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thra. Patients typically describe losses of small volumes of urine with activities resulting in transiently increased intra-abdominal pressure (coughing, sneezing, running, laughing). It is thought that these changes become more pronounced following menopause as estrogen deficiency allows atrophy of the genitourinary tissues; however, there is no real evidence that this is the case. Physical examination may reveal evidence of pelvic relaxation, such as cystocele, rectocele, and/or uterine prolapse. Urine loss can usually be demonstrated with coughing while the patient is in the supine position. Urge Incontinence: It is diagnosed when the detrusor muscle contracts, spontaneously or on provocation, during the filling phase of the bladder while the woman is attempting to inhibit micturition. 59 Urge incontinence is more common in older adults. This type of incontinence is also known as detrusor overactivity, detrusor instability, detrusor hyper-reflexia, or uninhibited bladder. Patients with detrusor overactivity have early, forceful detrusor contractions, well before the bladder is full. This creates a sensation of urinary urgency and frequency. Patients with detrusor overactivity tend to lose small to moderate volumes of urine. If the detrusor contraction is strong enough to overcome the urethral resistance, incontinence occurs. The diagnosis of detrusor overactivity is made primarily by history and confirmed with urodynamic testing. There are no pathognomonic findings on physical examination, although a careful pelvic and rectal examination and neurologic screening can occasionally reveal anatomic abnormalities (e.g., uterine prolapse, fecal impaction) or evidence of neurologic disease. Mixed Incontinence: It is a combination of both stress and urge incontinence and is most common in older women. Overflow Incontinence: In overflow incontinence, the bladder becomes too full because it can’t be fully emptied. This condition is rare and is the result of bladder obstruction or injury. Those with 210 overflow incontinence commonly present with symptoms of markedly reduced urinary stream, incomplete or unsuccessful voiding, and frequent or even continuous urinary dribbling. Overflow incontinence is generally due to bladder contractile dysfunction (hypotonic/atonic bladder) or vesicles obstructing urinary outflow. In either case, large bladder volumes result in the intravesicular pressure exceeding intraurethral resistance, and symptoms of urinary dribbling. Physical examination often reveals a distended bladder, and measurement of urine volume after voiding reveals an elevated postvoid residual volume. Patients also demonstrate low urinary flow rates on urodynamic tests. Other factors can cause incontinence, such as decreased mobility, cognitive impairment, or medications (table 10–3). 5.2 Evaluation Evaluation and treatment for incontinence is dependent on the type of incontinence and the person’s age, medical history, and desire for therapy. The assessment for incontinence should include a history; physical examination; and mental, functional, and environmental assessments. The characteristics of the incontinence are noted, including the onset, frequency, and severity as determined through the person’s description of the problem and the pattern of incontinence behavior. Urinary symptoms provide clues to possible causes of the problem and, when combined with the information obtained from a history and physical examination, a provisional diagnosis can often be made. The patient should be thoroughly questioned about related urinary symptoms and habits. Symptoms can be classified as obstructive or irritative. Obstructive symptoms include hesitancy, dribbling, intermittency, impaired trajectory, and sensation of incomplete emptying. Irritative symptoms include nocturia, frequency, urgency, and dysuria. Obstructive symptoms often require referral to a specialist, whereas irritative symptoms can often be controlled by behavioral interventions.
