齊魯醫(yī)學(xué)HOMONEREPLACEMENTTHERAPY(HRT)：激素替代療法(HRT)

1、 MENOPAUSE12021/10/23 星期六WHAT ?Menopause is a deviation of the ancient Greek words menos ( month) and pauses (ending).The menopause is sometimes known as the change of life and is marked by the ending of menstruation. 22021/10/23 星期六WHAT?It be defined with certainty after twelve months spontaneous a

2、menorrhoea. End of reproductive life.32021/10/23 星期六Age (years)Pre-menopausePost-menopauseMENOPAUSE1 YEARPeri-menopause “ Climacteric”RELATED TERMINOLOGY42021/10/23 星期六WHEN?Menopausal age: 45-55 years (mean : 50.7 years)If the menopause occurs in a woman who is under 45 years of age, it is known as

3、premature menopause. Late menopause: 55 years old52021/10/23 星期六WHEN?Other factors that can affect the age at which women have their final period include age at menarche, parity, previous oral contraceptive history ethnicity and family history.62021/10/23 星期六WHY?RELATIVE ACTIVITY OF ESTROGEN72021/10

4、/23 星期六WHY?The menopause is the end of egg production (ovulation). This occurs as a result of falling levels of the female sex hormone oestrogen, which regulates a womans periods.82021/10/23 星期六WHY?The menopause results from a fall in the level of the female hormone oestrogen in the blood. 92021/10/

5、23 星期六WHY?At a hormonal level - as ovarian follicular activity begins to fail, oestrogen and progesterone levels fall and the reduced negative feedback to the pituitary causes a rise in luteinising hormone (LH) and follicle stimulating hormone (FSH). 102021/10/23 星期六HOW?Oestrogen reduction eventuall

6、y results in menstrual cycle disruption and other menopausal symptoms.112021/10/23 星期六HOW?Oestrogen reduction eventually results in menstrual cycle disruption and other menopausal symptoms. * FSHhigh (30 170 mU/ml) * LHhigh (20 80 mU/ml) * Estradiollow ( 110 pmol/L)122021/10/23 星期六Vasomotor Symptoms

7、Sleep DisordersMenstrual DisordersMood ChangesVaginal AtrophyDyspareuniaSkin AtrophyOsteoporosisAtherosclerosisCoronary Heart DiseaseCerebrovascular Disease40 yrs50 yrsMenopause60 yrsSYMPTOMS!ONSET OF SYMPTOMS IN RELATION TO AGE OF MENOPAUSE132021/10/23 星期六SYMPTOMS!Changes in your periodtime between

8、 periods or flow may be different.Hot flashes (“hot flushes”)getting warm in the face, neck and chest.Night sweats and sleeping problems that may lead to feeling tired, stressed or tense.Vaginal changesthe vagina may become dry and thin, and sex may be painful.Thinning of your bones, which may lead

9、to loss of height and bone breaks (osteoporosis).142021/10/23 星期六SYMPTOMS!It is estimated that 8 out of 10 women in the UK experience symptoms leading up to the menopause. Of these, 45% find their symptoms difficult to deal with.152021/10/23 星期六SYMPTOMS!Without treatment, most menopausal symptoms gr

10、adually stop naturally. This usually happens two to five years after the symptoms start.Although some women experience symptoms for many more years.162021/10/23 星期六SYMPTOMS!172021/10/23 星期六SYMPTOMS!NORMAL TRABECULAR BONEOSTEROPEROTIC BONE 182021/10/23 星期六TREATMENTOnly 1 in 10 women seek medical advi

11、ce when they go through the menopause and many do not need any treatment. If menopausal symptoms are severe enough to interfere with daily life, there are treatments that can help.192021/10/23 星期六TREATMENTThe kind of treatment you can take depends on the severity of the symptoms, medical history and

12、 patients own preferences.202021/10/23 星期六TREATMENTHRTNON- HRT212021/10/23 星期六HOMONE REPLACEMENT THERAPY (HRT)As the name suggests, HRT works by replacing oestrogen.Hormone replacement therapy (HRT) can be an effective treatment for the typical menopause-related symptoms.222021/10/23 星期六HOMONE REPLA

13、CEMENT THERAPY (HRT)HRT may also have an influence on the long term health problems(osteoporosis, cardiovascular disease and stroke) , though it should be noted that it does not necessarily reduce their risk for all women.232021/10/23 星期六HOMONE REPLACEMENT THERAPY (HRT)BENEFITSRISKS242021/10/23 星期六H

14、OMONE REPLACEMENT THERAPY (HRT)For the treatment of menopausal symptoms where the risk-benefit ratio* is favorable, in fully informed women, in the lowest possible dose to control symptoms and for the shortest duration possible.252021/10/23 星期六HOMONE REPLACEMENT THERAPY (HRT)BENEFITSRelieve menopaus

15、al symptomsMaintenance of quality of lifePrevention of osteoporosis Note: HRT should not be used as a first-line treatment in osteoparosis except in women who have premature menopause 262021/10/23 星期六HOMONE REPLACEMENT THERAPY (HRT)RISKS OF VTEHRT (combined or oestrogen-alone) increases the risk of

