月經(jīng)相關(guān)疾病Course

OverviewIntroductionofthemenstrualcycleDysmenorrheaPremenstrualsyndrome(PMS)Toxicshocksyndrome(TSS)2Course

OverviewIntroductionofthemenstrualcycleDysmenorrheaPremenstrualsyndrome(PMS)Toxicshocksyndrome(TSS)Otherdisorders3月經(jīng)的開始與結(jié)束初經(jīng)

(Menarche)9-17歲剛開始前兩年周期不穩(wěn)定2-5年內(nèi)沒有LHsurge，所以大約50-80%左右的比例是沒有排卵的Onset影響因子：種族、基因、營養(yǎng)狀態(tài)、身體質(zhì)量更年期

(Menopause)45-55歲癥狀為潮紅、睡眠障礙、骨質(zhì)疏松、精神狀況差導(dǎo)致情緒差、陰道干澀以至于容易泌尿道感染、賀爾蒙改變以致于慢性疾病發(fā)生率上升4MenstrualCycle

Hypothalamic-Pituitary-OvarianAxisHypothalamus

regulatesthemenstrualcyclebyproducinggonadotropinreleasinghormone(GnRH).

Lowlevelsofbothestradiolandprogesterone

stimulatethehypothalamustoreleaseGnRH,

whichstimulatespituitarygonadotrophcellstosynthesizeandsecreteLHandFSH.5MenstrualCycleMenstrualcycle經(jīng)期Monthlycycleoffemalereproductivehormones.Amenstrualcycle:1stdayofmensesthebeginningofthenext.Average28days(15%);variesbetween21-40daysMenses經(jīng)血期Average4days(±2days).Themajorcomponentsareendometrialcellulardebrisandblood.Averagewholebloodlosspercycleis30-80mlOvariancycle卵巢周期Follicularphase(Day1~14)濾泡期Ovulation(Day14)排卵期Lutealphase(Day14+/-2)黃體期Uterinecycle子宮周期Menstrualphase(Day1~5)月經(jīng)期Proliferativephase(Day6~14)增生期Secretoryphase

(Day14~28)分泌期6Menstrual

PhaseProliferationPhaseSecretory

PhaseMenstrual

PhaseFollicularPhaseLutealPhase7Course

OverviewIntroductionofthemenstrualcycleDysmenorrhea月經(jīng)困難Premenstrualsyndrome(PMS)Toxicshocksyndrome(TSS)Otherdisorders8ClassificationofDysmenorrheaPrimarySecondaryCauseNotreallysureInabsenceofpelvicdiseasePelvicpathologyEndometriosisPIDOvariancystsUterinetumorsUterinefibroidsCervicalosstenosisCongenital

abnormalitiesAgeTeens&early20sLate20sororderOccurOnlyatmenstrualcycleAllthetimeDurationOnly2-3daysVarywithcauseMensesRegularNormalbloodlossIrregularMenorrhagiaResponsetoNSAIDsYesNoSymptomsNV,fatigue,dizziness,irritability,diarrhea,headache,dysmenorrpheapainVaryaccordingtosecondarycauses;mayincludedyspareunia,pelvictenderness9PathophysiologyTheactualpathophysiologyofprimarydysmenorrheaisnotreallysure!!!Prostaglandin：stimulateuterinecontractionsLeukotrieneVasopressin10Stronguterinecontractionsandsignificantvasoconstriction,resultinginuterineandischemiaandpain.RiskofDysmenorrheaAge：youngfemalePregnancyLifestyle:stress,anxietyExercise:preventdysmenorrheaSmoking:nicotineinducevasoconstrictionAlcoholintakeObesity11TreatmentGoalsProviderelief/significantimprovementinsymptomsMinimizedisruptionofusualactivitiesAnimportantinitialstepDistinguishingbetweenprimaryandsecondarydiseaseEssentiallyallpatientswithprimarydysmenorrhea

canobtainadequatereliefofsymptomswithNondruginterventionsNonprescriptionPrescriptiondrugtherapy12NonpharmacologicTherapySleepHotbaths/HeatingpadExerciseLifestylealterationsSmoking↓ConsumptionofOmega-3fattyacids13

