Dysfunctional uterine bleeding in women

Dysfunctional uterine bleeding (DUB, abnormal uterine bleeding) is a regulatory bleeding caused by dysfunction of one of the links in the neurohumoral regulation of menstrual function. This is pathological bleeding from the genital tract, not associated with organic lesions of the organs involved in the menstrual cycle. It is necessary to pay attention to the relative nature of this definition, to some conventionality of it. Firstly, it is quite possible to think that organic causes of uterine bleeding cannot be identified by existing diagnostic methods, and secondly, the lesions of the endometrium observed in DUB cannot be considered anything other than organic.

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Epidemiology

It occurs most often in women over 45 years of age (>50% of cases) and in adolescents (20% of cases).

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Causes dysfunctional uterine bleeding

Dysfunctional uterine bleeding is the most general term for abnormal uterine bleeding.

The main reason is increased production of estrogens and decreased production of progesterone. Increased production of estrogens can lead to endometrial hyperplasia. In this case, the endometrium is rejected unevenly, which leads to either profuse or prolonged bleeding. Endometrial hyperplasia, especially atypical adenomatous hyperplasia, predisposes to the development of endometrial cancer.

In most women, dysfunctional uterine bleeding is anovulatory. Anovulation is usually secondary, such as in polycystic ovary syndrome, or idiopathic; hypothyroidism may occasionally cause anovulation. In some women, dysfunctional uterine bleeding may be anovulatory despite normal gonadotropin levels; the causes of such bleeding are idiopathic. About 20% of women with endometriosis have dysfunctional uterine bleeding of unknown origin.

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Symptoms dysfunctional uterine bleeding

Bleeding may occur more frequently than a typical menstruation (less than 21 days - polymenorrhea). Prolongation of menstruation itself or increased blood loss (>7 days or >80 ml) is called menorrhagia or hypermenorrhea, the occurrence of frequent, irregular bleeding between menstruations - metrorrhagia.

Dysfunctional uterine bleeding, depending on the time of occurrence, is divided into juvenile, reproductive period and climacteric. Dysfunctional uterine bleeding can be ovulatory and anovulatory.

Ovulatory bleeding is characterized by the preservation of the two-phase cycle, but with a disruption of the rhythmic production of ovarian hormones of the type:

• Shortening of the follicular phase. Occurs more often during puberty and menopause. During the reproductive period, they can be caused by inflammatory diseases, secondary endocrine disorders, and vegetative neurosis. In this case, the interval between periods is reduced to 2-3 weeks, and menstruation occurs as hyperpolymenorrhea.

When examining the ovarian TFD, the rise in rectal temperature (RT) above 37°C begins on the 8th-10th day of the cycle, cytological smears indicate a shortening of the 1st phase, histological examination of the endometrium gives a picture of secretory transformations of its type of insufficiency of the 2nd phase.

Therapy is primarily aimed at eliminating the underlying disease. Symptomatic treatment - hemostatic (vicasol, dicinone, syntocinone, calcium preparations, rutin, ascorbic acid). In case of heavy bleeding - oral contraceptives (non-ovlon, ovidon) according to the contraceptive (or initially hemostatic - up to 3-5 tablets per day) scheme - 2-3 cycles.

• Shortening of the luteal phase is often characterized by the appearance of usually small bloody discharge before and after menstruation.

According to the TFD of the ovaries, an increase in rectal temperature after ovulation is noted only for 2-7 days; cytologically and histologically, insufficiency of secretory transformations of the endometrium is revealed.

Treatment consists of prescribing corpus luteum drugs - gestagens (progesterone, 17-OPK, duphaston, uterozhestan, norethisterone, norcolut).

• Prolongation of the luteal phase (persistence of the corpus luteum). Occurs when the pituitary gland is dysfunctional, often associated with hyperprolactinemia. Clinically, it can be expressed as a slight delay in menstruation followed by hyperpolymenorrhea (meno-, menometrorrhagia).

TFD: prolongation of the rise in rectal temperature after ovulation to 14 days or more; histological examination of uterine scraping - insufficient secretory transformation of the endometrium, scraping is often moderate.

Treatment begins with scraping the uterine mucosa, which stops bleeding (interruption of the current cycle). Then - pathogenetic therapy with dopamine agonists (parlodel), gestagens or oral contraceptives.

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Anovulatory bleeding

Anovulatory dysfunctional uterine bleeding, characterized by the absence of ovulation, is more common. The cycle is single-phase, without the formation of a functionally active corpus luteum, or there is no cyclicity.

During puberty, lactation and premenopause, frequently occurring anovulatory cycles may not be accompanied by pathological bleeding and do not require pathogenetic therapy.

Depending on the level of estrogens produced by the ovaries, anovulatory cycles are distinguished:

1. With insufficient maturation of the follicle, which subsequently undergoes reverse development (atresia). It is characterized by an extended cycle followed by scanty, prolonged bleeding; often occurs in juveniles.
2. Long-term persistence of the follicle (hemorrhagic metropathy of Schroeder). The mature follicle does not ovulate, continuing to produce estrogens in increased quantities, the corpus luteum does not form.

