医学精品课件：10阴道流血.ppt

1、Abnormal Vaginal/Uterine BleedingZhejiang University School of Medicine,Womens HospitalWu Ruijin Abnormal vaginal bleedingnOne of the most common gynecologic symptoms.nInclude bleeding from uterus,cervix,vaginal,hymen etc.nMost from uterine,but called vaginal bleeding except normal cycle of menstrua

2、tion.nAppearance of bleeding vary from their causes.Abnormal Uterine BleedingnIncludes abnormal menstrual bleeding and bleeding due to other causes such as pregnancy,systemic diseases,or cancer.nThe diagnosis and management present some of the most difficult problems in gynecology.nIn childbearing w

3、omen,a complication of pregnancy must always be considered,and more than one entity may be present,eg,uterine myomas and cervical cancer.Part I Etiological factors of abnormal vaginal bleeding1.Ovarian endocrine dysfunction2.Pregnancy-related bleeding3.Infections4.Malignant Lesions5.Genitals damage,

4、extraneous material and exogenous hormone6.Bleeding due to systemic diseases1.Ovarian endocrine dysfunctionDue to dysfunction of the hypothalamic-pituitary-ovarian axis(HPOA).nanovulatory dysfunctional uterine bleeding (无排卵性功能失调性子宫出血)novulatory menstrual dysfunction (排卵性月经失调)nintermenstrual bleeding

5、(经间期出血)(1)Anovulatory dysfunctional uterine bleeding nPuberty（20%）：unstable HPOA regulation with growing follicle but no LH peak and ovulation does not occur.nPerimenopause（50%）：ovary becomes low responsive to Gn and its function declines.nChild bearing period（30%）：inside/outside interference,such a

6、s psychologic factor,environment,stress,etc.(2)Ovulatory menstrual dysfunctionnLuteal phase defect(LPD)(黄体功能不全)Abnormal FSH/LH or ratio,low LH peak or following pulse defect.nIrregular shedding of endometrium(子宫内膜不规则脱落）HPOA dysfuction and corpus luteum degenerate uncompletely(3)intermenstrual bleedi

7、ng nWith the rupture of dominant follicle,estrogens declines in a short time and endometrium break-through bleeding.2.Bleeding due to pregnancynAbortion 流产nEctopic pregnancy异位妊娠nGestational trophoblastic disease(GTD)妊娠滋养细胞疾病nAnomaly of placenta 胎盘异常-placenta praevia(前置)、abruption(早剥)、adherence(粘连)、i

8、mplantation(植入)nPostpartum part placenta remain胎盘部分残留nInvolution of uterus unhealthy 子宫复旧不良 AbortionnMorphologic and genetic abnormalities:Abnormal chromosome is the main factor.nMaternal factors:1.Systemic diseases：infections,cardiovascular disorders,severe anaemia,etc.2.Endocrine disorder：hypothyr

9、oidism,poorly controlled diabetes mellitus.3.Immunologic disorders4.Uterine defects：congenital anomalies,submucous or intramural myomas,intrauterine adhensious.5.Trauma(创伤刺激)nToxic factors：unhealthy life style,radiation,uncontrolled drugsEctopic pregnancyMore than 95%occur in the fallopian tube.n50%

10、had salpingitis.nHistory of fallopian operation.nIntrauterine Device(IUD)nFallopian dysplasia or dysfunction,affect the transmigration of fertilized ovum.nOthers：surrounding oncothlipsis,EMsGestational Trophoblastic Disease Trophohyper plasiacyte,erosin and destroy surrounding blood vessel.nHydatidi

11、form mole(葡萄胎)nInvasive hydatidiform mole(侵蚀性葡萄胎)nChorionic carcinoma(绒毛膜癌)3.Genitals inflammationnVulvovaginitis(外阴阴道炎)：disorder of vaginal ecological balance or exogenous pathogen invasionnCervicitis(宫颈炎)nCervical polyp(宫颈息肉):long-term chronic inflammation stimulationnEndometritis(子宫内膜炎)：common in

