1. Elaine E. Jolly, O.C., M.D., F.R.C.S.(C.) Medical Director Shirley E. Greenberg Women’s Health Centre Professor of Obstetrics and Gynaecology University of Ottawa GYNECOLOGIC ISSUES IN THE LATE POST MENOPAUSAL WOMAN

2. GYNECOLOGIC ISSUES in the “Geripause” Introduction Introduction Life Threatening Disorders: Cancers Life Threatening Disorders: Cancers Most Common Gynecologic problems Most Common Gynecologic problems Summary Summary

3. Physiology of the “Geripause” Decreased Estrogen Causes Progressive Atrophy   Thinning of vulvar tissue   Thinning, greying, loss of pubic hair   Diminution of labia minora   Presence of petechia   Vaginal walls are atrophic and pale   Shortening and narrowing of vagina   Atrophy of cervix / cervical stenosis   Decreased uterine size   Atrophic endometrium   Fibrous myometrium   Ovarian senescense

4. Gynecologic Examination in the Elderly Female   Abdominal/inguinal exam   Vulvar/perineal inspection   Inspection of Vagina/Vault   Cervix (stenosis), Pap Smear (brush)   Bimanual exam (uterus/adnexa)   Pelvirectal exam Gently, slowly, sensitively Be innovative and accommodating Respect patient’s modesty Warm hands – warm instruments

5. Gynecologic Issues Life Threatening Disorders Life Threatening Disorders Quality of Life Issues Quality of Life Issues

6. Life Threatening Disorders Ovarian Cancer Ovarian Cancer Uterine Cancer Uterine Cancer Cervical Cancer Cervical Cancer Vulvar Cancer Vulvar Cancer

7. Incidence of Cancer in Women Ref: 1988 Annual Rate Estimates Based on NGI SEER Programme 1982-1984

8. Causes of Cancer Death in Women Ref: 1988 Annual Rate Estimates Based on NGI SEER Programme 1982-1984

9. Ovarian Cancer Lifetime Risk 1/70 Lifetime Risk 1/70 2% of Deaths over age 40 2% of Deaths over age 40 Difficult/delayed diagnosis Difficult/delayed diagnosis 5 year survival, all stages 35-38% 5 year survival, all stages 35-38% 2/3 of women diagnosed at Stage 3 or 4 2/3 of women diagnosed at Stage 3 or 4

10. Ovarian Cancer: Risk Factors Lifetime RisksR.R.Risk No Risk1.01.2 Familial CA SyndromeUnknownup to 50 One 1st/2nd 0 Relative3.13.7 2 or 3 Relatives4.65.5 Oral Contraceptive Use0.650.8 Pregnancy0.50.6 Ref: Carlson et al. Ann Int. Med. 1994, 121:126

11. Ovarian Cancer Diagnosis: Screening Routine Exam Routine Exam - - inadequate sensitivity/specificity 18,000 exams in 1,319 women 6 cancers all widely disseminated - - transvaginal ultrasound (TVU) CA 125 CA 125 Doppler blood flow Doppler blood flow Genetic markers Genetic markers - - Hereditary Cancer Syndromes 0.05%

12. Endometrial Carcinoma Most common gynecologic cancer 80% post menopausal (age 55 to 69) 90% patients present with BLEEDING Endometrial biopsy: Endometrial biopsy: Diagnosis Thickened endometrial echo on Thickened endometrial echo on vaginal ultrasound Stage 1 disease 75 to 97% survival

13. Endometrial Cancer: Risk Factors RISK FACTOR n % Oligomenorrhea 382 5.5 Obesity297143.0 Diabetes174624.0 Hypertension304844.1 Polycystic Ovarian Disease 80 1.2 CA of Ovary 90 1.3 CA of Breast 211 3.1 CA of Colon/Rectum 88 2.0 Ref: Wharton J.T. Surg. Gynecol. 1986, 162-515

14. Endometrial Cancer Unopposed ERT Tamoxifen Rx “Endometrial Surveillance”

15. Endometrial Surveillance 1964 1.Cytology (Pap Smear) 2.Endometrial Biopsy 3.D & C (Dilation & Currettage) 2007 1.Endometrial Biopsy / D & C 2.Vaginal Ultrasound 3.Doppler blood flow (TVU) 4.SIS (Saline Infused Sonohysterography) 5.Hysteroscopy / D & C

16. Office Endometrial Biopsy

17. Assessing Endometrial Thickness with Vaginal USS

18. Cervical Intraepithelial Cancer Steady decline in incidence 70% decrease in death rate over 40 yrs. PAPANICOLAOU SMEAR Preinvasive → Invasive CA 20 years Related to sexual activity Related to Herpes Simplex type 2 HPV types 16 and 18

19. Cervical Cancer: Risk Factors Risk Ratio Age at first intercourse (<17)1.9 to 5 Number of sexual partners (>6)2.8 to 6 High risk male partner2.7 to 6.8 Herpes Simplex II2.8 to > 10 HPV3.0 to >10 Cigarette Smoking4.0

