1. Protocols for the diagnosis and treatment of diseases of the Ministry of Health of the Republic of Kazakhstan (Order No. 764 of 28.12.2007)
   1. 1. Miscarriage and miscarriage of pregnancy // A guide for doctors and interns / Okhapkin MB, Khitrov MV, Ilyashenko I.N.-Yaroslavl 2002, p34 2. Obstetric bleeding / Methodical recommendations.- Bishkek, 2000, p. .13 3. Providing care in complicated pregnancy and childbirth. / Guide for midwives and doctors. Reproductive Health and Research, WHO, Geneva, 2002 4.Daylene L. Ripley MD. Atony, Invertion, and Rupture. Emergent Care Uterine Emergencies. Obstetrics and Gynecology Clinics, V.26, No. 3, Sept. 1999 5. Allan B MacLean, James Neilson. Maternal Morbility and Mortality. Report Of WHO, 2000 6.University of Iowa Family Practice Handbook, Fourth Edition, 2002 7.McDonald S, Prendiville WJ, Elbourne D Prophylactic syntometrine vs oxytocin in the third stage of labor (Cochrane Review) The Cochrane Library, 1998, 2, Update Software Oxford, Prendiville 1996 8. Prendiville WJ, The prevention of post partum haemorrhage: optimizing routine management of the third stage of labor Eur J Obstet Gynecol Reprod Biol, 1996, 69, 19-24 9.Khan GQ, John IS, Chan T, Wani S, Hughes AO, Stirrat GM Abu Dhabi third stage trial: oxytocin versus Syntometrine in the active management of the third stage of labor Eur J Obstet Gynaecol and Reprod Biol, 1995, 58, 147-51 10. K. Niswander, A. Evans. Obstetrics / UCLA Handbook, 1999 11. Managing Complications in Pregnancy and Childbirth: a Guide for midwives and doctors. Department of Reproductive Health and Reserch Family and Community Health. World Health Organization, Geneva, 2003 12. Postpartum Haemorrage Module: Education Material for teachers of Midwifery. Maternal Health and Safe Motherhood Program. Family and Reproductive Health. World Health Organization, Geneva, 1996 13. Haemorrage: Intervention Group 6. Mother-Baby Package Spreadsheet. Family and Reproductive Health. World Health Organization, Geneva, 1999 14. Prendeville WD, Elbourne D, Macdonald S. Active management of third stage labor versus expectant (Cochrane Library Abstract, Issue 1, 2003). 15. Caroli G., Bergel E. Injections into the umbilical cord vein to eliminate the placental defect / placental remnants (Abstract of the Cochrane library, issue 1, 2003) .16.15 Vorobiev A. Hematology in the fight for human life 2005.-№9. pp. 2-5. 16.Eliasova L.G. Indicators of maternal mortality as criteria for the quality and level of organization of the work of obstetric institutions. // St. Petersburg State Pediatric medical Academy 10.02.06.-p.1-3. 17 Barbara Shane. Outlok: Maternal and Neonatal Health Special. // Issue 19, number 3 18.Sara Mackenzie MD Obstetrics: late antenatal haemorrhage. // Leadership of the University of Yova Family Medicine. Ed. 4, chapter 14.

Information

Bazylbekova Z.O. d.m.s. Head of the Department of Pregnant Women with Obstetric Pathology and Extragenital Diseases of the Republican Scientific Research Center for Maternal and Child Health (RNITsOZMiR).

Nauryzbaeva B.U. d.m.s. Department of Physiology and Pathology of Childbirth of the Republican Scientific Research Center for Maternal and Child Health Protection (RNICOZMiR).

UTERINE DYSFUNCTIONAL BLEEDING honey.
Dysfunctional uterine bleeding (DMC) is bleeding due to pathology of endocrine regulation, not associated with organic causes, most often arising in connection with anovulatory cycles (90% DMC). Provided that at least 2 years have passed since menarche, DMC refers to regular menstrual cycles with heavy bleeding lasting more than 10 days; a menstrual cycle of less than 21 days and an irregular menstrual cycle. As a rule, DMC is accompanied by anemia.
Frequency - 14-18% of all gynecological diseases... Prevailing age: 50% of cases are over 45 years old (premenopausal and menopausal periods), 20% - adolescence (menarche).

