The current definition of menorrhagia varies from country to country. In North America, menorrhagia is defined as uterine bleeding with ovulation, including both functional and organic causes, while DUB refers to anovulatory menorrhagia. However, Europe and other countries define :menorrhagia as a symptom in which the complaint is the loss of >80 ml. of blood during menstruation for several consecutive regular cycles.
I. Its causes are: organic diseases of the reproductive system in about 30%, hematologic and systemic endocrinopathies in <5% each, and menorrhagia is defined as abnormal uterine bleeding caused by non-organic diseases, including anovulatory and ovulatory, in about 60% of cases. Menorrhagia is also the name of a disease that refers to idiopathic menorrhagia of the ovulatory type. The understanding of the obstetrics and gynecology community in mainland China is the same as in European countries, but there is some confusion. For example, the terms abnormal uterine bleeding, menstrual bleeding and excessive menstruation were originally different, but sometimes they are mixed, so it is necessary to propose a standardized treatment.
Second, the classification, diagnosis and differential diagnosis of uterine bleeding is defined as abnormal uterine bleeding, no organic disease is found, then it is defined essentially as abnormal neuroendocrine regulation of the hypothalamus-pituitary-ovarian axis of the central nervous system or abnormal local regulation of the endometrium.
There are two types of eclampsia. 70-80% of eclampsia seen in clinical practice in mainland China are anovulatory, mostly seen in adolescence and menopausal transition. In the UK, Professor Sheppard reported that more than 90% of women of childbearing age in the UK have ovulatory type. The reason for this discrepancy may be due to the difference in the population they are dealing with, as community hospitals in the UK are dealing with women of childbearing age, while hospitals in mainland China are dealing with patients with more serious cases of meritorious hemorrhage, while women of childbearing age with lighter cases of menorrhagia may not come to the clinic, thus creating a discrepancy.
(1) The etiology of anovulatory dysfunctional hemorrhage varies slightly according to age. In adolescence, the cause of anovulation is a delay in the establishment of a positive feedback response to estrogen. One may be temporary anovulation, which can be caused by internal or external environmental stimuli, such as fatigue, stress, miscarriage, surgery or disease, etc., causing a short period of anovulation. However, there are also long-term factors, such as obesity, insulin resistance, high PRL, etc., that can cause persistent anovulation. The cause of the menopausal transition is due to a decrease in follicular reserve and sensitivity to FSH. Irregularities in follicular development as well as ovulation eventually lead to anovulatory dysfunction.
The etiology of anovulatory anemia, according to the World Health Organization classification of anovulation, is Type I: hypothalamic pituitary anovulation; prolactin can be high or normal; Type II refers to polycystic ovary syndrome, and Type III is: ovarian anovulation. All three types of anovulation can cause anovulation, but polycystic ovary syndrome is the most common. The most important pathophysiological change in anovulatory anemia is progesterone deficiency, which is caused by anovulation. The clinical manifestations of estrogen withdrawal bleeding or breakthrough bleeding caused by single estrogen stimulation of the endometrium are: menstruation can be completely irregular, including irregular menstrual cycle, irregular menstrual period and irregular menstrual volume. The LH, FSH, and E2 in the blood do not change cyclically. The endometrium is proliferating and hyperplastic.
(2) Ovulation type (1) Ovulation type is classified as idiopathic menorrhagia, which is defined as the loss of more than 80ml of blood during several consecutive cycles, but the menstrual cycle and the length of the period are normal, and the cyclic fluctuations of blood reproductive hormones are also normal. After many studies, it is found to be an abnormality in the local regulation of the endometrium. One is the local hyperfibrinolysis of the endometrium, which makes the thrombus unstable and the endometrial exfoliation persistent. The second is an imbalance in the ratio of prostatic components produced locally in the endometrium, an increase in the ratio of prostaglandin E2 to prostaglandin F2a, and then an increase in the ratio of PGI 2/TXA 2, which results in a tendency for vasodilation and inhibition of platelet aggregation. As a result, hemostasis is compromised.
