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1 ABNORMAL VAGINAL (UTERINE) BLEEDING 陰道異常出血 Dr Leslie Lo Specialist in O&G

2 DEFINITION 定義 Abnormal uterine bleeding (AUB) is any bleeding from the uterus other than normal monthly period Normal menstrual cycle is regular 3-7 days bleeding every 28+/-7 days Bleeding can be abnormal in frequency, duration, amount or timing (i.e. IMB or PMB) 非正常陰部出血 (AUB) 指除每月例假外的陰部出血正常的月經週期是 3-7 天, 每 28+/-7 天出血一次出血可能在頻率, 持續時間, 量或者時間方面出現異常 (i.e. IMB or PMB)

4 COMMON SYMPTOM 常見的症狀 Heavy menstrual bleeding (HMB) Irregular bleeding: unpredictable Abnormal frequency too frequent (polymenorrhoea) or too few (oligo-amenorrhoea) Intermenstrual bleeding (IMB) Postcoital bleeding (PCB) Postmenopausal bleeding (PMB) 月經量過大非常規出血 : 不可預測非正常頻率 --- 太頻繁 ( 月經頻繁 ) 或者太少 ( 閉經 ) 月經間不規則出血 (IMB) 性交後出血 (PCB) 絕經後出血 (PMB)

5 CAUSE OF AUB 異常子宮出血的病因 Hormonal : Dysfunctional uterine bleeding (DUB) Pelvic pathology Pregnancy related Bleeding disorder Drug related (OCP, Warfarin/Aspirin) 激素 : 功能失調性子宮出血盆腔病變懷孕相關的出血障礙藥物相關的 (OCP, 阿司匹林和華法令 )

6 DYSFUNCTIONAL UTERINE BLEEDING (DUB) 功能失調性子宮出血病 (DUB) Diagnosis by exclusion Ovulatory verses anovulatory Common in extremity of reproductive life irregular bleeding in adolescent and climacteric Example: Metropathia haemorrhagica in adolescent; perimenopausal DUB 排除診斷法排卵的 VS. 不排卵的常見於育齡末期青春期更年期非常規出血例如 : 青春期功能性子宮出血, 絕經期非正常出血

7 PELVIC PATHOLOGY 盆腔病變

8 Vulvo-vaginal: infection, post-traumatic Cervical: infection, polyp, pre-cancer, CA Uterine: infection, endometrial lesion (polyp, fibroid, CA) Pregnancy related: miscarriage, ectopic, APH Tubo-ovarian: hormonal secreting tumours (eg. Granulosa cell tumour) 外陰陰道的 : 感染, 創傷後子宮頸的 : 感染, 息肉, 癌前潛伏期,CA 子宮 : 感染, 子宮內膜病變 ( 息肉, 纖維瘤,CA) 懷孕相關的 : 流產, 異位, 垂體前葉激素輸卵管卵巢 : 激素分泌性腫瘤 ( 如 : 卵巢粒層細胞瘤 )

9 HEAVY MENSTRUAL BLEEDING(HMB) 月經量過大 Average blood loss per cycle is 37-43ml HMB if > 80ml per cycle (i.e.90 th percentile) 60% cases with >80ml blood loss per cycle become anaemic if untreated Incidence increase with age Use of pictorial blood loss assessment chart (PBAC) 每個週期的平均失血量為 37-43ml HMB > 80ml 每週期 ( 例如 :90th 百分位數 ) 出血量 > 80ml 的案例中有 60% 如沒有治療會導致貧血發病率隨著年齡的增長使用圖案失血評估表 (PBAC)

10 PICTORIAL BLOOD LOSS ASSESSMENT CHART 失血評估表

11 PROTOCOL OF MANAGEMENT 管理協議 History taking 病史詢問 Physical examination 體格檢查 Investigation & Imaging 調查研究 & 成像 Treatment 治療

12 HISTORY 病史 Menstrual history menarche, cycle length, duration and amount of bleeding Flooding, passage of clots, pads used LMP, PMP Sexual history Contraceptive, pregnancy test Other symptoms: pain, abnormal vag discharge, pregnancy symptom, anaemia Past medical/gyn history, drug intake 月經史 --- 初潮, 週期時間, 持續時間和出血量產後出血, 血塊 LMP 末次月經, PMP 性史避孕藥, 驗孕其他症狀 : 疼痛, 不正常的分泌物, 妊娠征狀, 貧血病史, 藥物食用

13 PHYSICAL EXAMINATION 體格檢查 General: sign of anaemia, goitre Abdominal: old scar, abnormal mass Pelvic: speculum exam, bimanual digital exam 普遍的 : 貧血跡象, 甲狀腺腫腹部 : 舊傷痕, 不正常的組織盆腔 : 內窺器檢查, 雙合診檢查

