Second, physical examination, physical examination. Pay attention to whether there are cardiovascular diseases, liver and kidney diseases, obesity, edema, malnutrition diseases and mental-nervous system functional status. Gynecological examination should be routine cervical cytology examination, and pay attention to asexual organ inflammation and tumor. If there is postmenopausal bleeding, staged diagnosis, curettage and endometrial examination should be performed. If cytology is abnormal, cervical multi-point biopsy and curettage of cervical canal should be done. If the ovary is enlarged, the tumor should be ruled out. Routine breast examination.
Three, there are indications of special inspection.
(1) Hormone measurement: including the hormone measurement of HPO axis, adrenal axis, thyroid axis and pancreatic function.
(2) Blood chemistry: including blood calcium, blood phosphorus, blood sugar, blood lipid, BUN and liver and kidney functions. Urine sugar, urine protein. Ca++/C, hydroxyproline /C ratio.
(3) Medical imaging examination: the key point is to diagnose osteoporosis. Including bone mineral density, cortical thickness, single/multi-beam light absorption measurement, neutron activity measurement, CT and MRI examination.
Treatment measures
First, sex hormone therapy is estrogen/progesterone replacement therapy.
(1) indications: vasomotor syndrome, osteoporosis, atrophic vaginitis, early menopause, recurrent or intractable urethritis; Lipoproteinemia.
Contraindications: history of embolism, chronic hepatic and renal insufficiency, sex hormone-dependent tumors (hysteromyoma, endometrial cancer, breast cancer, ovarian cancer), prevention, severe hypertension, diabetes, severe varicose veins, smoking, and failure to adhere to long-term follow-up.
(3) Methods: Oral medication is recommended, and subcutaneous implantation and intramuscular injection are abandoned. Local medication is limited to senile vaginitis and should not be used for a long time.
1. Estrogen-progesterone cycle therapy: a standardized alternative therapy. Combined estrogen 0.625mg/d×25 days (or other estrogens equivalent to this dose), supplemented with secretory progesterone from day16 to day 25 * *10. 3 ~ 6 cycles are 1 course of treatment. Those who draw blood periodically should continue to add progesterone. If blood is not drawn for 3 consecutive cycles, progesterone can be stopped.
2. Simple estrogen cycle therapy: taking an alternative dose of estrogen 25 days a month. Only those who have undergone hysterectomy and have obvious menopausal symptoms. Those who have not undergone hysterectomy and have negative progesterone withdrawal can also try simple estrogen treatment, but they must do/kloc-0 progesterone withdrawal every 2 ~ 3 months. Anyone with positive blood should be treated with estrogen and progesterone cycle. If progesterone withdrawal is negative for three consecutive times, estrogen cycle treatment can be continued, but in principle it should not exceed 3 ~ 6 cycles.
3. Nilestriol therapy: suitable for all menopausal women. 5mg, taken orally within 0 months 1 time. After the symptoms improved, it was changed to 1 ~ 2 mg 1 ~ 2 times a month, and the total effective rate was 75.8 ~ 98.4% (Lu Xiangyun 1984). Advantages: simple, long-acting, and less intimal irritation. The symptoms of vaginitis and urethritis in the elderly have been significantly improved.
4. Estrogen-androgen therapy: suitable for women with breast pain and sexual dysfunction. Estrogen combined with methyltestosterone 5 ~10 mg/d. And can inhibit estrogen and promote intimal hyperplasia.
(4) efficacy
1. Estrogen and progesterone therapy can significantly improve psychosomatic symptoms. The total effective rate is 84-97%. The effective rate of inhibiting flushing is 96% for monoester, 95% for estrogen and progesterone, 9 1% for androgens and 56% for monoester and progesterone. Headache relief rate: estrogen or estrogen-androgen 93%.
2. Estrogen therapy can obviously improve osteoporosis: the fracture rate is reduced from 50 ~ 70% to 3%. However, the fracture rate of androgen or anabolic steroids is still 40%. However, after stopping estrogen therapy, the fracture rate rose to 25%. The ratio of urinary Ca++/C and hydroxyproline /C decreased during estrogen therapy, and further decreased after progesterone therapy, indicating the importance of estrogen and progesterone therapy.
