HEALTH OF WOMAN. 2016.4(110):17–27 
 

Національний консенсус щодо ведення пацієнток у клімактерії 
 

де Вільєрс Тобі, Татарчук Т. Ф.

Міжнародне товариство з менопаузи, Національний Південно-Африканський фонд з остеопорозу, ПАР

ДУ «Інститут педіатрії, акушерства та гінекології НАМН України», м. Київ 
 

Опубліковано: Репродуктивна ендокринологія. – №1(27) / березень 2016. Друкується зі скороченнями 
 

У документі представлено огляд існуючих методів діагностики і терапії клімактеричних розладів у жінок, запропоновано алгоритми діагностики і лікування даної патології з метою профілактики серцево-судинних захворювань, остеопорозу та покращення якості життя жінок в Україні.

Єдиним патогенетично обґрунтованим і ефективним методом корекції клімактеричних розладів є менопаузальна гормональна терапія. У якості такої терапії використовують натуральні естрогени (17b-естрадіол, естрадіолу валерат, естріол) в комбінації з гестагенами (дидрогестерон) або андрогенами. Можливе введення гормонів парентерально (в ін’єкціях), трансдермально, вагінально та перорально.

Для корекції клімактеричного синдрому, урогенітальних розладів використовують короткострокові курси менопаузальної гормональної терапії (протягом 1–5 років). Для профілактики та лікування остеопорозу менопаузальна гормональна терапія триває більше 3 років, за необхідності – в комбінації з біфосфонатами.

Ключові слова: консенсус, асоціація гінекологів-ендокринологів України, клімактерій, менопауза, перименопауза, постменопауза, менопаузальна гормональна терапія.

Література

1. The North American Menopause Society position statement. «Management of osteoporosis in postmenopausal women: 2010 position statement of The North American Menopause Society». 2010. Menopause 17: 25–54.

2. de Villiers TJ, Pines A, Panay N et al. 2013. «Updated 2013 International Menopause Society recommendations on menopausal hormone therapy and preventive strategies for midlife health». Climacteric 16:316–37. http://dx.doi.org/10.3109/13697137.2013.795683; PMid:23672656

3. Santen RJ, Allred DC, Ardoin SP et al. 2010. «Postmenopausal hormone therapy: An Endocrine Society Scientific Statement». J Clin Endocrinol Metab 95.7.1:1–66. http://dx.doi.org/10.1210/jc.2009-2509; PMid:20566620

4. Wierman ME, Basson R, Davis SR et al. 2006. «Androgen therapy in women: an Endocrine Society clinical practice guideline». J Clin Endocrinol Metab 91:3697–710. http://dx.doi.org/10.1210/jc.2006-1121; PMid:17018650

5. National Institutes of Health. «National Institutes of Health State-of-the-Science Conference Statement: management of menopause-related symptoms». Ann Intern Med. 2005. 142:1003–13. http://dx.doi.org/10.7326/0003-4819-142-12_Part_1-200506210-00117; PMid:15968015

6. Bell RJ, Lijovic M, Fradkin P, Davis SR. 2008. «A pragmatic approach to the classification of menopausal status for community-based research». Menopause 15:978–83. http://dx.doi.org/10.1097/gme.0b013e318162c487; PMid:18779681

7. Gold EB, Crawford SL, Avis NE et al. 2013. «Factors related to age at natural menopause: longitudinal analyses from SWAN». Am J Epidemiol 178:70–83. http://dx.doi.org/10.1093/aje/kws421; PMid:23788671 PMCid:PMC3698989

8. Qiu C, Chen H, Wen J et al. 2013. «Associations between age at menarche and menopause with cardiovascular disease, diabetes, and osteoporosis in Chinese women». J Clin Endocrinol Metab 98:1612–21. http://dx.doi.org/10.1210/jc.2012-2919; PMid:23471979

9. Castelo-Branco C, Blumel JE, Chedraui P et al. 2006. «Age at menopause in Latin America». Menopause 13:706–12. http://dx.doi.org/10.1097/01.gme.0000227338.73738.2d; PMid:16837893