Ovulatory idiopathic menorrhagia is often confused with submucosal fibroids, myometriosis, and endometrial polyps.
The clinical manifestation of intermenstrual bleeding can be divided into three types by comparing the timing of bleeding with the basal body temperature curve.
The second type is premenstrual bleeding (also called luteal bleeding), which occurs before the basal body temperature drops and lasts for a variable number of days; after the drop, the bleeding increases like menstruation and stops on time.
The third type is the long menstrual period (also known as follicular bleeding), in which the bleeding lasts for more than 7 days after the fall in basal body temperature.
(2) The pathophysiology of intermenstrual bleeding with ovulation refers to minor abnormalities in ovulatory function, such as sporadic ovulation, luteal deficiency, premature degeneration, or incomplete luteal atrophy, poor endometrial repair, and incomplete endometrial shedding. This condition needs to be differentiated from mild inflammation of the reproductive tract, endometrial polyps, and IUD reaction.
(3.) Diagnosis of gynecological hemorrhage The diagnosis of gynecological hemorrhage should be done in four steps.
The first step is to exclude non-genital bleeding, such as bleeding from the urinary tract, rectum and anus, and to exclude bleeding from other parts of the genital tract, such as localized bleeding from the cervix and vagina.
The second step is to determine the type of abnormal uterine bleeding. .
Step 3: Exclude organic disease Step 4: If it is functional disease, determine whether there is ovulation. If anovulation, what is the cause ? If ovulation is present, what is the function of the corpus luteum?
Then normal uterine bleeding is menstruation, the normal range of its cycle is 21-35 days, the period of 3-7 days. As for the volume of menstruation: In 1966, RyboG in Sweden established the alkaline orthohemoglobin method, which objectively measured the blood loss of 476 normal Swedish women during their entire menstrual period. The result: the average menstrual blood loss per cycle was 43 ml (range 20-60 ml). The cut-off point for a decrease in hemoglobin was then 80 ml, so that more than 80 ml was considered as excessive menstruation.
There are several types of abnormal uterine bleeding, the first of which is a change in the cycle.
(1) frequent menstruation: cycles shorter than 21 days; (2) scanty menstruation: cycles longer than 35 days and shorter than 6 months; (3) amenorrhea: cycles longer than 6 months and irregular cycles, indicating that her cycles are of different lengths.
The second change in menstrual period is that the prolonged period is more than 7 days and the shortened period is less than 3 days.
The third is the change of menstrual volume. As we have just described, the amount of blood loss during menstruation is too much if it is more than 80ml, and too little if it is less than 20ml, so irregular menstruation means that the cycle, period and volume are not normal.
After the type of abnormal uterine bleeding is confirmed, we have to exclude whether there are organic causes, which include many kinds of organic causes, first of all, systemic diseases, such as blood diseases, such as thrombocytopenic purpura, reocclusion, other endocrine diseases, such as hypothyroidism, liver diseases, kidney failure after dialysis. Diseases of the reproductive system include complications of pregnancy, tumors, various uterine tumors, endometrial inflammation, meibomian gland disease, endometriosis, polyps, trauma to the reproductive tract, foreign bodies, arteriovenous fistulas of the uterine vessels, endometrial hemangiomas, and so on. The third category is the medical source of diseases, after the IUD, hormonal contraceptives, sex hormones, cervical electrocautery, anticoagulants, antifibrinolytics, bactericides, etc., can cause some abnormal bleeding.
(4) Differential diagnosis of menstrual history and bleeding history is very important. Systemic examination, pelvic examination, and complete blood examination are necessary, and transvaginal ultrasonography should be done routinely. These tests are performed when there is a suspicion.
Transvaginal ultrasound can detect small organisms such as small ovarian cysts, PCOS, small submucosal fibroids, and endometrial polyps. It is important to understand the thickness and echo of the endometrium and can provide clues to the next step in the examination; however, ultrasound is not a substitute for pathological examination.
