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

MENOPAUSE WHAT MenopauseisadeviationoftheancientGreekwordsmenos month andpauses ending Themenopauseissometimesknownasthe changeoflife andismarkedbytheendingofmenstruation WHAT Itbedefinedwithcertaintyaftertwelvemonths spontaneousamenorrhoea Endofreproductivelife Age years Pre menopause Post menopause MENOPAUSE 1YEAR Peri menopause Climacteric RELATEDTERMINOLOGY WHEN Menopausalage 45 55years mean 50 7years Ifthemenopauseoccursinawomanwhoisunder45yearsofage itisknownasprematuremenopause Latemenopause 55yearsold WHEN Otherfactorsthatcanaffecttheageatwhichwomenhavetheirfinalperiodincludeageatmenarche parity previousoralcontraceptivehistoryethnicityandfamilyhistory WHY RELATIVEACTIVITYOFESTROGEN WHY Themenopauseistheendofeggproduction ovulation Thisoccursasaresultoffallinglevelsofthefemalesexhormoneoestrogen whichregulatesawoman speriods WHY Themenopauseresultsfromafallinthelevelofthefemalehormoneoestrogenintheblood WHY Atahormonallevel asovarianfollicularactivitybeginstofail oestrogenandprogesteronelevelsfallandthereducednegativefeedbacktothepituitarycausesariseinluteinisinghormone LH andfolliclestimulatinghormone FSH HOW Oestrogenreductioneventuallyresultsinmenstrualcycledisruptionandothermenopausalsymptoms HOW Oestrogenreductioneventuallyresultsinmenstrualcycledisruptionandothermenopausalsymptoms FSHhigh 30 170mU ml LHhigh 20 80mU ml Estradiollow 110pmol L VasomotorSymptomsSleepDisordersMenstrualDisordersMoodChanges VaginalAtrophyDyspareuniaSkinAtrophy OsteoporosisAtherosclerosisCoronaryHeartDiseaseCerebrovascularDisease 40yrs 50yrs Menopause 60yrs SYMPTOMS ONSETOFSYMPTOMSINRELATIONTOAGEOFMENOPAUSE SYMPTOMS Changesinyourperiod timebetweenperiodsorflowmaybedifferent Hotflashes hotflushes gettingwarmintheface neckandchest Nightsweatsandsleepingproblemsthatmayleadtofeelingtired stressedortense Vaginalchanges thevaginamaybecomedryandthin andsexmaybepainful Thinningofyourbones whichmayleadtolossofheightandbonebreaks osteoporosis SYMPTOMS Itisestimatedthat8outof10womenintheUKexperiencesymptomsleadinguptothemenopause Ofthese 45 findtheirsymptomsdifficulttodealwith SYMPTOMS Withouttreatment mostmenopausalsymptomsgraduallystopnaturally Thisusuallyhappenstwotofiveyearsafterthesymptomsstart Althoughsomewomenexperiencesymptomsformanymoreyears SYMPTOMS SYMPTOMS NORMALTRABECULARBONE OSTEROPEROTICBONE TREATMENT Only1in10womenseekmedicaladvicewhentheygothroughthemenopauseandmanydonotneedanytreatment Ifmenopausalsymptomsaresevereenoughtointerferewithdailylife therearetreatmentsthatcanhelp TREATMENT Thekindoftreatmentyoucantakedependsontheseverityofthesymptoms medicalhistoryandpatient sownpreferences TREATMENT HRTNON HRT HOMONEREPLACEMENTTHERAPY HRT Asthenamesuggests HRTworksbyreplacingoestrogen Hormonereplacementtherapy HRT canbeaneffectivetreatmentforthetypicalmenopause relatedsymptoms HOMONEREPLACEMENTTHERAPY HRT HRTmayalsohaveaninfluenceonthelongtermhealthproblems osteoporosis cardiovasculardiseaseandstroke thoughitshouldbenotedthatitdoesnotnecessarilyreducetheirriskforallwomen HOMONEREPLACEMENTTHERAPY HRT BENEFITS RISKS HOMONEREPLACEMENTTHERAPY HRT Forthetreatmentofmenopausalsymptomswheretherisk benefitratio isfavorable infullyinformedwomen inthelowestpossibledosetocontrolsymptomsandfortheshortestdurationpossible HOMONEREPLACEMENTTHERAPY HRT BENEFITSRelievemenopausalsymptomsMaintenanceofqualityoflifePreventionofosteoporosisNote HRTshouldnotbeusedasafirst linetreatmentinosteoparosisexceptinwomenwhohaveprematuremenopause HOMONEREPLACEMENTTHERAPY HRT RISKSOFVTEHRT combinedoroestrogen alone increasestheriskofadeepveinthrombosisorpulmonaryembolism especiallyinthefirstyearoftreatment