10. Harlow SD, Gass M, Hall JE et al. 2012. «Executive summary of the Stages of Reproductive Aging Workshop 10: addressing the unfinished agenda of staging reproductive aging». J Clin Endocrinol Metab 97:1159–68. http://dx.doi.org/10.1210/jc.2011-3362; PMid:22344196 PMCid:PMC3319184

11. Zumoff В, Strain GW, Miller LK, Rosner W. 1995. «Twenty-four hour mean plasma testosterone concentration declines with age in normal premenopausal women». J Clin Endocrinol Metab 80.4:1429–30. http://dx.doi.org/10.1210/jcem.80.4.7714119; http://dx.doi.org/10.1210/jc.80.4.1429

12. Davison SL, Bell R, Donath S et al. 2005. «Androgen levels in adult females: changes with age, menopause, and oophorectomy». J Clin Endocrinol Metab 90:3847–53. http://dx.doi.org/10.1210/jc.2005-0212; PMid:15827095

13. Burger HG, Dudley EC, Cui J et al. 2000. «A prospective longitudinal study of serum testosterone, dehydroepiandrosterone sulfate, and sex hormone-binding globulin levels through the menopause transition». J Clin Endocrinol Metab 85:2832–8. http://dx.doi.org/10.1210/jc.85.8.2832; http://dx.doi.org/10.1210/jcem.85.8.6740; PMid:10946891

14. Judd HL, Lucas WE, Yen SS. 1974. «Effect of oophorectomy on circulating testosterone and androstenedione levels in patients with endometrial cancer». Am J Obstet Gynecol 118:793–8. http://dx.doi.org/10.1016/0002-9378(74)90490-6

15. van der Stege JG, Groen H, van Zadelhoff SJ et al. 2008. «Decreased androgen concentrations and diminished general and sexual wellbeing in women with premature ovarian failure». Menopause 15:23–31. http://dx.doi.org/10.1097/gme.0b013e3180f6108c; PMid:18257141

16. Kalantaridou SN, Calis KA, Vanderhoof VH et al. 2006. «Testosterone deficiency in young women with 46, XX spontaneous premature ovarian failure». Fertil Steril 86:1475–82. http://dx.doi.org/10.1016/j.fertnstert.2006.04.028; PMid:17070197

17. Van Look PF, Lothian H, Hunter WM et al. 1977. «Hypothalamic-pituitary-ovarian function in perimenopausal women». Clin Endocrinol 7:13–31. http://dx.doi.org/10.1111/j.1365-2265.1977.tb02936.x

18. Gold ЕВ, Colvin A, Avis N et al. 2006. «Longitudinal analysis of the association between vasomotor symptoms and race/ethnicity across the menopausal transition: Study of Women’s Health Across the Nation». Am J Public Health 96:1226–35. http://dx.doi.org/10.2105/AJPH.2005.066936; PMid:16735636 PMCid:PMC1483882

19. Mishra GD, Kuh D. 2012. «Health symptoms during midlife in relation to menopausal transition: British prospective cohort study». BMJ 344:e402. http://dx.doi.org/10.1136/bmj.e402; PMid:22318435 PMCid:PMC3275131

20. Avis NE, Brockwell S, Randolph JF Jr et al. 2009. «Longitudinal changes in sexual functioning as women transition through menopause: results from the Study of Women’s Health Across the Nation». Menopause 16:442–52. http://dx.doi.org/10.1097/gme.0b013e3181948dd0; PMid:19212271 PMCid:PMC2908487

21. Chuni N, Sreeramareddy CT. 2011. «Frequency of symptoms, determinants of severe symptoms, validity of and cut-off score for Menopause Rating Scale (MRS) as a screening tool: a cross-sectional survey among midlife Nepalese women». BMC Women’s Health 11:30. http://dx.doi.org/10.1186/1472-6874-11-30; PMid:21672198 PMCid:PMC3126771

22. Olaolorun FM, Lawoyin ТО. 2009. «Experience of menopausal symptoms by women in an urban community in Ibadan, Nigeria». Menopause 16:822–30. http://dx.doi.org/10.1097/gme.0b013e318198d6e7; PMid:19242385