The disease is often characterized by heavy, prolonged bleeding for up to three months, which may be preceded by delays in menstruation for up to 2-3 months. It occurs more often in women over 30 years of age with concomitant hyperplastic processes of the target organs of the reproductive system or in early premenopause. It is accompanied by anemia, hypotension, and dysfunction of the nervous and cardiovascular systems.

Differential diagnostics: RT - single-phase, colpocytology - decreased or increased estrogenic influence, serum E2 level _- multidirectional, progesterone - sharply decreased. Ultrasound - linear or sharply thickened (more than 10 mm) heterogeneous endometrium. Histological examination reveals the endometrium's compliance with the onset of the follicular phase of the cycle or its pronounced proliferation without secretory transformations. The degree of endometrial proliferation varies from glandular hyperplasia and endometrial polyps to atypical hyperplasia (structural or cellular). Severe cellular atypia is considered as preinvasive endometrial cancer (clinical stage 0). All patients with dysfunctional uterine bleeding in reproductive age suffer from infertility.

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Diagnostics dysfunctional uterine bleeding

The diagnosis of dysfunctional uterine bleeding is a diagnosis of exclusion and may be considered in patients with unexplained vaginal bleeding. Dysfunctional uterine bleeding should be differentiated from disorders that cause such bleeding: pregnancy or pregnancy-related disorders (eg, ectopic pregnancy, spontaneous abortion), anatomical gynecologic disorders (eg, fibroids, cancer, polyps), foreign bodies in the vagina, inflammatory processes (eg, cervicitis), or disorders of the hemostatic system. If patients have ovulatory bleeding, anatomical changes should be excluded.

History and physical examination focus on detecting signs of inflammation and tumor. For women of reproductive age, a pregnancy test is necessary. If there is profuse bleeding, hematocrit and hemoglobin are determined. The TGG level is also examined. Transvaginal ultrasonography is performed to detect anatomical changes. To determine anovulatory or ovulatory bleeding, serum progesterone levels are determined; if the progesterone level is 3 ng/ml or more (9.75 nmol/l) during the luteal phase, the bleeding is assumed to be ovulatory. In order to exclude endometrial hyperplasia or cancer, it is necessary to perform an endometrial biopsy in women over 35 years of age, in case of obesity, in case of polycystic ovary syndrome, in the presence of ovulatory bleeding, irregular menstruation that suggests the presence of chronic anovulatory bleeding, with an endometrial thickness of more than 4 mm, with questionable ultrasound data. In women without the above situations with an endometrial thickness of less than 4 mm, including patients with an irregular menstrual cycle, having a shortened anovulation period, further examination is not required. In patients with atypical adenomatous hyperplasia, it is necessary to perform hysteroscopy and separate diagnostic curettage.

Tests used to rule out the cause of anovulatory bleeding:

• Human chorionic gonadotropin (hCG).
• Complete blood count.
• Pap smear.
• Endometrial examination.
• Functional tests of the thyroid gland and prolactin.
• Liver function tests.
• Coagulogram.
• Other hormonal studies.
• Histological studies.
• In obese patients and with suspected ovarian or uterine cancer, uterine fibroids, an ultrasound of the pelvic organs is performed.

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Treatment dysfunctional uterine bleeding

In the presence of anovulatory dysfunctional uterine bleeding, the most effective use of oral contraceptives. For heavy bleeding, oral contraceptives can be prescribed in the following regimen: 1 tablet 4 times a day for 3 days; then 1 tablet 3 times a day for 3 days; then 1 tablet 2 times a day for 3 days; then 1 tablet 1 time per day. For very heavy bleeding, estrogens can be prescribed at 25 mg intravenously every 6-12 hours until the bleeding decreases. After the bleeding has decreased, a combination of estrogen-progestin oral contraceptives should be prescribed for 3 months to prevent relapse.

If patients have contraindications to the use of estrogens or if normal menstruation does not resume after 3 months of oral contraceptive therapy and pregnancy is not desired, a progestin is prescribed (for example, medroxyprogesterone 510 mg once a day orally for 10-14 days each month). If the patient wishes to become pregnant and bleeding is not heavy, clomiphene 50 mg orally is prescribed from the 5th to the 9th day of the menstrual cycle to induce ovulation.

If dysfunctional uterine bleeding does not respond to hormonal therapy, hysteroscopy with separate diagnostic curettage is necessary. Hysterectomy or endometrial ablation may be performed.

Endometrial ablation is an alternative for patients who wish to avoid hysterectomy or who are not candidates for major surgery.

In the presence of atypical adenomatous endometrial hyperplasia, medroxyprogesterone acetate is prescribed at 20-40 mg orally once a day for 36 months. If a repeat intrauterine biopsy reveals improvement in the condition of the endometrium in hyperplasia, cyclic medroxyprogesterone acetate is prescribed (5-10 mg orally once a day for 10-14 days of each month). If pregnancy is desired, clomiphene citrate can be prescribed. If a biopsy reveals no effect from treatment of hyperplasia or progression of atypical hyperplasia is noted, a hysterectomy should be performed. In benign cystic or adenomatous endometrial hyperplasia, cyclic medroxyprogesterone acetate should be prescribed; the biopsy is repeated after approximately 3 months.