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1、 MENOPAUSEWHAT ?nMenopauseisadeviationoftheancientGreekwordsmenos(month)andpauses(ending).nThemenopauseissometimesknownasthechangeoflifeandismarkedbytheendingofmenstruation.WHAT?n nItbedefinedwithcertaintyaftertwelvemonthsspontaneousamenorrhoea.n nEndofreproductivelife.Age(years)Pre-menopausePost-me
2、nopauseMENOPAUSE1YEARPeri-menopause“Climacteric”RELATED TERMINOLOGYWHEN?n nMenopausalage:45-55years(mean:50.7years)n nIfthemenopauseoccursinawomanwhoisunder45yearsofage,itisknownasprematuremenopause.n nLatemenopause:55yearsoldWHEN?n nOtherfactorsthatcanaffecttheageatwhichwomenhavetheirfinalperiodinc
3、ludeageatmenarche,parity,previousoralcontraceptivehistoryethnicityandfamilyhistory.WHY?RELATIVEACTIVITYOFESTROGENRELATIVEACTIVITYOFESTROGENWHY?n nThemenopauseistheendofeggproduction(ovulation).Thisoccursasaresultoffallinglevelsofthefemalesexhormoneoestrogen,whichregulatesawomansperiods.WHY?n nThemen
4、opauseresultsfromafallinthelevelofthefemalehormoneoestrogenintheblood.WHY?n nAtahormonallevel-asovarianfollicularactivitybeginstofail,oestrogenandprogesteronelevelsfallandthereducednegativefeedbacktothepituitarycausesariseinluteinisinghormone(LH)andfolliclestimulatinghormone(FSH).HOW?n nOestrogenred
5、uctioneventuallyresultsinmenstrualcycledisruptionandothermenopausalsymptoms.HOW?n nOestrogenreductioneventuallyresultsinmenstrualcycledisruptionandothermenopausalsymptoms.*FSHhigh(30170mU/ml)*LHhigh(2080mU/ml)*Estradiollow(110pmol/L)Vasomotor SymptomsVasomotor SymptomsSleep DisordersSleep DisordersM
6、enstrual DisordersMenstrual DisordersMood ChangesMood ChangesVaginal AtrophyVaginal AtrophyDyspareuniaDyspareuniaSkin AtrophySkin AtrophyOsteoporosisOsteoporosisAtherosclerosisAtherosclerosisCoronary Heart DiseaseCoronary Heart DiseaseCerebrovascular DiseaseCerebrovascular Disease40 yrs40 yrs50 yrs5
7、0 yrsMenopauseMenopause60 yrs60 yrsSYMPTOMS!ONSETOFSYMPTOMSINRELATIONTOAGEOFMENOPAUSESYMPTOMS!n nChangesinyourperiodtimebetweenperiodsorflowChangesinyourperiodtimebetweenperiodsorflowmaybedifferent.maybedifferent.n nHotflashes(“hotflushes”)gettingwarmintheface,Hotflashes(“hotflushes”)gettingwarminth
8、eface,neckandchest.neckandchest.n nNightsweatsandsleepingproblemsthatmayleadtoNightsweatsandsleepingproblemsthatmayleadtofeelingtired,stressedortense.feelingtired,stressedortense.n nVaginalchangesthevaginamaybecomedryandVaginalchangesthevaginamaybecomedryandthin,andsexmaybepainful.thin,andsexmaybepa
9、inful.n nThinningofyourbones,whichmayleadtolossofThinningofyourbones,whichmayleadtolossofheightandbonebreaks(osteoporosis).heightandbonebreaks(osteoporosis).SYMPTOMS!n nItisestimatedthat8outof10womenintheUKexperiencesymptomsleadinguptothemenopause.n nOfthese,45%findtheirsymptomsdifficulttodealwith.S
10、YMPTOMS!n nWithouttreatment,mostmenopausalsymptomsgraduallystopnaturally.Thisusuallyhappenstwotofiveyearsafterthesymptomsstart.n nAlthoughsomewomenexperiencesymptomsformanymoreyears.SYMPTOMS!SYMPTOMS!NORMALTRABECULARBONEOSTEROPEROTICBONETREATMENTn nOnly1in10womenseekmedicaladvicewhentheygothroughthe
11、menopauseandmanydonotneedanytreatment.n nIfmenopausalsymptomsaresevereenoughtointerferewithdailylife,therearetreatmentsthatcanhelp.TREATMENTn nThekindoftreatmentyoucantakedependsontheseverityofthesymptoms,medicalhistoryandpatientsownpreferences.TREATMENTn nHRTn nNON- HRTHOMONE REPLACEMENT THERAPY (H
12、RT)n nAsthenamesuggests,HRTworksbyreplacingoestrogen.n nHormonereplacementtherapy(HRT)canbeaneffectivetreatmentforthetypicalmenopause-relatedsymptoms.HOMONE REPLACEMENT THERAPY (HRT)n nHRTmayalsohaveaninfluenceonthelongtermhealthproblems(osteoporosis,cardiovascular diseaseandstroke),thoughitshouldbe
