Perimenopausal dysfunctional uterine bleeding

Introduction to perimenopausal dysfunctional uterine bleeding Perimenopausal dysfunctional uterine bleeding, referred to as perimenopausal dysfunctional uterine bleeding, peri-menopausal refers to a period of menopause before and after menopause, that is, ovarian function begins to decline until one year after the last menstruation. This period is mainly caused by anovulatory uterine bleeding with anovulatory dysfunction. Peri-menopausal women are terminated by menstruation after a period of menopausal irregular menopause. basic knowledge The proportion of illness: 10% Susceptible people: women Mode of infection: non-infectious Complications: anemia shock

Peri-menopausal dysfunctional uterine bleeding

(1) Causes of the disease

Peri-menopausal dysfunctional uterine bleeding is mostly anovulatory dysfunctional uterine bleeding. This is because women's ovarian function has begun to decline at this time, the number of eggs in the ovary is significantly reduced or even depleted, and the loss of sex hormones to the hypothalamus and pituitary gland is lost. Feedback, pituitary secretion of follicle stimulating hormone (FSH) and luteinizing hormone (LH) increased (FSH is higher than LH), lack of LH intermediate peak, can not cause ovulation, on the other hand, growing follicles due to aging on gonadotropins The stimulation becomes insensitive, and it is also an important reason why follicular development does not reach mature ovulation. In the anovulatory cycle, the ovary cannot produce progesterone normally. The estrogen level fluctuates with the development of follicles, and the endometrium is not. After long-term stimulation of the single estrogen against progesterone, it becomes hypertrophy, the gland is enlarged, the glandular cavity is enlarged, and the glandular epithelium is abnormally proliferated. When the estrogen level in the body decreases, the endometrium loses support, that is, necrosis and hemorrhage, but because of Estrogen causes the polymerization and gelation of acid mucopolysaccharide (AMPS) in the intimal tissue, which reduces the permeability of interstitial blood vessels and affects the exchange of substances, resulting in The endometrial tissue is ischemic, necrosis and shedding causes hemorrhage, and the agglomeration of AMPS also hinders the endometrial detachment, causing the endometrium to be non-synchronized, resulting in long-term irregular bleeding of the endometrium. The degree of intimal hyperplasia and the degree of necrosis are related.

Although peri-menopausal dysfunctional uterine bleeding is caused by ovarian failure, anovulation, and sexual hormone secretion disorders, not every premenopausal woman has dysfunctional uterine bleeding. Therefore, the exact mechanism of uterine bleeding caused by anovulatory cycles remains to be further studied. Studies have shown that peri-menopausal dysfunctional uterine bleeding is also related to local factors of the endometrium of the seed, several of which include:

1. An abnormal vascular morphology. The structure and morphology of the spiral arterioles in patients with dysfunctional uterine bleeding showed that 80% of the patients with abnormal endometrial hyperplasia had abnormal spiral arterioles, and the abnormal vascular morphology had perivascular fibrosis according to the frequency of occurrence. , subendocardial hyaline degeneration, vascular smooth muscle hyperplasia or hypertrophy, vascular elastic tissue degeneration, etc., spiral small artery abnormalities, interfere with endometrial microcirculation function, affect the intimal functional layer shedding and peeling surface vascular and epithelial repair, affecting blood vessels Shutdown and local coagulation and fibrinolysis lead to abnormal uterine bleeding.

2. Fibrinolytic activity enhances uterine bleeding, endometrial plasminogen activator increases, activity increases, activates plasminogen to form fibrinolytic enzyme, plasmin cleaves fibrin to increase fibrin degradation product (FDP), plasma fiber The protein is reduced, and the fibrinogen state is formed in the uterus, thereby affecting the coagulation of the apical and vascular lakes of the normal endometrial spiral arterioles, and the hemostasis process causes a long-term massive bleeding.

3. Local prostaglandin production abnormalities Recent experimental results show that a large amount of estrogen against progesterone can cause an increase in the amount of prostacyclin (PGI2) secreted by cultured endometrial capillary endothelium, resulting in PGI2 and thromboxane. The pair A2 (TXA2) mainly regulates the balance between uterine local blood volume, spiral arterioles, muscle contractile activity and coagulation factors. Under the action of a large number of PGI2, uterine spiral arterioles, microvascular dilatation, blocked thrombosis, uterus The bleeding time is prolonged.

