beyond menopause : the new age of old age care clinical obstetrics and gynecology vol 50 / no 3 /...

Beyond Menopause : The New Age of Old Age Care

Clinical Obstetrics and GynecologyVol 50 / No 3 / Sep. 2007

Prof. Ki Tae Kim

Common Gynecologic Problems in Geriatric-aged Woman

Practicalities and Pitfalls of Pessaries in Older woman

Beyond the Bladder: Management of Urinary Incontinence in Older Woman

Unique Dermatologic Aspects of the Postmenopausal Vulva

Osteoporosis in the Older Woman

Screening for Common Clinical Conditions in the Older Woman

Common Gynecologic Problems in Geriatric-aged Woman

Cervical Disease

Breast Disease

Adnexal Cyst/masses

Abnormal Uterine Bleeding, Endometrial Hyperplasia, and Cancer

Cervical Disease

Background

incidence : over the age of 70 to 75

Cervical Disease

Screening : When to Stop

Cervical Disease

ASC guideline

: over the age of 70 years

       with 3 successive normal Pap test

        no abnormalities in the preceding 10 years

Continue Screening

- History of cervical cancer

- In utero DES exposure

 - HIV positive, weakened immune system

- Not previously screened,

      screening information is not available 

      from country without screening program

- HPV DNA positive

- Multiple partners

- Previously abnormal cytology

Cervical Disease

Cervical Disease

Against routine screening in over 65 years

(normal pap smear, no risk)

    1. the yield of screening is low

    2. increased potential for harms

Cervical Disease

Summary

Discontinuation of screening beyond age 65 to 70 years

Cervical Disease

Frequency of screening

Screening after prior hysterectomy

- history of CIN 2-3 - DES exposure in utero - subtotal hysterectomy

   Factors affecting screening

- brush type of sampling device - liquid based cytology - An awareness of the morphologic change - ASCUS, endometrial cell

   HPV DNA testing

Breast Disease

Breast Cancer

 22.2% : over the age of 75 years

  5.4% : over 85 years of age

      tumor biology

      effectiveness of screening method

      effects of hormone use

      cost-effectiveness 

Breast Disease

  Screening : summary

Adnexal Cyst / Masses

Postmenopausal adnexal cyst : Incidence

   : Bailey study 7,705 PMS no Sx, TVUS

unilocular cyst: 3.3%

                90%: less than 5 cm

              100%: less than 10 cm

              spontaneous resolution within 60 days: 49%

             not developed cancer

complex cyst : 3.2%

                89%: less than 5 cm

                 45% : persisted

                 7 : ovarian cancer

                 1 : peritoneal carcinoma

Adnexal Cyst / Masses Management strategy for incidental adnexal masses

FIGURE 1. Proposed management algorithm for postmenopausal women with an adnexal mass [Reproduced by permission Am J Obstet Gynecol. 2005;193:35, copyright Elsevier (2005)].

Abnormal Uterine Bleeding, Endometrial Hyperplasia, and

Cancer

Background

AUB: 20% of over the age of 65

22% of AUB: endometrial hyperplasia or cancer

Abnormal Uterine Bleeding, Endometrial Hyperplasia, and

Cancer

Diagnosis

Principle goal of any investigation

1) to identify treatable disease such as endometrial

hyperplasia or uterine cancer

2) minimizing discomfort and risk

Uterine sampling: novak curette

Pipelle device

TVUS

Hysteroscopy

Abnormal Uterine Bleeding, Endometrial Hyperplasia, and

Cancer

Treatment

Hysterectomy

High dose progestin with or without GnRH analogs

Mirena

Aromatase inhibitor anastrazole

Follow up:

Common Gynecologic Problems in Geriatric-aged Woman

Practicalities and Pitfalls of Pessaries in Older woman

Beyond the Bladder: Management of Urinary Incontinence in Older Woman

Unique Dermatologic Aspects of the Postmenopausal Vulva

Osteoporosis in the Older Woman

Screening for Common Clinical Conditions in the Older Woman

Practicalities and Pitfalls of Pessaries in Older woman

Abstract :

pelvic floor disorder :

conservative form of therapy

Introduction

- suited for elderly patients

- noninvasive with minimal risk

- immediate relief of symptom

- cost effective compared with surgery

Practicalities and Pitfalls of Pessaries in Older woman

TABLE 1. Benefits and Pitfalls of Pessary Use to Manage Prolapse-Physician and Patient PerspectivePCP indicates primary

care physician.

