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Matern.alfredo da costa
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  • 1. Menopausa o ponto da situação por Manuel Neves-e-Castro LisboaXXVI Curso Pós-Graduado de Endocrinologia e Andrologia Junho 2005
  • 2. TerroristaHormonal
  • 3. Quero fazer TH ! Terrorista Hormonal
  • 4. Quero fazer TH ! TerroristaMas todos Hormonalos médicosdizem queNÃO!
  • 5. O que é que temosaprendido sôbre a Menopausa? porManuel Neves-e-Castro Lisboa Junho 2005
  • 6. As discussões sobre o climatério são devidas a:• Uma falta de cultura que impede uma crítica correcta dos resultados publicados• Uma má prática da Medicina que ignora a mulher na sua totalidade• “Lobbies” politicos do NIH …• Uma falta de honestidade científica manifestada por muitos dos relatores do WHI• “Lobbies” de várias indústrias farmacêuticas através da actividade de muitos médicos bem conhecidos que se oferecem… para transmitir as suas mensagens… MNC
  • 7. 3rd International Symposium of the Portuguese Menopause Society In Celebration of the World Menopause Day The Transatlantic Controversies - The State of the ArtOctober 23, 2004 Fundação Engº António Almeida Oporto – Portugal
  • 8. The Menopausal “Stars”... 14 15 5 6 7 8 9 10 11 12 13 4 2 3 11.D.Barlow, 2.H.Kuhl, 3.P.Kenemans, 4.A.Pines, 5 F.Al-Azzawi, 6.J.Rossouw,7.J.Stevenson, 8.R.Chlebowski, 9.S.Palacios, 10.Th.Clarkson, 11.M.Sousa,12.M.Neves-e-Castro, 13.A.Genazzani, 14.J.Calaf, 15.R.Lobo
  • 9. “MATURITAS” Special Issue VOL. 51/1.(May 2005) “Menopausal Health in 2005”PART 1. Women’s health after WHI.Reports from the Amsterdam MenopauseSymposium, October 2-4, 2004.PART 2. Transatlantic confrontation ofoptions.Proceedings of the III International Symposiumof the Portuguese Menopause SocietyOctober 23, 2004. Guest-editor: M. Neves-e-Castro.
  • 10. The U.S.A. “team” 1 2 3 41. R. Chlebowski, 2.J.Rossow, 3. R. Lobo, 4. Th.Clarkson
  • 11. The USA VisionChair: M.Neves-e-Castro and Mario de Sousa09.00-09.30 –Controversies about HRT – Lessons from Monkey Models Th.Clarkson, Wake Forest Univ.09.30-10.00 – Appropriate Use of Hormones Should Alleviate Concerns Regarding CV and Breast Cancer Risks R.Lobo, Columbia Univ10.00-10.30 –Implications of clinical trials for CVD in younger women Jacques Rossouw, NIH/NHLBI/WHI10.30-11.00 Coffee Break11.00-11.30 – Menopausal Therapy and Cancer Risk in the WHI R.Chlebowski, WHI11.30-12.00 - The state of the Art in the USA L.Speroff,Portland.Or12.00-13.00 - Debate and Discussion
  • 12. The European “team” 1 2 3 41. D.Barlow, 2. H. Kuhl, 3.P.Kenemans, 4. A.Pines
  • 13. The European VisionChair: Mario de Sousa and M. Neves-e-Castro14.30-15.00 – WHI and Cardioprotection: Looking Beyond the Figures A.Pines, Il15.00-15.30 – Hormone Therapy and Breast Cancer: What is the Problem? P.Kenemans,Nl15.30-16.00 – Do Estrogens Really Increase Breast Cancer Risk? H. Kuhl, D16.00-16.30 –Coffee Break16.30-17.00 Strategy in Osteoporosis Management Following WHI D.Barlow, UK17.00-18.00 Debate and DiscussionChair:A. Genazzani (I) and J.Calaf (Sp)18.00 - Conclusions M.Neves-e-Castro
  • 14. Conclusões
  • 15. Acreditamos que no que se refere àsDCV’s,quer os estudos experimentaisem primatas como a evidência clínicasugerem fortemente que os TH’spodem ser preventivos se iniciadosmuito precocemente após amenopausa,de preferência depois deum regime de contraceptivos oraisdurante a premenopausaClarkson TB. Fertil Steril 2004;81:1498-1501Grodstein F et al. N Engl J Med 2000;343:530-537Stampfer MJ. NAMS 2004;PS#2Victory R et al. Fertil Steril 2004;82:O-130
