34. Estrogen and progestin sequence therapy Estrogen E dose stepdown 3 d E normal dose hemoglobin recovered Progestin 10 d withdrow
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Editor's Notes
Dear students, today we will learn something about abnormal menstruation, which is common and frequent in female patients.
Abnormal menstruation mostly presents as dysfunctional uterine bleeding and amenorrhea. However , broadly it includes dysmenorrhea , irregular bleeding after menopause and so on. So, today, during the 2 classes, we could only focus on dysfunctional uterine bleeding and amenorrhea.
First of all, we simply review the occurrence of normal menstruation. The hypothalamus must secret gonadotropin-releasing hormone (GnRH) in a pulsatile pattern, which is modulated by neurotransmitters and hormones. The GnRH stimulates secretion of follicle –stimulating hormone (FSH) and luteinizing hormone (LH) from pituitary, which promotes ovarian follicular development and ovulation. Meanwhile, estrogen and progesterone are produced. These hormones stimulate proliferative or secretory endometrial development, which is the basic of withdrawal bleeding. If outflow tract including cervix and vagina is obstructed, bleeding cannot occur.
This is a picture about positive and negative feedback mechanism of H-P-O axis
我们先讨论功能失调性子宫出血 , 简称 DUB 。 Firstly, we discuss dysfunctional uterine bleeding, DUB for short.
DUB is defined as the abnormal uterine bleeding caused by abnormal regulation of H-P-O axis.
功能失调性子宫出血的分类 : 根据是否伴随排卵 , 功血分为无排卵性功血和有排卵性功血 , 无排卵性功血较常见 , 约功血病例的 70%-80%, 容易发生于青春期和绝经过渡期 ; 有排卵性功血占 20-30%, 又进一步分为月经频发 , 月经延长 , 经间期出血 , 月经过多 . Classification of DUB : according to the ovulational situation, DUB is classified as Ovulatory DUB and Anovulatory DUB. approximately 70%-80% of DUB patients is Anovulatory ( 20%of cases occur in adolescence and 50% in perimenopause),by contrast,ovulatory DUB patients occupy 20%-30%, which can be polymenorrhea, Post menstrual bleeding ,interval bleeding, menorragia.
Pathology of endometrium in anovulatory DUB often present as endometrial hyperplasia, proliferative phase endometrium, atrophic endometrium. Yet,endometrial hyperplasia can be classified as simple hyperplasia, complex hyperplasia and atypical hyperplasia. If there is no proper treatment, hyperplasia and atypical hyperplasia may become carcinoma someday.
Anovulatory DUB is estrogen withdrawl bleeding or breakthrough bleeding. which presents as irregular bleeding, heavy bleeding ,long time bleeding with anemia, dizziness, or shock. Basal body temperature shows single phase.
Ovulatory DUB can be classified as polymenorrhea(menstrual periods occur less than 24 days apart), Post menstrual bleeding : （ menses last more than 7 days ）， Mid-cycle spotting ( spotting bleeding during ovulation), Menorrhagia (menstrual flow is more than 80ml ) Basal body temperature is double phase.
Dysfunctional uterine bleeding is an exclusive diagnosis. We have to exclude organic diseases which can cause menorrhagia. For the married women with a regular menstruation in the past ， the most common change is the sudden irregulation of menstrual cycle and abnormal bleeding.we have to rule out the pregnancy-related complications, such as threatened abortion, incomplete abortion, or ectopic pregnancy. it is also necessary to rule out trophoblastic disease
Differential diagnosis: Pathological changes of the reproductive tract and systemic pathological changes
Pedunculated myomas can cause intermenstrual bleeding of variable amt. Cervical polyps and ectropion may cause post coital spotting Infections usually cause bleeding in combination with a symptom complex Episodic intermenstrual spotting of varying amts and duration is the most common symptom in women with chronic endometritis Trauma and FB usually come with appropriate histories but we’ve all had that awful encounter with a patient who can FORGET that she put something in and then we have to close half of the clinic because it smells so bad.
