The speakers have no conflicts of interest or financial relationships to disclose.

Transcription

1 Battling the Menopause Bully Together: The APRN and the Pelvic Floor Physical Therapist 28 th Annual Conference Excellence in Healthcare Delivery in Texas Texas Nurse Practitioners * Joyce Miller, DNP, WHNP-BC, FNP-BC * Kathryn Curry, PT, DPT * LaMicha Hogan, MSN, RN, FNP-BC The speakers have no conflicts of interest or financial relationships to disclose. September 9, 2016 Objectives What is GSM? Discuss background and clinical presentation of Genitourinary Syndrome of Menopause (GSM) in post-menopausal women Provide an overview of NAMS clinical care recommendations for GSM Review current American College of Obstetrician/Gynecologist (ACOG) guidelines for hormone replacement therapy (HRT) during menopause Explore pelvic floor physical therapy (PFPT) during menopause Utilize case study discussion of GSM scenario(s) with APRNs and PFPT in clinical practice Constellation of vulvovaginal and genitourinary symptoms caused by decreased estrogen levels in menopause Excluding other causes such as: infection, allergy, skin conditions, pelvic floor muscle dysfunction, cystitis, or pudendal neuralgia *Affects about half of all postmenopausal women Women hesitate to discuss with providers Providers hesitate to discuss with women The new term GSM (formerly VVA) is to be used to help standardize physical exams to facilitate treatment such as vaginal moisturizers, vaginal estrogen, and estrogen mimics. (Menopause - http: Menopause.northwestern.edu) Calling the Bully Out Conversation Continues. -Only 56% of women discussed VVA symptoms with HCP (REVIVE Study) (Kingsberg, Wysocki, Magnus et al., 2013) -Women reported only 19% of HCP addressed sexual lives, with only 13% addressing GU symptoms (REVIVE) -80% reported vaginal discomfort adverse impacts (VIVA Study) (Simon, Kokot-Kierpa, Goldstein, & Nappi, 2013) -75% reported impacted intimacy/sex lives negatively (VIVA Study) (Simon, Kokot-Kierpa, Goldstein, & Nappi, 2013) 68% reported feeling less sexual (VIVA) 33% reported negative impacts in intimate relationships (VIVA) 26% reported lowered self-esteem (VIVA) -77% believed women are uncomfortable discussing atrophy -Women reported mod/severe symptoms (66% in U.S. vs <50% in Sweden/Finland) (Nappa & Kokot-Kierpa, 2010) -<50% of US respondents in the CLOSER study aware of available treatments (non hormonal and hormonal) (Simon et al., 2014) By Billion women worldwide over age of 50 with GSM-related needs (Nappi & Palacios, 2014) 1

2 Barriers to Identification/Treatment Vaginal Symptoms Patients Lack of awareness of treatment options to improve QoL Embarrassing, underreporting s/s Expensive medication regimens Assumption of normal part of aging Vasomotor symptoms decrease, but GSM does not resolve spontaneously HCPs Time constraints during visits Age/Gender of the HCP may limit discussion Unaware of recent clinical guidelines Difficulty in finding specialists for referrals if indicated (urology, sexual dysfunction, pelvic floor, etc) Sexual health not always priority in healthcare curricula (Dahir, 2011; Gott & Hinchliff 2003) Lindau et al., 2007) Epithelial cells become more fragile and may bleed leading to tears or fissures. Loss of fat and subcutaneous fat. Narrowing, fusion of labia, and shrinking of clitoral prepuce and urethra. Increase in vaginal ph and colonization by lactobacilli decreases. Vaginal secretions, largely transudate from vaginal vasculature, may decrease leading to dyspareunia (Barker, 2015) Vulva & Lower Urinary Tract Vulva & Lower Tract - (Barker, 2015) Estrogen and lower urinary tract Urogenital changes Hormones: Important role in function of lower urinary tract Receptors for estrogen/progesterone found in vagina, urethra, bladder and pelvic floor Estrogens may increase urethral resistance, raise the sensory threshold of the bladder, or increase alphaadrenoreceptor sensitivity in the urethral smooth muscle Postmenopausal deficiency = atrophic changes, associated with lower urinary tract such as frequency, urgency, nocturia, urge incontinence, and recurrent infection. Also genital and sexual symptoms such as prolapse and sexual dysfunction Common embryonic origin for genitourinary structures and density of estrogen receptors make them vulnerable to change once hormone levels drop. decrease in collagen and elastin thinning epithelium altered function of smooth muscle loss of elasticity and flexibility diminished blood supply (Lewis, 2014) 2