  • 16. O grupo de “estrogénios isolados” do WHIsugere fortemente que uma medicaçãoapenas com estrogénios é destituida deriscos como parece até ser protectora emrelação ao cancro da mama.Resultados idênticos foram verificados emestudos de gravidez após cancro da mama eem TH’s nas sobreviventes de cancro da mama.Gelber s et al. J Clin Oncol 2001;19:1671-1675WHI Group J Am Med Assoc 2004;291:1701-1712O’Meara et al. J N C I 2001DiSaia et al. Am J Clin Oncol 2000Nananda F Col et al.J Clin Oncol;2001:19:2357-2363
  • 17. Em estudos recentes não severificou,nos tratamentos combinadoscontínuos qualquer risco aumentadode DCV’s ou de cancro da mama.Esta diferença em relação ao WHI deve-se a que as mulheres eram maisnovas,sintomáticas,e com menor pêsocorporal Heikkinen J. NAMS 2004, Abstract LB38 Lobo R. Arch Int Med 2004;164:482-484
  • 18. Acentuamos a necessidade de implementar medidas colaterais muito importantes tais como:• normalização do peso corporal• abstenção de tabaco• baixo consumo de alcool• execício• Dieta Mediterrânica etc. MNC
  • 19. Em conclusão, e à luz da evidência actual,deve dar-se aos médicos e àsmulheres a garantia de que os TH’spara o alívio dos sintomas damenopausa são seguros e muitoeficazes MNC
  • 20. WHI
  • 21. What Was the WHI Study designed to do?Long-term effect of hormone therapy on theprevention of heart disease and hip fractures andon monitoring possible increases in risk for breast cancer and colon cancer. Message from the President on WHI Study www.hormone.org
  • 22. White woman’s risk of death betweenthe ages of 50 and 94 are: 31.0% from heart disease 2.8% from breast cancer 2.8% from hip fracture Brinton LA, Schairer C. N Engl J Med.1997;336:1769-1775
  • 23. Effect on the risk of breast cancerWHI Nonsignificant increased risk RR 1.26 (CI 1.00-1.59); 26% increased risk AR 0.38% vs 0.30% (ie, 38 vs 30 events annually per 10.000 women)HERS Nonsignificant increased risk RR 1.27 (CI 0.84-1.94); 27% increased risk AR 0.59% vs 0.47% (ie, 59 vs 47 events annually per 10.000 women)
  • 24. WHI (JAMA 2002;288:321-331)• Results: “the difference reaches “almost nominal statistical significance” (i.e. not statistically different!)• Discussion: “the substantial risks for CVD and breast cancer” (?!...)
  • 25. Thus… “The breast cancer findings are reported as statistically insignificant but are regarded as clinically relevant !” Utian W. Menopause Management 2003;12:9-10
  • 26. WHI results calculated as NNT/1 year NNH/1 yearCHD 1428Stroke 1250VTE 588Breast Cancer 1250Colon Cancer 1667Osteoporotic fractures 227(totals)Neves-e-Castro M. Menopause in crisis post-Women’s Health Initiative? Aview based on personal clinical experience. Human Reproduction2003;18:2512-8
  • 27. “Women considering taking CEE should becounseled about an increased risk of strokebut can be reassured about no excess riskof heart disease or breast cancer for atleast 6.8 years of use.”Effects of conjugated Equine Estrogen in Postmenopausal Women withHysterectomy. JAMA 2004;291:1701-1712
  • 28. Effects of conjugated Equine Estrogen in Postmenopausal Womenwith Hysterectomy.JAMA, 2004;291:1701-1712
  • 29. Why Was the Study Stopped?• Small increase in the risk of strokes, which put healthy women at risk and made it unacceptable to continue with the study.• No increased risk for breast cancer and a decrease in the risk of hip fractures. Message from the President on WHI Study www.hormone.org
  • 30. Stroke“In women 50-59 years not taking HT,ischemic stroke is expected to occur in3 out of 1000 women during 5 years.Five years use of HT would yield 1additional case of stroke/ 1000 women” EMAS Statement; 2004.
