围绝经期全程激素管理病例解析

2019-09-22 不详 妇产科网

围绝经期全程激素管理病例解析

病例1

患者方某,女,47岁,初诊2016年5月

主诉:不规则阴道流血2月

现病史:患者既往月经规律5-6天/28-30天,量中,无痛经。2月前开始出现月经期后不规则阴道流血,量少,无腹痛。在当地医院就诊,阴超提示宫腔有1cm左右占位,予中药治疗无效。为进一步诊治,转我院宫颈疾病科。

既往史及家族史:无特殊;

体格检查:无特殊,体重52kg;妇科检查:外阴已婚式;阴道通畅、粘膜未见异常;宫颈轻度糜烂、未见赘生物;子宫体中位,正常大小;双侧附件区未扪及肿块;盆腔无压痛。

辅助检查:阴超:子宫大小正常,内膜9mm,宫腔占位10*10*8mm;附件区未见占位。血常规提示Hb:102g/L,尿HCG阴性。

治疗经过:患者2016年5月在我院宫颈疾病科门诊行宫腔镜检查+诊刮术,病理结果为子宫内膜单纯性增生过长;遂转诊到本人专家门诊。诊断:异常子宫出血,子宫内膜单纯性增生过长。再次了解病史,患者无明显潮热盗汗等症状,故予孕激素后半周期治疗,从月经周期第14天开始,地屈孕酮10mg bid*10天。3个周期治疗后,患者月经周期规律,但经期后仍有少许阴道流血,持续数天。经期第5天阴超检查提示子宫内膜5mm,未见异常占位。再改经期第5天开始地屈孕酮10mg bid*20天全周期治疗,阴道流血症状没有改善。再次询问病史,患者虽无潮热盗汗,但自述阴道干涩、同房刺痛等不适。考虑存在围绝经期综合征的泌尿生殖道症状,故改用芬吗通1/10mg口服,用药前乳腺检查未见异常。用药后阴道流血症状消失,阴道干涩症状明显缓解。

病例2

患者魏某,女,50岁,初诊时间:2019年4月

主诉:月经稀发伴潮热盗汗半年

现病史:患者既往月经规律,7天/30天,量中,无痛经。半年前开始月经周期延长,2-3月,伴有潮热盗汗,每天发作3-4次,不以为意未就诊。之后症状逐渐加重,现每天发作10余次,睡眠欠佳。

既往史:高胆固醇血症,未规范治疗。3月前单位体检,胆固醇5.6mmol/L,血常规、肝肾功能、凝血功能、血糖、肿瘤指标未见异常,肝胆乳腺妇科B超未见异常,宫颈筛查未见异常。

家族史:家族无肿瘤病史。

体格检查:生命体征平稳,妇科检查:外阴已婚式;阴道通畅、粘膜未见异常;宫颈轻度糜烂、未见赘生物;子宫体前位,正常大小;双侧附件区未扪及肿块。

辅助检查:阴超:子宫及双附件未见异常占位,内膜5mm。乳腺钼靶:双侧腺体增生,BI-RADS:2级。骨密度提示骨量减少。

诊断:围绝经期综合征

治疗经过:芬吗通1/10mg口服。一月后复诊,症状消失,有撤退性出血。继续用药。

诊治心得

1、 这两位患者都处于围绝经期,但是初诊诊断不尽相同。病例1以异常子宫出血初诊,诊刮之后提示子宫内膜单纯性增生过长,先后给予孕激素的后半周期和全周期疗法,都不能解决月经期之后的阴道流血症状。根据我们以往的经验,这样的患者在给予孕激素全周期或后半周期治疗后,月经基本都是能规律的,那这个病例是什么原因呢?因为患者已经处于围绝经期,体内雌激素相对不足,子宫内膜增生不足,孕激素无法形成有效的转化,所以一旦改用芬吗通1/10mg,补充了雌激素之后,阴道出血的症状马上消失。

2、 有人或许担心子宫内膜单纯增生过长受到外来雌激素刺激,会不会病情恶化。我们可以分析一下,不伴有非典型增生的内膜增生过长,极少癌变;患者内源性雌激素不足,我们每天仅给予1mg雌二醇口服,并不刺激内膜异常增生;每个周期还有140mg的地屈孕酮,可以有效转化内膜。所以,患者内膜增生过长没有复发,随访过程中多次在经期第5天复查内膜,无增厚。

3、 病例2是非常典型的围绝经期综合征患者,同时月经稀发,经过一系列检查,排除用药禁忌症之后,给予芬吗通1/10mg口服,症状消失。

4、 围绝经期患者使用激素调经或者缓解低雌症状,建议选择天然的雌激素和孕激素、或者接近天然的地屈孕酮,这样对于乳腺和代谢的影响相对较低。口服的天然雌激素包括戊酸雌二醇和17β雌二醇,孕激素包括黄体酮胶囊和地屈孕酮,但是黄体酮胶囊的生物利用度较低,通常需要较大剂量,容易带来头晕、嗜睡、水肿等不良反应。

5、 最后两位患者均选择芬吗通,还有一个重要的原因:使用方便。因为芬吗通特殊的配方,患者每天只要按照药片板上的数字标记服用一片,方便不易用错药片。如果用补佳乐和黄体酮来配方,我们交代地再详细清晰,也经常会遇到吃错药片的“粗心”患者。

6、 围绝经患者使用激素,要严格按照指南,排除激素治疗的禁忌症,了解是否有慎用情况,在与患者充分沟通、知情同意之后,再开具处方。如果能进行知情同意的签字,那就更好了。

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    2019-12-03 hongbochen
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    2019-09-24 海豹

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