Hysteroscopy is a very important tool to identify the cause of uterine bleeding, it is more sensitive and at the same time you can select a biopsy under direct vision, which is more sensitive than the blind scraping, but its reliability is also related to the knowledge and experience of the operator, and hysteroscopy is not a substitute for pathological examination. Hysteroscopy also has the advantage of being able to perform some treatments at the same time.
After the above description of how to exclude organic diseases, the next step is to identify the presence or absence of ovulation.
It is very important to distinguish between ovulatory and anovulatory function hemorrhage. Patients with ovulatory function hemorrhage may have chaotic menstruation, but there is still a certain pattern to follow. Therefore, we should ask in detail about the start and end time of bleeding and the amount of bleeding, take the basal body temperature, and select the appropriate time for progesterone measurement and endometrial biopsy against the basal body temperature, so that we can distinguish. Progesterone is often measured 5-9 days before bleeding, and blood is drawn for the test, which corresponds to the mid-luteal phase.
It has been reported that half of the abnormal bleeding with ovulatory type is organic after hysteroscopy and laparoscopy, with myomas, endometriosis, endometrial polyps, and meibomian gland disease being the most common. At the same time, the ovulatory type of gonorrhea should be distinguished from blood diseases, some coagulation disorders, arteriovenous fistula of the uterus and hypothyroidism.
What is the status of endocrine therapy or surgical treatment and endometrial resection?
The treatment strategies for the two types of gonorrhea are different. Endocrine therapy for anovulatory type should be effective, mainly referring to progesterone supplementation. If progesterone supplementation is not effective or even if the diagnosis of miscarriage should be suspected and continued testing is performed for underlying organic problems, then surgical treatment includes: diagnostic scraping, and hysterectomy. Hysterectomy is only necessary in some cases. The treatment of idiopathic menorrhagia is localized to the endometrium, either by medication or endometrial resection, and the treatment of intermenstrual bleeding is mainly for the luteal function by medication.
(1) The treatment of anovulatory uterine bleeding requires hemostasis during the bleeding period.
The measures to stop bleeding are endocrine drugs, hemostatic drugs, and surgery. Endocrine drugs are traditionally divided into three types.
1. endothelial shedding method, which refers to the use of progestin; 2. endothelial growth method, which refers to high doses of estrogen 3. endothelial atrophy method, which refers to high doses of synthetic and efficient progestin. Then in recent years, high doses of oral contraceptives have been used abroad to stop bleeding. General hemostatic drugs are an adjunctive treatment in anovulatory uterine bleeding and can be used when progestin retreats from bleeding.
Diagnostic scraping to stop bleeding is definitely effective, and also endometrial examination can be done to exclude malignant changes, and also to understand the size of the uterine cavity and whether there is any unevenness. Then it should be used routinely for patients with long duration of disease, married and fertile age or menopausal transition. However, unmarried patients or those who have recently been scraped are negative, there is no need to scrape the uterus repeatedly.
As mentioned earlier, the pathological basis of anovulatory “functional hemorrhage” is the lack of progesterone, so progesterone is used to make the endometrium turn into the secretory phase, and withdrawal bleeding occurs after stopping the drug, just like an ovulatory menstruation. The bleeding stops when the old endometrium is completely shed and the new endometrium covers the traumatic surface.
Drug usage.
Progesterone (20mg intramuscularly once daily for 3-5 days) is commonly used. To prevent excessive withdrawal bleeding, testosterone propionate may be used in combination with progesterone (25-50mg per dose). Other progestins can also be used (e.g., progesterone 8 mg/day for 7-10 days, norethindrone 5 mg/day for 7-10 days, and megestrol 8 mg/day for 7-10 days). The bleeding of endothelial detachment usually occurs within 1-3 days after stopping the drug, and sometimes the bleeding is heavy and usually lasts for 7-10 days; if the bleeding is heavy, other hemostatic agents can be used.
