The pathophysiology of menopausal symptoms

Increasing life expectancy means that most Western women will experience the menopausal transition. This phase of reproductive life involves a biopsychosocial process where the majority of women experience physiological changes, influenced by a wide range of ethnic, psychological, social and cultural factors. With relatively similar endocrine changes, symptom reporting should be generalised, yet more women in Western cultures report vasomotor symptoms (hot flushes and night sweats) compared to women in Asian cultures. Different approaches to menopause based on biological, medical, psychological or psychosocial premises result in different treatments for women who have troublesome symptoms.Hormone Replacement Therapy (HRT) is widely used in the management of symptoms associated with oestrogen withdrawal such as hot flushes, night sweats, sleep disturbance, vaginal dryness and dyspareunia, but has no known role in the treatment of midlife depression or arthritis. HRT prevents menopausal bone loss and osteoporotic fracture, though long-term use remains controversial because of the increased risk of breast cancer, myocardial infarction and stroke, as reported by the Women's Health Initiative. An understanding of the pathophysiology of menopausal symptoms and the risks and benefits of both hormonal and non-hormonal treatments assists in the individual management of patients.     

The pathophysiology of menopausal symptoms

Increasing life expectancy means that most Western women will experience the menopausal transition. This phase of reproductive life involves a biopsychosocial process where the majority of women experience physiological changes, influenced by a wide range of ethnic, psychological, social and cultural factors. With relatively similar endocrine changes, symptom reporting should be correspondingly similar, yet more women in Western cultures report vasomotor symptoms (hot flushes and night sweats) compared to women in Asian cultures. Different approaches to menopause based on biological, medical, psychological or psychosocial premises result in different treatments for women who have troublesome symptoms.Hormone Replacement Therapy (HRT) is widely used in the management of symptoms associated with oestrogen withdrawal such as hot flushes, night sweats, sleep disturbance, vaginal dryness and dyspareunia, but has no proven role in the treatment of midlife depression or arthritis. HRT prevents menopausal bone loss and osteoporotic fracture, though long-term use remains controversial because of the increased risk of breast cancer, myocardial infarction and stroke, as reported by the Women's Health Initiative. An understanding of the pathophysiology of menopausal symptoms and the risks and benefits of both hormonal and non-hormonal treatments assists in the individual management of patients.     

The pathophysiology and management of menopausal symptoms

The menopause is a significant event in a women's life that can potentially impact on her quality of life in several ways. It marks the end of the reproductive life cycle and the clinical manifestations of the menopause result from the eventual exhaustion of oocytes within the ovaries. The depletion of these oocytes results in chronic hypoestrogenic state, which in the short term can cause menopausal symptoms and over a longer period, may impact upon bone and cardiovascular health. This review summarises current understanding of pathophysiology of the symptoms of the menopause as well as reviewing the current recommendations for HRT use in symptomatic menopausal women. The benefits of HRT in improving the symptoms of menopause are discussed as well as a review of the evidence pertaining to the potential risks associated with HRT.     

Safety and efficacy of tibolone and menopausal transition: a randomized,double-blind placebo-controlled trial

Objective: To evaluate the efficacy, safety and tolerability of Tibolone use during the menopausal transition (MT). Methods: Sixty-five healthy women aged 40–55 years (48.5?±?3.5 years) were recruited for a randomized, double-blind controlled trial. Thirty participants were recruited to receive oral Tibolone 2.5?mg/day – Tibolone Group (TG), and 35 participants were assigned to the Placebo Group (PG), which received one capsule of lactose/day. Both groups were treated for 12 consecutive weeks. The Blatt-Kupperman Menopausal Index (KMI) and the Greene Climacteric Scale (GCS) were used. The glycaemic and lipid profiles, biochemical measures of hepatic function and endometrial thickness were measured for safety. A daily registry of complaints related to the treatment was maintained, and anthropometric measures were obtained to assess tolerability. Results: A total of 57 women completed the study. After 12 weeks of Tibolone use, the total score and percentage of the KMI and GCS were significantly decreased compared to baseline, which reflected the efficacy of the treatment of climacteric symptoms. The improvement in blood biochemistry, endometrial atrophy and maintenance of the anthropometrical measures reflected the safety of Tibolone use. The absence of serious side effects demonstrated good tolerability for Tibolone use. Conclusions: The results showed good efficacy, tolerability and safety of Tibolone use during the MT.     

