Menopause

·         Women over 65 should have all of the following immunizations: tetanus-diphtheria booster every 10 years, influenza virus vaccine annually, and a one-time pneumococcal vaccine. A hepatitis B vaccine would be indicated only in individuals at high risk, i.e., international travelers, intravenous drug users and their sexual contacts, those who have occupational exposure to blood or blood products, persons with chronic liver or renal disease, or residents of institutions for the developmentally disabled and of correctional institutions.

·         Women over 65 years old should undergo cholesterol testing every 3 to 5 years, fasting glucose testing every 3 years, screening for thyroid disease with a TSH every 3 to 5 years, and periodic urinalysis. CA-125 testing is not recommended for ovarian cancer screening in women who are at low risk for ovarian cancer. A urinalysis that is positive for blood should be followed up with a urine culture to detect an asymptomatic urinary tract infection before further workup is done or referral to a urologist is made.

·         The two most common causes of urinary incontinence are stress (loss of urine due to increased intra-abdominal pressure [e.g., with cough or sneeze]) and detrusor instability (urgency accompanies incontinence).

1.Stress incontinence may include topical estrogens, medications to increase sphincter tone, pelvic muscle rehabilitation, and surgical approaches.

One of the abdominal procedures that successfully cures stress incontinence is the Marshall-Marchetti-Krantz (MMK) procedure, which involves the attachment of the periurethral tissue to the symphysis pubis. However, in approximately 3% of patients undergoing the procedure, the painfully debilitating condition of osteitis pubis will develop. Treatment of this aseptic inflammation of the symphysis is suboptimal, and the course is usually chronic. An alternative procedure (the Burch procedure) was therefore introduced; this involves the attachment of the periurethral tissue to Cooper’s ligament. The incidences of urinary retention, recurrent urinary tract infections, and failure are essentially the same in the MMK and Burch procedures. Other procedures commonly employed in the treatment of stress incontinence are anterior repair and needle urethropexy (Stamey-Pererya procedure – Sling procedure). The traditional anterior repair, or Kelly plication, has a 5-year failure rate of approximately 50%. The initial cure rate (90%) for the Stamey-Pererya procedure appears to equal that for the Burch or MMK procedures. Kegel exercises may strengthen the pelvic musculature and improve bladder control in women with stress urinary incontinence.

The success rate of the suburethral sling procedure to treat intrinsic urethral sphincter dysfunction is 80-90%. Periurethral bulking injections with GAX-collagen have a lower success rate of 45-65%

2. Detrusor instability is treated with behavioral modification and medications to control involuntary contractions.

Urge incontinence is the involuntary loss of urine associated with a strong desire to void. Most urge incontinence is caused by detrusor or bladder dyssynergia in which there is an involuntary contraction of the bladder during distension with urine. The management of urge incontinence includes bladder training, biofeedback, or medical therapy. Treatment with anticholinergic drugs (oxybutynin chloride), β-sympathomimetic agonists (metaproterenol sulfate), Valium, antidepressants (imipramine hydrochloride), and dopamine agonists (Parlodel) has been successful. These pharmacologic agents will relax the detrusor muscle. In postmenopausal women who are not on estrogen replacement therapy, estrogen therapy may improve urinary control.

Multichannel urodynamic study should be done for patients with stress incontinence prior to surgical correction and in patients with urge incontinence not responsive to medical therapy.

·         Dyspareunia, which is genital pain associated with intercourse, and vaginismus, which involves involuntary spasm of the muscles of the outer third of the vagina, preventing vaginal penetration.

·         Hormone replacement therapy is recommended for treatment of vasomotor symptom and urogenital atrophy and to decrease the risk of vertebral and hip fractures.

·         Lichen sclerosus was formerly termed lichen sclerosus et atrophicus, but recent studies have concluded that atrophy does not exist. Patients with lichen sclerosus of the vulva tend to be older; they typically present with pruritus, and the lesions are usually white with crinkled skin and well-defined borders. The histologic appearance of lichen sclerosus includes loss of the rete pegs within the dermis, chronic inflammatory infiltrate below the dermis, the development of a homogenous subepithelial layer in the dermis, a decrease in the number of cellular layers, and a decrease in the number of melanocytes. Mechanical trauma produces bullous areas of lymphedema and lacunae, which are then filled with erythrocytes. Ulcerations and ecchymoses may be seen in these traumatized areas as well. Mitotic figures are rare in lichen sclerosus, and hyperkeratosis is not a feature. While a significant cause of symptoms, lichen sclerosus is not a premalignant lesion. Its importance lies in the fact that it must be distinguished from vulvar squamous cancer.

·         Current studies to watch for menopause:

1. Kronos Early Estrogen Prevention Study (KEEPS) is an ongoing study evaluating estrogen given either orally or transdermally to recently postmenopausal women to see if starting HT earlier modifies the effect on atherosclerotic disease. Progesterone is given to women who have their uterus.
2. The Early versus Late Intervention Trial with Estradiol (ELITE) study is currently evaluating women less than 6 years postmenopausal versus women greater than 10 years postmenopausal and the effect of estradiol on the development of atherosclerotic changes. Progesterone is given to women with their uterus.
3. The Study of Women Across the Nation (SWAN) is observing midlife transition and normal aging in women of five different American ethnic groups.