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中华妇幼临床医学杂志(电子版)

Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition) ›› 2023, Vol. 19 ›› Issue (06): 621 -628. doi: 10.3877/cma.j.issn.1673-5250.2023.06.001

Standard·Proposal·Guideline

Tiered medical process for health management of climacteric women in primary medical institutions (2023)

Linglingli Kong1, Qing Chang2, Yan Ding3, Yun Feng4, Hui Huang5, Ping Lu6, Yi Lin7, Jun Li8, Jing Zhang1, Liangzhi Xu1,†()   

  1. 1. Department of Obstetrics and Gynecology, Key Laboratory of Birth Defects and Related Disease of Women and Children, Ministry of Education, Reproductive Endocrinology and Regulation Laboratory, West China Second University Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
    2. Department of Obstetrics and Gynecology, the Southwest Hospital of Army Medical University, Chongqing 400038, China
    3. Department of Obstetrics and Gynecology, the First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, Xinjiang Uygur Autonomous Region, China
    4. Department of Gynecological Reproduction, the First People′s Hospital of Yunnan Province, Kunming 650034, Yunnan Province, China
    5. Reproductive Medical Center, Guizhou Rui De Er Maternity Hospital, Guiyang 550002, Guizhou Province, China
    6. Department of Gynecology, Xinjiang Uygur Autonomous Region People′s Hospital, Urumqi 830001, Xinjiang Uygur Autonomous Region, China
    7. Department of Gynecological Endocrinology, Chongqing Health Center for Women and Children, Chongqing 401147, China
    8. Reproductive Medical Center, Hefei BOE Hospital, Hefei 230012, Anhui Province, China
  • Received:2023-06-22 Revised:2023-11-02 Published:2023-12-01
  • Corresponding author: Liangzhi Xu
  • Supported by:
    Projects of Key Research and Development Program of Science and Technology Department of Sichuan Province(2019YFS0030, 2020YFS0130, 2021YFS0127)
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Climacteric is an important physiological period for women. With China entering an aging society, the number of climacteric women is increasing year by year, leading to a growing demand for climacteric health services. However, most primary medical institutions have not set up climacteric health care clinic, and primary gynecologists are generally lack of climacteric health management knowledge. Based on the principles of tiered medical services, experts in gynecological endocrinology in western China developed Tiered Medical Process for Health Management of Climacteric Women in Primary Medical Institutions (2023), which is concise and easy to master and operate for the first time, so as to make gynecologists in primary medical institutions master the efficient and standardized climacteric health assessment and management methods, aiming to provide reference for climacteric health care in primary medical institutions.