  • 31. NAMS position statement onestrogen and progestagen use inperi-and postmenopausal women Revised breast cancer statements indicate that the risk of breast cancer probably increases with EPT use but not with ET use.
  • 32. Second thoughts on the WHI study: the effect of age on the safety HRT Studd J. Climacteric 2004;7:412-414
  • 33. O “braço” do WHI com estrogéniosisolados foi interrompido! Porquê ? ! …
  • 34. • Parece que se tivesse havido mais um caso de cancro da mama no grupo placebo os resultados deste estudo teriam sido considerados como estatisticamente muito significativos… MNC
  • 35. Portanto… o grupo WHI/NIH teria sido forçado a declarar que:• Os estrogénios não induzem o cancro da mama , e que• Os estrogénios protegem a mama contra o cancro ! MNC
  • 36. Porque é que os investigadoresnão quiseram que o estudo fosseterminado e pudesse chegar aconclusões tão importantes?Seria pela necessidade de algunsinvestigadores continuarem areceber milhões de dólares? MNC
  • 37. Million Women StudyThe follow-up for breast cancerdiagnosis was just over 2½ years,meaning that these breast cancerswere almost certainly pre-existent atthe start of the observational period. Press Release from the British Menopause Society, 2003
  • 38. Occult Breast Cancer in medicolegal autopsies Breast malignancy was found in 22 women(20%) Nielsen M et al-Br J Cancer 1987;56:814-9
  • 39. Occult Breast CancerMalignancy was significantly more frequentamong women. aged more than 40 years. with late age at first full-term pregnancy. with alcohol abuse. with steatosis or cirrhosis of the liver Nielsen M et al-Br J Cancer 1987;56:814-9
  • 40. Breast CancerMWS data compared to other publish data MWS GPRD Beral Ross Weiss WHI (2003) (2002) (1997) (2000) (2002) (2003)EPT 2.00 1.211 1.152 1.243 1.22 1.26ET 1.30 0.97 0.992 1.063 0.84 ongoing 4Tibolone 1.45 1.02 1 Seq EPT 2 ≤ 5 y use 3 Per 5y 4 >6y use
  • 41. HRT and RR of DEATH from BREAST CANCER (MW Study,2003)• AR never users 238/2894 = 0.0822• AR current users 191/3202 = 0.0597• RR = 0.0597/0.0822 = 0.73• RR for mortality = 1.22• RR for morbidity =1.66• RR for dying from BC = 1.22/1.66 = 0.73
  • 42. Fatal Breast Cancers Case-death Case-No death Current use 191 3011 3203 Never use 238 2656 2894 RR=0.71 (95% CI 0.58-0.87)Million Women Study Collaborators. Breast Cancer and hormone replacementtherapy in the Million Women Study. Lancet 2003;362:419-427
  • 43. “Recurrent breast cancer wasfound in 9% of HRT usersand 15% of nonuser”. O’Meara ES et al
  • 44. Estrogen replacement therapy inpatients with early breast cancer The mortality rates from breast cancer for the ERT users was 4.28% compared with 22.3% in the nonusers. Natrajan PK and Gambrell RD. Am J Obstet Gynecol 2002;187:289-95
  • 45. O que é que aprendemos com osprincipais estudos observacionais e ensaios clinicos?1ª.lição Os progestagénios administrados por via sistémica podem em parte suprimir alguns dos efeitos benéficos dos estrogénios e podem tambem aumentar ligeiramente o risco de cancro da mama após tratamentos com uma duração superior a cinco anos MNC
  • 46. O que é que aprendemos com osprincipais estudos observacionais e ensaios clinicos?2ª.lição Os estrogénios quando administrados isoladamente em mulheres histerectomizadas não afectaram minimamente o risco para o cancro da mama quando comparado com os controlos MNC
  • 47. O que é que aprendemos com osprincipais estudos observacionais e ensaios clinicos?3ª.lição Os efeitos metabólicos dos estrogénios e progestagénios, como um todo, podem diferir em função da via de administração i.e. oral vs. parentérica, e da combinação de ambos em regimes de administração sequencial ou combinada contínua MNC