20. Cervical Cancer: Older Women Age 65 + Annual death rate 159 per million Age 35 + Annual death rate 44 per million More than ½ of women with invasive cervical cancer have NOT had a pap within 3 years. Unscreened women are older, less sexually active, less well-educated and their cancers are more advanced. Ref: Clinics in Geriatric Medicine: G.U. problems 1998; 306-12

21. Cancer of the Vulva 5% gynecologic cancers 65% 5 year survival Readily accessible on examination Delay in diagnosis/biopsy Amenable to Surgical Rx Associated with: -obesity -chronic irritation -vulvar dystrophy -diabetes

22. Cancer of the Vulva Treatment: Surgical Excision Prognosis: Good if lesion < 2 cm Poor if lesion > 2 cm + nodes Look! - Biopsy!

23. Screening for Malignancy: Factors Incidence and natural history of cancer Age related changes in test sensitivity & specificity Ability to influence the course of disease Risks of death/disability from other health problems. Barriers to screening Patient preferences and values Estimated life expectancies Age 78 – women have 10 more years Age 89 – women have 5 more years Comorbidities affect these estimates

25. The Aging Woman The Aging Woman Most Common Gynecologic Problems: Vulvar vaginal Genital prolapse Alterations in bladder function Post menopausal bleeding “Geripause” Ref: Gyne assessment of the Elderly Patient - Mark Williams, April 2007, MEDSCAPE Review

26. Vulvar Vaginal Problems in the Aging Women

27. Vulvar/Vaginal Conditions in the Elderly Vulvar skin conditions Pruritus Burning and Irritation Vulvar swelling

28. Vulvar Conditions in the Elderly Skin changes – seborrheic keratosis – skin tags Fissures Ulcerations Hypertrophic or verrucous lesions R / O MALIGNANCY

29. Vulvar Pruritus in the Elderly Estrogen Deficiency Lichen Sclerosis (LS&A) Candida Infection  Diabetes  Antibiotics  Corticosteroids  Immunosuppression  Pernicious Anemia  Liver Disease  Diabetes Mellitus  Lymphoma  Leukemia R/O MALIGNANCY

30. Vulvar Burning in the Elderly Vulvar Burning in the Elderly R/O MALIGNANCY Vulvovaginal Atrophy Candida Infection Paget’s Disease of the Vulva Adenocarcinoma in Situ

31. PAGET’S DISEASE OF THE VULVA Velvety red or eczematous appearance When a yeast infection does not clear up Colposcopy of the Vulva - Biopsy reddened/affected areas Associated with 30% coexistent cancer Search for “occult malignancy” Breast, Cervix, Bladder, Gall Bladder, Colon

32. Vulvovaginal Discharge in the Elderly Atrophic Vaginitis Often misdiagnosed as a yeast infection - no odour - bacteria minimal - responds to local estrogen Bacterial Vaginosis “malodorous & abundant” Candida – white, flocculent, itchy Trichomoniasis – malodorous, – yellow-green & itchy

33. Quality of Life: Atrophic Vaginitis Decreased Vaginal mucosal thickness Decreased Vaginal acidity Decreased Vaginal secretions Pain, irritation, infection Dyspareunia Decreased sexuality RELIABLY REVERSED BY ESTROGEN

34. Sexuality in the Mature Woman Estrogen Deficiency Sexual Changes Mental and Physical Health

36. Quality of Life: Urothelial Atrophy Estrogen Deficiency Atrophy urethral mucosa, bladder Frequency, urgency, nocturia Urinary incontinence Recurrent Cystitis REVERSED BY ESTROGEN

37. Vulvar Swelling in the Elderly Vulvar Swelling in the Elderly BIOPSY - R / O Malignancy Urethral caruncle – common Extrogen R X - If no response in 6 wk biopsy Vulvar lesions – white-brown-red-raised - ulcerated Swelling in Posterior Vulva – Adenocarcinoma is aggressive here Swelling of Anterior Vulva – most common site of invasive cancer – around the clitoris, vestibule or labia – flat infiltrative or ulcerative lesion Basal Cell Cancer – pearly appearance with telangiactasia

38. The Aging Woman Genital Prolapse or Pelvic Organ Prolapse (POP)

39. Prevalence POP > 50% of women over 50. Life time prevalence of 30-50%. 1 Women > 65 are the fastest growing segment of the population. Demand for services expected to double in the next 30 years. 2 1-Subak LL et.al Obstet Gynecol 2001;98:646-51 2-Luber KM et.al. Am J Obstet Gynecol 2001;184:1469-1501

40. Clinical Classification of Pelvic Organ Prolapse Anterior Vaginal Wall – Cystocele – Cystourethrocele Apical Vaginal Wall – Uterovaginal – Vaginal vault (after hysterectomy) Posterior Vaginal Wall – Enterocele – Rectocele

