Diagnosis of dysfunctional uterine bleeding

The following criteria for uterine bleeding during puberty are distinguished:

• duration of vaginal bleeding less than 2 days or more than 7 days against the background of shortening (less than 21-24 days) or lengthening (more than 35 days) of the menstrual cycle;
• blood loss of more than 80 ml or subjectively more pronounced compared to normal menstruation;
• the presence of intermenstrual or postcoital bleeding;
• absence of structural pathology of the endometrium;
• confirmation of an anovulatory menstrual cycle during the period of uterine bleeding (the level of progesterone in venous blood on the 21st-25th day of the menstrual cycle is less than 9.5 nmol/l, monophasic basal temperature, absence of a preovulatory follicle according to echography data).

The diagnosis of uterine bleeding during puberty is a diagnosis of exclusion:

• spontaneous termination of pregnancy (in sexually active girls);
• uterine pathologies (myoma, endometrial polyps, endometritis, arteriovenous anastomoses, endometriosis, presence of an intrauterine contraceptive device, very rarely adenocarcinoma and sarcoma of the uterus);
• pathologies of the vagina and cervix (trauma, foreign body, neoplastic processes, exophytic condylomas, polyps, vaginitis);
• ovarian pathologies (polycystic ovaries, premature exhaustion, tumors and tumor-like formations);
• blood diseases (von Willebrand disease and deficiency of other plasma hemostasis factors, Werlhof's disease - idiopathic thrombocytopenic purpura, Glanzmann's thrombosthenia, Bernard-Soulier's, Gaucher's, leukemia, aplastic anemia, iron deficiency anemia);
• endocrine diseases (hypothyroidism, hyperthyroidism, Addison's disease or Itsenko-Cushing's disease, hyperprolactinemia, postpubertal form of congenital adrenal cortex hyperplasia, adrenal tumors, empty sella syndrome, mosaic variant of Turner syndrome):
• systemic diseases (liver disease, chronic renal failure, hypersplenism);
• iatrogenic causes (errors in taking medications containing female sex hormones and glucocorticoids, long-term use of high doses of NSAIDs, antiplatelet agents and anticoagulants, psychotropic drugs, anticonvulsants and warfarin, chemotherapy).

It is necessary to differentiate between uterine bleeding in puberty and uterine bleeding syndrome in adolescents. Uterine bleeding syndrome can be accompanied by practically the same clinical and parametric attributes as uterine bleeding in puberty. However, uterine bleeding syndrome certainly has specific signs of the disorder that caused it in its pathophysiological and clinical content, which must be taken into account first of all when prescribing treatment and preventive measures.

Anamnesis

It is necessary to find out the family history during a conversation with the patient's relatives, preferably with the mother. They evaluate the characteristics of the mother's reproductive function, the course of pregnancy and childbirth, the course of the neonatal period, psychomotor development and growth rates, find out living conditions, nutritional characteristics, past illnesses and operations, data on physical and psychological stress, emotional stress.

Clinical examination

A general examination is performed, height and body weight are measured, the distribution of subcutaneous fat is determined, and signs of hereditary syndromes are noted. The compliance of the patient's individual development with age standards is determined, including sexual development according to Tanner (taking into account the development of the mammary glands, sexual hairiness).

In most patients with uterine bleeding during puberty, there is a clear acceleration in height and body weight, but according to the Bray index (kg/m2 ⁾, there is a relative insufficiency of body weight relative to their height (with the exception of 11- and 18-year-olds).

Excessive acceleration of the rate of biological maturation at the beginning of puberty is replaced by a slowdown in development in older age groups,

During examination, symptoms of acute or chronic anemia can be detected (paleness of the skin and visible mucous membranes).

Hirsutism, galactorrhea, and thyroid enlargement are signs of endocrine pathology. The presence of significant deviations in the endocrine system, as well as in the immune status in patients with uterine bleeding during puberty, may indicate a general violation of self-regulation of homeostasis, but in cases of functional disorders in the reproductive system of adolescents, these signs should alert the clinician and indicate the need for differential diagnostics.

Evaluation of the menstrual calendar (menocyclogram)

Based on the data from the menstrual cycle chart, it is possible to judge the development of menstrual function, the nature of the menstrual cycle before the first bleeding, and the intensity and duration of bleeding.

The debut of the disease with menarche is more often observed in the younger age group (up to 10 years), in the age group of 11-12 years after menarche before uterine bleeding, irregular menstruations are more often observed, and in girls over 13 years old, regular menstrual cycles are most often observed. Early menarche increases the likelihood of uterine bleeding in puberty. The clinical picture of uterine bleeding in puberty is extremely typical with atresia and persistence of follicles. With persistence of follicles, menstrual-like or slightly more abundant than menstruation bloody discharge occurs after a delay of the next menstruation for 1-3 weeks, while with atresia of follicles, the delay is from 2 to 6 months, and the bleeding is scanty and prolonged. At the same time, various gynecological diseases can manifest themselves with bleeding of identical nature and the same type of menstrual cycle disorders. Spotting of blood from the genital tract shortly before and immediately after menstruation may be a symptom of endometriosis, endometrial polyps, chronic endometritis, or endometrial hyperplasia.