14NonpharmacologicTherapyNonpharmacologicTherapy飲食均衡根據(jù)調(diào)查，蔬菜水果攝取量不足、及油脂比例過高的女性，較容易出現(xiàn)生理期不適的癥狀，例如腰酸背痛、胸部漲痛、頭痛、易怒情緒不穩(wěn)定因為高脂肪的攝取及暴飲暴食，都會增加身體新陳代謝的負擔，導(dǎo)致血糖值的不穩(wěn)定，引起生理期不適。蔬菜有助于降低膽固醇、平衡血糖值等功效。15充足蔬菜水果攝取，避免暴飲暴食及高脂肪攝取!NonpharmacologicTherapy忌吃冷食及油炸食品油炸食品含有大量油脂，除了影響內(nèi)分泌，

也會造成生理期間在心理及生理上的不適許多女性偏愛冰品冷飲，

這些溫度較低的食物進入人體后，

很可能會引起子宮收縮，擾亂整個生理周期，

甚至影響到中年以后的更年期。16NonpharmacologicTherapy盡量選擇暖性食物各類紅豆、堅果類、豆類、大蒜、蔥、姜、芝麻、菠菜、A菜、紅菜、杏菜、甘藍菜、花椰菜、牛蒡、海帶等，皆屬于暖性蔬果。白菜、高麗菜、白蘿卜、冬瓜、絲瓜、綠豆、水梨、芒果、楊桃、柑橘、西瓜等瓜類則為偏寒食物。女性在選擇食物時，除了考慮到營養(yǎng)均衡外，

可多選擇暖性蔬果活絡(luò)體質(zhì)。17NonpharmacologicTherapy長期補充鐵質(zhì)由于生理期身體都會大量失血，

女性常會有「缺鐵性貧血」的情形，

如果身體一直處于貧血的狀態(tài)，

每逢生理期就會更加不舒服。因此平日就要補充鐵質(zhì)，例如透過食用豬肝、葡萄、葡萄干、黑糖、黑芝麻等來攝取鐵質(zhì)。18NonpharmacologicTherapy19NonpharmacologicTherapy子宮溫暖操嬰兒式彎膝跪下坐在腳跟，前額觸地，雙臂伸直于耳朵兩側(cè)，保持姿勢，深吸深吐。20NonpharmacologicTherapy

子宮溫暖操貓式步驟一步驟二步驟三雙手約與肩同寬，

雙腳自然張開。吸氣將背部往前，

吐氣時將雙手往前延伸，眼睛看前方，

臀部往天花板延伸。胸部盡量靠近地面，

使雙手往前延伸，

感覺下腹延展。

每個深呼吸都感覺背部更加延伸，停留5個呼吸。21NonpharmacologicTherapy子宮溫暖操蝴蝶式坐下將雙腳放地面上，雙腳呈菱形，腳底板相對，膝蓋外側(cè)放置瑜珈磚，頭部和上半身都放松于地板上，

后背放瑜珈枕或瑜珈鋪巾，兩手放在腿外側(cè)，放松休息。22NonpharmacologicTherapy穴道按摩位置作用行間穴足背上，當?shù)?、2趾間，

趾蹼緣的后方赤白肉際處。刺激肝經(jīng)的穴位，

能幫助打通肝經(jīng)，

有助解除肝氣郁滯。三陰交小腿內(nèi)側(cè)。

足內(nèi)踝上方四指橫寬處。

將小指放在內(nèi)踝尖上，

其余三指自然向上貼近小腿，食指上緣所到之處即是。脾、肝、腎三經(jīng)經(jīng)過的交點，經(jīng)期間單純只有腹痛的人，

應(yīng)該是寒氣太重、

凝結(jié)小腹，

刺激三陰交可以止痛、去寒。23穴道按摩NonpharmacologicTherapy位置作用崑侖穴足外踝尖處與足跟肌腱連線的中點。是膀胱經(jīng)的穴道，

若腰痠背痛、筋骨僵硬，就是膀胱經(jīng)郁熱，除了多做運動以外，還可刺激崑侖穴。關(guān)元穴肚臍直下3寸（四指幅寬）。位于任脈，又叫做下丹田，是元氣之所在。可調(diào)節(jié)生殖系統(tǒng)，