3 GSM Symptoms & Signs North American Menopause Society Recommendations for GSM (2014) Symptoms Genital dryness Decreased lubrication / sex Discomfort or pain with sex Post-coital bleeding Decreased arousal, orgasm, desire Irritation/burning/itching of vulva/vagina Dysuria Urinary frequency/urgency Signs Decreased moisture Decreased elasticity Labia minora resorption Pallor/erythema Loss of vaginal rugae Tissue fragility/fissures/petechiae Urethral eversion or prolapse Prominence of urethral meatus Introital retraction Recurrent UTIs (Portman & Gass, 2014) Consensus that the term genitourinary syndrome of menopause is medically more accurate, all-encompassing, publicly acceptable term than vulvovaginal atrophy S/S associated with decreased estrogen and other sex steroids involving changes to the labia majora/minora, clitoris, vestibule/introitus, vagina, urethra and bladder Raising patients awareness of vaginal estrogen treatment for symptoms of GSM has the potential to reduce discomfort and pain as well as maintain vitality and quality of life for postmenopausal women.. (Portman & Gass, 2014) Management of GSM Non-Hormonal Therapies (1 st line) Growing number of aging women with GSM BUT Decline in use of systemic HRT for s/s! Women s Health Initiative 2 arm study = one arm estrogen only therapy, with second arm estrogen and progesterone. Changed the world of hormone therapy Breast cancer, Thromboembolic disease 1 st line therapy-non-hormonal lubricants with intercourse, longacting vaginal moisturizers 2 nd line therapy-if NO response + with moderate to severe genitourinary symptoms localized vaginal estrogen therapy (low dose) or systemic (low dose) is the therapeutic standard (Kim, H.K. et al., 2015; NAMS, 2014) Moisturizers (2-3X week) Replens Fresh Start KY Liquibeads Luvena Vagisil Lubricants (Prn/before sex Silicone-based ID Millenium, KY Intrigue Water-based Astroglide, Femglide, Just Like Me, etc Oil-based Elegance, Mineral Oil Vaginal Estrogen-2 nd Line Therapy NAMS recommendations: Lowest effective dose for the shortest duration to relieve vasomotor symptoms and genitourinary symptoms If only genitourinary symptoms = lowest dose vaginal estrogen Vaginal estrogen: Vaginal dryness & burning Dyspareunia Urinary frequency and urgency, poss. Incontinence Painful / difficult urination Recurrent UTI s.did I mention recurrent UTI s!!!!!! Early detection and treatment critical to avoid irreversible changes Treatment - Vaginal Estrogen Preparations (Zagaria, 2014) Dosage Dosage/Administration Vaginal Cream Intra-vaginally via measured-dose applicator then gradually reduce over 1-2 weeks to maintenance of 1 to 3 Estrace (estradiol) 0.01% cream times/week (0.1 mg/g) g once daily for 21 days, then off 7 days cyclically Premarin Vaginal (estrogens, 0.5 g once daily for 21 days, then off 7 days cyclically, or conjugated) mg/g cream 0.5 g 2 x week Vaginal Tablet Vagfem (estradiol hemihydrate 10 mcg. Tab) Vaginal ring Estring (estradiol) 2 mg 90-day ring (7.5 mg/day) Femring (estradiol acetate) Intravaginally (deep via prepackaged disposable applicator, tables dissolve into a gel gradually releasing estriadiol Initially, 10 mcg daily for 2 weeks then 10 mcg 2 x weekly Inserted manually into upper 1/3 of vagina, worn continuously and replaced every 90 days 2-mg 90-day ring every 90 days Initially 0.05-mg/day ring every 90 days, may be increased to 0.1 mg if needed. Not preferred if local symptoms only 3

4 Treatment Testosterone???? Specialty Referrals Local estrogen delivered vaginally is successful in relieving urogenital atrophy and perhaps sexual function Consider using estrogen-androgen therapy if not relieved with estrogen only for women with decreased sexual drive and satisfaction S/S testosterone therapy: Hirsutism, acne, weight gain, voice changes and clitoromegaly (irreversible) Contraindicated with breast ca, uterine ca, cardiovascular or liver disease (Raghunandan, Agrawal, Dubey, Choudhury, & Jain, 2010) Women s Health/Menopause-Certified Practitioner/Gynecology Urology Endocrinology Psychosocial support BUT APRNs Guess what!.there s another important partner against the Menopause Bully and GSM. Pelvic Floor Physical Therapy (to the rescue!) Preparing for the PFPT Visit Locate a PFPT online: APTA: Find a PT ( -choose zip code/city -scroll through and note Practice of Focus (pelvic pain, incontinence) Women s Health Section: PT Locator ( -click on pelvic pain or urinary incontinence -choose zip code/state Herman and Wallace ( -click on Resources -choose Practitioner Directory (map of USA with pins) Pelvic Floor Physical Therapy Pelvic Floor Physical Therapy Herman and Wallace: Practitioner Directory 4