4. The number of lysosomes, functional abnormalities The lysosomal function of endometrial cells is regulated by sex hormones and directly affects prostaglandin synthesis, which is associated with endometrial shedding and hemorrhage. Ultrastructural observation of endometrium confirms: from follicular phase During the luteal phase, the number of lysosomes and enzyme activity increase progressively, progesterone acts to stabilize the lysosomal membrane, while estrogen destroys the stability of the lysosomal membrane. Therefore, when progesterone is reduced or When the blood is female, the progesterone ratio is imbalanced, which will destroy the stability of the lysosomal membrane, leading to the release of phospholipase A2 from the lysosome and into the cytoplast cells, causing arachidonic acid activation and prostaglandins (PGs). Large amounts of formation, on the other hand, lysosomal membrane rupture causes the destructive hydrolase to precipitate and release, which will cause rupture of intimal cells, collapse of the intimal layer, necrosis and hemorrhage.

(two) pathogenesis

1. Peri-menopausal women's ovarian pathophysiological changes sexual maturity women's ovary weight is 5 ~ 6g, after perimenopausal weight is only 1/2 ~ 1/3 of sexual maturity women, vaginal ultrasound observation of ovarian area : Peri-menopausal group, postmenopausal group and normal menstrual control group, the ovarian area of the three groups were 3.4cm2±2.0cm2, 2.1cm2±1.2cm2 and 5.0cm2±1.2cm2, respectively. 32% and 56%, indicating that the ovarian area of the peri-menopausal period is significantly reduced, the ovarian cortex is thinner, the surface is wrinkled, the primordial follicles are gradually reduced to exhaustion, and a few remaining follicles are not sensitive to gonadotropins, and the follicles mature. Obstruction, stop ovulation.

2. Peri-menopausal dysfunctional uterine bleeding in patients with endometrial pathological changes anovulatory dysfunctional uterine bleeding due to endometrial deficiencies limiting the growth of progesterone (P), only by a single estrogen (E) Stimulation, the endometrium may show different degrees of hyperplasia due to the level of E in the blood, the duration of E action and the sensitivity of the endometrium to E response, and a few are atrophic changes.

(1) Proliferative endometrium: There is no difference between the endometrium and the proliferative period in the normal menstrual cycle, but it is still in the proliferative phase in the second half of the menstrual cycle or even in the menstrual period.

(2) Endometrial hyperplasia: According to the International Association of Gynecologic Pathology (ISGP, 1998), the classification is as follows:

1 simple hyperplasia is too long (glandular cystic hyperplasia): refers to glandular hyperplasia with mild to moderate structural abnormalities, partial or total thickening of the endometrium, or polypoid hyperplasia, microscopic features are the number of glands Increased, cystic enlargement of the glandular cavity, the size is different, like the Swiss cheese-like appearance, so it is also called Swiss cheese-like hyperplasia; or the contour of the gland is irregular, the gland is crowded, the proportion of gland and interstitial is increased; but no Glandular back-to-back phenomenon and cell abnormality, glandular epithelial cells are high columnar, can proliferate to form pseudo-stratified layer, nuclear ellipse, chromatin dense, visible nucleolus; cytoplasm is rich in RNA, staining slightly blue, and visible translucent Cells, which are dividing cells, are stopped in the early or middle stage of division, active in DNA synthesis, often contain glycogen droplets and lipid particles in the cells, and the glands contain more mucus, especially acidic mucopolysaccharides. At the top edge of the cell, the interstitial often presents with edema, necrosis, with a small amount of bleeding and leukocyte infiltration.

2 complex hyperplasia is too long (adenomatous hyperplasia): refers to hyperplasia of glandular hyperplasia and complex structure, endometrial gland hyperplasia, budding growth, formation of subgland or protruding glandular cavity, gland outline Irregular, can be jagged or papillary, gland crowded dense, forming back-to-back phenomenon, only a small amount of connective tissue between the glands, glandular epithelial cells are active, high columnar, stratified or pseudo-stratified, translucent cells increased; The nucleus is rich in RNA, the nucleus is rich in deoxyribonucleic acid, the division is active, and the division is increased; the gland cells can undergo cilia metaplasia, eosinophilic metaplasia, serous papillary metaplasia, etc.; mature scales can appear in the interstitial Cells, or small nodular, less mature squamous cells, even forming a mulberry-like structure in the gland; lipid-containing foam cells are still visible in the interstitial, in short, in the complex hyperplasia of the intima The gland has various structural abnormalities and hyperplasia of glandular epithelium, but the morphology of glandular epithelial cells is still normal. The nucleus of various metaplastic cells is regular, does not have the characteristics of malignant cells, and is still a benign lesion.

