Hormone therapy: During the menopausal transition, the restructuring of hormonal homeostasis causes a number of changes in the female body, which negatively affect the quality of life and can lead to the formation of chronic diseases.
Hormonal therapy (contraception) and prevention of unwanted pregnancy
Hormonal contraception (combined and purely gestational) is widely used in gynecological practice, and the need for its appointment for the purpose of preventing pregnancy persists until the onset of menopause. Hormonal contraceptives are based on progestins-derivatives of nortestosterone, 17-hydroxyprogesterone or spironolactone. They are used as monopreparations or in combination with estrogens (ethinyl estradiol, estradiol, etc.), the main purpose of which is to level the side effects of progestogens.
Hormonal contraceptives have many positive non-contraceptive properties. Reducing the risk of ovarian cancer directly depends on the duration of combined oral contraception, and this effect persists up to 20 years after discontinuation of the method. The same is true for reducing the risk of endometrial cancer, which correlates with the duration of use of combined oral contraceptives and is observed for more than 20 years after their withdrawal. Combined oral contraceptives also reduce the risk of colorectal cancer and, without significantly affecting the risks of other malignancies, generally reduce the cancer risk. In addition, there is evidence of proven therapeutic or preventive effects of combined hormonal contraception (CGC) in relation to a number of gynecological and extragenital diseases and conditions.
But even if there are additional indications in the instructions for the use of the contraceptive drug, hormonal contraception remains primarily a method of preventing pregnancy. Ignoring this circumstance, recommending a contraceptive to a patient who does not live a sexual life, or is absolutely unable to conceive, or who wants to become pregnant, is possible only in cases where there is no alternative way to resolve a clinically significant problem. However, it is during the menopausal transition against the background of a decrease in sexual activity and the ability to conceive that complaints of menstrual cycle disorders often appear, requiring the appointment of therapy, not contraception.
Menopausal hormone therapy and correction of menopausal disorders
The late phase of the menopausal transition begins with the prolongation of menstrual delays up to 60 days and the appearance of episodes of amenorrhea, characterized by an increase in the frequency of anovulatory cycles. The duration of this stage of reproductive aging is usually one to three years before menopause. Do not forget about stimulating ovulation with clomid. There is an opinion that the secretion of estradiol at this time steadily decreases, and the level of follicle-stimulating hormone increases. However, monitoring of hormonal indicators demonstrates their significant variability and the possibility of periodic return to the premenopausal range. Given such significant fluctuations in the secretion of follicle-stimulating hormone, it is not recommended to use the determination of its concentration in the blood to clarify the status of the reproductive system. Like the early phase of the menopausal transition, the late phase is established clinically by the appearance of intermenstrual intervals, the duration of which exceeds 60 days.
Of course, the clinical criteria for entering the menopausal transition are valid only if the initial regular rhythm of menstruation and the non-use of hormonal drugs that simulate the menstrual rhythm. If it is impossible to establish the status of the reproductive system clinically, the average population characteristics should be used, according to which the majority of women enter perimenopause after 45 years. Starting from this age, complaints of hot flashes and other vasomotor and psychosomatic symptoms signal the onset of a late phase of the menopausal transition associated with estrogen deficiency, and require MGT. There may be a reasonable objection: according to the instructions for the use of MGT drugs, they are recommended to be prescribed to women during the menopausal transition with a duration of menstruation delay of more than six months. Why do the instructions and clinical recommendations of international and expert communities contradict each other?
Thus, vasomotor and psychosomatic symptoms caused by estrogen deficiency, which not only negatively affect the quality of life, but also reflect delayed health problems, become the main starting point in solving the issue of MHT. Waiting for six months of amenorrhea to initiate MGT is advisable when a woman’s complaints are insignificant, do not violate the quality of life and, accordingly, call into question the very need for treatment.
Principles of prescribing hormone therapy
After studying the characteristics of the three types of hormone therapy and the indications for their appointment, it becomes clear that the choice of one or another of them will depend on the status of the reproductive system, evaluated clinically or, if such an approach is impossible, established presumably by the age of the patient.
Contraception will be the first in the order of use of hormone therapy methods, which is built depending on the age. Recommendations on the specifics of the primary appointment of KGC come into force when consulting women over 35 years old, that is, long before the beginning of the menopausal transition.
The main concern when using hormonal contraception is the risk of thrombosis due to the action of the estrogenic component. The generalized data indicate a low frequency of thrombotic complications of KGC: the frequency of acute conditions caused by thrombosis is 6-9. 9 cases per 10,000 women per year. These conditions are usually represented by venous thromboembolism. The risk of myocardial infarction increases exclusively in women who smoke, and a twofold increase in the risk of ischemic stroke does not look so threatening due to its rarity in the population of women of fertile age (1 case per 10,000 women per year) and dependence on other factors, especially migraines.
Nevertheless, the increased risk of thrombotic complications in the older age group imposes a number of restrictions on the use of KGK, including in women who smoke or patients with migraine. In the absence of contraindications to taking KGK, only those drugs that contain estradiol or a microdose of ethinyl estradiol are suitable for primary administration. Minimizing the effect of the estrogenic component allows not only to reduce thrombotic risks, but also to reduce the likelihood of estrogen-dependent weight gain associated with fluid retention, as well as to increase the level of triglycerides entering the fat depots. Overweight is an additional risk factor for thrombosis in adult women, which deserves attention in the process of individual selection of a contraceptive.
If there are appropriate indications and there are no contraindications, drugs of sex steroid hormones and their combinations can be used in the periods of late reproduction, menopausal transition and postmenopause, providing a high quality of life and prevention of diseases associated with aging. The skillful use of this resource is really able to provide women with active longevity.
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