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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 !