16、a deep vein thrombosis or pulmonary embolism, especially in the first year of treatment. The risk is more pronounced in women with pre-existing risk factors.A recent meta-analysis suggests that transdermal oestrogens may be a safer option than oral oestrogens for HRT.272021/10/23 星期六HOMONE REPLACEME

17、NT THERAPY (HRT)RISKS OF BREAST CANCERThe increased breast cancer risk is proportional to the duration of HRT. HRT increases this risk by about 1.6times after 5 years of use and 2.3times after 10years of use. Risk decreases within a few years of stopping HRT.Women considering HRT should be counselle

18、d that the absolute risk for breast cancer for any individual remains relatively low* Her actual risk increases 0.08% (ACOG)282021/10/23 星期六HOMONE REPLACEMENT THERAPY (HRT)RISKS OF ENDOMETRIAL CANCEREndometrial cancer: increased risk only with unopposed oestrogen. There is no increased risk with com

19、bined (oestrogen and progestogen) HRT.RISKS OF OVARIAN CANCERlong-term use of oestrogen-only HRT and combined HRT may slightly increase the risk. Risk decreases after stopping HRT. 292021/10/23 星期六HOMONE REPLACEMENT THERAPY (HRT)RISKS OF CARDIOVASCULAR DISEASE There is not the same evidence of cardi

20、oprotection from HRT as was originally thought. Assess all womens risk of CHD prior to starting HRT.302021/10/23 星期六HRTE+PEHOMONE REPLACEMENT THERAPY (HRT)312021/10/23 星期六E+PEFor hysterectomized ptsHOMONE REPLACEMENT THERAPY (HRT)sSequentially combined HRT E(continuously D1-D21) P(sequentially D11-D

21、21)Continuous combined HRT E &P(continuous: D1-D28)322021/10/23 星期六HOMONE REPLACEMENT THERAPY (HRT)Women with an intact uterusVasomotor symptomsPerimenopausal: systemic cyclical combined HRT .Postmenopausal: systemic continuous combined HRT or tibolone.Urogenital symptomsPerimenopausal: low-dose vag

22、inal oestrogen or systemic cyclical combined HRT.Postmenopausal: low-dose vaginal oestrogen or systemic continuous combined HRT.332021/10/23 星期六HOMONE REPLACEMENT THERAPY (HRT)Women who have had a hysterectomyVasomotor symptoms: systemic oestrogen-only HRT.Urogenital symptoms: low-dose vaginal oestr

23、ogen or systemic oestrogen-only HRT.342021/10/23 星期六HOMONE REPLACEMENT THERAPY (HRT)352021/10/23 星期六HOMONE REPLACEMENT THERAPY (HRT)362021/10/23 星期六CONTRAINDICATIONS OF HRT!Pregnancy and breast-feedingUndiagnosed abnormal vaginal bleedingVenous thromboembolic diseaseActive or recent angina or myocar

24、dial infarctionSuspected, current or past breast cancerEndometrial cancer or other oestrogen-dependent cancerActive liver disease with abnormal liver function tests372021/10/23 星期六START-UP SYMPTOMS OF HRT!Breast tendernessNipple sensitivityBloatingNausea, headachesAppetite Weight gainLeg cramps38202

25、1/10/23 星期六INVESTIGATIONS BEFORE HRT! Investigations are not usually necessary before starting HRT unless there is :sudden change in menstrual pattern (IMB/PCB) High risk of breast cancerPersonal /family history of VTEWoman has arterial risk factors392021/10/23 星期六ALTERNATIVE TO HRT! “ Tibolone” is

26、a synthetic hormone that acts in the same way as HRT (SERM)Useful for post-menopausal women who want to end their periods.Which has oestrogenic, progestogenic and androgenic properties. (estrogenic activity in bone, CNS vasomotor suppression of hot flushes and helpful in improving sexual function .4

27、02021/10/23 星期六STARTING HRT! “A full physical examination is mandatory”Full blood countRenal Profile- BaselineLiver Function TestLipid profile412021/10/23 星期六FOLLOW UP OF TAKING HRT!Review the woman 3 months after starting HRT and once each year thereafter.At 3-months:Enquire about bleeding patterns

28、, check blood pressure, and body weight.Assess the effectiveness of treatment and adjust to achieve symptom control.Enquire about adverse effects and manage appropriately.422021/10/23 星期六FOLLOW UP OF TAKING HRT!Once each year:Check blood pressure, effectiveness of treatment and adjust to achieve sym

29、ptom control.Enquire about adverse effects and manage appropriately.Consider switching from cyclical HRT to continuous combined HRT, if appropriate.432021/10/23 星期六FOLLOW UP OF TAKING HRT!Discuss the risks and benefits of HRT. Perform a breast examination if indicated by personal or family history.E

30、ncourage breast awareness and participation in the national breast screening programme as appropriate for their age.Pelvic examination is required only if clinically indicated442021/10/23 星期六NON- HRTLifestyle modificationStop smokingHealthy dietWeight controlRegular moderate-intensity exerciseControl blood pressure and cholesterol452021/10/23 星期六NON- HRTFor vasomotor symptoms A trial (2 weeks) of paroxetine,fluoxetine citalopram or venlafaxine (SSRI)A trial (24 w