Etiology

Spotting in the middle of the cycle - a consequence of a decrease in estrogen production after ovulation
Frequent menstruation is a consequence of the shortening of the follicular phase due to inadequate feedback from the hypothalamic-pituitary system
Shortening of the luteal phase - premenstrual spotting or polymenorrhea due to a premature decrease in progesterone secretion; the result of insufficient functions of the corpus luteum
Prolonged activity of the corpus luteum is a consequence of the constant production of progesterone, which leads to a lengthening of the cycle or prolonged bleeding
Anovulation - excess estrogen production, not associated with the menstrual cycle, not accompanied by cyclic production of LH or secretion of progesterone by the corpus luteum
Other causes are damage to the uterus, leiomyoma, carcinoma, vaginal infections, foreign bodies, ectopic pregnancy, cystic drift, endocrine disorders (especially dysfunction thyroid gland), blood dyscrasia. Pathomorphology. Depends on the cause of the DMK. Necessarily pathohistological study of endometrial preparations.

Clinical picture

Uterine bleeding, irregular, often painless, the volume of blood loss is variable.
The absence of:
Manifestations of systemic diseases
Dysfunctions of the urinary system and gastrointestinal tract
Long-term use of aspirin (acetylsalicylic acid) or anticoagulants
Applications hormonal drugs
Diseases of the thyroid gland
Galactorrhea
Pregnancy (especially ectopic)
Signs of malignant neoplasms of the genital organs.

Laboratory research

Needed in case of suspicion of other endocrine or hematological disorders, as well as in patients in the premenopausal period
They include an assessment of thyroid function, a complete blood count, determination of PT and PTT, chorionic gonadotropin (to exclude pregnancy or cystic drift), diagnosis of hirsutism, determination of prolactin concentration (in the case of pituitary dysfunction).

Special studies

Special tests to determine the presence of ovulation and its timing
Measurement of basal temperature to detect anovulation
Determination of the pupil phenomenon
Definition of the fern phenomenon
Symptom of tension in cervical mucus
Pap smear
Ultrasound to check for an ovarian cyst or uterine tumor
Transvaginal ultrasound - in case of suspicion of pregnancy, anomalies in the development of the genitals, polycystic ovaries
Endometrial biopsy
All patients over 35 years old:
With obesity
With diabetes mellitus
When arterial hypertension
Curettage of the uterine cavity - with a high risk of endometrial hyperplasia or carcinoma. If endometritis, atypical hyperplasia, and carcinoma are suspected, curettage of the uterine cavity is preferable to endometrial biopsy.

Differential diagnosis

Liver disease
Hematological diseases (von Willebrand disease, leukemia, thrombocytopenia)
Iatrogenic causes (damage, drift of infection)
Intrauterine spirals
Taking drugs (oral contraceptives, anabolic steroids, glucocorticoids, anticholinergic drugs, digitalis drugs, anticoagulants)
Pregnancy (ectopic), spontaneous abortion
Diseases of the thyroid gland
Trauma
Uterine cancer
Leiomyoma of the uterus.

Treatment:

Mode. Outpatient; hospitalization for severe bleeding and hemodynamic instability.

Surgery

Emergencies (profuse bleeding, severe hemodynamic disturbances)
Curettage of the uterine cavity with DMC of the reproductive and climacteric periods
Removal of the uterus is indicated only in the presence of concomitant pathology.
Conditions that do not require urgent care - curettage of the uterine cavity is indicated with the ineffectiveness of drug treatment.

Drug therapy

Drugs of choice
In case of emergency (severe bleeding; hemodynamic instability)
Conjugated estrogens 25 mg IV every 4 hours, maximum 6 doses allowed
After stopping bleeding - medroxy-progesterone acetate 10 mg / day for 10-13 days or oral combined contraceptives containing 35 mg of ethinyl estradiol or its equivalent
Correction of anemia - replacement therapy with iron preparations.
For conditions that do not require emergency treatment
Estrogen hemostasis - folliculin 10,000-20,000 IU or ethinylestradiol 0.05-0.1 mg, or estrone 1-2 ml 0.1% solution IM every 3-4 hours - 4-5 injections day. Then the dose is gradually reduced over 5-7 days (up to 10,000 IU of folliculin) and continue to be administered for 10-15 days, and then 10 mg of progesterone is injected over 6-8 days
Progesterone hemostasis (contraindicated in moderate and severe anemia) - medroxyprogesterone 10 mg / day for 6-8 days or 20 mg / day for 3 days
Oral contraceptives - on the first day, 1 tablet after 1 hour until the bleeding stops (no more than 6 tablets), then 1 tablet / day is reduced daily. Continue taking 1 tablet / day until 21 days, after which they stop taking it, which provokes a menstrual-like reaction.
Alternative drug
Progesterone instead of medroxy-lrogesterone
100 mg oil solution progesterone in / m - for emergency stop bleeding; not used in cyclic therapy
Vaginal suppositories should not be used because dosing drugs in this case is difficult
Danazol - 200-400 mg / day. May cause virilization; mainly used in patients with the forthcoming extirpation of the uterus.
Contraindications

Treatment

carried out only after excluding other causes of uterine bleeding
Blind hormone therapy is not recommended.

