Vaginal bleeding

Introduction Vaginal bleeding is a common symptom of female genital diseases. Bleeding can come from the vulva, vagina, cervix and endometrium, but it is most common in the uterus. Although the amount of vaginal bleeding can be life-threatening, but the cause of good disease, the prognosis is good; and the amount of bleeding is also the earliest symptoms of malignant tumors, such as neglect and delay treatment, causing adverse consequences.

Cause

Classification of causes:

Vaginal bleeding refers to bleeding from any part of the genital tract. The form of bleeding can be divided into menstrual periods and prolonged menstruation. Irregular bleeding or contact bleeding, etc., the amount of bleeding can be more or less. For different reasons, vaginal bleeding can be divided into the following categories:

(1) Endocrine-related bleeding: neonatal vaginal bleeding, bleeding associated with contraceptives, dysfunctional uterine bleeding, intermenstrual bleeding, postmenopausal uterine bleeding, etc.

(B) pregnancy-related bleeding: threatened abortion, incomplete abortion, ectopic pregnancy, placenta previa, placental abruption, hydatidiform mole, choriocarcinoma.

(c) bleeding associated with inflammation:

1. Vulvar bleeding: seen in vulvar ulcers, urethra meat and so on.

2. Vaginal bleeding: seen in vaginal ulcers, vaginitis, especially senile vaginitis, trichomonas vaginitis.

3. Cervical hemorrhage: seen in acute and chronic cervicitis, cervical erosion, cervical ulcer, cervical polyps and so on.

4. Uterine bleeding: seen in acute and chronic endometritis, chronic uterine myositis, acute and chronic pelvic inflammatory disease.

(4) Bleeding related to tumors:

1. Irregular vaginal bleeding in young girls: seen in grape sarcoma.

2. Vaginal bleeding in women over middle age: more common in uterine fibroids.

3. Contact or irregular bleeding in middle-aged or postmenopausal women in cervical cancer, endometrial cancer, functional tumors of the ovaries, etc.

(5) Bleeding related to trauma:

1. Bleeding caused by trauma.

2. Bleeding after sexual intercourse: seen in the rupture of the hymen, rupture of the vaginal wall or posterior malleolus.

(6) Bleeding related to systemic diseases: diffuse intravascular coagulation complicated by liver disease, aplastic anemia, thrombocytopenic purpura leukemia, and gynecological diseases.

Mechanism

First, endocrine-related vaginal bleeding: The most common disease is functional uterine bleeding, the pathogenesis of which is related to the following factors.

1. Sex Hormone Secretion: In the absence of ovulatory functional uterine bleeding, single and long-term estrogen stimulation causes progressive proliferation of the endometrium, proliferation to a high adenoid sac, adenoma hyperplasia, and even progressive endometrial cancer. Due to the lack of progesterone resistance and glandular secretion, endometrial hypertrophy, glandular enlargement, glandular enlargement, and abnormal glandular epithelial hyperplasia. The endometrial blood supply increased, and the spiral arterioles were twisted and twisted. The estradiol-induced acid polysaccharide (AMPS) polymerization and gelation, reduce the permeability of interstitial blood vessels, affect the exchange of substances, causing local endometrial tissue ischemia, necrosis, shedding and bleeding, and the acid polysaccharide The agglomeration also hinders the endometrial detachment, causing the endometrium to be non-synchronized, resulting in long-term irregular bleeding of the endometrium.

When there is ovulatory functional uterine bleeding, the corpus luteum is too early to cause the luteal phase to be too short, frequent; or atrophy, progesterone continued secretion of the luteal phase (premenstrual) bleeding, menstrual extension, dripping, or For both. The mechanism is insufficient secretion of estrogen and progesterone, especially insufficient progesterone secretion, so that the endometrium is completely secreted, the gland, interstitial and vascular development are immature, and the intrauterine is caused by the asynchronous withdrawal of the estrogen and progesterone. Irregular exfoliation and abnormal bleeding.

2. The role of prostaglandins: Prostaglandins (PGs), especially PGE2, PGF2 plugin (TXA2) and prostacyclin (PGL2), are a group of highly active vascular and hemagglutination regulators that regulate uterine blood flow. Endometrial hemorrhage is affected by spiral arterioles and microcirculation, muscle contractile activity, endometrial lysosomal function, and hemagglutination activity.

TXA2 is involved in platelet production, which causes microvascular contraction. Platelet aggregation, thrombosis, and hemostasis. PGL2 is produced in the blood vessel wall, and its effect is opposite to that of TXA2. It is a strong dilatation of microvessels, anti-platelet aggregation, and prevention of thrombosis. PGFa causes contraction of the endometrial spiral arteries, while PGE2 acts as a vasodilator. So TXA2 and PGL2, PGF2a. Deregulation of function and dynamic balance with PGE2 can cause endometrial hemorrhage.

