Diagnosis of dysfunctional uterine bleeding

There are the following criteria for uterine bleeding in the pubertal period:

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

The diagnosis of uterine bleeding in the pubertal period is the diagnosis of an exception:

• spontaneous abortion (in sexually active girls);
• uterine pathology (myoma, endometrial polyps, endometritis, arteriovenous anastomoses, endometriosis, the presence of an intrauterine contraceptive, extremely rare adenocarcinoma and uterine sarcoma);
• pathology of the vagina and cervix (trauma, foreign body, neoplastic processes, exophytic condylomas, polyps, vaginitis);
• pathology of the ovaries (polycystic ovaries, premature exhaustion, tumors and tumor-like formations);
• blood diseases (von Willebrand's disease and deficiency of other plasma factors of hemostasis, Verlhof's disease - idiopathic thrombocytopenic purpura, Glanzmann's thrombocasthenia, Bernara-Soulier, Gaucher, leukemia, aplastic anemia, iron deficiency anemia);
• endocrine diseases (hypothyroidism, hyperthyroidism, Addison's disease or Itenko-Cushing's disease, hyperprolactinaemia, post-puerperate form of congenital hyperplasia of the adrenal cortex, adrenal gland tumors, empty Turkish saddle syndrome, mosaic version of Turner syndrome):
• systemic diseases (liver disease, chronic renal failure, hypersplenism);
• iatrogenic causes (errors in taking medications containing female sex hormones and glucocorticoids, prolonged use of high doses of NSAIDs, antiaggregants and anticoagulants, psychotropic drugs, anticonvulsants and warfarin, chemotherapy).

It is necessary to distinguish uterine bleeding of the pubertal period and uterine bleeding syndrome in adolescents. The uterine bleeding syndrome can be accompanied by practically the same clinical and parametric attributes as the uterine bleeding of the pubertal period. However, the uterine bleeding syndrome unconditionally carries in its pathophysiological and clinical content the specific signs of the disorder causing it, which must first of all be taken into account when prescribing therapeutic and prophylactic measures.

Anamnesis

It is necessary to find out a family anamnesis during a conversation with the patient's relatives, preferably with the mother. Assess the characteristics of the reproductive function of the mother, the course of pregnancy and childbirth, the period of the newborn, psychomotor development and growth rates, find out the conditions of life, the features of nutrition, the transferred diseases and operations, data on physical and psychological stress, emotional stress.

Clinical examination

Carry out a general examination, measurement of growth and body weight, determine the distribution of subcutaneous fat, note the signs of hereditary syndromes. Determine the correspondence of the individual development of the patient to the age standards, including sexual development according to Tanner (taking into account the development of the mammary glands, sexual pilosis).

Most patients with pubertal uterine bleeding have an obvious advance (acceleration) in height and body weight, but according to the Brey's index (kg / m ² ), relative weight deficiency relative to their growth (with the exception of 11- and 18-year-olds) is noted.

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

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

Hirsutism, galactorrhea, enlargement of the thyroid gland - signs of endocrine pathology. The presence of significant abnormalities in the endocrine system, as well as in the immune status in patients with uterine bleeding in the pubertal period, 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 point out the need for differential diagnosis.

Evaluation of the menstrual calendar (menocycgram)

According to the data of the menocyclogram it is possible to judge the formation of menstrual function, the nature of the menstrual cycle before the first bleeding, the intensity and duration of bleeding.

The debut of the disease with menarche is more often noted in the younger age group (up to 10 years), in the age group 11-12 years after menarche to uterine bleeding irregular irregular menstruation is more common, and in girls over 13, regular menstrual cycles are most often noted. Early menarche increases the probability of uterine bleeding in the pubertal period. The clinical picture of pubertal uterine bleeding during the atresia and persistence of follicles is extremely characteristic. When the follicles are persistent, menstrual-like or slightly more ample than menstruation, blood discharge occurs after a delay of another menstruation for 1-3 weeks, whereas with follicular atresia, the delay is 2 to 6 months, and the bleeding is meager and prolonged. At the same time, various gynecological diseases can manifest themselves with identical bleeding patterns and the same type of menstrual irregularity. Spotting blood from the genital tract shortly before menstruation and immediately after it can be a symptom of endometriosis, endometrial polyps, chronic endometritis, endometrial hyperplasia.