23. Waidyasekera H, Wijewardena K, Lindmark G, Naessen Т. 2009. «Menopausal symptoms and quality of life during the menopausal transition in Sri Lankan women». Menopause 16:164–70. http://dx.doi.org/10.1097/gme.0b013e31817a8abd; PMid:18703984

24. Blumel JE, Chedraui P, Baron G et al. 2011. «A large multinational study of vasomotor symptom prevalence, duration, and impact on quality of life in middle-aged women». Menopause 18:778–85. http://dx.doi.org/10.1097/gme.0b013e318207851d; PMid:21407137

25. Vikstrom J, Spetz Holm AC, Sydsjo G et al. 2013. «Hot flushes still occur in a population of 85-year-old Swedish women». Climacteric 16:453–9. http://dx.doi.org/10.3109/13697137.2012.727199; PMid:23514136

26. Kroenke CH, Caan BJ, Stefanick ML et al. 2012. «Effects of a dietary intervention and weight change on vasomotor symptoms in the Women’s Health Initiative». Menopause 19:980–8. http://dx.doi.org/10.1097/gme.0b013e31824f606e; PMid:22781782 PMCid:PMC3428489

27. Elavsky S, Gonzales JU, Proctor DN et al. 2012. «Effects of physical activity on vasomotor symptoms: examination using objective and subjective measures». Menopause 19:1095–103. http://dx.doi.org/10.1097/gme.0b013e31824f8fb8; PMid:22735162 PMCid:PMC3460032

28. de Villiers TJ, Gass ML, Haines CJ et al. 2013. «Global Consensus Statement on menopausal hormone therapy». Climacteric 16:203–4. http://dx.doi.org/10.3109/13697137.2013.771520; Mid:23488524

29. The North American Menopause Society. «Estrogen and progestogen use in peri- and postmenopausal women: March 2007 position statement of The North American Menopause Society». Menopause. 2007. 14:168–82. http://dx.doi.org/10.1097/gme.0b013e31803167ab; PMid:17259911

30. Chrisman C, Ribeiro P, Dalton VK. 2007. «The levonorgestrel-releasing intrauterine system: an updated review of the contraceptive and noncontraceptive uses». Clin Obstet Gynecol 50:886–97. http://dx.doi.org/10.1097/GRF.0b013e318159c0d9; PMid:17982331

31. Simon JA. 2014. «What if the Women’s Health Initiative had used transdermal estradiol and oral progesterone instead?» Menopause 21:769–83. http://dx.doi.org/10.1097/GME.0000000000000169; Mid:24398406

32. Fournier A, Fabre A, Mesrine S et al. 2008. «Use of different postmenopausal hormone therapies and risk of histology- and hormone receptor-defined invasive breast cancer». J Clin Oncol 26:1260–8. http://dx.doi.org/10.1200/JCO.2007.13.4338; PMid:18323549 PMCid:PMC2346534

33. Leonetti H, Longo S, Anasti J. 1999. «Transdermal progesterone cream for vasomotor symptoms and postmenopausal bone loss». Obstet Gynecol 94:225–8. http://dx.doi.org/10.1097/00006250-199908000-00013; http://dx.doi.org/10.1016/S0029-7844(99)00266-5

34. Leonetti HB, Wilson KJ, Anasti JN. 2003. «Topical progesterone cream has an antiproliferative effect on estrogen stimulated endometrium». Fertil Steril 79:221–2. http://dx.doi.org/10.1016/S0015-0282(02)04542-9

35. Cooper A, Spencer MI, Whitehead M et al. 1998. «Systemic absorption of progesterone from Progest cream in postmenopausal women». Lancet 351:1255. http://dx.doi.org/10.1016/S0140-6736(05)79323-5

36. Birkhauser MH, Panay N, Archer DF et al. 2008. «Updated practical recommendations for hormone replacement therapy in the peri- and postmenopause». Climacteric 11:108–23. http://dx.doi.org/10.1080/13697130801983921; PMid:18365854

