HOMONEREPLACEMENTTHERAPY(HRT：激素替代疗法(HRT.ppt

MENOPAUSE第一页，共五十四页。WHAT?nMenopauseisadeviationoftheancientGreekwordsmenos(month)andpauses(ending).nThemenopauseissometimesknownasthechangeoflifeandismarkedbytheendingofmenstruation.第二页，共五十四页。WHAT?n nItbedefinedwithcertaintyaftertwelvemonthsspontaneousamenorrhoea.n nEndofreproductivelife.第三页，共五十四页。Age(years)Pre-menopausePost-menopauseMENOPAUSE1YEARPeri-menopause“Climacteric”RELATED TERMINOLOGY第四页，共五十四页。WHEN?n nMenopausalage:45-55years(mean:50.7years)n nIfthemenopauseoccursinawomanwhoisunder45yearsofage,itisknownasprematuremenopause.n nLatemenopause:55yearsold第五页，共五十四页。WHEN?n nOtherfactorsthatcanaffecttheageatwhichwomenhavetheirfinalperiodincludeageatmenarche,parity,previousoralcontraceptivehistoryethnicityandfamilyhistory.第六页，共五十四页。WHY?RELATIVEACTIVITYOFESTROGENRELATIVEACTIVITYOFESTROGEN第七页，共五十四页。WHY?n nThemenopauseistheendofeggproduction(ovulation).Thisoccursasaresultoffallinglevelsofthefemalesexhormoneoestrogen,whichregulatesawomansperiods.第八页，共五十四页。WHY?n nThemenopauseresultsfromafallinthelevelofthefemalehormoneoestrogenintheblood.第九页，共五十四页。WHY?n nAtahormonallevel-asovarianfollicularactivitybeginstofail,oestrogenandprogesteronelevelsfallandthereducednegativefeedbacktothepituitarycausesariseinluteinisinghormone(LH)andfolliclestimulatinghormone(FSH).第十页，共五十四页。HOW?n nOestrogenreductioneventuallyresultsinmenstrualcycledisruptionandothermenopausalsymptoms.第十一页，共五十四页。HOW?n nOestrogenreductioneventuallyresultsinmenstrualcycledisruptionandothermenopausalsymptoms.*FSHhigh(30170mU/ml)*LHhigh(2080mU/ml)*Estradiollow(110pmol/L)第十二页，共五十四页。Vasomotor SymptomsVasomotor SymptomsSleep DisordersSleep DisordersMenstrual DisordersMenstrual DisordersMood ChangesMood ChangesVaginal AtrophyVaginal AtrophyDyspareuniaDyspareuniaSkin AtrophySkin AtrophyOsteoporosisOsteoporosisAtherosclerosisAtherosclerosisCoronary Heart DiseaseCoronary Heart DiseaseCerebrovascular DiseaseCerebrovascular Disease40 yrs40 yrs50 yrs50 yrsMenopauseMenopause60 yrs60 yrsSYMPTOMS!ONSETOFSYMPTOMSINRELATIONTOAGEOFMENOPAUSE第十三页，共五十四页。SYMPTOMS!n nChangesinyourperiodtimebetweenperiodsorflowmayChangesinyourperiodtimebetweenperiodsorflowmaybedifferent.bedifferent.n nHotflashes(“hotflushes”)gettingwarmintheface,neckHotflashes(“hotflushes”)gettingwarmintheface,neckandchest.andchest.n nNightsweatsandsleepingproblemsthatmayleadtofeelingNightsweatsandsleepingproblemsthatmayleadtofeelingtired,stressedortense.tired,stressedortense.n nVaginalchangesthevaginamaybecomedryandthin,andsexVaginalchangesthevaginamaybecomedryandthin,andsexmaybepainful.maybepainful.n nThinningofyourbones,whichmayleadtolossofheightandThinningofyourbones,whichmayleadtolossofheightandbonebreaks(osteoporosis).bonebreaks(osteoporosis).第十四页，共五十四页。SYMPTOMS!n nItisestimatedthat8outof10womenintheUKexperiencesymptomsleadinguptothemenopause.n nOfthese,45%findtheirsymptomsdifficulttodealwith.第十五页，共五十四页。SYMPTOMS!n nWithouttreatment,mostmenopausalsymptomsgraduallystopnaturally.Thisusuallyhappenstwotofiveyearsafterthesymptomsstart.n nAlthoughsomewomenexperiencesymptomsformanymoreyears.第十六页，共五十四页。SYMPTOMS!第十七页，共五十四页。SYMPTOMS!NORMALTRABECULARBONEOSTEROPEROTICBONE第十八页，共五十四页。TREATMENTn nOnly1in10womenseekmedicaladvicewhentheygothroughthemenopauseandmanydonotneedanytreatment.n nIfmenopausalsymptomsaresevereenoughtointerferewithdailylife,therearetreatmentsthatcanhelp.第十九页，共五十四页。TREATMENTn nThekindoftreatmentyoucantakedependsontheseverityofthesymptoms,medicalhistoryandpatientsownpreferences.