BLEAR BLEEDING DYSFUNCTIONAL

Uterine bleeding disorders are caused by a disturbance of the functional state of the hypothalamus-pituitary-ovary-adrenal system that regulates the hormonal function of the ovaries. Dysfunctional uterine bleeding (DMC) occurs acyclic at intervals of 1.5-6 months, usually lasting more than 10 days. They are observed mainly during periods of the formation and withering of the reproductive system: in the period of puberty (juvenile bleeding) and in premenopause. They can also occur in the reproductive period under stresses, infections, intoxications and, as a rule, have anovulatory nature.

Juvenile bleeding accounts for 10-12% of all gynecological diseases observed at the age of 12 to 18 years. In their pathogenesis, a certain role belongs to the infectious-toxic effect on the hypothalamic structures that have not reached functional maturity, which regulate the function of the ovaries. Especially unfavorable effect of tonsillogenic infection. A certain role is played by mental trauma, physical overload, malnutrition (in particular, hypovitaminosis).

Juvenile bleeding is characterized by a special type of anovulation, in which atresia occurs in follicles that have not reached the ovulatory degree of maturity. In this case, expressed hyperplastic changes in the endometrium, as a rule, does not occur. Long bleeding is also promoted by insufficient contractile activity of the uterus, which has not yet reached its final development.

Juvenile bleeding is observed more often in the first 2 years after menarche (the first menstruation). The condition of the patient depends on the degree of blood loss and severity of anemia . Characterized by weakness, lack of appetite, fatigue, headaches, pallor of the skin and mucous membranes, tachycardia . Changes in the rheological and coagulation properties of the blood are determined.

Differential diagnosis is carried out with blood diseases, accompanied by increased bleeding, a hormone-active tumor of the ovary, interrupted by pregnancy in persons older than 14-15 years. In case of bleeding disorders, there are indications in the history of nasal bleeding and bleeding after extraction of the teeth, bleeding gums, petechiae, multiple subcutaneous hemorrhages. Very rare cause of bleeding at this age are myoma , sarcoma , cervical cancer.

Of great informative value is the ultrasound, which determines the increase in size and the characteristic echoscopic picture of the contents of the uterine cavity, the shape and size of the ovaries.

Treatment of juvenile bleeding includes two stages: stopping bleeding (haemostasis) and preventing the recurrence of bleeding. The choice of method of hemostasis depends on the patient's condition. In severe conditions, when there are severe symptoms of anemia and hypovolemia (paleness of the skin and mucous membranes, hemoglobin content in the blood below 80 g / l, hematocrit less than 25%) and bleeding continues, surgical hemostasis is shown - scraping endometrium and subsequent histological examination of the scraping. In order to avoid violation of the integrity of the hymen, it is necessary to use children's vaginal mirrors, hymen before the operation to chop the solution dissolved in 0.25% novocaine with lidase. There is also a therapy aimed at eliminating anemia and restoring hemodynamics: transfusion of plasma, whole blood, rheopolyglucin (8-10 ml / kg), prescribe vitamins C and B, iron-containing preparations (ferkovene, ferroplex, conferon, gemostimulin, etc.). Recommended abundant drink, high-grade high-calorie food.

If the patient is of medium severity or satisfactory, when the symptoms of anemia and hypovolemia are not clearly expressed (hemoglobin content in the blood above 80 g / L, hematocrit more than 25%), hemostasis is given by hormonal preparations: estrogen-progestational drugs such as oral contraceptives or pure estrogens followed by Reception of progestins. Estrogen-progestational medications ( non-vellon , ovidon , anovlar, bisekurin) are prescribed for 4-5 tablets per day until bleeding stops, which usually occurs by the end of the first day. Then the dose is reduced to a tablet per day, bringing up to 1 tablet, after which the treatment is continued for 18 days. Menstruation-like discharge after discontinuation of estrogen-progestogen administration is quite abundant; to reduce blood loss, calcium gluconate is administered orally 0.5 g 3 to 4 times a day, if necessary, reducing uterine funds. In the course of conservative hemostasis, anti-anemia therapy is performed: iron-containing preparations, vitamins C and group B are prescribed.

