异常子宫出血病因及子宫内膜恶变和不典型增生的相关因素分析

Etiology of abnormal uterine bleeding and analysis of risk factors associated with endometrial malignancy and atypical hyperplasia

摘要

目的 探讨异常子宫出血(AUB)的病因,以及子宫内膜恶变和不典型增生所致AUB(AUB-M)的相关因素。方法 选择2019年6月至2023年6月就诊于湖北医药学院附属国药东风总医院的609例AUB患者为研究对象.按照国际妇产科联盟的AUB病因分类将患者分为子宫内膜息肉所致AUB(AUB-P)(n=155)、子宫腺肌病所致AUB(AUB-A)(n=36)、子宫平滑肌瘤所致AUB(AUB-L)(n=33)、AUB-M(n=31)、全身凝血相关疾病所致AUB(AUB-C)(n=2)、排卵障碍所致AUB(AUB-O)(n=316)、子宫内膜局部异常所致AUB(AUB-E)(n=3)、医源性所致AUB(AUB-I)(n=15)、其他病因所致AUB(AUB-N)(n=18);按照年龄将患者分为青春期组(10~19岁,n=140)、生育期组(20~39岁,n=214)、绝经过渡期组(≥40岁,n=255);再按照年龄将患者分为<40岁组(n=268)、40~50岁组(n=269)、>50岁组(n=72);将患者按照子宫内膜病理类型分为子宫内膜息肉(EP)组(n=155)、子宫内膜增生不伴不典型增生(EH)组(n=10)、子宫内膜不典型增生(AH)组(n=12)、子宫内膜癌(EC)组(n=9),再将EP、EH、AH设为子宫内膜良性病变组.记录患者的临床一般资料,分析AUB的病因、比较不同子宫内膜病理类型患者的临床资料,采用Logistic回归分析AUB-M的相关因素。结果 在609例AUB患者中,AUB患者病因分类中以AUB-O最为常见(51.89%),其次为AUB-P(25.45%),最少见的是AUB-C(0.33%).青春期组和生育期组及绝经过渡期组AUB-P(χ²=46.442)、AUB-A(Fisher法P=0.006)、AUB-M(Fisher法P<0.001)、AUB-O(χ²=106.888)分类的患病率比较,差异均有统计学意义(P<0.05);青春期组AUB-O分类最为常见(90.00%),高于生育期组(37.85%)和绝经过渡期组(42.75%).不同年龄组EH(Fisher法P<0.001)、AH(Fisher法P<0.001)、EC(Fisher法P<0.001)的患病率比较,差异均有统计学意义,且>50岁组EH、AH、EC的患病率均高于其他两个年龄组.EP组、EH组、AH组和EC组患者年龄(F=4.908)、体质量指数(BMI)(F=3.901)、腰臀比(F=2.203),以及糖尿病史(Fisher法P<0.001)和高血压史(Fisher法P=0.009)分布比例比较,差异均有统计学意义(P<0.05).多因素Logistic回归分析显示,年龄增加(≥50岁,OR=2.345)、超重(OR=1.865)或肥胖(OR=2.698)、腰臀比≥0.85(OR=2.027)、有糖尿病史(病程≥5年,OR=3.025)和高血压史(病程≥5年,OR=2.775)均是AUB-M发生的危险因素(P<0.05).在609例AUB患者中,EC患者9例(1.48%),与子宫内膜良性病变组(EP、EH、AH)比较,EC组患者的年龄(t=4.126,P<0.05)、BMI(t=3.567,P<0.05)、腰臀比(t=2.146,P<0.05)更高,病程更长(t=4.521,P<0.05),糖尿病史(Fisher法P<0.001)和高血压史(Fisher法P=0.003)所占比例也更高。结论 不同年龄AUB患者病因分类存在差异,青春期女性以AUB-O为主,生育期和绝经过渡期除AUB-O外,还易发生子宫器质性疾病.超重或肥胖、腰臀比≥0.85、糖尿病史和高血压史≥5年的绝经过渡期女性应警惕子宫内膜恶性病变.