13、notedthatitdoesnotnecessarilyreducetheirriskforallwomen.HOMONE REPLACEMENT THERAPY (HRT)BENEFITSBENEFITSRISKSRISKSHOMONE REPLACEMENT THERAPY (HRT)n nForthetreatmentofmenopausalsymptomswheretherisk-benefitratio*isfavorable,infullyinformedwomen,inthelowestpossibledosetocontrolsymptomsandfortheshortest
14、durationpossible.HOMONE REPLACEMENT THERAPY (HRT)n nBENEFITSRelievemenopausalsymptomsMaintenanceofqualityoflifePreventionofosteoporosisNote:HRTshouldnotbeusedasafirst-linetreatmentinosteoparosisNote:HRTshouldnotbeusedasafirst-linetreatmentinosteoparosisexceptinwomenwhohaveexceptinwomenwhohaveprematu
15、re menopausepremature menopause HOMONE REPLACEMENT THERAPY (HRT)n nRISKS OF VTEHRT(combinedoroestrogen-alone)increasestheriskofHRT(combinedoroestrogen-alone)increasestheriskofadeepveinthrombosisorpulmonaryembolism,adeepveinthrombosisorpulmonaryembolism,especiallyinthefirstyearoftreatment.Theriskismo
16、reespeciallyinthefirstyearoftreatment.Theriskismorepronouncedinwomenwithpre-existingriskfactors.pronouncedinwomenwithpre-existingriskfactors.Arecentmeta-analysissuggeststhattransdermalArecentmeta-analysissuggeststhattransdermaloestrogensmaybeasaferoptionthanoraloestrogensforoestrogensmaybeasaferopti
17、onthanoraloestrogensforHRTHRT. .HOMONE REPLACEMENT THERAPY (HRT)n nRISKS OF BREAST CANCERn nTheThe increasedincreased breastbreast cancercancer riskrisk isis proportionalproportional toto thethedurationdurationofofHRT.HRT. HRTHRTincreasesincreasesthisthisriskriskbybyaboutabout1.6times1.6timesafteraf
18、ter55yearsyears ofofuseuseandand2.3times2.3timesafterafter10years10years ofofuse.use.RiskdecreaseswithinafewyearsofstoppingHRT.RiskdecreaseswithinafewyearsofstoppingHRT.nWomen considering HRT should be counselled that theabsoluteriskforbreastcancerforanyindividualremains relatively low*Heractualrisk
19、increasesHeractualriskincreases0.08%0.08%(ACOG)(ACOG)HOMONE REPLACEMENT THERAPY (HRT)n nRISKS OF ENDOMETRIAL CANCEREndometrialcancer:increasedriskonlywithEndometrialcancer:increasedriskonlywithunopposedoestrogen.Thereisnoincreasedriskwithunopposedoestrogen.Thereisnoincreasedriskwithcombined(oestroge
20、nandprogestogen)HRT.combined(oestrogenandprogestogen)HRT.RISKS OF OVARIAN CANCERlong-termuseofoestrogen-onlyHRTandcombinedlong-termuseofoestrogen-onlyHRTandcombinedHRTmayslightlyincreasetherisk.RiskdecreasesHRTmayslightlyincreasetherisk.RiskdecreasesafterstoppingHRT.afterstoppingHRT.HOMONE REPLACEME
21、NT THERAPY (HRT)n nRISKS OF CARDIOVASCULAR DISEASEThereisnotthesameevidenceofThereisnotthesameevidenceofcardioprotectionfromHRTaswasoriginallycardioprotectionfromHRTaswasoriginallythought.thought.AssessallwomensriskofCHDpriortostartingAssessallwomensriskofCHDpriortostartingHRT.HRT. HRTE+PEHOMONE REP
22、LACEMENT 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(continu
23、ous:D1-(continuous:D1-D28)D28)HOMONE REPLACEMENT THERAPY (HRT)n nWomen with an intact uterusWomen with an intact uterusVasomotorsymptomsVasomotorsymptomsn nPerimenopausal:systemiccyclicalcombinedHRT.Perimenopausal:systemiccyclicalcombinedHRT.n nPostmenopausal:systemiccontinuouscombinedPostmenopausal
24、:systemiccontinuouscombinedHRTortibolone.HRTortibolone.UrogenitalsymptomsUrogenitalsymptomsn nPerimenopausal:low-dosevaginaloestrogenorPerimenopausal:low-dosevaginaloestrogenorsystemiccyclicalcombinedHRT.systemiccyclicalcombinedHRT.n nPostmenopausal:low-dosevaginaloestrogenorPostmenopausal:low-dosev
25、aginaloestrogenorsystemiccontinuouscombinedHRT.systemiccontinuouscombinedHRT.HOMONE REPLACEMENT THERAPY (HRT)n nWomen who have had a hysterectomyWomen who have had a hysterectomyVasomotorsymptoms:systemicoestrogen-onlyHRT.Vasomotorsymptoms:systemicoestrogen-onlyHRT.Urogenitalsymptoms:low-dosevaginal
26、oestrogenorUrogenitalsymptoms: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 bleedingUndi
27、agnosed 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