Prevention of recurrence of juvenile uterine bleeding is aimed at the formation of a regular ovulatory menstrual cycle, conducted in outpatient settings. The optimal results were achieved with the use of estrogen-progestational drugs (oral contraceptives). These drugs are prescribed for the first three menstrual cycles of 1 tablet from the 5th to the 25th day from the beginning of the menstrual reaction, then for another three cycles from the 16th to the 25th day of the cycle. Applied also pure gestagens from the 16th to the 25th day of the menstrual cycle for 4 to 6 months, for example, dorroton, diphiston. Of great importance are measures aimed at improving the body:

Sanitation of foci of infection ( dental caries , tonsillitis , etc.), hardening and physical training (outdoor games, gymnastics, skis, skating, swimming), full nutrition with the restriction of fatty and sweet food, vitamin therapy in spring and winter ( Aevit , vitamins B, and C). Patients with juvenile moles should be under the supervision of a gynecologist.

The prognosis with appropriate therapy is favorable. Anemia can have a negative impact on the development of the body during puberty. In the absence of adequate treatment, abnormal ovarian function can lead to infertility (endocrine infertility).

Prevention of juvenile bleeding includes hardening from an early age, physical training, nutrition, reasonable alternation of work and rest, the prevention of infectious diseases, especially sore throats, timely sanation of foci of infection.

Dysfunctional uterine bleeding of the reproductive period accounts for about 30% of all gynecological diseases occurring at the age of 18-45. The causes may be violations of hormonal homeostasis after abortion , with endocrine, infectious diseases, intoxications, stress, taking certain medications (for example, phenothiazine derivatives).

In DMC of the reproductive period, in contrast to juvenile hemorrhages in the ovary, non- atresia occurs rather than follicles with excessive production of estrogens. As a result, hyperplastic changes develop in the endometrium; Mainly glandular-cystic hyperplasia. The risk of developing atypical (adenomatous) hyperplasia and adenocarcinoma (cancer) of the endometrium is increasing.

The clinical picture is determined by the degree of hemorrhage and anemia; With prolonged bleeding develops hypovolemia and there are changes in the blood coagulation system.

Diagnosis is established only after exclusion of diseases and pathological conditions, which can also cause uterine bleeding: abnormal uterine pregnancy , retention of parts of the fetal egg in the uterus, placental polyp, uterine myoma with submucosal or intermuscular arrangement of the node, endometrial polyps, internal endometriosis (adenomyosis), Endometrial cancer, ectopic (tubal) pregnancy (progressive or interrupted by tubal abortion ), polycystic ovaries, damage to the endometrium with intrauterine contraceptives if they are abnormal or due to the formation of pressure sores.

The main stage of diagnosis and differential diagnosis is a separate scraping of the mucous membrane of the cervical canal and the body of the uterus. By the type of scrapes obtained (abundant, polypoid, crumbly), one can indirectly judge the nature of the pathological process in the endometrium. Histologically, with dysfunctional uterine bleeding in women of reproductive age in the endometrium, as a rule, there are hyperplastic processes: glandular-cystic hyperplasia, adenomatosis, atypical hyperplasia. With recurrent bleeding, scraping is performed under the control of hysteroscopy. During hysteroscopy, it is possible to identify polyps and fragments of the mucous membrane of the uterus that are not removed during scraping, myomatous nodes, endometriotic passages. Ultrasound examination allows to evaluate the structure of myometrium, to reveal and determine the sizes of myomatous nodes and foci of internal endometriosis. In addition, ultrasound is important in the diagnosis of uterine and ectopic pregnancy .

Treatment includes surgical haemostasis (scraping) and prevention of bleeding recurrence. Carry out a separate scraping of the mucous membrane of the cervical canal and the body of the uterus (scraping is directed to histological examination). An attempt to stop bleeding in a woman of reproductive age by conservative methods, including with the help of hormonal drugs, should be regarded as a mistake. With anemia and hypovolemia, the same therapy is performed as in these conditions in patients with juvenile bleeding.

