1、Dysfunctional uterine bleeding(DUB)Patterns nMenorrhagia(hypermenorrhea)月经过多月经过多nHypomenorrhea(cryptomenorrhea)月经过少月经过少nMetrorrhagia(intermenstrual bleeding)子宫不子宫不规则出血规则出血nPolymenorrhea 月经频发（月经过频）月经频发（月经过频）nOligomenorrhea 月经稀发月经稀发nMenometrorrhagia子宫不规则出血过多子宫不规则出血过多nContact bleeding(postcoital bleedi
2、ng)接触性出接触性出血、性交后出血血、性交后出血DefinitionnIrregular bleeding,unrelated to anatomic lesions of the uterus,exclusion of pathologic causes of abnormal bleeding,is referred to as dysfunctional uterine bleeding.nDisturbance of endocrinenMost common at the reproductive agenReview the normal menstruationcycle 21
3、-35,period 2-8,amount 20-60mlPathogenesisnClassification Anovulatory:85%Ovulatory:15%nIncidence IncidenceClassificationnIntroduction Breakthrough bleeding:only estrogen stimulate endometrium,no progesteronenLow plasma concentrations of estrogens infrequent and light bleedingnChronic stimulation of e
4、ndometrium from increased plasma concentrations of estrogens frequent and heavy bleedingWithdrawal bleeding:single estrogen influent endometrium,atresia of follicles estrogen bleedingAnovulatory dysfunctional bleedingnPathological changes of endometriumHyperplasia of endometriumnsimple hyperplasianc
5、omplex hyperplasianatypical hyperplasia:not belong to DUB,glandular epithelium hyperplasia,polarity of cell disappear,size enlarged,dark and large nucleus,karyokinesis Proliferative phase of endometriumAtrophic endometriumClinical findings nIrregular uterine bleedingPatterns:nMenorrhagia（月经过多）（月经过多）
6、nMetrorrhagia(子宫不规则出血子宫不规则出血)nMenometrorrhagia（子宫不规则出血过多）（子宫不规则出血过多）nPolymenorrhea（月经过频）（月经过频）nNo abdominal pain and discomfortablenAnemianPelvic exam:uterine size is normalDiagnosis nExclude anatomic causes of abnormal uterine bleedingnHistoryAge,menses,marital,contraceptive,treatmentnPhysical exam
7、:General:exclude systemic diseases Pelvic:exclude genital diseasenLab examUltrasound:uterine size,shape,endometriumUrine or serum HCGCytologic exam of cervix:cervical cancerDetermination of ovarian functionBBT:monophaseSerum hormones:progesterone is lowerHysteroscope:pathologic changes of cavityCyto
8、logic smear of vaginal shed cell:anovulatory periodic changesCervical mucosa:1-2 days before uterine bleeding,fernlike pattern(羊齿状结晶羊齿状结晶)(picture)Coagulation function,blood cell countpSampling of endometriumD&C(诊刮诊刮)nhemostasis and finding causesnbefore menses or within 6 hours of menstrual onsetnF
9、ractional D&C:different cervix and corpusnproliferative or hyperplasia,no secretory changesBiopsy of endometriumDifferential diagnosisnAbnormal pregnancy or complications of pregnancy:abortion,ectopic pregnancy,retained placentanSystemic disease:hematopathy,failure of liver or kidney,hyperthyroidism
10、 or hypothyroidismrectal or urologic disordersnGenital tumors:carcinoma of endometrium,cervix,myomas,ovarian tumornGenital infection:endometritis,salpingitis,cervical and endometrial polypsnMisuse of sexual hormone,IUDnIn different age,the differential diagnosis is differentnPuberty hemologic system
11、 diseasenReproductive age pregnancy induced diseasenPremenopause tumorTreatments nGeneral treatmentIron,vitamine C,protein,antibiotic,restnMedicine:the first-line therapynSurgeryHysterectomy:medicine is no effectEndometrial ablation:laser,roller ball,necrosis of endometrium,premenopause,no desire of
