Dysfunctional uterine bleeding - Treatment

When treating dysfunctional uterine bleeding, two tasks are set:

1. stop the bleeding;
2. prevent its recurrence.

When solving these problems, one cannot act according to a standard, stereotypically. The approach to treatment should be strictly individual, taking into account the nature of the bleeding, the age of the patient, her health condition (degree of anemia, presence of concomitant somatic diseases).

The range of treatment options available to a general practitioner is quite diverse. It includes both surgical and conservative treatment methods. Surgical methods of stopping bleeding include scraping of the uterine mucosa, vacuum aspiration of the endometrium, cryodestruction, laser photocoagulation of the mucosa and, finally, extirpation of the uterus. The range of conservative treatment methods is also quite wide. It includes non-hormonal (medicinal, preformed physical factors, various types of reflexology) and hormonal methods of influence.

Rapid stopping of bleeding can only be achieved by scraping the mucous membrane.uterus. In addition to the therapeutic effect, this manipulation, as noted above, has great diagnostic value. Therefore, dysfunctional uterine bleeding that has arisen for the first time in patients of the reproductive and premenopausal periods is rationally stopped by resorting to this method. In case of recurrent bleeding, curettage is resorted to only if conservative therapy is ineffective.

Juvenile bleeding requires a different treatment approach. Scraping of the mucous membrane of the uterine body in girls is performed only for vital indications: in case of heavy bleeding against the background of sharp anemia of patients. In girls, it is advisable to resort to endometrial curettage not only for vital indications. Oncological alertness dictates the need for diagnostic and therapeutic curettage of the uterus if bleeding, even moderate, often recurs over 2 years or more.

In women of late reproductive and premenopausal periods with persistent dysfunctional uterine bleeding, the method of cryodestruction of the mucous membrane of the body of the uterus is successfully used. J. Lomano (1986) reports on the successful stopping of bleeding in women of reproductive age by photocoagulation of the endometrium using a helium-neon laser.

Surgical removal of the uterus for dysfunctional uterine bleeding is rare. L. G. Tumilovich (1987) believes that a relative indication for surgical treatment is recurrent glandular-cystic hyperplasia of the endometrium in women with obesity, diabetes, hypertension, i.e. in patients from the "risk" group for endometrial cancer. Unconditional surgical treatment is subject to women with atypical hyperplasia of the endometrium in combination with myoma or adenomyoma of the uterus, as well as with an increase in the size of the ovaries, which may indicate their thecamatose.

Bleeding can be stopped conservatively by influencing the reflexogenic zone of the cervix or the posterior vaginal fornix. Electrical stimulation of the specified areas by means of a complex neurohumoral reflex leads to an increase in neurosecretion of Gn-RH in the hypophysiotropic zone of the hypothalamus, the end result of which is secretory transformations of the endometrium and stopping of bleeding. Physiotherapeutic procedures that normalize the function of the hypothalamic-pituitary region contribute to enhancing the effect of electrical stimulation of the cervix: indirect electrical stimulation with low-frequency pulsed currents, longitudinal inductothermy of the brain, galvanic collar according to Shcherbak, cervicofacial galvanization according to Kellat.

Hemostasis can be achieved using various methods of reflexology, including traditional acupuncture, or by exposing acupuncture points to helium-neon laser radiation.

Hormonal hemostasis is very popular among practicing doctors ; it can be used in patients of different ages. However, it should be remembered that the scope of hormone therapy in adolescence should be limited as much as possible, since the introduction of exogenous sex steroids can cause the shutdown of the functions of the patient's own endocrine glands and hypothalamic centers. Only in the absence of the effect of non-hormonal treatment methods in girls and young women of puberty is it advisable to use synthetic combined estrogen-gestagen drugs (non-ovlon, ovidon, rigevidon, anovlar). These drugs quickly lead to secretory changes in the endometrium, and then to the development of the so-called phenomenon of glandular regression, due to which drug withdrawal is not accompanied by significant blood loss. Unlike adult women, they are prescribed no more than 3 tablets of any of the above drugs per day for hemostasis. Bleeding stops within 1-2-3 days. The dose of the drug is not reduced until the bleeding stops, and then gradually reduced to 1 tablet per day. The duration of hormone intake is usually 21 days. Menstrual-like bleeding occurs 2-4 days after discontinuing the drug.