14 INVESTIGATION 排查 Lab test: blood x CBC, +/- pregnancy test, +/- cervical smear, +/- high vaginal swab Imaging: pelvic USG (TAS verses TVS), saline sonohysterography CT scan, MRI Office hysteroscopy Endometrial biopsy H&C, D&C 實驗室檢驗 : 血球記數化驗 ( CBC, ), 妊娠試驗, 宮頸塗片檢查, 陰道藥簽成像 : 盆腔超聲成像 (TAS VS. TVS), 子宮超聲顯像術 CT 掃描, 核磁共振成像宮腔鏡檢查子宮內膜活組織檢查 H&C, D&C

15 OFFICE HYSTEROSCOPY 宮腔鏡檢查

16 PIPELLE FOR EB 宮腔負壓吸管

18 MEDICAL TREATMENT 醫療 NSAID: inhibits cyclo-oxygenase & decrease PG level (blood loss less 20-50%) Tranexamic acid: anti-fibrinolytic effect (blood loss less 40%) Combined OCP: endometrial atrophy Mirena IUCD: steady release levo-norgestrel Danazol NSAID: 抑制環加氧酶 & 降低 PG 程度 ( 失血量小於 20-50%) 凝血酸 : 抗纖維蛋白溶解作用 ( 失血量小於 40%) 複合 OCP: 子宮內膜萎縮宮內節育器曼月樂 : 穩定的釋放左炔諾孕酮安宮唑

19 SURGICAL TREATMENT 手術治療 Myomectomy/polypectomy: open, laparoscopic, hysteroscopic Endometrial ablation Hysterectomy: open, laparoscopic, vaginal Uterine artery embolization (UAE) MRgFUS 肌瘤剔除術 / 息肉切除術 : OPEN, 腹腔鏡, 宮腔鏡子宮內膜切除術子宮切除術 : OPEN, 腹腔鏡, 陰道的子宮動脈血管栓塞 (UAE) MRgFUS

20 ALGORITHM OF HMB TREATMENT 治療大量月經出血的處理方法 Age 年齡 Duration 持續時間 Severity 重症率 Physical exam finding 體檢發現 Response to treatment 療效 Investigation result 調查結果

21 AGE 年齡 <20: tend to observe 20-40: trial of medical treatment >40: tend to investigate (USG, EB ) Menopausal: must exclude CA <20: 傾向於觀察 20-40: 臨床治療 >40: 傾向於檢查 (USG, EB ) 更年期 : 必須排除 CA

22 DURATION 持續時間 Once: tend to observe < 3 months: tend to start treatment > 3 months: investigate & treat 一次 : 傾向於觀察 < 3 個月 : 傾向於開始治療 > 3 個月 : 檢查與治療

23 SEVERITY 重症率 Mild: observe Moderate: treat Severe: investigate & treat 輕度 : 觀察中度 : 治療重度 : 檢查 & 治療

24 PHYSICAL FINDINGS 體檢發現 Symptom of anaemia: investigate & treat Enlarged uterus: investigate & treat 貧血跡象 : 檢查 & 治療增大的子宮 : 檢查 & 治療

25 RESPONSE TO MEDICAL TREATMENT 療效 Yes: observe No: investigate Yes: 觀察 No: 檢查

26 INVESTIGATION 檢查 Anaemia Fibroid/endometrial polyp on USG 貧血症纖維瘤 / 子宮內膜息肉

27 FIBROID 纖維瘤 لا Fibroid is the most common benign uterine tumour لا Up to 40% women of reproductive age has fibroid; 80% has multiple fibroids لا Etiology unknown (? uterus hypersensitive to estrogen) fibroid originates from one smooth muscle cell لا 子宮肌瘤是最常見的子宮良性腫瘤 لا 高達 40% 的育齡婦女有子宮肌瘤 ; 80% 有多個肌瘤 لا 病因不明 (? 子宮的雌激素 ) لا 一個纖維瘤起源於一個平滑肌細胞

28 لا 3 types of symptoms: 1) Menstrual 2) Pressure 3) Fertility لا Depends on size & site لا In general, the deep seated (submucosal) fibroid would cause menstrual & fertility problem; the superficial (subserous) fibroid > 5 cm may cause pressure/stretching symptom 3 種類型的症狀 1) 月經 2) 壓力 3) 生育力取決於大小和位子在一般情況下, 深層次 ( 粘膜下 ) 子宮肌瘤會導致月經和生育問題 ; 肌瘤表面 > 5cm 可能造成的壓力 / 拉伸的症狀

29 DIFFERENT TYPES OF FIBROID 不同種類的肌瘤

30 MENSTRUAL SYMPTOM 月經症狀 لا About 30% of fibroids cause menorrhagia +/- dysmenorrhoea لا Submucous fibroid increases surface area of endometrial lining لا Intramural fibroid preferentially obstruct the venous return of endometrial cavity لا Fibroids increase prostaglandin release in the uterus menorrhagia & pain لا 約 30% 的肌瘤引起月經過多 +/- 痛經 لا 粘膜下纖維瘤增加子宮內膜表面積 لا 壁內肌瘤優先阻止子宮內膜腔靜脈回流 لا 子宮肌瘤增加前列腺素的釋放月經過多及疼痛