Several problems should be noted when using progestin endothelial detachment hemostasis ① Sometimes such a withdrawal bleeding can cause the hematocrit to drop by 20-30 g/l. Therefore, this method is only suitable for patients with less severe anemia, especially those who have been dripping for a long time but the bleeding is not much. It is not recommended for patients with severe anemia.
② Be sure to tell the patient that withdrawal bleeding will occur after discontinuation of the drug, and that the amount of bleeding may sometimes be more than the amount of menstruation, which is to be expected. If the patient is informed, it will reduce unnecessary panic and indiscriminate treatment, and will avoid repeated abnormal bleeding of medical origin.
If the bleeding does not stop beyond this time, other causes of bleeding should be further excluded. If necessary, a vaginal examination or diagnostic scraping should be performed to exclude organic lesions.
④ This method is suitable for women of any age, including adolescence, childbearing and perimenopause.
The principle of this method is to use estrogen to make the endometrium grow and repair the wound so that the bleeding can be stopped more quickly.
The commonly used method is estradiol benzoate. (The first dose is 2-4mg intramuscularly and is repeated every 6-8 hours depending on the bleeding situation until the bleeding stops. Other estrogen preparations can be used in appropriate doses, e.g., oral combined estrogen 2.5-5.0 mg/q8h or estradiol valerate 4-6 mg/q8h until bleeding stops.) The bleeding usually stops in 1 – 3 days. After the bleeding has stopped, start tapering the estrogen by about one-third of the previous dose for 2-3 days, maintaining each dose reduction for 2-3 days.
This can be maintained when the dose is reduced to 1-2 mg of estradiol per day or equivalent until the anemia is significantly corrected and then withdrawn with progesterone and testosterone propionate, as described above for progesterone endothelial shedding.
Several issues should be noted in the application of the estrogen endothelial growth method of hemostasis.
① For cases with heavy bleeding and severe anemia, with hemoglobin below 60-70 g/L. In cases where rapid hemostasis is urgently needed and scraping is not appropriate.
② Mainly used for adolescent “meritorious bleeding”, not generally used for perimenopausal “meritorious bleeding”.
③ Pay attention to the correction of anemia while stopping bleeding, and if necessary, blood transfusion or other auxiliary hemostatic drugs should be added.
The hemostatic principle of this method is that high doses of synthetic progestins or estrogen and progestin preparations inhibit the secretion of estrogen by the pituitary gland, which in turn inhibits the secretion of estrogen by the ovaries, and the reduction of endogenous estrogen causes the endometrium to atrophy, resulting in rapid reduction or cessation of bleeding (1-3,).
Commonly used drugs ① Synthetic progestin preparations: Learn about the commonly used drugs (levonorgestrel 2 mg/day, norethindrone 2.5-5 mg/day, megestrol acetate 4-8 mg/day, and progesterone 10-30 mg/day) Generally, the bleeding stops or decreases significantly 1 – 3 days after administration. After the bleeding stops, the dosage can be gradually reduced for maintenance. Continuous use for about 21 days, during this period, actively correct anemia. When the hematocrit regains near normal, the drug can be stopped and the blood withdrawn.
② Estrogen and progestin preparations: Oral contraceptives are available in any available oral contraceptive preparation. 2-3 tablets daily, usually 1 – 3 days after administration, the blood stops or decreases significantly. Gradually reduce the dosage to 1 tablet daily for about 21 days after the blood stops for a week, and actively correct the anemia during this period. After the hematocrit has risen to near normal, the drug can be stopped and the bleeding withdrawn.
Several issues should be noted when applying the endothelial atrophy method to stop hemorrhage ① In cases with a lot of blood and severe anemia, hemoglobin is below 60-70g/L. Those who need rapid hemostasis urgently and are not suitable for curettage.
② For women of any age, including adolescence, fertility and perimenopausal anovulatory “hemorrhage”.
(3) In case of breakthrough bleeding with synthetic progestin preparations, small doses of estrogens, such as combined estrogens 0.625 mg/day or estradiol valerate 1 mg/day, may be used.
