Division of Preventive Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
Fertil Steril. 2014 Apr;101(4):916-21. doi: 10.1016/j.fertnstert.2014.02.043.
Menopausal hormone therapy (HT) has complex biologic effects but continues to have an important clinical role in the management of vasomotor and other menopausal symptoms. The rational use of menopausal HT requires balancing the potential benefits and risks of treatment. Findings from the Women's Health Initiative (WHI) and other randomized clinical trials have helped to clarify the benefits and risks of HT and have provided insights to improve decision making. Several clinical characteristics have utility in identifying women for whom benefits of HT are likely to outweigh the risks. Age and time since menopause are strong predictors of health outcomes and absolute risks associated with HT, and differences by age have been particularly apparent for estrogen alone. In the WHI trial of conjugated equine estrogens (CEE) alone, younger women (50-59 years) had more favorable results for all-cause mortality, myocardial infarction, and the global index, but not for stroke and venous thrombosis. Age trends were less clear for CEE + medroxyprogesterone acetate, owing to increased risks of breast cancer, stroke, and venous thrombosis in all age groups. Absolute risks of adverse events were lower in younger than in older women in both trials, however. Other predictors of lower vascular risk from HT include favorable lipid status and absence of the metabolic syndrome. Transdermal administration may be associated with lower risks of venous thrombosis and stroke, but additional research is needed. The use of risk stratification and personalized risk assessment offers promise for improved benefit-risk profile and safety of HT. One approach to decision making is presented. Key elements include: assessment of whether the patient has moderate to severe menopausal symptoms, the primary indication for initiating systemic HT (vaginal estrogen may be used to treat genitourinary symptoms in the absence of vasomotor symptoms); understanding the patient's own preference regarding therapy; evaluating the patient for the presence of any contraindications to HT, as well as the time since menopause onset and baseline risks of cardiovascular disease and breast cancer; reviewing carefully the benefits and risks of treatment with the patient, giving more emphasis to absolute than to relative measures of effect; and, if HT is initiated, regularly reviewing the patient's need for continued treatment.
绝经激素治疗（HT）具有复杂的生物学效应，但在管理血管舒缩和其他绝经症状方面仍然具有重要的临床作用。合理使用绝经激素治疗需要平衡治疗的潜在益处和风险。妇女健康倡议（WHI）和其他随机临床试验的结果有助于阐明 HT 的益处和风险，并提供了改善决策的见解。一些临床特征可用于确定 HT 的益处可能超过风险的女性。年龄和绝经后时间是与 HT 相关的健康结果和绝对风险的强有力预测因素，并且年龄差异对于单独使用雌激素尤为明显。在 WHI 单独使用结合雌激素（CEE）的试验中，较年轻的女性（50-59 岁）在全因死亡率、心肌梗死和整体指数方面的结果更为有利，但在中风和静脉血栓形成方面并非如此。由于所有年龄组中乳腺癌、中风和静脉血栓形成的风险增加，CEE + 醋酸甲羟孕酮的年龄趋势不太明显。然而，在两项试验中，年轻女性发生不良事件的绝对风险均低于年龄较大的女性。HT 降低血管风险的其他预测因素包括有利的血脂状况和无代谢综合征。经皮给药可能与静脉血栓形成和中风的风险降低有关，但需要进一步的研究。风险分层和个性化风险评估的使用为改善 HT 的获益-风险状况和安全性提供了希望。提出了一种决策方法。关键要素包括：评估患者是否有中度至重度绝经症状、开始全身 HT 的主要指征（如果没有血管舒缩症状，可以使用阴道雌激素治疗泌尿生殖系统症状）；了解患者对治疗的个人偏好；评估患者是否存在 HT 的任何禁忌症，以及绝经后发病时间和心血管疾病和乳腺癌的基线风险；与患者仔细审查治疗的益处和风险，更强调绝对而非相对的效果衡量标准；并且，如果开始使用 HT，则定期审查患者继续治疗的需求。
