Dören M
Department of Family Planning, King's College Hospital, Denmark Hill, London, UK.
Maturitas. 2000 Jan;34 Suppl 1:S17-23. doi: 10.1016/s0378-5122(99)00069-9.
Hormone replacement therapy may increase the quality of life of postmenopausal women. Any regimen need to offer long-term endometrial safety. It is a standard to consider the co-administration of a sequential progestogen when estrogen replacement should be initiated in non-hysterectomized women. It is almost impossible to decide which combination of an estrogen and a progestogen seems to be optimal as individual tolerance of HRT may very well limit acceptability despite metabolic benefits and proven endometrial safety of a given combination. Several combinations of oral and transdermal estradiol or conjugated equine estrogens, oral progestogens, transdermal norethisterone acetate and levonorgestrel, and intrauterine levonorgestrel may achieve endometrial safety. It is noteworthy that there is no uniform correlation between the timing of onset of bleeding induced by any sequential estrogen and progestogen replacement and a certain pattern of histology. Therefore, although it is likely, there is no absolute reassurance that regular bleeding on or after day 11 of progestogen administration rules out abnormal histopathology. Transvaginal sonography seems not to be of pivotal importance to screen asymptomatic women on replacement therapy for detection of serious abnormal endometrial findings such as hyperplasia and endometrial cancer. Continuous combined hormone replacement therapy or the use of tibolone may be an alternative in postmenopausal women, who do not want any uterine bleedings after menopause. However, spottings or bleedings most often occur at the beginning of treatment. Vaginal administration of estriol and estradiol for urogenital symptoms of estrogen deficiency may stimulate the endometrium unintentionally. Available data suggest that use of oral estriol may be associated with endometrial hyperplasia and endometrial carcinoma relatively more often compared to sequential HRT. Raloxifene, a benzothiophene derivative acting as a selective estrogen receptor modulator approved for prevention of vertebral osteoporosis, rarely causes uterine bleeding. There is no ideal therapy available to suit women looking for a permanently bleed-free hormonal replacement therapy today.
激素替代疗法可能会提高绝经后女性的生活质量。任何治疗方案都需要确保长期的子宫内膜安全性。对于未行子宫切除术的女性，在开始雌激素替代治疗时，联合使用序贯孕激素是一种标准做法。几乎不可能确定哪种雌激素和孕激素的组合似乎是最佳的，因为尽管某种组合具有代谢益处且已证实对子宫内膜安全，但激素替代疗法的个体耐受性很可能会限制其可接受性。口服和经皮雌二醇或结合马雌激素、口服孕激素、经皮醋酸炔诺酮和左炔诺孕酮以及宫内左炔诺孕酮的几种组合都可以实现子宫内膜安全。值得注意的是，任何序贯雌激素和孕激素替代疗法引起出血的时间与特定的组织学模式之间没有统一的相关性。因此，尽管有可能，但没有绝对的保证说在孕激素给药第11天或之后出现规律出血就可以排除异常组织病理学。经阴道超声检查对于筛查接受替代治疗的无症状女性以检测严重的子宫内膜异常发现（如增生和子宫内膜癌）似乎并非至关重要。连续联合激素替代疗法或使用替勃龙可能是绝经后不想在绝经后有任何子宫出血的女性的一种选择。然而，点滴出血或出血最常发生在治疗开始时。阴道给予雌三醇和雌二醇用于治疗雌激素缺乏引起的泌尿生殖系统症状可能会无意中刺激子宫内膜。现有数据表明，与序贯激素替代疗法相比，口服雌三醇使用相对更常与子宫内膜增生和子宫内膜癌相关。雷洛昔芬是一种苯并噻吩衍生物，作为一种被批准用于预防椎体骨质疏松症的选择性雌激素受体调节剂，很少引起子宫出血。目前没有理想的疗法适合寻求永久无出血激素替代疗法的女性。