Precautions

... If bleeding continues after the therapy, additional examination is necessary. Estrogens are not indicated in the perimenopausal period and when endometrial cancer is suspected. With juvenile DMC, curettage is necessary to exclude endometrial cancer, and with DMC of the climacteric period, hormones are not prescribed until the results of histological examination are obtained.
Observation of the patient. All women receiving estrogens for DMK should keep a diary to record abnormal bleeding and monitor the effectiveness of therapy.

Complications

Anemia
Uterine adenocarcinoma with prolonged unreasonable estrogen therapy. Course and forecast
Vary depending on the cause of the DMK
Possibly effective in young women drug treatment DMC with no surgery / Pregnancy. DMC must be differentiated from ectopic pregnancy or hydatidiform mole.
See also, Dysmenorrhea Reduction. DMC - dysfunctional uterine bleeding ICD N93.8 Other specified abnormal bleeding from the uterus and vagina

Handbook of diseases. 2012 .

See what "UTERINE DYSFUNCTIONAL BLEEDING" is in other dictionaries:

dysfunctional uterine bleeding - (h. uterina dysfunctionalis) K. m. in disorders menstrual cyclecaused by hormonal dysregulation ... Large Medical Dictionary

Uterine bleeding - The request for Bleeding from female genital organs is forwarded here. Uterine bleeding ICD 10 N92 N93 Uterine bleeding is different in etiology and the nature of the discharge of blood from the uterus. Bleeding can be caused by various ... ... Wikipedia

Female genital bleeding - The request for Bleeding from female genital organs is forwarded here. Uterine bleeding ICD 10 N92 N93 Uterine bleeding is different in etymology and the nature of the discharge of blood from the uterus. Bleeding can be caused by various ... ... Wikipedia

Honey. Hyperplasia is an increase in the number of cells in any tissue (with the exception of a tumor) or organ, as a result of which the volume of this anatomical formation or organ increases. There are several types of glandular proliferation with different ... ... Handbook of diseases

DCMK - dysfunctional menopausal uterine bleeding ... Dictionary of abbreviations of the Russian language

Honey. The perimenopausal period is the period of a woman's life, characterized by a natural age-related extinction of the functions of the reproductive system. Includes premenopausal, menopause and 2 years postmenopausal. The terms menopause, climacteric ... Disease Handbook - Dysfunctional climacteric uterine bleeding honey. Dictionary: S. Fadeev. Dictionary of abbreviations of the modern Russian language. S. Pb .: Polytechnic, 1997.527 p ... Dictionary of abbreviations and acronyms

RCHD (Republican Center for Healthcare Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols MH RK - 2013

Heavy and frequent menses with regular cycle (N92.0)

Obstetrics and Gynecology, Urology

general information

Short description

Blood loss of more than 80 ml or lasting more than 7 days ( menometrorrhagia), which manifests itself at irregular and shorter intervals (WHO, UK National Institute for Health and Clinical Excellence).

INTRODUCTORY PART

Protocol name: "Heavy, frequent and irregular menstruation (dysfunctional uterine bleeding)"
Protocol code:

ICD-10 code (s):N92 Heavy, frequent and irregular menses

Abbreviations used in the protocol:
OMT - pelvic organs
ESR - erythrocyte sedimentation rate
Ultrasound - ultrasound examination
COC - combined oral contraceptives
HELL - blood pressure

Protocol development date:april 2013

Protocol users:obstetricians-gynecologists

No Conflict of Interest Statement:no conflict of interest

Classification

Clinical classification:
N92 Heavy, frequent and irregular menses
N92.1 Heavy and frequent menstruation with irregular cycle

Diagnostics

METHODS, APPROACHES AND PROCEDURES OF DIAGNOSTICS AND TREATMENT

List of basic and additional diagnostic measures

The main diagnostic measures:
1. Laboratory research:
- Wasserman reaction;
- determination of blood group and Rh factor;
- complete blood count (hemoglobin, erythrocytes, hematocrit, platelets, leukocytes, color index);
- general urine analysis;
- coagulogram (prothrombin time, fibrinogen, thrombin time, APT, plasma fibrinolytic activity);
- examination of smears for gonorrhea, trichomoniasis and the degree of cleanliness of the vagina.
2. Ultrasound of the female genital organs.
3. Separate diagnostic curettage with histological examination.
4. Hysteroscopy.

