功能性子宮出血(xue)(xue),簡稱功(gong)(gong)(gong)血(xue)(xue),這種疾病(bing)(bing)是由(you)于下丘腦-垂體-卵巢(H-P-O)軸異(yi)常(chang)調節引起的(de)神經(jing)內分(fen)(fen)泌異(yi)常(chang)引發(fa)的(de)非(fei)正(zheng)常(chang)子宮(gong)出血(xue)(xue)的(de)非(fei)器(qi)質性(xing)病(bing)(bing)變(bian)。功(gong)(gong)(gong)血(xue)(xue)是婦科(ke)常(chang)見(jian)疾病(bing)(bing),約(yue)占(zhan)婦科(ke)門診患者的(de)10%。臨(lin)床上將這種疾病(bing)(bing)分(fen)(fen)為兩(liang)種,即無排卵型功(gong)(gong)(gong)血(xue)(xue)和排卵型功(gong)(gong)(gong)血(xue)(xue)。前(qian)一種,常(chang)發(fa)生于青春期(qi)(qi)和絕經(jing)過(guo)渡期(qi)(qi)婦女。青春期(qi)(qi)功(gong)(gong)(gong)能性(xing)子宮(gong)出血(xue)(xue)是由(you)于神經(jing)內分(fen)(fen)泌中(zhong)樞發(fa)育不全或成熟延遲所致。絕經(jing)婦女出現的(de)功(gong)(gong)(gong)血(xue)(xue)主(zhu)要是由(you)于下丘腦-垂體-卵巢軸功(gong)(gong)(gong)能減退,是卵巢功(gong)(gong)(gong)能不斷衰退而引起。
一般(ban)認為,機體內(nei)外(wai)許多因素(su)如精神(shen)過度(du)緊張(zhang)、恐懼(ju)、憂傷、環境和(he)氣候的驟變、過度(du)勞累及(ji)其他(ta)全(quan)身性疾病,均可通過大腦皮層的神(shen)經遞質影響下丘腦-垂(chui)體-卵巢(chao)軸(zhou)的相互調(diao)節(jie),導(dao)致(zhi)卵巢(chao)功能(neng)失調(diao),而(er)致(zhi)月經紊(wen)亂。營養(yang)不良、貧(pin)血及(ji)代射紊(wen)亂也可影響激素(su)的合成、轉運(yun)和(he)對靶器官的效應(ying)而(er)導(dao)致(zhi)月經失調(diao)。
無卵功血(xue)是在(zai)激素的(de)調(diao)解下(xia),導(dao)致子(zi)(zi)宮(gong)內膜微環(huan)境(包括生(sheng)(sheng)長因子(zi)(zi)、細胞因子(zi)(zi)、血(xue)管活性(xing)(xing)物質、細胞外基(ji)質等)改變。子(zi)(zi)宮(gong)內膜微環(huan)境的(de)改變,導(dao)致子(zi)(zi)宮(gong)內膜的(de)修復失控(kong),出現(xian)病理性(xing)(xing)改變,導(dao)致無卵性(xing)(xing)功血(xue)的(de)發生(sheng)(sheng)。
而(er)對于(yu)青春(chun)期功血是因(yin)為(wei)缺(que)乏孕酮對抗(kang)和腺體(ti)分泌化;PC升高(gao);凝血因(yin)子V、VII、X、XII等的(de)缺(que)乏以(yi)及螺旋小動脈和溶酶體(ti)作用子宮(gong)內膜螺旋小動脈和溶酶體(ti)結構和功能(neng)異(yi)常,影響內膜脫(tuo)落和血管上皮的(de)修復等。
