I. Pattern and etiology of abnormal uterine bleeding
1.The pattern of abnormal uterine bleeding
(1) Change of cycle: frequent <21 days; sparse >35 days but <6 months; amenorrhea >6 months; irregular, variable length.
(2) Menstrual period changes: prolonged >7 days; shortened <3 days.
(3) Menstrual volume: excessive: menstrual volume (MBL) > 80 ML. too little: menstrual volume < 20 ML. often clinically based on comparison with previous normal menstrual volume.
(4) Irregularity: abnormal cycle, period and volume of menstruation.
(5) Intermenstrual bleeding: uterine bleeding between 2 normal menstrual periods, divided into follicular bleeding, periovulatory bleeding and luteal bleeding.
2.The causes of abnormal uterine bleeding
(1) Organic etiology.
(1) Systemic diseases: hematologic diseases, endocrinopathies, liver diseases, post dialysis renal failure, lupus erythematosus.
(2) Reproductive system diseases: pregnancy complications, tumors, endometritis, myometriosis, endometriosis, endometrial polyps, genital tract trauma, foreign bodies, arteriovenous fistulas or endometrial hemangiomas.
(2) Medical origin.
Placement of contraceptive ring, hormonal contraceptives, sex hormones, anticoagulants, antifibrinolytic drugs; functional etiology – gonorrhea: no organic disease was found, and it is a neuroendocrine or endometrial local regulation abnormality of the hypothalamic-pituitary-ovarian axis of the central nervous system.
Classification and Diagnosis of Meritorious Blood
1.Anovulatory type of meritorious hemorrhage
In adolescence, the positive feedback regulation mechanism of estrogen has not yet been established. If stimulated by factors such as overwork, stress or obesity, insulin resistance, etc., ovulation function is delayed and may cause anovulation; during reproductive age, internal and external environmental stimuli (exertion, stress, miscarriage, surgery or disease, etc.) may cause transient anovulation; long-term factors such as obesity, insulin resistance, high PRL, etc. may also cause persistent anovulation; during menopausal transition, due to follicular reserve and sensitivity to During menopause, the follicular reserve and sensitivity to gonadotropins are reduced, or the positive feedback response to estrogen is low, resulting in luteal insufficiency, irregular ovulation and finally ovulation.
2. Ovulatory type of gonorrhea
(1) Menorrhagia.
It refers to several consecutive regular cycles with MBL more than 80ML, with normal cycles and periods, and normal cyclic fluctuations in blood reproductive hormone levels. The currently accepted pathogenesis is.
(i) imbalance in the ratio of different prostaglandins (PG) produced locally in the endometrium, resulting in vasodilatation and the tendency to inhibit platelet aggregation and causing excessive menstruation.
(ii) Local hyperfibrinolysis of the endometrium.
(2) Intermenstrual bleeding.
(i) periovulatory bleeding.
(ii) Premenstrual bleeding (luteal phase bleeding).
(3) Long menstrual period (follicular bleeding). It may be due to varying degrees of follicular development, ovulation or luteal incompetence, minor abnormalities in ovulatory function, or defects in the local hemostatic function of the endometrium.
Diagnosis of gonorrhea
The diagnosis of meritorious hemorrhage requires the exclusion method.
1.Determine the pattern of abnormal uterine bleeding
Accurate acquisition of medical history is a prerequisite for accurate diagnosis and management.
2.Excluding organic diseases
Including: bleeding from non-genital tract (urinary tract, rectum and anus) and other parts of the genital tract (cervix, vagina); systemic organic diseases: hematologic diseases, endocrinopathies; reproductive system diseases: pregnancy-related problems, benign gynecologic diseases, malignant gynecologic diseases; and bleeding of medical origin.
In addition to medical history, general physical examination and pelvic examination, routine blood tests, coagulation function, blood HCG measurement, sex hormones, thyroid function, diagnostic curettage or endometrial biopsy pathology can be helpful. Ovulatory type of meritorious bleeding is easily confused with organic diseases and medically induced bleeding. It has been reported that about half of the patients with menorrhagia have organic diseases. IUD placement, cervicitis, chlamydia or mycoplasma infection can also cause intermenstrual bleeding.
3.Determine the cause of ovulation and anovulation
The pathophysiological changes and management of ovulatory and anovulatory dysfunctional hemorrhage are very different, so it is necessary to distinguish between these two conditions.
Standardized management of anovulatory dysfunctional hemorrhage
1. Anovulatory uterine bleeding
The general principle is to stop bleeding and correct anemia as quickly and effectively as possible. After the bleeding has stopped, the cause of the bleeding should be clarified and targeted treatment should be carried out as much as possible, and a suitable plan (minimum effective dose) should be chosen to control the menstrual cycle or induce ovulation and prevent recurrence and long-term complications.
(1) Hemostasis: diagnostic curettage is rapid and endometrial pathological examination is feasible to exclude malignancy. It is used when necessary in patients of married reproductive age or menopausal transition who have a long course of disease. However, repeated scraping is not necessary in unmarried patients and those whose recent scraping has excluded malignancy.
(2) Progesterone endometrial shedding method: Intramuscular injection of progesterone 20MG/D for 3-5 days; or medroxyprogesterone acetate (MPA) 6-10MG/D, or Daphne 20MG/D for 10 days. It does work, but there is withdrawal bleeding for about 7 days after stopping the drug, and should only be used for patients with hemoglobin >80G/L. To reduce withdrawal bleeding, testosterone propionate 25 MG/D (in adolescent patients) or 50 MG/D (in patients in menopausal transition) can be dosed, and the total amount should be less than 300 MG. In case of heavy withdrawal bleeding, give general hemostatic agents and transfusion if necessary.