Additional diagnostic tests:
- determination of glucose;
- ultrasound of the thyroid gland to exclude thyroid pathology;
- ELISA for STIs;
- determination of thyroid hormones;
- determination of hormones of the reproductive system.

Diagnostic criteria

Complaints and anamnesis:
- Prolonged and profuse bleeding during menstruation (usually more than 7 days). Bloody discharge is irregular;
- weakness, dizziness, decreased performance.

Physical examination:
- inspection in mirrors;
- determination of the size of the uterus and appendages in a bimanual examination.

Laboratory research:a general blood test - a decrease in the level of hemoglobin (n 110 g / l), erythrocytes (n 3.9 - x 10 12 / l), hematocrit (n 0.36 l / l).

Instrumental research: Ultrasound of the female genital organs.

Indications for specialist consultation:
- Consultation of an endocrinologist with concomitant endocrine diseases
- Consultation with an oncologist for suspected malignant processes (diagnosed neoplasms of the cervix, adenocarcinoma)

Differential diagnosis

Differential diagnosis is carried out with the following diseases:

1. Complications of pregnancy:

Ectopic pregnancy
- Incomplete abortion
- miscarriage
- Threatened abortion

2. Minor bleeding:
- Ectropion of the cervix / erosion
- Neoplasia of the cervix / polyp
- Cervical or vaginal trauma
- Condylomas
- Atrophic vaginitis
- Foreign bodies

3. Pelvic inflammatory disease:
- Endometritis
- Tuberculosis

4. Uterine fibroids

DMK	Complications of pregnancy	Insufficient bleeding	Pelvic inflammatory disease	Myoma of the uterus
There are no delays in menstruation. Bleeding acyclic.	Bleeding is preceded by a delay in menstruation	Post-coital bleeding	There are no delays in menstruation	There are no delays in menstruation. Cyclic bleeding.
Endometrial hyperplasia according to ultrasound	Fertile egg	Polyps of the cervix, the presence of a foreign body.	Signs of chronic endometritis	ECHO signs of uterine fibroids
On a gynecological examination, the normal size of the uterus	The uterus is slightly enlarged, painful during vaginal examination.	When viewed in the mirrors, the presence of neoplasms on the cervix, atrophic changes in the mucous membrane, a foreign body.	Normal size of the uterus, pus-like discharge from the genital tract.	The uterus is enlarged according to the size of the uterine fibroids.
	There is pain and tension in the muscles of the anterior abdominal wall, symptoms of irritation of the peritoneum during an ectopic pregnancy. Cramping pains in the lower abdomen during uterine pregnancy.	Muscle tension front wall the abdomen is missing.	The abdomen is tense. Soreness is noted on palpation in the lower abdomen, usually on both sides.	There is no tension in the muscles of the anterior abdominal wall.
In the blood is noted	In the blood is noted decrease in hemoglobin, erythrocytes, hematocrit.	A decrease in hemoglobin, erythrocytes, hematocrit is possible.	In the blood is noted Leukocytosis, increased ESR. Hemoglobin and hematocrit values \u200b\u200bare normal.	In the blood is noted decrease in hemoglobin, erythrocytes, hematocrit
Immunological reactions to pregnancy are negative.	Immunological reactions to pregnancy are positive.		Immunological reactions to pregnancy are negative.	Immunological reactions to pregnancy are negative.

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Treatment

Treatment goals
Upon admission to the hospital, the main task is to normalize general condition, carrying out symptomatic therapy, stopping pathological blood loss with subsequent hormonal correction after excluding organic pathology of the pelvic organs. Hormonal hemostasis is performed in young patients (up to 18 years old) with moderate intensity of bloody discharge in the absence of signs posthemorrhagic anemia and after excluding other causes of uterine bleeding according to examination and ultrasound. Stationary surgery (curettage of the endometrium with histological examination of scraping) is recommended for all patients of reproductive age, regardless of the intensity of bleeding.

Treatment tactics

Drug-free treatment: no.

Drug treatment

Hormonal hemostasis with heavy and frequent bleeding is carried out after excluding atypical endometrial processes:
- combined oral contraceptives with ethinyl estradiol content 20-30mkg. The drugs are prescribed in a dose of 4 tablets on the first day, depending on the intensity of bleeding, reducing the dose by 1-2 tablets in three days until the bloody discharge stops, after which COCs are continued for 21 days.
- levonorgestrel containing hormonal intrauterine system.