3. Abnormal structure and function of endometrial spiral arterioles and lysosomes: Abnormal spiral arterioles interfere with endometrial microcirculation, affecting intimal functional layer shedding and detachment of vascular and epithelial repair, affecting vasomotor function and local hemagglutination Fibrinolysis results in abnormal uterine bleeding. From the follicular phase to the luteal phase, the number of lysosomes and enzyme activity increased progressively. Progesterone is stable and estrogen destroys the stability of the lysosomal membrane. Therefore, when the estrogen/progesterone ratio is imbalanced before menstruation, the stability of the lysosomal membrane will be destroyed, and the lysosomal membrane rupture will cause the destructive hydrolase to precipitate and release, which will cause the endometrial cells to rupture and the intimal layer to collapse. Necrosis and bleeding.

4. Functional uterine bleeding is often accompanied by a decrease in coagulation factors: clotting factor V, VII X, XII deficiency, thrombocytopenia, anemia, and iron deficiency. At the same time, endometrial plasminogen activator increased, activity increased, and plasminogen was activated to form plasmin. Fibrinolytic enzyme fibrin increases fibrin degradation products, reduces plasma fibrin, and forms intrauterine defibrinogen, which affects the normal endometrial spiral arterioles and vascular lake coagulation and hemostasis, resulting in long-term massive bleeding. .

Second, pregnancy-related vaginal bleeding: vaginal bleeding associated with pregnancy is common in abortion. Early abortion embryos have died, and the decidua necrosis has caused the embryo's villi to peel off from the aponeurosis, and the blood sinus is open and bleeding. Before the 8th week of pregnancy, the villi development is not yet mature, and the connection with the decidua is not strong. The entire blastocyst is easily peeled off from the uterine wall, and often there is not much bleeding. During the 8-12 weeks of pregnancy, the villi are vigorously developed and deep in the decidua. The connection is firm, and the incomplete detachment of the placenta can not be discharged simultaneously with the fetus. The residual part of the placenta in the uterine cavity affects the uterine contraction and causes severe bleeding. Late abortions such as fetal membranes and placenta residues can also cause excessive bleeding. Third, the bleeding associated with the tumor.

1. Uterine fibroids: Uterine fibroids are a common cause of vaginal bleeding. 1 patients with fibroids often because of high estrogen and endometrial proliferation and polyps, resulting in excessive menstrual flow; 2 myoma caused by increased volume of uterus, increased intimal area, excessive bleeding or bleeding. Especially in the submembrane fibroids, the area of the membrane increases, and the bleeding increases; 3 on the underlying fibroids, the surface of the membrane is often ulcerated and necrotic, leading to chronic endometritis and causing dripping and bleeding; 4 interstitial fibroids, affecting Uterine contraction and vascular function of the forceps, or submucosal fibroids can not contract itself, resulting in more bleeding and prolonged bleeding time; 5 larger fibroids can be combined with pelvic congestion, so that blood flow is strong and the amount.

2. Followed by cervical cancer and endometrial cancer caused by vaginal bleeding: cervical cancer bleeding is mainly seen in exogenous type, also known as cauliflower type, brittle, often contact bleeding; later with the tumor growth, tissue necrosis and hemorrhage occurred. In endometrial cancer, the endometrium has a polypoid-like mass that is enlarged, hard and brittle, with superficial ulcers on the surface, ulcers and necrosis in the late stage of the lesion, involving the entire endometrium, and necrotic tissue shedding bleeding is small to moderate or Dripping constantly.

Fourth, bleeding associated with inflammation and trauma: genital tract inflammation can cause congestion, erosion or ulceration of the membrane, resulting in less bleeding. Violent trauma, as well as new membranes of the genital tract that are stimulated by foreign bodies and can cause vaginal bleeding.

V. Bleeding associated with systemic diseases: abnormalities in platelet mass and quality, coagulation, anticoagulant dysfunction including thrombocytopenic purpura, severe liver disease, and disseminated intravascular coagulation can cause vaginal bleeding.

an examination

Related inspection

Uterine disease self-test vaginal secretion examination tubal ventilation test sugar chain antigen 125 X chromatin

Physical examination : pay attention to the general condition, with or without anemia, bleeding tendency, swollen lymph nodes and goiter. Gynecological examination should carefully peep into the vagina and cervix, pay attention to the source of bleeding; double diagnosis and triple repair examination attention to the size of the uterus, hardness, smooth, with or without cervical pain, no lumps and tenderness on both sides of the uterus. For unmarried patients, only anal examination is usually performed, but when there is a high degree of suspicion that a tumor may be present, a vaginal examination should also be performed.