TABLE 10–3 Other Factors Causing Incontinence Drug Side Effect Antidepressants, antipsychotics, sedatives/hypnotics Sedation, retention (overflow) Diuretics Frequency, urgency (OAB) Caffeine Frequency, urgency (OAB) Anticholinergics Retention (overflow) Alcohol Sedation, frequency (OAB) Narcotics Retention, constipation, sedation (OAB and overflow) Alpha-adrenergic blockers Decreased urethral tone (stress incontinence) Alpha-adrenergic agonists Increased urethral tone, retention (overflow) Beta-adrenergic agonists Inhibited detrusor function, retention (overflow) Calcium channel blockers Retention (overflow) ACE inhibitors Cough (stress incontinence) OAB = Overactive Bladder Obtaining a recent medical history can identify acute or reversible causes. Significant past medical history includes the number of births, recurrent urinary tract infections, bladder repair surgeries, and pelvic radiation. The history should include an assessment of memory impairment and environmental barriers. A mental status assessment should be performed if the person has memory loss. Certain environmental barriers, such as the location of the toilet, may be contributing to the incontinence. This is especially true in older persons. In these cases, incontinence may improve with the use of catheters or other urine assistive or collective devices. 5.3 Urodynamics Urodynamic assessment includes a group of tests that measure bladder function. Multichannel urodynamic studies include uroflow, cystometrogram, urethral pressure profiles, and electromyogram. Today, multichannel urodynamic studies to document bladder pressure and capacity, muscle contractibility, urethral length, and sphincter control are performed under the auspice of a gynecologist specializing in disorders of the pelvic floor or an urologist. These studies should be done if surgery on the pelvic floor is being considered for UI. 5.4 Treatment Treatment for incontinence depends on the type of incontinence, its causes, and the capabilities of the patient. The evidence on the effects of clinical interventions will be reviewed below. 5.4.1 Pelvic Muscle Rehabilitation (To Improve Pelvic Muscle Tone and Prevent Leakage) Pelvic Floor Muscle Exercises Kegel Exercises. Regular, daily exercising of pelvic muscles can improve, and even prevent, urinary incontinence. This is particularly helpful for younger women. Kegel exercises should be performed 30–80 times daily for at least 8 weeks. 211
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National Heart, Lung, and Blood Ins
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CHAIRS AND EDITORS Chair and Editor
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Anne McTiernan, M.D., Ph.D. Associa
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Lenore Manderson, Ph.D. Director an
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Michael Mendelsohn, M.D. Director,
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TABLE OF CONTENTS Preface XIII 1 Ex
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PREFACE Women’s health and menopa
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CHAPTER 1: EXECUTIVE SUMMARY Nanett
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TABLE 1-1 Evidence Categories Evide
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TABLE 1-2 (continued) Possible Bene
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symptom measures, cultural factors,
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5. PHYSIOLOGICAL ROLE OF ESTROGEN A
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The atherogenic risk profile of old
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• Hormone replacement therapy: Fi
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tion of the remaining ridge in area
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9.3.1 Interventions • In many cas
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Parkinson’s disease, no overall p
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TABLE 1-3 (continued) Sexuality •
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CHAPTER 2: THE MENOPAUSE AND AGING
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oped and are less prepared to addre
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FIGURE 2-4 Diabetes Mellitus. Estim
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Sarcopenia, defined as reduced musc
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Perimenopause WHO The term “perim
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decrease about 2 years before the F
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4.3 Menstrually Defined Menopausal
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to be under stress and to hold part
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21 Brincat MP. Hormone replacement
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62 Orentreich N, Brind JL, Rizer RL
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CHAPTER 3: SYMPTOMS AND THE MENOPAU
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women who may have reached natural
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numb-tingling feelings, headaches,
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(47 percent), problems sleeping (39
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FIGURE 3-2 Proportion of Women Both
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tomized hypogonadotropic women expe
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5.1 Exercise It has been suggested
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to consume 20-150 mg/day of isoflav
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REFERENCES 1 Stewart AL, Hays RD, W
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48 Avis NE, Crawford SL, McKinlay S
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92 Albertazzi P, Pansini F, Bonacco
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Hällström wrote that the psycholo
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countries. Perhaps, as the authors
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Beyene used a systematic ethnograph
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ange of variables, such as genetic
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REFERENCES 1 Gannon L, Ekstrom B. A
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47 George T. Women in a south India
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9. Estrogen and inhibins produced b
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HRT) display tissue-selective estro
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a partial agonist. In contrast, wit
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3. UROGENITAL TRACT ERα and ERβ a
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4. BONE: DEVELOPMENT AND HOMEOSTASI
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in response to estrogen. 106,105 In
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lation of sleep, motor behavior, an
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7. HORMONE REPLACEMENT THERAPY: TRA
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REFERENCES 1 Jensen EV, Jacobsen HI