Rapid hemostasis can be achieved by administering estrogenic drugs: 0.5-1 ml of a 10% solution of sinestrol, or 5000-10,000 U of folliculin, are administered intramuscularly every 2 hours until bleeding stops, which usually occurs on the first day of treatment due to proliferation of the endometrium. In the following days, the daily dose of the drug is gradually (by no more than a third) reduced to 1 ml of sinestrol at 10,000 U of folliculin, administered first in 2, then in 1 dose. Estrogen drugs are used for 2-3 weeks, simultaneously achieving the elimination of anemia, then switching to gestagens. Daily for 6-8 days intramuscularly administer 1 ml of 1% progesterone solution or every other day - 3-4 injections of 1 ml of 2.5% progesterone solution, or a single injection of 1 ml of 12.5% 17a-hydroxyprogesterone capronate solution. Menstrual-like bleeding occurs 2-4 days after the last administration of progesterone or 8-10 days after the injection of 17a-OPC. It is convenient to use norcolut tablets (10 mg per day), turinal (in the same dosage) or acetomepreginal (0.5 mg per day) as a gestagen drug for 8-10 days.

In women of reproductive age with favorable results of the histological examination of the endometrium performed 1-3 months ago, in case of repeated bleeding, there may be a need for hormonal hemostasis if the patient has not received appropriate anti-relapse therapy. For this purpose, synthetic estrogen-gestagen drugs (non-ovlon, rigevidon, ovidon, anovlar, etc.) can be used. The hemostatic effect usually occurs with large doses of the drug (6 and even 8 tablets per day). Gradually reducing the daily dose to 1 tablet. continue taking a total of up to 21 days. When choosing such a method of hemostasis, one should not forget about possible contraindications: liver and biliary tract diseases, thrombophlebitis, hypertension, diabetes mellitus, uterine fibroids, glandular-cystic mastopathy.

If recurrent bleeding occurs against a high estrogenic background and its duration is short, then pure gestagens can be used for hormonal hemostasis: 1 ml of 1% progesterone solution intramuscularly for 6-8 days. 1 % progesterone solution can be replaced with a 2.5% solution and injections can be made every other day or a prolonged-release drug can be used - 12.5% 17a-OPK solution once in the amount of 1-2 ml, enteral administration of norcolut at 10 mg or acetomepregenol A at 0.5 mg for 10 days is also possible. When choosing such methods of stopping bleeding, it is necessary to exclude possible anemia of the patient, since when the drug is discontinued, significant menstrual-like bleeding occurs.

In case of confirmed hypoestrogenism, as well as persistence of the corpus luteum, estrogens can be used to stop bleeding, followed by a transition to gestagens according to the scheme given for the treatment of juvenile bleeding.

If the patient received adequate therapy after curettage of the uterine mucosa, then recurrent bleeding requires clarification of the diagnosis, and not hormonal hemostasis.

In the premenopausal period, estrogenic and combined drugs should not be used. Pure gestagens are recommended to be used according to the above schemes or immediately begin therapy in a continuous mode: 250 mg 17a-OPK (2 ml 12.5% solution) 2 times a week for 3 months.

Any method of stopping bleeding should be comprehensive and aimed at relieving negative emotions, physical and mental fatigue, eliminating infection and/or intoxication, and treating concomitant diseases. Psychotherapy, sedatives, vitamins (C, B1, B6, B12, K, E, folic acid), and uterine contraction agents are integral parts of comprehensive treatment. It is necessary to include hemostimulating (hemostimulin, ferrum Lek, ferroplex) and hemostatic drugs (dicynone, sodium etamsylate, vikasol).

Stopping the bleeding completes the first stage of treatment. The task of the second stage is to prevent repeated bleeding. In women under 48, this is achieved by normalizing the menstrual cycle; in older patients, by suppressing the menstrual function.

Girls in puberty with moderate or increased levels of estrogen saturation in the body, determined by functional diagnostic tests, are prescribed gestagens (turinal or norcolut 5-10 mg from the 16th to the 25th day of the cycle, acetomepregenol 0.5 mg on the same days) for three cycles with a 3-month break and a repeat course of three cycles. Combined estrogen-gestagen drugs can be prescribed in the same regimen. Girls with low estrogen levels should be prescribed sex hormones in a cyclic regimen. For example, ethinyl estradiol (microfodlin) 0.05 mg from the 3rd to the 15th day of the cycle, then pure gestagens in the previously indicated regimen. In parallel with hormone therapy, it is recommended to take vitamins in a cycle (in phase I - vitamins B1 and B6, folic and glutamic acids, in phase II - vitamins C, E, A), desensitizing and hepatotropic drugs.

In girls and adolescents, hormonal therapy is not the primary method of preventing recurrent bleeding. Reflex methods of action should be preferred, such as electrical stimulation of the mucous membrane of the posterior vaginal fornix on the 10th, 11th, 12th, 14th, 16th, 18th days of the cycle or various acupuncture methods.