Laboratory examination: routine blood tests are performed and coagulation tests are performed if necessary. Do some special checks as needed.

(A) ovarian function test:

1. Basal body temperature measurement: In women of childbearing age with normal ovarian function, the basal body temperature of the menstrual cycle shows a characteristic curve. The basal body temperature in the first half of the menstrual cycle is maintained at a low level, generally around 36.5 °C; after ovulation, due to the pyrogenic effect of progesterone, the basal body temperature rises by 0.4~0.0.5 °C, maintained at about 37 °C; before menstruation 1~2 d or the first day of menstruation, the body temperature returned to the original level. Therefore, the basal body temperature of the normal menstrual cycle is a biphasic curve, indicating ovulation; anovulatory menstrual cycle, due to the lack of progesterone, the basal body temperature does not increase significantly during the cycle, called the single-phase curve.

2. Cervical mucus examination: The secretion of endometrial glands is also affected by female and progesterone, showing obvious cyclical changes. Menstruation is just clean, the level of estrogen in the body is low, and the secretion of cervical mucus is small. As estrogen continues to increase, cervical mucosal secretion increases. Before the ovulation, the secretion of estrogen reached a peak. The cervical mucus was thin, transparent and shaped like egg white. It could be drawn into filaments at a temperature of more than 10 cm. After the smear was dried, leafy crystals of the fern plant appeared. After ovulation, under the action of progesterone, the secretion of cervical mucus is reduced, becoming viscous and turbid, and the ductility is poor. The fangs in the smear disappear and the ellipsoids appear in rows.

3. Endometrial pathological examination: In order to judge the ovarian function, a diagnostic curettage should be performed within 2 to 3 days before the menstrual cramps or within 12 hours of the onset of menstruation. If the endometrium is secreted, ovulation is indicated.

4. Determination of pituitary and ovarian hormones; ovarian hormones are mainly estradiol and progesterone. The levels of FSH, LH, E2 and P in the normal ovarian cycle were dynamically changed. Determination of the above hormones can be used to understand ovarian function.

(B) pregnancy test: HCG secreted by blastocyst trophoblast cells after pregnancy can be measured from pregnant women's blood and urine. Determination of the presence or absence of HCG in the subject is called a pregnancy test. In addition to determining whether pregnancy is present, this test is also important for the diagnosis of hydatidiform mole and choriocarcinoma.

(3) Cervical scraping cytology and cervical biopsy:

1. Cervical scraping cytology: It is the main method for finding cervical precancerous lesions and early cervical cancer. If suspicious cancer cells or cancer cells are seen in the smear, cervical biopsy must be performed.

2. Cervical biopsy: single point clamp method is suitable for typical lesions, the site of the clamp is selected in the obvious lesion, or at the junction of cervical column and epithelial junction, the clamp is used for atypical lesions, generally in the cervix. JJ2 points were taken separately for pathological section examination. When suspected lesions in the neck, a small curette should be used to scrape the neck tissue for biopsy.

(D) Diagnostic curettage: scrape the endometrium for pathological examination to confirm the diagnosis. When scraping the palace, pay attention to the size and shape of the uterine cavity, the presence or absence of unevenness in the wall of the palace, and the amount of scraping. If you suspect cancer. When the scraped material is highly suspected of cancerous tissue by visual inspection, the tissue taken can be pathologically examined, and no comprehensive diagnosis is needed to prevent cancer cells from spreading and damaging the uterus. Suspected endometrial detachment incomplete, on the fifth day of menstrual period curettage; for irregular bleeding, the endometrium can be scraped at any time. When considering cervical cancer and endometrial cancer, in order to understand the extent of the lesion, a segmental diagnosis should be performed. The tissue in the neck can be scraped with a small curette, then the endometrium of the uterus is scraped, and the specimen is sent to the pathology. an examination.

Fourth, equipment inspection:

1. Hysteroscopy: It is one of the important methods for diagnosing uterine lesions. It can not only directly peep into the shape of the lesion, but also serve as an indicator for biopsy or diagnosis, and for endometrial hyperplasia and polyps. Submembrane fibroids, endometrial tuberculosis, and bleeding from early endometrial cancer have diagnostic value.

2. Laparoscopy: The morphology and location of the lesion can be directly observed. If necessary, biopsy should be performed to diagnose the pelvic inflammatory disease, tumor, ectopic pregnancy and endometriosis.

