内分泌知识轻松学 | 连载NO.11 病例三：绝经过渡期Ⅱ型排卵障碍治疗过程中的医源性出血

42岁女性，既往月经周期30～33天，因工作压力情绪焦躁，月经周期40～50天，月经量渐进性减少半年，月经第2天查FSH 2.1mIU/ml，LH1.5mIU/ml，E₂ 112pg/ml。考虑下丘脑问题，嘱调节情绪，月经第5天起服戊酸雌二醇片1片，服用2天出现阴道出血，量同月经，持续3天止，于第16天再次出现出血，停药复查性激素FSH 15mIU/ml，LH 49mIU/ml，E₂ 260pg/ml，为什么性激素会变成这样？

【问题1】患者为几型排卵障碍？如何治疗？

思路：患者月经稀发，月经量减少，在排除器质性病变后，可考虑发生了Ⅱ型排卵障碍。Ⅱ型排卵障碍，只需要补充孕激素，不需要补充雌激素。可以看做孕激素的药物包括口服单纯孕激素、COC、左炔诺孕酮宫内节育系统。此患者42岁，不属于COC的1级使用情况，应慎重选择，可以选用单纯孕激素或左炔诺孕酮宫内节育系统。

【问题2】患者是否为下丘脑功能异常导致的低促，用药后为什么会出血？

思路：本病例中的患者工作压力较大，情绪波动，是发生下丘脑功能异常的应激源，可是并非引起月经异常的主要原因。第一个化验单虽然FSH、LH偏低，但要看雌激素，雌激素比较高，已达112pg/ml，在雌激素处于高水平时不宜诊断为低促，考虑可能发生了残留卵泡囊肿；结合年龄，40岁以上女性已进入绝经过渡期，卵巢储备功能降低，卵泡募集提前，同时下丘脑有所老化，对雌激素的正反馈敏感性降低，从而发生排卵障碍，这也是更年期女性在月经早期发生卵泡囊肿的常见原因。因患者现阶段不缺少雌激素，并且卵泡囊肿分泌较大量的雌激素，外源给予雌激素后反而引起体内雌激素波动，可导致子宫出血，为医源性因素，在临床工作中应避免。

另外，性激素的检测应尽量全面，若此例未查孕激素，如果孕激素升高，要考虑与怀孕相关的疾病，虽然本病例通过后续的诊疗可以排除，但在首诊时不要忽视，务必全面评估患者情况。

【问题3】第二次出血的原因是什么？

思路：在第二个化验单中FSH、LH、E₂均高，为即将排卵起来的峰值，出血考虑为围排卵期出血。

【问题4】患者应如何诊疗？

思路：对于月经稀发或月经过少为主诉的女性，应首先鉴别有无排卵，若无排卵，属于Ⅱ型排卵障碍时，应定期补充孕激素；若有排卵，可随访观察，可以结合基础体温监测，较为简易。

END

版权声明

本文来自于李艳、贾彤编著的《妇科内分泌知识轻松学》第五册，版权归作者所有，中国妇产科网由作者授权推送。

作者简介

李艳、贾彤，为中国妇产科网妇科内分泌频道中的执行主编、副主编，制作的讲课视频约300多个，编写病例问答共约500余份，浏览率400万左右，现已有4万余受众。

2位老师编著出版妇科内分泌系列书籍《妇科内分泌知识轻松学》5本；编著发行1本妇科内分泌科普书籍:《坊间”泌”闻——妇科内分泌那些事》, 由人民卫生出版社发行。

专家简介

李艳

网名：明玥，太原市妇幼保健院生殖内分泌科、青春期保健科、更老年保健科主任。

社会任职：中国医药教育协会生殖内分泌专业委员会常务委员、中国医药教育协会生殖内分泌专业委员会更年期教育培训中心常务委员、中国妇女发展基金会“人人健康公益巡讲中国行”项目指导专家、北京妇产学会内分泌分会常务委员、中国科普作家协会医学科普创作专业委员会委员、山西省科普作家协会副理事长、山西省科普作家协会医学科普创作分会副会长、山西省女医师协会科学普及专业委员会副主任委员、太原市女医师协会常务副会长、山西省专家学者协会医学分会常务委员、山西省女医师协会生殖与遗传专业委员会常务委员、山西省女医师协会妇产科专业委员会常务委员、山西省妇幼保健协会女性生殖内分泌专业专家委员会常务委员、山西省优生优育协会理事会常务理事、省级健康教育专家委员会专家、太原市健康教育专家委员会专家、山西省科协科学传播专家。

专家简介

贾彤

遗传咨询师，健康管理师，网名大狐之舞。主要从事生殖健康及不孕专业，开展妇科内分泌及不孕诊疗工作，应用男女共诊共治模式及中西医整合方法，拓展优生项目。积极开展学术交流，以“互联网+”的形式组织妇科内分泌相关继续教育3期。参与中美国际合作项目1项，市级课题4项。

社会任职：包括苏州市预防医学会生殖健康专业委员会委员、苏州市中西医生殖医学委员会委员、中华预防医学会生育力保护分会生育力保护科学普及学组成员、中国医药教育协会生殖内分泌专业委员会委员、中国医药教育协会更年期教育培训中心委员、中国医疗保健国际交流促进会妇产科分会生殖激素相关多学科学组委员。

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