月经相关疾病

月经相关疾病Course

OverviewIntroductionofthemenstrualcycleDysmenorrheaPremenstrualsyndrome(PMS)Toxicshocksyndrome(TSS)2Course

OverviewIntroductionofthemenstrualcycleDysmenorrheaPremenstrualsyndrome(PMS)Toxicshocksyndrome(TSS)Otherdisorders3月经的开始与结束初经

(Menarche)9-17岁刚开始前两年周期不稳定2-5年内没有LHsurge，所以大约50-80%左右的比例是没有排卵的Onset影响因子：种族、基因、营养状态、身体质量更年期

(Menopause)45-55岁症状为潮红、睡眠障碍、骨质疏松、精神状况差导致情绪差、阴道干涩以至于容易泌尿道感染、贺尔蒙改变以致于慢性疾病发生率上升4MenstrualCycle

Hypothalamic-Pituitary-OvarianAxisHypothalamus

regulatesthemenstrualcyclebyproducinggonadotropinreleasinghormone(GnRH).

Lowlevelsofbothestradiolandprogesterone

stimulatethehypothalamustoreleaseGnRH,

whichstimulatespituitarygonadotrophcellstosynthesizeandsecreteLHandFSH.5MenstrualCycleMenstrualcycle经期Monthlycycleoffemalereproductivehormones.Amenstrualcycle:1stdayofmensesthebeginningofthenext.Average28days(15%);variesbetween21-40daysMenses经血期Average4days(±2days).Themajorcomponentsareendometrialcellulardebrisandblood.Averagewholebloodlosspercycleis30-80mlOvariancycle卵巢周期Follicularphase(Day1~14)滤泡期Ovulation(Day14)排卵期Lutealphase(Day14+/-2)黄体期Uterinecycle子宫周期Menstrualphase(Day1~5)月经期Proliferativephase(Day6~14)增生期Secretoryphase

(Day14~28)分泌期6Menstrual

PhaseProliferationPhaseSecretory

PhaseMenstrual

PhaseFollicularPhaseLutealPhase7Course

OverviewIntroductionofthemenstrualcycleDysmenorrhea月经困难Premenstrualsyndrome(PMS)Toxicshocksyndrome(TSS)Otherdisorders8ClassificationofDysmenorrheaPrimarySecondaryCauseNotreallysureInabsenceofpelvicdiseasePelvicpathologyEndometriosisPIDOvariancystsUterinetumorsUterinefibroidsCervicalosstenosisCongenital

abnormalitiesAgeTeens&early20sLate20sororderOccurOnlyatmenstrualcycleAllthetimeDurationOnly2-3daysVarywithcauseMensesRegularNormalbloodlossIrregularMenorrhagiaResponsetoNSAIDsYesNoSymptomsNV,fatigue,dizziness,irritability,diarrhea,headache,dysmenorrpheapainVaryaccordingtosecondarycauses;mayincludedyspareunia,pelvictenderness9PathophysiologyTheactualpathophysiologyofprimarydysmenorrheaisnotreallysure!!!Prostaglandin：stimulateuterinecontractionsLeukotrieneVasopressin10Stronguterinecontractionsandsignificantvasoconstriction,resultinginuterineandischemiaandpain.RiskofDysmenorrheaAge：youngfemalePregnancyLifestyle:stress,anxietyExercise:preventdysmenorrheaSmoking:nicotineinducevasoconstrictionAlcoholintakeObesity11TreatmentGoalsProviderelief/significantimprovementinsymptomsMinimizedisruptionofusualactivitiesAnimportantinitialstepDistinguishingbetweenprimaryandsecondarydiseaseEssentiallyallpatientswithprimarydysmenorrhea

canobtainadequatereliefofsymptomswithNondruginterventionsNonprescriptionPrescriptiondrugtherapy12NonpharmacologicTherapySleepHotbaths/HeatingpadExerciseLifestylealterationsSmoking↓ConsumptionofOmega-3fattyacids13

14NonpharmacologicTherapyNonpharmacologicTherapy饮食均衡根据调查，蔬菜水果摄取量不足、及油脂比例过高的女性，较容易出现生理期不适的症状，例如腰酸背痛、胸部涨痛、头痛、易怒情绪不稳定因为高脂肪的摄取及暴饮暴食，都会增加身体新陈代谢的负担，导致血糖值的不稳定，引起生理期不适。蔬菜有助于降低胆固醇、平衡血糖值等功效。15充足蔬菜水果摄取，避免暴饮暴食及高脂肪摄取!NonpharmacologicTherapy忌吃冷食及油炸食品油炸食品含有大量油脂，除了影响内分泌，