Key words: Climacteric, Depressive disorder, major, Health records, personal, Tiered medical services, Referral and consultation, Patient transfer, Menopausal hormone therapy, Women
表1 更年期女性典型症状
典型症状 主要表现
月经改变 ①多为月经周期紊乱，月经量减少，最后绝经；②部分为月经量增多，大出血或出血淋漓不尽；③少数为月经突然停止
血管舒缩症状 潮热、出汗
神经精神症状 ①激动、易怒、焦虑、多疑、情绪低落、不能自我控制等情绪症状；②记忆力减退、注意力不集中
泌尿生殖道症状 ①外阴瘙痒、阴道干燥疼痛、性交困难；②子宫和(或)阴道壁脱垂、尿频、尿急、尿失禁及反复尿路感染
心血管症状 ①心慌、胸闷，少数伴有血压轻度升高；②需与心血管疾病相鉴别
骨质疏松 腰、背、四肢酸痛，驼背、身高变矮、脱牙、骨关节痛
表2 改良Kupperman评分量表
症状 症状严重程度评分(分) 系数
0 1 2 3
潮热、出汗 无 <3次/d 3～9次/d ≥10次/d ×4
感觉异常 无 与天气有关 平常有冷、热、痛、麻木感 冷、热、痛感丧失 ×2
失眠 无 偶尔 经常，安眠药有效 影响工作、生活 ×2
情绪波动 无 偶尔 经常，无自知觉 自知，不能自控 ×2
抑郁、多疑 无 偶尔 经常，能自控 失去生活信心 ×1
眩晕 无 偶尔 经常，不影响生活 影响生活 ×1
疲乏 无 偶尔 上4楼困难 日常生活受限 ×1
骨、关节痛 无 偶尔 经常，不影响功能 功能障碍 ×1
头痛 无 偶尔 经常，能忍受 需服药 ×1
心悸 无 偶尔 经常，不影响 需治疗 ×1
皮肤蚁走感 无 偶尔 经常，能忍受 需治疗 ×1
性生活 正常 性欲下降 性生活困难 性欲丧失 ×2
泌尿道感染 无 偶尔 >3次/年，能自愈 >3次/年，需服药 ×2
表3 焦虑自评量表频度评分(分)
症状 无/偶尔 小部分 相当多 大多/全部
比平常容易紧张和着急 1 2 3 4
无缘无故感到害怕 1 2 3 4
容易烦乱或觉得惊恐 1 2 3 4
可能将要发疯 1 2 3 4
一切都好，也不会发生不幸 4 3 2 1
手脚发抖、打颤 1 2 3 4
因为头、颈部与背痛而苦恼 1 2 3 4
容易衰弱和疲劳 1 2 3 4
心平气和，容易安静坐着 4 3 2 1
心跳很快 1 2 3 4
因为一阵阵头晕而苦恼 1 2 3 4
有晕倒发作或要晕倒似的 1 2 3 4
呼气、吸气平稳 4 3 2 1
手脚麻木和刺痛 1 2 3 4
因胃痛和消化不良而苦恼 1 2 3 4
尿频 1 2 3 4
手干燥、温暖 4 3 2 1
脸红、发热 1 2 3 4
睡眠很好 4 3 2 1
常做噩梦 1 2 3 4
表4 抑郁自评量表频度评分(分)
症状 无/偶尔 小部分 相当多 大多/全部
闷闷不乐，情绪低沉 1 2 3 4
一天中早晨情绪最好 4 3 2 1
哭或想哭 1 2 3 4
晚上睡眠不好 1 2 3 4
吃得跟平常一样多 4 3 2 1
与异性密切接触时和以往一样感到愉快 4 3 2 1
觉得体重下降 1 2 3 4
有便秘的苦恼 1 2 3 4
心跳比平常快 1 2 3 4
无缘无故感到疲乏 1 2 3 4
头脑跟平常一样清楚 4 3 2 1
做事情无困难 4 3 2 1
觉得不安而平静不下来 1 2 3 4
对将来抱有希望 4 3 2 1
容易生气、激动 1 2 3 4
做决定容易 4 3 2 1
觉得自己有用，有人需要我 4 3 2 1
生活有意思 4 3 2 1
若我死了，别人会过得好些 1 2 3 4
平常感兴趣的事仍然感兴趣 4 3 2 1
表5 绝经激素治疗的适应证、禁忌证和慎用情况
绝经激素治疗 相关症状
适应证 ①绝经相关症状：月经紊乱、潮热、多汗、睡眠障碍、疲倦、情绪障碍等；②生殖泌尿道萎缩相关症状：阴道干涩，外阴与阴道疼痛、瘙痒，性交痛，反复发作的萎缩性阴道炎，反复下尿路感染，夜尿、尿频、尿急等；③低骨量及骨质疏松症：存在骨质疏松症的危险因素及绝经后骨质疏松症；④过早的低雌激素状态：POI、下丘脑垂体性闭经、手术绝经等
禁忌证 ①已知或可疑妊娠；②原因不明性阴道出血；③已知或可疑患乳腺癌；④已知或可疑患性激素依赖性恶性肿瘤；⑤最近6个月内患活动性静脉或动脉血栓栓塞性疾病；⑥严重肝肾功能不全
慎用情况 ①子宫肌瘤；②子宫内膜异位症和子宫腺肌病；③子宫内膜增生病史；④血栓形成倾向；⑤胆结石；⑥免疫系统疾病；⑦乳腺良性疾病及乳腺癌家族史；⑧癫痫、偏头痛、哮喘；⑨血卟啉症、耳硬化症；⑩现患脑膜瘤(禁用孕激素)
图1 《基层医院更年期妇女健康分级管理流程建议(2023)》的更年期妇女健康分级管理简明流程图 注：POF为卵巢早衰，POI为早发性卵巢功能不全
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