医学精品课件：10阴道流血

AbnormalVaginal/UterineBleedingZhejiangUniversitySchoolofMedicine,Women’sHospitalWuRuijinAbnormalvaginalbleedingOneofthemostcommongynecologicsymptoms.Includebleedingfromuterus,cervix,vaginal,hymenetc.Mostfromuterine,butcalledvaginalbleedingexceptnormalcycleofmenstruation.Appearanceofbleedingvaryfromtheircauses.AbnormalUterineBleedingIncludesabnormalmenstrualbleedingandbleedingduetoothercausessuchaspregnancy,systemicdiseases,orcancer.Thediagnosisandmanagementpresentsomeofthemostdifficultproblemsingynecology.Inchildbearingwomen,acomplicationofpregnancymustalwaysbeconsidered,andmorethanoneentitymaybepresent,eg,uterinemyomasandcervicalcancer.PartIEtiologicalfactorsofabnormalvaginalbleedingOvarianendocrinedysfunctionPregnancy-relatedbleedingInfectionsMalignantLesionsGenitalsdamage,extraneousmaterialandexogenoushormoneBleedingduetosystemicdiseases1.OvarianendocrinedysfunctionDuetodysfunctionofthehypothalamic-pituitary-ovarianaxis(HPOA).anovulatory

dysfunctionaluterinebleeding(无排卵性功能失调性子宫出血)ovulatorymenstrualdysfunction(排卵性月经失调)intermenstrualbleeding

(经间期出血)

(1)Anovulatory

dysfunctionaluterinebleeding

Puberty（20%）：unstableHPOA

regulationwithgrowingfolliclebutnoLHpeakandovulationdoesnotoccur.Perimenopause（50%）：ovarybecomeslowresponsivetoGnanditsfunctiondeclines.Childbearingperiod

（30%）：inside/outsideinterference,suchaspsychologicfactor,environment,stress,etc.

(2)OvulatorymenstrualdysfunctionLutealphasedefect(LPD)(黄体功能不全)AbnormalFSH/LHorratio,lowLHpeakorfollowingpulsedefect.Irregularsheddingofendometrium(子宫内膜不规则脱落）HPOAdysfuctionandcorpusluteumdegenerateuncompletely(3)

intermenstrualbleeding

Withtheruptureofdominantfollicle,estrogensdeclinesinashorttimeandendometriumbreak-throughbleeding.2.BleedingduetopregnancyAbortion流产Ectopicpregnancy异位妊娠Gestationaltrophoblasticdisease(GTD)妊娠滋养细胞疾病Anomalyofplacenta胎盘异常---placentapraevia(前置)、abruption(早剥)、adherence(粘连)、implantation(植入)Postpartumpartplacenta

remain胎盘部分残留Involutionofuterusunhealthy子宫复旧不良AbortionMorphologicandgeneticabnormalities:

Abnormalchromosomeisthemainfactor.Maternalfactors:Systemicdiseases：infections,cardiovasculardisorders,severeanaemia,etc.Endocrinedisorder：hypothyroidism,poorlycontrolleddiabetesmellitus.ImmunologicdisordersUterinedefects：congenitalanomalies,submucousorintramuralmyomas,intrauterineadhensious.Trauma(创伤刺激)Toxicfactors：unhealthylifestyle,radiation,uncontrolleddrugsEctopicpregnancyMorethan95%occurinthefallopiantube.50%hadsalpingitis.

