共识与争议:绝经激素治疗与乳腺癌发病风险

绝经激素治疗(menopausal hormone therapy,MHT)是以雌激素补充为核心的治疗,在有子宫的女性治疗中往往需联合雌激素和孕激素。妇科内分泌和乳腺外科专家就围绝经期MHT是否增加乳腺癌风险展开讨论并达成共识:MHT可增加乳腺癌风险,应用时需全面评估风险与收益;MHT存在用药窗口期、用药指征、禁忌证,应用前需告知患者相关风险并取得知情同意。对天然孕激素、替勃龙及单雌激素治疗是否增加乳腺癌发生风险等问题仍存在争议。     

绝经激素治疗的获益与风险

绝经激素治疗(menopausal hormone therapy,MHT)是对卵巢功能衰退的女性进行外源性雌激素补充以解决与雌激素不足相关的健康问题,MHT对于缓解绝经症状、防治泌尿生殖道萎缩相关疾病和预防骨质疏松的获益是毋庸置疑的。近80年来,医学界对MHT获益与风险的认识经历了跌宕起伏、崎岖发展的过程。特别是21世纪初美国大型前瞻性随机对照研究“妇女健康倡议(Women's Health Initiative,WHI) ”中期研究报告的发布,对全球MHT的应用产生了巨大震动,该项研究报告了老年女性使用MHT过程中心脑血管疾病事件及乳腺癌的发生风险升高,在2002年之后的18年里,医学界对MHT获益与风险的再评估从未停止过。目前,较为统一的认识是MHT的获益与风险与多种因素相关,包括启用MHT的年龄,绝经年限,性激素的种类、剂量、使用途径、用药时长,女性的基础健康状况,MHT管理是否规范等。本文参考过去10年内全球颁布的各项MHT指南、共识和发表的重要文献,对MHT的获益与风险进行论述。     

绝经激素治疗增加乳腺癌患病风险:Lancet最新文献解读

绝经激素治疗(menopausal hormone therapy, MHT)是否会增加乳腺癌的发病风险一直存在争议。2019年9月,Lancet发表了一篇荟萃分析,汇集了世界范围内关于MHT与乳腺癌发病风险的证据。此研究结果表明,除阴道应用雌激素外,所有方式应用MHT均增加乳腺癌发病风险,且该风险随MHT应用时间的延长逐渐升高。其中雌激素、孕激素联合治疗风险更高,停药后额外风险可持续10年以上。小剂量应用MHT或选择天然孕激素等并不能回避乳腺癌发病风险的增加。本文对该荟萃分析进行解读,强调应用MHT需考虑乳腺癌风险,全面评估患者风险与获益。     

理性看待绝经激素治疗与乳腺癌发病风险

随着当代女性对绝经认知的不断提高，越来越多的女性开始进行绝经激素治疗(menopausal hormone therapy，MHT)，以缓解绝经相关症状，如月经紊乱、潮热、多汗、睡眠障碍、情绪波动、泌尿生殖道萎缩以及骨质疏松等，进而提高生活质量。但在应用MHT的过程中，乳腺癌的发病风险一直是困扰女性的重要问题之一，而MHT与乳腺癌发病风险的争论亦成为妇科内分泌领域的热点问题。本文基于循证医学证据，阐述如何理性看待二者之间的关系。     

绝经管理任重而道远

女性绝经后,雌激素的缺乏会引发一系列严重危害生命质量的健康事件.根据目前平均寿命,女性近30年的时间将处于雌激素缺乏状态,而绝经激素治疗(menopausal hormone therapy,MHT)是全面解决绝经相关症状及疾病的唯一方案.虽然近年来我国医务工作者和大众对MHT的认识有所提高,但MHT的知晓率和使用率在...     

绝经后激素补充治疗(HRT)与子宫出血

绝经后妇女由于生殖内分泌激素的变化 ,尤其是卵巢分泌雌激素水平显著降低 ,机体发生许多生理病理改变 ,导致妇女身心功能失调 ,表现为潮热、烦躁、头痛、心悸等症状 ,不仅影响他们的生活质量和身体健康 ,还促使骨质疏松和心血管疾病的形成和发展。为了缓解症状 ,提高生活质量 ,促进健康 ,激素补充治疗 (hormonereplacementtherapy,HRT)是绝经后妇女保健不可缺少的措施。但目前自愿接受HRT的绝经后妇女仍占少数 ,其主要原因是对HRT副反应及潜在风险的顾虑。而HRT副反应中最主要的为子宫出血。本文主要介绍了对不同类型的激素补充疗法中…     

绝经激素治疗与女性恶性肿瘤

医学的快速发展显著提高了恶性肿瘤患者的生存率和生存时间，因此，越来越多的女性恶性肿瘤幸存者将经历自然绝经或由于肿瘤治疗导致的早发性卵巢功能不全(premature ovarian insufficiency，POI)。自然绝经或POI带来的雌激素水平缺乏，可引起潮热、出汗、失眠、泌尿生殖道萎缩等一系列症状，远期负面影响包括心血管疾病、骨质疏松等风险增加，严重影响女性生活质量。因此，绝经激素治疗(menopausal hormone therapy，MHT)在女性恶性肿瘤幸存者中的应用日益受到关注。本文将对MHT与女性恶性肿瘤的关系及恶性肿瘤幸存者应用MHT的利弊进行分析。     

