Division of Obstetrics and Gynecology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
Azienda USL Toscana Nord Ovest, Pisa, Italy.
Hum Reprod Update. 2021 Oct 18;27(6):1115-1150. doi: 10.1093/humupd/dmab026.
Menopausal symptoms can be very distressing and considerably affect a woman's personal and social life. It is becoming more and more evident that leaving bothersome symptoms untreated in midlife may lead to altered quality of life, reduced work productivity and, possibly, overall impaired health. Hormone therapy (HT) for the relief of menopausal symptoms has been the object of much controversy over the past two decades. At the beginning of the century, a shadow was cast on the use of HT owing to the concern for cardiovascular and cerebrovascular risks, and breast cancer, arising following publication of a large randomized placebo-controlled trial. Findings of a subanalysis of the trial data and extended follow-up studies, along with other more modern clinical trials and observational studies, have provided new evidence on the effects of HT.
The goal of the following paper is to appraise the most significant clinical literature on the effects of hormones in postmenopausal women, and to report the benefits and risks of HT for the relief of menopausal symptoms.
A Pubmed search of clinical trials was performed using the following terms: estrogens, progestogens, bazedoxifene, tibolone, selective estrogen receptor modulators, tissue-selective estrogen complex, androgens, and menopause.
HT is an effective treatment for bothersome menopausal vasomotor symptoms, genitourinary syndrome, and prevention of osteoporotic fractures. Women should be made aware that there is a small increased risk of stroke that tends to persist over the years as well as breast cancer risk with long-term estrogen-progestin use. However, healthy women who begin HT soon after menopause will probably earn more benefit than harm from the treatment. HT can improve bothersome symptoms, all the while conferring offset benefits such as cardiovascular risk reduction, an increase in bone mineral density and a reduction in bone fracture risk. Moreover, a decrease in colorectal cancer risk is obtainable in women treated with estrogen-progestin therapy, and an overall but nonsignificant reduction in mortality has been observed in women treated with conjugated equine estrogens alone or combined with estrogen-progestin therapy. Where possible, transdermal routes of HT administration should be preferred as they have the least impact on coagulation. With combined treatment, natural progesterone should be favored as it is devoid of the antiapoptotic properties of other progestogens on breast cells. When beginning HT, low doses should be used and increased gradually until effective control of symptoms is achieved. Unless contraindications develop, patients may choose to continue HT as long as the benefits outweigh the risks. Regular reassessment of the woman's health status is mandatory. Women with premature menopause who begin HT before 50 years of age seem to have the most significant advantage in terms of longevity.
In women with bothersome menopausal symptoms, HT should be considered one of the mainstays of treatment. Clinical practitioners should tailor HT based on patient history, physical characteristics, and current health status so that benefits outweigh the risks.
更年期症状可能非常令人痛苦，并严重影响女性的个人和社交生活。越来越明显的是，在中年时期不治疗烦人的症状可能会导致生活质量下降、工作效率降低，甚至可能整体健康状况受损。激素治疗（HT）缓解更年期症状在过去二十年中一直备受争议。本世纪初，由于对心血管和脑血管风险以及乳腺癌的担忧，一项大型随机安慰剂对照试验的发表，给 HT 的应用蒙上了阴影。试验数据亚分析和扩展随访研究的结果以及其他更现代的临床试验和观察性研究为 HT 的影响提供了新的证据。
本论文的目的是评估关于绝经后妇女激素作用的最重要的临床文献，并报告 HT 缓解更年期症状的益处和风险。
使用以下术语在 Pubmed 上进行临床试验搜索：雌激素、孕激素、巴多昔芬、替勃龙、选择性雌激素受体调节剂、组织选择性雌激素复合物、雄激素和更年期。
HT 是治疗烦人的更年期血管舒缩症状、泌尿生殖系统综合征和预防骨质疏松性骨折的有效方法。应该让女性知道，中风的风险会略有增加，并且长期使用雌激素-孕激素会增加乳腺癌的风险。然而，绝经后不久开始 HT 的健康女性可能会从治疗中获得更多的益处而不是危害。HT 可以改善烦人的症状，同时带来心血管风险降低、骨密度增加和骨折风险降低等益处。此外，接受雌-孕激素治疗的女性可以降低结直肠癌的风险，并且接受结合型马雌激素单独或与雌-孕激素联合治疗的女性观察到总体但无统计学意义的死亡率降低。在可能的情况下，应优先选择经皮途径给予 HT，因为它对凝血的影响最小。对于联合治疗，应首选天然孕激素，因为它没有其他孕激素对乳腺细胞的抗凋亡作用。开始 HT 时，应使用低剂量并逐渐增加，直到有效控制症状。除非出现禁忌症，否则只要益处大于风险，患者可以选择继续 HT。必须定期重新评估女性的健康状况。在 50 岁之前开始 HT 的早发性绝经女性在长寿方面似乎获益最大。
对于有烦人的更年期症状的女性，HT 应被视为治疗的主要方法之一。临床医生应根据患者的病史、身体特征和当前健康状况来调整 HT，以使益处大于风险。