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40 Power RF, Mani SK, Codina J, Con
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83 Oursler MJ, Pederson L, Fitzpatr
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125 Gabrielsson BG, Carmignac DF, F
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169 Renier MA, Vereecken A, Buytaer
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FIGURE 6-1 Structural features of E
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ound, the conformation of the recep
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with extremely potent estrogenic ac
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Its potency as an antiestrogen was
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The observation that the degree of
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findings were remarkable because a
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Recently, the use of phage display
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20 Crawley G. Non steroidal estroge
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65 Qu Q, Zheng H, Dahllund J, et al
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in their survey of postmenopausal w
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where over half the world’s popul
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The Danish study of Koster and Gard
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Many studies of sexual interest in
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7. ASSESSING SEXUAL ACTIVITY Clinic
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None of these studies evaluated the
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estrogen-androgen group during the
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REFERENCES 1 Sarrel PM, Whitehead M
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52 Utian WH. The true clinical feat
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140
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outes of administration and differe
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FIGURE 8-2 Change in Age-Adjusted D
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fied as overweight or obese. 32 The
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TABLE 8-1 148 Guide to Risk Reducti
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TABLE 8-1 (continued) 150 Recommend
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TABLE 8-1 (continued) 152 Recommend
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Interesting differences in atherosc
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similar effects in both patients wi
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a lowering of triglycerides, 140 an
Page 176 and 177: may account for a substantial propo
Page 178 and 179: associated with an independent prot
Page 180 and 181: eases preoperatively. Quality of li
Page 182 and 183: excess risk of 6-18 per 10,000 per
Page 184 and 185: REFERENCES 1 NHLBI Morbidity and Mo
Page 186 and 187: 36 Samaras K, Hayward CS, Sullivan
Page 188 and 189: 79 Collins P, Rosano GM, Jiang C, L
Page 190 and 191: 121 Mäkelä S, Savolainen H, Aavik
Page 192 and 193: 162 Clarke S, Kelleher H, Lloyd-Jon
Page 194 and 195: 201 Rahimtoola SH, Bennett AJ, Grun
Page 196 and 197: 243 Varas-Lorenzo C, Garcia-Rodriqu
Page 198 and 199: 7. A connection between menopausal
Page 200 and 201: 3. PATHOGENESIS OF FRACTURE Fractur
Page 202 and 203: Diagnosis of osteoporosis according
Page 204 and 205: density and has a favorable effect
Page 206 and 207: How should this information be inco
Page 208 and 209: emergence of proved treatment alter
Page 210 and 211: Data on the relation between skelet
Page 212 and 213: REFERENCES 1 Osteoporosis Preventio
Page 214 and 215: 42 Gluer CC. Quantitative ultrasoun
Page 216 and 217: 85 Ettinger B, Pressman A, Silver P
Page 218 and 219: 130 Jeffcoat MK, Lewis CE, Reddy M,
Page 220 and 221: 1. INTRODUCTION Perimenopausal wome
Page 222 and 223: for breast cancer are at increased
Page 224 and 225: findings on biopsy in women with an
Page 228 and 229: Biofeedback: Used in conjunction wi
Page 230 and 231: There has been one systematic revie
Page 232 and 233: ence in pelvic organ prolapse. The
Page 234 and 235: 21 Ferenczy A. Endometrial carcinom
Page 236 and 237: 65 Wyman JF, Fantl JA, McClish DK,
Page 238 and 239: 222
Page 240 and 241: 1. INTRODUCTION Worldwide, breast c
Page 242 and 243: difficult to compare because of com
Page 244 and 245: Although HRT has been related to an
Page 246 and 247: cyclic use and 2.9 (95 percent CI 2
Page 248 and 249: TABLE 11-3 Selected Studies on Horm
Page 250 and 251: TABLE 11-3 (continued) Thus, a stro
Page 252 and 253: TABLE 11-4 236 Cohort Studies on Ho
Page 254 and 255: TABLE 11-5 238 Case-Control Studies
Page 256 and 257: TABLE 11-5 (continued) 240 Adjustme
Page 258 and 259: When the same women in NSABP were r
Page 260 and 261: REFERENCES 1 Pisani P, Parkin DM, B
Page 262 and 263: 47 Day NE. Epidemiology: the role o
Page 264 and 265: 93 Rodriguez C, Patel AV, Calle EE,
Page 266 and 267: 139 Parazzini F, La Vecchia C, Negr
Page 268 and 269: 1. INTRODUCTION Menopause is associ
Page 270 and 271: inverse relation with nonverbal mem
Page 272 and 273: ease decreased significantly with i
Page 274 and 275: of households selected to be repres
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standard antipsychotic drugs increa
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5. FUTURE NEEDS • Explore the pos
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19 Berman KF, Schmidt PJ, Rubinow D
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64 Lerner A, Koss E, Debanne S, Row
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114 Smith R, Studd JW. A pilot stud
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162 Klein BE. Lens opacities in wom
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patients with strong personal convi
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Therefore, convincing evidence of t
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3.1.1 Risk Factors Many factors are
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278 lower dosages of estrogen will
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• Diabetes: Women with diabetes b
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Lipids and lipoproteins • LDL cho
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284 persists but is less steep in w
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5.2.3 Pharmacotherapy Breast Cancer
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• There is no clinical trial evid
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Sirtori CR, Pazzucconi F, Colombo L
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Hansson L, Zanchetti A, Carruthers
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Dementia and Mental Health Forette
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CRP C-reactive protein CT computed
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PTCA percutaneous transluminal coro
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U.S. DEPARTMENT OF HEALTH AND HUMAN
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