5 Pelvic Floor Physical Therapy Treatment: Manual assessment and education of PFM contraction and relaxation Biofeedback: up-train and down-train PFMs Electrical muscle stimulation Bladder re-training/scheduled voiding Manual techniques(mtrp release with ischemic compression and dry needling, MFR, positional inhibition) Vaginal dilators Yoga poses Progressive relaxation exercises UI and PFPT Urinary Incontinence (UI) 50-60% of post menopausal women have UI (may or may not be related to their onset of GSM) PFPT: 1 st line treatment recommended by American College of Physicians Clinical Guidelines (Quaseem et al., 2014) Cochrane Systematic Review of 21 trials: PFPT associated with UI cure (dry with 100% less leakage) or improvement (75% less leakage) PFPT as beneficial for postmenopausal women as as for premenopausal women (Nygaard, 2013) PFPT treatment: - pelvic floor muscle training - bladder retraining Sexual Dysfunction and PFPT Dyspareunia 50-60% of postmenopausal women have sexual dysfunction (Raghunandan et al., 2010) 50% of postmenopausal women have urogenital atrophy-related symptoms (Palacios & Neyro, 2015) 44% of postmenopausal women have dyspareunia (Kingsberg et al., 2013) Dyspareunia decreased with PFM treatment for UI (Beji et al 2003) PFPT treatment: - MTrP release - Biofeedback/EMG down-train and up-train - Dilators - Yoga (NAM Society recommendation) - Progressive relaxation exercises POP and PFPT Pelvic organ prolapse (POP) 50% of parous women have POP PFPT is 1 st line of treatment for mild-moderate POP (Hagen & Thakur 2012) PFPT is effective in decreasing bothersome symptoms of POP (Braekken et al 2010) PFPT treatment: -strengthening PFMs and transverse abdominals (TA) -teaching KNACK -practicing exertional ADL and transitional movements with EMG/Biofeedback on PFMs and TA Questions. References Beji, N.K., Onay, Y., Erkan, H.A. (2003). The effect of pelvic floor training on sexual function of treated patients. Int Urogynecol J, 14: DOI /s Braekken, I.H., Majida, M., Ellstrom Engh, M., & Bo, K. (2010). Can pelvic floor muscle training reverse pelvic organ prolapse and reduce prolapse symptoms? An assessor blinded, randomized, controlled trial. Am J Obstet Gynecol, 203:170.e1-7 Dahir, M. (2011). A sexual medicine health care model and nurse practitioner role. Urologic Nursing, 31(6): Dumoulin, C., Hay Smith, J., Habée Séguin, G.M., & Mercier, J. (2015). Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women: A short version Cochrane systematic review with meta analysis. Neurourology and Urodynamics, 34(4): Hagen, S., Thakur, R. (2012). Conservative management of pelvic organ prolapse. Obstet Gynaecol & Reprod Med, 22(5): Kingsberg, S.A., Wysocki, S., Magnus, L., & Krychman, M.L. (2013). Vulvar and vaginal atrophy in postmenopausal women: findings from the REVIVE (REal Women s Views of Treatment Options for Menopausal Vaginal ChangEs) Survey. Journal of Sexual Medicine, 10(7):

6 References References Moldwin, R.M., Fariello, J.Y. (2013). Myofascial trigger points of the pelvic floor: Associations with urological pain syndromes and treatment strategies including injection therapy. Curr Urol Rep, 14: doi: /s Nappi, R.E., Kokot-Kierpa, M. (2010) Women s voices in the menopause: Results from an international survey on vaginal atrophy. Maturitas, 67(3): Nygaard, C.C., Betschart, C., Hafez, A.A., Lewis, E., Chasiotis, I., & Doumouchtsis, S.K. (2013, December). Impact of menopausal status on the outcome of pelvic floor physiotherapy in women with urinary incontinence. Int Urogynecol J, 24(12): doi: / s Palacios, S., Mejia, A., & Neyro, J.L. (2015). Treatment of the genitourinary syndrome of menopause, Climacteric, 18:sup1, 23-29, D / Portman, D.J., Gass, L.S. (2014). Genitourinary syndrome of menopause: New terminology for vulvovaginal atrophy from the International Society for the Study of Women s Sexual Health and The North American Menopause Society, Climacteric, (17)5. Quaseem, A., Dallas, P., Forciea, M.A., Starkey, M., Denberg, T.D., & Shekelle, P. (2014, September). Non-surgical management of urinary incontinence in women: A clinical practice guideline from the American College of Physicians. Ann Int Med, 161(6): doi: /m Raghunandan, C., Agrawal, S., Dubey, P., Choudhury, M., & Jain, A. (2010). A comparative study of the effects of local estrogen with or without local testosterone on vulvovaginal and sexual dysfunction in postmenopausal women. J Sexual Med, 7(3): , Simon, J.A., Kokot-Kierpa, M. Goldstein, J., & Nappi, R.E. (2013). Vaginal health in the United States: Results from the Vaginal Health: Insights, Views & Attitudes survey. Menopause, 20(10):