3. Estrogen-progesterone cycle therapy: 97% of women will have periodic bleeding, which will last until the age of 60. 60% of patients aged 60 ~ 65 still have blood drawn, but the menstrual flow is decreasing day by day. Others insist that 17 is normal for blood drawing.
(5) Side effects: Gastrointestinal side effects are related to the dosage and dosage form of estrogen. But women are very tolerant. In order to reduce the side effects, we should follow the principle of individualization, adopt the minimum effective dose, and reduce or stop the drug after the symptoms and signs are relieved.
(6) Clinical trial and follow-up: The key point is to prevent endometrial hyperplasia and canceration, mammary gland hyperplasia and abnormal metabolic changes in the whole body. Those who receive sex hormone replacement therapy will be reviewed or petitioned every 3 months 1 time. 6 months 1 gynecological examination, ultrasound and endometrial biopsy if necessary. Breast examination should pay attention to lobular hyperplasia or mass, and pay attention to the monitoring of heart, liver, gallbladder and blood functions.
Secondly, drug therapy includes: α2 receptor agonists, β adrenergic blockers, sedatives-anxiolytics and antidepressants.
Clonidine is a derivative of α2 receptor agonist and central antihypertensive drug imidazoline, which has a good effect on preventing flushing, especially on nocturnal attacks, hyperhidrosis and insomnia. The initial dose is 0.075mg×3/d, which can be gradually increased to 0.45 ~ 0.9 mg/d, and the side effects are dizziness, drowsiness and dry mouth.
Beta-adrenergic blockers, such as Liu Anxin Ding, can relieve palpitations. Sedatives such as diazepam and phenobarbital and antidepressants such as imipramine and doxepin are only used when mental and neurological symptoms are obvious.
The combination of calcium, vitamin D, calcitonin and fluoride with sex hormones can effectively inhibit the development of osteoporosis and reduce the fracture rate. See the chapter on osteoporosis for details.
Third, mental health care and prevention and treatment of systemic diseases.
The physical and mental health care of menopausal women is the task of the whole society. Strengthen social health education and health care measures, set up health care consultation clinics, have regular physical examinations, actively prevent and treat psychosomatic diseases prone to menopause, and make early diagnosis and treatment of cardiovascular diseases, osteoporosis, endocrine and metabolic diseases and tumors. Organize the self-care of menopausal women to reduce the occurrence of menopausal syndrome.
clinical picture
The main manifestation of early menopause is vasomotor syndrome; In the later period (> 5 years), aging diseases of various organs and systems appeared one after another.
First, symptoms related to estrogen deficiency
(1) vasomotor syndrome: the incidence rate is 75-85% during postmenopausal 1-5 years. The incidence of 1 ~ 6 weeks after double ovariectomy in patients under 25 years old was 76%.
Vasodilator syndrome is a syndrome characterized by paroxysmal attacks, flushing, spontaneous sweating and palpitation caused by estrogen deficiency and autonomic nervous dysfunction. Flushing starts from the face, neck and chest, and then spreads to the lower abdomen, trunk and limbs. The blood vessels of the skin are dilated, the skin is ruddy and congested, and the temperature rises, accompanied by headache, dizziness, palpitation, irritability and dry mouth. In order to dissipate heat, patients often undress, bare their arms, open windows, fan or go outdoors to drive away heat. Flushing lasts for 3 ~ 4 minutes, and then ends with sweating, vasoconstriction and normal body temperature. The attack period was 54 10 minutes. During the night attack, Dotu woke up from his dream, sweating profusely, his clothes and quilt were soaked, accompanied by insomnia and anxiety. The next day, I was unconscious and forgetful, accompanied by nausea, vomiting, dizziness and other discomfort.
The mechanism of flushing: ① GnRH neurons in the preoptic area of hypothalamus have direct synaptic and neural connections with adjacent thermoregulatory neurons, so the functional changes of GnRH neurons will affect the latter; ② Postmenopausal estrogen deficiency can increase the activity of norepinephrine through feedback, thus stimulating the release activity of GnRH and activating the heat dissipation mechanism through neural connection. Flushing attack is related to GnRH fluctuation and norepinephrine activity fluctuation; ③ Dopamine and β -endorphin energy in central nervous system and hypothalamus.