The North American Menopause Society has coined the term “Genitourinary Syndrome of Menopause.” This recognizes that many women after menopause experience bothersome symptoms that affect the vagina, vulva, bladder, and the pelvic musculature. This syndrome refers to changes in the tissues of the vagina and vulva that become thin and dry with loss of estrogen after menopause. Another contributor related to aging is muscle weakness which occurs in all parts of our body, and the pelvic muscles are no exception. The pelvic floor is the group of muscles that are attached to the pelvic bones, and form a sling that supports our internal organs (uterus, badder and bowel) , as well as allow passage of the urethra, vagina, and rectum from internal to external. This complex system facilitates and accommodates childbirth, as well as control of urination and defecation. As muscles weaken with age and childbirth, and as the vaginal tissue thins with lack of estrogen, function can change.
Some women experience urinary problems that include frequency, urgency, incontinence, and increased urinary tract infections. Fecal incontinence and uncontrolled passage of gas are embarrassing and limiting. The use of pads and diapers is extremely common among the elderly. Vaginal atrophy and thinning of the vaginal wall can make intercourse painful, and even impossible. Gynecologists often prescribe vaginal estrogen to improve the vaginal mucosa and decrease burning with intercourse. Although there can be some improvement with urinary symptoms, many patients may face surgical procedures for prolapse and stress incontinence.
Gynecologists are now paying more attention to the pelvic floor muscles. Pelvic floor physical therapy and pelvic floor muscle training can teach the optimal function of the pelvic muscles and improve pain and dysfunction including incontinence, frequency, painful intercourse, and fecal incontinence of stool and gas. Other symptoms of pelvic floor dysfunction may include the feeling of incomplete defecation, painful urination, and pain in the pelvis, genitals or rectum.
In order to determine if you have pelvic floor dysfunction, a history and pelvic exam are performed. An exam can determine if there is atrophy of the tissues of the vagina and vulva, and prolapse of the organs. Muscle activity can be tested by using probes that measure the degree of muscle contraction of the vagina and the rectum. More sophisticated testing includes cystometrics which studies bladder function, and x-rays which can be used to evaluate the process of defecation.
Pelvic floor muscle training and physical therapy should always be considered as a first-line therapy when pelvic floor dysfunction is suspected. Pelvic floor muscle training uses probes or sensors to measure and teach the correct use of pelvic muscle contraction and relaxation. It is not painful at all. Improvement can be expected in about 75% of patients. Vaginal estrogen products can be used to improve vaginal tissue thickness and blood flow. Muscle relaxers can be used to relax the pelvic muscles if increased contractions are noted. There are also many medications available for overactive bladder. Surgery is an option for patients with prolapse of the bladder, rectum or uterus, or for patients with severe stress incontinence that is not corrected by non-surgical approaches.
Marilyn Jerome, MD
Foxhall OB-Gyn Associates
Cleveland Clinic, June 2, 2017
Pelvic Floor Dysfunction
Mammograms have been the mainstay of breast cancer screening for many years. The standard mammogram consists of four views which are taken as each breast is compressed from top to bottom and laterally. A radiologist interprets the mammogram by looking for a mass in the breast tissue. Breasts are composed of fat and glands.
Fat in a breast is very dark black and contrasts glandular tissue which is white. Dense breasts are composed of glandular tissue that can appear very white on a mammogram and can hide masses. Some breast masses are quite dense and contain calcium deposits that are more easily visible. Some types of cancer, often the lobular type, is often not as dense and can not always be seen within normal breast tissue. Therefore, mammograms are not without false negatives. We also know there are false positives, areas that look suspicious and need to be biopsied and cause much anxiety, but turn out to be benign.
Researchers and radiologists are looking for better tests: less false negatives and false positives, less discomfort for women, less risks, and less cost. The latest improvement in mammography is the 3D mammogram. With this technique, the breast tissue is visualized in "slices" that reduces overlapping tissue that can appear as a tumor because of superimposed images, and can demonstrate small tumors that were obscured by surrounding tissue. The result in studies that have been done demonstrate 17-34% less "call backs" for additional testing, and an increased breast cancer detection rate of as much as 50%. There was not found to be an increased in detection of DCIS with the 3D mammogram.
Although this new mammogram has improved detection rates, often finding cancers that are less than 10 mm, some cancers can be still be missed. At the recent North American Menopause Society meeting last week, attention was give to research being done on tests that target metabolically active tissue: the sestambi scan and MRI's. Molecular breast imaging has the potential of finding many more cancers than mammograms. An abbreviated MRI is being developed that will be much less expensive and more widely available. Stay tuned for further developments!