37. Nijland EA, Weijmar Schultz WC, Nathorst-Boos J et al. 2008. «Tibolone and transdermal E2/NETa for the treatment of female sexual dysfunction in naturally menopausal women: results of a randomized active-controlled trial». J Sex Med 5:646–56. http://dx.doi.org/10.1111/j.1743-6109.2007.00726.x; PMid:18304284

38. Cummings SR, Ettinger В, Delmas PD et al. 2008. «The effects of tibolone in older postmenopausal women». N Engl J Med 359:697–708. http://dx.doi.org/10.1056/NEJMoa0800743; PMid:18703472 PMCid:PMC3684062

39. Pinkerton JV, Abraham L, Bushmakin AG et al. 2014. «Evaluation of the efficacy and safety of bazedoxifene/ conjugated estrogens for secondary outcomes including vasomotor symptoms in postmenopausal women by years since menopause in the Selective Estrogens, Menopause and Response to Therapy (SMART) Trials». J Womens Health (Larchmt) 23:18–28. http://dx.doi.org/10.1089/jwh.2013.4392; PMid:24206058

40. Mirkin S, Komm BS, Pan K, Chines AA. 2013. «Effects of bazedoxifene/conjugated estrogens on endometrial safety and bone in postmenopausal women». Climacteric 16:338–46. http://dx.doi.org/10.3109/13697137.2012.717994; PMid:23038989

41. de Villiers TJ, Chines AA, Palacios S et al. 2011. «Safety and tolerability of bazedoxifene in postmenopausal women with osteoporosis: results of a 5-year, randomized, placebo-controlled phase 3 trial». Osteoporos Int 22:567–76. http://dx.doi.org/10.1007/s00198-010-1302-6; PMid:20535606

42. Pinkerton JV, Komm BS, Mirkin S. 2013. «Tissue selective estrogen complex combinations with bazedoxifene/conjugated estrogens as a model». Climacteric 16:618–28. http://dx.doi.org/10.3109/13697137.2013.810437; PMid:23805785

43. Portman DJ, Bachmann GA, Simon JA. 2013. «Ospemifene, a novel selective estrogen receptor modulator for treating dyspareunia associated with postmenopausal vulvar and vaginal atrophy». Menopause 20:623–30. http://dx.doi.org/10.1097/gme.0b013e318279ba64; PMid:23361170

44. Simon J, Portman D, Mabey RG Jr. 2014. «Long-term safety of ospemifene (52-week extension) in the treatment of vulvar and vaginal atrophy in hysterectomized postmenopausal women». Maturitas 77:274–81. http://dx.doi.org/10.1016/j.maturitas.2013.12.005; PMid:24411556

45. Shams Т, Firwana В, Habib F et al. 2014. «SSRIs for hot flashes: a systematic review and meta-analysis of randomized trials». J Gen Intern Med 29:204–13. http://dx.doi.org/10.1007/s11606-013-2535-9; PMid:23888328 PMCid:PMC3889979

46. Salmi Т, Punnonen R. 1979. «Clonidine in the treatment of menopausal symptoms». Int J Gynaecol Obstet 16:422–6.

47. Lindsay R, Hart DM. 1978. «Failure of response of menopausal vasomotor symptoms to clonidine». Maturitas 1:21–5. http://dx.doi.org/10.1016/0378-5122(78)90006-3

48. Bolli P, Simpson FO. 1975. «Clonidine in menopausal flushing: a double-blind trial». N Z Med J 82:196–7. PMid:1105267

49. Pandya KJ, Raubertas RF, Flynn PJ et al. 2000. «Oral clonidine in post- menopausal patients with breast cancer experiencing tamoxifen-induced hot flashes: a University of Rochester Cancer Center Community Clinical Oncology Program study». Ann Intern Med 132:788–93. http://dx.doi.org/10.7326/0003-4819-132-10-200005160-00004; PMid:10819701

50. Lavigne JE, Heckler C, Mathews JL et al. 2012. «A randomized, controlled, double-blinded clinical trial of gabapentin 300 versus 900 mg versus placebo for anxiety symptoms in breast cancer survivors». Breast Cancer Res Treat 136:479–86. http://dx.doi.org/10.1007/s10549-012-2251-x; PMid:23053645 PMCid:PMC4411951

