Osteoporosis is the single most

important health hazard associated with

menopause

No ; Yes

t 1

Genitourinary symptoms such as

vaginal dryness or pain

with intercoursc/scxual activity

Free of broast cancer endometrial cancer,

venous thromboembolism,CHD, strokc/TIA. and other

contraindicaions to HT and interested in considering HT?

Cardiovascular disease is the leading

cause of death post-menopause

Yes No Yes No

1

Froo of breast cancor, f

endometrial cancer, k

Prior Hysterectomy?

* Yes - Sec estrogen-only options in Table 19

• No = See combined estrogen-progestin options

in Table 19

Avoid HT Eroo of contraindications

to SSRIs/SNRIs?

and other

homronc-sensitrve

cancers?

Increased risk of breast cancer (RR 1.3) is

associated with estrogen+progesterone

HRT.but not with estrogen-only HRT

Yes No

£ £

Yes No • Considor

low-dose

paroxetine or

other

well-studied

SSRIs/SNRIs

Ivcnlafaxino,

cscitaloprarn,

others) if no

contraindications

• Avoid

SSRIs/SNRIs

• Consider

gabapentin,

pregabalin or

clonidine.if

no contraindications

I All women taking HRT should have

periodic surveillance and counselling

regarding its benefits and risks

Assess CVD risk and time since

_ menopause onset • Vaginal

lubricants

and/or

moistunzers

• Vaginal

lubricants

and/or

moisturizers

• Consider

low-dose

vaginal

estrogen if

response is

inadequate

Yrsince menopause onset

M <5 6-10 >10

s «

•5 Low15%) HT OK HTOK AvoidHT it Moderate HT OH

•c g (5-10%) Ichoose

HTOK AvoidHT

(chODSC

transdermat)transdcrmall

l

H Adequate control

of hot flashes?

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High|

< > l >10:

o!

Avoid HI Avoid HT Avoid HT

S Yes No

I

• Continue

low-doso

paroxotino or

other

SSRIs/SNRIs

• Adiustdose

or consider

gabapentin.

pregabalin or

clonidine

+

DECISION ABOUT DURATION OF USE continued moderatc-to-scvcrc symptoms;

patient preference;weigh baseline nsks of breast cancer,CVD,and osteoporosis

Figure 19. Hormone therapy in menopause

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GY38 Gynaecology Toronto Notes 2023

Table 19. Examples of MHT Regimens

MHT Regimen Trade Names Standard Doses

Menopausal Hormone Therapy end Health

Outcomes During the IniErreitkii and Eitended

Poststopping Phases of the Women'

s Health

Initiative Randomized Trials

JAMA 2013:310:1353-1363

Purpose: Toreport com pre’e'snt ringsfrom the

2 Women'

s Health Initiative (181) to

—ate therapy

trials with eitended postmteneutoa f: wr- up.

Methods: 4 total of 27341 posrr::a.sz women

ages 50-79 were enrolled a:40 US centers,la the

C£t*MPA trial.166

-33 noreLwit atadutcns.

received either conti nuoascorh-ed H!I(CEE 0.625

mg - MPA 2.5 rag once daily) or osteho.hr tie CEEonly trial, 10739 women,wdt pcor

-ysferectomy.

received either CEE 0.625-g once teiyor p aceoo.

Results: Results al : reported as cases per10000

person-yr,stratified for age (50-59.60-69.70-79:)

• CEE-MPJCHD:6 additional cases(50-591.0

additional cases160-69).19sddtoat cases

(70 79|

• CEE-MP& Invasive toast catcer:6 Mdrtrotal cases

(50-59).7 additional cases(6069).15 additional

cases(70-79)

CEE-MPA Stroke:5 addrtnral cases(50-59).11

additional cases (60-69).13 addrtnral cases

(70-79|

• CEE-MPi PE: 6 additional cases(50-591.S

additional cases (60-69).18 addtncal cases

(70-?9|

. CEE^MPA ColcrecUl cancer:T fencer case (50-S9).8

fewer cases(60-69).17 fewer cases (70-79)