Plenary Symposium B: Advances in Breast Imaging, Dr. Emily F. Conant, M.D.
Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
North American Menopause Society Annual Meeting, 2017
Think about these numbers.
Approximately 30% of people over the age of 65 fall every year. That number approaches 40% by age 70. 10-15% of all falls result in a serious injury or fracture. 94% of hip fractures are caused by falling. In an 8 year period from 2001-2008, 4 million adults over the age of 65 had an emergency room visit for a fracture. The risk certainly increases with age, and women fracture twice as often as men. Half of these fractures require hospitalization, which can lead to rehab, loss of mobility, and loss of INDEPENDENCE. We fear losing our independence more than anything as we age!
So, what are the risk factors for falling? The number one risk factor is lack of muscle strength. This muscle weakness increases the risk of falling 4-5 times. A history of falling increases the risk 3 times. Other factors that increase the risk include balance issues, visual impairment (bifocals distort vision), arthritis, depression, cognitive impairment, age, and medications.
Other risk factors include Parkinson’s disease, fear of falling, heart disease, orthostatic hypotension, urinary incontinence, depression, stroke, chronic pain, and a sedentary lifestyle.
Some of these factors are modifiable.
A particularly vulnerable time for older adults is post-hospitalization. When adults come home from the hospital, often in pain, maybe undernourished, and on multiple medications, the risk of falling is much increased. Over 40% fall within 6 months of discharge, with half causing severe injury. There are twice as many hip fractures in the month after a hospitalization.
Drugs that increase the risk of falling are benzodiazepines (Valium), antidepressants including SSRI’s, sleeping pills, antihypertensives, and psychotropic drugs. Often when medication doses are changed, or other drugs are added, interactions can cause side effects such as dizziness.
Decreased mobility caused by muscle weakness, osteoporosis, and medical problems such as obesity and diabetes can all lead to falls and fractures. Fractures must be taken seriously and some can be prevented. Fractures lead to loss of quality and length of life. Pain, immobility, and disability lead to decreased quality of life. 20-24% of those who sustain a hip fracture die within one year of the fracture! 40% of those who sustain a hip fracture are unable to walk independently, and 60% will still need assistance one year later. 33% of those who fracture will end up in a nursing home or be unable to ever live independently again.
90% of older adults rank staying in their homes and living independently as their number one concern. Preventing fractures is a significant intervention that can help to achieve this goal.
Physicians should be asking their patients about falling: the frequency, circumstances, loss of consciousness, and factors which led up to the fall. Appropriate studies should be done and interventions can be made to decrease risk.
So what can we do as patients to prevent falls and fractures? Modify your home environment by eliminating throw rugs, wires, and objects that clutter. Use more lighting, especially night lights to show the path to the bathroom. Install rails and bars to help stability with movement. Avoid ladders and put items at arm’s length. Minimize or taper medications that have effects on balance and cognition. Exercise, participate in balance, strength and gait training. Tai Chi is very effective. Treat visual impairment. Treat cardiac arrhythmias or other conditions that can cause fainting, including installing a pacemaker if needed. Take Vitamin D, to reach a serum level of 40 ng/ml. This may take 2,000-4,000 IU per day to achieve this goal Wear reasonable shoes, don’t walk on ice, and be careful about curbs and uneven pavement. Schedule physical therapy for musculoskeletal problems that can lead to imbalance or difficulty walking. Decrease or avoid medications such as sedatives, sleeping pills, psychotropic drugs, antihistamines, drugs for overactive bladder, and decrease alcohol! Alcohol on top of multiple medications can cause serious interactions, dizziness, and loss of consciousness. The elderly should practice getting up off of the floor, so that if they fall, they can get up again.
It is so important that we do not look at fractures and falling as just part of getting older. There is much that we can do, and starting sooner that later can make a huge difference in how long we can live happily independent!!
Marilyn C. Jerome, M.D.
Crash, Snap: Falls Cause ‘Osteoporosis-Related” Fractures. What Can a Clinician Do?
NAMS Pre-meeting, October 11, 2017
Dr. Neil Brinkley, M.D.
University of Wisconsin School of Medicine and Public Health
Why am I shrinking?
Not a day goes by that a patient voices a concern about her loss of height. It is not unusual to lose up to two inches after menopause.
