During my clinical experience the majority of the patients I saw for well women exams were post menopausal women. There seemed to be four reoccurring themes I would encounter when seeing these patients.
1.) Stenotic Os. The first issue was the stenotic os, particularly in nulliparous women. When obtaining a pap specimen from the stenotic os, it can be difficult to insert the brush or spatula into the os and lead to inadequate collection of endocervical cells from the SCJ or transformation zone. It is important to note on the report if the os was stenotic or not.
2.) Atrophic Vagina. The second issue was the atrophic vagina. The physical findings were similar from patient to patient. Friable tissue, scant and thin vaginal fluid, lack of rugae on the vaginal mucosa, and collapsing of the vaginal walls. Patients may or may not be symptomatic. It is important to be gentle with the pelvic exam and a smaller speculum may be needed as the tissue bleeds easily and is not as pliable.
3.) Small Uterus and Ovaries. The third issue was difficulty with palpating the uterus and ovaries. This is an expected finding because after menopause and as women age, these organs atrophies. You may need to palpate deeper when doing the bimanual which could be uncomfortable for some women. The point to remember is that an easily palpable uterus or ovary in a postmenopausal woman should raise your index of suspicion that something may not be right.
4.) Menopausal symptoms. The 4th and most complex issue was the vasomotor symptoms associated with menopause. The common complaints were insomnia, hot flashes, night sweats, irritability, and vaginal dryness. Some women were perimenopausal and some had 10 years + since menopause. What was common among most of these women, was that these symptoms were really affecting their quality of life. They also expressed feelings of isolation, because family, friends, coworkers did not understand how uncomfortable this time could be. It is important for FNPs to be understanding, reassuring, and knowledgeable about current therapies for menopausal vasomotor symptoms. Treatment can be complex and the options are numerous. These patients have usually been doing their own research about the options available and will ask questions that you cannot imagine. Having a good up to date resource about current therapies, myths, and facts regarding menopause is a must have in the family practice setting.
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Excellent summary of these important issues! As I was reading it I immediately thought that these would be good things to include in an article on peri/postmenopause or on cervical evaluation. Great job.
ReplyDeleteThe stenosic os is something that never occurred to me until recently. In one case I observed that the stenosis had prevented to a patient from receiving an IUD, in another the patient’s stenotic os presented a barrier to endometrial biopsy. It may be however that it is simply difficult to pass materials/instruments through the os as a result of the angle of approach (e.g. antiversion, reteroversion.) Per the Merck manual the most common causes of stenosis are as follows: menopause, cervical surgery (eg, conization, cautery,endometrial ablation procedures to treat uterine abnormalities that cause menorrhagia, cervical or uterine cancer and radiation therapy.
ReplyDeleteI too saw many peri and post-menopausal women in clinical this summer. The interesting thing for me though, was that most of my patients simply shrugged off their menopause symptoms like they were no big deal. Many of them stated that their mother also had these symptoms and they were content to handle them without any treatment. I think many of these women grew up in the age where you don't really talk about these issues and you don't complain about them or seek treatment. As providers, I think that it is important for us to continue to educate our patients on the therapies that are out there and things we can do to make their quality of life better. Although some women may indeed be "content" to deal with their menopause symptoms, I believe that most of them don't know what treatments are available or they are frightened of HRT because of the things they have heard.
ReplyDeletehttp://pause.acog.org/
ReplyDeleteTry this web link-it's the ACOG (American College of Obstetricians and Gynecologists) one-stop guide to the menopausal years. It addresses most concerns you can think of related to the transition through menopause/perimenopause. There is great helpful advice for patients AND Primary Care Providers from leading experts in Women's Health.
Look up the latest on-line issues, pass this information on to any of your patients/family members/friends going through "the Pause". Subscriptions are FREE-email pause@acog.org
Current Spring/Summer issue covers the following: Belly Fat; Vitamins and Minerals; Fibromyalgia; Hysterectomy; Bladder Matters; Healthy Living; Taming Hot Flashes; Vericose Veins; Yoga; Osteoarthritis...
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