Therefore, the key is the menstrual condition after 3 months of discontinuation, which has a high recurrence rate, so the judgment of cure should be carefully.
(2) The treatment of ovulatory function is based on the patient’s request. If the patient does not require contraception or does not want to use contraceptive drugs, then the antifibrinolytic drug tranexamic acid (the trade name is Torsemide) can be used 1 gram 2-3 times a day from the first to the fifth day of the cycle, which can reduce the blood loss of menstruation by 40-50%. There is also an anti-prostaglandin synthetic drug, mefenamic acid, which can reduce menstrual flow by 20%, but it is not available in China.
For those who require contraception, endometrial atrophy therapy can be used. Then you can use levonorgestrel cycle D5-26, which can reduce the menstrual volume by 30%. Then there is an intrauterine release system of levonorgestrel (also known as Mannorrhea). It releases 20 μg/d of levonorgestrel locally in the uterus and is valid for 5 years after the IUD is applied. Its effect is local and has little effect on the whole body. The side effect is that there may be breakthrough bleeding and breast pain within 6 months after the IUD is put in.
There are other drugs to stop bleeding, such as vitamin K, etc. These drugs can be taken orally, intramuscularly or intravenously as an aid to menstruation.
(3) The choice of hemostatic drugs is due to the decrease of luteinizing degenerative progesterone level, then the decrease of progesterone level causes the local inflammatory reaction of endometrium, the infiltration of white blood cells and the increase of tissue-type fibrinolytic enzyme activator activates fibrinolytic enzyme, which in turn activates the local matrix metalloproteinase of endometrium, this matrix metalloproteinase MMP is the enzyme that causes the disintegration of endometrium, then the normal menstruation In patients with excessive menstruation, there are fibrinolytic antagonists, so the use of these anti-fibrinolytic drugs should be effective.
(4) Treatment of intermenstrual bleeding For periovulatory bleeding, we use some hemostatic drugs, usually hemostatic drugs, because the amount is very small, it can sometimes stop by itself, not every month, so it is usually enough to use some hemostatic drugs. We can use progesterone or hCG before bleeding or clomiphene in the early follicular phase to improve follicular development and later luteal function. Long menstrual bleeding: also in the follicular phase, low dose estrogen can be used for 5-7 days of the cycle to help repair the bleeding, or clomiphene can be used to promote normal follicular development, or progestin can be used during the luteal phase of the previous cycle to promote endometrial shedding.
The prognosis of anovulatory hemorrhage is that the condition fluctuates naturally, so it can be treated intermittently or observed intermittently as long as organic disease is excluded.
The cause of anovulation is abnormalities of the ovarian axis, the pathophysiological changes are progesterone deficiency, and the pattern of menstruation is completely irregular, so the treatment should be progestin. The cause of excessive menstruation is local abnormality of the endometrium, mainly hyperfibrinolysis and imbalance between different PGs, the bleeding pattern is just a large amount, and the menstrual cycle is regular, it can also have dysmenorrhea, can have premenstrual tension, the focus of its differential diagnosis is myxoma, myxomatosis, polyps, hypothyroidism, blood disorders The differential diagnosis focuses on leiomyoma, myxoma, polyps, hypothyroidism, hematologic disorders, and its treatment includes antifibrinolytic drugs, NSAID, and endoscopic surgery. The cause of intermenstrual bleeding is a slight abnormality of ovulation, the pathophysiological changes can be sporadic ovulation, LPD, endometrial detachment or atrophy, or poor repair, it is a regular cycle, can be in the periovulatory period, premenstrual, or postmenstrual spotting bleeding, may be accompanied by dysmenorrhea, PMS. The focus of differentiation is on mild inflammation of the reproductive tract, polyps, and IUD. The treatment of choice should be progesterone CC, HCG.
For patients with dysfunctional uterine bleeding, it is necessary to go to the hospital and undergo standardized treatment according to the doctor’s recommendations.