We know that loss of vertebral height from osteoporosis fractures is one cause, but many patients who do not have osteoporosis of the spine also experience loss of height. As one of my colleagues put it, “your discs go from marshmallows to pancakes.” Simplistic yes, but it gets the point across. In the October, 2017, issue of Menopause,a study was reported that looked at intervertebral discs in men and women by MRI. The data seems to suggest that there is an increase in deterioration in the discs of the lumbar spine in women in the first 15 years after menopause which is independent of the aging process. This deterioration may contribute to increased vertebral fractures as the “cushion” between vertebrae is degraded.
What causes this deterioration? We know that there is deceased connective tissue such as collagen, as well as loss of water in the discs. Estrogen can preserve some of the collagen and molecules that hold water.
The impact of vertebral fractures is tremendous. It is thought that 15-20% of women in their 60’s will sustain a vertebral fracture, and 50% of women aged 80-84 have sustained a fracture.
Only about one third of fractures are diagnosed. Vertebral fractures, as hip fractures, are associated with increased mortality which extends up to 20 years.
The morbidity of vertebral fractures includes severe pain, decreased mobility, and an increased fall risk due to a change in a person’s center of gravity. Kyphosis (which is the curve of the spine forward) can cause problems with breathing and eating, and can lead to increased bouts of pneumonia .
Vertebrae are most susceptible in the anterior portion of the bone. A movement as simple as bending over can compress a vertebrae, and once one is fractured, it puts more force on adjacent vertebra, causing a domino effect. The decreased cushioning of the shrunken discs adds to the increased risk of fractures.
The chemical composition of the intervertebral disc is complex, as it contains various types of connective tissue and molecules that hold on to water. The vertebral column is a fascinating structure that must adapt to changes in muscle activity and heavy loads that must distribute the pressure evenly along the spine. When the chemical structure of the disc changes with age and menopause, tears and clefts in the discs weaken them which increases the degradation. There is some evidence that a reversal of some of these changes may occur with estrogen. Studies have shows that intervertebral discs have estrogen receptors, and that fibrous cells of the discs proliferate in the presence of estrogen. Estrogen also increases the collagen in bone which is an important factor in the prevention of osteoporosis.
Women who remain on estrogen after menopause have higher disc heights than women not on estrogen. We also know that estrogen prevents osteoporosis. It is becoming more clear that the genesis of vertebral fractures depends on not just the vertebral bone, but the cushions supporting them. Although more studies need to be done, this is fascinating science that explains why we seem to be shrinking!
Menopause: The Journal of the North American Menopause Society, October, 2017,
Editorial: Menopause and the Intervertebral Disc, Yves Muscat Baron, M.D.
Breast cancer is the most common cancer diagnosed in women, and second only to lung cancer in deaths per year in the US. About 250,000 new cases are diagnosed per year, with approximately 40,000 deaths. We know that 12% of women will be diagnosed with breast cancer in their lifetimes. No doubt, this is a disease that has touched us all one way or another.
Now there is some good news about breast cancer mortality.
In the recent publication CA: A Cancer Journal for Clinicians and its companion Breast Cancer Facts and Figures, it was noted that breast cancer mortality has decreased 40% from 1989 to 2015. This decrease translates into 322,000 lives saved over that period of time. This contrasts with an increase in breast cancer mortality from 1975 to 1989, where mortality increased about 0.4% per year.
So, what has changed during that period of time?
There have been many improvements in breast imaging in the last 20 years. Mammography has improved, with digital mammography and now tomosynthesis (3D imaging) adding to technical advances. Ten years ago it seems that most breast cancers were diagnosed that were larger than 1 cm in size. Now with tomosynthesis, many breast cancers are found that are less than 1 cm. When you think about the fact that a breast cancer is three dimensional, the difference between a 5 and 10 mm tumor is not half, it is much less. Less tumor volume translates into less invasion into nearby lymph and blood vessels. I believe we will continue to see decreases in mortality due to this recent technology.
Other advances are in treatment options. New forms of chemotherapy developed since the 1980's prevent metastases and recurrences. Tamoxifen, an anti-estrogen, was developed in the late 70's and is used to treat hormone sensitive breast cancer, and also for prevention in high-risk women. Aromatase inhibitors which prevents estrogen production in postmenopausal women also reduces recurrences. Herceptin treats breast cancers which contain a high level of HER2, a protein on breast cancer cells that is a growth factor which makes these tumors more aggressive.
More targeted therapies are currently being developed.
We have come a long way, but there is still a long way to go. Today's news, reported in the Washington Post, is very encouraging!!!
Marilyn C. Jerome, MD
Foxhall Ob-Gyn Associates
Washington Post, October 4, 2017. Study shows long-term drop in deaths from breast cancer