也会造成生理期间在心理及生理上的不适许多女性偏爱冰品冷饮，

这些温度较低的食物进入人体后，

很可能会引起子宫收缩，扰乱整个生理周期，

甚至影响到中年以后的更年期。16NonpharmacologicTherapy尽量选择暖性食物各类红豆、坚果类、豆类、大蒜、葱、姜、芝麻、菠菜、A菜、红菜、杏菜、甘蓝菜、花椰菜、牛蒡、海带等，皆属于暖性蔬果。白菜、高丽菜、白萝卜、冬瓜、丝瓜、绿豆、水梨、芒果、杨桃、柑橘、西瓜等瓜类则为偏寒食物。女性在选择食物时，除了考虑到营养均衡外，

可多选择暖性蔬果活络体质。17NonpharmacologicTherapy长期补充铁质由于生理期身体都会大量失血，

女性常会有「缺铁性贫血」的情形，

如果身体一直处于贫血的状态，

每逢生理期就会更加不舒服。因此平日就要补充铁质，例如透过食用猪肝、葡萄、葡萄干、黑糖、黑芝麻等来摄取铁质。18NonpharmacologicTherapy19NonpharmacologicTherapy子宫温暖操婴儿式弯膝跪下坐在脚跟，前额触地，双臂伸直于耳朵两侧，保持姿势，深吸深吐。20NonpharmacologicTherapy

子宫温暖操猫式步骤一步骤二步骤三双手约与肩同宽，

双脚自然张开。吸气将背部往前，

吐气时将双手往前延伸，眼睛看前方，

臀部往天花板延伸。胸部尽量靠近地面，

使双手往前延伸，

感觉下腹延展。

每个深呼吸都感觉背部更加延伸，停留5个呼吸。21NonpharmacologicTherapy子宫温暖操蝴蝶式坐下将双脚放地面上，双脚呈菱形，脚底板相对，膝盖外侧放置瑜珈砖，头部和上半身都放松于地板上，

后背放瑜珈枕或瑜珈铺巾，两手放在腿外侧，放松休息。22NonpharmacologicTherapy穴道按摩位置作用行间穴足背上，当第1、2趾间，

趾蹼缘的后方赤白肉际处。刺激肝经的穴位，

能帮助打通肝经，

有助解除肝气郁滞。三阴交小腿内侧。

足内踝上方四指横宽处。

将小指放在内踝尖上，

其余三指自然向上贴近小腿，食指上缘所到之处即是。脾、肝、肾三经经过的交点，经期间单纯只有腹痛的人，

应该是寒气太重、

凝结小腹，

刺激三阴交可以止痛、去寒。23穴道按摩NonpharmacologicTherapy位置作用崑仑穴足外踝尖处与足跟肌腱连线的中点。是膀胱经的穴道，

若腰痠背痛、筋骨僵硬，就是膀胱经郁热，除了多做运动以外，还可刺激崑仑穴。关元穴肚脐直下3寸（四指幅宽）。位于任脉，又叫做下丹田，是元气之所在。可调节生殖系统，

改善月经失调症状。24Dysmenorrhea

PharmacologicTherapy25PharmacologicTherapyNonsalicylateNSAIDs:Ibuprofen&NaproxenFirstlinetherapyUsageBegin1-2daysbeforeexpectedmensesTakefor2-3daysTakeonascheduled(notasneeded)SideeffectsGIsymptomsdecreasedbytakingdrugswithfood26PharmacologicTherapyAcetaminophenTreatingonlymildsymptomsofdysmenorrheaAweakinhibitorofprostaglandinsynthesis4g/day27PharmacologicTherapyAspirinTreatingmildsymptomsofdysmenorrheaInlowdose,

aspirinhasonlyalimitedeffectonprostaglandinsynthesis

→moderatelyeffectiveintreatingwithminimalsymptomsMayincreasemenstrualflowAdolescentshouldnotuse

→Reye’ssyndrome28PharmacologicTherapyRecommendeddosage29AgentRecommendedNonprescriptiondosageMaximumdailydosageIbuprofen200-400mgevery4-6hours1200mgNaproxen220-400mginitiallythen220mgevery8-12hours660mgAcetaminophen650-1000mgevery4-6hours4000mgAspirin650-1000mgevery4-6hours4000mgPharmacologicTherapyOralContraceptives排卵时前列腺素会上升，因此用避孕药抑制排卵，