在臨(lin)床實踐中,功(gong)(gong)血(xue)(xue)的(de)(de)準確(que)診(zhen)(zhen)斷(duan)并(bing)不容(rong)易,有報(bao)道一些(xie)器(qi)質(zhi)(zhi)性(xing)(xing)(xing)病(bing)(bing)變(bian)比較隱(yin)蔽,病(bing)(bing)程緩慢,被誤診(zhen)(zhen)為(wei)(wei)功(gong)(gong)血(xue)(xue)。診(zhen)(zhen)斷(duan)功(gong)(gong)血(xue)(xue),第(di)一,要除外器(qi)質(zhi)(zhi)性(xing)(xing)(xing)病(bing)(bing)變(bian)。器(qi)質(zhi)(zhi)性(xing)(xing)(xing)病(bing)(bing)變(bian)有很多種(zhong),如(ru)(ru)血(xue)(xue)小(xiao)板減少癥,再(zai)障(zhang)血(xue)(xue)液病(bing)(bing),甲低,甲亢(kang),服用性(xing)(xing)(xing)激素(su)(su),避孕藥,生(sheng)殖器(qi)外傷,異(yi)(yi)物(wu),異(yi)(yi)位妊娠,先兆流產,子(zi)(zi)(zi)宮(gong)(gong)平滑肌瘤和肉(rou)瘤、子(zi)(zi)(zi)宮(gong)(gong)腺(xian)肌病(bing)(bing)、子(zi)(zi)(zi)宮(gong)(gong)內膜(mo)癌、子(zi)(zi)(zi)宮(gong)(gong)內膜(mo)炎(yan)、子(zi)(zi)(zi)宮(gong)(gong)內膜(mo)息(xi)肉(rou),紅斑狼(lang)瘡等。第(di)二,長期(qi)功(gong)(gong)能(neng)(neng)性(xing)(xing)(xing)失(shi)調可(ke)能(neng)(neng)會轉化為(wei)(wei)器(qi)質(zhi)(zhi)性(xing)(xing)(xing),兩者(zhe)并(bing)無絕對界限,如(ru)(ru)無排卵功(gong)(gong)血(xue)(xue)的(de)(de)患(huan)者(zhe)由于受(shou)體內高雌(ci)激素(su)(su)的(de)(de)影響轉為(wei)(wei)子(zi)(zi)(zi)宮(gong)(gong)內膜(mo)息(xi)肉(rou),子(zi)(zi)(zi)宮(gong)(gong)內膜(mo)癌。臨(lin)床多見反復異(yi)(yi)常子(zi)(zi)(zi)宮(gong)(gong)出血(xue)(xue)的(de)(de)患(huan)者(zhe),早(zao)期(qi)診(zhen)(zhen)刮術后病(bing)(bing)理是(shi)增生(sheng)期(qi)內膜(mo),因未按時復診(zhen)(zhen)及正確(que)治療,后期(qi)診(zhen)(zhen)刮術后病(bing)(bing)理診(zhen)(zhen)斷(duan)為(wei)(wei)子(zi)(zi)(zi)宮(gong)(gong)內膜(mo)癌。第(di)三,導致異(yi)(yi)常子(zi)(zi)(zi)宮(gong)(gong)出血(xue)(xue)的(de)(de)器(qi)質(zhi)(zhi)性(xing)(xing)(xing)病(bing)(bing)變(bian)和功(gong)(gong)能(neng)(neng)性(xing)(xing)(xing)障(zhang)礙可(ke)能(neng)(neng)并(bing)存。功(gong)(gong)血(xue)(xue)的(de)(de)患(huan)者(zhe)可(ke)能(neng)(neng)同時患(huan)有其他(ta)疾病(bing)(bing),如(ru)(ru)功(gong)(gong)血(xue)(xue)與內膜(mo)炎(yan)并(bing)存,功(gong)(gong)血(xue)(xue)與子(zi)(zi)(zi)宮(gong)(gong)肌瘤并(bing)存,功(gong)(gong)血(xue)(xue)與子(zi)(zi)(zi)宮(gong)(gong)內膜(mo)異(yi)(yi)位癥并(bing)存等。
目前輔助(zhu)檢(jian)(jian)(jian)查(cha)功(gong)能(neng)性(xing)子宮出血的手(shou)段包(bao)括(kuo)診斷性(xing)刮宮、排(pai)卵和黃體功(gong)能(neng)檢(jian)(jian)(jian)測(包(bao)括(kuo)基(ji)礎體溫的測定、陰道(dao)細胞學和宮頸粘液(ye)功(gong)能(neng)的檢(jian)(jian)(jian)查(cha)、激素的測定、超聲檢(jian)(jian)(jian)查(cha))、血液(ye)和凝血纖(xian)溶功(gong)能(neng)檢(jian)(jian)(jian)查(cha)、肝功(gong)能(neng)檢(jian)(jian)(jian)查(cha)。
