Women generally begin to experience ovarian hypofunction after the age of 40, resulting in estrogen deficiency and eventually a range of physical and psychological symptoms around the time of menopause. To improve the health and quality of life of older women, hormone replacement therapy (HRT) has become an indispensable health care and treatment tool. Since the 1960s, basic, clinical and epidemiological research on HRT during menopause has developed rapidly, and people’s understanding of HRT has also changed greatly, and there are concerns about its safety, especially the risk of malignant tumors after HRT has been a hot topic of research. So, is the application of hormone replacement more beneficial or harmful? Combined with the development of research and the change of people’s concept, we can get some inspiration from it.
1. The understanding of menopause and HRT
In the early days, people’s understanding of the indications of HRT was non-selective and they thought there were only benefits but no disadvantages. With the improvement of experience and technology, the content of understanding has changed and we know the contraindications and cautions of HRT that we did not pay attention to before. Through practice, it is found that reasonable HRT can significantly alleviate and improve menopausal syndrome and effectively prevent cardiovascular disease and osteoporosis, etc. Therefore, the selection of cases and the mastery of indications are very important.
2.Benefits of HRT
2.1 Treatment of menopausal syndrome
HRT is very effective in relieving short-term or long-term menopausal syndromes, such as vasodilatory symptoms, vaginal and other genitourinary symptoms, and psychological or emotional changes. It has been reported that more than 50% of postmenopausal women have symptoms such as hot flashes, night sweats and insomnia, and the effective rate is 90%-95% after 8 weeks of medication.
2.2 Prevention of postmenopausal osteoporosis
Postmenopausal women lose 2%-3% of cortical bone and 5%-8% of marrow bone every year, which results in severe osteoporosis (PMOP).
most often causes hip fractures. The lifetime risk of hip fracture in women is greater than the combined risk of breast, endometrial and ovarian cancers, making PMOP one of the main therapeutic goals of HRT. HRT prevents the rapid loss of bone mass, thus stabilizing bone density and reducing the incidence of osteoporotic fractures. If HRT is used for more than 6 years, the risk of hip or wrist fracture can be reduced by 50%, and the incidence of vertebral deformity can be reduced by 90%, but once HRT is stopped, bone loss will be accelerated again.
2.3 Prevention of coronary heart disease
HRT supplements estrogen, which is physiologically necessary, to maintain normal lipid metabolism and has a protective effect on the heart.
2.4 Prevention of Alzheimer’s disease
Alzheimer’s disease (AD) is the most common type of dementia, and women are more likely to suffer from it. The hippocampus, which has a memory function in the human brain, contains estrogen and its receptors, and the level of serum estrone sulfate (the main estrogen in postmenopausal women) is lower in AD patients than in women of the same age. Current neurological studies, animal behavioral studies, and population studies suggest that estrogen may be beneficial in improving cognitive function and mood in AD patients. Computerized tests of cognitive speed and cognitive accuracy and positive ion emission tomography measurements of brain glucose metabolism have also found that estrogen may improve cognitive and memory function to some extent, and has anti-aging effects. Some studies have demonstrated a dose-effect relationship between HRT and AD, suggesting that the longer estrogen is used and the higher the dose, the better the effect. However, this inevitably increases the side effects, restricts its use, and affects the therapeutic effect, resulting in contradictions.
3. Disadvantages of HRT
The current research shows that HRT has no adverse effects on blood pressure and blood sugar in postmenopausal women, but the application of HRT to patients with hypertension and diabetes needs to be carefully monitored. Whether long-term application of HRT causes cancer is the most concerned issue. At present, it is believed that HRT does not increase the risk of genital tract squamous cancer, and may not increase the occurrence of ovarian, cervical and vaginal cancers. However, in general, the risk of cancer caused by HRT in the study results is more increased and less decreased.
3.1 Coronary heart disease
After 1998, seven large-scale clinical trials of HERS, ERA, and WHI on the prevention of recurrence (i.e., secondary prevention) of HRT in postmenopausal women with CHD found that HRT was not beneficial to CHD and increased the occurrence of venous embolism and breast cancer. Therefore, it is generally accepted that HRT should not be used for primary and secondary prevention of CHD.