Practicalities and Pitfalls of Pessaries in Older woman

Evidence Supporting Pessary Use

prolapse Sx.: 71-90%

urinary Sx.(urgency and voiding difficulty) : 40%

Current Role and Use of Pessaries by Gynecologists

significant risk for surgical morbidity and mortality

Practicalities and Pitfalls of Pessaries in Older woman

Indications for Pessary Use in Elderly Patients

- Relief of prolapse symptoms

- Diagnosis and preoperative evaluation

- Temporary treatment

- Urinary incontinence

Practicalities and Pitfalls of Pessaries in Older woman

Patient Evaluation

History

Physical examination

Pelvic floor assessment

Prolapse severity and specific pelvic floor defects

Health of vaginal epithelium

Practicalities and Pitfalls of Pessaries in Older woman

FIGURE 1. Various types of pessaries: (A) Ring, (B) Shaatz, (C) Gellhorn, (D) Gellhorn, (E) Ring with support, (F) Gellhorn, (G) Risser, (H) Smith, (I) Tandem cube, (J) Cube, (K) Hodge with knob, (L) Hodge, (M) Gehrung, (N) Incontinence dish with support, (O) Donut, (P) Incontinence ring, (Q) Incontinence dish, (R) Hodge with support, (S) Inflatoball (latex) (Photograph courtesy of Milex products, Inc).

Practicalities and Pitfalls of Pessaries in Older woman

Follow-up and Management

Practicalities and Pitfalls of Pessaries in Older woman

Complications

pessary expulsion

urinary incontinence

rectal pain

vaginal discharge

impacted pessary

Practicalities and Pitfalls of Pessaries in Older woman

TABLE 5. Possible Symptoms and Problems That may Arise With the Device and

Potential Solutions

Common Gynecologic Problems in Geriatric-aged Woman

Practicalities and Pitfalls of Pessaries in Older woman

Beyond the Bladder: Management of Urinary Incontinence in Older Woman

Unique Dermatologic Aspects of the Postmenopausal Vulva

Osteoporosis in the Older Woman

Screening for Common Clinical Conditions in the Older Woman

Beyond the Bladder : Management of Urinary

Incontinence in Older Woman

In the Background : Age related Changes in the Lower Urinary Tract

Detrusor

detrusor overactivity : 42% of healthy women over age 65

2/3 of nursing home

detrusor contractility decline : D.M., Vitamin B12 deficiency

detrusor hyperactivity with impaired contractility (DHIC)

urge UI, stress leakage, hesitancy, dribbling, frequency

decreased bladder sensation

Beyond the Bladder : Management of Urinary

Incontinence in Older Woman

Urethra

decreased urethral closure pressure & urogenital atrophy

urethral diverticula

Pelvic floor

Common Gynecologic Problems in Geriatric-aged Woman

Practicalities and Pitfalls of Pessaries in Older woman

Beyond the Bladder: Management of Urinary Incontinence in Older Woman

Unique Dermatologic Aspects of the Postmenopausal Vulva

Osteoporosis in the Older Woman

Screening for Common Clinical Conditions in the Older Woman

Unique Dermatologic Aspects of the Postmenopausal Vulva

Introduction

declined skin barrier function

- possibility of microbial colonization and invasion

- increased susceptibility to mechanical and chemical injury

cell mediated immunity

Unique Dermatologic Aspects of the Postmenopausal Vulva

TABLE 1. Postmenopausal Vulvar Dermatologic Problems

Unique Dermatologic Aspects of the Postmenopausal Vulva

Aging and Vulvar Skin Barrier Changes

a rise in skin pH

a decline in lipid production

cell mediated immunity

Unique Dermatologic Aspects of the Postmenopausal Vulva

Therapeutic Considerations

Restoration of the skin lipid

Estrogen

Anti-inflammatory therapy

Common Gynecologic Problems in Geriatric-aged Woman

Practicalities and Pitfalls of Pessaries in Older woman

Beyond the Bladder: Management of Urinary Incontinence in Older Woman

Unique Dermatologic Aspects of the Postmenopausal Vulva

Osteoporosis in the Older Woman

Screening for Common Clinical Conditions in the Older Woman

Osteoporosis in the Older Woman

Introduction

defined as a skeletal disorder characterized by

diminished bone strength predisposing a person to

an increased risk of fracture.

