Wathen P I, Henderson M C, Witz C A
Division of General Internal Medicine, University of Texas Health Science Center, San Antonio.
Med Clin North Am. 1995 Mar;79(2):329-44. doi: 10.1016/s0025-7125(16)30071-2.
Concerns about abnormal menstrual bleeding are a common reason for women to consult a primary care physician. The first step in the evaluation is to determine the patient's ovulatory status. Women with heavy bleeding but normal ovulatory cycles should be evaluated for coagulopathies, structural lesions, and hypothyroidism. In the absence of a systemic or structural cause, menorrhagia can be treated with OCPs or NSAIDs. Intermenstrual bleeding in OCP users may be due to noncompliance or the use of low-dose pills. Encouraging patient compliance and adjustment of the estrogen dose can often solve the problem. If the patient is not on OCPs, intermenstrual bleeding is usually due to a structural or inflammatory lesion. The differential diagnosis for anovulatory bleeding is extensive. Pregnancy, systemic illnesses, and structural lesions should be ruled out by history, physical examination, and laboratory evaluation. Endometrial biopsy is indicated in patients over age 35 and younger patients with risk factors for endometrial cancer, such as chronic anovulation and obesity. Dysfunctional uterine bleeding is a nonspecific term for abnormal uterine bleeding in the absence of systemic or structural disease. It is usually associated with anovulation. Adolescents frequently have dysfunctional uterine bleeding owing to immaturity of the hypothalamic-pituitary-ovarian axis. Perimenopausal women have an increased incidence of irregular bleeding secondary to decreased estrogen production by the ovary. Obesity, polycystic ovary syndrome, stress, crash diets, and vigorous exercise can all disrupt normal ovulatory function. Treatment options for dysfunctional uterine bleeding include oral contraceptives, cyclic progesterone, or hormone replacement with estrogen and progesterone. Patients with structural lesions or those who do not resume normal withdrawal bleeding patterns on hormone therapy should be referred to a gynecologist for further evaluation and treatment.
对异常子宫出血的担忧是女性咨询初级保健医生的常见原因。评估的第一步是确定患者的排卵状态。月经过多但排卵周期正常的女性应评估是否存在凝血障碍、结构性病变和甲状腺功能减退。在没有全身性或结构性病因的情况下，月经过多可用口服避孕药或非甾体抗炎药治疗。服用口服避孕药的女性出现经间期出血可能是由于服药不规律或使用低剂量避孕药。鼓励患者坚持服药并调整雌激素剂量通常可以解决问题。如果患者未服用口服避孕药，经间期出血通常是由于结构性或炎性病变。无排卵性出血的鉴别诊断范围广泛。应通过病史、体格检查和实验室评估排除妊娠、全身性疾病和结构性病变。35岁以上以及有子宫内膜癌危险因素（如慢性无排卵和肥胖）的年轻患者应进行子宫内膜活检。功能失调性子宫出血是指在没有全身性或结构性疾病的情况下出现的异常子宫出血的非特异性术语。它通常与无排卵有关。青少年由于下丘脑-垂体-卵巢轴不成熟，经常出现功能失调性子宫出血。围绝经期女性因卵巢雌激素分泌减少，不规则出血的发生率增加。肥胖、多囊卵巢综合征、压力、快速节食和剧烈运动都可能扰乱正常的排卵功能。功能失调性子宫出血的治疗选择包括口服避孕药、周期性孕激素或雌激素和孕激素联合的激素替代疗法。有结构性病变的患者或在激素治疗后未恢复正常撤退性出血模式的患者应转诊至妇科医生处进行进一步评估和治疗。