3.2 Breast Cancer
The duration of HRT application has a certain relationship with the occurrence of breast cancer. According to an overseas survey, the risk of breast cancer in women who use HRT increases by 2.3% every year. However, the risk of developing breast cancer within 5 years is still low. At present, people prefer that the risk of breast cancer does not increase for those who have used HRT for less than 10 years, and the risk factor only increases by 1.3% to 1.5% for those who have used HRT for more than 10 years. Some scholars believe that since women who use HRT can have regular preventive mammograms, they can detect early and limited cancer in time, and their prognosis is better than that of non-users, because the latter are mostly found at an advanced stage. HRT should be used cautiously in the high-risk group of breast cancer and breast cancer patients, and regular follow-up is necessary for long-term HRT users.
3.3 Endometrial cancer
The use of estrogen replacement therapy may increase the chance of endometrial cancer, which is one of the earliest and most concerned issues. The use of estrogen replacement therapy alone, which causes endometrial cancer, once decreased the use of estrogen by 40%, but later, with the cyclical addition of progestin, it seemed to solve this problem. However, this was not the case, but only partially, because a large number of studies have demonstrated that although the incidence of endometrial cancer is significantly lower with the addition of progestin than with estrogen alone, it does not completely reduce the risk of estrogen cancer to the same level as that of non-HRT users. However, most of these endometrial cancer patients are diagnosed as stage I or II and have a 5-year survival rate of more than 80% after regular treatment. Currently, the mainstay of HRT is the combination of estrogen and progestin, and regular cancer screening is necessary.
To sum up, in the process of applying HRT, some contradictory phenomena appear, and it is the key to the success or failure of the whole work whether these contradictory phenomena can be analyzed and dealt with rationally, so that patients can achieve the best effect and avoid the occurrence of adverse reactions as much as possible.
4.The principle of individualized treatment
The clinical application in the past half century has proved the positive effect of HRT on relieving menopausal syndrome and preventing menopause-related diseases, but also found its serious side effects and contraindications and cautions, so it can be said that HRT is a double-edged sword. The key to the correct use of HRT is to strictly control the contraindications, cautions, administration methods and doses. Therefore, the basis for the safety and efficacy of HRT is to realize the individualized administration of HRT in clinical practice. The principle of individualization requires doctors to apply the principle of the relationship between the general and the specific, and the general and the individual when making the choice, and to decide to use HRT according to the risk of special people,
Weighing the advantages and disadvantages, we decide to adopt HRT and make specific plans.
5.Guided by the system view
A system is a unified organic whole with specific functions composed of interrelated and interacting elements according to a certain structure. The system is not a simple mechanical addition of elements, but a qualitative change in the functional characteristics of the elements constituting the system due to the coherence of the elements, and the emergence of new characteristics and new laws of motion that individual elements do not have. Modern medical model believes that the patient is a complete “social-psychological-physical” organic unity, which can be regarded as a system, and all adverse stimuli, inappropriate lifestyle, behavior and environmental factors can lead to the occurrence of disease. Treatment also emphasizes an integrated approach, not only focusing on the improvement of clinical symptoms, but also on improving the quality of life of patients and achieving comprehensive physical and mental health. Therefore, the World Health Organization is now actively advocating a multi-level intervention approach, suggesting that HRT and its supporting drugs, quantitative analysis and supplementation of nutrition, control of health care intake, control of environmental hormones or harmful substances, quantitative guidance of exercise, rehabilitation treatment, guidance of lifestyle habits and spiritual and psychological counseling should be considered as comprehensive measures in clinical practice. And gradually establish a quality assurance system for menopausal women’s health care. Since menopause involves endocrinology, gynecology, internal medicine, neurology, orthopedics and geriatrics, the only way to solve menopause-related problems in a comprehensive and systematic way is to develop menopause outpatient clinics in hospitals in conjunction with multiple disciplines and to establish a well-equipped comprehensive health care guidance center that specializes in serving middle-aged and elderly women, and to realize a quality assurance system in the center.