绝经后高血压研究进展

绝经后高血压是指女性在生理性绝经1年以后出现的血压升高,由于激素水平等其他方面的影响,常伴有肥胖、血脂异常、糖代谢异常和胰岛素水平增高,以及交感神经兴奋性增高等。由于其已成为冠心病(CHD)的危险因素之一,因此愈来愈受到人们的关注。绝经后女性血压升高的机制复杂且是多因素的,包括雌激素减少、垂体激素过多、体重增加,以及综合因素和其他未知神经体液因素的影响。鉴于绝经后女性症状的多样性,治疗高血压时,在降压药物的选用上需考虑患者的具体病症,因人而异。关于应用激素替代疗法(HRT)的机制已有多项实验研究证实,但对于患有高血压的绝经后妇女的疗效证据尚不确切。目前能确定的是,高血压不是应用HRT的禁忌证。而是否一些患有CHD的妇女可从HRT治疗中获益,仍需等待更前沿的随机临床实验结果。     

绝经后女性失眠相关因素前瞻性队列基线调查研究

目的研究影响绝经后女性失眠的相关因素。方法选取2018年1月至2020年5月首都医科大学附属北京妇产医院2188例40~83岁的绝经后女性为研究对象,其中787例应用绝经激素治疗(menopausal hormone therapy,MHT),972例未应用MHT,429例受试者未回答是否应用MHT。应用改良Kupperman评分对失眠情况进行调查,应用简单和非条件logistic回归方法分析失眠的影响因素。结果绝经后女性失眠的患病率为66.72%,其中轻度35.38%,中度21.83%,重度9.51%。失眠发生率随着受教育程度降低而升高(OR=1.502~1.618,P<0.05);失眠发生率随着食用豆制品次数增多而降低,但仅当次数≥7次/周时,差异有显著性(OR=0.366,95%CI 0.221~0.607,P<0.05);失眠发生率随着每日运动强度降低而增加(OR=1.775~2.141,P<0.05)。与规律应用MHT相比,不用MHT会增加失眠发生率(OR=1.602,95%CI 1.105~2.321,P<0.05),而每日运动量、抽烟、饮酒、月经初潮年龄、孕次、产次及分娩方式与失眠均无关。结论规律应用MHT有助于改善失眠,部分社会环境因素与绝经后女性失眠相关,应给予足够重视。     

甲基异炔诺酮治疗绝经后骨质疏松症

由绝经后骨质疏松引起的骨折并发症使得妇女的发病率和死亡率的提高，已严重危害了老年人健康，影响老年人生活质量，本院对自然绝经1年以上的妇女，应用甲基异炔诺酮(商品名利维爱)行激素替代治疗(HRT)治疗，观察骨密度，骨代谢生化指标，进行绝对期症状评分，以明确利维爱对绝经后骨赓疏松症行HRT的可行性和安全性。     

绝经后雌激素补充治疗对阴道微生态的影响

目的探讨绝经后激素补充治疗(MHT)对绝经女性阴道微生态的影响。方法选择妇科门诊就诊的绝经女性322例,按绝经时间分为≤5年组、5年且11年组和≥11年组;按照MHT使用与否分为使用MHT组(n=104)与未使用MHT组(n=218);取阴道分泌物进行微生态检测,比较各组阴道微生态的数据。结果细菌性阴道病在不同绝经时间组中的发病率最高,在≤5年组为21.1%、5年且11年组为19.3%、≥11年组为16.0%;使用MHT组菌群/功能异常的阳性率明显低于未使用MHT组(P0.05);使用MHT组菌群正常率显著高于未使用MHT组(P0.01)。结论细菌性阴道病是绝经女性常见的阴道感染性疾病之一。MHT有助于阴道微生态的改善。     

Osteoporosis treatment by gynecologist

Postmenopausal bone loss is accelerated since women experience menstrual irregularity. Postmenopausal women lose their bone mineral density by 20 to 25% during 10 years after menopause, therefore early detection of risks for postmenopausal osteoporosis is mandatory for prevention of the disease. Because estrogen deficiency is the primary cause of postmenopausal bone loss, hormone replacement therapy can be a reasonable choice for the first treatment of osteoporosis. However, to those who have contraindications against estrogen or who complain severe estrogen-related symptoms, other medication using SERM and bisphosphonate should be considered.     