改善月經(jīng)失調(diào)癥狀。24Dysmenorrhea

PharmacologicTherapy25PharmacologicTherapyNonsalicylateNSAIDs:Ibuprofen&NaproxenFirstlinetherapyUsageBegin1-2daysbeforeexpectedmensesTakefor2-3daysTakeonascheduled(notasneeded)SideeffectsGIsymptomsdecreasedbytakingdrugswithfood26PharmacologicTherapyAcetaminophenTreatingonlymildsymptomsofdysmenorrheaAweakinhibitorofprostaglandinsynthesis4g/day27PharmacologicTherapyAspirinTreatingmildsymptomsofdysmenorrheaInlowdose,

aspirinhasonlyalimitedeffectonprostaglandinsynthesis

→moderatelyeffectiveintreatingwithminimalsymptomsMayincreasemenstrualflowAdolescentshouldnotuse

→Reye’ssyndrome28PharmacologicTherapyRecommendeddosage29AgentRecommendedNonprescriptiondosageMaximumdailydosageIbuprofen200-400mgevery4-6hours1200mgNaproxen220-400mginitiallythen220mgevery8-12hours660mgAcetaminophen650-1000mgevery4-6hours4000mgAspirin650-1000mgevery4-6hours4000mgPharmacologicTherapyOralContraceptives排卵時前列腺素會上升，因此用避孕藥抑制排卵，

讓前列腺素的分泌下降，減少子宮收縮，減輕疼痛。30DrugSelectionAdolescents

Acetaminophen

&Ibuprofen

Aspirin：maycauseReye’ssyndromeBreast-feeding

Acetaminophen

&

Ibuprofen

Aspirin

&

Naproxen：infectonbabycardiovascularsystemPepticulcer

Acetaminophen

&

Oralcontraceptive

NSAIDs：mayworsenGIsyndrome31DrugSelectionHypertension/Asthma/CHF

NSAIDs：maycausefluidretentionAnticoagulants/Drugsmayincreasebleeding

NSAIDs：maycausebleedingLithium

NSAIDs：moderateriskoflithiumtoxicityAlcohol

Acetaminophen：livertoxicity

Aspirin：GItoxicity32ComplementaryTherapyVitaminB1:緩和子宮肌肉痛VitaminB6:舒緩經(jīng)痛、頭痛的不適，可以鎮(zhèn)定情緒Sweetfennelextract甜茴香萃取物:減緩經(jīng)痛，但不適用于嚴重癥狀時，因為會減少血液凝結(jié)Magnesium:具有調(diào)節(jié)神經(jīng)細胞的功能，舒緩情緒及肌肉緊繃33Fishoil主成分有omega-3fattyacids里面含DHA(Docosahexanoicacid)、EPA(Eicosapenteanoicacid)增加抗發(fā)炎激素、減少發(fā)炎前驅(qū)激素Omega-3不飽和脂肪酸會跟花生四烯酸競爭生成促發(fā)炎介質(zhì)(proinflammatorymediators)。Omega-3不飽和脂肪酸會抑制發(fā)炎介質(zhì)和纖維化因子(fibroticmediators)包括、白介素(interleukins)、腫瘤壞死因子-α(tumornecrosisfactor-α，TNF-α)ComplementaryTherapy34給虛寒體質(zhì)女性生化湯功能:

排除惡露、調(diào)節(jié)子宮收縮、幫助子宮復(fù)舊、減少宮縮腹痛等作用。使用時間通常是即月經(jīng)來的第一天開始，一日一帖，連續(xù)服用三天。注意:若經(jīng)血過多、或患有巧克力囊腫、子宮肌瘤、子宮內(nèi)膜異位，不要使用生化湯。ComplementaryTherapy35給虛寒體質(zhì)女性四物湯:被稱為婦人病的圣藥，由當歸、熟地黃、川芎及芍藥組成，可用來調(diào)經(jīng)止痛、養(yǎng)血疏筋。幫助活血化瘀，排除血塊，并減輕腹脹腹痛，使經(jīng)血排出順暢?？裳a充鐵劑，減少月經(jīng)來潮時的貧血、頭暈?zāi)垦＜敖?jīng)血不出的狀況。服用時機及使用方法:經(jīng)期后每次在經(jīng)期干凈后，就連續(xù)服用六天份的四物湯。ComplementaryTherapy36給燥熱體質(zhì)女性:不適合用生化湯，會造成血崩可在喝四物飲時，搭配牛奶、白木耳等涼補生理期不要喝茶:茶類鞣質(zhì)含量高，會妨礙腸黏膜吸收鐵質(zhì)。經(jīng)期間不宜吃寒涼性的食物，如：水梨、西瓜、螃蟹、田螺、竹筍，會導(dǎo)致血液循緩減緩或不通的情形。中藥使用上采補益藥，不要使用補血藥，可能使經(jīng)血過多多補充雞肉、牛肉、羊肉、蘋果、紅糖有頭昏、心悸、貧血的人盡量不用caffeine，會讓癥狀更嚴重，經(jīng)期間可能缺少太多維生素、礦物質(zhì)，會阻礙碳水化合物的代謝ComplementaryTherapy37Course

