Hill D Ashley, Crider Mark, Hill Susan R
University of Central Florida College of Medicine, Orlando, FL, USA.
Orlando, FL, USA.
Am Fam Physician. 2016 Dec 1;94(11):884-889.
The results of large clinical trials have led physicians and patients to question the safety of hormone therapy for menopause. In the past, physicians prescribed hormone therapy to improve overall health and prevent cardiac disease, as well as for symptoms of menopause. Combined estrogen/progestogen therapy, but not estrogen alone, increases the risk of breast cancer when used for more than three to five years. Therefore, in women with a uterus, it is recommended that physicians prescribe combination therapy only to treat menopausal symptoms such as vasomotor symptoms (hot flashes) and vaginal atrophy, using the smallest effective dosage for the shortest possible duration. Although estrogen is the most effective treatment for hot flashes, nonhormonal alternatives such as low-dose paroxetine, venlafaxine, and gabapentin are effective alternatives. Women with a uterus who are using estrogen should also take a progestogen to reduce the risk of endometrial cancer. Women who cannot tolerate adverse effects of progestogens may benefit from a combined formulation of estrogen and the selective estrogen receptor modulator bazedoxifene. There is no highquality, consistent evidence that yoga, paced respiration, acupuncture, exercise, stress reduction, relaxation therapy, and alternative therapies such as black cohosh, botanical products, omega-3 fatty acid supplements, and dietary Chinese herbs benefit patients more than placebo. One systematic review suggests modest improvement in hot flashes and vaginal dryness with soy products, and small studies suggest that clinical hypnosis significantly reduces hot flashes. Patients with genitourinary syndrome of menopause may benefit from vaginal estrogen, nonhormonal vaginal moisturizers, or ospemifene (the only nonhormonal treatment approved by the U.S. Food and Drug Administration for dyspareunia due to menopausal atrophy). The decision to use hormone therapy depends on clinical presentation, a thorough evaluation of the risks and benefits, and an informed discussion with the patient.
大型临床试验的结果让医生和患者对更年期激素疗法的安全性产生了质疑。过去，医生开激素疗法是为了改善整体健康状况、预防心脏病以及缓解更年期症状。联合雌激素/孕激素疗法（而非单独使用雌激素），使用超过三到五年会增加患乳腺癌的风险。因此，对于有子宫的女性，建议医生仅在使用最小有效剂量并尽可能短疗程的情况下，开联合疗法来治疗潮热和阴道萎缩等更年期症状。虽然雌激素是治疗潮热最有效的方法，但低剂量帕罗西汀、文拉法辛和加巴喷丁等非激素替代疗法也是有效的选择。正在使用雌激素的有子宫的女性也应服用孕激素以降低子宫内膜癌的风险。无法耐受孕激素不良反应的女性可能会从雌激素与选择性雌激素受体调节剂巴多昔芬的联合制剂中获益。没有高质量、一致的证据表明瑜伽、有节奏的呼吸、针灸、运动、减压、放松疗法以及黑升麻、植物产品、ω-3脂肪酸补充剂和中药等替代疗法比安慰剂更能使患者受益。一项系统评价表明，豆制品对潮热和阴道干燥有适度改善，一些小型研究表明临床催眠能显著减轻潮热。患有更年期泌尿生殖综合征的患者可能会从阴道雌激素、非激素阴道保湿剂或奥培米芬（美国食品药品监督管理局批准的唯一用于治疗绝经后萎缩引起的性交困难的非激素疗法）中获益。是否使用激素疗法取决于临床表现、对风险和益处的全面评估以及与患者的充分沟通。
