Climaterio para el manejo clínico de la mujer climatérica, Riesgo Cardiovascular

b. Riesgo cardiovascular.

b1. Cambios de estilos de vida33-36:

• Actividad física. Mejora los factores de riesgo CV. Disminuye hasta en 43% el riesgo coronario.
• Dieta. El riesgo coronario disminuye 4% por cada fruta o porción de verdura que se ingiera al día.
• Cigarrillo. Aumenta el riesgo de eventos coronarios y cerebro-vasculares. El aban-dono del hábito provoca una reducción de 36% en la mortalidad coronaria.

b2. Terapias farmacológicas37-40:
• Dislipidemia. Estatina, fibratos.
• Hipertensión arterial. Hipotensores, diuréticos.
• Resistencia a insulina. Metformina.
• Obesidad. Sibutramina, orlistat.

c. Riesgo de Osteoporosis.
c1. Cambios de estilos de vida41-44:

• Actividad física. Caminar 4 hrs. a la semana disminuye el riesgo de fractura en 41%.
• Mayor exposición al sol. Las personas que sufren fracturas tienen menos exposi-ción al sol (Vit D).
• Disminuir cigarrillos. Fumar se asocia con mayor riesgo de fractura (RR: 1,25; IC 95%:1,15- 1,36).

c2. Calcio y Vitamina D (45-46):

• Tienen un efecto positivo sobre la densidad ósea y cierta tendencia a reducir fracturas vertebrales; no es claro si disminuyen las fracturas no vertebrales.
• Para lograr efectos terapéuticos las evidencias sugieren dosis de 1200 mg. de Ca y 800 UI de vitamina D al día.

c3. Terapias farmacológicas47-48:
• Alendronato, calcitonina, risedronato y raloxifeno disminuyen fracturas vertebrales. Alendronato y risedronato disminuyen el riesgo de fracturas de cadera.
• Alendronato disminuye 45% el riesgo de fracturas vertebrales. La reducción de fracturas de cadera es de 40%, pero sólo en prevención secundaria.
• La TH y la Tibolona son también otras opciones terapéuticas válidas.

Conclusión. Mejorar los estilos de vida y aplicar terapias farmacológicas son terapias efectivas para prevenir el deterioro de la calidad de vida y el aumento de las enfermedades crónicas que se asocian con la menopausia.

Conclusiones

1. Evaluar en toda mujer climatérica la cali-dad de vida y el riesgo de enfermedades crónicas.
2. Si hay deterioro clínico indicar terapias.
3. Las principales medidas terapéuticas son mejorar los estilos de vidas y las terapias farmacológicas específicas.

