifenacin (VESIcare) specific to M 2 and M 3 muscarinic receptors (smooth muscle receptors in bladder); darifenacin (Enablex) has 50 times affinity for M 3 receptors (effective on bladder; associated with high rates of constipation); trospium (Sanctura, Regurin; generic form available); oxybutynin and trospium least expensive; avoid medications in patients with dementia (drugs can cross blood-brain barrier and lead to negative cognitive effects); mirabegron (Myrbetriq) option for patients who cannot tolerate anticholinergics; β 3 -adrenergic receptor agonist; causes relaxation of detrusor muscle and increases bladder capacity; effective; well tolerated; expensive; [Q4] contraindicated in patients with uncontrolled hypertension; other neuromodulation (vaginal electrical stimulation); percutaneous tibial nerve stimulation (weekly stimulation of posterior tibial nerve for ≥12 wk); InterStim Therapy; injection of detrusor muscle with botulinum toxin type A (Botox, Botox Cosmetic, Dysport; paralyzes bladder; associated with high rates of urinary incontinence) Anal incontinence: depends on stool volume and consistency, internal and external anal sphincter function, puborectalis muscle (maintains anorectal angle) damage, and anorectal reflexes; diagnosis patient history; physical examination; staining of stool; sphincter defect; testing recommended for patients who fail conservative management with bulking agents (or laxatives in patients with constipation) and under consideration for surgery or biofeedback; if sphincter defect suspected, consider endoanal or endovaginal ultrasonography; anorectal manometry gives indication of capacity and compliance; pudendal nerve latency testing gives indication of nerve function; magnetic resonance imaging defecography useful for patients with suspected problem not seen on physical examination ( eg , intussusception); conservative treatments bulking agents; laxatives; constipating agents; physical therapy; sphincteroplasty for patients with sphincter defect (success rate 30%-50%); anal bulking (administration of dextranomer and sodium hyaluronate [Solesta] as in-office procedure); InterStim Therapy; sling procedure to restore anorectal angle in women with puborectalis defects under investigation Mesh: no mesh products recalled; [Q5] concerns exist regarding use in vaginal prolapse surgery, but mesh does not necessarily need to be removed; removal of mesh associated with risk for bleeding and injury to organs; if not problematic, we leave it alone; most common problems include pain with intercourse, bleeding, discharge, chronic pain (in, eg , groin), pudendal neuropathy, musculoskeletal pain, voiding dysfunction, and recurrent urinary tract infections; estrogen therapy for mesh exposure typically ineffective unless exposure very small; surgery only treatment of complications; mesh removal more complicated than mesh placement, and more difficult with greater number of past surgeries for mesh exposures; associated with legal complications and psychosocial issues; refer to original surgeon (many patients reluctant to confront original surgeon); discuss options with patient; mesh removal must be performed by highly experienced surgeon Menopause Update: Hormone Replacement Therapy Rachel M. Franklin, MD, Associate Professor, Department of Family and Preventive Medicine, University of Oklahoma College of Medicine; Medical Director, University of Oklahoma Health Sciences Center, OU Physicians Family Medicine Center, Oklahoma City Menopause: estradiol levels fluctuate before cessation of menses; sudden drop in estradiol levels leads to development of symptoms; serotonin may play role in severity of symptoms; estrogen has some effects on serotonin reuptake Symptoms: hot flashes; night sweats; insomnia; reduced quality of life (QOL); vaginal dryness; mood disturbances; word-finding difficulties; lack of verbal fluency; anxiety; depression; poor concentration Diagnosis: clinical; [Q6] physical examination ( eg , decreased vaginal rugae, vaginal dryness, other atrophic signs); laboratory studies not required ( eg , elevated follicle-stimulating hormone and luteinizing hormone levels and low estradiol level not required) Risks associated with menopause: 2 to 3 times higher risk for myocardial infarction (MI) and stroke; by 65 yr of age, 1 in 3 women have heart disease; osteoporosis and Alzheimer disease (AD) associated with menopausal syndrome; AD animal models show that estradiol helps inhibit formation of amyloid plaques; endogenous estrogen and progestin cycling (natural biochemical body processes) inhibit Aβ amyloid formation; unknown whether use of hormones helpful Studies: Nurses Health Study observed 120,000 younger ( eg , <60 yr of age) menopausal women over time; showed 20% reduction in age-adjusted all-cause mortality at 7.5 yr (40% at 15 yr) and 30% reduction in incidence of coronary heart disease (CHD) in women; Womens Health Initiative (WHI) looked at primary outcomes of nonfatal MI, risk for CHD, invasive breast cancer, stroke, pulmonary embolism, cancers, and hip fractures; [Q7] in 2002, WHI reported absolute excess risk for CHD events (7 more per 10,000 woman-years), stroke, and pulmonary embolism (8 more per 10,000 woman-years for stroke and pulmonary embolism); absolute risk reductions reported in colorectal cancers (6 fewer per 10,000 woman-years) and hip fractures (5 fewer per 10,000 woman-years); differences between Nurses Health Study and WHI Nurses Health Study less rigorous and less well controlled than WHI, and studied younger, healthy women; in WHI, average age of women 63 yr, and women ≤79 yr of age included; 2002 report did not discriminate or report ages separately; study