12、 reproduction in young womennUse danazol,gestrinone or GnRHa before operationnNotice some key pointsIn diagnosis,must exclude pathologic causesIn hemostasis,rapidly stop hemorrhage and regulate cycles,choice the most suitable drugs and usageTo young women,the cured indications are recovering ovulati
13、onOvulatory menstrual dysfunctionnOvulation,abnormal of corpus luteumnTwo typesLuteal phase defect(LPD)Irregular shedding of endometriumLuteal phase defect(LPD)nPathologySecretory reaction of endometrium but luteal phase defect,corpus luteum secrete inadequate progesterone,derangement of gland and i
14、nterstitium,less edema of interstitium nClinical manifestationShortening of cycles,luteal phase7dnDiagnosisSymptoms BBT:double phase,decrease slowlyD&C:the 5th of menses,mixed endometriumnTreatmentProgesteronen12days after ovulation or 1014 days before next menses,MPA 10mg for 10 daysHCGCOCSummary o
15、f diagnosis and therapyhistory,PE,labno systemic and genital disease35 ybiopsy of endometriumproliferativeatypical hyperplasiahysterectomymedicinedesire of fertility no desire of fertilityhysteroscope,D&Chysteroscope,D&C,ablationfurther therapyno effectAUBThank you High phase96 hours,complicating ot
16、her diseasenCombined useSlight bleeding:combination low-dose oral contraceptive,the first day of menses 21daysSevere bleeding:combination monophasic oral contraceptive,1 2pill/812 hours,3 days after bleeding stop,reduce 1/3 dose every 3 days,maintain 1pill for total 21 day.Such as MarvelonCommonly u
17、sed in reproductive age or premenopause nEstrogenRecovery endometriumAcute severe bleeding:nbenzestrofol（苯甲酸雌二醇）（苯甲酸雌二醇）:34mg/d,adjust according to bleeding,total dose80g/L17-Hydroxyprogesterone（羟孕酮）（羟孕酮）,norethindrone（炔诺酮）（炔诺酮）:5mg once every 8 hours,3 days after bleeding stop,reduce dose,maintain
18、dose 2.55mg/d to 21days after bleeding stop nD&C:acute severe bleeding,risk factornAdjuvant treatmentTranexamic Acid(氨甲环酸氨甲环酸)、etamsylate(酚磺酚磺乙胺乙胺)、VitKTestosterone propionate（丙酸睾丸酮）（丙酸睾丸酮）Correct anemiaAntibiotic2.Regulate cycles:36 coursesnEstrogens followed by progesteronenCombination(oral contra
19、ceptives)nProgesterone alonenPromote ovulation(CC,HMG,HCG,GnRH-a)nIUDEstrogens followed by progesteronen Lower estrogenn Conjugated estrogen 1.25mg or estradiol 2mg qd 21days,10 days later adding MPA10mg 10dCombinationn High estrogen and premenopausen Oral contraceptive:the 5th day of menses,every n
20、ight 1 pill for 3 weeks,stop for 7 days Progesterone alonenAdolescence or premenopausenThe 1625 days of menses,MPA 10mg/d or progestin IM 20mg/d or dydrogesterone 1020mg/d or micronize progesterone 200mg for 1014 daysNumber of glandsGlandular cavity enlarged,size is irregular,glandular epithelium is
21、 simple columnar or pseudostratified,no heteromorphism,interstitium hyperplasia Simple hyperplasiaNormal glandinterstitiumEnlarged glandn Gland hyperplasia are obvious,crowding,close together,glandular epithelium protrude into cavity or interstitia,stratified columnar epithelia,no karyokinesisComple
22、x hyperplasiaAtypical hyperplasiaCarcinoma of endometrium Atypical hyperplasia glandular epithelium hyperplasia,polarity of cell disappear,size enlarged,dark and large nucleus,karyokinesis Endometrium carcinomaThe same as proliferative phase in normal menstrual cycleproliferative phase of endometriumatrophic endometriumGlands decreased,simple cuboidal or columnar epithelium,interstitia decreased and dense,collagen fibers increasedCervical mucosaVaginal shed cell
