I. Anovulatory uterine bleeding
Endocrine therapy should be effective. The general principle is to stop the bleeding quickly and effectively and to correct the anemia. After the hemorrhage is stopped, the cause of the hemorrhage should be clearly identified and targeted treatment should be carried out to control the menstrual cycle or induce ovulation with an appropriate plan (minimum effective dose) to prevent recurrence and long term complications.
1.Stopping the hemorrhage
(1) Diagnostic scraping: rapid hemostasis and endometrial pathological examination is feasible to exclude malignant changes. It should be used routinely in patients of married reproductive age or menopausal transition who have a long course of disease. However, repeated scraping is not necessary for unmarried patients and those whose recent scraping has excluded malignant changes.
(2) Progesterone endometrial shedding method: progesterone intramuscular injection 20 mg/d for 3-5 days; or progesterone amylin (MPA) 6-10 mg/d, or Daphne 20 mg/d for 10 days. It does work, but there is withdrawal bleeding for about 7 days after discontinuation and should only be used in patients with HB > 70 g/L. To reduce the amount of withdrawal bleeding, testosterone propionate 25 mg/d (in adolescent patients) or 50 mg/d (in patients with menopausal transition) can be dispensed, and the total amount should be less than 200 mg. In case of heavy withdrawal bleeding, bed rest should be given, general hemostatic agents and blood transfusion if necessary, when sex hormones are no longer used.
(3) Estrogen endothelial growth method: Only for unmarried adolescent patients with HB < 70 g/L. Estradiol benzoate (E2B) 3-4 mg/d, divided into 2-3 intramuscular injections. If there is no tendency to reduce bleeding, gradually increase to 8-12 mg/d. It is also possible to start with high doses. In recent years, Pemerix 1.25-2.5 mg every 6-8 hours has been used. At the same time, active correction of anemia, blood transfusion and addition of general hemostatic drugs. After 2-3 days of hemostasis, the dose can be gradually reduced by E2B at a rate that no longer causes bleeding, until 1 mg/d when it is no longer necessary to reduce the dose, maintain until about 20 days of medication, or when HB has been higher than 80g/L, then switch to progesterone and testosterone propionate to make the endothelium shed and end this hemostatic cycle. This method should not be used frequently and is important to prevent another serious bleeding.
(4) High-efficiency synthetic progestin endometrial atrophy method: Applicable to patients of childbearing age or menopausal transition with HB<70g/L, those whose recent scraping has excluded malignant conditions and those with hematologic conditions requiring menstrual cessation. Levonorgestrel 1.5-3 mg/d, norethindrone (gynecologic tablets) 5-10 mg/d, MPA 10 mg/d, etc. for 22 consecutive days. The aim is to make the proliferating or hyperplastic endothelium metaphylatorize and then atrophy. The dosage can be gradually reduced for maintenance after the hemorrhage has stopped, while actively correcting anemia. Withdrawal bleeding after discontinuation of the drug. Patients with hematologic disorders should decide whether to discontinue the drug as needed.
General hemostatic drugs have an adjuvant effect. Commonly used drugs.
(1) Antifibrinolytic drugs: tranexamic acid (torsemide) 1g with 5% GS intravenously, total 1-2g/d, or 2g/d orally.
(2) Coagulation-promoting drugs: VitK4 4mg Tid po; or VitK3 4mg intramuscular injection, 1-2 times/d; or Lithopodium, 1 unit, im, Qd, for 3 days.
(3) Enhance capillary resistance: VitC, orally or intravenously, 300mg-3g/d; Anlaemic 5-10mg Tid po or 10-20mg, im Bid-Tid.
(4) Hemostasis can enhance platelet function and capillary resistance: 0.25-0.5g im Qd-Bid, or with 5% GS IV, 5-10g/d.
Mafron and other OCs are used to stop bleeding in patients with meritorious bleeding. The dose used is 2-4 tablets a day. Even if the hemostatic cycle is stopped with momofolone, there is no need to use a high dose for the second cycle, just adjust the cycle with one tablet of momofolone a day.
2.Ovulation induction or menstrual cycle control
The most commonly used ovulation-promoting drug is CC. Short-acting contraceptives can be given to fertile and adolescent patients who require contraception. Progestin can be used in the second half of the cycle to make the endometrium shed on a regular basis, and estrogen and progestin cycle sequential therapy can be applied to those with low estrogen levels.
If ultrasound shows excessive thickening of the endometrium and biopsy has simple or compound hyperplasia of the endometrium, it can still be counteracted with a larger amount of progestin in the second half of the cycle.
However, if there is atypical hyperplasia, if the lesion is light and the young person has fertility requirements, progesterone caproate 500mg per week, levonorgestrel 2-4mg/d, MPA 10mg/d, etc. After 3 months, the endometrium will be reviewed and if the lesion disappears, ovulation drugs will be used instead for pregnancy; if the lesion is heavy, the person is over 40 years old and has no fertility requirements, the uterus can be surgically removed.
II. Ovulatory function hemorrhage: excessive menstruation
1.Medication
For patients who do not require contraception or are unwilling to use hormone therapy, Toxopamine 1g, 2-3 times/day, or Flumioxane 0.2g, 3 times/day, to be taken for 5 days from the first day of menstruation.
For patients who require contraception, the endometrial atrophy method can be used: it has been reported that oral administration of norethindrone on days 5-26 of the cycle can reduce blood loss by 30%.
2.Surgical treatment
For patients who are not treated with medication, persistent, older and without fertility requirements, surgical hysterectomy or transcervical endometrial resection (TCRE) can be performed, which is not suitable for anovulatory uterine bleeding. In addition, uterine artery embolization can be used to treat heavy menstrual flow due to uterine arteriovenous fistula.
Intermenstrual bleeding
1. For periovulatory bleeding: usually only symptomatic hemostasis is used.
2. For premenstrual bleeding: progesterone or hcg supplementation before bleeding, early follicular phase CC to improve follicular development and luteal function.
3. For long menstrual periods: D5-7 days of small dose estrogen to assist repair, or CC to promote normal follicle development and progesterone to promote endometrial shedding in the luteal phase of the premenstrual cycle.