3. Colposcopy: using colposcopy to detect cervical lesions, you can observe the slight changes in the cervical epithelial layer that are invisible to the naked eye, and can detect the epithelial and abnormal blood vessels associated with cancer, which is helpful for early detection of cancerous changes. In order to accurately select suspicious parts for biopsy, it is a powerful auxiliary method for diagnosing early cervical cancer.

4. Ultrasound examination: pelvic B-mode ultrasound can understand the size, shape and internal structure of the uterus and ovary, and is of great value for the diagnosis of uterine fibroids, adenomyosis, ovarian tumors, early pregnancy, ectopic pregnancy and hydatidiform mole.

5. Uterine tubal lipiodol angiography: can help diagnose subconjunctival fibroids, endometrial polyps, intrauterine devices and genital tuberculosis.

6. Pelvic CT examination: especially to understand the metastasis of cancer in the pelvic cavity.

Differential diagnosis

Differential diagnosis:

1. Excessive vaginal bleeding: a large amount of bleeding in the vagina during non-menstrual periods.

2. Irregular vaginal bleeding: Irregular menstruation, that is, irregular vaginal bleeding with no obvious organic lesions inside and outside the genitalia.

3. A small amount of bleeding in the vagina: a small amount of continuous bleeding in the vaginal period.

4. The vagina continues to have a moderate amount of bleeding: non-menstrual period, the vagina continues to bleed, and the amount of bleeding is moderate.

diagnosis:

First, medical history:

Pay attention to the age of the patient when asking for a medical history. Age is important for identifying vaginal bleeding. A small number of vaginal bleedings on the day after the birth of a newborn baby girl is caused by a sudden drop in estrogen from the mother, causing withdrawal bleeding, which usually stops within a few days. Malignant tumors should be considered in early childhood and postmenopausal vaginal bleeding. Adolescent girls with vaginal bleeding are often functional uterine bleeding. Pregnant women with vaginal bleeding should consider more pregnancy-related diseases. To ask about the menarche age, the menstrual cycle before the onset. Menstrual and menstrual blood volume. There is no history of menopause and the exact date of the last menstrual period before vaginal bleeding. The duration of vaginal bleeding is long, whether there is persistent or intermittent irregular bleeding, the amount of bleeding and whether or not accompanied by tissue excretion.

Increased menstrual flow, prolonged menstruation but normal cycle, generally seen in uterine fibroids, adenomyosis, irregular detachment of the endometrium and placement of the IUD. Shortening of the cycle and frequent menstruation are insufficient luteal function. A small amount of bleeding between menstrual periods is mostly ovulation bleeding. When vaginal bleeding occurs after menopause, women with childbearing age should first think of pregnancy-related diseases; if they occur in menopausal women, they are mostly dysfunctional uterine bleeding. Irregular vaginal bleeding after menopause should be considered more genital malignant tumors. Post-sexual bleeding should consider early cervical cancer, cervical polyps, cervical erosion and subtympanic myoma.

Asked whether vaginal bleeding is associated with abdominal pain and its nature, paroxysmal abdominal pain is more common in abortion, persistent severe abdominal pain may indicate rupture of ectopic pregnancy, menstrual period of severe pain should consider endometriosis. Vaginal bleeding with malodorous vaginal discharge should be concomitant with advanced cervical cancer or subdural fibroids. Ask about the presence or absence of systemic diseases such as hypertension, anemia, liver disease, thrombocytopenic purpura and other diseases. Understand whether or not to take sex hormones, including contraceptives, and whether to place an IUD.

Second, physical examination: pay attention to the general condition, with or without anemia, bleeding tendency, lymphadenopathy and thyroid enlargement. Gynecological examination should carefully peep into the vagina and cervix, pay attention to the source of bleeding; double diagnosis and triple repair examination attention to the size of the uterus, hardness, smooth, with or without cervical pain, no lumps and tenderness on both sides of the uterus. For unmarried patients, only anal examination is usually performed, but when there is a high degree of suspicion that a tumor may be present, a vaginal examination should also be performed.

Third, laboratory examination: routine blood tests, if necessary, for coagulation function test. Do some special checks as needed.

(A) ovarian function test:

1. Basal body temperature measurement: In women of childbearing age with normal ovarian function, the basal body temperature of the menstrual cycle shows a characteristic curve. The basal body temperature in the first half of the menstrual cycle is maintained at a low level, generally around 36.5 °C; after ovulation, due to the pyrogenic effect of progesterone, the basal body temperature rises by 0.4~0.0.5 °C, maintained at about 37 °C; before menstruation 1~2 d or the first day of menstruation, the body temperature returned to the original level. Therefore, the basal body temperature of the normal menstrual cycle is a biphasic curve, indicating ovulation; anovulatory menstrual cycle, due to the lack of progesterone, the basal body temperature does not increase significantly during the cycle, called the single-phase curve.