Women of reproductive age can undergo hormonal treatment according to the schemes proposed for girls suffering from juvenile bleeding. Some authors suggest prescribing 2 ml of 12.5% 17a-oxyprogesterone capronate solution intramuscularly on the 18th day of the cycle as a gestagenic component. Women from the endometrial cancer "risk" group are administered this drug continuously for 3 months at 2 ml 2 times a week, and then switch to a cyclic regimen. Combined estrogen-gestagenic drugs can be used as a contraceptive. E. M. Vikhlyaeva et al. (1987) suggest that patients in the late reproductive period of life who have a combination of hyperplastic changes in the endometrium with myoma or internal endometriosis be prescribed testosterone (25 mg on the 7th, 14th, and 21st days of the cycle) and norcolut (10 mg from the 16th to the 25th day of the cycle).

Restoration of the menstrual cycle.

After excluding (clinical, instrumental, histological) inflammatory, anatomical (tumors of the uterus and ovaries), oncological nature of uterine bleeding, tactics for hormonal genesis of DUB are determined by the age of the patient and the pathogenetic mechanism of the disorder.

In adolescence and reproductive age, the appointment of hormonal therapy should be preceded by mandatory determination of the level of prolactin in the blood serum, as well as (if indicated) hormones of other endocrine glands of the body. Hormonal testing should be carried out in specialized centers 1-2 months after the cancellation of previous hormonal therapy. Blood sampling for prolactin is performed with a preserved cycle 2-3 days before the expected menstruation, or in case of anovulation against the background of their delay. Determination of the level of hormones of other endocrine glands is not associated with the cycle.

The use of sex hormone treatment is determined by the level of estrogens produced by the ovaries.

In case of insufficient estrogen levels: the endometrium corresponds to the early follicular phase - it is advisable to use oral contraceptives with an increased estrogen component (anteovin, non-ovlon, ovidon, demulen) according to the contraceptive scheme; if the endometrium corresponds to the middle follicular phase - only gestagens (progesterone, 17-OPK, uterozhestan, duphaston, nor-colut) or oral contraceptives are prescribed.

With elevated estrogen levels (proliferating endometrium, especially in combination with its hyperplasia of varying degrees), conventional restoration of the menstrual cycle (gestagens, COCs, parlodel, etc.) is effective only in the early stages of the process. The modern approach to the treatment of hyperplastic processes in the target organs of the reproductive system (endometrial hyperplasia, endometriosis and adenomyosis, uterine myoma, fibromatosis of the mammary glands) requires a mandatory stage of switching off the menstrual function (the effect of temporary menopause for the reverse development of hyperplasia) for a period of 6-8 months. For this purpose, the following are used in continuous mode: gestagens (norcolut, 17-OPK, depo-provera), testosterone analogues (danazol) and luliberin (zoladex). Immediately after the suppression stage, these patients are shown pathogenetic restoration of a full menstrual cycle in order to prevent relapse of the hyperplastic process.

In patients of reproductive age with infertility, in the absence of the effect of sex hormone therapy, ovulation stimulants are additionally used.

1. During the climacteric period (perimenopause), the nature of hormonal therapy is determined by the duration of the latter, the level of estrogen production by the ovaries and the presence of concomitant hyperplastic processes.
2. In late premenopause and postmenopause, treatment is carried out with special HRT agents for climacteric and postmenopausal disorders (klimonorm, cycloprogynova, femoston, klimen, etc.).

In addition to hormonal treatment for dysfunctional uterine bleeding, general strengthening and antianemic therapy, immunomodulatory and vitamin therapy, sedative and neuroleptic drugs that normalize the relationship between the cortical and subcortical structures of the brain, physiotherapy (galvanic collar according to Shcherbak) are used. Hepatoprotectors (Essentiale-forte, Wobenzym, Festal, Chofitol) are used to reduce the effect of hormonal drugs on liver function.

The approach to the prevention of dysfunctional uterine bleeding in women of the premenopausal period of life is twofold: up to 48 years of age, the menstrual cycle is restored, after 48 years, it is advisable to suppress the menstrual function. When starting to regulate the cycle, it should be remembered that at this age, taking estrogens and combined drugs is undesirable, and the administration of pure gestagens in the second phase of the cycle is desirable to carry out longer courses - at least 6 months. Suppression of the menstrual function in women under 50 years of age, and in older women - with pronounced endometrial hyperplasia, it is advisable to carry out gestagens: 250 mg of 17a-OPK 2 times a week for six months.

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