anovulatory dysfunctional uterine bleeding
Introduction
Introduction to anovulatory dysfunctional uterine bleeding Dysfunctional uterine bleeding referred to as dysfunctional uterine bleeding, dysfunctional uterine bleeding is defined as abnormal uterine bleeding caused by various organic diseases of the systemic and reproductive systems, which can be characterized by excessive menstrual bleeding and prolonged duration, and The interval time is short, unpredictable, or the amount of bleeding is not much, but it is dripping, and even the uterus needs to be removed. Dysfunctional uterine bleeding can be divided into anovulatory dysfunctional uterine bleeding and ovulatory dysfunctional uterine bleeding. Anovulatory dysfunctional uterine bleeding occurs mainly in adolescent and perimenopausal women. The common pathological feature of abnormal uterine bleeding is anovulation. basic knowledge The proportion of the disease: the incidence of this disease in women of childbearing age is about 0.04%-0.1% Susceptible people: women Mode of infection: non-infectious Complications: infertility uterine fibroids
Cause
Anovulatory dysfunctional uterine bleeding cause
Causes
The HPOU axis is immature (30%):
Adolescent dysfunctional uterine bleeding is seen in young girls after menarche. Because the HPOU axis is immature, they have not established stable periodic regulation and positive and negative feedback between ovarian endocrine and ovarian endocrine. Clinical manifestations of menarche after menarche, short-term menstruation after irregular irregular menstruation, menstrual extension, dripping more than, resulting in severe anemia.
Decreased ovarian function (28%):
Menopausal women are due to the gradual decline of ovarian function, follicles are nearly exhausted, and the remaining follicles are often less responsive to pituitary gonadotropin, resulting in decreased estrogen secretion and weaker negative feedback to the pituitary, so gonadotropin levels Elevation, often FSH is more obvious than LH, but can not form the peak of LH before ovulation, anovulatory dysfunctional uterine bleeding. Most anovulatory dysfunctional uterine bleeding is estrogen withdrawal bleeding or estrogen breakthrough bleeding.
Other factors (30%):
These include poor trauma, stress, malnutrition, endocrine and metabolic disorders such as iron deficiency, anemia, aplastic anemia, blood and bleeding, diabetes, thyroid and adrenal diseases.
Pathogenesis
The pathophysiological changes of dysfunctional uterine bleeding are abnormalities in neuroendocrine regulation of the hypothalamic-pituitary-ovarian axis of the central nervous system or local regulation of ovarian, endometrial or muscular layers.
A small number of anovulatory women can have regular menstruation, clinically known as "anovulatory menstruation", most women with anovulation have menstrual disorders, irregular ovarian follicles, varying degrees of development, no dominant follicles and corpus luteum formation, developing Follicles continue to secrete unequal amounts of estrogen, but not enough to induce blood LH peak; progesterone levels are low, so that the endometrium continues to proliferate or even proliferate, due to irregular development and degeneration of follicles, blood estrogen levels are also irregular Fluctuation; endometrial due to insufficient or fluctuating estrogen, irregularly detached, that is, the site of degeneration, depth, range and timing can be irregular, estrogen withdrawal or breakthrough bleeding.
1. Estrogen withdrawal bleeding After the appropriate dose and course of estrogen is given to women who have undergone ovariectomy, or the amount of estrogen is reduced by more than half, uterine bleeding occurs, which is called "estrogen withdrawal bleeding". However, if the dose of estrogen given is too low, the course of treatment is too short, or the magnitude of estrogen reduction is too small, there is no uterine bleeding. The blood estrogen concentration of postmenopausal women also fluctuates at a low level, but there is no menstrual cramps. This is because bleeding occurs when the endometrial proliferation must reach a certain thickness and loses hormone support. Some scholars conceive of "the endometrial bleeding threshold of estrogen"; after exceeding this threshold, if the estrogen stimulation is weakened Below the above threshold, uterine bleeding may occur; conversely, if the estrogen stimulation intensity is below the above threshold and fluctuates below this threshold level, no bleeding occurs.
2. Estrogen breakthrough bleeding A considerable concentration of estrogen long-term effects, no progesterone antagonistic effects, can cause endometrial hyperproliferation to varying degrees of hyperplasia, no anti-estrogen stimulation through direct action on blood vessels, reduce blood vessels Tension; stimulates the expression of interstitial VEGF, reduces the production of PGF2a, AngII, promotes the formation of nitric oxide (NO), PGE2, prostacyclin (PGI2), etc., causes vasodilation, increased blood flow, or due to endometrial stroma, blood vessels Gland development is not synchronized, lysosome development is too unstable and unstable, releasing hydrolase, causing increased or continuous bleeding, unpredictable, known as "estrogen breakthrough bleeding."
Fraser et al (1996) performed hysteroscopy on patients with endometrial hyperplasia. The endometrium was distorted, the superficial blood vessels were thin and easily broken, the vascular structure of the endometrium was abnormal, and the spiral artery was poorly developed. Increased, and sinus formation, can also increase the tendency of bleeding, other studies have also shown that endometrial bleeding has increased to varying degrees, local PGF2a production decreased or PGE2 synthesis increased, NO and fibrinolytic activity may increase, these local Changes in factors may have a role in the bleeding of this disease.
