Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY; Division of Endocrinology, Diabetes, and Bone Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY.
Am J Obstet Gynecol. 2020 Dec;223(6):820-833. doi: 10.1016/j.ajog.2020.05.051. Epub 2020 Jun 1.
Heart disease and cancer are the leading causes of death in the United States. In women, the clinical appearance of both entities-coronary heart disease and cancer (breast, endometrium, and ovary)-escalate during the decades of the midlife transition encompassing the menopause. In addition to the impact of aging, during the interval between the age of 40 and 65 years, the pathophysiologic components of metabolic syndrome also emerge and accelerate. These include visceral adiposity (measured as waist circumference), hypertension, diabetes, and dyslipidemia. Osteoporosis, osteoarthritis, sarcopenia, depression, and even cognitive decline and dementia appear, and most, if not all, are considered functionally related. Two clinical reports confirm the interaction linking the emergence of disease: endometrial cancer and metabolic syndrome. One describes the discovery of unsuspected endometrial cancer in a large series of elective hysterectomies performed in aged and metabolically susceptible populations. The other is from the Women's Health Initiative Observational Study, which found a positive interaction between endometrial cancer and metabolic syndrome regardless of the presence or absence of visceral adiposity. Both provide additional statistical support for the long-suspected causal interaction among the parallel but variable occurrence of these common entities-visceral obesity, heart disease, diabetes, cancer, and the prevalence of metabolic syndrome. Therefore, 2 critical clinical questions require analysis and answers: 1: Why do chronic diseases of adulthood-metabolic, cardiovascular, endocrine-and, in women, cancers of the breast and endometrium (tissues and tumors replete with estrogen receptors) emerge and their incidence trajectories accelerate during the postmenopausal period when little or no endogenous estradiol is available, and yet the therapeutic application of estrogen stimulates their appearance? 2: To what extent should identification of these etiologic driving forces require modification of the gynecologist's responsibilities in the care of our patients in the postreproductive decades of the female life cycle? Part l of this 2-part set of "expert reviews" defines the dimensions, gravity, and interactive synergy of each clinical challenge gynecologists face while caring for their midlife (primarily postmenopausal) patients. It describes the clinically identifiable, potentially treatable, pathogenic mechanisms driving these threats to quality of life and longevity. Part 2 (accepted, American Journal of Obstetrics & Gynecology) identifies 7 objectives of successful clinical care, offers "triage" prioritization targets, and provides feasible opportunities for insertion of primary preventive care initiatives. To implement these goals, a reprogrammed, repurposed office visit is described.
心脏病和癌症是美国的主要死亡原因。在美国女性中，这两种实体（冠心病和癌症（乳房、子宫内膜和卵巢））的临床表现都在中年过渡期的几十年中逐渐加重，该过渡期涵盖了绝经。除了衰老的影响外，在 40 岁至 65 岁之间的间隔期间，代谢综合征的病理生理成分也会出现并加速。这些包括内脏肥胖（以腰围衡量）、高血压、糖尿病和血脂异常。骨质疏松症、骨关节炎、肌肉减少症、抑郁症，甚至认知能力下降和痴呆症也会出现，而且大多数（如果不是全部）都被认为是功能相关的。有两项临床报告证实了疾病出现之间的相互作用：子宫内膜癌和代谢综合征。一项描述了在高龄和代谢易感人群中进行的大量选择性子宫切除术系列中发现的意外子宫内膜癌。另一项来自妇女健康倡议观察性研究，该研究发现无论是否存在内脏肥胖，子宫内膜癌和代谢综合征之间存在积极的相互作用。这两项研究都为长期以来怀疑的这些常见实体（内脏肥胖、心脏病、糖尿病、癌症和代谢综合征的患病率）同时发生但变化的平行但可变的发生之间的因果相互作用提供了额外的统计支持。因此，需要分析和回答两个关键的临床问题：1：为什么成年期的慢性疾病——代谢、心血管、内分泌——以及女性的乳腺癌和子宫内膜癌（富含雌激素受体的组织和肿瘤）在绝经后期间出现，并且其发病轨迹加速，而此时几乎没有或没有内源性雌二醇，但是雌激素的治疗应用会刺激它们的出现？2：在多大程度上，这些病因驱动力的识别需要修改妇科医生在女性生命周期的生殖后期照顾患者的责任？这两套“专家评论”的第 1 部分定义了妇科医生在照顾中年（主要是绝经后）患者时面临的每个临床挑战的维度、严重性和相互协同作用。它描述了可临床识别的、潜在可治疗的、驱动这些对生活质量和长寿的威胁的发病机制。第 2 部分（已接受，美国妇产科杂志）确定了成功临床护理的 7 个目标，提供了“分诊”优先级目标，并为插入初级预防保健计划提供了可行的机会。为了实现这些目标，描述了重新编程、重新定位的就诊。