Referencias

1.Heinemann K, Ruebig A, Potthoff P, Schneider HP, Strelow F, Heinemann LA, Do MT. The Menopause Rating Scale (MRS) scale: a methodological review. Qual Life Outcomes 2004;2:45.
2. Chedraui P, Blümel JE, Baron G, Belzares E, Bencosme A, Calle A, et al. Impaired quality of life among middle aged women: a multicentre Latin American study. Maturitas 2008;61(3):23-9.
3. Kuh D, Langenberg C, Hardy R, Kok H, Cooper R, Butterworth S, Wadsworth ME. Cardiovascular risk at age 53 years in relation to the menopause transition and use of hormone replacement therapy: a prospective British birth cohort study. BJOG 2005;112:476-85.
4.Palmer JR, Rosenberg L, Shapiro S. Reproductive factors and risk of myocardial infarction. Am J Epidemiol 1992;136:408-16.
5.Rosenberg L, Hennekens CH, Rosner B, Belanger C, Rothman KJ, Speizer FE. Early menopause and the risk of myocardial infarction. Am J Obstet Gynecol 1981;139:47-51.
6.Hoshino H, Kushida K, Takahashi M, Yamazaki K, Denda M, Atsumi K, et al. Changes in Levels of Biochemical Markers and Ultrasound Indices of Os Calcis Across the Menopausal Transition. Osteoporosis international 2000;11:128-33.
7.Warming L, Hassager C, Christiansen C. Changes in bone mineral density with age in men and women: a longitudinal study. Osteoporos Int 2002;13:105-12.
8.Acquadro C, Berzon R, Dubois D, Leidy NK, Marquis P, Revicki D, et al. Incorporating the patient’s perspective into drug development and communication: an ad hoc task force report of the Patient-Reported Outcomes (PRO) Harmonization Group meeting at the Food and Drug Administration, February 16, 2001. Val. Health 2003;5:522-31.
9. Aedo S, Porcile A, Irribarra C. Calidad de Vida Relacionada con el Climaterio en una Población Chilena de Mujeres Saludables. Rev Chil Obstet Ginecol 2006;71:402-09.
10.NCEP ATP III. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Final Report. Circulation 2002;106:3143-21.
11.Royer M, Castelo-Branco C, Blümel JE, Chedraui P, Danckers L, Bencosme A, et al. The US National Cholesterol Education Programme Adult Treatment Panel III (NCEP ATP III): prevalence of the metabolic syndrome in postmenopausal Latin American women. Climacteric 2007;10:164-170.
12.Cadarette SM, Jaglal SB, Kreiger N, McIsaac WJ, Darlington GA, Tu JV. Development and validation of the Osteoporosis Risk Assessment Instrument to facilitate selection of women for bone densitometry. CMAJ 2000; 162:1289-94.
13.https://www.shef.ac.uk/FRAX/index_SP. htm (20/08/2009)
14.https://www.menopause-rating-scale.info/ documents/ Ref_Values_CountrGr. Pdf. (10/04/2009)
15.Qaseem A, Snow V, Shekelle P, Hopkins R Jr, Forciea MA, Owens DK. Pharmacologic treatment of low bone density or osteoporosis to prevent fractures: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2008;149:404-15.
16.Farquhar CM, Marjoribanks J, Lethaby A, Lamberts Q, Suckling JA; Cochrane HT Study Group. Long term hormone therapy for perimenopausal and postmenopausal women. Cochrane Database Syst Rev 2005;(3): CD004143.
17.Nelson HD. Commonly used types of postmenopausal estrogen for treatment of hot flashes: scientific review. JAMA. 2004;291:1610-20.
18.Olson MB, Bairey Merz CN, Shaw LJ, Mankad S, Reis SE, Pohost GM, et al. Hormone replacement, race, and psychological health in women: a report from the NHLBI-Sponsored WISE Study. J Womens Health (Larchmt) 2004;13:325-32.
19.Blumel JE, Bravo F, Recavarren M, Sarra S. Sexual function in postmenopausal women using hormone replacement therapy. Rev Med Chil 2003;13:1251-5.
20.Grady D, Gebretsadik T, Kerlikowske K, Ernster V, Petitti D. Hormone replacement therapy and endometrial cancer risk: a meta-analysis. Obstet Gynecol 1995;85:304-13.
21.Fournier A, Berrino F, Riboli E, Avenel V, Clavel-Chapelon F. Breast cancer risk in relation to different types of hormone replacement therapy in the E3N-EPIC cohort. Int J Cancer 2005;114:448-54.
22.De Lignieres B, de Vathaire F, Fournier S, Urbinelli R, Allaert F, Le MG, Kuttenn F. Combined hormone replacement therapy and risk of breast cancer in a French cohort study of 3175 women. Climacteric 2002;5:332-40.
23. Writing Group for the Women’s Health Initiative Investigators. Risks and Benefits of Estrogen Plus Progestin in Healthy Postme-nopausal Women. Principal Results From the Women’s Health Initiative Randomized Controlled Trial. JAMA 2002;288:321-33.
24. McKenzie J, Jaap AJ, Gallacher S, Kelly A, Crawford L, Greer IA, Rumley A, Petrie JR, Lowe GD, Paterson K, Sattar N. Metabolic, inflammatory and haemostatic effects of a low-dose continuous combined HRT in women with type 2 diabetes: potentially safer with respect to vascular risk?. Clin Endocrinol (Oxf) 2003;59:682-9.