功(gong)血診(zhen)(zhen)(zhen)斷(duan)的要點:應(ying)準確(que)地采集病(bing)(bing)(bing)史,詳細詢問月(yue)經和出血史,近期服用(yong)避孕藥(yao)及性激(ji)(ji)素(su)(su)藥(yao)物,判斷(duan)不正常月(yue)經的出血類型。婦科檢(jian)查(cha)(cha)可排除宮(gong)(gong)頸疾病(bing)(bing)(bing)、陰道疾病(bing)(bing)(bing)引起的出血,明確(que)子宮(gong)(gong)腔(qiang)(qiang)出血。育(yu)齡期婦女檢(jian)查(cha)(cha)人絨(rong)毛膜促(cu)性腺激(ji)(ji)素(su)(su)排除妊娠相(xiang)關疾病(bing)(bing)(bing)。超聲(sheng)影像學檢(jian)查(cha)(cha)排除生殖系統器(qi)質性病(bing)(bing)(bing)變。診(zhen)(zhen)(zhen)斷(duan)性刮宮(gong)(gong)排除子宮(gong)(gong)內膜增(zeng)生性疾病(bing)(bing)(bing)或癌前病(bing)(bing)(bing)變。宮(gong)(gong)腔(qiang)(qiang)鏡檢(jian)查(cha)(cha)和子宮(gong)(gong)內膜活檢(jian)是(shi)有效的診(zhen)(zhen)(zhen)斷(duan)手(shou)段。
臨床(chuang)上對于功血的治療,西醫主要采取刮宮和激素(su)藥物治療。
對于已婚婦女,多采用(yong)(yong)刮(gua)宮治(zhi)療的方法,通過(guo)刮(gua)宮,能夠起(qi)到快速止血的目的,并且刮(gua)出物(wu)可以作為病(bing)理(li)檢驗(yan)的標本(ben),起(qi)到雙重功效。性激(ji)素(su)也可以應用(yong)(yong)其(qi)中,起(qi)到止血的作用(yong)(yong),目前常用(yong)(yong)的激(ji)素(su)包括雌激(ji)素(su)、雄(xiong)激(ji)素(su)、孕激(ji)素(su)。
對于青春期功(gong)血(xue)(xue)且(qie)貧血(xue)(xue)不嚴(yan)重(zhong)者(Hb>=80g/L),可(ke)應用(yong)大劑量的(de)(de)(de)雌(ci)(ci)激素(su)(su)(su),雌(ci)(ci)激素(su)(su)(su)能夠(gou)刺激子(zi)(zi)(zi)宮(gong)內(nei)(nei)膜(mo)增生,使得創面得以(yi)(yi)修(xiu)復(fu),但是(shi)停(ting)藥后可(ke)引(yin)起更(geng)嚴(yan)重(zhong)的(de)(de)(de)出(chu)(chu)血(xue)(xue),并且(qie)胃腸(chang)道(dao)反應比較嚴(yan)重(zhong)。孕激素(su)(su)(su)適(shi)用(yong)于各類型(xing)的(de)(de)(de)出(chu)(chu)血(xue)(xue),能夠(gou)促進子(zi)(zi)(zi)宮(gong)內(nei)(nei)膜(mo)同步性分(fen)泌化(hua)(hua),以(yi)(yi)達到止(zhi)(zhi)血(xue)(xue)的(de)(de)(de)目的(de)(de)(de)。藥物性刮宮(gong)適(shi)用(yong)于淋(lin)漓出(chu)(chu)血(xue)(xue)而(er)無(wu)大出(chu)(chu)血(xue)(xue)者,通過使用(yong)孕酮使內(nei)(nei)膜(mo)在(zai)短期內(nei)(nei)分(fen)泌化(hua)(hua)并集中撤退。以(yi)(yi)上服用(yong)孕激素(su)(su)(su)者,均需要從撤退性出(chu)(chu)血(xue)(xue)第五天開始進行調(diao)經(jing)治療(liao)。