31 DIAGNOSIS 診斷結論 لا 症狀 symptom( 例如 : 定期月經過多 /regular menorrhagia) لا Physical exam ( 臨牀檢查 ) لا Imaging ( 造影檢查 ) Pelvic USG 盆腔超聲波 MRI 磁力共震 CT Scan 電腦掃描 Endoscopy 內視鏡

32 TAS 經腹超聲

33 TVS 經陰道超聲

34 SALINE SONOHYSTEROGRAM 子宮聲學造影

35 MRI 核磁共振成像

36 LAPAROSCOPIC VIEW 腹腔鏡視圖

37 HYSTEROSCOPIC VIEW 宮腔鏡視圖

41 LAPAROSCOPIC SURGERY 腹腔鏡手術

42 LAPAROSCOPIC SURGERY 腹腔鏡手術

43 LAPAROSCOPIC MYOMECTOMY 腹腔鏡子宮肌瘤剔除術

48 TLH 腹腔鏡全子宮切除微創手術

49 RESECTOSCOPE 前列腺切除器

50 RESECTING LOOP 切除環

52 HYSTEROSCOPIC MYOMECTOMY 宮腔鏡子宮肌瘤切除術

53 BASIS FOR UFE/UAE 子宮肌瘤栓塞 (UFE) / 子宮動脈栓塞 (UAE) 的概念 لا Use micron Polyvinyl alcohol (PVA) particles to occlude both uterine arteries لا Transient ischaemia fibroids die, uterus lives! لا Shrinkage of fibroid size by 30-60% ( by 12 months) لا Collateral blood supply from ovarian arteries formed until recovery of uterine arteries later لا 用聚乙烯醇 (PVA) 微米顆粒閉塞雙側子宮動脈 لا 短暫性腦缺血 --- 肌瘤死, 子宮活 لا 30-60% 縮小肌瘤的大小 (12 個月 ) لا 從卵巢動脈側支供血形成直到恢復後子宮動脈

59 ADVANTAGES OF UFE 子宮肌瘤栓塞 (UFE) 的好處 لا No need GA or surgery لا Short hospital stay, quick recovery لا Global treatment, all fibroids treated لا Conserve uterus لا High patient satisfaction rate, up to 70-80% لا Complication rate low لا 無需全身麻醉或手術 لا 住院時間短, 恢復快 لا 全球的治療, 子宮肌瘤的治療 لا 保留子宮 لا 患者滿意率高達 70-80%, لا 併發症發生率低

60 UFE COMPLICATIONS 子宮肌瘤栓塞的併發症 لا Pain - within 1 st 24 hrs & severe; due to uterine ischaemia (uterine attack) - post-op Day 2-3 & associated with fever & leucocytosis (post-embolization syndrome), may last for 1 week لا Infection : especially submucous fibroid لا Premature ovarian failure : 1-10% (from retrograde embolization of ovarian arteries) لا 疼痛 لا 在第一個 24 小時 & 嚴重 ; 由於子宮 ( 子宮缺血發作 ) لا 手術後 2-3 天與發熱和白細胞增多相關 ( 栓塞後綜合征 ), 可能會持續 1 周 لا 感染 : 尤其是粘膜下肌瘤 لا 卵巢早衰 :1~10%( 卵巢動脈逆行栓塞 )

61 MRGFUS 磁共振引導聚焦超聲手術

62 MRGFUS 磁共振引導聚焦超聲手術 لا Magnetic Resonance guided Focused Ultrasound Surgery لا ExAblate 2000 for treating fibroid, FDA approval in Oct 2004 لا Out-patient procedure لا High-intensity focused ultrasound (HIFU) thermo-ablate (destroy) tissue لا Sonication لا 磁共振引導聚焦超聲手術 لا 用於治療子宫肌瘤的 ExAblate 2000, 在 10 月 2004 美國食品及藥物管理局 (FDA) 批准 لا 門診流程 لا 高强度聚焦超聲 (HIFU) 熱消融 ( 破壞 ) 組織 لا 超聲波降解法

65 TREATMENT OF DUB 功能不良性子宮出血 (DUB) 的治療 1 st line: oral medical treatment hormonal for anovulatory DUB, non-hormonal for ovulatory DUB 2 nd line: Mirena IUCD 3 rd line: surgery endometrial ablation, hysterectomy 第一線 : 口腔醫療激素無排卵性功血, 非激素排卵功血第二線 : 曼月樂宮內節育器第三線 : 手術子宮內膜切除術, 子宮切除術

66 MIRENA IUCD 曼月樂宮內節育器

67 藥性子宮環好處顯著縮短經期經血量減少取出宮內避孕系統之後, 便會回復原來的月經週期紓緩月經期間的身體不適如腹部疼痛

68 TCRB 子宮內膜消融術

69 EA - THERMAL BALLOON 熱球子宫内膜消除術

70 Thank you!

第三十三章子   瘤

第三十三章子   瘤 2 1 2 3 Myoma of uterus Definition Etiology Classification Uterine myomacervical myoma 1(intramural myoma) 2(sub serous myoma) 3(sub mucous myoma) Pathology Pathological anatomy Microscopic examination