Antianemic therapy to correct hemoglobin levels:
- folic acid, daily dose - up to 0.005 g (5 tablets);
- iron preparations.

When irregular periods:
- when regulating the COC cycle
- if pregnancy is necessary, hormone therapy in phase I and / or II with stimulation of ovulation. HT in phase I - estriol 2mg, in phase II micronized progesterone 20 0mg. For stimulation - clomiphene 50-150 mg from 5-9 days of the menstrual cycle.

Other treatments: acupuncture, physiotherapy.

Surgery
Under the control of hysteroscopy, separate scraping of the walls of the uterine cavity is performed, followed by a histological examination of the endometrium.
The issue of surgical treatment in the volume of hysterectomy (laparoscopic) should be considered in situations where:
- with malignant endometrial processes
- in the presence of uterine fibroids and adenomyosis (see relevant protocols).

Preventive actions
Regulation of the menstrual cycle when planning pregnancy by taking COCs for 3 cycles, then 3 cycles of progestogens in phase II of the cycle (dydrogesterone 10 mg x 2 r / s or progesterone 100 mg x 2 r / s from 16 to 25 days of the menstrual cycle ) regulation of the menstrual cycle without planning pregnancy - COCs and levonorgestrel containing hormonal intrauterine system.

Further management:
- the introduction of the intrauterine hormonal levonorgestrelling system;
- recommendations for planning pregnancy.

Treatment effectiveness indicators:
- clinical recovery (improvement of the general condition, normalization of the blood picture);
- restoration of the endocrine function of the reproductive system (restoration of the normal menstrual cycle);
- restoration of the reproductive function of women.

