Risks and benefits of long-term treatment with estrogens.
Risks and benefits of long-term treatment with estrogens.
复制标题
长期雌激素治疗的风险和益处。
作者：
T. Mack;R. Ross
当代激素替代的目标是将净可预测的终生风险降至最低；因此，成功与否取决于对净生活质量、净发病率和净死亡率的定量评估。雌激素改善更年期症状，维持骨骼完整，并产生子宫内膜癌；这些事实及其数量方面可以加以刺激。其他的联系也逐渐变得清晰：雌激素会增加胆道疾病，但能预防心脏病，现在看来还能预防中风。尽管传统观点与之相反，但一项重要的综述表明，长期使用雌激素可能会增加乳腺癌的发病率；作为一种风险因素，这种增加是适度的，但由于乳腺癌是一种常见疾病，因此从绝对值来看，这种增加是很大的。添加黄体酮作为一种对抗不良雌激素对子宫内膜影响的方法似乎很有吸引力。事实上，我们有理由担心添加黄体酮会增加乳腺癌、心脏病和中风的风险；即使是预期的子宫内膜癌的减少幅度，当激素被连续使用时，也可能不是很大。使用激素替代绝经后生活的简单确定性模型，我们插入了每种结果的特定方案相对风险的可用估计，并将每种净影响转化为发病率和死亡率的共同分母。虽然雌激素可能会增加净发病率，以预期住院次数或更随意的预期残疾天数来衡量，但这些负面变化主要是由于胆囊疾病和子宫内膜癌，这两种疾病在很大程度上是可以治疗的。在很大程度上，由于对心脏病的保护作用，适度剂量的雌激素替代可能会大大减少75岁甚至更高龄妇女的死亡人数。包括全身补充黄体酮在内的激素替代疗法尚未经过经验检验；它可能是有益的，但它至少同样可能是有害的。由雌激素引起的额外乳腺癌的数量适度增加，由雌激素预防的心脏事件的数量适度减少，或者对每一种情况同时在同一方向上发生微小的变化，都会产生将累计死亡的净减少转变为治疗导致的死亡人数增加的效果。（摘要删节为400字）
The goal of contemporary hormone replacement is to minimize net predictable lifetime risk; success therefore depends upon quantitative assessments of the net quality of life, of net morbidity and of net mortality. Estrogens ameliorate menopausal symptoms, maintain bone integrity, and produce endometrial cancer; these facts and their quantitative aspects can be stimulated. Other links are gradually becoming clear: estrogens increase biliary disease, but prevent heart disease, and, it now seems, stroke. Conventional wisdom to the contrary notwithstanding, a critical review suggests that breast cancer is probably increased in frequency by long-term estrogen use; the increase is modest as a risk factor but because breast cancer is a common disease, it is substantial in absolute terms. The addition of progestin seems attractive as a method of opposing undesirable estrogenic effects on the endometrium. In fact, there is reason for concern about the effect of an added progestin upon the risks from breast cancer, heart disease, and stroke; even the magnitude of the expected reduction in endometrial cancer may not be great when the hormone is administered sequentially. Using a simple deterministic model of post-menopausal life with hormone replacement, we have inserted available estimates of the regimen-specific relative risk for each outcome, and translated each net impact into common denominators of morbidity and mortality. While estrogens probably increase net morbidity, as measured by either the number of hospitalizations to be anticipated or by the more arbitrary measure of expected days of disability, these negative changes are mostly due to gallbladder disease and endometrial cancer, both largely treatable conditions. Largely because of protection against heart disease, estrogen replacement in modest dose is likely to reduce substantially the number of deaths to be expected in women treated through age 75 and even into more advanced age. Hormone replacement which includes systemic progestin supplementation has not been empirically tested; it may be beneficial, but it is at least as likely to be harmful. Either a modest increment in the number of additional breast cancers produced by estrogens, a modest reduction in the number of cardiac events prevented by estrogens, or a simultaneous minor shift in the same direction for each condition, would have the effect of shifting the net reduction in cumulative deaths into an increase in the number of deaths as a result of treatment.(ABSTRACT TRUNCATED AT 400 WORDS)