3 dysplasia is too long: that is, precancerous lesions 10% to 15% can be converted into endometrial cancer, atypical hyperplasia of the intima on the basis of the above simple and complex type of hyperplasia, glandular epithelium The abnormality of the cells appears. The small area glands can have a sieving structure, the gland cells are stratified or pseudo-stratified, the arrangement is disordered, the cell size, the shape is different, the nucleus is enlarged, the deep staining, the polarity is lost, and the nucleoplasmic ratio is increased. The nucleoli are obvious, the chromatin is irregularly aggregated, the chromatin is bright, and there are megakaryocytes, inflammatory exudation in the cells and glandular cavity, and the identification of complex and dysplasia is too long, mainly in the nucleus. Mild heterogeneous cells, enlarged nuclei, fine chromatin, uniform distribution; moderately abnormal cells, nuclear enlargement and pleomorphic, nucleoli are obvious; chromatin clusters, uneven distribution, cell atypical In simple hyperplasia, the simple type of cells with dysplasia is too long (simple atypical hyperplasia); cells are not typical in complex hyperplasia, said complex with cell atypical hyperplasia Long (complex atypical Health).

4 atrophic endometrium: detection rate of 1.9% to 21.9%, endometrial atrophy, thin, small and small glands, narrow and straight glandular duct, glandular epithelium is a single layer of cubic or low columnar cells, less interstitial Dense, relatively increased collagen fibers.

Perimenopausal dysfunctional uterine bleeding prevention

Improve the cognitive ability of perimenopausal women in the disease, actively treat early conditions, prevent perimenopausal dysfunctional uterine bleeding and complications.

Perimenopausal dysfunctional uterine bleeding complications Complications anemia shock

Severe bleeding or prolonged bleeding can lead to anemia, shock and infection.

Perimenopausal dysfunctional uterine bleeding symptoms Common symptoms Menopausal menopausal abnormal uterine bleeding vaginal irregular bleeding amenorrhea uterine bleeding menstrual cycle changes

The patient's menstrual cycle is irregular, amenorrhea or frequent menstruation; the amount of bleeding is uncertain, and the amount of bleeding is related to the degree of endometrial hyperplasia and necrotic loss; the length of menstruation is different, that is, the so-called three irregularities.

Anovulatory dysfunctional uterine bleeding often has several weeks or months of menopause, and then there is a lot of bleeding, but also can be irregular vaginal bleeding at the beginning, clinical manifestations of menorrhagia, frequent menstruation, irregular uterine bleeding, uterus Irregular excessive bleeding.

Peri-menopausal dysfunctional uterine bleeding

Sex hormone determination

In order to reflect the most accurate indicators of reproductive endocrine status and ovarian function in the body, blood was selected before hormone therapy or under the guidance of basal body temperature (BBT) to determine FSH, LH, prolactin (PRL), estradiol (E2), pregnancy Hormone (P), testosterone (T) levels, distinguish between dysfunctional uterine bleeding types, and polycystic ovary syndrome, hyperprolactinemia, to guide the clinical development of treatment options, making treatment more targeted.

2. Vaginal exfoliated cell smear dynamic observation of vaginal exfoliated cells, through the vaginal epithelial cell maturity index (MI) to understand the level of E in the body, as a monitoring, typing and monitoring indicators.

Auxiliary inspection

Cervical mucus score

Understand the level of E in the body, such as before the bleeding or even the bloody stage of the cervical mucus is still fern-like crystals, suggesting a single E effect, no ovulation function, can be used as a clinical classification of dysfunctional uterine bleeding, E level estimation and observation of efficacy index.

2.BBT

It is one of the most common and easy methods used in the diagnosis of dysfunctional uterine bleeding. According to the BBT phase, combined with other monitoring indicators, as the most simple and easy way to observe the efficacy and guide the treatment as a dysfunctional uterine bleeding classification. .

3. Diagnostic curettage

Can understand the functional status of the endometrium and ovary, and can directly stop bleeding, for peri-menopausal bleeding and high risk factors of endometrial cancer, should first be treated with segmental curettage, exclude malignant lesions, the diagnosis must scrape the endometrium Functional layer, tissue delivery pathological examination, should also pay attention to the depth of the uterine cavity, morphology, smooth wall, etc., the sensitivity of diagnostic curettage is 78.8% ~ 84.5%, specificity 100%.