• CEE-MPA Hip iractuies:2 lews cases(50-59).3

fewei cases(60-691.H lews cases(79-79)

. CEE-only CHD:11 lew«cases(50-59).2 fewer

cases(60-69). 7 addrtnral cases(70-791

• CEE-only Invasive breast cancer 5fewer casesISO59).II iewee cases(60-691.5fewer cases(70-79)

• CEtonlySlmte: lieneecase(50-59).ttadSional

cases(60-69).18 additional cases(70-791

• CEE-only PE:4 additional cases(50-59).7

additional cases|60-69|.2 fewer cases(70-79)

• CEE-only Colorectal cancer 3fewer cases|50-59|.

3(ewer cases(60-69).18 arkhbceal cases(70-79)

• CEE-only Hip Iraclures:3 edtoccalcases(50-59). 7

fewei cases(60-69). 21fewer cases(29-79)

Estrogen-only -oral Estrace!

Premara:

Estragyn:

17 8-estradiOl 0.5-1mg tablet dally

CE 0.3-0.625mg tablet daily

Esterrfied estrogens 0-3-0-625 mg cyclic

Estrogen-only -transdermal Patches:

Estradot:

.Sandoz Estradiol Derm ;

. 17 fl- estradiol 25-100 pg1-2x/wk

Oesdia -.Climara -

Gel:

Estrogel

Oivigel:

1-2 metered dosev'actualion daily

0.25-1mg packets daily

Estrogen-only -vaginal Cream:

CE 0.625 mg 'g

Estrone1mg'g

17 p-estradiol10 pg

17 (l-estradiol 2mg

1 mg 17 9-estradiol0.5 mg NEA

1 mg17 O- eshadioll mg drosprrenone

17 P-estradiolHEA:

50140 mpg continuous 2xi'wk

50.140 mag or 50250 mpg cyclic 2*

/vvk

Premarin3

Estragyn '

Inserts:Vagrfem :

Ring:Estr.ng :

Actrvelle"

Angeiiq -

Combined E-P - oral

Combined E Patch:Estahs (2 doses available)

-P -transdermal

CE*conjugated estrogen:E-P - estrogen-progestin:NEA- noretlrindrone acetate

Current common practice Includes using trie Mrrera IUO asthe progesterone component pevonorgesbel 52 mg over 5yr. approximately 20 us d)

Side Effects of MHT

• estrogen

• breast tenderness

• nausea

headache

• bloating

• progestins

• mood alterations

• breast tenderness

• bloating

sedation (micronized progesterone)

Contraindications to MHT

• absolute

acute liver disease

undiagnosed vaginal bleeding

history of breast cancer

known or suspected uterine cancer/breast cancer

acute vascular thrombosis, or history of severe thrombophlebitis or thromboembolic disease

cardiovascular disease

• relative

pre-existing uncontrolled HTN

uterine fibroids and endometriosis

Absolute Contraindications to MHT

ABCD

Acute liver disease

Undiagnosed vaginal Bleeding

Cancer (breast

- uterine).Cardiovascular

disease

DVT (thromboembolic disease)

familial hyperlipidemias

migraine headaches

• family history of estrogen-dependent cancer

• chronic thrombophlebitis

• DM (with vascular disease)

• gallbladder disease, hypertriglyceridemia, and impaired liver function (consider transdermal

estrogen)

• fibrocystic disease of the breasts

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GY39 Gynaecology TorontoNotes 2023

Urogynaecology

i fr .c Sacrum

2

Small I intestine

ligaments 5

1

Uterus

Reek

Vaginal Canal

rl i r d

Rectocele Cystocele Uterine Prolapse Enterocele

Figure 20. Pelvic anatomy

Pelvic Organ Prolapse

Etiology

• related to:

vaginal childbirth

aging

decreased estrogen (post-menopause)

increased intra-abdominal pressure (obesity, chronic cough, constipation, ascites, heavy lilting)

ethnicity (greater incidence in White women > Asian or African women)

connective tissue disorders

Pelvic Organ Prolapse

A weakening in the structures of the

pelvic floor resulting in descent of one or

more of the pelvic structures (bladder/

rectum/smatt intestine/uterus) into the

vagina

Diagnosis

• medical history

assess symptomsspecific to prolapse:pressure, bulge

assess urinary,defecatory, and sexual concerns, which are often associated with pelvic organ

prolapse

• physical exam (each component with patient relaxed and then while straining)