  • 48. Relative risks associated with use of different hormones by women Cases Person/ Age-adjusted RR Years (CI – 95%)Estrogens used aloneTransdermal 29 8.961 1.2 (0.8 – 1.8)Oral 2 1.204 0.6 (0.2 – 2.4)Estrogens combined with oral progesteroneEstrogens combined with micronized progesterone 55 21.994 0.9 (0.7 – 1.2)Transdermal 55 20.685 0.9 (0.7 – 1.2)Oral 0 1.385Estrogens combined with synthetic progestinsTransdermal 187 46.252 1.4 (1.2 – 1.7)Oral 80 20.504 1.4 (1.1 – 1.8) Fournier A et al. Int J Cancer 2005;114:448-54
  • 49. Progesterone and Breast Cancer Combinations containing micronized progesterone appeared to be associated with a significantly lower breast cancer risk than those containing synthetic progestagens. Fournier A et al. Int J Cancer 2005;114:448-54
  • 50. O que é que aprendemos com osprincipais estudos observacionais e ensaios clinicos?4ª.lição Os tratamentos hormonais são a primeira escolha para a abolição dos sintomas vasomotores enquanto necessários. Não devem ser usados para a prevenção secundária da DCV, quando já houver placas de ateroma. MNC
  • 51. O que é que aprendemos com osprincipais estudos observacionais e ensaios clinicos?4ª.lição (continuação) Os estrogénios podem proteger contra DCV’s se iniciados precocemente durante a transição para a pós menopausa. Os tratamentos hormonais são preventivos da osteopenia e osteoporose em qualquer fase da vida MNC
  • 52. Postmenopausal hormone therapy: critical reappraisal and unified hypothesis 83:558-66
  • 53. Postmenopausal former oral contraceptives users may have lower rates of heart disease 702 postmenopausal women enrolled in the WISE. Use of oral contraceptive in the past was an independent negative predictor of CAD severity (p=0.04 after adjustment for smoking, aspirin use, lipid lowering medication, and socioeconomic variables ) 14th Annual Meeting of the North American Menopause Society. Abstract P-51
  • 54. Combined effect of oral contraceptive use and hormone replacement therapyon breast cancer risk in postmenopausal women The increase in risk with CHRT was stronger in women who had never used OC’s in the past than in women who had used OC’s Norman SA et al. Cancer Causes Control 2003;14(10):933-43
  • 55. DiscussionThe results of this study show a strongassociation of current HT with reducedodds of severe coronary arterycalcification, an indicator ofatherosclerotic plaque burden. Barrett-Connor E et al. Menopause 2005;12:40-48
  • 56. DiscussionThe protective association of HT withCACS was greater in longer versusshorter duration users and tended to bestronger in those whose HT use beganearly in postmenopause. Barrett-Connor E et al. Menopause 2005;12:40-48
  • 57. O que é que aprendemos com osprincipais estudos observacionais e ensaios clinicos?5ª.lição Os estrogénios podem evitar lesões degenerativas do SNC uma vez que, até à data, são os únicos agentes com efeito no crescimento dos neurónios MNC
  • 58. Postmenopausal Estrogen UseAffects Risk for Parkinson Disease • Estrogen therapy has been associated with improved cognitive functioning, a reduced risk of dementia in women with Parkinson disease (PD), and a decreased risk of Alzheimer disease. • Postmenopausal estrogen therapy may be associated with a reduced risk of PD in women. Currie LJ et al. Arch Neurol 2004;61(6):886-8
  • 59. IADRD: Estrogens ExhibitsNeuroprotective effect in preliminary analysis of Swedish Data Preliminary analysis of data from the Swedish Twin Registry suggests that estrogen is neuroprotective and the effect is not related to length of estrogen therapy. Estrogen use was significantly related to better cognitive functioning (odds ratio [OR]=0.43 95% confindence interval [CI]=0.26, 0.70) Peck P. DG News Stockholm, July 24, 2002.
  • 60. Como se podem reduzir os riscos potenciais ?