Osteoporosis in the Older Woman

Demographics and Impact

In 2004 American women

10 M : osteoporosis

34 M : osteopenia

Postmenopausa : 20% have osteoporosis

52% have low bone density at the hip

White women over the age of 50

: over 40% chance of suffering a fracture

Fracture : 1.5 M annually. (wrist, spine, hip)

Osteoporosis in the Older Woman

- Risk Factor -

Risk factor for osteoporosis

- genetic and environmental

- smoking

Additional suggested risk factors

- a history of fracture in a first degree relative

- low body weight

- oral corticosteroid (3 months)

- estrogen deficiency (under 45)

Osteoporosis in the Older Woman

- Risk Factor -

TABLE 2. Risk Factors for Falls

Fall

Osteoporosis in the Older Woman

Pathogenesis

Osteoporosis in the Older Woman

- Primary and Secondary Causes of Osteoporosis -

TABLE 3. Common Causes of Secondary Osteoporosis

Osteoporosis in the Older Woman

- Diagnostic Evaluation -

TABLE 4. WHO Criteria for the Diagnosis of Bone Status

Osteoporosis in the Older Woman

Indication for BDM measurement

- all females aged 65 years or greater

- under age 65 years if additional risk factors exist

- adults with a fragility fracture

- adults with a condition or taking a medication associated with low bone mass or bone loss

- anyone considering or being monitored for pharmacologic therapy for osteoporosis

Continued …

Osteoporosis in the Older Woman

Indication for BDM measurement

- anyone in whom evidence of bone loss would lead to treatment

- men over age 70 years

- women discontinuing estrogen

- low body weight (less than 127 lb)

- corticosteroid use

- sedentary life style

- family history of a fragility fracture in a first degree relative

Osteoporosis in the Older Woman

- Treatment -

General Treatment Considerations

Nutritional Considerations for Bone Health and Treatment of Osteoporosis

Estrogen

Selective Estrogen Receptor Modulation

Calcitonin

Bisphosphonates

Anabolic Therapy

Surgical Approaches

Osteoporosis in the Older Woman

- Treatment -

General Treatment Considerations

Indication

Follow up

Optima duration of treatment

individualized : fracture or fall risk

life expectancy

potential adverse drug effects

cost

Osteoporosis in the Older Woman

- Treatment -

Nutritional Considerations for Bone Health and Treatment of Osteoporosis

recommended in postmenopausal women

- 1500 mg of calcium

- 800 IU of vitamin D

- Protein

- caffeine

Osteoporosis in the Older Woman

- Treatment -

Estrogen - Prevention - Treatment

Selective Estrogen Receptor Modulation Raloxifene

- vertebral fracture: 0.64

- hip fracture

- BDM: 2-3 %

- thromboembolic events: 2.17

Osteoporosis in the Older Woman

- Treatment -

Calcitonin

- calcium lowering hormone

- salmon calcitonin: nasal spry

- vertebral fracture: 0.67

- adverse effect: nasal congestion, irritation

- concern: antibody formation

Osteoporosis in the Older Woman

- Treatment -

Bisphosphonates

Alendronate

Risedronate

Ibandronate

- safety issue: gastrointestinal toxicity

bone quality

disturbances in calcium balance

osteonecrosis of the jaw

Osteoporosis in the Older Woman

- Treatment -

Anabolic Therapy

- Fluoride therapy

- Growth hormone

- Insulinlike Growth Factor -1

- Androgen

- Teriparatide

Osteoporosis in the Older Woman

- Treatment -

TABLE 5. Fracture Efficacy Comparison

Osteoporosis in the Older Woman

- Treatment -

Surgical Approaches :

- Kyphoploasty

- Vertebroplasty

Exercise

Pertinent Geriatric Considerations

- Falls

- Hip protectors

- Pharmacologic considerations in the older patient

Osteoporosis in the Older Woman

- Treatment -

FIGURE 2. Pyramidal approach to bone health: bone health and osteoporosis: a report of the surgeon general

(modified version).

Conclusions

Common Gynecologic Problems in Geriatric-aged Woman

Practicalities and Pitfalls of Pessaries in Older woman

Beyond the Bladder: Management of Urinary Incontinence in Older Woman

Unique Dermatologic Aspects of the Postmenopausal Vulva

Osteoporosis in the Older Woman

Screening for Common Clinical Conditions in the Older Woman

Screening for Common Clinical Conditions in the Older Woman

Introduction

D.M.

Dyslipidemia

Hypertension

Thyroid disorders

Key Points to Overall Care

Thank you for your attention !