12、 after abortion,parturition,postmenopause women and IUD4.Genitals tumor（1）Tumor erosion the vessel wall,cause cellular necrosis,ulcer.（2）Tumor cause steroid hormone disorder.（3）Myoma enlarged endometrial area,interfere uterine contraction and blood sinus shut.nVulovaginal tumor,cervix cancer,myoma,e

13、ndometrial carcinoma,sarcoma of uterus,ovarian cancer,oviduct cancer5.Genitals damage,extraneous material and exogenous hormonenGenitals damage:vulovaginal straddle injury(外阴阴道骑跨伤)nSexual intercause cause hymen and vaginal injury and bleeding.nIUD:hard and large area IUD oppress cause local endometr

14、ium necrosis and ulcernE2/P misapply.6.Bleeding due to systemic diseasesnPurpura haemorragica(血小板减少性紫癜)nAplastic anemia(再生障碍性贫血)nLeukemia(白血病)nHepatic function damage disturbances of blood coagulation(凝血机制障碍)thrombocytopenia(血小板减少)increased capillary permeability(毛细血管通透性增加)some liver disorder hormon

15、e change.7.Others nPelvic inflammation：congestion(充血),vessel wall brittleness(脆性脆性)increasednEndometrial polypsnEMs：steroid hormone disorder Part II Patterns of Abnormal Uterine Bleeding(阴道流血特点与相关疾病的联系)nAge factorsnRegulation of period or notnPregnancy or not 1.menorragia/hypermenorrhea(经量增多)Heavy(8

16、0ml)or prolonged（7d）menstrual flow.nSubmucous myomas(子宫粘膜下肌瘤)nComplications of pregnancynEndometrial hyperplasiasnMalignant tumorsnEndometrial polyps(子宫内膜息肉)nAdenomyosis(子宫腺肌病)nDysfunctional bleeding(排卵性月经失调)nIUDs(放置宫内节育器)MyomasSymptoms：1.Abnormal uterine bleeding：30%,prolonged and heavy menses，irre

17、gular uterine bleeding often in submucous myomas2.Abdominal mass(腹块腹块)3.Leucorrhea(白带白带)increased4.Pain or sore waist(腰酸腰酸)5.Pressure effects6.Infertility,spontaneous abortion,malposition(胎位不正等胎位不正等)7.Secondary anemia(继发贫血继发贫血)8.B type ultrasound,CT,MRI help to diagnosisEndometrial polypsnSpotting o

18、r irregular uterine bleedingnUltrasound help to diagnosisnDiagnosis curettage(诊断性刮宫),hysteroscope(宫腔镜检查)and pathology examination help final diagnosisAdenomyosisnMenstruation change:50%hypermenorrheanMenalgia(痛经)，increasingly severenEnlarged uterus,hardnUltrasound,MRI help to diagnosisOvulatory mens

19、trual dysfunctionnLuteal phase defect(LPD)(黄体功能不全)（1）shorten cycle,luteal phase 11d,frequently cycle（2）infertility（3）repeating spontaneous abortion（4）D&C：luteal phase endometrium defected and backward 2d to standard phasenIrregular shedding of endometrium(子宫内膜不规则脱落）（1）prolonged and heavy menses（2）D&

20、C:proliferative and secretary endometrium coexist in cycle d5（3）BBT high temperature phase prolonged to next menstruation (4)Serum E2,P and BBT,D&G,cervix mucus score help to diagnosis2.Menometrorrhagia(周期不规则的阴道流血)nBleeding occurs at irregular intervals.nAmount and duration of bleeding also vary.nAn

21、ovulatory dysfunctional uterine bleedingnExclude early endometrial cancernComplications of pregnancyAnovulatory dysfunctional uterine bleedingnIrregular uterus bleedingnCharacteristic of bleeding:（1）irregular cycle and duration（2）not stop by oneself（3）irregular amount（4）no menalgia(痛经)（5）anaemiaEndo

22、metrial cancer1.Irregular bleeding：Post-menopause bleeding:middle or less amount,durative(持续性)or intermittence(间歇性)；Child-bearing age women:prolonged and heavy menses or intermenstrual bleeding2.Vaginal apocenosis(排液)3.pain4.General symptom5.Enlarged uterus,tender,tissue emersion in advanced stage(组

