Let’s look at MHT menopause-related hormone supplementation therapy with respect to breast issues. First, we review the three main indications for menopausal hormone therapy: (i) when there are menopausal symptoms; (ii) when there are symptoms related to urogenital tract atrophy; and (iii) for the prevention of osteoporosis, including postmenopausal osteoporosis or the presence of risk factors for osteoporosis. With the three indications, contraindications must be excluded, and the benefits of using hormone therapy during the treatment window (age <60 years, menopause <10 years) far outweigh the disadvantages, and there are also cautionary indications in our country, but in foreign countries there are only indications and contraindications, not cautionary indications. When menopause-related hormone therapy is used, estrogen can not only maintain female appearance and improve menopausal symptoms, but also protect our bones, cardiovascular protection, brain protection, and prevention of Alzheimer's disease. We women have estrogen receptors from head to toe, and estrogen is very important for women. When menopausal women are supplemented with estrogen, the immediate effect is an improvement in menopausal symptoms that is noticeable. Menopausal symptoms work immediately with estrogen, but the cardiovascular, bone and brain benefits of estrogen are not visible for the time being and only become apparent after a longer period of time. I think the most important benefits of hormone therapy for women after menopause are the latter ones: cardiovascular protection, bone protection, and prevention of Alzheimer's. These are the most important ones. In the past, many people passed menopause without hormone therapy; however, when these problems occur, we cannot survive them even if we want to: if osteoporosis and fractures occur, we will be paralyzed in bed; if myocardial infarction occurs, it will endanger our lives; if Alzheimer's disease occurs, these diseases cannot be overcome by gritting our teeth. So I think the biggest benefit of menopausal hormone therapy is these benefits that cannot be seen immediately at the time, but can be manifested after prolonged use. When it comes to menopausal hormone therapy, we are most worried about two problems: one is the problem of blood clots, and the other is the problem of breast, and today we will focus on breast-related problems. Compared to Europeans and Americans, Chinese people have two major characteristics of MHT: (1) the risk of blood clots is the lowest; (2) the risk of breast cancer is also the lowest. The incidence of breast cancer among American women is 6 times higher than that of Chinese, which is of course related to their genes. We all know that women in Europe and the United States have large breasts, their breast structure is more fat and less glandular, this ratio is prone to breast cancer; while the Chinese are the opposite, it is more glandular and less fat, this ratio itself is not prone to breast cancer. It takes years or decades for a cancer cell to develop into a small nodule that can be seen clinically with ultrasound or mammogram. If there are no cancer cells when MHT is used, then hormone therapy will not induce the growth of breast cancer cells; if cancer cells are already present at the time of use, but cannot be seen by ultrasound or mammogram at that time, then using hormone therapy may induce the cancer to grow, but this effect is still less than the effect of obesity and alcohol consumption on breast cancer. In Europe and the United States, the incidence of breast cancer increases with age, but in our China, the peak age of breast cancer incidence is about 10 years earlier than women in Europe and the United States, that is, before menopause is instead the high incidence of breast cancer in China, and those who need post-menopausal hormone therapy are no longer the high incidence of breast cancer. Therefore, the incidence of breast cancer is lower in Chinese, both genetically and in terms of peak incidence, with postmenopausal hormone supplementation. Most common diseases of the breast: ① mammary hyperplasia; ② fat necrosis; ③ fibrocystic changes; ④ papilloma in the milk ducts. MHT can be used for mammary hyperplasia; fat necrosis and fibrocystic lesions without hyperplasia have a very low cancer rate and can be used for MHT; for intraductal papilloma, there is about 7% probability of malignancy and up to 35% malignancy rate for multiple cases, and the probability of cancer in intraductal papilloma is significantly increased. For breast lesions with no significant increase in cancer rate, after a thorough evaluation of the indications and contraindications for MHT and after fully informing the patient of the condition and treatment options, the safer tibolone or transdermal hormone therapy can be used; for breast lesions with a significant increase in cancer rate, specialist consultation is recommended for surgical treatment if necessary. Patients with a history of intraductal papilloma and obvious menopausal symptoms (for which there is an indication) need to undergo relevant examinations and are recommended to go to the mammography department for further