  • 61. Dimitrakakis C et al. Menopause 2004;11:531-535
  • 62. A physiologic role for testosteronein limiting estrogenic stimulation of the breast. These findings suggest that treatment with a balanced formulation including all ovarian hormones may prevent or reduce estrogenic cancer risk in the treatment of girls and women with ovarian failure. Dimitrakakis C et Al. Menopause 2003;10(4):292-8
  • 63. Quais são os melhores tratamentosdurante e para além do climatério? Não tem sido prestada a devida atenção a outras intervenções farmacológicas (não hormonais) e a estratégias que se verificou serem importantes para a prevenção de tais doenças e para a manutenção ou melhoria da saúde MNC
  • 64. A TH não é possivel … • Quando não é desejada pela mulher • Quando a mulher não sente a sua necessidade • Quando há contraindicações MNC
  • 65. Intervenções Farmacológicas • Sintomáticas • Perventivas – primárias – Secundárias MNC
  • 66. Nurses’s Health Study from 1980 to 1994 CHD ↓ 31% ↓ Smoking ↓ 13% ↑ Obesity ↑ 8% ↑ THS ↓ 9% ↑ Better nutrition ↓ 16%Hu FB, Grodstein F et al. Trends in the Incidence of Coronary Heart Diseaseand Changes in Diet and Lifestyle in Women. NEJM 2000;343:530-537.
  • 67. “It appears that half of thebenefits in the prevention ofcardiovascular diseases arenot hormone related”! Mosca L, Grundy SM, Judelson D, et al. Circulation 99;99:2480-4
  • 68. Association between alcohol consumption and postmenopausal breast cancerresults of a case-control study in Montreal, Quebec, Canada Women who started to drink wine on or before the age of 40 were at a 2.5 times increased risk (95% CI 1.4-4.4). CONCLUSIONS: Our findings provide further support for a positive association between the risk of postmenopausal breast cancer and alcohol consumption. Lenz SK et al.Cancer Causes Control 2002;13(8):701-10
  • 69. Mediterranean Diet, Lifestyle Factors, and 10-Year Mortality inElderly European Men and WomenThe combination of 4 low risk factors loweredthe all-cause mortality rate to 0.35 (95% CI,0.28-0.44). In total, lack of adherence to thislow-risk pattern was associated with apopulation attributable risk of 60% of alldeaths, 64% of deaths from coronary heartdisease, 61% from cardiovascular diseases,and 60% from cancer. Knoops K et al. JAMA 2004;292:1433-9
  • 70. The PolymealFranco O et al. BMJ 2004;329:1447-50
  • 71. Doctors could retrain asPolymeal chefs or wine advisersThe Polymeal—an evidence based menu thatincludes wine, fish, dark chocolate, fruits,vegetables, garlic, and almonds—promises to be aneffective, safe, cheap, and tasty solution to reducingcardiovascular morbidity and increasing lifeexpectancy.Polymeal could reduce cardiovascular disease bymore than 75%. Franco O et al. BMJ 2004;329:1447-50
  • 72. Tea, circulating estrogens and breast cancer Levels were13% lower in regular green-tea drinkers (25.8 pg/ml)19% higher in regular black tea drinkers (35.0 pg/ml). Wu A. et al. Carcinogenesis 2005.