» inspection in the dorsal lithotomy position

evaluate for apical prolapse with a bivalve speculum exam, then evaluate for anterior and

posterior prolapse with the posterior blade of the bivalve speculum

use the POP-Q staging system to quantify stage of prolapse

evaluate for any coexisting pelvic abnormalities with a bimanual exam

test the strength of pelvic floor muscles with voluntary Kegel contractions

• ancillary studies

if continent with apical prolapse, consider clinical or urodynamic testing with and without

reduction of prolapse to investigate for occult stress urinary incontinence

if voiding symptoms,consider post-void residual volume to evaluate urinary retention

if urgency or other UT1symptoms,consider urine microscopy and culture to test for UT1

H

POP-Q Staging of Pelvic Organ

Prolapse

• 0- no prolapse

• 1- most distal portion of prolapse

on above level of hymen

• 2-most distal portion of prolapse

is between1cm above or below the

hymen

• 3 most distal portion of prolapse

>1cm below level of hymen but no

further than 2 cm lessthan the total

vaginal length

• 4 - complete procidentia (uterus

present with complete herniation

of anterior, posterior, and apical

compartments) or vault eversion

(no uterus present with complete

eversion of the anterior, posterioc

and apical compartments), most

distal prolapse protrudes 2 cm of

total vaginal length

GENERAL CONSERVATIVE TREATMENT

• weight loss

• pelvic floor muscle training (e.g. Kegel exercises, pelvic physiotherapy)

• local vaginal estrogen therapy

• vaginal pessary (intravaginal devices that are either supportive orspace-occupying)

Ihe primary clinicalfeatures of pelvic organ prolapse are vaginal bulge and pressure

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GY40 Gynaecology Toronto Notes 2023

Table 20. Types and Management of Pelvic Organ Prolapse

Type Clinical Features Treatment

General conservative treatment(see above)

Anterior colporrhaphy (“anterior repair*

)

Consider additional/alternative surgical

increased incidence olUTIs (may lead to renal procedure if documented urinary stress

impairment)

Straining/digitation to evacuate stool

Constipation

Anterior Vaginal Wall Prolapse (previously

"cystocelo")

(protrusion of bladder into the anterior vaginal Incompletebladder emptying 2 associated

wall)

Frequency,urgency,nocturia

Stress incontinence

incontinence

Posterior Vaginal Wall Prolapse(previously

"rectocele”)

(protrusion of rectum into posterior vaginal

wall)

General conservative treatment(see above)

Also laxatives and stool softeners

Posterior colporrhaphy (“posteriorrepair*),

plication ofendopelvic fascia andpenneal

muscles approximated in midline to

support rectum and perineum (can result in

dyspareunia)

General conservative treatment (see above)

Vaginal hysterectomy 2 surgical prevention of

vault prolapse

Consider additional surgical procedures if

urinary incontinence,cystocele.rectocele.

and'or enterocele are present

Uterine Prolapse

(protrusion of cervix and uterus mto vagina)

A type of apicalprolapse

Groinfback pain (stretching of uterosacral

ligaments)

Feeling of heaviness pressure in thepelvis

Worse with standing,lifting

Worse at the end of the day

Relieved by lying down

Ulceration/bleedng (particularly if

hypoestrogenic)

2 urinary incontinence

A type of apicalprolapse

Same as uterineprolapse

General conservative treatment (see above)

Sacralcolpopexy (vaginal vault suspension),

sacrosp nous Fixation,or uterosacral ligament

suspension

Vault Prolapse

(previously "enterocele".protrusion of apex of

vaginal vault into vagina,post-hysterectomy,

often containingsmall bowel)

The only true hernia of the pelvis is

an ENTEROCELE because peritoneum

herniates with the small bowel

Surgery:native tissue repair vs.meshreconstruction (usually reserved for severe,recurrent prolapse)