OverviewIntroductionofthemenstrualcycleDysmenorrhea月經(jīng)困難Premenstrualsyndrome(PMS)

經(jīng)前癥候群Toxicshocksyndrome(TSS)38Introduction:PMSDefinitionCyclicdisorderPhysical&emotionalsymptomsOccurduringthelutealphaseofthemenstrualcycle

(Aweekbeforemenstrualflow)Usuallyoriginateinearly20s.Occuronlyduringovulatorycycles.Notoccurinpregnancy,breast-feeding,menopausewomen.Moresevere

form:Premenstrualdysphoricdisorder(PMDD)經(jīng)前不悅癥39PMSPathophysiologyTheactualpathophysiologyis

unknown

!!!Fluctuationofestrogenandprogesteronelevelscauseschangesinneurotransmitterslevels.Serotonin↓GABAEndorphinsExogenoushormonesGeneticpredispositionSocioculturalfactors40PMD&PMDDWomen

aremoresensitiveto

thesechanges.41增加serotoninreceptor的數(shù)量和敏感度誘導(dǎo)身體將糖分集中到子宮的區(qū)域負向癥狀正向癥狀生理癥狀胸部疼痛腹部脹氣頭痛四肢腫脹情緒癥狀疲倦憂郁發(fā)怒社交萎縮焦躁焦慮混亂食欲增加精神變好工作效率佳性欲增加有自信ClinicalPresentation42NonpharmacologicTherapyExercise每周進行三次20-30分鐘的有氧運動或瑜珈。

Cognitive-behavioraltherapy讓婦女了解PMS疾病相關(guān)癥狀，

并教導(dǎo)其安排適當工作避免過度壓力。43NonpharmacologicTherapy避免過咸的食物、單糖食物、咖啡因和酒精。適當補充會提高血清素的食物：乳制品、香蕉、堅果類、雞肉、牛肉、菠菜、五榖雜糧、蛋、海藻、巧克力…等黑糖所含的鈣和鎂能一起發(fā)揮鎮(zhèn)靜、放松的作用；鐵質(zhì)則補充生理期間的耗損，讓身體不會因為缺鐵感覺疲倦。有研究發(fā)現(xiàn)，碳酸飲料能提升血清素前驅(qū)物tryptophan的含量，并改善經(jīng)前不悅癥(premenstrualdysphoricdisorder,PMDD)的情緒44Dietarymodification少攝取:高脂肪、高糖、高鹽、生冷食物、咖啡因、菸酒多補充:45舉例作用

B群谷類、堅果安撫經(jīng)前情緒、

減少乳房腫脹及疲倦等癥狀鐵質(zhì)瘦肉、豬肝、豬血、葡萄干、黑棗、紅棗、桂圓、紅豆補血

Vit.C芭樂、奇異果、草莓、西紅柿幫助鐵質(zhì)吸收，可于飯后服用適量。NonpharmacologicTherapyPharmacologicTherapy劑量適應(yīng)癥備注VitaminB6(Pyridoxine)50-100