Estrogen endothelial repair method: Only for unmarried patients with hemoglobin <80 G/L during puberty. It can be started with high dose or 4-6 MG every 6-8 hours of Glivec, along with active correction of anemia, blood transfusion and addition of general hemostatic agents. After 2 to 3 days of hemostasis, the dose can be gradually reduced by 1/3 each time, maintained for 3 days, reduced to maintenance dose, maintained until about 20 days of medication or longer, when hemoglobin has been higher than 90G/L, then add progesterone and testosterone propionate to make the endothelium shed and end this hemostatic cycle. This method should not be used frequently, and the importance is to prevent another serious bleeding.
Endometrial atrophy method: Applicable to.
①Patients of childbearing age or menopausal transition with hemoglobin <80G/L.
②Patients with hematological diseases: those whose condition requires cessation of menstrual flow. The method is oral administration of highly effective synthetic progestin: levonorgestrel 1.5-3MG/D, norethindrone (gynecomastia) 5-10MG/D, amnestic progesterone 10MG/D, etc. for 22 consecutive days.
Oral contraceptives: for patients of any age and severe anemia, 2 to 3 tablets/day x 7 days, gradually reducing the dosage to maintenance. The drugs are Mafulon (deoxyprogesterone ethinyl estradiol tablets), Daing-35 (ethinyl estradiol cyproterone tablets), Eusemide (drospirenone ethinyl estradiol tablets), etc. The aim is to molify the proliferating or hyperplastic endothelium and then atrophy it. After the blood stops, the dosage can also be gradually reduced to maintain, and at the same time actively correct the anemia, there is also withdrawal of bleeding after stopping the drug. Patients with hematologic diseases should decide whether to stop or continue the drug depending on the needs of the hematologic disease. ③Other: cotton wool, mifepristone, etc.
General hemostatic drugs have auxiliary effects. Commonly used are: ①Antifibrinolytic drugs: tranexamic acid; ②Promoting coagulation drugs: vitamin K4; ③Enhancing capillary resistance: vitamin C, carbachol, phenolsulfonamide (hemostatic min), etc.
(3) Induction of ovulation or control of menstrual cycle: Patients who require fertility should choose ovulation-promoting drugs according to the etiology of anovulation. Various short-acting contraceptives can be taken for patients of reproductive age and adolescence who require contraception. Progestin can be used in the second half of the cycle to make the endometrium shed on schedule for adolescent patients without sexual intercourse and patients in the transition to menopause. For patients with low estrogen levels, sequential treatment with estrogen and progestin cycles is used.
Ovulatory anovulation is not an indication for transcervical endometrial resection because it does not correct the cause of anovulation and pathophysiological changes, and it is not possible or desirable to remove all the functional and basal layers of the endometrium, so there is still irregular bleeding, endometrial hyperplasia or even adenocarcinoma after surgery, and medication is still needed, while the price is much higher than medication and patients are in pain.
2.Menorrhagia
(1) Medication: For patients who do not require contraception or are unwilling to use hormone therapy, antifibrinolytic drugs or anti-PG synthesis drugs can be used: tranexamic acid 1.0G, 2 to 3 times/day. It is taken for 5 days from the first day of menstruation. Results of a randomized double-blind controlled study showed that tranexamic acid reduced menstrual flow by 54%. Adverse effects may include mild nausea, dizziness, and headache.
For patients with contraceptive requirements, endometrial atrophy treatment is available: oral administration of a potent progestin on days 5 to 25 of the cycle, or the pill may reduce blood loss by 30% to 50%. The levonorgestrel intrauterine release system ( LNG-IUS, Mannorrhea), which releases LNG 20 ΜG every 24 hours intrauterine, is effective for 5 years. The drug acts directly on the endometrium to make it shrink and thin, and menstruation decreases, with amenorrhea occurring in 20-30%; it has few side effects on the whole body and the effect disappears after 1 month of discontinuation. However, breakthrough bleeding may occur within 6 months of initial use.
(2) Surgical treatment: Patients with ineffective drug treatment, persistent failure to heal, old age and no fertility requirements can be surgically removed from the uterus or transcervical endometrial resection (TCRE). TCRE is suitable for patients with ovulatory menstruation who are not suitable or unwilling to remove the uterus and have no fertility requirements. Uterine artery embolization can be used for heavy menstruation caused by uterine arteriovenous fistula.
3.Intermenstrual bleeding
(1) Periovulatory bleeding.
(1) Generally give symptomatic hemostatic treatment only.
(ii) Small doses of estrogen during ovulation.
(3) Clomiphene for those who want to have children.
(4) Oral contraceptive pills for those who do not want to have children.
(2) Premenstrual bleeding: progesterone can be supplemented before bleeding, or clomiphene can be used in the early follicular phase to improve follicular development and subsequent luteal function;
(3) Prolonged menstrual period.
(i) progestin in the luteal phase of the previous cycle.
(ii) administration of small doses of estrogen during the follicular phase to help with endometrial repair.
(3) Use clomiphene to promote normal follicular development in those with fertility requirements.
V. Determination of treatment effect and prognosis
Although the cycles of patients with anovulation are normal when they are treated with hormones, as long as the cause of the disease is not corrected, they may relapse soon after stopping the medication, and complete cure is rare. Half of the patients of reproductive age can become pregnant and give birth after using ovulatory drugs, but most of them are still anovulatory after delivery, and their menstruation is irregular or continues to be irregular.
Individuals may develop endometrial atypical hyperplasia or adenocarcinoma. Even patients with normal menstruation are susceptible to recurrence due to certain stimuli. Patients with menopausal transition may have a long or short course, ending with menopause. Patients with ovulatory type of gonorrhea have natural fluctuations and can be intermittently treated and observed after excluding organic diseases.