Hospitalization

Information:Dysfunctional uterine bleeding occurs as a result of a violation of the production of ovarian hormones. They are subdivided into bleeding in juvenile age, in childbearing age and in menopause. In girls, they are usually associated with dysfunctions of the hypothalamus-pituitary-ovaries system. In women of childbearing age, dysfunctional uterine bleeding is more often caused by inflammatory diseases of the genital organs, in the climacteric period - by dysregulation of menstrual function. The pathogenesis is based on violations of the ovulation process (anovulation) as a result of persistence or atresia of follicles. As a result, the corpus luteum is not formed, the secretory transformation of the endometrium does not occur. Prolonged exposure to estrogens (with follicle atresia) or their increased production (with follicle persistence) lead to endometrial proliferation. This is expressed in the development of polyposis or glandular cystic hyperplasia. Under the influence of the subsequent decline in the concentration of estrogens in the body, the hyperplastic endometrium is rejected for a long time, which is accompanied by acyclic bleeding. The bleeding continues until the entire endometrium is rejected (sometimes for days or even weeks). Symptoms, course. The disease is characterized by an alternation of delayed menstruation (for several weeks) and bleeding. Bleeding is of varying strength and duration. With prolonged and severe bleeding, post-hemorrhagic anemia develops. In a gynecological examination outside of bleeding, the uterus is normal or somewhat larger than usual in size; cystic changes in one ovary are often found. Outside of bleeding (phase of temporary amenorrhea), tests of functional diagnostics are of great diagnostic value (see Amenorrhea). Anovulatory cycle with persistence of the follicle is characterized by signs of increased estrogen production: pupil symptoms +++, ++++; KPI 70-80%; monophasic basal temperature. The diagnosis of dysfunctional bleeding due to follicular atresia is based on a longer delay in bleeding (up to 1-2 months); monotonous symptom of the pupil at ++ level, relative low CRPI (20-30%), monophasic basal temperature. In a histological examination of the endometrial scraping, in both cases, secretory transformation of the mucous membrane is not detected, while polyposis or endometrial hyperplasia is often observed. In the urine, the content of pregnandiol is low - below 1 -1.5 mg / day. Differential diagnosis carried out with beginning or incomplete abortion, ectopic pregnancy, inflammation of the uterine appendages, uterine myoma, endometriosis of the uterus, cancer of the body, cervix, hormonally active ovarian tumors, blood diseases. Treatment has two main goals: stopping bleeding and preventing re-bleeding. The cessation of bleeding can be achieved with the help of curettage of the uterus and the introduction of hormonal drugs (estrogens, progesterone, combined estrogen-progestin drugs, androgens). With menopause, if there was no curettage of the uterus before, it is necessary to begin with this operation to exclude, first of all, uterine cancer. In adolescence, curettage of the uterus is resorted to only in extreme cases, mainly for health reasons (severe uterine bleeding that does not stop under the influence of hormones). At childbearing age, curettage of the uterus is performed depending on the specific situation (duration of the disease, the strength of bleeding, the effectiveness of hormonal hemostasis). Estrogens for hemostasis are prescribed in large doses: Sinestrol 1 ml of 0.1% solution in / m every 2-3 hours; ethinylestradiol 0.1 mg every 2-3 hours. Usually, hemostasis occurs within a day from the start of drug administration. After that, estrogens continue to be administered for 10-15 days, but in smaller doses under the control of functional diagnostics tests (KPI, pupil symptom), followed by the introduction of progesterone for 8 days (10 mg daily i / m). 2-3 days after the end of the progesterone administration, a menstrual reaction occurs. During the next months of treatment, combined hormone therapy is used according to the generally accepted scheme (the first 15 days - estrogens, then for 6-8 days - progesterone). Progesterone for hemostasis can only be prescribed to patients without anemia, since it relaxes the muscles of the uterus and can increase bleeding. The drug is administered at 10 mg daily / m for 6-8 days. Combined estrogen-progestational drugs are prescribed for the purpose of hemostasis, 4-6 tablets per day until bleeding stops. Bleeding usually stops after 24-48 hours. After that, taking the drug must be continued for 20 days, but 1 tablet per day. 2 days after the end of the drug intake, a menstrual-like reaction occurs. To prevent re-bleeding, hormonal regulation of the menstrual cycle is necessary in combination with fortifying, anti-inflammatory drugs and other Vedas of therapy for concomitant diseases. For this, zstrogens are usually used at 5000-10,000 IU daily (folliculin, etc.) for the first 15 days, followed by the introduction of 10 mg of progesterone for 6-8 days or such ovulation stimulants as clostilbegid (see Amenorrhea). Combined esgrogenogestagens are also effective. Their introduction begins 5-6 days after diagnostic curettage of the uterus and continues for 21 days (1 tablet per day). After 2-3 days, a menstrual-like reaction occurs. It is necessary to carry out 5-6 such courses of therapy. In the climacteric period after diagnostic curettage and exclusion of endometrial cancer, androgens can be prescribed: methyltestosterone 30 mg per day under the tongue for 30 days; testosterone propionate 1 ml of 2.5% solution in / m 2 times a week for 1 month. Androgen treatment is designed to suppress ovarian function and create persistent amenorrhea. In addition to hormone therapy, symptomatic therapy is widely used for the treatment of dysfunctional uterine bleeding: oxytocin, 0.5-1 ml (2.5-5 U) i / mg; methylergometrine, 1 ml of 0.2% solution in / m; pregnanthol, 1 ml of a 1.2% solution in / m; extract of water pepper, 20 drops 3 times a day, etc. Prescribe vitamin therapy, donor blood transfusions of 100 ml, physiotherapy (electrical stimulation of the cervix, galvanic collar according to Sherbak, diathermy of the mammary glands). X-ray castration is practically not used.

Dysfunctional uterine bleeding - anovulatory bleeding caused by impaired ovarian function. Dysfunctional uterine bleeding at reproductive age - diagnosis of exclusion of the organic cause of bleeding.

ICD-10 CODE N93.8 Other specified abnormal bleeding from the uterus and vagina.

EPIDEMIOLOGY

IN reproductive period the frequency of dysfunctional uterine bleeding is variable, according to different authors, ranging from 10% to 37%.

PREVENTION

Healthy lifestyle, normalization of work and rest.

SCREENING

Regular visits to the antenatal clinic. Clinical manifestations violations of the menstrual cycle, manifested by uterine bleeding after a delay in menstruation.

ETIOLOGY (REASONS)

The causes of ovarian dysfunction in the reproductive period are various environmental factors: stress, infection, surgery, trauma, termination of pregnancy, metabolic syndrome, drugs etc.

PATHOGENESIS

At the heart of the pathogenetic mechanisms of dysfunctional uterine bleeding is a violation of the neuroendocrine control of synthesis and release of gonadoliberin in the hypothalamus, respectively, in the pituitary gland - gonadotropic hormones that regulate ovarian function. As a result, the function of the ovaries is disrupted by the type of anovulation with persistence or atresia of the follicles, which leads to absolute or relative hyperestrogenism with a low level of progesterone.

Hyperestrogenism causes hyperplastic processes in the endometrium, which becomes the substrate of uterine bleeding. The intensity of bleeding is largely determined by local, endometrial factors: increased fibrinolysis, a violation of the ratio of vasoconstrictors and vasodilators (prostaglandins and thromboxanes), as well as the expression of various growth factors.