Clarification of the patient's psychological characteristics

The psychological characteristics of the patient are clarified with the help of psychological testing and consultation with a psychotherapist. It has been proven that in the clinical picture of typical forms of uterine bleeding in the pubertal period, an important role is played by signs of depressive disorders and social dysfunction, which are aggravated by subjective experiences, and the relationship between distress and hormonal metabolism of patients should raise in each specific case the question of the probable primacy of disorders in the neuropsychic sphere.

Gynecological examination

When examining the external genitalia, the following are assessed: pubic hair growth lines, the shape and size of the clitoris, labia majora and minora, the external opening of the urethra, the features of the hymen, the color of the mucous membranes of the vaginal vestibule, and the nature of discharge from the genital tract. Vaginoscopy allows you to assess the condition of the vaginal mucosa, esgrogen saturation, and exclude the presence of a foreign body in the vagina, condylomas, lichen planus, neoplasms of the vagina and cervix.

Signs of hyperestrogenemia: pronounced folding of the vaginal mucosa, juicy hymen, cylindrical cervix, positive "pupil" symptom, abundant streaks of mucus in bloody discharge.

Signs of hypoestrogenemia: the vaginal mucosa is pale pink, the folds are weakly expressed, the hymen is thin, the cervix is subconical or conical in shape, bloody discharge without mucus.

Laboratory diagnostics

• A complete blood count to determine hemoglobin levels, platelet count, and reticulocytes is performed on all patients with uterine bleeding during puberty.
• Hemostasis (activated partial thromboplastin time, prothrombin index, activated recalcitration time) and bleeding time assessment will help to exclude gross pathology of the blood coagulation system.
• Determination of the beta-subunit of human chorionic gonadotropin in blood serum of sexually active girls.
• Microscopy of a smear (Gram staining), bacteriological examination and PCR diagnostics of chlamydia, gonorrhea, mycoplasmosis, ureaplasmosis in a scraping of the vaginal walls.
• Biochemical blood test (concentrations of glucose, protein, bilirubin, cholesterol, creatinine, urea, serum iron, transferrin, calcium, potassium, magnesium, alkaline phosphatase activity, alanine and aspartate aminotransferases).
• Carbohydrate tolerance test for polycystic ovary syndrome and overweight (BMI 25 and above).
• Determination of the level of thyroid hormones (TSH, free thyroxine, antibodies to TPO) to clarify the function of the thyroid gland; estradiol, testosterone, dehydroepiandrosterone sulfate, LH, FSH, insulin, C-peptide to exclude polycystic ovary syndrome; 17-hydroxyprogesterone, testosterone, dehydroepiandrosterone sulfate. The daily rhythm of cortisol to exclude congenital adrenal hyperplasia; prolactin (at least 3 times) to exclude hyperprolactinemia; progesterone in the blood serum on the 21st day of the cycle (with a 28-day menstrual cycle) or on the 25th day (with a 32-day menstrual cycle) to confirm the anovulatory nature of uterine bleeding.

At the first stage of the disease (MCPP), in early puberty, activation of the hypothalamic-pituitary system causes a periodic release of LH (primarily) and FSH, the concentration of which in the blood plasma exceeds normal levels. In late puberty, especially with relapses of uterine bleeding, the secretion of gonadotropins decreases. The main predictors of uterine bleeding in the pubertal period are LH, estradiol, and cortisol.

Instrumental methods

X-ray of the left hand and wrist to determine bone age and growth prognosis.

Most patients with uterine bleeding during puberty have an advancement of biological age compared to chronological age, especially in younger age groups. Biological age is a fundamental and multifaceted indicator of development rates, reflecting the level of the morphofunctional state of the body against the background of the population standard, the main characteristics of ontogenetic development and, above all, heterochronicity of growth, maturation and aging at different stages of organization.

X-ray of the skull is an informative method for diagnosing tumors of the hypothalamic-pituitary region that deform the sella turcica, changes in cerebrospinal fluid dynamics, intracranial hemodynamics, osteosynthesis disorders due to hormonal imbalance, and previous intracranial inflammatory processes.

Ultrasound of the pelvic organs allows to specify the size of the uterus and endometrium to exclude pregnancy, malformations of the uterus (bicornuate, saddle-shaped uterus), pathologies of the body of the uterus and endometrium (adenomyosis, uterine myoma, polyps or hyperplasia, adenomatosis and endometrial cancer, endometritis, intrauterine adhesions), to assess the size, structure and volume of the ovaries, to exclude functional cysts and volumetric formations in the uterine appendages.

Diagnostic hysteroscopy and curettage of the uterine cavity in adolescents are rarely used (to clarify the condition of the endometrium when ultrasound signs of endometrial or cervical canal polyps are detected).

Ultrasound of the thyroid gland and internal organs (as indicated) in patients with chronic diseases and pathologies of the endocrine system.