Specification of the psychological characteristics of the patient

Psychological features of the patient are clarified with the help of psychological testing and counseling of a psychotherapist. It has been proved that in the clinical picture of typical forms of uterine bleeding in the pubertal period, the signs of depressive disorders and social dysfunction play an important role, which are exacerbated by subjective experiences, and the relationship between distress and hormonal exchange of patients should raise in each concrete case the question of the probable primacy of disorders in the neuropsychic sphere .

Gynecological examination

When examining the external genitalia, the hair growth lines on the pubis are evaluated, the shape and dimensions of the clitoris, the large and small labia, the external opening of the urethra, the features of the hymen, the color of the mucous membranes of the vestibule, the character of the discharge from the genital tract. Vaginoscopy allows you to assess the condition of the mucous membrane of the vagina, esrogrogennuyu saturation and exclude the presence of a foreign body in the vagina, condyloma, red flat lichen, neoplasms of the vagina and cervix.

Signs of hyperestrogenemia: pronounced folding of the mucous membrane of the vagina, juicy hymen, cervix of the cylindrical form, symptom of "pupil" positive, abundant veins of mucus in the blood secretions.

Signs of hypoestrogenemia: the mucosa of the vagina is pale pink, the folding is poorly expressed, the hymen is thin, the cervix is of subconic or conical shape, bloody discharge without mucus.

Laboratory diagnostics

• The general analysis of a blood with definition of a level of a hemoglobin, an amount of thrombocytes. Reticulocytes are carried out to all patients with uterine bleeding puberty.
• Hemostasiogram (activated partial thromboplastin time, prothrombin index, activated recultivation time) and evaluation of bleeding time will exclude the gross pathology of the coagulation system.
• Determination in the serum of the beta-subunit of human chorionic gonadotropin in sexually active girls.
• Smear microscopy (Gram staining), bacteriological examination and PCR diagnostics of chlamydia, gonorrhea, mycoplasmosis, ureaplasmosis in the scrapings of the vaginal walls.
• Biochemical blood test (concentration of glucose, protein, bilirubin, cholesterol, creatinine, urea, serum iron, trasferrin, calcium, potassium, magnesium, activity of alkaline phosphatase, alanine and aspartic aminotransferases).
• Carbohydrate tolerance test for polycystic ovary syndrome and excess body weight (BMI - 25 and above).
• Determination of the level of thyroid hormones (TSH, free thyroxin, 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. Daily rhythm of cortisol to exclude congenital hyperplasia of the adrenal cortex; prolactin (at least 3 times) to exclude hyperprolactinemia; progesterone in 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 (MTCT), in early pubertal, activation of the hypothalamic-pituitary system causes the periodic release of LH (primarily) and FSH, whose concentration in the blood plasma exceeds normal levels. In late pubertal, especially with relapses of uterine bleeding, the secretion of gonadotropins decreases. The main predictors of uterine bleeding are the pubertal period - LH, estradiol. Cortisol.

Instrumental methods

Radiography of the left wrist and wrist to determine the bone age and growth forecast.

In most patients with uterine bleeding pubertal period, notice the advancing of biological age in comparison with the chronological, especially in younger age groups. Biological age is a fundamental and multilateral indicator of the rate of development, reflecting the level of the morphofunctional state of the organism against the background of the population standard, the main characteristics of ontogenetic development and, above all, the heterochronality of growth, maturation and aging at different stages of organization.

Radiography of the skull is an informative method for diagnosing tumors of the hypothalamic-pituitary region, deforming the Turkish saddle, changes in liquor dynamics, intracranial hemodynamics, osteosynthesis disorders due to hormonal imbalance, and intracranial inflammatory processes.

The ultrasound of the pelvic organs allows us to refine the size of the uterus and endometrium to exclude pregnancy, the developmental defects of the uterus (bicorne, saddle-uterus), the pathology of the uterus and endometrium (adenomyosis, uterine myoma, polyps or hyperplasia, adenomatosis and endometrial cancer, endometritis, intrauterine synechia) to estimate the size, structure and volume of ovaries, exclude functional cysts and volumetric formations in the appendages of the uterus.

Diagnostic hysteroscopy and curettage of the uterine cavity in adolescents are rarely used (to clarify the state of the endometrium in the detection of echographic signs of polyps of the endometrium or cervical canal).

Ultrasound of the thyroid gland and internal organs (according to indications) in patients with chronic diseases and pathology of the endocrine system.

Differential diagnostics

The main goal of differential diagnosis of uterine bleeding in the pubertal period is to clarify the main etiological factors provoking the development of uterine bleeding in the pubertal period. Differential diagnosis should be carried out with the conditions and diseases listed below.