早发性卵巢功能不全激素补充治疗利弊评价

早发性卵巢功能不全（POI）指女性在40岁之前卵巢活动衰退的临床综合征,以月经紊乱伴高促性腺激素及低雌激素为特征。POI患者可出现潮热、出汗等绝经期症状,远期可发生骨质疏松、心血管疾病等问题。激素补充治疗（HRT）是POI患者的有效治疗方法。文章对POI患者应用HRT的获益及可能存在的风险进行综合分析与评价。     

Awareness of hormone replacement therapy in medical care personnel in Jiaxing,China: a questionnaire survey

This study was aimed to investigate the attitudes and knowledge of medical personnel on hormone replacement therapy (HRT) in treating perimenopausal syndrome. A total of 2580 self-administered questionnaire forms were sent to medical care professionals and the responses collected were anonymous. The questionnaire included information on levels of awareness, benefits, and potential risks of HRT. A total of 2158 questionnaire forms were filled and used for statistical analysis; 61.4% of gynecologists believed that it was necessary to conduct HRT in suitable patients, 89.1% would like to recommend the therapy to patients with perimenopausal syndrome, and 83.2% of the participants were willing to take training on HRT. The mean score of awareness of HRT among the respondents was 3.14 out of 10. The main reason for them to avoid HRT was fear of cancer (43.8%), weight gain (30.4%), addiction (21.9%), and thrombus (3.9%). These results indicated that a large proportion of gynecologists are willing to recommend HRT to a woman complaining of climacteric disorders. However, awareness of HRT among the health workers (including gynecologists) is relatively low. They are also worried about the risks. A more concerted effort should be made to better disseminate information on HRT.     

Hormone replacement therapy in menopausal women: Past problems and future possibilities

Oral administration of conjugated equine estrogens (CEE) with and without the synthetic progestin medroxyprogesterone acetate (MPA) in postmenopausal women is associated with side-effects that include increased risk of stroke and breast cancer. The current evidence that transdermal administration of estradiol may provide a safer alternative to orally administered CEE is reviewed. Transdermally administered estradiol has been shown to be an efficacious treatment for hot flushes possibly without the increase in blood clotting that is associated with administration of oral CEE. Further, natural progesterone may have a more beneficial spectrum of physiological effects than synthetic progestins. The substantial differences between CEE compared with estradiol and estriol, as well as the differences between synthetic MPA and natural progesterone, are detailed. Estriol is an increasingly popular alternative hormone therapy used for menopausal symptoms. There is evidence that estriol, by binding preferentially to estrogen receptor-β, may inhibit some of the unwanted effects of estradiol. New clinical trials are needed to evaluate the safety and efficacy of topically or transdermally administered combinations of estradiol, estriol and progesterone. Future studies should focus on relatively young women who begin estrogen supplement use near the start of menopause.     

早发性卵巢功能不全激素补充治疗利弊评价

早发性卵巢功能不全（POI）指女性在40岁之前卵巢活动衰退的临床综合征,以月经紊乱伴高促性腺激素及低雌激素为特征。POI患者可出现潮热、出汗等绝经期症状,远期可发生骨质疏松、心血管疾病等问题。激素补充治疗（HRT）是POI患者的有效治疗方法。文章对POI患者应用HRT的获益及可能存在的风险进行综合分析与评价。     

The pathophysiology of menopausal symptoms

Increasing life expectancy means that most Western women will experience the menopausal transition. This phase of reproductive life involves a biopsychosocial process where the majority of women experience physiological changes, influenced by a wide range of ethnic, psychological, social and cultural factors. With relatively similar endocrine changes, symptom reporting should be generalized, yet more women in Western cultures report vasomotor symptoms (hot flushes and night sweats) compared to women in Asian cultures. Different approaches to menopause based on biological/medical, psychological or psychosocial premises result in different treatments for women who have troublesome symptoms.Hormone replacement therapy (HRT) is widely used in the management of symptoms associated with oestrogen withdrawal (hot flushes, night sweats, sleep disturbance, vaginal dryness and dyspareunia), but has no known role in the treatment of midlife depression or arthritis. HRT prevents menopausal bone loss and osteoporotic fracture, though long-term use remains controversial because of the increased risk of breast cancer, myocardial infarction and stroke, as reported by the Women’s Health Initiative.     

A pilot study on the effects of a Chinese herbal preparation on menopausal symptoms

This study was conducted to determine whether a particular Chinese medicinal preparation is effective in alleviating menopausal symptoms. Chinese women with menopausal symptoms were recruited to receive treatment for 3 months followed by 3 months without treatment. The severity of menopausal symptoms and serum follicle-stimulating hormone (FSH), luteinizing hormone (LH) and estradiol levels were assessed at baseline, 3 and 6 months. Data from 97 women with a mean age of 52.3 years were analyzed. Sixty women (62%) were postmenopausal. The serum FSH level (interquartile range) was 58.0 (39.5–72.4) IU/l at baseline and rose significantly 3 months after treatment. The difference remained significant in the postmenopausal group while there was no significant difference in the perimenopausal women. The changes in serum LH and estradiol levels remained unchanged. The baseline menopausal symptom score was 8.9 ± 6.0. The menopausal symptom score improved markedly after treatment and remained at the same level at 6 months. All individual menopausal symptoms improved significantly after 3 months of treatment except dry eye. Most of these symptoms remained significantly improved at 6 months compared with the pre-treatment assessment. We observed that the Chinese medicinal preparation used in this study is effective in improving menopausal symptoms in healthy Chinese women. Further randomized controlled trial will be needed to confirm this observation.     

