1. 1 Clinical Practice Guidelines 40-59 18 2533 24 2548 2563 28 74.7 70.2 40-59 ( Menopausal Symptoms ) , 1. ( Perimenopause ) 2 8 1 2. ( menopause ) 3. ( Postmenopause ) Menopausal Symptoms 4 1. Somatic Symptoms Urogenital Atrophy Senile vaginitis , urethritis , 2. Psychological Symptoms , , , , , , , , , ,

2. 2 3. Vasomotor Symptoms hot flushes 3-4 hot flushes 4. Sexual Symptoms ( Hormonal Therapy ) Women s Health Initiative ( WHI-I ) JAMA July 17,2002 Randomize , double blind , placebo controlled trial ( 2548 ) Benefits ( ) Risks ( ) 1. Vasomotor Symptoms 2. Urogenital Symptoms 3. Osteoporosis Fracture 4. Colorectal cancer 5. Endometrial cancer ( EPT ) uncertainty ? - Cognitive Function - quality of life 1. Venous thromboembolism 2. Cardiovascular disease 3. Stroke 4. Cancer - Breast ( EPT ) - Endometrium ( ET ) - Ovarian ? EPT = Estrogen Progestogen therapy ET = Estrogen therapy

3. 3 ( Golds of therapy ) 1. menopausal symptoms Vasomotor Urogenital Symptoms 2. Osteoporotic fracture 2 Hormonal Therapy ( HT ) Hormonal Replacement Therapy ( HRT ) ( Absolute Contraindications ) 1. estrogen 2. ( venous thrombosis / venous Thrombophlebitis ) 3. 4. ( Relative Contraindications ) 1. ( > 70 ) , High breast density , breast cell atypia , high bone mineral density , Family history of breast cancer in 1st degree relatives , late menopause ( > 55 ) , late first delivery ( > 30 ) , high body mass index ( BMI > 30 ) 2. ( Coronary heart disease ) ( Cerebrovascular disease Stroke ) 3. , , 4. Malignant melanoma , ( Myoma uteri ) , ( Endometriosis ) , Adenocarcinoma ( . . XVI FIGO World Congress of Gynecology and Obstetrics , Washington , D.C. , September 2000 44-63 - ( WTH ) > 0.49 dyslipidemia 66 - ( WHR ) > 0.8 dyslipidemia 58 - > 78.0 . dyslipidemia 57.6 )

4. 4 1. 2. 3. CBC, FBS , BUN/Cr. , LFT , Lipid profile EKG 50 Chest X-ray Mammogram ( ) ( CPG menopausal osteoporosis) Urogenital 5 4-5 3 1. dose ( dose taper ) CEE 0.625 . 0.3 . 2. ( dosing interval taper ) 3 3. ( day taper ) 7 6

5. 5 HT Estrogen 1 Estrogen - gel ( Divigel ) - ( Climara ) - Premorin 0.3 , 0.625 - Estradiol 1 . ( Estrofem ) - Estradiol valerate 1 . ( Progynova ) 2 Estrogen Estrogen Urogenital Symptoms Estrogen Urogenital Symptoms Estrogen

6. 6 ( HT ) Estrogen + Progestogen Cyclic sequential ( CSR ) Continuous Combined ( CCR ) Perimenopause Early postmenopause Postmenopause - estrogen 28 + progestogen 12 4-5 - estrogen 21 Progestogen 10-14 cycloprogynova 7 - estrogen progestogens - Premarin ( 0.3 0.625 ) + MPA 2.5 . - Premarin 0.3 . + MPA 1.5 . ( Premelle lite ) - estradiol 1 . + NETA 0.5 . ( Activelle ) - Tibolone 2.5 . ( Livial )

7. 7 Dose progesterone progestogens endomotrium ( ) Progesterone + Progestogens ( Cyclic sequential ) ( Continuous Combined ) Progesterone microniszed Dydrogesterone Medroxyprogesterone acetate Norethisterone Cyproterone acetate 200-300 10-20 5-10 1 1 100 5-10 1.5-2.5 0.5 - 1. 1-2 3-4 2. 3. 4. Osteoporosis Bisphosphonates 5. 6. , EKG , PV + pap smear , transvaginal ultrasound mammogram ( Alternative therapy ) 1. hot flushes - - - - -

8. 8 2. Phytoestrogens 3. Nonhormonal therapy - Antidepressants Tricyclic SSRI SNRI - Bellergal Sedative Diazepam mammogram - 20 - 1 - 1 - 20-39 3 - 40 - 35 - 40 - 50 1-2 mammogram

9. 9 www.nso.go.th.2547 . . : , , . . : 2548 : 29-45 . ! . . : , , , . . : 2548 : 97-202 . The visionary wisdom of the menopause . Menopause Academic Conference 2005 . 16-18 2548 . HRT today . Menopause Academic Conference 2005 . 16-18 2548 The writing Group for the Women s Health Initiative Investigators Risks and Benefits of estrogen plus progestin in Healthy post menopausal women : principle results from the woman s Health Initiative RCT. JAMA 2002 ; 288:321-33 . . Management of Menopause After WHI . 2nd Intensive Course on Menopausal Therapy , 4-5 2546 . , . . : . . : 2543 : 1 - 25 - 13 2548