To prevent the recurrence of bleeding hormonal preparations are used, the composition and dose of which are selected depending on the results of histological examination of scraping of the endometrium. In the modern gynecological clinic, hormonal therapy with preparations containing estrogens and gestagens (such as oral contraceptives of single or biphasic: rigevidone, ovidon , marvelon, etc., or anteovin, etc., respectively) is established in a modern gynecological clinic, during 3-6 menstrual periods Cycles from the 5th to the 25th day from the beginning of the cycle or the day of scraping. With recurrent and / or atypical hyperplasia, continuous therapy is indicated with preparations of pure progestogens: medroxyprogesterone or 17-hydroxyprogesterone capronate, as well as preparations having an antigonadotropic effect, suppressing the ovarian hormonal function (for example, zaladex). The drugs are prescribed for 3-6 months in a continuous mode with the subsequent histological examination of scraping of the endometrium.

The prognosis with proper treatment is usually favorable. In 3-4% of women who do not receive adequate therapy, the evolution of hyperplastic endometrial processes (adenomatosis, atypical hyperplasia) in adenocarcinoma is possible. Progesterone deficiency is a favorable background for the development of fibrocystic mastopathy , uterine fibroids , endometriosis . The risk of endometriosis increases dramatically with repeated curettage of the uterine mucosa.

Prevention is the same as with juvenile bleeding. Effective preventive measures include the use of oral contraceptives, which not only reduce the incidence of unwanted pregnancies and, consequently, abortion , but also inhibit proliferative processes in the endometrium.

Dysfunctional uterine bleeding in the menopause (premenopausal) period in women 45 to 55 years old is the most frequent gynecological pathology. These bleedings occur due to age-related changes in the functional state of hypothalamic structures that regulate ovarian function. Such hyperplastic processes as atypical hyperplasia, adenomatosis, in premenopause occur much more often than in the reproductive age.

The condition of patients as well as with dysfunctional uterine bleeding of other age periods is determined by the degree of hypovolemia and anemia. But, given the high incidence of concomitant diseases and metabolic-endocrine disorders ( hypertension , obesity , hyperglycemia), these bleeding in women aged 45 to 55 years is more severe than in other age periods.

The diagnosis is difficult, as in the menopausal period the incidence of endometriosis , myoma and adenocarcinoma of the uterus, endometrial polyps, causing uterine bleeding, whose acyclic nature may be due to age- related anovulation, increases .

To detect organic intrauterine pathology, separate scraping of the mucous membrane of the cervical canal and the uterus body is performed. After this, hysteroscopy, hysterography and ultrasound of the uterus and ovaries are performed. The latter allows one to identify an increase in one of them, which should be regarded as a sign of a hormone-active tumor.

The main curative measure is a separate scraping of the mucous membrane of the cervical canal and the body of the uterus. The use of conservative hemostasis with hormonal drugs before scraping is unacceptable. In the future, the tactics of treatment is determined by the presence of concomitant gynecological pathology, diseases of other organs and systems, the age of the patient. Absolute indication for the removal of the uterus is a combination of dysfunctional uterine bleeding with recurrent adenomatous or atypical endometrial hyperplasia, a nodose form of the endometriosis (adenomyosis) of the uterus, submucous uterine myoma .

To prevent the recurrence of bleeding in the period after scraping, only pure gestagens are used. It should be taken into account that therapy with preparations of gestagens and estrogens at any age is contraindicated in thrombophlebitis , varicose veins of the lower extremities and rectum, chronic hepatitis and cholecystitis , cholelithiasis , chronic pyelonephritis . Relative contraindications to their reception are expressed obesity , hypertension (with blood pressure above 160/100 mm Hg), heart disease accompanied by edema.

The drugs are administered continuously for 3 to 6 months under the control of the endometrial condition by ultrasound (a vaginal sensor). In recent years, women with DMC in the climacteric age over 50 years of age use endometrial resection with a special resectoscope device. Under the vision control, the lining of the uterus is resected with a laser knife, after which the walls of its cavity undergo cicatricial changes and the cavity itself is partially or completely obliterated.

The prognosis for correct treatment is favorable in many cases. However, the risk of developing adenomatous and atypical changes in the endometrium and adenocarcinoma from the hyperplastic endometrium is high (the rate of development of these processes in premenopausal bleeding can reach 40%). Factors that increase the risk of the transition of glandular-cystic hyperplasia to adenomatous and atypical, as well as to adenocarcinoma, are obesity , clinically expressed diabetes , arterial hypertension . It was found that in women who used oral contraceptives, dysfunctional uterine bleeding during the premenopause is very rare; Therefore, oral contraception can be considered as a prophylaxis for these bleedings.