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Dysfunctionaluterine
bleeding(DUB)PatternsMenorrhagia(hypermenorrhea)月经过多Hypomenorrhea(cryptomenorrhea)月经过少Metrorrhagia(intermenstrualbleeding)子宫不规则出血Polymenorrhea月经频发(月经过频)Oligomenorrhea月经稀发Menometrorrhagia子宫不规则出血过多Contactbleeding(postcoitalbleeding)接触性出血、性交后出血DefinitionIrregularbleeding,unrelatedtoanatomiclesionsoftheuterus,exclusionofpathologiccausesofabnormalbleeding,isreferredtoasdysfunctionaluterinebleeding.DisturbanceofendocrineMostcommonatthereproductiveageReviewthenormalmenstruationcycle21-35,period2-8,amount20-60mlPathogenesisClassificationAnovulatory:85%Ovulatory:15%IncidenceIncidenceClassificationIntroductionBreakthroughbleeding:onlyestrogenstimulateendometrium,noprogesteroneLowplasmaconcentrationsofestrogensinfrequentandlightbleedingChronicstimulationofendometriumfromincreasedplasmaconcentrationsofestrogensfrequentandheavybleedingWithdrawalbleeding:singleestrogeninfluentendometrium,atresiaoffolliclesestrogenbleedingAnovulatorydysfunctionalbleedingPathologicalchangesofendometriumHyperplasiaofendometriumsimplehyperplasiacomplexhyperplasiaatypicalhyperplasia:notbelongtoDUB,glandularepitheliumhyperplasia,polarityofcelldisappear,sizeenlarged,darkandlargenucleus,karyokinesisProliferativephaseofendometriumAtrophicendometriumClinicalfindings
IrregularuterinebleedingPatterns:Menorrhagia(月经过多)Metrorrhagia(子宫不规则出血)Menometrorrhagia(子宫不规则出血过多)Polymenorrhea(月经过频)NoabdominalpainanddiscomfortableAnemiaPelvicexam:
uterinesizeisnormalDiagnosisExcludeanatomiccausesofabnormaluterinebleedingHistoryAge,menses,marital,contraceptive,treatmentPhysicalexam:General:excludesystemicdiseasesPelvic:excludegenitaldiseaseLabexamUltrasound:uterinesize,shape,endometriumUrineorserumHCGCytologicexamofcervix:cervicalcancerDeterminationofovarianfunctionBBT:monophaseSerumhormones:progesteroneislowerHysteroscope:pathologicchangesofcavityCytologicsmearofvaginalshedcell:anovulatoryperiodicchangesCervicalmucosa:1-2daysbefore
uterinebleeding,fernlikepattern
(羊齿状结晶)(picture)
Coagulationfunction,bloodcellcountSamplingofendometriumD&C(诊刮)hemostasisandfindingcausesbeforemensesorwithin6hoursofmenstrualonsetFractionalD&C:differentcervixandcorpusproliferativeorhyperplasia,nosecretorychangesBiopsyofendometriumDifferentialdiagnosisAbnormalpregnancyorcomplicationsofpregnancy:abortion,ectopicpregnancy,retainedplacentaSystemicdisease:hematopathy,failureofliverorkidney,hyperthyroidismorhypothyroidismrectalorurologicdisordersGenitaltumors:carcinomaofendometrium,cervix,myomas,ovariantumorGenitalinfection:endometritis,salpingitis,cervicalandendometrialpolypsMisuseofsexualhormone,IUDIndifferentage,thedifferentialdiagnosisisdifferentPubertyhemologicsystemdiseaseReproductiveagepregnancyinduceddiseasePremenopausetumorTreatments
GeneraltreatmentIron,vitamineC,protein,antibiotic,restMedicine:thefirst-linetherapySurgeryHysterectomy:medicineisnoeffectEndometrialablation:laser,rollerball,necrosisofendometrium,premenopause,nodesireofreproductioninyoungwomenUsedanazol,gestrinoneorGnRHabeforeoperationNoticesomekeypointsIndiagnosis,mustexcludepathologiccausesInhemostasis,rapidlystophemorrhageandregulatecycles,choicethemostsuitabledrugsandusageToyoungwomen,thecuredindicationsarerecoveringovulationOvulatorymenstrualdysfunctionOvulation,abnormalofcorpusluteumTwotypesLutealphasedefect(LPD)IrregularsheddingofendometriumLutealphasedefect(LPD)PathologySecretoryreactionofendometriumbutlutealphasedefect,corpusluteumsecreteinadequateprogesterone,derangementofglandandinterstitium,lessedemaofinterstitiumClinicalmanifestationShorteningofcycles,lutealphase<11daysAbortion,infertilityDiagnosis