SYMPTOMS AND CLINICAL PICTURE

The clinical picture is characterized by profuse bleeding for more than 7 days, which occurs after a delay of menstruation for 1.5–3 months. Less often, dysfunctional uterine bleeding proceeds as menomerorrhagia, when minor bleeding continues after heavy menstruation. The intensity of bleeding can be judged by the presence or absence of clots. Symptoms are also determined by the severity of posthemorrhagic anemia and are characterized by pallor of the skin, tachycardia, weakness, dizziness, drowsiness. With minor bleeding, the general well-being suffers little.

DIAGNOSTICS

Diagnostics is not difficult due to typical clinical picture abnormal uterine bleeding.

ANAMNESIS

When examining the anamnesis, the fact of menstrual irregularities is revealed after exposure to external factors (neuroinfection, mental or physical stress, surgery, trauma, etc.). In puberty, these patients often have menstrual irregularities such as juvenile bleeding; frequent ARVI, chronic tonsillitis, extragenital diseases.

PHYSICAL STUDY

Assess the state of the mucous membranes, skin, measure the pulse, blood pressure to determine the degree of anemization. Determine the body mass index, in obesity - the nature of the distribution of adipose tissue by calculating the ratio of the waist circumference to the hip circumference. In a gynecological examination, the degree of uterine bleeding is assessed, colposcopy is performed to exclude pathology of the cervix.

LABORATORY RESEARCH METHODS

A clinical blood test, a coagulogram is performed to determine the degree of anemia and to exclude the pathology of the hemostasis system. Determination of sex and pituitary hormones has no informative value.

INSTRUMENTAL METHODS

Ultrasound can exclude submucous fibroids, polyps, internal endometriosis. The most informative is hysteroscopy, which is carried out in a hospital during separate therapeutic and diagnostic curettage, followed by histological examination of the remote endometrium.

DIFFERENTIAL DIAGNOSTICS

Differential diagnosis is carried out in order to exclude other causes of uterine bleeding in the reproductive period:

• pregnancy-related - spontaneous abortion, ectopic pregnancy, placental polyp, trophoblastic disease;
• due to infection - cervicitis, endometritis;
• benign diseases of the endo and myometrium - polyps, submucous myoma, internal endometriosis;
• precancerous and malignant diseases of the cervix, cervical canal, endometrium (adenocarcinoma) and myometrium (sarcoma);
• systemic diseases: thrombocytopenia, von Willebrand disease, Fanconi anemia, thyroid and liver diseases.

INDICATIONS FOR CONSULTATION OF OTHER SPECIALISTS

The presence of systemic diseases that can cause dysfunctional uterine bleeding, as well as diagnosed malignant diseases organs of the reproductive system.

TREATMENT OF DYSFUNCTIONAL UTERINE BLEEDING

OBJECTIVES OF TREATMENT

Stopping bleeding, restoration of hemodynamic parameters, hormonal therapy of endometrial hyperplasia, prevention of recurrence of dysfunctional uterine bleeding.

INDICATIONS FOR HOSPITALIZATION

Profuse bleeding with clots, signs of post-hemorrhagic anemia.

NON-MEDICINAL TREATMENT

Non-drug treatment is categorically contraindicated.

MEDICINAL TREATMENT

Hormonal hemostasis is performed only in young patients (18-30 years old) with a moderate intensity of bloody discharge in the absence of signs of post-hemorrhagic anemia and after excluding other causes of uterine bleeding according to examination and ultrasound. For hormonal hemostasis, COC preparations are used with an estrogenic component of 0.03 mg (rigevidon ©, Marvelon ©, Femoden ©, etc.). The drugs are prescribed in a dose of 4 tablets on the first day, depending on the intensity of bleeding, reducing the dose by 1-2 tablets in three days until the bloody discharge stops, after which COCs are continued for 21 days. After discontinuation of the drug, the menstrual reaction can be profuse, therefore, symptomatic and uterotonic agents are prescribed. Further, it is recommended to continue taking COCs to prevent recurrence of dysfunctional uterine bleeding.

SURGERY

Inpatient surgical treatment is recommended for all patients over 30 years old, regardless of the intensity of bleeding. Under the control of hysteroscopy, separate scraping of the walls of the uterine cavity is performed. Hysteroscopy allows not only to completely remove the hyperplastic endometrium (bleeding substrate), but also to reveal concomitant pathology (polyps, submucous myoma, internal endometriosis).