Menopause

The body of evidence now swings the scale toward the benefit of HRT for women beginning at the menopause. Based on newer studies, the risks for osteoporosis, cardiovascular morbidity, breast carcinoma, symptomatic vasomotor and anatomic changes occurring postmenopausally outweigh the risks of hormone replacement therapy in the end of the 20th century. Women should be instructed in adequate calcium intake, 1000 mg per day premenopausally and 1500 mg per day postmenopausally. Osteoporotic, breast carcinoma, and cardiovascular risks should be investigated at age 35 with appropriate lab screening, including lipoprotein analysis. Screening mammography should begin at age 40, continuing every 5 years until age 50, and yearly between ages 50 and 65. A diet high in calcium, low in cholesterol and fat, and a weight reduction program should be made available as early as possible and continued indefinitely. HRT should be made available beginning at menopause and continued to age 70. Moderate exercise should be encouraged at all ages. The next 5 to 10 years will answer some of the questions about the benefits of long-term HRT postmenopausally, especially with respect to its influence on cardiovascular risk. New progestational agents will probably be developed that will have fewer adverse effects on lipid profiles, while maintaining the protective effect on the endometrium and breast and further influencing the benefits of HRT postmenopausally. Modern medicine certainly cannot ensure living forever. The body of knowledge now available can modify the major causes for morbidity and mortality as the baby boom population reaches their middle age and golden years.     

Hormone therapy in perimenopausal and postmenopausal women: examining the evidence on cardiovascular disease risks

Women may live for 30 years or longer after menopause with cardiovascular disease as their highest mortality risk. Menopause may correspond to health alterations for women, yet the use of estrogen during and after this transition has been controversial for the past four decades. The evidence from recent scientific studies does not support the use of hormone therapy for the prevention or treatment of cardiovascular disease, which has resulted in its removal from national guideline recommendations. However, because of concerns related to specific aspects of the research, there are gaps in the evidence. Studies are under way to evaluate alternate methods for hormone delivery, low-dose hormone therapy, and selective estrogen receptor modulators (SERMs) in reducing cardiovascular risks in perimenopausal and postmenopausal women. Implications for clinical nursing practice include education as well as assessment and counseling related to individual risk factors.     

Hormone Therapy for Menopausal Women in the Primary Care Setting

Menopausal hormone therapy (MHT) is the most effective treatment for vasomotor symptoms; however, many women receive inadequate treatment because of a misunderstanding of important MHT research. Reanalysis of findings from the Women’s Health Initiative, in conjunction with recent findings from the Study of Women Across the Nation and the Kronos Early Estrogen Prevention Study, support the use of MHT in women who are < 10 years from the onset of menopause and are free of contraindications. Primary care providers are in the ideal position to provide evidence-based counseling to patients and help women make an individualized decision to use MHT safely.     

Epidemiology of postmenopausal hypertension

Hypertension is more common in younger men than women but this trend is inverted at approximately 60 years of age--thereafter hypertension is more common in women. Menopause's contribution to this phenomenon is complex. Oestrogen deficiency after menopause precipitates a number of factors and these have established the 'menopausal metabolic syndrome' as a concept in postmenopausal women. However, studies have indicated that changes in the prevalence of hypertension, and overall cardiovascular risk profiles in postmenopausal women, might be due to ageing and not oestrogen deficiency. Undoubtedly, there is a strong multicolinearity between the two phenomena. Furthermore, hormone replacement therapy (HRT) may reduce age-induced blood pressure increases, thus decreasing cardiovascular risks. However, recent results have questioned HRT's role in cardiovascular disease (CVD) prevention in postmenopausal women and trials have unequivocally shown that CVD risk in postmenopausal women with hypertension can be effectively reduced by common antihypertensive drugs.     

OSTEOPOROSIS: A GROWING EPIDEMIC

SUMMARY The osteoporosis epidemic will continue unabated unless the issue of prevention of bone loss is seriously addressed. While a continuing programme of education for both the medical profession and the general public is necessary, positive action is required. Women lose bone at an accelerated rate following the menopause and this seems to be the optimal time for intervention. Those women who enter the menopause with the lowest bone density are at greatest risk of subsequent fracture. An individual's bone density can be accurately measured and those women who have the lowest bone density should have hormone replacement therapy (HRT) recommended, but it is important to discuss fully the possible benefits and risks. It is probable that non-hormonal agents for prevention of bone loss will be available in the near future, and cyclical diphosphonate therapy appears particularly promising. However, at the present time, long-term HRT is the mainstay for the prevention of bone loss.     

Osteoporosis: a growing epidemic.

The osteoporosis epidemic will continue unabated unless the issue of prevention of bone loss is seriously addressed. While a continuing programme of education for both the medical profession and the general public is necessary, positive action is required. Women lose bone at an accelerated rate following the menopause and this seems to be the optimal time for intervention. Those women who enter the menopause with the lowest bone density are at greatest risk of subsequent fracture. An individual's bone density can be accurately measured and those women who have the lowest bone density should have hormone replacement therapy (HRT) recommended, but it is important to discuss fully the possible benefits and risks. It is probable that non-hormonal agents for prevention of bone loss will be available in the near future, and cyclical diphosphonate therapy appears particularly promising. However, at the present time, long-term HRT is the mainstay for the prevention of bone loss.