妇产科学课件：功能失调性子宫出血(英文版)

Dysfunctionaluterine

bleeding(DUB)PatternsMenorrhagia(hypermenorrhea)月經過多Hypomenorrhea(cryptomenorrhea)月經過少Metrorrhagia(intermenstrualbleeding)子宮不規則出血Polymenorrhea月經頻發（月經過頻）Oligomenorrhea月經稀發Menometrorrhagia子宮不規則出血過多Contactbleeding(postcoitalbleeding)接觸性出血、性交後出血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（月經過多）Metrorrhagia(子宮不規則出血)Menometrorrhagia（子宮不規則出血過多）Polymenorrhea（月經過頻）NoabdominalpainanddiscomfortableAnemiaPelvicexam:

uterinesizeisnormalDiagnosisExcludeanatomiccausesofabnormaluterinebleedingHistoryAge,menses,marital,contraceptive,treatmentPhysicalexam:General:excludesystemicdiseasesPelvic:excludegenitaldiseaseLabexamUltrasound:uterinesize,shape,endometriumUrineorserumHCGCytologicexamofcervix:cervicalcancerDeterminationofovarianfunctionBBT:monophaseSerumhormones:progesteroneislowerHysteroscope:pathologicchangesofcavityCytologicsmearofvaginalshedcell:anovulatoryperiodicchangesCervicalmucosa:1-2daysbefore

uterinebleeding,fernlikepattern

(羊齒狀結晶)(picture)

Coagulationfunction,bloodcellcountSamplingofendometriumD&C(診刮)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(妊馬雌酮)0.625mgor17β-estrodiolfor5~7daysAfterovulation,progestinIM10mg/dfor10~14daysPromoteLHsurgeinthemiddlecycleofmensesAfterfolliclemature,HCG5000-10000UimStimulatecorpusluteumAfterBBTrise,HCG1000-2000Uimveryotherday,total5timesCompanywithhyperprolactinemiaBromocriptine(溴隱亭)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，補佳樂)：2mgq4-6hInterruptedslightlong-termbleeding:conjugatedestrogen:1.25mg/dfor21days,thelast7~10days,addingmedroxyprogesteroneacetate(MPA)10mg/dContraindication:hemoconcentrationorthrombusCommonlyuseinpubertyProgesterone(ablationofendometrium)Convertendometrium,baseonestrogen,Hb>80g/L17

-Hydroxyprogesterone（羥孕酮）,norethindrone（炔諾酮）:5mgonceevery8hours,3daysafterbleedingstop,reducedose,maintaindose2.5~5mg/dto21daysafterbleedingstopD&C:acuteseverebleeding,riskfactorAdjuvanttreatmentTranexamicAcid(氨甲環酸)、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