Curriculum Vitae Dr. Lama Taiser Mohammad Yousef QUALIFICATIONS: Jordanian Board in Obstetrics and Gynecology from the Jordanian Medical Council, Jordan, 2004. Bachelor of General Medicine and Surgery (MBCHB), Damascus University, Syria, 1997. MEMBERSHIP: Jordanian Medical Association, 1998 till now. Jordanian Society of Obst.Gyn, Jordan Medical Association, since 2004 till now. Genetics & Infertility Society, Jordan. Member of Jordan Society for Islamic Medical Sciences, Jordanian Medical Association, 2006 till now.
GYNECOLOGIC PROBLEMS of the elderly female Dr. Lama T. Yousef, MD Senior specialist Obest.Gyn Dr. Mazen Y. El-Zibdeh MD, FRCOG, Senior Consultant Obest.Gyn Islamic Hospital-Amman-Jordan Jakarta, September 17, 2011
Significance of the problem • In 1990, 12.6% of the population in US were older than 65 year. • By 2050, 22.9% or 100 million will be elderly. • These older female has medical problems which may result in morbidity and disability that relatively impact quality of life. • Many of these problems have an underlying gynecologic etiology and up to 30% of post menopausal women have undiagnosed gynecologic problem.
Common problems of elderly female • Urogenital atrophy and vulvovaginitis. • Pelvic floor prolapse. • Urinary incontinence and urinary tract infection. • Gynecologic malignancies. • Post menopausal bleeding and HRT. • Sexual dysfunction.
Leading causes of deaths in elderly female: • Heart Disease. • Malignant neoplasm e.g: (Lung, colorectal, Breast). • Cerebrovascular disease. • Chronic obstructive pulmonary disease (COPD). • Pneumonia and influenza.
Common gynecologic problems of the Elderly female
( 1 )Urogenital atrophy and vulvovaginits (vulvovaginal problems ): • Vulvitis. • Vulvodynia (focal valvitis, vestibualitis). • Vulvar dystrophy and dysplasia (pagets hyperplastic dystrophy). • Lichen sclerosis. • Simple atrophic vaginitis. • Desquamative vaginitis. • Urethral caruncle. • Other vulvar problems (e.g: sebrorrheic keratosis senile hemangiomas, Bartholin’s cyst)
Treatment according to the cause • Vulvitis according to the cause. • Simple atrophic vaginitis (can be treated by HT). • Desquamative vaginitis ( treated by clindamycin creams). • Urethral caruncle can be treated by Estrogen creams, and biopsy should be taken if there is no improvement.
( 2 ) Pelvic floor prolapse: Relaxation of any or all part of pelvic floor muscles and fasica, includes the following: • Cystocele. • Urethrocele. • Rectocele. • Uterine prolapse. • Eversion of the vaginal vault in hysterectomized patients. • Enterocele.
Patient with prolapse usually complain of: • Feeling something coming down. • Low abdominal and pelvic discomfort. • Discharge P.V. • Urinary symptoms (urgency, incontinence, voiding difficulty and recurrent cystitis). • Interference with sexual function.
Treatment of pelvic floor prolapse: • Asymptomatic patient do not require surgical treatment. • Pessaries ( can be used in patient with sufficient levator muscle). • Surgery should be reserved for those who can tolerate this elective procedures without excessive risk.
Surgical procedures for proplapse • Vaginal hysterectomy. • Anterior and posterior repair. • Perineorrhaphy. • Paravaginal repair (laparsocpoic or by lapratomy). • Sacrocolpopexy. • Sacrospinous ligament fixation. • Lefort procedure (for very old and sexually inactive women).
( 3 ) Urinary incontinence and urinary tract infection: • 15-30% of women age 65 and older experience some degree of urinary incontinence. • 50% of nursing home residence have some degree of incontinence. • Elderly women more likely to experience detroser instability . Stress incontinence is more common in the younger women.
Treatment 1.Stress incontinence • Pelvic floor exercise like (kegel exercises). • Use of vaginal pessary. • Surgery: • Burch procedure. • T.V.T or T.O.T. • Bulking agent.
2. Bladder instability • Reduce caffeine. • Bladder training. • Pharmocotheray e.g: • Detropan (oxybutynin). • Detrol (tolteridine). • Vesicare (solifenacin). • Spasmex (Trospium chloride).
Urinary tract infection Elderly women are more likely to develop interstitial cystitis and urinary tract infection due to age related changes: • Declining estrogen levels. • Detrusor muscle degeneration. • Low urethral closure pressure. • Neurotransmittor dysfunction.
The most common organisms causing U.T.I: • Escherichia coli. • Enterobacteria. • Enterococci. • 50% of UTI in older population are nosocomial. The most common source of bacteremia in elderly population is urinary tract infection.
(4)Gynecologic Malignancies American cancer society found that the incidence of all gynecologic cancers increase with increasing age: • 25-27% of cervical cancer and 40% of related deaths of cervical cancer occur in this group. • 45% of endometrial cancer. • 43% of ovarian cancer occur over the age of 65 years. • 44% of breast cancer occur in this age. • 65-75% of vulvar cancer. • 57% of vaginal cancer occur in this age group.
Screening ( 1 ) • The American College of obstetrics and Gynecology recommends annual screening for at least 3 years with the option to perform smears less frequently after three normal results. • Hysterectomy dose not eliminate the need of cytologic assessment. • Aggressive evaluation of postmenopausal bleeding or spotting especially if the patients are not on hormonal replacement or those who use tomoxifen.