Differential diagnostics

The main goal of differential diagnostics of uterine bleeding in puberty is to clarify the main etiological factors that provoke the development of uterine bleeding in puberty. Differential diagnostics should be carried out with the conditions and diseases listed below.

Complication of pregnancy in sexually active adolescents. Complaints and anamnesis data that allow to exclude interrupted pregnancy or bleeding after an abortion, including in girls who deny sexual contacts, are specified first. Bleeding occurs more often after a short delay of over 35 days, less often - when the menstrual cycle is shortened to less than 21 days or at times close to the expected menstruation. The anamnesis, as a rule, indicates sexual contacts in the previous menstrual cycle. Patients note complaints of engorgement of the mammary glands, nausea. Bloody discharge, as a rule, is profuse with clots, pieces of tissue, often painful. The pregnancy test is positive (determination of the beta subunit of human chorionic gonadotropin in the patient's blood serum).

Defects of the blood coagulation system. In order to exclude defects of the blood coagulation system, family history data (a tendency to bleeding in parents) and life history (nosebleeds, prolonged bleeding time during surgical manipulations, frequent and causeless occurrence of petechiae and hematomas) are clarified. Uterine bleeding that develops against the background of diseases of the hemostasis system, as a rule, has the character of menorrhagia with menarche.

Examination data (pale skin, bruises, petechiae, yellowing of the palms and upper palate, hirsutism, striae, acne, vitiligo, multiple birthmarks, etc.) and laboratory research methods (hemostasis, general blood test, thromboelastogram, determination of the main coagulation factors) allow us to confirm the presence of pathology of the hemostasis system.

Polyps of the cervix and body of the uterus. Uterine bleeding is usually acyclic with short light intervals, discharge is moderate, often with mucus strands. During an echographic examination, endometrial hyperplasia is often determined (the thickness of the endometrium against the background of bleeding is 10-15 mm), with hyperechoic formations of various sizes. The diagnosis is confirmed by hysteroscopy and subsequent histological examination of the removed endometrial formation.

Adenomyosis. Uterine bleeding during puberty against the background of adenomyosis is characterized by severe dysmenorrhea. Long-term spotting bloody discharge with a characteristic brown tint before and after menstruation. The diagnosis is confirmed by echography data in the 1st and 2nd phases of the menstrual cycle and hysteroscopy (in patients with severe pain syndrome and in the absence of effect from drug therapy).

Inflammatory diseases of the pelvic organs. As a rule, uterine bleeding is acyclic, occurs after hypothermia, unprotected, especially casual or promiscuous (promiscuity) sexual intercourse in sexually active adolescents, against the background of exacerbation of chronic pelvic pain, discharge. There are pains in the lower abdomen, dysuria, hyperthermia, profuse pathological leucorrhoea outside of menstruation, acquiring a sharp unpleasant odor against the background of bleeding. During a rectoabdominal examination, an enlarged softened uterus is palpated, pastosity of tissues in the area of the uterine appendages is revealed, the examination is usually painful. Data from microscopy of smears according to Gram, PCR diagnostics of vaginal discharge for the presence of sexually transmitted infections, bacteriological culture from the posterior vaginal fornix help to clarify the diagnosis.

Trauma of the external genitalia or foreign body in the vagina. For diagnosis, it is necessary to obtain anamnestic data and perform vulvovaginoscopy.

Polycystic ovary syndrome. In girls with polycystic ovary syndrome, uterine bleeding during puberty, along with complaints of delayed menstruation, excessive hair growth, simple acne on the face, chest, shoulders, back, buttocks and thighs, there are indications of late menarche with progressive menstrual cycle disorders such as oligomenorrhea.

Hormone-producing formations. Uterine bleeding during puberty may be the first symptom of estrogen-producing tumors or tumor-like formations of the ovaries. A more precise diagnosis is possible after an ultrasound examination of the genitals with an assessment of the volume and structure of the ovaries and determination of the level of estrogens in the venous blood.

Thyroid dysfunction. Uterine bleeding during puberty usually occurs in patients with subclinical or clinical hypothyroidism. Patients with uterine bleeding during puberty against the background of hypothyroidism typically complain of chills, edema, weight gain, memory loss, drowsiness, and depression. In hypothyroidism, palpation and ultrasound with determination of the volume and structural features of the thyroid gland allow to detect its enlargement, and examination of patients - the presence of dry subicteric skin, pastosity of tissues, puffiness of the face, glossomegaly, bradycardia, and increased relaxation time of deep tendon reflexes. Determination of the concentration of TSH and free thyroxine in venous blood allows to clarify the functional state of the thyroid gland.

Hyperprolactinemia. To exclude functional or tumor hyperprolactinemia (as a cause of uterine bleeding during puberty), examination and palpation of the mammary glands with clarification of the nature of discharge from the nipples, determination of the prolactin content in venous blood, X-ray of the skull bones with a targeted study of the size and configuration of the sella turcica or MRI of the brain are indicated.

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