mg/day緩解各種PMS癥狀過量可能有神經(jīng)毒性VitaminE400IU/day乳房脹痛功效未證實Calcium&VitaminDCa600

mgBID情緒不穩(wěn)、嘴饞、其他身體不適極少案例有惡心、、腎結(jié)石的副作用Ca1200

mg+VitaminD400

IU預(yù)防PMS惡化、預(yù)防骨質(zhì)疏松MagnesiumMg360mginlutealphase情緒癥狀副作用很少，最常見是腹瀉Vitamin&MineralElements46PharmacologicTherapyNSAIDsSeveraldaysbeforeandduringthemenses.Reducephysicalsymptomsandmoodsymptoms.ThebenefitfromtheseagentsmaybearesultofthecoexistenceofdysmenorrheaandPMS.47Diuretics:Forwomenwhohavewaterretention.劑量機轉(zhuǎn)副作用備注NH4Cl1

gTID不超過連續(xù)六天腎小管內(nèi)Cl濃度上升，增加Na、水排除GIproblem,CNSproblem弱酸性、短效。可能造成肝腎功能不全者代謝性酸中毒。Caffeine100-200mgQ3H/Q4H抑制腎小管再吸收Na和水失眠、興奮、心搏過速、刺激腸胃胃潰瘍患者、服用MAOI避免使用。Pamabrom50

mgQID有效成分為8-bromotheophylline，是茶堿衍生物可與acetaminophen并用，治療背痛或緩解經(jīng)期不適。PharmacologicTherapy48DrugselectionBreastfeeding

Herbalproducts

Diuretics：Caffeine,

Pamabrom

Vitamins

andMineralsTakingPPIorH2-blocker

Cacitrate>CacarbonateMinddrug-drugordrug-diseaseinteraction49PatientCounselingforPMS告知病人非處方藥品及維生素的適當使用方法及可能的副作用。告知病人要經(jīng)過幾個cycle，才會有整體的療效出現(xiàn)，所以這幾個月的周期都需依照指示服藥。癥狀符合嚴重PMS/PMDD時，應(yīng)鼓勵病人去看醫(yī)生評估，接受處方藥的治療。50Course

OverviewIntroductionofthemenstrualcycleDysmenorrheaPremenstrualsyndrome(PMS)Toxicshocksyndrome(TSS)

毒性休克癥候群Otherdisorders51Introduction:TSSArare,life-threateningcomplicationofbacterialinfections.OftenresultsfromtoxinsofStaphylococcusaureus(staph)orgroupAstreptococcus(strep)bacteriaMenstrual

TSS

affectyoungwomen(13-19y/o).Occurwithin2daysoftheonsetofmenses,duringmenses,orwithin2daysaftermenses.RiskfactorsUseofhigh-absorbencytampon.Useofbarrier

contraceptives.

52PathophysiologyofTTSStaphylococcusaureusorStreptococcuspyogenesBacteriaproliferationMenstrualbloodservesasamediumofbacteriagrowth.Tamponcausesbloodretentioninvagina.Somefiberinhibitlactobacilli.SuperantigentoxinTSST-1

productionElevatedProteinlevelpH=7ElevatedCO2levelElevatedO2levelTSST-1

triggersimmuneresponse,productinginterleukin-1

&TNF,causinginflammatoryeffect53MenstrualbloodTamponBloodretention54棉條棉墊優(yōu)點可避免外漏，較少異味皮膚不易發(fā)炎體積小、較輕薄適合運動量大的女性感染TSS機率較低價位較低缺點因為是置入性產(chǎn)品，

感染TSS的機率比較高價位較高皮膚可能因長期潮濕而起疹子或過敏，并產(chǎn)生難聞異味體積較大運動受限多棉條(Tampons)vs棉墊(Pad)ProdromalsymptomsMalaise,Myalgia,ChillRash：Sunburn-like,diffuse,notpruriticGIsymptoms：Vomiting,DiarrheaFull-blownTSSFever,Hypotension,Shock,Myalgia,Cardiacinvolvement,Respiratorydistress,Decreasedurineoutput,Neurologicmanifestations,Acuterenalfailure.Desquamationoftheskin2-3dayspriortoTSS5-12daysaftertheonsetofTSS55ClinicalPresentationEarlyintheillnessTSSevolvesrapidlyWhatCanWedo…仔細評估。若病人來有這些類似流行性感冒癥狀(發(fā)燒、嘔吐、腹瀉、暈眩)，或皮膚有不正常皮膚紅疹，若有藥師評估有TSS疑慮，盡快就醫(yī)，避免用NS