51. Pandya KJ, Morrow GR, Roscoe JA et al. 2005. «Gabapentin for hot flashes in 420 women with breast cancer: a randomised double-blind placebo-controlled trial». Lancet 366:818–24. http://dx.doi.org/10.1016/S0140-6736(05)67215-7

52. Nguyen ML. 2013. «The use of pregabalin in the treatment of hot flashes». Can Pharm J 146:193–6. http://dx.doi.org/10.1177/1715163513490636; PMid:23940474 PMCid:PMC3734907

53. Elkins GR, Fisher WI, Johnson AK et al. 2013. «Clinical hypnosis in the treatment of postmenopausal hot flashes: a randomized controlled trial». Menopause 20:291–8. PMid:23435026

54. Mann Е, Smith MJ, Hellier J et al. 2012. «Cognitive behavioural treatment for women who have menopausal symptoms after breast cancer treatment (MENOS 1): a randomised controlled trial». Lancet Oncol 13:309–18. http://dx.doi.org/10.1016/S1470-2045(11)70364-3

55. Ayers В, Hunter MS. 2013. «Health-related quality of life of women with menopausal hot flushes and night sweats». Climacteric 16:235–9. http://dx.doi.org/10.3109/13697137.2012.688078; PMid:22809134

56. Lipov EG, Joshi JR, Sanders S et al. 2008. «Effects of stellate-ganglion block on hot flushes and night awakenings in survivors of breast cancer: a pilot study». Lancet Oncol 9:523–32. http://dx.doi.org/10.1016/S1470-2045(08)70218-3; http://dx.doi.org/10.1016/S1470-2045(08)70131-1

57. Davis SR, Davison SL, Donath S, Bell R. 2005. «Relationships between circulating androgen levels and self-reported sexual function in women». JAMA 294:91–6. http://dx.doi.org/10.1001/jama.294.1.91; PMid:15998895

58. Simon J, Braunstein G, Nachtigall L et al. 2005. «Testosterone patch increases sexual activity and desire in surgically menopausal women with hypoactive sexual desire disorder». J Clin Endocrinol Metab 90:5226–33. http://dx.doi.org/10.1210/jc.2004-1747; PMid:16014407

59. Davis SR, Moreau M, Kroll R et al. 2008. «Testosterone for low libido in menopausal women not taking estrogen therapy». N Engl J Med 359:2005–17. http://dx.doi.org/10.1056/NEJMoa0707302; PMid:18987368

60. Panay N, Al-Azzawi F, Bouchard C et al. 2010. «Testosterone treatment of HSDD in naturally menopausal women: the ADORE study». Climacteric 13:121–31. http://dx.doi.org/10.3109/13697131003675922; PMid:20166859

61. Davis SR, Panjari M, Stanczyk FZ. 2011. «DHEA replacement for postmenopausal women». J Clin Endocrinol Metab 96:1642–53. http://dx.doi.org/10.1210/jc.2010-2888; PMid:21411558

62. Alkatib AA, Cosma M, Elamin MB et al. 2009. «A systematic review and meta-analysis of randomized placebo-controlled trials of DHEA treatment effects on quality of life in women with adrenalin sufficiency». J Clin Endocrinol Metab 94:3676–81. http://dx.doi.org/10.1210/jc.2009-0672; PMid:19773400

63. Татарчук ТФ, Ефименко ОА, Исламова АО. 2013. Менопауза: новый взгляд на старую проблему. Репродуктивная эндокринология:1(9).

64. Локшин ВН, Петренко АА, Арефьева НЕ. 2005. Влияние заболеваний репродуктивной системы на качество жизни женщин. Российский вестник акушера-гинеколога 5;1:52–55.

65. Татарчук ТФ, Єфименко ОА. 2009. Принципи діагностики, профілактики та лікування клімактеричних розладів. Журнал української лікарської еліти 4(10):24–29.

66. Мазур ИП, Поворознюк ВВ. 2002. Костная система и заболевания пародонта. Современная стоматология 3:32–40.

