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

MENOPAUSEWHAT?nMenopauseisadeviationoftheancientGreekwordsmenos(month)andpauses(ending).nThemenopauseissometimesknownasthechangeoflifeandismarkedbytheendingofmenstruation.WHAT?n nItbedefinedwithcertaintyaftertwelvemonthsspontaneousamenorrhoea.n nEndofreproductivelife.Age(years)Pre-menopausePost-menopauseMENOPAUSE1YEARPeri-menopause“Climacteric”RELATED TERMINOLOGYWHEN?n nMenopausalage:45-55years(mean:50.7years)n nIfthemenopauseoccursinawomanwhoisunder45yearsofage,itisknownasprematuremenopause.n nLatemenopause:55yearsoldWHEN?n nOtherfactorsthatcanaffecttheageatwhichwomenhavetheirfinalperiodincludeageatmenarche,parity,previousoralcontraceptivehistoryethnicityandfamilyhistory.WHY?RELATIVEACTIVITYOFESTROGENRELATIVEACTIVITYOFESTROGENWHY?n nThemenopauseistheendofeggproduction(ovulation).Thisoccursasaresultoffallinglevelsofthefemalesexhormoneoestrogen,whichregulatesawomansperiods.WHY?n nThemenopauseresultsfromafallinthelevelofthefemalehormoneoestrogenintheblood.WHY?n nAtahormonallevel-asovarianfollicularactivitybeginstofail,oestrogenandprogesteronelevelsfallandthereducednegativefeedbacktothepituitarycausesariseinluteinisinghormone(LH)andfolliclestimulatinghormone(FSH).HOW?n nOestrogenreductioneventuallyresultsinmenstrualcycledisruptionandothermenopausalsymptoms.HOW?n nOestrogenreductioneventuallyresultsinmenstrualcycledisruptionandothermenopausalsymptoms.*FSHhigh(30170mU/ml)*LHhigh(2080mU/ml)*Estradiollow(110pmol/L)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!ONSETOFSYMPTOMSINRELATIONTOAGEOFMENOPAUSESYMPTOMS!n nChangesinyourperiodtimebetweenperiodsorflowChangesinyourperiodtimebetweenperiodsorflowmaybedifferent.maybedifferent.n nHotflashes(“hotflushes”)gettingwarmintheface,Hotflashes(“hotflushes”)gettingwarmintheface,neckandchest.neckandchest.n nNightsweatsandsleepingproblemsthatmayleadtoNightsweatsandsleepingproblemsthatmayleadtofeelingtired,stressedortense.feelingtired,stressedortense.n nVaginalchangesthevaginamaybecomedryandVaginalchangesthevaginamaybecomedryandthin,andsexmaybepainful.thin,andsexmaybepainful.n nThinningofyourbones,whichmayleadtolossofThinningofyourbones,whichmayleadtolossofheightandbonebreaks(osteoporosis).heightandbonebreaks(osteoporosis).SYMPTOMS!n nItisestimatedthat8outof10womenintheUKexperiencesymptomsleadinguptothemenopause.n nOfthese,45%findtheirsymptomsdifficulttodealwith.SYMPTOMS!n nWithouttreatment,mostmenopausalsymptomsgraduallystopnaturally.Thisusuallyhappenstwotofiveyearsafterthesymptomsstart.n nAlthoughsomewomenexperiencesymptomsformanymoreyears.SYMPTOMS!SYMPTOMS!NORMALTRABECULARBONEOSTEROPEROTICBONETREATMENTn nOnly1in10womenseekmedicaladvicewhentheygothroughthemenopauseandmanydonotneedanytreatment.n nIfmenopausalsymptomsaresevereenoughtointerferewithdailylife,therearetreatmentsthatcanhelp.TREATMENTn nThekindoftreatmentyoucantakedependsontheseverityofthesymptoms,medicalhistoryandpatientsownpreferences.TREATMENTn nHRTn nNON-HRTHOMONE REPLACEMENT THERAPY(HRT)n nAsthenamesuggests,HRTworksbyreplacingoestrogen.n nHormonereplacementtherapy(HRT)canbeaneffectivetreatmentforthetypicalmenopause-relatedsymptoms.HOMONE REPLACEMENT THERAPY(HRT)n nHRTmayalsohaveaninfluenceonthelongtermhealthproblems(osteoporosis,cardiovascular diseaseandstroke),thoughitshouldbenotedthatitdoesnotnecessarilyreducetheirriskforallwomen.HOMONE REPLACEMENT THERAPY(HRT)BENEFITSBENEFITSRISKSRISKSHOMONE REPLACEMENT THERAPY(HRT)n nForthetreatmentofmenopausalsymptomswheretherisk-benefitratio*isfavorable,infullyinformedwomen,inthelowestpossibledosetocontrolsymptomsandfortheshortestdurationpossible.HOMONE REPLACEMENT THERAPY(HRT)n nBENEFITSRelievemenopausalsymptomsMaintenanceofqualityoflifePreventionofosteoporosisNote:HRTshouldnotbeusedasafirst-linetreatmentinosteoparosisNote:HRTshouldnotbeusedasafirst-linetreatmentinosteoparosisexceptinwomenwhohaveexceptinwomenwhohavepremature