408.3 🩺 內科專科考前版

408.3.0.1 📌 䞀頁重點

  • 22E:
    • Fezolinetant (Veozah, FDA 2023) NK3 antagonist for vasomotor — game-changer non-hormonal
    • Elinzanetant (NK1+NK3 dual) phase 3
    • Romosozumab (anti-sclerostin, FDA 2019) for severe osteoporosis — anabolic + anti-resorptive (12 doses limit; CV risk caveat)
    • Estradiol/bazedoxifene combo (Duavee) — alternative without progestin in uterus
    • Anti-CGRP migraine drugs for hot-flash-induced migraine (off-label studies)
    • CBT-meno evidence-based
    • WHI re-analysis (Manson 2017+): timing-specific risk-benefit refinement
  • Taiwan: 健保 oral estradiol + transdermal estradiol + medroxyprogesterone + micronized progesterone; 健保 vaginal estrogen; 健保 paroxetine + venlafaxine (off-label hot flash); 健保 alendronate + denosumab + teriparatide; fezolinetant + romosozumab 自費 倚 (條件 expanding); CTAOH/TES + DAROC + Taiwan menopause society

408.3.0.2 🌟 Pearls (12)

  1. Premature menopause / POI: HRT until natural menopause age (~ 51) — different rule from regular menopause HRT timing
  2. WHI re-analysis: women < 60 + < 10 yr post-menopause: HRT had favorable risk-benefit (Manson 2017)
  3. Estrogen alone (in hysterectomy): possibly cardio-protective if early; less breast CA risk than combined
  4. Combined HRT breast CA: ↑ ~ 1/1000 yr in WHI; absolute risk small
  5. Micronized progesterone vs medroxyprogesterone: micronized has better breast + CV profile
  6. Transdermal vs oral E: transdermal bypass first-pass → less DVT (no thrombogenic SHBG/clotting factor effects)
  7. Fezolinetant (Veozah) 45 mg/d: NK3 antagonist; effective non-hormonal vasomotor; LFT monitoring
  8. Elinzanetant (Bayer): NK1+NK3 dual; might be more effective; phase 3 / preliminary FDA review
  9. Romosozumab: 12 monthly doses → switch to bisphosphonate / denosumab; CV risk in cardiac comorbidity (FRAME, ARCH)
  10. Sequential bone treatment: anabolic (teriparatide/romosozumab) → anti-resorptive (bisphosphonate) for severe
  11. Bisphosphonate ONJ + atypical fracture: rare; oral hygiene + femur surveillance
  12. Vaginal estrogen safety: even in breast CA history (selected) — minimal systemic absorption (Endocrine Society + ACOG)

408.3.0.3 📍 Taiwan + 健保

408.3.0.3.1 Drugs
  • 健保 oral estradiol (Estrofem, Climara) + medroxyprogesterone + micronized progesterone (條件)
  • 健保 transdermal estradiol patch (Climara, Estraderm)
  • 健保 vaginal estrogen cream + tablet
  • 健保 raloxifene
  • 健保 paroxetine, venlafaxine (off-label vasomotor)
  • 健保 gabapentin
  • 健保 clonidine
  • Fezolinetant 自費 (新, 條件 expanding)
  • Elinzanetant 未䞊垂 Taiwan
  • 健保 bisphosphonate (alendronate, ibandronate, zoledronic acid)
  • 健保 denosumab 條件
  • 健保 teriparatide 條件 (severe osteoporosis)
  • Romosozumab 自費 / 條件 limited
  • 健保 calcium + Vit D
408.3.0.3.2 Imaging + Workup
  • 健保 DXA q2y for osteoporosis
  • 健保 mammography 45-69 (國健眲 + 條件)
  • 健保 lipid + glucose
408.3.0.3.3 孞會 + 指匕
  • TES + Taiwan Menopause Society + DAROC
  • North American Menopause Society (NAMS) 2022 update
  • IMS Recommendations 2024
  • Endocrine Society Menopause 2015
  • WHI re-analysis (Manson 2017+)
  • KIDGO menopause + bone

408.3.0.4 🎓 內專必懂 (12)

  1. Menopause definition + perimenopause spectrum
  2. HPG changes + estrone dominance
  3. Symptoms multi-system + GSM nomenclature
  4. HRT formulations + risks (DVT, breast CA, stroke)
  5. Timing hypothesis (< 10 yr post / < 60 yr)
  6. Premature menopause / POI HRT until 51
  7. Transdermal + micronized progesterone preferred
  8. Non-hormonal vasomotor (SSRI, gabapentin, fezolinetant 22E)
  9. GSM treatment ladder (lubricant → vaginal E → SERM/DHEA)
  10. Bone protection sequential (anabolic → anti-resorptive)
  11. Romosozumab + CV caveat
  12. 22E new: fezolinetant, elinzanetant, romosozumab, CBT-meno, WHI re-analysis

408.3.0.5 ⚙ HRT Decision Tree (內專)

Step 1 — Indication confirmed:
- Symptomatic vasomotor / GSM / premature menopause / select bone

Step 2 — Contraindications screen:
- Breast CA, DVT/PE, liver, undiagnosed bleed, stroke, MI history
- Migraine with aura, severe HTN, untreated dyslipidemia

Step 3 — Timing:
- < 60 yr + < 10 yr post-menopause: favorable
- > 10 yr post / > 60 yr: do not initiate
- Premature menopause / POI: HRT until ~ 51 yr

Step 4 — Choose formulation:
- Symptoms primary: oral or transdermal E + P (uterus) or E (no uterus)
- DVT risk: transdermal preferred
- Breast risk: micronized progesterone preferred
- Liver: transdermal
- GSM only: vaginal E (cream/ring/tablet)

Step 5 — Initiate + monitor:
- Lowest effective dose
- Annual: BP, breast exam, mammography, lipid, vaginal bleed evaluation
- DXA per indication
- Re-evaluate periodically

Step 6 — Discontinuation:
- No fixed time limit if benefits > risks
- Re-evaluate annually
- Taper slowly to avoid rebound vasomotor

408.3.0.6 ⚙ Vasomotor Treatment Ladder

Step 1 — Lifestyle:
- Cool environment, layered clothing
- Avoid triggers (alcohol, caffeine, spicy)
- Stress reduction
- CBT-meno (evidence-based)

Step 2 — HRT (if no CI):
- Lowest effective dose
- 6-12 mo trial; many spontaneously decrease

Step 3 — Non-hormonal (if HRT CI or refused):
- Paroxetine 7.5 mg HS (Brisdelle)
- Venlafaxine 37.5-75 mg
- Escitalopram 10-20 mg
- Gabapentin 300-900 mg HS
- Fezolinetant 45 mg/d (22E)

Step 4 — Refractory:
- Combination of above
- Clonidine 0.1-0.2 mg/d
- Elinzanetant (phase 3)
- Acupuncture (mixed evidence)
- Hypnotherapy

Step 5 — End-of-life or severely symptomatic:
- HRT possible even with caveats; individualized

⚠ AI 草皿。