Bronz L, Dreher E, Almendral A, Studer A, Haller U
Arbeitsgruppe PMPB der SGGG (Präsident: Dr. Lucio Bronz), Ospedale Regionale Bellinzona e Valli, CH-6500 Bellinzona (Schweiz).
Gynakol Geburtshilfliche Rundsch. 2000;40(2):71-9. doi: 10.1159/000022335.
2.1. History and clinical-gynecological investigation including a Pap smear are the first step in the clarification. The history should make sure if there is in fact bleeding from the genital and not from the urological or the intestinal region. Drug intake should be recorded, and risk factors for the development of endometrial carcinoma should be considered. This will not affect further investigation. The clinical-gynecological investigation should prove the source of postmenopausal bleeding according to the anatomical site--uterine, infra-, or suprauterine. The causes of infrauterine bleeding may easily be diagnosed by means of inspection of the external genitalia and further by using a speculum. The causes of uterine bleeding are of major importance. Cytology and colposcopy, supported by bimanual investigation, exclude cervical carcinoma as a cause of bleeding. Atypical endometrial cells on the cytological smear arouse suspicion of endometrial carcinoma. 2.2. Transvaginal sonography (TVS) is the next step if the above-mentioned investigations are negative. Both adnexa should always be investigated and the findings sonographically documented, so that solid cystic masses in the adnexal area can be better identified as suprauterine causes of postmenopausal bleeding. Then the uterus should be investigated. Further procedures are decided from the results of measurement of the longitudinal section of the endometrium at the level of maximum endometrial thickness. If the endometrial thickness is _<4 mm, an observant attitude can be assumed. After 3 months the patient should be controlled against using TVS. If bleeding recurs or the endometrial thickness is >4 mm on TVS, the procedure given in subparagraph 2.3 should be followed. In case the endometrial thickness is >4mm or not measurable, a histomorphological investigation according to subparagraph 2.3 should be performed. In such cases, saline infusion sonohysterography(SIS) is useful as a simple method to supplement TVS. It can aid in the decision making as to which further, more invasive measures should be taken (endometrial biopsy/hysteroscopic resection). Computerized tomography or magnetic resonance imaging are, as a rule, not indicated in patients with postmenopausal bleeding. 2.3. A definite diagnosis is possible only on the basis of a histological investigation. If TVS or SS show evidence of a polypoid state, removal under hysteroscopic control is the diagnostic method of choice. In cases of symmetrical or asymmetrical thickening of the endometrium on SIS, a less invasive biopsy may be sufficient. If the biopsy specimen does not yield representative diagnostic material, one should proceed as described above. A fractionated curettage should as a rule not be performed solely, but in combination with hysteroscopy.
2.1. 病史及临床妇科检查（包括巴氏涂片）是明确诊断的第一步。病史应确定出血是否确实来自生殖系统，而非泌尿系统或肠道。应记录用药情况，并考虑子宫内膜癌发生的危险因素。这不会影响进一步检查。临床妇科检查应根据解剖部位（子宫、子宫下段或子宫上段）确定绝经后出血的来源。子宫下段出血的原因可通过检查外阴并进一步使用窥器轻松诊断。子宫出血的原因至关重要。在双合诊检查的辅助下，细胞学和阴道镜检查可排除宫颈癌作为出血原因。细胞学涂片上的非典型子宫内膜细胞会引起对子宫内膜癌的怀疑。2.2. 如果上述检查结果为阴性，下一步是经阴道超声检查（TVS）。应始终检查双侧附件，并将超声检查结果记录在案，以便更好地识别附件区的实性囊性肿块作为绝经后出血的子宫上段原因。然后检查子宫。根据子宫内膜最大厚度水平处子宫内膜纵切面测量结果决定进一步的检查步骤。如果子宫内膜厚度≤4mm，可采取观察态度。3个月后应使用TVS对患者进行复查。如果出血复发或TVS显示子宫内膜厚度＞4mm，则应遵循2.3小节所述的步骤。如果子宫内膜厚度＞4mm或无法测量，则应按照2.3小节进行组织形态学检查。在这种情况下，盐水灌注超声子宫造影（SIS）作为补充TVS的一种简单方法很有用。它有助于决定应采取哪些进一步的、更具侵入性的措施（子宫内膜活检/宫腔镜切除）。通常，绝经后出血患者不建议进行计算机断层扫描或磁共振成像检查。2.3. 只有基于组织学检查才能做出明确诊断。如果TVS或SIS显示有息肉样状态的证据，在宫腔镜控制下切除是首选的诊断方法。如果SIS显示子宫内膜对称或不对称增厚，进行侵入性较小的活检可能就足够了。如果活检标本未获得具有代表性的诊断材料，则应按上述方法进行。通常不应单独进行分段刮宫，而应与宫腔镜检查联合进行。