stopped early primarily due to reaching of breast cancer threshold; landmark decision by Journal of American Medical Association to override concerns of principal investigators (PIs) by not allowing PIs to respond, and to break media embargo before physicians received copy of journal; WHI reported aggregate data ( ie , irrespective of age, ethnicity, or comorbidity, patients reported to have 7 more per 10,000 woman-year risk for MI); two-thirds of participants >60 yr of age or >10 yr past menopause Reactions to WHI: initially obstetrics and gynecologists used fewer hormones; ≈ 50% decline overall in number of women receiving hormone replacement therapy (HRT) for symptoms; higher use of anxiolytics, clonidine, and selective serotonin reuptake inhibitors for treatment of menopausal symptoms; led to development of bioidentical hormones and herbal remedies; currently ≈ 5% of women receive HRT to treat symptoms; increase in osteoporosis-related fractures and hip fractures; analysis of WHI data continues Heart and Estrogen/Progestin Replacement Study (HERS): branch of WHI study; HERS arm reported no increased cardiovascular risk with HRT, and suggested slight benefit; WHI reported increased risk for MI related to HRT (7 more per 10,000 woman-years); [Q8] HERS suggests women <60 yr of age and within first 10 yr of menopause on HRT had 6 fewer events per 10,000 woman-years; HRT may be appropriate initially in patients <60 yr of age and <10 yr into menopause; other studies have shown that estrogen alone decreases coronary calcium scores in younger patients, and that combination HRT associated with statistically significant reduction in CHD in younger women <10 yr after menopause Meta-analyses: compared initial WHI evaluation to follow-up evaluation; in HRT group, CHD event rate over 4.5 yr 0.29, compared to 0.65 in control group; in younger women, meta-analyses found number needed to treat with HRT over 5 yr to prevent one MI 256; absolute risk reduction 1 per 1000 patient-years; in younger women, use of HRT for symptoms does not cause MI; in older women, HRT increased CHD events in first year, but risk began to decline after 2 yr; HRT only effective treatment of symptoms ( eg , hot flashes, vaginal atrophy), and prevents fractures due to osteoporosis; treatment of symptomatic patients <60 yr of age and <10 yr after menopause has good risk-benefit profile AD and HRT: lack of strong randomized controlled trial evidence related to AD and HRT; few heterogeneous randomized controlled trials looked at cognition; HRT improves verbal memory, word finding, reasoning, and motor speed; case-control studies suggest that HRT might reduce dementia (unclear due to bias); some experts advocate that HRT may be useful in women <60 yr of age and <10 yr after menopause for improving QOL, but not for preventing AD Current trends: treatment of symptoms rather than replacement of hormones; moderate exercise ≥30 min 5 to 6 days per week; huffing and puffing ≥4 hr before bedtime; reduces hot flashes and night sweats and improves insomnia; effects require ≥6 wk of moderate exercise; [Q9] HRT remains gold standard of treatment of symptoms; limitations of HRT benefits seem to outweigh risks in women <60 yr of age and <10 yr since menopause; in other patients, carefully select and discuss increased risk for MI (7 more per 10,000 woman-years), stroke (8 more per 10,000 woman-years), and breast cancer (8 more per 10,000 woman-years); help patients with decision making; prevention studies related to coronary disease (particularly in younger women) and dementia; United States Preventive Services Task Force gives grade D recommendation for using HRT as prevention for anything Patient selection for HRT: optimal timing important; discuss reasons of use; monitor use and effects; ask about improvement and problems; find best time to stop medication; patient should be young, healthy, and in early menopause; women >60 yr of age with preexisting comorbid conditions, metabolic syndrome, or hyperlipidemia at higher risk; patient should be symptomatic; no evidence that preventive dose effective; use shortest duration and lowest dose; after 2 to 3 yr, breast cancer risk increases; supplements studies show that >50% of over-the-counter supplements have no active ingredients, and some may be dangerous; supplements not regulated; very little evidence of efficacy Bioidentical hormones: estriol primary hormone in compounded medications; patients given estriol had higher risk for breast cancer and more aggressive metastases; primarily unopposed estrogen; patients must be willing to take oral progestin to help protect endometrium (progestin cream not protective); progestin cream alone can be beneficial Cancer risk and HRT: slight increased risk for ovarian cancer; breast cancer risk depends on when HRT given; use of HRT in women <60 yr of age and <10 yr since menopause associated with increased risk for breast cancer (important to discuss with patient); [Q10] colon cancer HRT reduces risk slightly; benefit prolonged (after 5 yr of HRT use, benefit seen throughout lifetime [unlike benefit of reduced fracture risk, which goes away after HRT stopped]) Acknowledgments Drs. OLeary and Franklin were recorded in Midwest City, OK, at the 17th Annual Primary Care Update , presented May 13-17, 2014, by the University of Oklahoma College of Medicine. Please visit cme.ouhsc.edu for more information about course offerings from the University of Oklahoma College of Medicine. The Audio Digest Foundation thanks the speakers and the University of Oklahoma College of Medicine for their cooperation in the production of this program.
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