Abstract

Objective To explore the etiology of abnormal uterine bleeding (AUB) and the related factors of AUB caused by endometrial malignancy and atypical hyperplasia (AUB-M). Methods A total of 609 women with AUB who were admitted to Sinopharm Dongfeng General Hospital Affiliated to Hubei University of Medicine of Shiyan City from June 2019 to June 2023 were selected as the study subjects. According to the International Federation of Gynecology and Obstetrics (FIGO) classification of AUB causes, the patients were divided into the following groups: AUB due to endometrial polyp (AUB-P) (n=155), AUB due to adenomyosis (AUB-A) (n=36), AUB due to leiomyoma (AUB-L) (n=33), AUB-M (n=31), AUB due to coagulopathy (AUB-C) (n=2), AUB due to ovulatory dysfunction (AUB-O) (n=316), AUB due to endometrial causes (AUB-E) (n=3), AUB due to iatrogenic causes (AUB-I) (n=15), and AUB due to not yet classified causes (AUB-N) (n=18). According to age, patients were divided into the adolescent group (10-19 years, n=140), reproductive-age group (20-39 years, n=214), and perimenopausal group (≥40 years, n=255). Patients were further grouped as <40 years (n=268), 40-50 years (n=269), and >50 years (n=72). According to endometrial pathological type, patients were categorized into the endometrial polyp (EP) group (n=155), endometrial hyperplasia without atypia (EH) group (n=10), atypical endometrial hyperplasia (AH) group (n=12), and endometrial carcinoma (EC) group (n=9). EP, EH, and AH were defined as benign endometrial lesions. Patients' general clinical data were recorded. The etiologies of AUB were analyzed, clinical data among different endometrial pathological types were compared, and Logistic regression analysis was used to identify the risk factors of AUB-M. Results Among the 609 AUB patients, AUB-O was the most common etiology (51.89%), followed by AUB-P (25.45%), while AUB-C was the least common (0.33%). Comparison of prevalence of AUB-P (χ ²=46.442), AUB-A (Fisher's exact test P=0.006), AUB-M (Fisher's exact test P<0.001), and AUB-O (χ²=106.888) across the adolescent, reproductive-age, and perimenopausal groups showed statistically significant differences (P<0.05). AUB-O was most prevalent in the adolescent group (90.00%), higher than in the reproductive-age group (37.85%) and perimenopausal group (42.75%). The prevalence of EH (Fisher's exact test P<0.001), AH (Fisher's exact test P<0.001), and EC (Fisher's exact test P<0.001) differed significantly across age groups, with higher prevalence in the >50 years group compared with the other two groups. Comparisons among EP, EH, AH, and EC groups revealed significant differences in age (F=4.908), body mass index (BMI) (F=3.901), waist-to-hip ratio (WHR) (F=2.203), history of diabetes (Fisher's exact test P<0.001), and history of hypertension (Fisher's exact test P=0.009) (all P<0.05). Multivariate Logistic regression analysis showed that increased age (≥50 years, OR=2.345), overweight (OR=1.865) or obesity (OR=2.698), WHR≥0.85 (OR=2.027), history of diabetes (duration≥5 years, OR=3.025), and history of hypertension (duration≥5 years, OR=2.775) were independent risk factors for AUB-M (P<0.05). Among the 609 AUB patients, there were 9 cases of EC (1.48%). Compared with the benign endometrial lesion group (EP, EH, AH), patients in the EC group had higher age (t=4.126, P<0.05), higher BMI (t=3.567, P<0.05), higher WHR (t=2.146, P<0.05), longer disease duration (t=4.521, P<0.05), and higher proportions of diabetes (Fisher's exact test P<0.001) and hypertension (Fisher's exact test P=0.003). Conclusion The etiology of AUB varies across different age groups. In adolescents, AUB-O is predominant, while in reproductive-age and perimenopausal women, in addition to AUB-O, organic uterine diseases are also common. Perimenopausal women who are overweight or obese, have WHR≥0.85, and have a history of diabetes or hypertension lasting ≥5 years should be vigilant regarding endometrial malignancy.

关键词

异常子宫出血 / 病因分类 / 绝经过渡期 / 子宫内膜恶变 / 相关因素

Key words

abnormal uterine bleeding / etiological classification / menopausal transition / endometrial malignancy / related factor

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