Symptomatic hemostatic therapy - inhibitors of fibrinolysis (tranexamic acid), NSAIDs (diclofenac, naproxen), angioprotective and microcirculation-improving drugs (etamsylate) - does not cause full hemostasis. These drugs only reduce blood loss and are considered complementary. As a second stage, the prevention of recurrent bleeding in patients who underwent hormonal hemostasis is recommended. The drugs of choice for this in young women are monophasic COCs (Marvelon ©, Janine ©, Yarina ©, etc.). If a woman does not plan pregnancy in the coming years, then after 6–8 months the introduction of Mirena © is recommended - an intrauterine hormonal releasing system that reliably protects the endometrium from proliferative processes for 5 years.

Patients who underwent separate diagnostic curettage and, based on the results of histological examination, were diagnosed with HPE, are prescribed hormonal therapy. The principles of hormone therapy HPE is the central antigonadotropic action of the drug, as a result of which the synthesis and release of gonadotropins and, as a result, ovarian steroids are reduced. When choosing drugs, it is necessary to take into account: the histological structure of the endometrium, the patient's age, contraindications and tolerability of the drug, the presence of concomitant metabolic disorders, estrogenital and gynecological pathology. In patients under 35 years of age, the use of monophasic COCs with a content of 0.03 mg of the estrogenic component in a prolonged mode is recommended for 6 months. After such a rebound-type therapy, ovulatory menstrual cycles are restored.

Women of late reproductive age (after 35 years) with recurrent dysfunctional uterine bleeding, contraindications to the use of estrogen-containing COCs are recommended to use antigonadotropic drugs: gestrinone 2.5 mg 2 times a week for 6 months, danazol 400 mg per day for 6 months. The most effective of them are buserelin, goserelin, triptorelin, which are prescribed parenterally 1 time in 28 days, 6 injections. Women should be warned that during therapy, climacteric symptoms appear: hot flashes, sweating, palpitations and others, which stop after discontinuation of the drug.

The most effective prevention of dysfunctional uterine bleeding, recurrence of HPE in women over 35 years old who are not interested in pregnancy is the use of the IUD, the intrauterine hormonal releasing system Mirena ©, which secretes levonorgestrel from a special reservoir with its maximum concentration in the endometrium and minimum in the blood. As a result local action the drug occurs atrophy of the endometrium.

Hysterectomy as a method of treating dysfunctional uterine bleeding at reproductive age is used extremely rarely, as a rule, when dysfunctional uterine bleeding is combined with myoma or internal endometriosis, with contraindications for hormone therapy.

APPROXIMATE TIME OF FAILURE

7-14 days depending on the severity of post-hemorrhagic anemia.

FURTHER INTRODUCTION

Dispensary observation, restoration of ovulatory menstrual cycles or regulation of the menstrual cycle by taking COCs, progestogens in phase II of the cycle, the introduction of the intrauterine hormonal levonorgestrelling system Mirena ©.

PATIENT INFORMATION

For any irregularities in the menstrual cycle (heavy menstruation with clots after a delay in menstruation or at the time of the next menstrual period, continuing spotting for more than 7 days), you should consult a doctor.

FORECAST

The prognosis for health and life is favorable.

BIBLIOGRAPHY
Burlev V.A. // Problems of Reproduction. - 2004. - No. 6. -S. 51-57.
Manukhin I.B., Tumilovich L.G., Gevorkyan M.A. Clinical lectures on gynecological endocrinology. - M.: GeotarMedia, 2006. - pp. 113–141.
Smetnik V.P., Tumilovich L.G. In the book. Non-operative gynecology. - M .: MIA, 2003. - S. 145-152.
Cameron J. et al. Clinical Disorders of the “Endometrium and Menstr. Cycle ". - Oxford Univers. Press, 1998.
Cameron J. et al. // Obstetr. a Gynecol. - 1990. - Vol. 76. - P. 85–88.
Dahmon M. et al. // Journ. Clinical Endocrin and Metabol. - 1999. - Vol. 89. - P. 1737-1743.
De Cherry A., Polan M. // Obstetrics and Gynecol. - 1983. - Vol. 6. - P. 392–397.
Hillard P. Novak's Gynecology. - 2002. - ed. 13. - Ch. 13. - P. 372.
Lessey B. et al. Molecul. Reprod. Dev. - 2000. - 62. - P. 446–455.
Mote P. et al. // Human Reprod. - 2000. - Vol. 15. - Suppl. 3. - P. 48–56.
Nicas G. et al. // Human Reprod. -Vol. 14, Suppl. 2 - P. 99-106.
Robertson S. et al. Endometrium / Glasse S. et al. - London, 2002. - P. 416-430.