Munro Malcolm G
Chair of the Southern California Permanente Medical Group's Abnormal Uterine Bleeding Working Group, Director of Gynecological Services for the Los Angeles Medical Center in California, and a Professor in the Department of Obstetrics and Gynecology at the David Geffen School of Medicine at the University of California Los Angeles.
Perm J. 2014 Winter;18(1):55-70. doi: 10.7812/TPP/13-072. Epub 2013 Dec 30.
Postmenopausal uterine bleeding is defined as uterine bleeding after permanent cessation of menstruation resulting from loss of ovarian follicular activity. Bleeding can be spontaneous or related to ovarian hormone replacement therapy or to use of selective estrogen receptor modulators (eg, tamoxifen adjuvant therapy for breast carcinoma). Because anovulatory "cycles" with episodes of multimonth amenorrhea frequently precede menopause, no consensus exists regarding the appropriate interval of amenorrhea before an episode of bleeding that allows for the definition of postmenopausal bleeding. The clinician faces the possibility that an underlying malignancy exists, knowing that most often the bleeding comes from a benign source. Formerly, the gold-standard clinical investigation of postmenopausal uterine bleeding was institution-based dilation and curettage, but there now exist office-based methods for the evaluation of women with this complaint. Strategies designed to implement these diagnostic methods must be applied in a balanced way considering the resource utilization issues of overinvestigation and the risk of missing a malignancy with underinvestigation. Consequently, guidelines and recommendations were developed to consider these issues and the diverse spectrum of practitioners who evaluate women with postmenopausal bleeding. The guideline development group determined that, for initial management of spontaneous postmenopausal bleeding, primary assessment may be with either endometrial sampling or transvaginal ultrasonography, allowing patients with an endometrial echo complex thickness of 4 mm or less to be managed expectantly. Guidelines are also provided for patients receiving selective estrogen receptor modulators or hormone replacement therapy, and for an endometrial echo complex with findings consistent with fluid in the endometrial cavity.�
绝经后子宫出血被定义为因卵巢卵泡活动丧失导致月经永久停止后的子宫出血。出血可以是自发性的，也可能与卵巢激素替代疗法或选择性雌激素受体调节剂的使用有关（例如，用于乳腺癌的他莫昔芬辅助治疗）。由于无排卵的“周期”伴有数月闭经发作常常先于绝经，对于允许定义绝经后出血的出血发作之前的适当闭经间隔尚无共识。临床医生面临着存在潜在恶性肿瘤的可能性，同时知道大多数情况下出血来自良性来源。以前，绝经后子宫出血的金标准临床检查是基于机构的刮宫术，但现在有基于门诊的方法来评估有此主诉的女性。考虑到过度检查的资源利用问题和漏诊恶性肿瘤的风险，必须以平衡的方式应用旨在实施这些诊断方法的策略。因此，制定了指南和建议来考虑这些问题以及评估绝经后出血女性的不同类型从业者。指南制定小组确定，对于自发性绝经后出血的初始管理，初步评估可以采用子宫内膜取样或经阴道超声检查，对于子宫内膜回声复合体厚度为4毫米或更小的患者可进行观察处理。还为接受选择性雌激素受体调节剂或激素替代疗法的患者以及子宫内膜回声复合体有与子宫内膜腔内积液一致的发现的患者提供了指南。