menopausepremature menopause HOMONE REPLACEMENT THERAPY(HRT)n nRISKS OF VTEHRT(combinedoroestrogen-alone)increasestheriskofHRT(combinedoroestrogen-alone)increasestheriskofadeepveinthrombosisorpulmonaryembolism,adeepveinthrombosisorpulmonaryembolism,especiallyinthefirstyearoftreatment.Theriskismoreespeciallyinthefirstyearoftreatment.Theriskismorepronouncedinwomenwithpre-existingriskfactors.pronouncedinwomenwithpre-existingriskfactors.Arecentmeta-analysissuggeststhattransdermalArecentmeta-analysissuggeststhattransdermaloestrogensmaybeasaferoptionthanoraloestrogensforoestrogensmaybeasaferoptionthanoraloestrogensforHRTHRT.HOMONE REPLACEMENT THERAPY(HRT)n nRISKS OF BREAST CANCERn nTheThe increasedincreased breastbreast cancercancer riskrisk isis proportionalproportional toto thethedurationdurationofofHRT.HRT.HRTHRTincreasesincreasesthisthisriskriskbybyaboutabout1.6times1.6timesafterafter55yearsyears ofofuseuseandand2.3times2.3timesafterafter10years10years ofofuse.use.RiskdecreaseswithinafewyearsofstoppingHRT.RiskdecreaseswithinafewyearsofstoppingHRT.nWomen considering HRT should be counselled that theabsoluteriskforbreastcancerforanyindividualremains relatively low*HeractualriskincreasesHeractualriskincreases0.08%0.08%(ACOG)(ACOG)HOMONE REPLACEMENT THERAPY(HRT)n nRISKS OF ENDOMETRIAL CANCEREndometrialcancer:increasedriskonlywithEndometrialcancer:increasedriskonlywithunopposedoestrogen.Thereisnoincreasedriskwithunopposedoestrogen.Thereisnoincreasedriskwithcombined(oestrogenandprogestogen)HRT.combined(oestrogenandprogestogen)HRT.RISKS OF OVARIAN CANCERlong-termuseofoestrogen-onlyHRTandcombinedlong-termuseofoestrogen-onlyHRTandcombinedHRTmayslightlyincreasetherisk.RiskdecreasesHRTmayslightlyincreasetherisk.RiskdecreasesafterstoppingHRT.afterstoppingHRT.HOMONE REPLACEMENT THERAPY(HRT)n nRISKS OF CARDIOVASCULAR DISEASEThereisnotthesameevidenceofThereisnotthesameevidenceofcardioprotectionfromHRTaswasoriginallycardioprotectionfromHRTaswasoriginallythought.thought.AssessallwomensriskofCHDpriortostartingAssessallwomensriskofCHDpriortostartingHRT.HRT.HRTE+PEHOMONE REPLACEMENT THERAPY(HRT)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-(continuousD1-D28)D28)HOMONE REPLACEMENT THERAPY(HRT)n nWomen with an intact uterusWomen with an intact uterusVasomotorsymptomsVasomotorsymptomsn nPerimenopausal:systemiccyclicalcombinedHRT.Perimenopausal:systemiccyclicalcombinedHRT.n nPostmenopausal:systemiccontinuouscombinedPostmenopausal:systemiccontinuouscombinedHRTortibolone.HRTortibolone.UrogenitalsymptomsUrogenitalsymptomsn nPerimenopausal:low-dosevaginaloestrogenorPerimenopausal:low-dosevaginaloestrogenorsystemiccyclicalcombinedHRT.systemiccyclicalcombinedHRT.n nPostmenopausal:low-dosevaginaloestrogenorPostmenopausal:low-dosevaginaloestrogenorsystemiccontinuouscombinedHRT.systemiccontinuouscombinedHRT.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.HOMONE REPLACEMENT THERAPY(HRT)HOMONE REPLACEMENT THERAPY(HRT)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 testsSTART-UP SYMPTOMS OF HRT!n nBreast tendernessBreast tendernessn nNipple sensitivityNipple sensitivityn nBloatingBloatingn nNausea,headachesNausea,headachesn nAppetite Appetite n nWeight gainWeight gainn nLeg crampsLeg crampsINVESTIGATIONS BEFORE HRT!Investigations are not usually necessary before Investigations are not usually necessary before starting HRT unless there is:starting HRT 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 factorsALTERNATIVE TO HRT!“Tibolone”is a synthetic hormone that acts in the Tibolone”is a synthetic hormone that acts in the same way as HRT same way as HRT(SERM)(SERM)n nUsefulforpost-menopausalwomenwhowanttoendUsefulforpost-menopausalwomenwhowanttoendtheirperiods.theirperiods.n nWhichhasoestrogenic,progestogenicandandrogenicWhichhasoestrogenic,progestogenicandandrogenicpropertiesproperties.