Historyoffallopianoperation.IntrauterineDevice(IUD)Fallopiandysplasiaordysfunction,affectthetransmigrationoffertilizedovum.Others：surroundingoncothlipsis,EMsGestationalTrophoblasticDisease

Trophohyperplasiacyte,erosinanddestroysurroundingbloodvessel.Hydatidiformmole(葡萄胎)Invasivehydatidiformmole(侵蚀性葡萄胎)Chorioniccarcinoma(绒毛膜癌)3.GenitalsinflammationVulvovaginitis(外阴阴道炎)：disorderofvaginalecologicalbalanceorexogenouspathogeninvasionCervicitis(宫颈炎)Cervicalpolyp(宫颈息肉):long-termchronicinflammationstimulationEndometritis(子宫内膜炎)：commoninafterabortion,parturition,postmenopausewomenandIUD4.Genitalstumor（1）Tumorerosionthevesselwall,causecellularnecrosis,ulcer.（2）Tumorcausesteroidhormonedisorder.（3）Myomaenlargedendometrialarea,interfereuterinecontractionandbloodsinusshut.Vulovaginaltumor,cervixcancer,myoma,endometrialcarcinoma,sarcomaofuterus,ovariancancer,oviductcancer5.Genitalsdamage,extraneousmaterialandexogenoushormoneGenitalsdamage:vulovaginalstraddleinjury(外阴阴道骑跨伤)Sexualintercausecausehymenandvaginalinjuryandbleeding.IUD:hardandlargeareaIUDoppresscauselocalendometriumnecrosisandulcerE2/Pmisapply.

6.BleedingduetosystemicdiseasesPurpurahaemorragica(血小板减少性紫癜)Aplasticanemia(再生障碍性贫血)Leukemia(白血病)Hepaticfunctiondamage

disturbancesofbloodcoagulation(凝血机制障碍)thrombocytopenia(血小板减少)increasedcapillarypermeability(毛细血管通透性增加)someliverdisorderhormonechange.7.Others

Pelvicinflammation：congestion(充血),vesselwallbrittleness(脆性

)increasedEndometrialpolypsEMs：steroidhormonedisorder

PartIIPatternsofAbnormalUterineBleeding(阴道流血特点与相关疾病的联系)AgefactorsRegulationofperiodornotPregnancyornot

menorragia/hypermenorrhea

(经量增多)Heavy(>80ml)orprolonged（>7d）menstrualflow.Submucousmyomas(子宫粘膜下肌瘤)ComplicationsofpregnancyEndometrialhyperplasiasMalignanttumorsEndometrialpolyps(子宫内膜息肉)Adenomyosis(子宫腺肌病)Dysfunctionalbleeding(排卵性月经失调)IUDs(放置宫内节育器)MyomasSymptoms：Abnormaluterinebleeding：30%,prolongedandheavymenses，irregularuterinebleedingofteninsubmucousmyomasAbdominalmass(腹块)Leucorrhea(白带)increasedPainorsorewaist(腰酸)PressureeffectsInfertility,spontaneousabortion,malposition(胎位不正等)Secondaryanemia(继发贫血)Btypeultrasound,CT,MRIhelptodiagnosisEndometrialpolypsSpottingorirregularuterinebleedingUltrasoundhelptodiagnosisDiagnosiscurettage(诊断性刮宫),hysteroscope(宫腔镜检查)andpathologyexaminationhelpfinaldiagnosisAdenomyosisMenstruationchange:50%hypermenorrheaMenalgia(痛经)，increasinglysevereEnlargeduterus,hardUltrasound,MRIhelptodiagnosisOvulatorymenstrualdysfunctionLutealphasedefect(LPD)(黄体功能不全)（1）shortencycle,lutealphase<11d,frequentlycycle（2）infertility（3）repeatingspontaneousabortion（4）D&C：lutealphaseendometriumdefectedandbackward2dtostandardphaseIrregularsheddingofendometrium(子宫内膜不规则脱落）（1）prolongedandheavymenses（2）D&C:proliferativeandsecretaryendometriumcoexistincycled5（3）BBThightemperaturephaseprolongedtonextmenstruation