Theriskismorepronouncedinwomenwithpre existingriskfactors Arecentmeta analysissuggeststhattransdermaloestrogensmaybeasaferoptionthanoraloestrogensforHRT HOMONEREPLACEMENTTHERAPY HRT RISKSOFBREASTCANCERTheincreasedbreastcancerriskisproportionaltothedurationofHRT HRTincreasesthisriskbyabout1 6timesafter5yearsofuseand2 3timesafter10yearsofuse RiskdecreaseswithinafewyearsofstoppingHRT WomenconsideringHRTshouldbecounselledthattheabsoluteriskforbreastcancerforanyindividualremainsrelativelylow Heractualriskincreases0 08 ACOG HOMONEREPLACEMENTTHERAPY HRT RISKSOFENDOMETRIALCANCEREndometrialcancer increasedriskonlywithunopposedoestrogen Thereisnoincreasedriskwithcombined oestrogenandprogestogen HRT RISKSOFOVARIANCANCERlong termuseofoestrogen onlyHRTandcombinedHRTmayslightlyincreasetherisk RiskdecreasesafterstoppingHRT HOMONEREPLACEMENTTHERAPY HRT RISKSOFCARDIOVASCULARDISEASEThereisnotthesameevidenceofcardioprotectionfromHRTaswasoriginallythought Assessallwomen sriskofCHDpriortostartingHRT HOMONEREPLACEMENTTHERAPY HRT HOMONEREPLACEMENTTHERAPY HRT s SequentiallycombinedHRTE continuouslyD1 D21 P sequentiallyD11 D21 ContinuouscombinedHRTE P continuous D1 D28 HOMONEREPLACEMENTTHERAPY HRT WomenwithanintactuterusVasomotorsymptomsPerimenopausal systemiccyclicalcombinedHRT Postmenopausal systemiccontinuouscombinedHRTortibolone UrogenitalsymptomsPerimenopausal low dosevaginaloestrogenorsystemiccyclicalcombinedHRT Postmenopausal low dosevaginaloestrogenorsystemiccontinuouscombinedHRT HOMONEREPLACEMENTTHERAPY HRT WomenwhohavehadahysterectomyVasomotorsymptoms systemicoestrogen onlyHRT Urogenitalsymptoms low dosevaginaloestrogenorsystemicoestrogen onlyHRT HOMONEREPLACEMENTTHERAPY HRT HOMONEREPLACEMENTTHERAPY HRT CONTRAINDICATIONSOFHRT Pregnancyandbreast feedingUndiagnosedabnormalvaginalbleedingVenousthromboembolicdiseaseActiveorrecentanginaormyocardialinfarctionSuspected currentorpastbreastcancerEndometrialcancerorotheroestrogen dependentcancerActiveliverdiseasewithabnormalliverfunctiontests START UPSYMPTOMSOFHRT BreasttendernessNipplesensitivityBloatingNausea headachesAppetiteWeightgainLegcramps INVESTIGATIONSBEFOREHRT InvestigationsarenotusuallynecessarybeforestartingHRTunlessthereis suddenchangeinmenstrualpattern IMB PCB HighriskofbreastcancerPersonal familyhistoryofVTEWomanhasarterialriskfactors ALTERNATIVETOHRT Tibolone isasynthetichormonethatactsinthesamewayasHRT SERM Usefulforpost menopausalwomenwhowanttoendtheirperiods Whichhasoestrogenic progestogenicandandrogenicproperties estrogenicactivityinbone CNSvasomotorsuppressionofhotflushesandhelpfulinimprovingsexualfunction STARTINGHRT Afullphysicalexaminationismandatory FullbloodcountRenalProfile BaselineLiverFunctionTestLipidprofile FOLLOWUPOFTAKINGHRT Reviewthewoman3monthsafterstartingHRTandonceeachyearthereafter At3 months Enquireaboutbleedingpatterns checkbloodpressure andbodyweight Assesstheeffectivenessoftreatmentandadjusttoachievesymptomcontrol Enquireaboutadverseeffectsandmanageappropriately FOLLOWUPOFTAKINGHRT Onceeachyear Checkbloodpressure effectivenessoftreatmentandadjusttoachievesymptomcontrol Enquireaboutadverseeffectsandmanageappropriately ConsiderswitchingfromcyclicalHRTtocontinuouscombinedHRT ifappropriate FOLLOWUPOFTAKINGHRT DiscusstherisksandbenefitsofHRT Performabreastexaminationifindicatedbypersonalorfamilyhistory Encouragebreastawarenessandparticipationinthenationalbreastscreeningprogrammeasappropriatefortheirage Pelvicexaminationisrequiredonlyifclinicallyindicated NON HRT LifestylemodificationStopsmokingHealthydietWeightcontrolRegularmoderate intensityexerciseControlbloodpressureandcholesterol NON HRT ForvasomotorsymptomsAtrial 2weeks ofparoxetine fluoxetinecitalopramorvenlafaxine SSRI Atrial