23、织物脱出)。6.Segmenting diagnosis curettage(分段诊刮)help to diagnose lesions whether involve cervix canal.7.Hysteroscope,ultrasound,CT、MRI help to diagnosis.3.Last and durative uterine bleeding(长期持续阴道流血长期持续阴道流血)nOften happen in reproductive malignant tumornNeed exclude carcinoma of cervix uteri and corpus u

24、teriCervix cancer1.Contact bleeding(接触性出血):after sex intercross or pelvic examination young：prolonged and heavy menses,short cycle old：post-menopause irregular bleeding2.Vagina apocenosis(流液)：white or uprightness(血性)、smell of fish(腥臭)or foul smell(恶臭)3.Often early onset of sexual activity or marriag

25、e and child bear,multiple sexual partner(多个性伙伴).4.Pelvic examination5.Special examination:cervical cytology,HPV testing,iodine test,colposcopy(阴道镜),biopsy,endocervical curettage,cone biopsy(宫颈锥切)4.Bleeding after menelipsis(停经后阴道流血)nChild-bearing age:first consider pregnancy-related disease Abortion

26、Ectopic pregnancy Gestational trophoblastic disease(GTD)nPeri-menopause period:Anovulatory dysfunctional uterine bleeding Exclude genital malignant tumor AbortionnBleeding and pelvic pain after menelipsis(停经).nClinic types and feature：amount pelvic pain tissue discharge cervix uterus ziseThreatened

27、less no or light no close match Inevitable middle to heavy severe no expand match/smallIncomplete less to heavy light part discharge expand /close/block smaller Complete less to heavy no total discharge close normal/larger Three special types:missed(稽留流产),habitual(习惯性流产)or recurrence(复发性流产）,abortion

28、 infection(流产感染)Ectopic pregnancy1.Menelipsis(停经)2.Pelvic pain3.Bleeding：less and irregular4.Faint and shock (晕厥与休克)5.Abdomen mass1.General state2.Abdomen examination:3.Pelvic examination：Lifting pain(宫颈举痛),pelvic mass(盆腔包块),uterus soft and a little largerGestational trophoblastic disease(GTD)1.Blee

29、ding after Menelipsis2.Uterus significantly larger and soft3.Serum HCG abnormal higher4.Pain5.Vomiting of pregnancy(妊娠呕吐)6.Ovarian luteinizing cysts(黄素化囊肿)7.Gestational hypertension(妊娠高血压疾病)and hyperthyreosis signDifferentiate(鉴别)1.History:menelipsis,morning sickness(早孕反应）2.Pelvic examination3.Speci

30、fic examination：Serum or urine HCG Ultrasound Retro-fornix puncture(后穹隆穿刺)Laproscope(腹腔镜检查)5.Vaginal bleeding with increased leucorrhea(阴道流血伴白带增多)nAdvanced stage cervix cancernEndometrial cancernSubmucous myomas infected nUltrasound,CT,MRI,hysteroscope,colposcopy,cervical scraping smear(or TCT),biop

31、sy.6.Postcoital Bleeding(性交后出血)nCervical erosion(宫颈糜烂)：fluor sanguinolentus(血性白带),contact bleeding,increased vaginal dischargenCervical polyps：sprinkle or contact bleeding,increased vaginal dischargenSubmucous myomasnInvasive cervical cancer:early stage appear as cervical erosion,contact bleeding nP

32、elvic examination,cervical scraping smear,colposcopy,ultrasound and biopsy.7.intermenstrual bleeding(月经间期出血)nBleeding occurring at any time between menstrual periods.nOccurs at mid-cycle as spotting(排卵期出血)nSymptoms：14-15d before next menstruation，sparking bleeding last 3-4 dnCan be documented with b

33、asal body temperatures.nEndometrial polyps and endometrial and cervical carcinomas are pathologic causes.nExogenousnEstrogen administration 8.Peri-menstruation spotting bleeding(经前或经后点滴出血)nOvulatory menstrual dysfunction nIUDnEMs EndometriosisnMenalgia(痛经)nDyspareunia(性交不快)nInfertilitynPelvic examin