67. «Consensus Development Conference Diagnosis, prophylaxis, and treatment of osteoporosis». Am J Med. 1993. 94:646–50. http://dx.doi.org/10.1016/0002-9343(93)90218-E

68. Kanis JA, McCloskey Е, Johansson H et al. 2012. «FRAX® with and without bone mineral density». Calcif Tissue Int 90:1–13. http://dx.doi.org/10.1007/s00223-011-9544-7

69. Kanis JA, McCloskey EV, Johansson H, Cooper C et al. 2013. Scientific Advisory Board of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) and the Committee of Scientific Advisors of the International Osteoporosis Foundation (IOF). «European guidance for the diagnosis and management of osteoporosis in postmenopausal women». Osteoporos Int 24.1:23–57. http://dx.doi.org/10.1007/s00198-012-2074-y

70. WHO Study Group. «World Health Organisation Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Report of a WHO Study Group». World Health Organ Tech Rep Ser 1994. 843:1–129. PMid:7941614

71. Okechukwu Ibeanu, Susan Modesitt C, Jennifer Ducie. 2011. «Hormone replacement therapy in gynecologic cancer survivors: Why not?» Gynecologic Oncology 122.2:447–54. http://dx.doi.org/10.1016/j.ygyno.2011.03.012; PMid:21474167

72. Geza Acs, Michael Wagoner J. 2010. «Postmenopausal hormone therapy and breast cancer-clinicopathological associations and molecular mechanisms». Cancer Growth and Progression 12:187–202.

73. Michaelson-Cohen R, Beller U. 2009. «Managing menopausal symptoms after gynecological cancer». Current Opinion in Oncology 21.5:407–11. http://dx.doi.org/10.1097/CCO.0b013e32832efc5b; PMid:19587594

74. Mueck AO, Seeger H. 2004. «Hormone therapy after endometrial cancer». Endocrine-Related Cancer 11:305–14. http://dx.doi.org/10.1677/erc.0.0110305

75. Piksi Singh, Martin Oehler K. 2010. «Hormone replacement after gynaecological cancer». Maturitas 65.3:190–7. http://dx.doi.org/10.1016/j.maturitas.2009.11.017; PMid:20018467

76. Michaelson-Cohen R, Beller U. 2009. «Managing menopausal symptoms after gynecological cancer». Current Opinion in Oncology 21.5:407–11. http://dx.doi.org/10.1097/CCO.0b013e32832efc5b; PMid:19587594

77. Biglia N, Gadducci A, Ponzone R et al. 2004. «Hormone replacement therapy in cancer survivors». Maturitas 48:333–46. http://dx.doi.org/10.1016/j.maturitas.2003.09.031; PMid:15283925

78. Neal Freedman D, Wong-Ho Chow, Yu-Tang Gao et al. 2007. «Menstrual and reproductive factors and gastric cancer risk in a large prospective study of women». Gut 56:1671–1677. http://dx.doi.org/10.1136/gut.2007.129411; PMid:17627962 PMCid:PMC2095686

79. Lindblad P, Mellemgaard A, Schlehofer B et al. 1995. «International renal-cell cancer study. Reproductive factors, gynecologic operations and exogenous hormones». International Journal of Cancer 61.2:192–8. http://dx.doi.org/10.1002/ijc.2910610209; PMid:7705947

80. Cantwell MM, Lacey JV Jr, Schairer C et al. 2006. «Reproductive factors, exogenous hormone use and bladder cancer risk in a prospective study». International Journal of Cancer 119.10:2398–2401. http://dx.doi.org/10.1002/ijc.22175; PMid:16894568

81. Razavi P, Pike MC, Horn-Ross PL et al. 2010. «Long-term Postmenopausal Hormone Therapy and Endometrial Cancer». Cancer Epidemiol Biomarkers 19:475–83. http://dx.doi.org/10.1158/1055-9965.EPI-09-0712; PMid:20086105 PMCid:PMC2821215

82. Harlow SD, Gass M, Hall JE, Lobo R et al. 2012. «Executive Summary of the Stages of Reproductive Aging Workshop + 10». Menopause 19.4:387–39. http://dx.doi.org/10.1097/gme.0b013e31824d8f40; PMid:22343510 PMCid:PMC3340903