Screening ( 2 ) • Careful examination (clinical and ultrasound). • Office biopsy and if the office biopsy indicates atypia with hyperplasia or inadequate,then full dilatation and curettage (D&C) should be done. • Hysteroscopy will improve the diagnostic rate because focal biopsy can be taken.
For ovarian cancer annual pelvic examination in addition to : • Ultrasound. • CT scan. • Ca125 And finally laparoscopy or laparatomy for staging and treatment if needed.
Fallopian tube carcinoma: • Although it is rare but it occurs in this age group. • Manifested with pain, watery vaginal discharge and pelvic mass. • Diagnosis usually made intraoperatively.
Vulvar cancer: Careful inspection and biopsy of any suspicious lesion should be taken.
(5)Post menopausal bleeding • 80% of postmenopausal bleeding has benign cause. • Evaluation requires pelvic examination and ultrasound for endometrial thickness, pap smear and endometrial sampling and finally hystroscopy.
Endometrial atrophy is found in 70% of these cases. • Endometrial hyperplasia in 15%. • Polyps in about 9%. • Carcinoma or other lesions in about 1% of cases.
Management of post menopausal bleeding If patient on H.R.T: • Change HRT regimen or to stop HRT. • Reduce estrogen. • Unopposed estrogen. • Endometrial ablation. • Hysterectomy.
( 6 )HRT ( Hormonal Replacement Therapy)
Benefits of HRT: • It reduce the incidence of osteoporosis, coronary artery disease, genital atrophy, AlZheimers disease and osteoarthritis and tooth loss. • Also it increases mental acuity.
Potential Risk of HRT Most of potential risks are extremely controversial and confusing, e.g: • Endometrial hyperplasia. • Breast Cancer. • Thromboembolism. • Hypertension. • Glucose intolerance.
Absolute contraindication: • Undiagnosed genital bleeding. • Active intrinsic liver disease. • Active thromboembolic disease. • Recent myocardial infarction. • Estrogen dependent tumors. • History of estrogen related thromboembolism.
Relative contraindication to HRT: • Chronic intrinsic liver disease (prevents metabolism of estrogen). • Poorly controlled hypertension. • Acute intermittent porphyria. • History of estrogen dependent tumor (breast and endometrial cancers, decision must be individualized to each patient. • History of sever depression (contraindication of progestin)
(7)Sexual dysfunction of old age: • Loss of interest. • Arousal problem. • Achieving orgasm. • Dyspareunia (pain during coitus).
Treatment of S.D: • Prescribing Hormonal treatment. • Local vaginal Estrogen. • Lubricant. • Encouraging regular intercourse to maintain vaginal function.
Old age and surgery complication: • This age group of women are at high risk for surgery. • They require special care in the preoperative and post operative period.
Preoperative and postoperative medical care: In the U.S about 190 surgical procedures per 100,000 persons of older than 65 year are performed annually.
10.8% mortality rate for patients between the ages of 90-94 years. 80% of those older than 65 years have a chronic illness and 35% have more than three problems. There is no specific risk assessment for gynecologic and urogynecologic surgery. (Few data mentioned that overall mortality rate of gynecologic surgery in this age is 0.6%).
Incontinence procedures found to have mortality rate of only 0.33% and most of deaths related to coronary artery disease and embolism.
The American Society of anesthesiologists (ASA) scale is a clinical measure that correlates with arterial blood gas, pulmonary capillary wedge pressures, and right heart Catheterization in predicting mortality. • cardiac complication peaks. In the 3rd to the 5th day post surgery.
Goldman Multifactorial Index of Cardiac Risk in noncardiac surgical procedures
A point score greater than 26 carries a 22% chance of life threatening complication and 56% chance of death.
Disease Prevention in older women: • The three leading causes of death for patients 55 years old or more are: • Cancer. • Cardiac disease. • Cerebrovascular accident.
Cigarette smoking, hypertension, hypercholesterolemia, diabetes, obesity, and sedentary life style are risk factors.
1-Hormone Replacement Therapy • Estrogen/progestogen use is no longer recommended for disease prevention or risk reduction in older women. • The major advantages of its use in younger women are in prevention of osteoporosis urogenital atrophy and possibly colon cancer and cognitive decline. • The risk benefit profiles are less clear for women older than 65 years.
2- Prevention and treatment of osteoporosis • Is the second major prevention issue in women older than 65 years. • Physicians should assess bone density status. Calcium, and vitamin D intake. It is known that bisphosphonates and H.R.T can arrest bone loss no matter how late it is begun and it can increase the bone density and decrease the risk of femoral neck and vertebral fractures.
Calcium supplementation to a level of 1500mg/day and vitamin D should routinely be advised. • (Dexa) Dual-energy x-ray absorptiometry scanning is recommended for all women older than 60 years. Dexa can be used also for follow up and to observe the response of treatment. • Prevention of falls in the elderly is important in preventing fractures.
3-Cardiovascular disease: Causes 46% of deaths in women in the United States compared with 4% of deaths from breast cancer.
Observational and preclinical studies of HT tended to show a consistent 50% reduction of coronary artery disease in estrogen treated women in their fifties compared with untreated women. • Women health initiative has definitely confirmed that in older women there is no justification in starting HT with the sole indication of reduction of cardiovascular disease.
Conclusion • Elder female require special care and attention by gynecologist. • Appropriate care of this population requires an understanding of medical problems related to aging and to the female endocrine state.
Women at this age are at increase risk of cancer, genital prolapse and urinary dysfunction. • Special care required for preoperative and postoperative assessment. • Screening for certain gyn. disorder are mandatory. • HRT is controversial in the management and the prevention of problems related to hormonal deficiency in this age.