Urinary Incontinence

• see Urology, U6

STRESS INCONTINENCE

Definition

• involuntary loss of urine with increased intra-abdominal pressure (cough,laugh,sneeze, walk, run)

• affects 4-35% of all women

Risk Factors for Stress Incontinence in Women

• increased age

• obesity

• pregnancy/vaginal delivery

• hypoestrogenic state (post-menopause)

• smoking/chronic cough

• neurological

• genetics

• high impact exercise

Diagnosis

• history

» onset,frequency',severity, and pattern of urinary'incontinence

frequency, dvsuria, urgency, and nocturia

pads used per 24 h

• obstructive urinary symptoms (incomplete voiding, hesitancy,straining, post-void dribbling, and

recurrent Ull)

• pelvic organ prolapse symptoms

• neurological conditions/symptoms

• obstetric history, and current menopause/hormone therapy status

medications (sedatives, diuretics, anticholinergic medications, and OTCs)

lifestyle risk factors (caffeine,smoking,weight, exercise, and occupation)

urinary diary

• physical exam

height, weight, and BM1

• abdominal exam:scars, abdominal mass,and presence of a full bladder

neurological exam:S2-S4 sacral nerves (motor,sensory, and reflexes)

elderly: mini mental status exam, and observe mobility

» pelvic exam:inspect vulva and urogenital epithelium, assess forsigns of pelvic organ prolapse,

and digital rectal exam to assess for analsphincter tone and perineal sensation

• standing stress test

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GY41 Gynaecology Toronto Notes 2023

•studies

urinalysis:hematuria, pyuria,ghicosuria,proteinuria

hematuria/irritative voiding symptoms:cytology

pyuria/bacteria;urine culture

post-void residual

normal <1/3total volume

abnormal:>1/3 total volume (poor bladder contractility or bladder outlet obstruction)

urodynamic testing

Society of Obstetricians and Gynaecologists of Canada (SOGC):uncertain diagnosis,failsto

improve with treatment, clinical trials, orsurgical intervention is planned

Treatment

•for conservative management,see Pelvic Organ Prolapse, GY39

•procedures:vaginal laser, urethral bulking

•surgical

« midurethralsling (TVT,TOT)

urethropexy (Burch procedure)

pubovaginalsling

• urethral bulking

OVERACTIVE BLADDER

Definition

•symptom syndrome defined as "

urgency, with or without urge urinary incontinence ( UU1), usually

with frequency and nocturia”

•16% of all women

•UU1:involuntary leakage with or immediately preceded by a strong desire to void

involuntary bladder contraction that overcomes the urethral sphincter mechanism OR

poor bladder compliance

Etiology

•idiopathic:congenital and aging

•medical:CHF,DM,and diuretics

•neurogenic:multiple sclerosis,Parkinson s,CVD,dementia, and spinal cord injury

•bladder outlet obstruction:previous bladder neck surgery and pelvic organ prolapse

•gynaecologic:UT1,pregnancy,pelvic mass, and urethral diverticulum

•psychosomatic:habits, anxiety, and high fluid consumption

Diagnosis

•see Stress Incontinence,GY40 for diagnosis

Treatment

.behaviour modification ( reduce bladder irritants(caffeine,smoking, alcohol, acidic,spicy); adequate

water intake;regular voiding schedule)

•bladder training with pelvic physiotherapist

•medications

anticholinergics

• oxvbutynin (oral:Ditropan*; patch:Oxytro!*;transdermal gel:Gelnique')

tolterodine (Detrol*)

fesoterodine (Toviaz* )

• solifenacin (Vesicare’)

• trospium (Trosec*)

darifenacin (Enablex*)

• (J-adrenergic agonist:mirabegron (Myrbetriq*)

•procedures:sacral neuromodulation,detrusor botox injection

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GY42 Gynaecology Toronto Notes 2023

Gynaecological Oncology

Pelvic Mass

( Pelvic Mass ]

v. 1

[ Ovarian ) [ Tube j Uterine [ Ollier ]

± T ’