第二十页，共五十四页。TREATMENTn nHRTn nNON-HRT第二十一页，共五十四页。HOMONE REPLACEMENT THERAPY(HRT)n nAsthenamesuggests,HRTworksbyreplacingoestrogen.n nHormonereplacementtherapy(HRT)canbeaneffectivetreatmentforthetypicalmenopause-relatedsymptoms.第二十二页，共五十四页。HOMONE REPLACEMENT THERAPY(HRT)n nHRTmayalsohaveaninfluenceonthelongtermhealthproblems(osteoporosis,cardiovascular diseaseandstroke),thoughitshouldbenotedthatitdoesnotnecessarilyreducetheirriskforallwomen.第二十三页，共五十四页。HOMONE REPLACEMENT THERAPY(HRT)BENEFITSBENEFITSRISKSRISKS第二十四页，共五十四页。HOMONE REPLACEMENT THERAPY(HRT)n nForthetreatmentofmenopausalsymptomswheretherisk-benefitratio*isfavorable,infullyinformedwomen,inthelowestpossibledosetocontrolsymptomsandfortheshortestdurationpossible.第二十五页，共五十四页。HOMONE REPLACEMENT THERAPY(HRT)n nBENEFITSRelievemenopausalsymptomsMaintenanceofqualityoflifePreventionofosteoporosisNote:HRTshouldnotbeusedasafirst-linetreatmentinosteoparosisexceptinNote:HRTshouldnotbeusedasafirst-linetreatmentinosteoparosisexceptinwomenwhohavewomenwhohavepremature menopausepremature menopause 第二十六页，共五十四页。HOMONE REPLACEMENT THERAPY(HRT)n nRISKS OF VTEHRT(combinedoroestrogen-alone)increasestheriskofadeepveinHRT(combinedoroestrogen-alone)increasestheriskofadeepveinthrombosisorpulmonaryembolism,especiallyinthefirstyearofthrombosisorpulmonaryembolism,especiallyinthefirstyearoftreatment.Theriskismorepronouncedinwomenwithpre-existingtreatment.Theriskismorepronouncedinwomenwithpre-existingriskfactors.riskfactors.Arecentmeta-analysissuggeststhattransdermaloestrogensmayArecentmeta-analysissuggeststhattransdermaloestrogensmaybeasaferoptionthanoraloestrogensforHRTbeasaferoptionthanoraloestrogensforHRT.第二十七页，共五十四页。HOMONE REPLACEMENT THERAPY(HRT)n nRISKS OF BREAST CANCERn nTheThe increasedincreased breastbreast cancercancer riskrisk isis proportionalproportional toto thethedurationdurationofofHRT.HRT.HRTHRTincreasesincreasesthisthisriskriskbybyaboutabout1.6times1.6timesafterafter55yearsyearsofofuseuseandand2.3times2.3timesafterafter10years10yearsofofuse.use.RiskRiskdecreasesdecreaseswithinwithinafewyearsofstoppingHRT.afewyearsofstoppingHRT.nWomen considering HRT should be counselled that theabsolute risk for breast cancer for any individualremains relatively low*HeractualriskincreasesHeractualriskincreases0.08%0.08%(ACOG)(ACOG)第二十八页，共五十四页。HOMONE REPLACEMENT THERAPY(HRT)n nRISKS OF ENDOMETRIAL CANCEREndometrialcancer:increasedriskonlywithunopposedEndometrialcancer:increasedriskonlywithunopposedoestrogen.Thereisnoincreasedriskwithcombinedoestrogen.Thereisnoincreasedriskwithcombined(oestrogenandprogestogen)HRT.(oestrogenandprogestogen)HRT.RISKS OF OVARIAN CANCERlong-termuseofoestrogen-onlyHRTandcombinedHRTmaylong-termuseofoestrogen-onlyHRTandcombinedHRTmayslightlyincreasetherisk.RiskdecreasesafterstoppingHRT.slightlyincreasetherisk.RiskdecreasesafterstoppingHRT.第二十九页，共五十四页。HOMONE REPLACEMENT THERAPY(HRT)n nRISKS OF CARDIOVASCULAR DISEASEThereisnotthesameevidenceofcardioprotectionThereisnotthesameevidenceofcardioprotectionfromHRTaswasoriginallythought.fromHRTaswasoriginallythought.AssessallwomensriskofCHDpriortostartingAssessallwomensriskofCHDpriortostartingHRT.HRT.第三十页，共五十四页。HRTE+PEHOMONE REPLACEMENT THERAPY(HRT)第三十一页，共五十四页。E+PEForForhysterectomizedhysterectomizedptsptsHOMONE REPLACEMENT THERAPY(HRT)sSequentially Sequentially combined HRTcombined HRT E(continuouslyE(continuouslyD1-D21)D1-D21)P(sequentiallyP(sequentiallyD11-D21)D11-D21)Continuous Continuous combined HRTcombined HRT E&PE&P(continuous:D1-(continuous:D1-D28)D28)第三十二页，共五十四页。