(.(estrogenicactivityinestrogenicactivityinbonebone,CNSvasomotor,CNSvasomotorsuppressionofsuppressionofhotflusheshotflushesandandhelpfulinimprovingsexualfunction.helpfulinimprovingsexualfunction.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 profileFOLLOW UP OF TAKING HRT!n nReviewthewoman3monthsafterstartingHRTReviewthewoman3monthsafterstartingHRTandonceeachyearthereafter.andonceeachyearthereafter.n nAt3-months:At3-months:Enquireaboutbleedingpatterns,checkbloodEnquireaboutbleedingpatterns,checkbloodpressure,andbodyweight.pressure,andbodyweight.AssesstheeffectivenessoftreatmentandAssesstheeffectivenessoftreatmentandadjusttoachievesymptomcontrol.adjusttoachievesymptomcontrol.EnquireaboutadverseeffectsandmanageEnquireaboutadverseeffectsandmanageappropriately.appropriately.FOLLOW UP OF TAKING HRT!n nOnceeachyear:Onceeachyear:Checkbloodpressure,effectivenessoftreatmentandCheckbloodpressure,effectivenessoftreatmentandadjusttoachievesymptomcontrol.adjusttoachievesymptomcontrol.EnquireaboutadverseeffectsandmanageEnquireaboutadverseeffectsandmanageappropriately.appropriately.ConsiderswitchingfromcyclicalHRTtoConsiderswitchingfromcyclicalHRTtocontinuouscombinedHRT,ifappropriate.continuouscombinedHRT,ifappropriate.FOLLOW UP OF TAKING HRT!DiscusstherisksandbenefitsofHRT.DiscusstherisksandbenefitsofHRT.PerformabreastexaminationifindicatedbypersonalPerformabreastexaminationifindicatedbypersonalorfamilyhistory.orfamilyhistory.EncouragebreastawarenessandparticipationintheEncouragebreastawarenessandparticipationinthenationalbreastscreeningprogrammeasappropriatenationalbreastscreeningprogrammeasappropriatefortheirage.fortheirage.PelvicexaminationisrequiredonlyifclinicallyPelvicexaminationisrequiredonlyifclinicallyindicatedindicatedNON-HRTLifestyle modificationStop smokingHealthy dietWeight controlRegular moderate-intensity exerciseControl blood pressure and cholesterolNON-HRTn nFor vasomotor symptoms For vasomotor symptoms Atrial(2weeks)ofparoxetine,fluoxetineAtrial(2weeks)ofparoxetine,fluoxetinecitalopramorvenlafaxine(SSRI)citalopramorvenlafaxine(SSRI)Atrial(24weeks)ofclonidineAtrial(24weeks)ofclonidineAprogestogensuchasnorethisteroneorAprogestogensuchasnorethisteroneormegestrolmegestrolNON-HRTn nFor vaginal drynessFor vaginal drynessVaginallubricantormoisturizer,suchasReplensVaginallubricantormoisturizer,suchasReplens.NON-HRTn nFor osteoporosisAlendronate(Alendronate(FosamaxFosamax)RocaltriolRocaltriolAlpha-calcidolAlpha-calcidolRaloxifene(Raloxifene(EvistaEvista)NON-HRTn nFor psychological symptoms-Self-helpgroupsSelf-helpgroups-Psychotherapy-Psychotherapy-Otherformsofcounselling-Otherformsofcounselling-Antidepressants.-Antidepressants.NON-HRTComplementary therapiesn nRemifemin(Cimicifugarhizomeextract)Remifemin(Cimicifugarhizomeextract)n nRedcloverplantRedcloverplant n nSoyproductsSoyproductsn nEveningprimroseEveningprimrosen nBlackcohoshBlackcohoshn nPhytoestrogensPhytoestrogensn nGinsengGinsengNON-HRTComplementary interventionsComplementary interventionsn nAcupunctureAcupuncturen nReflexologyReflexologyDiet and supplementsDiet and supplementsn nVitamins and mineralsVitamins and mineralsn nVitamin EVitamin EHomeopathyHomeopathyPremature menopause?n nMenopausalsymptomsinwomenwhoareyoungerthanMenopausalsymptomsinwomenwhoareyoungerthan40years(1%)40years(1%)n nOfferlifestyleadvice.Offerlifestyleadvice.n nOffersystemichormonereplacementtherapy(HRT)orOffersystemichormonereplacementtherapy(HRT)orthecombinedoralcontraceptivepill(COC)thecombinedoralcontraceptivepill(COC)n nDecreasedlibido:testosteroneimplantsandpatchesDecreasedlibido:testosteroneimplantsandpatchesmaybeconsideredmaybeconsideredTHANK YOU