2. Cervical mucus examination: The secretion of endometrial glands is also affected by female and progesterone, showing obvious cyclical changes. Menstruation is just clean, the level of estrogen in the body is low, and the secretion of cervical mucus is small. As estrogen continues to increase, cervical mucosal secretion increases. Before the ovulation, the secretion of estrogen reached a peak. The cervical mucus was thin, transparent and shaped like egg white. It could be drawn into filaments at a temperature of more than 10 cm. After the smear was dried, leafy crystals of the fern plant appeared. After ovulation, under the action of progesterone, the secretion of cervical mucus is reduced, becoming viscous and turbid, and the ductility is poor. The fangs in the smear disappear and the ellipsoids appear in rows.

3. Endometrial pathological examination: In order to judge the ovarian function, a diagnostic curettage should be performed within 2 to 3 days before the menstrual cramps or within 12 hours of the onset of menstruation. If the endometrium is secreted, ovulation is indicated.

4. Determination of pituitary and ovarian hormones: ovarian hormones are mainly estradiol and progesterone. The levels of FSH, LH, E2 and P in the normal ovarian cycle were dynamically changed. Determination of the above hormones can be used to understand ovarian function.

(B) pregnancy test: HCG secreted by blastocyst trophoblast cells after pregnancy can be measured from pregnant women's blood and urine. Determination of the presence or absence of HCG in the subject is called a pregnancy test. In addition to determining whether pregnancy is present, this test is also important for the diagnosis of hydatidiform mole and choriocarcinoma.

(3) Cervical scraping cytology and cervical biopsy:

1. Cervical scraping cytology: It is the main method for finding cervical precancerous lesions and early cervical cancer. If suspicious cancer cells or cancer cells are seen in the smear, cervical biopsy must be performed.

2. Cervical biopsy: single point clamp method is suitable for typical lesions, the site of the clamp is selected in the obvious lesion, or at the junction of cervical column and epithelial junction, the clamp is used for atypical lesions, generally in the cervix. JJ2 points were taken separately for pathological section examination. When suspected lesions in the neck, a small curette should be used to scrape the neck tissue for biopsy.

(D) Diagnostic curettage: scrape the endometrium for pathological examination to confirm the diagnosis. When scraping the palace, pay attention to the size and shape of the uterine cavity, the presence or absence of unevenness in the wall of the palace, and the amount of scraping. If you suspect cancer. When the scraped material is highly suspected of cancerous tissue by visual inspection, the tissue taken can be pathologically examined, and no comprehensive diagnosis is needed to prevent cancer cells from spreading and damaging the uterus. Suspected endometrial detachment incomplete, on the fifth day of menstrual period curettage; for irregular bleeding, the endometrium can be scraped at any time. When considering cervical cancer and endometrial cancer, in order to understand the extent of the lesion, a segmental diagnosis should be performed. The tissue in the neck can be scraped with a small curette, then the endometrium of the uterus is scraped, and the specimen is sent to the pathology. an examination.

Fourth, equipment inspection:

1. Hysteroscopy: It is one of the important methods for diagnosing uterine lesions. It can not only directly peep into the shape of the lesion, but also serve as an indicator for biopsy or diagnosis, and for endometrial hyperplasia and polyps. Submembrane fibroids, endometrial tuberculosis, and bleeding from early endometrial cancer have diagnostic value.

2. Laparoscopy: The morphology and location of the lesion can be directly observed. If necessary, biopsy should be performed to diagnose the pelvic inflammatory disease, tumor, ectopic pregnancy and endometriosis.

3. Colposcopy: using colposcopy to detect cervical lesions, you can observe the slight changes in the cervical epithelial layer that are invisible to the naked eye, and can detect the epithelial and abnormal blood vessels associated with cancer, which is helpful for early detection of cancerous changes. In order to accurately select suspicious parts for biopsy, it is a powerful auxiliary method for diagnosing early cervical cancer.

4. Ultrasound examination: pelvic B-mode ultrasound can understand the size, shape and internal structure of the uterus and ovary, and is of great value for the diagnosis of uterine fibroids, adenomyosis, ovarian tumors, early pregnancy, ectopic pregnancy and hydatidiform mole.

5. Uterine tubal lipiodol angiography: can help diagnose subconjunctival fibroids, endometrial polyps, intrauterine devices and genital tuberculosis.

6. Pelvic CT examination: especially to understand the metastasis of cancer in the pelvic cavity.

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