28、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 sensitivity
29、n 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 th
30、ere 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
31、 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,progestogeni
32、candandrogenicWhichhasoestrogenic,progestogenicandandrogenicpropertiesproperties.(.(estrogenicactivityinestrogenicactivityinbonebone,CNSvasomotor,CNSvasomotorsuppressionofsuppressionofhotflusheshotflushesandandhelpfulinimprovingsexualfunction.helpfulinimprovingsexualfunction.STARTING HRT! “ “A full
33、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 nReviewthewoman3monthsafterstartingHRTReviewt
34、hewoman3monthsafterstartingHRTandonceeachyearthereafter.andonceeachyearthereafter.n nAt3-months:At3-months:Enquireaboutbleedingpatterns,checkbloodEnquireaboutbleedingpatterns,checkbloodpressure,andbodyweight.pressure,andbodyweight.AssesstheeffectivenessoftreatmentandAssesstheeffectivenessoftreatment
35、andadjusttoachievesymptomcontrol.adjusttoachievesymptomcontrol.EnquireaboutadverseeffectsandmanageEnquireaboutadverseeffectsandmanageappropriately.appropriately.FOLLOW UP OF TAKING HRT!n nOnceeachyear:Onceeachyear: Checkbloodpressure,effectivenessoftreatmentandCheckbloodpressure,effectivenessoftreat
36、mentandadjusttoachievesymptomcontrol.adjusttoachievesymptomcontrol. EnquireaboutadverseeffectsandmanageEnquireaboutadverseeffectsandmanageappropriately.appropriately. ConsiderswitchingfromcyclicalHRTtoConsiderswitchingfromcyclicalHRTtocontinuouscombinedHRT,ifappropriate.continuouscombinedHRT,ifappro
37、priate.FOLLOW UP OF TAKING HRT! DiscusstherisksandbenefitsofHRT.DiscusstherisksandbenefitsofHRT. PerformabreastexaminationifindicatedbypersonalPerformabreastexaminationifindicatedbypersonalorfamilyhistory.orfamilyhistory. EncouragebreastawarenessandparticipationintheEncouragebreastawarenessandpartic
38、ipationinthenationalbreastscreeningprogrammeasappropriatenationalbreastscreeningprogrammeasappropriatefortheirage.fortheirage. PelvicexaminationisrequiredonlyifclinicallyPelvicexaminationisrequiredonlyifclinicallyindicatedindicatedNON- HRTLifestyle modificationStop smokingHealthy dietWeight controlR
39、egular 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(24week
40、s)ofclonidineAprogestogensuchasnorethisteroneorAprogestogensuchasnorethisteroneormegestrolmegestrolNON- HRTn nFor vaginal drynessFor vaginal drynessVaginallubricantormoisturizer,suchasReplensVaginallubricantormoisturizer,suchasReplens. .NON- HRTn nFor osteoporosisAlendronate(Alendronate(FosamaxFosam
41、ax) )RocaltriolRocaltriolAlpha-calcidolAlpha-calcidolRaloxifene(Raloxifene(EvistaEvista) )NON- HRTn nFor psychological symptoms-Self-helpgroupsSelf-helpgroups-Psychotherapy-Psychotherapy-Otherformsofcounselling-Otherformsofcounselling-Antidepressants.-Antidepressants.NON- HRTComplementary therapiesn
42、 nRemifemin(Cimicifugarhizomeextract)Remifemin(Cimicifugarhizomeextract)n nRedcloverplantRedcloverplant n nSoyproductsSoyproductsn nEveningprimroseEveningprimrosen nBlackcohoshBlackcohoshn nPhytoestrogensPhytoestrogensn nGinsengGinsengNON- HRTComplementary interventionsComplementary interventionsn n
43、AcupunctureAcupuncturen nReflexologyReflexologyDiet and supplementsDiet and supplementsn nVitamins and mineralsVitamins and mineralsn nVitamin EVitamin EHomeopathyHomeopathyPremature menopause?n nMenopausalsymptomsinwomenwhoareyoungerthanMenopausalsymptomsinwomenwhoareyoungerthan40years(1%)40years(1
44、%)n nOfferlifestyleadvice.Offerlifestyleadvice.n nOffersystemichormonereplacementtherapy(HRT)orOffersystemichormonereplacementtherapy(HRT)orthecombinedoralcontraceptivepill(COC)thecombinedoralcontraceptivepill(COC)n nDecreasedlibido:testosteroneimplantsandpatchesDecreasedlibido:testosteroneimplantsandpatchesmaybeconsideredmaybeconsideredTHANK YOU