HOMONE REPLACEMENT THERAPY(HRT)n nWomen with an intact uterusWomen with an intact uterusVasomotorsymptomsVasomotorsymptomsn nPerimenopausal:systemiccyclicalcombinedHRT.Perimenopausal:systemiccyclicalcombinedHRT.n nPostmenopausal:systemiccontinuouscombinedHRTPostmenopausal:systemiccontinuouscombinedHRTortibolone.ortibolone.UrogenitalsymptomsUrogenitalsymptomsn nPerimenopausal:low-dosevaginaloestrogenorsystemicPerimenopausal:low-dosevaginaloestrogenorsystemiccyclicalcombinedHRT.cyclicalcombinedHRT.n nPostmenopausal:low-dosevaginaloestrogenorPostmenopausal:low-dosevaginaloestrogenorsystemiccontinuouscombinedHRT.systemiccontinuouscombinedHRT.第三十三页，共五十四页。HOMONE REPLACEMENT THERAPY(HRT)n nWomen who have had a hysterectomyWomen who have had a hysterectomyVasomotorsymptoms:systemicoestrogen-onlyHRT.Vasomotorsymptoms:systemicoestrogen-onlyHRT.Urogenitalsymptoms:low-dosevaginaloestrogenorUrogenitalsymptoms:low-dosevaginaloestrogenorsystemicoestrogen-onlyHRT.systemicoestrogen-onlyHRT.第三十四页，共五十四页。HOMONE REPLACEMENT THERAPY(HRT)第三十五页，共五十四页。HOMONE REPLACEMENT THERAPY(HRT)第三十六页，共五十四页。CONTRAINDICATIONS OF HRT!n nPregnancy and breast-feedingPregnancy and breast-feedingn nUndiagnosed abnormal vaginal bleedingUndiagnosed abnormal vaginal bleedingn nVenous thromboembolic diseaseVenous thromboembolic diseasen nActive or recent Active or recent anginaangina or or myocardial infarctionmyocardial infarctionn nSuspected,current or past breast cancerSuspected,current or past breast cancern nEndometrial cancer or other oestrogen-dependent cancerEndometrial cancer or other oestrogen-dependent cancern nActive liver disease with abnormal Active liver disease with abnormal liver function testsliver function tests第三十七页，共五十四页。START-UP SYMPTOMS OF HRT!n nBreast tendernessBreast tendernessn nNipple sensitivityNipple sensitivityn nBloatingBloatingn nNausea,headachesNausea,headachesn nAppetite Appetite n nWeight gainWeight gainn nLeg crampsLeg cramps第三十八页，共五十四页。INVESTIGATIONS BEFORE HRT!Investigations are not usually necessary before starting HRT Investigations are not usually necessary before starting HRT unless there is:unless there is:n nsudden change in menstrual pattern(IMB/PCB)sudden change in menstrual pattern(IMB/PCB)n nHigh risk of breast cancerHigh risk of breast cancern nPersonal/family history of VTEPersonal/family history of VTEn nWoman has arterial risk factorsWoman has arterial risk factors第三十九页，共五十四页。ALTERNATIVE TO HRT!“Tibolone”is a synthetic hormone that acts in the same way Tibolone”is a synthetic hormone that acts in the same way as HRT as HRT(SERM)(SERM)n nUsefulforpost-menopausalwomenwhowanttoendtheirUsefulforpost-menopausalwomenwhowanttoendtheirperiods.periods.n nWhichhasoestrogenic,progestogenicandandrogenicpropertiesWhichhasoestrogenic,progestogenicandandrogenicproperties.(estrogenicactivityinestrogenicactivityinbonebone,CNSvasomotorsuppressionof,CNSvasomotorsuppressionofhotflusheshotflushesandandhelpfulinimprovingsexualfunction.helpfulinimprovingsexualfunction.第四十页，共五十四页。STARTING HRT!“A full physical examination is mandatory”A full physical examination is mandatory”n nFull blood countFull blood countn nRenal ProfileRenal Profile-Baseline-Baselinen nLiver Function TestLiver Function Testn nLipid profileLipid profile第四十一页，共五十四页。