4. Type B ultrasound

B-ultrasound can be found in the submucosal small fibroids that are neglected by the diagnosis, and found that ovarian tumors, endometrial thickness measurement and dynamic observation, etc., due to their non-invasive and reproducible, diagnosis and differential diagnosis of dysfunctional uterine bleeding, It is important to judge the therapeutic effect and guide clinical treatment.

5. Hysteroscopy

Hysteroscopy can directly observe the appearance, location and extent of intrauterine and cervical lesions, and conduct biopsy on suspicious lesions. Therefore, hysteroscopy of dysfunctional uterine bleeding for long-term treatment can help to detect intrauterine lesions. Select points under direct vision to reduce misdiagnosis. The sensitivity of hysteroscopy is 94.1% and the specificity is 95.5%.

Diagnosis and diagnosis of perimenopausal dysfunctional uterine bleeding

diagnosis

The diagnosis of perimenopausal dysfunctional uterine bleeding must first exclude all systemic and reproductive system organic diseases, except for iatrogenic factors, such as abnormal bleeding caused by the abuse of sex hormones, etc., before the diagnosis is not clear, hormone therapy should not be blindly performed.

History

Carefully ask about your personal menstrual history, birth and contraceptive history, age of onset, incidence, possible causes, presence or absence of thyroid, adrenal gland, liver and blood disease and its treatment history. Sex hormone therapy should pay special attention to the name and dose of hormones and drugs used. Efficacy, hormonal determination and pathological results of endometrial smear have important reference value for diagnosis and further treatment.

2. Physical examination

Pay attention to systemic nutrition, mental status, with or without anemia, blood disease, signs and symptoms of bleeding disease (bleeding point, ecchymosis, cyanosis and jaundice), lymph node and thyroid and breast examination, basin, abdominal cavity with or without swelling and liver and spleen swelling Wait.

3. Gynecological examination

Married women should be routinely diagnosed by triple examination, pay attention to observe the amount of bleeding, source, nature, cervix, uterus, ovary with or without tumor, inflammation, endometriosis and other organic diseases, anal examination to understand the pelvic and rectal Happening.

Differential diagnosis

In clinical work, accurate diagnosis of dysfunctional uterine bleeding is not easy, and misdiagnosis of "dysfunctional uterine bleeding" often occurs, abnormal uterine bleeding can be caused by a variety of diseases.

1. Pregnancy and pregnancy related diseases

(1) abortion: when the patient has no history of menopause accompanied by irregular small amount of vaginal bleeding, especially near menopausal, easily misdiagnosed as dysfunctional uterine bleeding.

(2) ectopic pregnancy: some patients with ectopic pregnancy have no history of menopause and irregular vaginal bleeding as the main performance, individual can also show a greater amount of vaginal bleeding, such as "dysfunctional uterine bleeding" to give estrogen and progesterone treatment, often can lead to Severe consequences, rupture of tubal pregnancy may occur.

(3) trophoblastic disease: patients with menopausal hydatidiform mole may be neglected of pregnancy, and patients with choriocarcinoma without a history of hydatid may also be misdiagnosed as dysfunctional uterine bleeding.

2. Reproductive tumors

(1) uterine fibroids: especially in small submucosal fibroids with peri-menopausal patients with irregular vaginal bleeding may be misdiagnosed, should understand the normal size of the uterus, there is still the possibility of organic disease, if the dysfunction When the treatment of uterine bleeding is ineffective, the diagnosis should be further confirmed.

(2) cervical and uterine malignant tumors: such as endometrial cancer often with irregular vaginal bleeding as the main symptoms, such as not timely treatment of scraping may be misdiagnosed as dysfunctional uterine bleeding and delay treatment.

(3) Functional ovarian tumors: such as ovarian granulosa cell tumor and follicular tumor, the endometrial hyperplasia may be caused by the estrogen secretion by the tumor. For example, only for the treatment of endometrial lesions, the diagnosis of ovarian tumor is delayed.

3. Other organic diseases of the genitalia are endometriosis, uterine adenomyosis, pelvic inflammatory disease, pelvic tuberculosis, especially in the early stage of endometrial tuberculosis, and endometrial polyps, intrauterine device Irregular vaginal bleeding is often confused with dysfunctional uterine bleeding.

4. Systemic diseases including acute infection, thrombocytopenia, aplastic anemia, leukemia, cirrhosis, and anticoagulant therapy may all be mistaken for "dysfunctional uterine bleeding" for a period of time.

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