Complication of pregnancy in sexually active adolescents. Complaints and data of anamnesis that allow to exclude an interrupted pregnancy or bleeding after the abortion, including those denying sexual contacts, is clarified in the first place. Bleeding occurs more often after a short delay of more than 35 days, less often - with a shortening of the menstrual cycle less than 21 days or in terms close to the expected menstruation. In the anamnesis, as a rule, there are indications of sexual contacts in the previous menstrual cycle. Patients report complaints of breast engorgement, nausea. Bloody discharge, as a rule, abundant 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 coagulation system. In order to exclude defects in the coagulation system, the family history (predisposition to bleeding in parents) and the history of life (nasal bleeding, prolonged bleeding time during surgical manipulation, frequent and unreasonable occurrence of petechiae and hematomas) are clarified. Uterine bleeding, developed against the backdrop of diseases of the hemostatic system, usually have the character of menorrhagia with menarche.

The examination data (pallor of the skin, bruises, petechiae, yellowness of palms and upper palate, hirsutism, striae, acne, vitiligo, multiple birthmarks and others) and laboratory methods of investigation (hemostasiogram, general blood test, thromboelastogram, determination of the main coagulation factors) allow confirm the presence of pathology of the hemostasis system.

Polyps of the cervix and the body of the uterus. Uterine bleeding, as a rule, acyclic with short light intervals, mild secretions, often with mucus bands. When echography is often determined by endometrial hyperplasia (the thickness of the endometrium on the background of bleeding is 10-15 mm), with hyperechoic formations of various sizes. The diagnosis is confirmed by the data of hysteroscopy and the subsequent histological examination of the remote formation of the endometrium.

Adenomyosis. Uterine bleeding of the pubertal period against adenomyosis is characterized by pronounced dysmenorrhea. Prolonged spotting blood extracts with a characteristic brown hue 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 the effect of drug therapy).

Inflammatory diseases of the pelvic organs. As a rule, uterine bleeding is acyclic in nature, occurs after hypothermia, unprotected, especially accidental or promiscuous (promiscuity) of sexual contacts in sexually active adolescents, against the backdrop of exacerbation of chronic pelvic pains, discharge. There are pains in the lower abdomen, dysuria, hyperthermia, abundant abnormalities outside the menstruation, acquiring a sharp unpleasant odor against bleeding. During recto-abdominal examination, palpated enlarged soft uterus, revealing the pastosity of the tissues in the area of the uterine appendages, the study, as a rule, painful. Gram stain smear microscopy, PCR diagnostics of the vaginal discharge for sexually transmitted infections, bacteriological culture from the posterior vaginal foramen contribute to clarifying the diagnosis.

Injury of external genital organs or foreign body in the vagina. For diagnosis, it is necessary to clarify the anamnestic data and conduct a vulvovaginoscopy.

Polycystic ovary syndrome. In uterine bleeding of the pubertal period, girls with polycystic ovary syndrome, along with complaints of menstruation, excess hair growth, simple acne on the face, chest, shoulders, back, buttocks and hips, indicate later menarche with progressive irregularities of the menstrual cycle as oligomenorrhoea.

Gormonoproduktsiruyuschie education. Uterine bleeding of the pubertal period may be the first symptom of estrogen-producing tumors or tumor-like ovarian formations. Clarification of the diagnosis is possible after ultrasound examination of the genitals with an assessment of the volume and structure of the ovaries and the determination of the level of estrogens in venous blood.

Thyroid dysfunction. Uterine bleeding of the pubertal period occurs, as a rule, in patients with subclinical or clinical hypothyroidism. Patients with uterine bleeding of the pubertal period against a background of hypothyroidism are characterized by complaints of chilliness, swelling, weight gain, memory loss, drowsiness, depression. With hypothyroidism, palpation and ultrasound with the definition of the volume and structural features of the thyroid gland can reveal its increase, and the examination of patients - the presence of dry sub-bacterial skin, pastose tissue, puffiness of the face, glossomegalia, bradycardia, an increase in the relaxation time of deep tendon reflexes. To clarify the functional state of the thyroid gland allows the determination of the concentration of TSH. Free thyroxine in venous blood.

Hyperprolactinemia. To exclude functional or tumor hyperprolactinemia (as a cause of uterine bleeding in the pubertal period), examination and palpation of the mammary glands are shown with a refinement of the nature of the discharge from the nipples, determination of prolactin in venous blood, radiography of the bones of the skull, aiming at studying the size and configuration of the Turkish saddle or MRI of the brain.

[1], [2], [3], [4]