Brill A I
University of Illinois, College of Medicine, Department of Obstetrics and Gynecology, Chicago 60612-7313, USA.
Clin Obstet Gynecol. 1995 Jun;38(2):319-45. doi: 10.1097/00003081-199506000-00017.
Many otherwise healthy women will experience a significant disruption in lifestyle from abnormal uterine bleeding. Most of those seeking medical attention will not be at risk for developing anemia. In each case, a thorough search for underlying systemic, hormonal, and organic causes should be instituted. The use of blind endometrial sampling to evaluate the uterine cavity, by itself, is an inaccurate technique for diagnosing pathologic conditions commonly associated with menorrhagia, such as endometrial polyps, submucous myomata, and focal endometrial abnormalities including adenocarcinoma and its precursors. The supplementary application of diagnostic hysteroscopy with directed biopsy will ensure the recognition of these intracavitary lesions. The majority of women found to have endometrial polyps and submucous myomata can gain a successful reduction in their menstrual flow without hysterectomy by undergoing hysteroscopic removal of these lesions. Those without other uterine or pelvic pathology and who are closer to perimenopause are more likely to sustain long-lasting relief from these procedures. Medical therapy should be the first line of treatment for premenopausal women who are found to have no obvious cause for their abnormal uterine bleeding. Many of those who do not respond to, are unable to tolerate, or are unwilling to attempt this approach will undergo hysterectomy as the final answer. The absence of uterine pathology in most of these cases places an absolute demand on our specialty to innovate, and, whenever suited, to use more conservative surgical solutions. Our efforts to alter this behavior will undoubtedly be closely monitored by agents of managed care aiming to reward measures that reduce cost and improve the quality of care. The use of hysteroscopic ablation and resection to treat women suffering from intractable menorrhagia can safely and effectively reduce menstrual blood flow and should significantly curtail the performance of unnecessary hysterectomy. The comparative benefits and long-term advantages of these techniques beyond hysterectomy await the results of further studies. Furthermore, the risks of these hysteroscopic procedures to produce iatrogenic adenomyosis or to conceal or delay the usual signs of adenocarcinoma have yet to be ascertained. Vigilance for endometrial disease must not dwindle in the face of amenorrhea, as evidenced by a recent case report describing the development of endometrial carcinoma after 5 years of amenorrhea following endometrial electrocoagulation. Future methods of endometrial destruction for the control of abnormal uterine bleeding may include the nonhysteroscopic use of radio frequency, thermal transfer, hyperthermia, and photodynamic therapy.(ABSTRACT TRUNCATED AT 400 WORDS)
许多原本健康的女性会因异常子宫出血而经历生活方式的重大改变。大多数寻求医疗帮助的女性不会有患贫血的风险。在每种情况下，都应全面排查潜在的全身、激素和器质性病因。单独使用盲目子宫内膜取样来评估子宫腔，对于诊断通常与月经过多相关的病理状况，如子宫内膜息肉、黏膜下肌瘤以及包括腺癌及其前驱病变在内的局灶性子宫内膜异常来说，是一种不准确的技术。补充应用诊断性宫腔镜检查并进行定向活检将确保识别这些腔内病变。大多数被发现患有子宫内膜息肉和黏膜下肌瘤的女性，通过宫腔镜切除这些病变，无需进行子宫切除术就能成功减少月经量。那些没有其他子宫或盆腔病变且更接近围绝经期的女性更有可能从这些手术中获得持久缓解。对于经检查发现子宫异常出血无明显病因的绝经前女性，药物治疗应作为一线治疗方法。许多对这种方法无反应、无法耐受或不愿尝试这种方法的女性最终会接受子宫切除术。在大多数此类病例中，子宫无病变这一情况对我们专业领域提出了创新的绝对要求，并且在合适的时候，要采用更保守的手术解决方案。我们改变这种行为的努力无疑会受到管理式医疗机构的密切关注，这些机构旨在奖励那些降低成本并提高医疗质量的措施。使用宫腔镜消融和切除术治疗患有顽固性月经过多的女性，可以安全有效地减少月经量，并应显著减少不必要的子宫切除术的实施。这些技术相对于子宫切除术的比较益处和长期优势有待进一步研究的结果。此外，这些宫腔镜手术导致医源性子宫腺肌病或掩盖或延迟腺癌常见体征的风险尚未确定。面对闭经时，对子宫内膜疾病的警惕性绝不能降低，最近一份病例报告描述了子宫内膜电凝术后闭经5年发生子宫内膜癌的情况就证明了这一点。未来用于控制异常子宫出血的子宫内膜破坏方法可能包括非宫腔镜下使用射频、热传递、热疗和光动力疗法。（摘要截选至400词）