34、ation：tender nodules in posterior vaginal fornix,cul-de-sac(子宫直肠陷窝),uterosacral ligament(宫骶韧带)and tender adnexal masses may be felt when lesions involve ovary and form endometriomas.nUltrasound,CT,Laproscope.nSerum CA125may light increased9.Bleeding after years of menopause(绝经多年后阴道出血)nSmall amount,l

35、ast 2-3d，normally menopause endometrial ablate(脱落),or senile vaginitis(老年性阴道炎).nLarge amount or continue repeatedly bleeding,consider endometrial cancer.10.Intermittence bleeding or apocenosis(间歇性阴道排液流血间歇性阴道排液流血)nExclude fallopian carcinoma 70%may be chronic salpingitis 50%infertility history Trilog

36、y(三联症)of fallopian carcinoma:vagina apocenosis,pelvic pain and pelvic massnSymptoms,vagina cytological examination,D&C,ultrasound,CT,MRI,Laproscope,serum CA125may light increased11.Bleeding after injury(外伤后阴道流血)nOften after straddle injury(骑跨伤)nBleeding amount varynCompany with local pain Part IIIEv

37、aluation of abnormal uterine bleedingnHistory(病史病史)nPhysical examination and pelvic examination(全身与妇科体全身与妇科体检检)nAuxiliary examination(辅助检查辅助检查)（1）HCG（2）Endometrial biopsy/Dilatation and Curettage(D&C)诊断性刮宫诊断性刮宫（3）Ultrasound(or saline hysterosonogram)/CT/MRI（4）Hysteroscopy宫腔镜宫腔镜/Laparoscope腹腔镜腹腔镜/col

38、poscope 阴阴道镜道镜BBT（6）Steroid hormone（7）Cytologic examination(细胞学检查细胞学检查):cervical and vaginal.（8）Others：tumor markers,leucorrhea examination,cervical discharging,blood/live/clotting function test and retro-fornix puncture.Part Treatment nGeneral treatment:antiinflammatory,stop bleeding,retrieve anaem

39、ia(纠正贫血),enhance nutritionnIdentify etiological factor,etiological treatment nDrug treatment：hormonal therapy,chemotherapy and medical treatment.(1)dysfunctional bleeding：stop bleeding,cycle regulation,induce ovulation；(2)endometrial cancer:PnCervix physiotherapeutics(理疗),polyps removal,cervix cone

40、biopsy or leep.nExtraneous material remove：extraneous material,IUD residOperation treatmentnWound neoplasty(修补术)：straddle injury(骑跨伤)and defloration(处女膜破裂)bleeding.nComplete Curettage：hydatidiform mole(葡萄胎),inevitable and incomplete abortion nDiagnosis Curettage:often used in acute heavy bleeding or

41、 exist high risk of endometrial cancernEndometrial ablation(子宫内膜切除术）：Perimenopause heavy bleeding,hormone therapy does not work and no child-bearing requestnHysterectomy(子宫切除术）：medicine therapy does not work and patient choose nOperation on fallopian tube：tubal pregnancy(tube resection),conservative

42、 operation(保守性手术)nTreatment on neoplasmata genitalisGeneral principles of managementnA careful history and pelvic examination are vital.nPregnancy must be considered as well as use of oral contraceptives,IUDs,and hormones.nAdequate sampling of the endometrium is essential for a definitive diagnosis.

43、nImproved diagnostic techniques and treatment have resulted in decreased use of hysterectomy to treat abnormal bleeding patterns.nIf pathologic causes can be excluded,no risk of cancer developing and no acute life-threatening hemorrhage,most patients can be treated with hormone preparations.nMyomect

44、omy can be suggested for myoma if the patient wishes to retain her potential for childbearing.nEndometrial ablation and resection may offer successful outpatient and inpatient alternatives.nFor menorrhagia,PGs inhibitors decrease blood loss during menses,as has antifibrinolytic therapy.nLong-acting intramuscular progestin can be given,but may result in erratic bleeding or even amenorrhea.nLevonorgestrel-releasing intrauterine devices are effective in decreasing blood loss.