让前列腺素的分泌下降，减少子宫收缩，减轻疼痛。30DrugSelectionAdolescents

Acetaminophen

&Ibuprofen

Aspirin：maycauseReye’ssyndromeBreast-feeding

Acetaminophen

&

Ibuprofen

Aspirin

&

Naproxen：infectonbabycardiovascularsystemPepticulcer

Acetaminophen

&

Oralcontraceptive

NSAIDs：mayworsenGIsyndrome31DrugSelectionHypertension/Asthma/CHF

NSAIDs：maycausefluidretentionAnticoagulants/Drugsmayincreasebleeding

NSAIDs：maycausebleedingLithium

NSAIDs：moderateriskoflithiumtoxicityAlcohol

Acetaminophen：livertoxicity

Aspirin：GItoxicity32ComplementaryTherapyVitaminB1:缓和子宫肌肉痛VitaminB6:舒缓经痛、头痛的不适，可以镇定情绪Sweetfennelextract甜茴香萃取物:减缓经痛，但不适用于严重症状时，因为会减少血液凝结Magnesium:具有调节神经细胞的功能，舒缓情绪及肌肉紧绷33Fishoil主成分有omega-3fattyacids里面含DHA(Docosahexanoicacid)、EPA(Eicosapenteanoicacid)增加抗发炎激素、减少发炎前驱激素Omega-3不饱和脂肪酸会跟花生四烯酸竞争生成促发炎介质(proinflammatorymediators)。Omega-3不饱和脂肪酸会抑制发炎介质和纤维化因子(fibroticmediators)包括、白介素(interleukins)、肿瘤坏死因子-α(tumornecrosisfactor-α，TNF-α)ComplementaryTherapy34给虚寒体质女性生化汤功能:

排除恶露、调节子宫收缩、帮助子宫复旧、减少宫缩腹痛等作用。使用时间通常是即月经来的第一天开始，一日一帖，连续服用三天。注意:若经血过多、或患有巧克力囊肿、子宫肌瘤、子宫内膜异位，不要使用生化汤。ComplementaryTherapy35给虚寒体质女性四物汤:被称为妇人病的圣药，由当归、熟地黄、川芎及芍药组成，可用来调经止痛、养血疏筋。帮助活血化瘀，排除血块，并减轻腹胀腹痛，使经血排出顺畅。可补充铁剂，减少月经来潮时的贫血、头晕目眩及经血不出的状况。服用时机及使用方法:经期后每次在经期干净后，就连续服用六天份的四物汤。ComplementaryTherapy36给燥热体质女性:不适合用生化汤，会造成血崩可在喝四物饮时，搭配牛奶、白木耳等凉补生理期不要喝茶:茶类鞣质含量高，会妨碍肠黏膜吸收铁质。经期间不宜吃寒凉性的食物，如：水梨、西瓜、螃蟹、田螺、竹笋，会导致血液循缓减缓或不通的情形。中药使用上采补益药，不要使用补血药，可能使经血过多多补充鸡肉、牛肉、羊肉、苹果、红糖有头昏、心悸、贫血的人尽量不用caffeine，会让症状更严重，经期间可能缺少太多维生素、矿物质，会阻碍碳水化合物的代谢ComplementaryTherapy37Course

OverviewIntroductionofthemenstrualcycleDysmenorrhea月经困难Premenstrualsyndrome(PMS)

经前症候群Toxicshocksyndrome(TSS)38Introduction:PMSDefinitionCyclicdisorderPhysical&emotionalsymptomsOccurduringthelutealphaseofthemenstrualcycle

(Aweekbeforemenstrualflow)Usuallyoriginateinearly20s.Occuronlyduringovulatorycycles.Notoccurinpregnancy,breast-feeding,menopausewomen.Moresevere

form:Premenstrualdysphoricdisorder(PMDD)经前不悦症39PMSPathophysiologyTheactualpathophysiologyis

unknown

!!!Fluctuationofestrogenandprogesteronelevelscauseschangesinneurotransmitterslevels.Serotonin↓GABAEndorphinsExogenoushormonesGeneticpredispositionSocioculturalfactors40PMD&PMDDWomen

aremoresensitiveto

thesechanges.41增加serotoninreceptor的数量和敏感度诱导身体将糖分集中到子宫的区域负向症状正向症状生理症状胸部疼痛腹部胀气头痛四肢肿胀情绪症状疲倦忧郁发怒社交萎缩焦躁焦虑混乱食欲增加精神变好工作效率佳性欲增加有自信ClinicalPresentation42NonpharmacologicTherapyExercise每周进行三次20-30分钟的有氧运动或瑜珈。

Cognitive-behavioraltherapy让妇女了解PMS疾病相关症状，

并教导其安排适当工作避免过度压力。43NonpharmacologicTherapy避免过咸的食物、单糖食物、咖啡因和酒精。适当补充会提高血清素的食物：乳制品、香蕉、坚果类、鸡肉、牛肉、菠菜、五榖杂粮、蛋、海藻、巧克力…等黑糖所含的钙和镁能一起发挥镇静、放松的作用；铁质则补充生理期间的耗损，让身体不会因为缺铁感觉疲倦。有研究发现，碳酸饮料能提升血清素前驱物tryptophan的含量，并改善经前不悦症(premenstrualdysphoricdisorder,PMDD)的情绪44Dietarymodification少摄取:高脂肪、高糖、高盐、生冷食物、咖啡因、菸酒多补充:45举例作用