Endometrial cancer incidence increases with age. Other risk factors are: long history of oligo or anovulation unopposed estrogen obesity Abnormal bleeding in peri and postmenopausal patients should be considered cancer until proven otherwise it is not the most common etiology but is the most important found in 10% of perimenopausal women found in 25% of postmenopausal women Endometrial hyperplasia is a cancer precursor
Platelet deficiency: leukemia, sepsis, ITP, hypersplenism Platelet function: von Willebrand's disease vWD or another blood dyscrasia is present in significant proportion of women in whom reproductive tract disease has been ruled out. 1% of general population 20% of adolescents hospitalized for Abnormal bleeding 95% of these pts are unaware of there condition The incidence of hypothyroidism in women with menorrhagia is dependent on the sensitivity of the tests used to make the diagnosis (.3-2.5%) When TRH stim test used in pts with unexplained severe menorrhagia, up to 20% have an abnormal response. Wilansky and Griesman used this test to detect subclinical hypothyroidism in 15 of 67 women. ALL had normal TSH and thyroxine levels. With replacement all had resolution of symptoms within 3-6 months. HYPERTHYROIDISM is usually not associated with menstrual abnormalities but they have been reported With cirrhosis there is decreased metabolism of Estradiol and synthesis of procoagulant factors. Also in advanced liver disease, the ability metabolize and conjugate estrogen is decreased. This will eventually lead to hyperprothrombinemia.
Steroids may be being used for contraception, hrt, hirsutism, dysmenorrhea, pms, acne, and endometriosis Tranquilizers may interfere with neurotransmitters responsible for hypothalamic releasing and inhibiting hormones Copper IUD’s can bleed. However, progesterone or progestin releasing IUD’s usually decrease the amount of blood loss or even result in amenorrhea
Determine hemodynamic stability FIRST Urinalysis, stool guaiac if origin of bleeding in doubt Point of this slide is there are many questions that need to be asked Does she have sxs of infection Bleeding from multiple sights Symptoms of hypothyroidism etc... Cervical cultures and gram stain should be obtained Inspection of the vagina identifies trauma, severe infections, atrophy, foreign bodies Inspection of the cervix may identify polyps, erosions, cancerous lesions A symmetrically enlarged uterus may suggest adenomyosis if not pregnant A uterus with asymmetric contours may suggest fibroids
诊断工具包括：。。。。。。
This picture demonstrates endometrial biopsy by the negative-pressure pipelle. .
图示子宫腔镜检查。 This picture is of hysteroscopy examination.
宫腔镜下诊断子宫内膜息肉。 Endometrial polyp is diagnosed by hysteroscopy.
宫腔镜下见到子宫内膜增厚，子宫内膜活检结果为子宫内膜增生过长。 There is thicken endometrium in hysteroscopy, and the result of biopsy is endometrial hyperlasia.
宫腔镜下见到子宫内膜异常增生病灶，活检结果为子宫内膜腺癌。 There is atypical hyperlasia in hysteroscopy, and the result of biopsy is adenocarcinoma.
Treatment of Anovulatory Dysfunctional Uterine Bleeding: The main choice is progesterone, or oral contraceptives, or estrogen, or diagnostic curettage surgery ， which are used for hemostasis and regulating menstruation.
孕激素：口服或宫腔内缓释的孕激素，也有口服的天然或类天然孕激素。用于止血及调经。用于治疗子宫内膜增生过长。 Oral or intrauterine sustained release of progesterone, as well as oral natural or subnatural progesterone. ， are used for hemostasis and regulating menstruation, and for the treatment of endometrial hyperplasia.
Short-acting oral contraceptives, which is composed of ethinyl estradiol and different pregestin composites ， can be used for hemostasis and regulating menstruation.
Estrogen: combined estrogen and 17 - beta estradiol , achieve hemostasis by promoting endometrial hyperplasia
Mirena, a kind of intrauterine device containing levonorgestrel, with a validity of five years, can treat endometrial hyperplasia and menorrhagia, its curative effect is no worse than endometrial ablation. And it can reduce the incidence of pelvic infection for long-term use.
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