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

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,MENOPAUSE,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.,WHAT?,It be defined with certainty after twelve months spontaneous amenorrhoea.,End of reproductive life.,Age(years),Pre-menopause,Post-menopause,MENOPAUSE,1 YEAR,Peri-menopause“Climacteric”,RELATED TERMINOLOGY,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 premature menopause.,Late menopause:55 years old,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.,WHY?,RELATIVE ACTIVITY OF ESTROGEN,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.,WHY?,The menopause results from a fall in the level of the female hormone oestrogen in the blood.,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).,HOW?,Oestrogen reduction eventually results in menstrual cycle disruption and other menopausal symptoms.,HOW?,Oestrogen reduction eventually results in menstrual cycle disruption and other menopausal symptoms.,*,FSH,high,(30 170 mU/ml),*LH,high,(20 80 mU/ml),*Estradiol,low,(110 pmol/L),Vasomotor Symptoms,Sleep Disorders,Menstrual Disorders,Mood Changes,Vaginal Atrophy,Dyspareunia,Skin Atrophy,Osteoporosis,Atherosclerosis,Coronary Heart Disease,Cerebrovascular Disease,40 yrs,50 yrs,Menopause,60 yrs,SYMPTOMS!,ONSET OF SYMPTOMS IN RELATION TO AGE OF MENOPAUSE,SYMPTOMS!,Changes in your periodtime between 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 to loss of height and bone breaks(osteoporosis).,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.,SYMPTOMS!,Without treatment,most menopausal symptoms gradually stop naturally.This usually happens two to five years after the symptoms start.,Although some women experience symptoms for many more years.,SYMPTOMS!,SYMPTOMS!,NORMAL TRABECULAR BONE,OSTEROPEROTIC BONE,TREATMENT,Only 1 in 10 women seek medical advice 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.,TREATMENT,The kind of treatment you can take depends on the severity of the symptoms,medical history and patients own preferences.,TREATMENT,HRT,NON-HRT,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.,HOMONE REPLACEMENT 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.,HOMONE REPLACEMENT THERAPY(HRT),BENEFITS,RISKS,HOMONE 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.,HOMONE REPLACEMENT THERAPY(HRT),BENEFITS,Relieve menopausal symptoms,Maintenance of quality of life,Prevention of osteoporosis,Note:HRT should not be used as a first-line treatment in osteoparosis except in women who have,premature menopause,HOMONE REPLACEMENT THERAPY(HRT),RISKS OF VTE,HRT(combined or oestrogen-alone)increases the risk of 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,.,HOMONE REPLACEMENT THERAPY(HRT),RISKS OF BREAST CANCER,The 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 counselled that the absolute risk for breast cancer for any individual,remains relatively low*,Her actual risk increases,0.08%,(ACOG),HOMONE REPLACEMENT THERAPY(HRT),RISKS OF ENDOMETRIAL CANCER,Endometrial cancer:increased risk only with unopposed oestrogen.There is no increased risk with combined(oestrogen and progestogen)HRT.,RISKS OF OVARIAN CANCER,long-term use of oestrogen-only HRT and combined HRT may slightly increase the risk.Risk decreases after stopping HRT.,HOMONE REPLACEMENT THERAPY(HRT),RISKS OF CARDIOVASCULAR DISEASE,There is not the same evidence of cardioprotection from HRT as was originally thought.,Assess all womens risk of CHD prior to starting HRT.,HRT,E+P,E,HOMONE REPLACEMENT THERAPY(HRT),E+P,E,For hysterectomized pts,HOMONE REPLACEMENT THERAPY(HRT),s,Sequentially combined HRT,E(continuously D1-D21),P(sequentially D11-D21),Continuous combined HRT,E&Pcontinuous:D1-D28),HOMONE REPLACEMENT THERAPY(HRT),Women with an intact uterus,Vasomotor symptoms,Perimenopausal:systemic cyclical combined HRT.,Postmenopausal:systemic continuous combined HRT or tibolone.,Urogenital symptoms,Perimenopausal:low-dose vaginal oestrogen or systemic cyclical combined HRT.,Postmenopausal:low-dose vaginal oestrogen or systemic continuous combined HRT.,HOMONE REPLACEMENT THERAPY(HRT),Women who have had a hysterectomy,Vasomotor symptoms:systemic oestrogen-only HRT.,Urogenital symptoms:low-dose vaginal oestrogen or systemic oestrogen-only HRT.,HOMONE REPLACEMENT THERAPY(HRT),HOMONE REPLACEMENT THERAPY(HRT),CONTRAINDICATIONS OF HRT!,Pregnancy and breast-feeding,Undiagnosed abnormal vaginal bleeding,Venous thromboembolic disease,Active or recent,angina,or,myocardial infarction,Suspected,current or past breast cancer,Endometrial cancer or other oestrogen-dependent cancer,Active liver disease with abnormal,liver function tests,START-UP SYMPTOMS OF HRT!,Breast tenderness,Nipple sensitivity,Bloating,Nausea,headaches,Appetite,Weight gain,Leg cramps,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 cancer,Personal/family history of VTE,Woman has arterial risk factors,ALTERNATIVE TO HRT!,“,Tibolone”is 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.,STARTING HRT!,“,A full physical examination is mandatory”,Full blood count,Renal Profile-Baseline,Liver Function Test,Lipid profile,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,check blood pressure,and body weight.,Assess the effectiveness of treatment and adjust to achieve symptom control.,Enquire about adverse effects and manage appropriately.,FOLLOW UP OF TAKING HRT!,Once each year:,Check blood pressure,effectiveness of treatment and adjust to achieve symptom control.,Enquire about adverse effects and manage appropriately.,Consider switching from cyclical HRT to,continuous combined HRT,if appropriate.,FOLLOW UP OF TAKING HRT!,Discuss the risks and benefits of HRT.,Perform a breast examination if indicated by personal or family history.,Encourage breast awareness and participation in the national breast screening programme as appropriate for their age.,Pelvic examination is required only if clinically indicated,NON-HRT,Lifestyle modification,Stop smoking,Healthy diet,Weight control,Regular moderate-intensity exercise,Control blood pressure and cholesterol,NON-HRT,For vasomotor symptoms,A trial(2 weeks)of paroxetine,fluoxetine citalopram or venlafaxine(SSRI),A trial(24 weeks)of clonidine,A progestogen such as norethisterone or megestrol,NON-HRT,For vaginal dryness,Vaginal lubricant or moisturizer,such as Replens,.,NON-HRT,For osteoporosis,Alendronate(,Fosamax,),Rocaltriol,Alpha-calcidol,Raloxifene(,Evista,),NON-HRT,For psychological symptoms,-,Self-help groups,-Psychotherapy,-Other forms of counselling,-Antidepressants.,NON-HRT,Complementary therapies,Remifemin(Cimicifuga rhizome extract),Red clover plant,Soy products,Evening primrose,Black cohosh,Phytoestrogens,Ginseng,NON-HRT,Complementary interventions,Acupuncture,Reflexology,Diet and supplements,Vitamins and minerals,Vitamin E,Homeopathy,Premature menopause?,Menopausal symptoms in women who are younger than 40 years(1%),Offer lifestyle advice.,Offer systemic hormone replacement therapy(HRT)or the combined oral contraceptive pill(COC),Decreased libido:testosterone implants and patches may be considered,THANK YOU,