examination, and after excluding contraindications, MHT can be used; if patients do not want to use MHT, they can use Livermin or Quintax, which can even be used for patients with contraindications to MHT and are safer. The main hormone associated with breast cancer when treated with menopause-related hormone supplementation is synthetic progestin, so natural progestins are recommended for MHT. Here is a look at the relative risk values for breast cancer caused by using different progestins and estrogens If the estrogens are the same and the progestins are different: the relative risk value for natural progesterone is 1, the relative risk value for the use of dydrogesterone is 1.16, the relative risk value for medroxyprogesterone is 1.27, and the relative risk value for norethindrone is 1.69, from which we can see that the use of synthetic progestins, especially those derived from testosterone derivatives, increases the risk of breast cancer; if the progestins are the same and different estrogens are used, the relative risk value for oral The relative risk value for oral estrogen is 1.38, for transdermal estrogen is 1.08, for estrogen alone (in patients without uterus) is 0.97 and for Levitra is 0.86, so Levitra can even reduce the incidence of breast cancer; the relative risk value for sequential treatment with estrogen and progestin cycles (menstrual regimen) is 1.33 and for continuous combined treatment (non-menstrual regimen) is 1.33. There was no significant difference in the risk with a relative risk value of 1.29 for the menstruation regimen. Therefore, to reduce the risk of breast cancer, transdermal estrogen or Levitra can be used. There are 2 options for menopausal hormone therapy in patients with a uterus: the menstrual regimen and the non-menstrual regimen. Regardless of the regimen, the goal is to get the estrogen in and the only purpose of progestin supplementation is to counteract the proliferative effect of estrogen on the endometrium for patients with a uterus. So estrogen alone is fine for those without a uterus, no progestin supplementation is needed. When to use the non-menstrual regimen and when to use the non-menstrual regimen? Generally speaking, the non-menstrual regimen can be used after 1 year of menopause. But the patient wants to have a period, is it possible? It is perfectly fine, because our goal is to get estrogen in. Therefore, the choice of the regimen: ① depends on the patient's wishes. If the patient especially wants to have menstruation, we will use the non-menstrual regimen; ② for patients who have just entered menopause, using the non-menstrual regimen directly may cause unintended bleeding during the use process, which will reduce the patient's confidence in hormone therapy, so it is better to use the menstrual regimen and then gradually switch to the non-menstrual regimen later. This will reduce unintended bleeding during hormone use and can increase the patient's confidence in using hormone therapy. When using MHT, the more common symptoms are: ① breast swelling and pain. It is necessary to explain to the patient that since the breast is an estrogen-sensitive organ, breast swelling and pain indicate that estrogen is already working in the body, so do not worry about it, and the symptoms will disappear after a period of adaptation; ② irregular bleeding. Since relevant examinations have been done before using MHT and endometrial lesions have been excluded, there is no need to worry about it. For irregular bleeding in the menstrual program, such as bleeding when using Clomid, bleeding is not much continue to finish this course of treatment; bleeding is much, stop the drug completely and wait for the blood to be clean to review the ultrasound. If the endometrium is <0.5cm, continue to take the second box of Clomid (the previously unused Clomid is not used up, start from a new box). For irregular bleeding in the non-menstrual program, a small amount of bleeding can be continued, more bleeding will be stopped and an ultrasound will be done after the bleeding is clean. If the endometrium is less than 0.5cm, continue to use; if it is greater than 0.5cm, further examination is required. The specific treatment plan when irregular bleeding occurs in the non-menstrual program (continuous combined use of estrogen and progestin): 1. Stop using the drug first and review the ultrasound after the bleeding stops, if the thickness of the endometrium is less than 0.5cm, you can continue to use it; 2. If the endometrium is less than 0.5cm, then continue to use Anjingyi; 4. When you continue to use the drug, you can add progesterone for 10 days in the second half of the cycle, and use it for 3 cycles to do regular withdrawal, and do ultrasound after the bleeding stops, if the endometrium is less than 0.5cm, continue to use it. So how long to use MHT? It depends on the purpose of the medication, if it is to improve menopausal symptoms, short-term use is sufficient; if it is for the protection of bones, cardiovascular protection, prevention of Alzheimer's disease, annual routine check-ups, as long as there is no contraindication, the expected benefits outweigh the risks, you can always use, there is no time limit.