CEU:Managing menopausal symptoms after the women's health initiative

Until the results of the Women's Health Initiative (WHI) were released in July 2002, hormone replacement therapy (HRT) had been thought to be the most effective way to manage unwanted menopausal symptoms and to prevent long-term health problems associated with aging. The results of the WHI, showing that HRT is less beneficial and associated with more risks than previously thought, has complicated the management of unwanted menopausal symptoms. This article discusses the effectiveness of HRT and other modalities used to relieve menopausal symptoms and discusses how to choose an HRT product to match specific menopausal complaints and provide maximum safety.     

绝经激素治疗新进展

2002年美国妇女健康干预（Women’s Health Initiative,WHI）的发表使绝经激素治疗进入了一个低谷。近10年来该领域取得了重大进展,目前的观点已经有很大的不同。该文在具体介绍WHI 研究后,着重介绍了该领域10年来的最重要研究,包括WHI再分析、丹麦的DOPS研究、欧洲的EURAS-HRT研究等,突出了这10年来最重要的进展为“窗口期”理论和孕激素选择。最后介绍了2013年关于绝经激素治疗（menopausal hormone therapy,MHT）的国际共识要点。     

The use of menopausal hormone therapy after cancer

The changing landscape of gynaecological and breast cancers has involved the development of more targeted and effective therapies, and improved survival. Ultimately, these changes result in an increasing number of women surviving their cancer diagnosis, with increasing emphasis on quality-of-life issues by following treatments. Many of these women experience severe menopausal symptoms associated with cancer treatments, but the hormonal nature of many gynaecological and breast cancers complicates the effective management of these symptoms. Generally, there is a paucity of high-quality data directly examining the safety of menopausal hormone therapy (MHT) following many female cancers, and more research is needed with long term follow-up to ensure the provision of comprehensive, patient-focussed care. This article aims to synthesise and evaluate the current evidence to provide comprehensive yet accessible information to clinicians to help guide treatment decisions about the use of MHT in women, who have experienced, or are at increased risk of, both gynaecological and breast cancers. These treatment decisions should often be made in a multi-disciplinary setting which encourages shared decision-making with patients.     

绝经后激素治疗应用时机及期限

最新发表的《绝经过渡期和绝经后期激素治疗临床应用指南(2009版)》指出,对具有适应证的妇女,在卵巢功能开始衰退并出现相关症状时即可开始应用激素治疗(HT);没有必要限制HT的期限。对妇科恶性肿瘤术后患者给予HT应谨慎选择。     

绝经激素治疗与妇科恶性肿瘤

随着人口老龄化,女性绝经后雌激素缺乏所导致的相关疾病越来越受到关注。同时,随着妇科恶性肿瘤发病趋于年轻化,肿瘤治疗导致的医源性绝经进而造成的各种低雌激素相关问题又严重影响患者的生存质量。女性期望在延长生命的同时获得较高的生存质量,绝经激素治疗（MHT）是有效的治疗方案。明确MHT与妇科恶性肿瘤之间关系,选择最佳MHT个体化治疗方案,将成为成功实施MHT的关键。     

激素补充治疗与中老年女性骨质疏松症

骨质疏松症是中老年妇女的常见病。雌激素有明确抑制骨吸收的作用。绝经后由于雌激素的缺乏,导致骨量的快速丢失,使中、老年女性患骨质疏松症的危险大大高于男性。绝经后激素治疗能有效阻止骨丢失,维持骨量,降低骨折危险。特别提倡在60岁以前或绝经10年内开始使用激素治疗。此期间启用激素治疗,除对骨骼的保护作用外,还可以明显缓解绝经症状及降低冠心病风险,获益最多,风险最小。选择绝经激素治疗,是基于生活质量、健康优先原则和个人危险因素而做的个人决策。     

绝经激素治疗与骨质疏松症

绝经激素治疗（MHT）是治疗绝经相关的血管舒缩症状和外阴阴道萎缩症状最有效的方法。此外,MHT对绝经后骨质疏松症的预防和治疗均有显著疗效。国际绝经学会及中国绝经学组制定的相关指南已将预防或治疗绝经后骨质疏松症纳入为MHT适应证之一。但雌激素的生理作用广泛,使用时获益和风险并存,故使用MHT预防或治疗绝经后骨质疏松症需注意掌握好适应证及禁忌证。     

Hormone replacement therapy on ovarian and uterine cancer risk and cancer survivors: how shall we do no harm?

This article will focus on the results of the Women's Health Initiative on the effects of hormone replacement therapy on coronary heart disease, stroke, venous thromboembolism, breast cancer, and colorectal cancer. Data from other relevant trials, including the most recent data on ovarian and uterine cancer risk and on gynecologic cancer patients, are also discussed to provide some guidelines on prescribing hormone replacement therapy in clinical practice, particularly in gynecologic cancer survivors.