BBT:doublephaseCytologicsmearofvaginalshedcellPathologicexamofendometrium:secretorydelay2daysphaselag2daysTreatment
PromotethedevelopmentofovumChlomiphene,HMG-HCGLowerdoseofestrogen:the5thofmenses,conjugateestrogen(妊马雌酮)0.625mgor17β-estrodiolfor5~7daysAfterovulation,progestinIM10mg/dfor10~14daysPromoteLHsurgeinthemiddlecycleofmensesAfterfolliclemature,HCG5000-10000UimStimulatecorpusluteumAfterBBTrise,HCG1000-2000Uimveryotherday,total5timesCompanywithhyperprolactinemiaBromocriptine(溴隐亭)COC:for3-6monthsirregularsheddingofendometriumCharactersOvulation,developmentofcorpusluteumisnormal,thetimeoflutealregressionislongerPathology:inthe5thofmenses,secretoryphaseofendometrium,mixedendometrium(secretory,proliferative,hemorrhage,necrosis)irregularsheddingofendometriumClinicalfindingsCyclesarenormal,durationislonger,>7dDiagnosisSymptomsBBT:doublephase,decreaseslowlyD&C:the5thofmenses,mixedendometriumTreatmentProgesterone1~2daysafterovulationor10~14daysbeforenextmenses,MPA10mgfor10daysHCGCOCSummaryofdiagnosisandtherapyhistory,PE,labnosystemicandgenitaldisease<35y>35ybiopsyofendometriumproliferativeatypicalhyperplasiahysterectomymedicinedesireoffertilitynodesireoffertilityhysteroscope,D&Chysteroscope,D&C,ablationfurthertherapynoeffectAUBThankyou
Highphase<11daysObjectives:ConversionfromprolilferativetosecretaryendometriumPrinciples:PubertyandreproductiveageHemostasis,regulatecycles,promoteovulationPremenopauseHemostasis,regulatecycles,preventendometrialmalignantchangeHemostasisMedicineprogesterone,estrogen,androgenAntiprostaglandinOtherdrugs:TraditionalChineseMedicineSlightbleeding:thelowest,effectivedoseSeverebleeding:haveeffectswithin8hours;bleedingstopin24~48hours;>96hours,complicatingotherdiseaseCombineduseSlightbleeding:combinationlow-doseoralcontraceptive,thefirstdayofmenses21daysSeverebleeding:combinationmonophasicoralcontraceptive,1~2pill/8~12hours,3daysafterbleedingstop,reduce1/3doseevery3days,maintain1pillfortotal21day.SuchasMarvelonCommonlyusedinreproductiveageorpremenopauseEstrogenRecoveryendometriumAcuteseverebleeding:benzestrofol(苯甲酸雌二醇):3~4mg/d,adjustaccordingtobleeding,totaldose<12mg/d
conjugatedestrogen:25mgivevery4~6h,2nddayconjugatedestrogen3.75~7.5mg/dpo,bleedingiscontrolledwithin2~3days,reducedosageevery3daysProgynova(estradiolvalerate,补佳乐):2mgq4-6hInterruptedslightlong-termbleeding:conjugatedestrogen:1.25mg/dfor21days,thelast7~10days,addingmedroxyprogesteroneacetate(MPA)10mg/dContraindication:hemoconcentrationorthrombusCommonlyuseinpubertyProgesterone(ablationofendometrium)Convertendometrium,baseonestrogen,Hb>80g/L17
-Hydroxyprogesterone(羟孕酮),norethindrone(炔诺酮):5mgonceevery8hours,3daysafterbleedingstop,reducedose,maintaindose2.5~5mg/dto21daysafterbleedingstopD&C:acuteseverebleeding,riskfactorAdjuvanttreatmentTranexamicAcid(氨甲环酸)、etamsylate(酚磺乙胺)、VitKTestosteronepropionate(丙酸睾丸酮)CorrectanemiaAntibioticRegulatecycles:3~6coursesEstrogensfollowedbyprogesteroneCombination(oralcontraceptives)ProgesteronealonePromoteovulation(CC,HMG,HCG,GnRH-a)IUDEstrogensfollowedbyprogesteroneLowerestrogenConjugatedestrogen1.25mgorestradiol2mgqd×21days,10dayslateraddingMPA10mg×10dCombinationHighestrogenandpremenopauseOralcontraceptive:
the5thdayofmenses,everynight1pillfor3weeks,stopfor7daysProgesteronealoneAdolescenceorpremenopauseThe16~25daysofmenses,MPA10mg/dorprogestinIM20mg/dordydrogesterone10~20mg/dormicronizeprogesterone200mgfor10~14days
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