Prevention
Anovulatory dysfunctional uterine bleeding prevention
In order to prevent the occurrence of anovulatory dysfunctional uterine bleeding and complications, early diagnosis and irregular treatment of irregular bleeding should be carried out; and the cause of anovulatory dysfunctional uterine bleeding in different periods should be prevented.
Complication
Anovulatory dysfunctional uterine bleeding complications Complications infertility uterine fibroids
Anovulatory dysfunctional uterine bleeding can be secondary infection, infertility, mental burden, and sometimes this disease can also exist with certain organic diseases, such as uterine fibroids, ovarian secretion of estrogen tumors.
Symptom
Anovulatory dysfunctional uterine bleeding symptoms Common symptoms Menstrual bleeding menstrual cycle changes menstrual time and time ... and amenorrhea
Anovulatory dysfunctional uterine bleeding is characterized by completely irregular menstruation, generally without dysmenorrhea. The type of bleeding depends on the level of serum estrogen and the rate of decline, and the duration and duration of estrogen on the endometrium. The thickness of the membrane can be as small as dripping, or as large as a large blood clot can cause severe anemia; the duration can vary from 1 to 2 days to several months; the interval can be from several days to several months, so it can be mistaken for amenorrhea, Due to the lingering disease, there may be anemia, hairiness, obesity, lactation, infertility, etc.
Examine
Anovulatory dysfunctional uterine bleeding check
1. Estrogen levels in vaginal smears are mild to moderate.
2. The serum E2 concentration is equivalent to the middle and late follicular phase, and the normal periodic changes are lost.
3. Progesterone concentration <3ng/ml.
4. The levels of luteinizing hormone (LH) and follicle stimulating hormone (FSH) are normal or the ratio of LH/FSH is too high, and the periodic peak disappears.
5. Blood routine, blood coagulation function test, blood chorionic gonadotropin (HCG), prolactin (PRL), determination and thyroid function test.
6. Histopathological examination Endometrial biopsy pathological examination can be proliferated, simple hyperplasia, complex hyperplasia (glandular structure is irregular, but no glandular epithelial dysplastic changes), endometrial polyps or atypical hyperplasia (glandular epithelium has atypical Change), no secretion period, atypical hyperplasia is a precancerous lesion, and occasionally endometrial adenocarcinoma.
7. Hysterosalpingography.
8. Transvaginal ultrasound examination.
9. Hysteroscopy.
10. The basal body temperature (BBT) curve is single-phase.
Diagnosis
Diagnosis and differentiation of anovulatory dysfunctional uterine bleeding
The key to diagnosis is the exclusion of non-genital tract (urinary tract, rectal anus) and other parts of the genital tract (cervix, vagina), bleeding from systemic or reproductive systemic diseases and iatrogenic uterine bleeding, combined with symptoms and signs. And laboratory tests can be diagnosed.
Differential diagnosis
Differential diagnosis depends on detailed history of menstruation and hemorrhage, full physical examination and pelvic examination for diagnostic curettage or endometrial biopsy pathology, hysterosalpingography, cervical scraping, etc., but the above diagnostic methods have been reported for small intrauterine lesions (eg The rate of missed diagnosis of polyps, submucosal fibroids is 17% to 38%.
1. Transvaginal ultrasonography is of great value in differential diagnosis. Dodson (1994) used transvaginal ultrasonography to study the etiology of 45 patients with frequent menstruation. The results showed that ultrasound detected organic disease 31%, sensitivity General pelvic examination (detection rate 9%) is 3.5 times higher, can find small ovarian cysts, with or without polycystic ovary ultrasound phase, and according to the characteristics of endometrial ultrasound phase to determine the body, progesterone levels, if the intima thickens, echo Enhance, should be suspected of hyperplasia, adenocarcinoma or submucosal fibroids, need to undergo a curettage examination to help diagnose, Indman (1995) compared 238 cases, 25-75 years old patients with abnormal uterine bleeding, vaginal ultrasound, hysteroscopy, diagnosis and pathology The results showed that vaginal ultrasound could detect 99% of submucosal fibroids, 89% of endometrial polyps; the positive predictive value of vaginal ultrasound abnormalities was 87%, and the negative predictive value of normal vaginal ultrasound was 89%, Widrich et al ( 1996) It is reported that intrauterine injection of normal saline has increased contrast, sensitivity and specificity can be compared with hysteroscopy, and the pain caused to patients is reduced. Ultrasound examination can not distinguish the benign and malignant nature of the lesion, and can not replace Li inspection.
2. Hysteroscopy has become an indispensable means to identify the cause of uterine bleeding. Lewis (1990) reported that only 62% of patients with submucosal fibroids were found to have polyps, and 74% of uterine salpingography were positive. The reliability of endoscopy is also related to the surgeon's experience. Skilled people may have 20% false positives without false negatives. Many authors recommend hysteroscopy and direct biopsy under direct vision, with a sensitivity of 98%. The blind shaving is only 65%.