41. Prolapse Cystocele Descent of anterior vaginal wall and overlying bladder base Rectocele herniation and bulging of posterior vaginal wall and underlying rectum into vaginal lumen Enterocele herniation of peritoneum (+/- intraperitoneal contents) in areas of pelvic floor

42. Uterine / Vaginal Vault Prolapse First degree/grade prolapse – mild degree of prolapse of upper vagina and cervix; – descent halfway to the hymen

43. Second Degree Prolapse – cervix or vaginal apex extends to the hymen Uterine / Vaginal Vault Prolapse

44. Uterine Prolapse Third Degree Prolapse – cervix or corpus uteri extend outside of hymen – or vaginal vault is everted

45. Treatment options Expectant management. Pelvic floor exercises. - Kegels, vaginal cones, biofeedback - Electrical stimulation of pelvic floor Mechanical supportive devices: Pessary Surgery

47. Progression of prolapse Handa and Jones ’03: – 56 women fitted with pessary – 19 followed over 1 year – No women had worsening in stage of prolapse. – Four women had improvement.

48. Complications of Pessaries Most common problems involve vaginal discharge (leukorrhea) and vaginitis. Vaginal erosions especially with the cube pessary Ulceration Incarceration Urosepsis Fistula formation

49. Surgery for Pelvic Organ Prolapse An elective procedure Medically indicated if: ‒Urinary retention ‒Hydronephrosis/renal failure Complications of surgery: ‒Urinary incontinence ‒Dyspareunia ‒Recurrence

50. Vaginal vs Abdominal Procedures Evidence from randomized trials has demonstrated that abdominal repairs are more durable and offer anatomically superior results, while vaginal repairs have fewer complications, including foreign body complications.

51. Vault Prolapse Vault prolapse occurs after 1/200 (0.5%) hysterectomies

52. Laparoscopic Surgery for Repair of Pelvic Floor Defects short hospital stay decreased pain smaller scar faster post-op recovery improved visualization of the surgical field accuracy of suture placement possibly improve long-term outcome.

53. The Aging Woman The Aging Woman Alterations in Bladder Function

54. Prevalence of Urinary Incontinence Population Subgroups Prevalence (%) Nursing Home Residents (>65 years) 50 Homebound Elderly Persons (>65 years) 50 Hospitalized Elderly Persons (>65 years) Adult (age 15-64 years) 25-30 10-70

55. Implications of Incontinence Morbidity Medical: Decubitus ulcer Skin rashes UTI, Urosepsis Falls Social:Loss of self-esteem Social restriction Depression Economic:Personal costs Societal costs

56. Economic Implications of Incontinence Personal: – Containment devices – Medication Societal: – Direct costs for incontinence care in US $12.43 billion (2001) nursing facilities – Leading cause of institutionalization in US – Leading cost to Medicare for home care in US

57. Treatment Options Vaginal Atrophy estrogen polycarbophil gel regular coitus Recurrent UTI estrogen antibiotics cranberry juice Incontinence estrogen pelvic floor muscle retraining pessaries surgery antimuscarininc Rx bladder drill

58. Kegel Exercises 10 – 20 repetitions three times per day Hold contraction for 5 to 10 seconds A set can be done to suppress urgency Results take 6 – 8 weeks to manifest NOT done while voiding Improvement & cure rates as high as 80% BLADDER DRILL

59. Retro Pubic Urethropexy Major Surgery

60. Tension Free Vaginal Tape Day Care Surgery

61. TVT

62. Advantages of TVT Out Patient procedure Short OR time May be performed under local anesthesia Tape is loosely placed (tension free) minimizing anatomic distortion Decreased incidence of post–op voiding dysfunction

63. TVT results at 7 yrs Observational prospective study on 90 women Cured 81.3% Negative stress test Negative 24h pad weighing test Improved 16.3% Failed 2.5% Ref: Nilsson CG, Obstet Gynecol 2004

64. The Aging Woman Post Menopausal Bleeding

65. Post Menopausal Bleeding: Causes Vaginal - Atrophic Vaginitis - Trauma - Malignancy Uterine - Hormone R X - Unopposed Estrogen - Continuous Combined E + P - Insufficient Progesterone - Tamoxifen - Endometrial Polyp - Endometrial Cancer

66. Post Menopausal Bleeding: Causes (2) Ovarian - Malignancy - Benign Tumour Fallopian tube - Malignancy Vulvar Neoplasia Urinary Tract - Infection/stone - Bladder cancer G.I. Tract- Colorectal cancer

67. SUMMARY In 2005 Cdn Census – 5.5 million women aged 50+ By 2026 women 50+ will represent 22% of pop. Health promotion, disease prevention, early diagnosis, state of the art treatments and promoting quality of life is vital for geriatric health It is imperative that all aging women have appropriate Gynaecological assessment, treatment and follow-up. Otherwise…