  • 73. Tea, circulating estrogens and breast cancer “We recently provided the first set of human evidence that breast cancer risk is significantly inversely associated with tea intake, largely confined to intake of green tea.” “Green tea may have down-regulatory effects on circulating sex-steroid hormones, whereas black tea may have up-regulatory effects .” Wu A. et al. Carcinogenesis 2005
  • 74. RELATIVE RISK OF BREAST CANCER BY BODY WEIGHT Weight (Kg) Age at Diagnosis <60 60-69 70+ 35-49 1.00 0.54 1.16 50-59 1.00 1.22 1.43 60-69 1.00 1.61 1.81from deWaard et al ,1964,1978
  • 75. HU FB et al. NEJM 2004;351:2694-2703
  • 76. HU FB et al. NEJM 2004;351:2694-2703
  • 77. HU FB et al. NEJM 2004;351:2694-2703
  • 78. Recreational Physical Activityand the Risk of Breast Cancer in Postmenopausal WomenWomen who engaged in the equivalent of 1.25to 2.5 hours per week of brisk walking had an18% decreased risk of breast cancer (RR,0.82; 95% CI, 0.68-0.97) compared withinactive women. McTiernan A et al. JAMA 2003;290:1331-6
  • 79. Aspirin could be used to prevent cancerThree recently published studies indicatethat aspirin, already enjoying a secondlease of life in the prevention of heartdisease, may soon become a first line ofdefense against cancer. London O. BMJ 2003;326:565
  • 80. Breast Cancer and Nonsteroidal Anti-Inflammatory Drugs: Prospective Resultsfrom the Women’s Health Initiative1 COX-2 induction may promote breast cancer development by enhancing local estrogen biosynthesis, and COX-2 inhibition may reverse the process. Harris R et al. Cancer Research 2003;63:6096-6101
  • 81. Inhibitory effect of statins on theproliferation of human breast cancer cells. Atorvastatin and fluvastatin were able to inhibit the proliferation of MCF-7 cells in the absence of estradiol. This effect seems to depend on an apoptotic statin effect. Muck AO et al. Int J Clin Pharmacol Ther 2004;42(12):695-700
  • 82. Inhibitory effect of statins on theproliferation of human breast cancer cells. The present data indicate that statins may possess anticancerogenic properties concerning the development of breast cancer in postmenopausal women. Muck AO et al. Int J Clin Pharmacol Ther 2004;42(12):695-700
  • 83. The PolypillWald N and Law M. BMJ 2003;326:1419-25
  • 84. A strategy to reducecardiovascular disease by more than 80%One third of people taking this pill from age 55would benefit, gaining on average about 11years of life free from an IHD event orstroke. Wald N and Law M. BMJ 2003;326:1419-25
  • 85. Wald N and Law M. BMJ 2003;326:1419-25
  • 86. O que pensam os outros?... Após uma viragem de 180º em dois anos… a NAMS (North American Menopause Society) acaba de concluir…
  • 87. NAMS position statement onestrogen and progestagen use inperi-and postmenopausal women No single trial should be used to set public health policy. The practice of medicine must ultimately be based on the interpretation of the entire body of evidence currently available, given that there will never be adequate clinical trials to cover all populations, eventualities, and regimens.
  • 88. NAMS position statement onestrogen and progestagen use inperi-and postmenopausal women Place NO LIMIT on ET/EPT treatment duration, provided it is consistent with treatment goals; if monitored regularly, NO stipulation is made regarding when to reduce or stop therapy
  • 89. Há riscos?É indispensável que seja dadainformação sôbre as diferenças entreriscos relativos e riscos absolutos umavez que os primeiros são a principal causade desinformação e alarmismo, sendo osfavoritos dos media… MNC
  • 90. Analisem-se os factores de risco• Cardiovasculares• Oncológicos• Ósseos• SNC MNC
  • 91. Years of healthy life can be increased 5- 10 years, W O says H W need to concentrate on the e major risks if we are to improve healthy life expectancy by about 10 years, and life expectancy by even m ore. A n Lo p e z , Ph. D. , WHO Se nio r Sc ie nc e A v is o r a nd c o - la d d ire c to r o f the WHO re p o rt (2 0 0 2 )
  • 92. Welty F. Menopause 2004;11(4):484-94
  • 93. As mulheres não são estatísticas…
  • 94. Têm que ser tratatadas individualmente !