雄(xiong)激素(su)(su)(su)作為雌(ci)(ci)、孕激素(su)(su)(su)止(zhi)(zhi)血(xue)(xue)的(de)(de)(de)輔助療(liao)法(fa),目的(de)(de)(de)是(shi)抗雌(ci)(ci)激素(su)(su)(su),減少盆腔充血(xue)(xue)和增強子(zi)(zi)(zi)宮(gong)肌張力并減少出(chu)(chu)血(xue)(xue)量,但不能縮短出(chu)(chu)血(xue)(xue)時間和完全止(zhi)(zhi)血(xue)(xue)。藥物療(liao)法(fa)包(bao)括止(zhi)(zhi)血(xue)(xue)藥、抗纖(xian)溶藥、用(yong)以(yi)(yi)抵(di)抗纖(xian)維(wei)蛋白(bai)溶解并且(qie)抑制纖(xian)溶酶(mei)原(yuan)激活(huo)因子(zi)(zi)(zi),達到止(zhi)(zhi)血(xue)(xue)的(de)(de)(de)目的(de)(de)(de)、前列腺素(su)(su)(su)合成酶(mei)抑制劑,抑制前列腺素(su)(su)(su)的(de)(de)(de)生成,抵(di)制前列腺素(su)(su)(su)的(de)(de)(de)促進出(chu)(chu)血(xue)(xue)的(de)(de)(de)機制;使用(yong)凝(ning)血(xue)(xue)因子(zi)(zi)(zi)如纖(xian)維(wei)蛋白(bai)原(yuan)和血(xue)(xue)小板。除了上述止(zhi)(zhi)血(xue)(xue)方法(fa)之外(wai),還可(ke)以(yi)(yi)通過調(diao)節月經(jing)周(zhou)期,重(zhong)建規律月經(jing),也(ye)可(ke)以(yi)(yi)采用(yong)促排卵療(liao)法(fa),避免功(gong)血(xue)(xue)的(de)(de)(de)復(fu)發。
對于(yu)排卵型功血的治療(liao)(liao),臨床上(shang)采(cai)用(yong)雄激素療(liao)(liao)法(fa)、孕激素周(zhou)期療(liao)(liao)法(fa)等,以抑制月經過多(duo);輔助黃體功能,如孕酮療(liao)(liao)法(fa)。
中醫在治療功能(neng)性(xing)子宮出血(xue)(xue)(xue)(xue)(xue)(xue)上具有其優越性(xing),中醫認為(wei)(wei)(wei)功血(xue)(xue)(xue)(xue)(xue)(xue)屬(shu)于“崩(beng)(beng)(beng)(beng)漏(lou)”。婦女不(bu)在行經(jing)(jing)期(qi)間陰道突然大量(liang)出血(xue)(xue)(xue)(xue)(xue)(xue),或(huo)淋漓下(xia)血(xue)(xue)(xue)(xue)(xue)(xue)不(bu)斷者,稱(cheng)為(wei)(wei)(wei)“崩(beng)(beng)(beng)(beng)漏(lou)”,前(qian)者稱(cheng)為(wei)(wei)(wei)“崩(beng)(beng)(beng)(beng)中”,后者稱(cheng)為(wei)(wei)(wei)“漏(lou)下(xia)”。若(ruo)經(jing)(jing)期(qi)延長達2周以上者,應屆崩(beng)(beng)(beng)(beng)漏(lou)范(fan)疇,稱(cheng)為(wei)(wei)(wei)“經(jing)(jing)崩(beng)(beng)(beng)(beng)”或(huo)“經(jing)(jing)漏(lou)”。崩(beng)(beng)(beng)(beng)漏(lou)之(zhi)病,本乎(hu)一證(zheng),輕(qing)者謂之(zhi)漏(lou)下(xia),甚者謂之(zhi)崩(beng)(beng)(beng)(beng)中。