25.Zegura B, Guzic-Salobir B, Sebestjen M, Keber I. The effect of various menopausal hormone therapies on markers of inflammation, coagulation, fibrinolysis, lipids, and lipopro-teins in healthy postmenopausal women. Menopause 2006;13:643-50.
26.straczek C, Oger E, Yon de Jonage-Canonico MB, Plu-Bureau G, Conard J, Meyer G, et al. Prothrombotic mutations, hormone therapy, and venous thromboembolism among postmeno-pausal women: impact of the route of estrogen administration. Circulation 2005;112:3495-500.
27.Kenemans P, Speroff L. Tibolone: clinical recommendations and practical guidelines. A report of the International Tibolone Consensus Group. Maturitas 2005;51:21-8.
28.Suckling J, Lethaby A, Kennedy R. Local oestrogen for vaginal atrophy in postmeno-pausal women. Cochrane Database Syst Rev
2006;(4):CD001500.
29.Mattsson LA, Cullberg G. A clinical evaluation of treatment with estriol vaginal cream versus suppository in postmenopausal women. Acta
Obstet Gynecol Scand 1983;62:397-401.
30. Weisberg E, Ayton R, Darling G, Farrell E, Murkies A, O’Neill S, Kirkegard Y, Fraser IS. Endometrial and vaginal effects of low-dose estradiol delivered by vaginal ring or vaginal tablet. Climacteric 2005;8:83-92.
31.Cheema D, Coomarasamy A, El-Toukhy T. Non-hormonal therapy of post-menopausal vasomotor symptoms: a structured evidence-based review. Arch Gynecol Obstet 2007; 276:463-9.
32. Nedrow A, Miller J, Walker M, Nygren P, Huffman LH, Nelson HD. Complementary and alternative therapies for the management of menopause-related symptoms: a systematic evidence review. Arch Intern Med 2006;166: 1453-65.
33.Shaw K, Gennat H, O’Rourke P, Del Mar C. Exercise for overweight or obesity. Cochrane Database Syst Rev 2006;(4):CD003817.
34.Manson JE, Greenland P, LaCroix AZ, Stefanick ML, Mouton CP, Oberman A, Perri MG, Sheps DS, Pettinger MB, Siscovick DS. Walking compared with vigorous exercise for the prevention of cardiovascular events in women. N Engl J Med 2002;347:716-25.
35.Dauchet L, Amouyel P, Hercberg S, Dallongeville J. Fruit and vegetable consump-tion and risk of coronary heart disease: a meta-analysis of cohort studies. J Nutr 2006;136:2588-93.
36.Critchley J, Capewell S. Smoking cessation for the secondary prevention of coronary heart disease. Cochrane Database Syst Rev
2004;(1):CD003041.
37. McPherson R, Frohlich J, Fodor G, Genest J, Canadian Cardiovascular Society. Canadian Cardiovascular Society position statement— recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease. Can J Cardiol 2006;22:913-27.
38.Khan NA, Hemmelgarn B, Herman RJ, Bell CM, Mahon JL, Leiter LA, et al.; Canadian Hypertension Education Program. The 2009 Canadian Hypertension Education Program recommendations for the management of hypertension: Part 2—therapy. Can J Cardiol 2009;25: 287-98.
39.American Heart Association. Diagnosis and management of the metabolic syndrome. An American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Executive summary. Cardiol Rev 2005;1:322-7.
40.Lau DC, Douketis JD, Morrison KM, Hramiak IM, Sharma AM, Ur E; Obesity Canada Clinical Practice Guidelines Expert Panel. 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children [summary]. CMAJ 2007;176:S1-13.
41.Feskanich D, Willett W, Colditz G. Walking and leisure-time activity and risk of hip frac-ture in postmenopausal women. JAMA. 2002;288:2300-6.
42.Masoni A, Morosano M, Tomat MF, Pezzotto SM, Sánchez A. Association between hip frac-tures and risk factors for osteoporosis. Multivariate análisis. Medicina (B. Aires) 2007;67:423-8.
43.Brot C, Vestergaard P, Kolthoff N, Gram J, Hermann AP, Sørensen OH. Vitamin D status and its adequacy in healthy Danish perime-nopausal women: relationships to dietary intake, sun exposure and serum parathyroid hormone. Br J Nutr 200;86 Suppl 1:S97-103.
44. Kanis JA, Johnell O, Oden A, Johansson H, De Laet C, Eisman JA, Fujiwara S, Kroger H, McCloskey EV, Mellstrom D, Melton LJ, Pols H, Reeve J, Silman A, Tenenhouse A. Smoking and fracture risk: a meta-analysis. Osteoporos Int 2005;16:155-62.
45. Tang BM, Eslick GD, Nowson C, Smith C, Bensoussan A. Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis. Lancet. 2007;370(9588):657-66.
46.Shea B, Wells G, Cranney A, Zytaruk N, Robinson V, Griffith L, et al; Osteoporosis Methodology Group; Osteoporosis Research Advisory Group. WITHDRAWN: Calcium supplementation on bone loss in postmeno-pausal women. Cochrane Database Syst Rev
2007;(1):CD004526.
47.Hauselmann HJ, Rizzoli R. A comprehensive review of treatments for postmenopausal osteoporosis. Osteoporos Int 2003;14:2-12.
48.Wells GA, Cranney A, Peterson J, Boucher M, Shea B, Robinson V, Coyle D, Tugwell P. Alendronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database Syst Rev 2008;(1):CD001155.