B群谷类、坚果安抚经前情绪、

减少乳房肿胀及疲倦等症状铁质瘦肉、猪肝、猪血、葡萄干、黑枣、红枣、桂圆、红豆补血

Vit.C芭乐、奇异果、草莓、西红柿帮助铁质吸收，可于饭后服用适量。NonpharmacologicTherapyPharmacologicTherapy剂量适应症备注VitaminB6(Pyridoxine)50-100

mg/day缓解各种PMS症状过量可能有神经毒性VitaminE400IU/day乳房胀痛功效未证实Calcium&VitaminDCa600

mgBID情绪不稳、嘴馋、其他身体不适极少案例有恶心、、肾结石的副作用Ca1200

mg+VitaminD400

IU预防PMS恶化、预防骨质疏松MagnesiumMg360mginlutealphase情绪症状副作用很少，最常见是腹泻Vitamin&MineralElements46PharmacologicTherapyNSAIDsSeveraldaysbeforeandduringthemenses.Reducephysicalsymptomsandmoodsymptoms.ThebenefitfromtheseagentsmaybearesultofthecoexistenceofdysmenorrheaandPMS.47Diuretics:Forwomenwhohavewaterretention.剂量机转副作用备注NH4Cl1

gTID不超过连续六天肾小管内Cl浓度上升，增加Na、水排除GIproblem,CNSproblem弱酸性、短效。可能造成肝肾功能不全者代谢性酸中毒。Caffeine100-200mgQ3H/Q4H抑制肾小管再吸收Na和水失眠、兴奋、心搏过速、刺激肠胃胃溃疡患者、服用MAOI避免使用。Pamabrom50

mgQID有效成分为8-bromotheophylline，是茶碱衍生物可与acetaminophen并用，治疗背痛或缓解经期不适。PharmacologicTherapy48DrugselectionBreastfeeding

Herbalproducts

Diuretics：Caffeine,

Pamabrom

Vitamins

andMineralsTakingPPIorH2-blocker

Cacitrate>CacarbonateMinddrug-drugordrug-diseaseinteraction49PatientCounselingforPMS告知病人非处方药品及维生素的适当使用方法及可能的副作用。告知病人要经过几个cycle，才会有整体的疗效出现，所以这几个月的周期都需依照指示服药。症状符合严重PMS/PMDD时，应鼓励病人去看医生评估，接受处方药的治疗。50Course

OverviewIntroductionofthemenstrualcycleDysmenorrheaPremenstrualsyndrome(PMS)Toxicshocksyndrome(TSS)

毒性休克症候群Otherdisorders51Introduction:TSSArare,life-threateningcomplicationofbacterialinfections.OftenresultsfromtoxinsofStaphylococcusaureus(staph)orgroupAstreptococcus(strep)bacteriaMenstrual

TSS

affectyoungwomen(13-19y/o).Occurwithin2daysoftheonsetofmenses,duringmenses,orwithin2daysaftermenses.RiskfactorsUseofhigh-absorbencytampon.Useofbarrier

contraceptives.

52PathophysiologyofTTSStaphylococcusaureusorStreptococcuspyogenesBacteriaproliferationMenstrualbloodservesasamediumofbacteriagrowth.Tamponcausesbloodretentioninvagina.Somefiberinhibitlactobacilli.SuperantigentoxinTSST-1

productionElevatedProteinlevelpH=7ElevatedCO2levelElevatedO2levelTSST-1

triggersimmuneresponse,productinginterleukin-1

&TNF,causinginflammatoryeffect53MenstrualbloodTamponBloodretention54棉条棉垫优点可避免外漏，较少异味皮肤不易发炎体积小、较轻薄适合运动量大的女性感染TSS机率较低价位较低缺点因为是置入性产品，

感染TSS的机率比较高价位较高皮肤可能因长期潮湿而起疹子或过敏，并产生难闻异味体积较大运动受限多棉条(Tampons)vs棉垫(Pad)ProdromalsymptomsMalaise,Myalgia,ChillRash：Sunburn-like,diffuse,notpruriticGIsymptoms：Vomiting,DiarrheaFull-blownTSSFever,Hypotension,Shock,Myalgia,Cardiacinvolvement,Respiratorydistress,Decreasedurineoutput,Neurologicmanifestations,Acuterenalfailure.Desquamationoftheskin2-3dayspriortoTSS5-12daysaftertheonsetofTSS55ClinicalPresentationEarlyintheillnessTSSevolvesrapidlyWhatCanWedo…仔细评估。若病人来有这些类似流行性感冒症状(发烧、呕吐、腹泻、晕眩)，或皮肤有不正常皮肤红疹，若有药师评估有TSS疑虑，尽快就医，避免用NS