是因為(wei)(wei)(wei)沖任失其固攝(she)引起,多是因為(wei)(wei)(wei)血(xue)(xue)(xue)(xue)(xue)(xue)熱(re)、氣虛(xu)、血(xue)(xue)(xue)(xue)(xue)(xue)瘀等,氣虛(xu)包(bao)括腎氣虛(xu)和脾氣虛(xu),脾主統血(xue)(xue)(xue)(xue)(xue)(xue),脾虛(xu)則(ze)血(xue)(xue)(xue)(xue)(xue)(xue)失固攝(she),遂成崩(beng)(beng)(beng)(beng)漏(lou)。臨床上根據月經(jing)(jing)血(xue)(xue)(xue)(xue)(xue)(xue)的(de)顏色、量(liang)、質變化以及全身證(zheng)候辨明寒、熱(re)、虛(xu)、實(shi)。治療應根據病情的(de)緩急輕(qing)重、出血(xue)(xue)(xue)(xue)(xue)(xue)的(de)久暫,采用“急則(ze)治其標,緩則(ze)治其本”的(de)原(yuan)則(ze),靈(ling)活運用塞(sai)流、澄(cheng)源、復舊三法。
對于血(xue)熱(re)型(xing)的(de)崩漏(lou),主方(fang)采(cai)用(yong)(yong)清熱(re)固經湯(tang);血(xue)瘀(yu)型(xing)采(cai)用(yong)(yong)逐(zhu)瘀(yu)止崩湯(tang);脾虛(xu)型(xing)采(cai)用(yong)(yong)固沖(chong)(chong)湯(tang);腎虛(xu)型(xing)采(cai)用(yong)(yong)大補(bu)元煎。傅氏(shi)辨治(zhi)育(yu)齡崩漏(lou),血(xue)熱(re)型(xing)屬虛(xu)熱(re)者(zhe),方(fang)選兩(liang)地湯(tang)加(jia)減;實熱(re)者(zhe)方(fang)選用(yong)(yong)丹(dan)梔消(xiao)遙(yao)散加(jia)減;氣虛(xu)型(xing)方(fang)選寄生膠艾湯(tang)加(jia)減;血(xue)瘀(yu)沖(chong)(chong)任型(xing)方(fang)選血(xue)府逐(zhu)瘀(yu)湯(tang)加(jia)減。
除了藥物治(zhi)療外,患者要注意飲(yin)食和休息(xi),根據寒熱虛實(shi)(shi),做到虛者補(bu),實(shi)(shi)者泄。食療與藥療相結(jie)合,對于(yu)疾(ji)病的恢復意義(yi)重大。
對藥物療效不(bu)佳或(huo)不(bu)宜用(yong)藥、無生育要(yao)求的患者,可采(cai)用(yong)手術(shu)(shu)治療。主要(yao)分為兩類手術(shu)(shu)即子宮(gong)內膜去(qu)除(chu)手術(shu)(shu)和(he)子宮(gong)切除(chu)手術(shu)(shu)。
1、 功能性(xing)子(zi)宮(gong)出血危害(hai)大,做好護理很關(guan)鍵,做功能性(xing)子(zi)宮(gong)出血護理的(de)時候,患者要特別注(zhu)意飲食,要制(zhi)定(ding)適合自己(ji)的(de)飲食計劃(hua),保持營養均衡,不要挑食,多(duo)吃(chi)一些含(han)鐵的(de)食物(wu),這樣對(dui)于功能性(xing)子(zi)宮(gong)出血的(de)治療有很大的(de)幫(bang)助(zhu)。
2、 功能(neng)性(xing)子宮出血(xue)是(shi)比較嚴重(zhong)的疾病,病情加(jia)重(zhong)的時候,出血(xue)量會很多,這(zhe)(zhe)樣會導致(zhi)患者(zhe)出現貧血(xue),所以這(zhe)(zhe)個時候,患者(zhe)要(yao)(yao)自行(xing)觀察自己的身體,臥床休息,配合醫(yi)生的治療,必要(yao)(yao)的時候要(yao)(yao)進行(xing)止血(xue)和輸血(xue)。
3、 功(gong)能性(xing)子宮出(chu)血患(huan)者要定時到醫院做(zuo)檢查(cha),還要記住醫生(sheng)要求,按時服用抗生(sheng)素藥物,預防感(gan)染,還要保(bao)(bao)持外陰的(de)(de)清潔(jie),保(bao)(bao)持心(xin)情舒暢,積極樂觀的(de)(de)面對病情,這樣才(cai)能將功(gong)能性(xing)子宮出(chu)血治療好。