(4)SerumE2,PandBBT,D&G,

cervixmucusscorehelptodiagnosis2.Menometrorrhagia

(周期不规则的阴道流血)Bleedingoccursatirregularintervals.Amountanddurationofbleedingalsovary.Anovulatory

dysfunctionaluterinebleedingExcludeearlyendometrialcancerComplicationsofpregnancyAnovulatory

dysfunctionaluterinebleedingIrregularuterusbleedingCharacteristicofbleeding:（1）irregularcycleandduration（2）notstopbyoneself（3）irregularamount（4）nomenalgia(痛经)（5）anaemiaEndometrialcancer1.Irregularbleeding：Post-menopausebleeding:middleorlessamount,durative(持续性)orintermittence(间歇性)；Child-bearingagewomen:prolongedandheavymensesorintermenstrualbleeding2.Vaginalapocenosis(排液)3.pain4.Generalsymptom5.Enlargeduterus,tender,tissueemersioninadvancedstage(组织物脱出)。6.Segmentingdiagnosis

curettage(分段诊刮)helptodiagnose

lesionswhetherinvolvecervixcanal.7.Hysteroscope,ultrasound,CT、MRIhelptodiagnosis.3.Lastanddurativeuterinebleeding

(长期持续阴道流血

)OftenhappeninreproductivemalignanttumorNeedexcludecarcinomaofcervixuteriandcorpusuteriCervixcancer1.Contactbleeding(接触性出血):aftersexintercrossorpelvicexamination

young：prolongedandheavymenses,shortcycle

old：post-menopauseirregularbleeding2.Vaginaapocenosis(流液)：whiteoruprightness(血性)、smelloffish(腥臭)orfoulsmell(恶臭)3.Oftenearlyonsetofsexualactivityormarriageandchildbear,multiplesexualpartner(多个性伙伴).4.Pelvicexamination5.Specialexamination:cervicalcytology,HPVtesting,iodinetest,colposcopy(阴道镜),biopsy,endocervicalcurettage,

conebiopsy(宫颈锥切)

4.Bleedingaftermenelipsis

(停经后阴道流血)

Child-bearingage:firstconsiderpregnancy-relateddisease

AbortionEctopicpregnancyGestationaltrophoblasticdisease(GTD)

Peri-menopauseperiod:

Anovulatory

dysfunctionaluterinebleeding

Excludegenitalmalignanttumor

AbortionBleedingandpelvicpainaftermenelipsis(停经).Clinictypesandfeature：

amountpelvicpain

tissuedischarge

cervix

uterusziseThreatened~

lessnoorlight

noclose

matchInevitable~

middletoheavy

severe

no

expand

match/smallIncomplete~

lesstoheavy

light

partdischarge

expand/close/block

smallerComplete~

lesstoheavyno

totaldischarge

close

normal/largerThreespecialtypes:missed~(稽留流产),habitual~(习惯性流产)orrecurrence~(复发性流产）,abortioninfection(流产感染)Ectopicpregnancy1.Menelipsis(停经)2.Pelvicpain3.Bleeding：

lessandirregular4.Faintandshock

(晕厥与休克)5.AbdomenmassGeneralstateAbdomenexamination:3.Pelvicexamination：Liftingpain(宫颈举痛),pelvicmass(盆腔包块),uterussoftandalittlelargerGestationaltrophoblasticdisease(GTD)Bleedingafter

MenelipsisUterussignificantlylargerandsoftSerumHCGabnormalhigherPainVomitingofpregnancy(妊娠呕吐)Ovarianluteinizingcysts(黄素化囊肿)Gestationalhypertension(妊娠高血压疾病)andhyperthyreosissignDifferentiate(鉴别)1.History:menelipsis,morningsickness(早孕反应）2.Pelvicexamination3.Specificexamination：

SerumorurineHCGUltrasoundRetro-fornixpuncture(后穹隆穿刺)Laproscope(腹腔镜检查)5.Vaginalbleedingwithincreasedleucorrhea

(阴道流血伴白带增多)