  • 95. Evidence based medicine: does it make a difference? Like any technology, evidence based medicine carries risks and benefits and can be used appropriately or inappropriately. Schon CR et al. BMC Health Serv Res 2003;3(1):14
  • 96. Evidence informed practice• It is clearly time to change “evidence based medicine” to “evidence informed practice”.• I suggest the era of evidence informed rather than evidence based medicine has arrived Glasziou P. Centre for Evidence-Based Medicine. University of Oxford OX3 7LF. BMJ 2005;330:92
  • 97. Medicina Baseada na Evidência e/ouEvidência Baseada na Medicina ? Manuel Neves-e-Castro
  • 98. Medicina Baseada na Evidência e/ouMedicina Baseada na Inteligência ? Lucas Viana Machado
  • 99. “Aquele que aprende mas não pensa está perdido. O que pensa mas não aprende é perigoso… Confucius
  • 100. Se aprendermos e pensarmos… nem estaremos perdidos nem seremos perigosospara as nossas doentes pos- menopausicas Wenger NK. Am J Geriatr Cardiol 2000;9:204-9
  • 101. “Each time we learn something new,the astonishment comes from therecognition that we were wrongbefore.In truth, whenever we discover a new fact, itinvolves the elimination of old ones.WE ARE ALWAYS, as it turns out,fundamentally IN ERROR.” Lewis Thomas English Biologist (1913-1993)
  • 102. Quais são as melhores recomendações do médico da mulher climatérica 1. Explicar o que se está passando no seu corpo durante o climatério e pós menopausa 2. Ocupação mental 3. Exercicio fisico 4. Alimentação adequada (consumo moderado de vinho tinto e abundante de: peixe, vegetais, frutos, soja, leite, alho, chocolate, etc) 5. Manter o índice de massa corporal dentro dos limites normais 6. Manter um perímetro normal da cintura 7. Abstenção do tabaco 8. Manter uma pressão arterial normal 9. Manter os lípidos sanguíneos nos valores normais (estatinas) 10. Exame mamário (palpação, inspecção mamografia)
  • 103. Qual é o melhor tratamento ?
  • 104. Qual é o melhor tratamento ?• Em termos gerais é o que estiver sensatamente indicado, se não contraindicado, após uma análise de benefícios e riscos, de todas as estratégias e intervenções, hormonais ou não hormonais• Deve estar dirigido a objectivos e alvos específicos que serão avaliados regularmente de modo a determinar a sua eficácia e a verificar a eventual ocorrência de quaisquer efeitos secundários, uma condição que determinará a sua duração MNC
  • 105. Qual é o melhor tratamento ?• As necessidades e preferências da mulher são decisivas baseadas no conselho do médico• Não deve esquecer-se que apesar de haver muitos tratamentos disponíveis não são no entanto indispensáveis• Os médicos têm o dever de dar a sua melhor informação independente às suas doentes de modo a que elas possam fazer as escolhas acertadas e assim aderir aos tratamentos• A mulher é quem toma a decisão se o médico não vir contraindicações• Portanto o melhor tratamento é aquele que a mulher escolher MNC
  • 106. Mensagens Finais (1)• Prescrevam tratamentos hormonais na pós menopausa quando clínicamente indicados, se não houver contraindicações MNC
  • 107. Mensagens Finais (2)• A prescrição de tratamentos hormonais de longa duração depende sempre de uma análise benefício/risco em comparação com medicações não hormonais e estratégias não medicamentosas MNC
  • 108. Mensagens Finais (3)• Não são indispensáveis quaisquer respostas dos ensaios clínicos em curso para que se possa hoje praticar uma boa Medicina MNC
  • 109. HT appears to be the best form of pharmacologic treatment to improve brain function, as well as to reduce the risk of colon cancer. It is probably the best preventive strategy for osteoporosis. With this in mind … limiting HT to the treatment of climacteric symptoms only is unjustified. Kopernik G and Shoham Z. Fertil Steril 2004;81(6):1458-1477
  • 110. Evitar que uma mulherbeneficie deum bom tratamentohormonal pós menopáusicosó pelo receio de efeitossecundários rarosnão parece ser umaMedicina satisfatória … Manuel Neves-e-Castro
  • 111. Mortality Associated with HRT in younger and older women Hormone Replacement Therapy reduced total mortality in trials with mean age of participants under 60 years. No change in mortality was seen in trials with mean age over 60 years. Salpeter SR et al. J Gen Intern Med 2004;19:791-804
  • 112. Por isso …Vários ilustres colegas , “especialistas” emmenopausa: H . Schneider (Alemanha) A . Genazzani (Itália) P . Kenemans (Holanda) e tambem eu próprio,continuamos a fazer tratamentos hormonaisde longa duração às nossas consortes comos seguintes resultados:
  • 113. Schneider Genazzani Neves-e-Castro Kenemans
  • 114. Estou muito grato …por terem tido a paciênciade me ouvirem,sem dormir…