1 2 3 前言 (menopause) 12 (natural menopause) 51.4 (estrogen) (follicular-stimulating hormone) (menstrual transition, or perimenopause, or climacteric) (menopausal symptoms) (climacteric syndrome) (vasomotor symptoms or hot flushes) 1 二林基督教醫院家庭醫學科住院醫師 2 二林基督教醫院婦產科主任 3 二林基督教醫院家庭醫學科主任 : menstrual transition, menopausal symptoms, climacteric syndrome, hormone therapy 停經症候群主要症狀 ( ) [1] 87 33 (chronic sleep disruption) (1) (2) (thermoregulatory dysfunction) 290 家庭醫學與基層醫療 第十一期
(3) (endogenous opioid peptide withdrawal) (serotonergic system) (noradrenergic system) (adrenergic system) (1) ( ) (2) ( ) (3) (4) (5) ( ) ph 停經症候群主要症狀治療方式 ( ) (1) (estrogen alone or combined hormone therapy) Women's Health Initiative (WHI) 2002 50 77 [2] [3] (standard dose) conjugated estrogen 0.625 mg/day micronized estradiol 17-1 mg/ 家庭醫學與基層醫療 第十一期 291
day (low dose) (conjugated estrogen 0.3~0.45 mg/day micronized estradiol 17-0.5 mg/day) [4.5] (ultra-low dose micronized estradiol 17-0.25 mg/day) conjugated estrogen 17- estradiol 60 2 3 ( 5 ) ( ) 65 (American college of obstetrics and gynecology) 40 50 65 75 (2) (progesterone) (cyclic therapy) (continuous therapy) 12 ( 14 12 ) medroxyprogesterone acetate(mpa) 5 10 mg/day micronized progesterone 200mg/day 2 3 MPA 2.5 mg/day micronized progesterone 100mg/day( ) (3) Tibolone Tibolone (selective tissue estrogen receptor activity regulator, STEAR) tibolone 2.5mg/day tibolone 292 家庭醫學與基層醫療 第十一期
表一有關熱潮紅非雌激素之荷爾蒙治療 藥物 治療劑量 有利證據 副作用 黃體素 MPA Micronized progesterone * 循環投藥 ( 排卵後連續使用 12 天 ) 5~10 mg/day * 持續投藥 2.5mg/day * 循環投藥 ( 排卵後連續使用 12 天 ) 200mg/day * 持續投藥 100mg/day 有 有 循環投藥 : 縮退性出血 (withdrawal bleeding) 其他 : 胃腸不適 憂鬱 增加心血管疾病及乳癌風險 選擇性雌激素之活性受體調節劑 Tibolone 2.5mg/day 有 陰道出血 頭痛 胃腸不 適 體重增加 影響血脂 (HDL TG ) 雄性素 Testosterone 無 血脂異常 陰蒂變大 (clitoromegaly) 多毛和痤 瘡 縮寫 :MPA= medroxyprogesterone 資料來源 :Management of menopausal symptoms. Practice Bulletin No. 141. Obstetrics & Gynecology 2014: 123:202-16. (4) (testosterone) [6] (clitoromegaly) (hirsutism) (acne) (5) 1. (selective serotonin reuptake inhibitors, SSRIs) (selective serotonin-norepinephrine reuptake inhibitors, SSNRIs) SSRIs SSNRIs SSRIs Paroxetine (7.5mg/day) SSNRIs desvenlafaxine (100mg/day) ( ) tamoxifen SSRIs SSNRIs tamoxifen tamoxifen 2. Clonidine Clonidine clonidine 0.1mg/day [7] clonidine 3. Gabapentin Gabapentin - (gamma aminobutyric acid analogue 家庭醫學與基層醫療 第十一期 293
表二有關熱潮紅非荷爾蒙之藥物治療 藥物治療劑量有利證據副作用選擇性血清素再吸收抑制劑 血清素及正腎上腺素再吸收抑制劑 Paroxetin 7.5mg/day 是噁心 口乾 頭暈 失眠 焦慮 便祕 冒汗 Desvenlafaxine 100mg/day 是 噁心 口乾 頭暈 頭痛 失眠 焦慮 心悸 便 祕 冒汗 體重改變 ( 增加和減少皆可能 ) 中樞腎上腺素 α 受體 Clonidine 0.1mg/day 是 口乾 失眠 嗜睡 註 :0.1mg/day 研究證實不會影響血壓 γ- 氨基丁酸相似物 Gabapentin 300mg 2~3 times/day 其他 是 嗜睡 周邊水腫 頭暈 疲勞 體重增加 植物動情素無治療效果及安全性尚有爭議 草藥 無 維生素 E 800IU/day 無資料來源 :Management of menopausal symptoms. Practice Bulletin No. 141. Obstetrics & Gynecology 2014; 123:202-16. GABA analogue) gabapentin 600~900mg/day [8.9] 4. (phytoestrogens isoflavones coumestans lignans) E(vitamin E 800 IU/day) E 5. ( ) (1) (2) (3) Ospemifene 294 家庭醫學與基層醫療 第十一期
Ospemifene SERM ospemifene 60mg/day [10] 2013 結語 paroxetin ospemifene 參考資料 1. Kronenberg F: Hot flashes: epidemiology and physiology. Ann N Y Acad Sci 1990; 592:52 86. 2. Rossouw JE, Anderson GL, Prentice RL et al: Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. Writing Group for the Women's Health Initiative Investigators. JAMA 2002; 288:321 33. 3. Anderson GL, Limacher M, Assaf AR et al: Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women's Health Initiative randomized controlled trial. Women's Health Initiative Steering Committee. JAMA 2004; 291:1701 12. 4. Panay N, Ylikorkala O, Archer DF, Gut R, Lang E: Ultra-low-dose estradiol and norethisterone acetate: effective menopausal symptom relief. Climacteric 2007; 10:120 31. 5. Diem S, Grady D, Quan J et al: Effects of ultralow-dose transdermal estradiol on postmenopausal symptoms in women aged 60 to 80 years. Menopause 2006; 13:130 8. 6. Somboonporn W, Bell RJ, Davis SR: Testosterone for peri and postmenopausal women. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD004509. 7. Nelson HD, Vesco KK, Haney E et al: Nonhormonal therapies for menopausal hot flashes: systematic review and meta-analysis. JAMA 2006; 295:2057 71. 8. Guttuso T Jr, Kurlan R, McDermott MP, Kieburtz K: Gabapentin's effects on hot flashes in postmenopausal women: a randomized controlled trial. Obstet Gynecol 2003;101:337 45. 9. Aguirre W, Chedraui P, Mendoza J, Ruilova I: Gabapentin vs. low-dose transdermal estradiol for treating post-menopausal women with moderate to very severe hot flushes. Gynecol Endocrinol 2010; 26:333 7. 10. Bachmann GA, Komi JO: Ospemifene effectively treats vulvovaginal atrophy in postmenopausal women: results from a pivotal phase 3 study. Ospemifene Study Group. Menopause 2010; 17:480 6. 家庭醫學與基層醫療 第十一期 295