FOLLOW UP OF TAKING HRT!n nReviewthewoman3monthsafterstartingHRTandonceReviewthewoman3monthsafterstartingHRTandonceeachyearthereafter.eachyearthereafter.n nAt3-months:At3-months:Enquireaboutbleedingpatterns,checkbloodEnquireaboutbleedingpatterns,checkbloodpressure,andbodyweight.pressure,andbodyweight.AssesstheeffectivenessoftreatmentandadjustAssesstheeffectivenessoftreatmentandadjusttoachievesymptomcontrol.toachievesymptomcontrol.EnquireaboutadverseeffectsandmanageEnquireaboutadverseeffectsandmanageappropriately.appropriately.第四十二页，共五十四页。FOLLOW UP OF TAKING HRT!n nOnceeachyear:Onceeachyear:Checkbloodpressure,effectivenessoftreatmentandCheckbloodpressure,effectivenessoftreatmentandadjusttoachievesymptomcontrol.adjusttoachievesymptomcontrol.Enquireaboutadverseeffectsandmanageappropriately.Enquireaboutadverseeffectsandmanageappropriately.ConsiderswitchingfromcyclicalHRTtoConsiderswitchingfromcyclicalHRTtocontinuouscombinedHRT,ifappropriate.continuouscombinedHRT,ifappropriate.第四十三页，共五十四页。FOLLOW UP OF TAKING HRT!DiscusstherisksandbenefitsofHRT.DiscusstherisksandbenefitsofHRT.PerformabreastexaminationifindicatedbypersonalorPerformabreastexaminationifindicatedbypersonalorfamilyhistory.familyhistory.EncouragebreastawarenessandparticipationinthenationalEncouragebreastawarenessandparticipationinthenationalbreastscreeningprogrammeasappropriatefortheirage.breastscreeningprogrammeasappropriatefortheirage.PelvicexaminationisrequiredonlyifclinicallyindicatedPelvicexaminationisrequiredonlyifclinicallyindicated第四十四页，共五十四页。NON-HRTLifestyle modificationStop smokingHealthy dietWeight controlRegular moderate-intensity exerciseControl blood pressure and cholesterol第四十五页，共五十四页。NON-HRTn nFor vasomotor symptoms For vasomotor symptoms Atrial(2weeks)ofparoxetine,fluoxetineAtrial(2weeks)ofparoxetine,fluoxetinecitalopramorvenlafaxine(SSRI)citalopramorvenlafaxine(SSRI)Atrial(24weeks)ofclonidineAtrial(24weeks)ofclonidine AprogestogensuchasnorethisteroneorAprogestogensuchasnorethisteroneormegestrolmegestrol第四十六页，共五十四页。NON-HRTn nFor vaginal drynessFor vaginal drynessVaginallubricantormoisturizer,suchasReplensVaginallubricantormoisturizer,suchasReplens.第四十七页，共五十四页。NON-HRTn nFor osteoporosis Alendronate(Alendronate(FosamaxFosamax)RocaltriolRocaltriolAlpha-calcidolAlpha-calcidolRaloxifene(Raloxifene(EvistaEvista)第四十八页，共五十四页。NON-HRTn nFor psychological symptoms-Self-helpgroupsSelf-helpgroups-Psychotherapy-Psychotherapy-Otherformsofcounselling-Otherformsofcounselling-Antidepressants.-Antidepressants.第四十九页，共五十四页。NON-HRTComplementary therapiesn nRemifemin(Cimicifugarhizomeextract)Remifemin(Cimicifugarhizomeextract)n nRedcloverplantRedcloverplant n nSoyproductsSoyproductsn nEveningprimroseEveningprimrosen nBlackcohoshBlackcohoshn nPhytoestrogensPhytoestrogensn nGinsengGinseng第五十页，共五十四页。NON-HRTComplementary interventionsComplementary interventionsn nAcupunctureAcupuncturen nReflexologyReflexologyDiet and supplementsDiet and supplementsn nVitamins and mineralsVitamins and mineralsn nVitamin EVitamin EHomeopathyHomeopathy第五十一页，共五十四页。Premature menopause?n nMenopausalsymptomsinwomenwhoareyoungerthan40Menopausalsymptomsinwomenwhoareyoungerthan40years(1%)years(1%)n nOfferlifestyleadvice.Offerlifestyleadvice.n nOffersystemichormonereplacementtherapy(HRT)ortheOffersystemichormonereplacementtherapy(HRT)orthecombinedoralcontraceptivepill(COC)combinedoralcontraceptivepill(COC)n nDecreasedlibido:testosteroneimplantsandpatchesmaybeDecreasedlibido:testosteroneimplantsandpatchesmaybeconsideredconsidered第五十二页，共五十四页。THANK YOU第五十三页，共五十四页。内容(nirng)总结MENOPAUSE。Peri-menopause“Climacteric”。Pregnancy and breast-feeding。Renal Profile-Baseline。THANK YOU第五十四页，共五十四页。