AdvancedstagecervixcancerEndometrialcancerSubmucousmyomasinfected

Ultrasound,CT,MRI,hysteroscope,colposcopy,cervicalscrapingsmear(orTCT),biopsy.6.PostcoitalBleeding(性交后出血)

Cervicalerosion(宫颈糜烂)：fluorsanguinolentus(血性白带),contactbleeding,increasedvaginaldischargeCervicalpolyps：sprinkleorcontactbleeding,increasedvaginaldischargeSubmucousmyomasInvasivecervicalcancer:earlystageappearascervicalerosion,contactbleeding

Pelvicexamination,cervicalscrapingsmear,colposcopy,ermenstrualbleeding

(月经间期出血)Bleedingoccurringatanytimebetweenmenstrualperiods.Occursatmid-cycleasspotting(排卵期出血)Symptoms：14-15dbeforenextmenstruation，sparkingbleedinglast3-4dCanbedocumentedwithbasalbodytemperatures.Endometrialpolypsandendometrialandcervicalcarcinomasarepathologiccauses.ExogenousEstrogenadministration8.Peri-menstruationspottingbleeding

(经前或经后点滴出血)

OvulatorymenstrualdysfunctionIUDEMsEndometriosisMenalgia(痛经)Dyspareunia(性交不快)InfertilityPelvicexamination：tendernodulesinposteriorvaginalfornix,cul-de-sac(子宫直肠陷窝),uterosacralligament(宫骶韧带)andtenderadnexalmassesmaybefeltwhenlesionsinvolveovaryandformendometriomas.Ultrasound,CT,

Laproscope.SerumCA125maylightincreased9.Bleedingafteryearsofmenopause

(绝经多年后阴道出血)

Smallamount,last2-3d，normallymenopauseendometrialablate(脱落),orsenilevaginitis(老年性阴道炎).Largeamountorcontinuerepeatedlybleeding,considerendometrialcancer.

10.Intermittencebleedingor

apocenosis(间歇性阴道排液流血

)

Excludefallopiancarcinoma

70%maybechronicsalpingitis50%infertilityhistoryTrilogy(三联症)offallopiancarcinoma:

vaginaapocenosis,pelvicpainandpelvicmassSymptoms,vaginacytologicalexamination,D&C,ultrasound,CT,

MRI,Laproscope,serumCA125maylightincreased11.Bleedingafterinjury(外伤后阴道流血)

Oftenafterstraddleinjury(骑跨伤)BleedingamountvaryCompanywithlocalpain

PartIII

EvaluationofabnormaluterinebleedingHistory(病史)Physicalexaminationandpelvicexamination(全身与妇科体检)Auxiliaryexamination(辅助检查)（1）HCG（2）Endometrialbiopsy/DilatationandCurettage(D&C)诊断性刮宫（3）Ultrasound(orsalinehysterosonogram)/CT/MRI（4）Hysteroscopy宫腔镜/Laparoscope腹腔镜/colposcope阴道镜（5）BBT（6）Steroidhormone（7）Cytologicexamination(细胞学检查):cervicalandvaginal.（8）Others：tumormarkers,leucorrheaexamination,cervicaldischarging,blood/live/clottingfunctiontestandretro-fornixpuncture.PartⅣTreatment

Generaltreatment:antiinflammatory,stopbleeding,retrieveanaemia(纠正贫血),enhancenutritionIdentifyetiologicalfactor,etiologicaltreatment

Drugtreatment：hormonaltherapy,chemotherapyandmedicaltreatment.

(1)dysfunctionalbleeding：stopbleeding,cycleregulation,induceovulation；

(2)endometrialcancer:PCervixphysiotherapeutics(理疗),polypsremoval,cervixconebiopsy

orleep.Extraneousmaterialremove：extraneousmaterial,IUDresidOperationtreatmentWoundneoplasty(修补术)：straddleinjury(骑跨伤)anddefloration(处女膜破裂)bleeding.CompleteCurettage：hydatidiformmole(葡萄胎),inevitableandincompleteabortionD