Dysfunctional uterine bleeding in women

Dysfunctional uterine bleeding (DMC, abnormal uterine bleeding) - regulatory bleeding caused by a violation of the function of one of the links of neurohumoral regulation of menstrual function. This pathological bleeding from the genital tract, not associated with organic lesions of organs participating in the menstrual cycle. It is necessary to pay attention to the relative nature of this definition, to some conventionality of it. First, the idea that organic causes of uterine bleeding can not be detected by existing diagnostic methods is quite acceptable, and secondly, the endometrial lesions observed in DMC can not be considered organic.

[1], [2], [3], [4], [5], [6]

Epidemiology

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

[7], [8], [9]

Causes of the dysfunctional uterine bleeding

Dysfunctional uterine bleeding is the most common indication of pathological uterine bleeding.

The main reason is increased production of estrogens and a decrease in progesterone production. 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, for example in the syndrome of polycystic ovaries, or has an idiopathic origin; Sometimes the cause of anovulation can be hypothyroidism. In some women, dysfunctional uterine bleeding may be anovulatory despite normal levels of gonadotropin; the causes of such bleeding are idiopathic. Approximately 20% of women with endometriosis have dysfunctional uterine bleeding of unknown origin.

[10]

Symptoms of the dysfunctional uterine bleeding

Bleeding may occur more often than typical menstruation (less than 21 days later - polymenorrhea). Lengthening the menstrual period or increasing blood loss (> 7 days or> 80 ml) is called menorrhagia or hypermenorrhoea, the appearance of frequent, irregular bleeding in the interval between menstruations - metrorrhagia.

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

Ovulatory bleeding is characterized by the preservation of biphasic cycle, but with a violation of rhythmic production of ovarian hormones of the type:

• Shortening of the follicular phase. There is a bowl during puberty and menopause. In the reproductive period, they can be caused by inflammatory diseases, secondary endocrine disorders, vegetative neurosis. At the same time, the interval between months is shortened to 2-3 weeks, the monthly ones are performed according to type-hyperpolymenorrhoea.

In the study of DTF ovaries, the elevation of the 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 the secretory transformations of its type of deficiency in the 2nd phase.

Therapy is primarily aimed at eliminating the underlying disease. Symptomatic treatment - hemostatic (Vikasol, dicinone, synthocinone, calcium preparations, rutin, ascorbic acid). In cases of heavy bleeding, oral contraceptives (non-vellon, ovidon) for contraceptive (or initially hemostatic - up to 3-5 tablets a day) scheme - 2-3 cycles.

• The shortening of the luteal phase is more often characterized by the appearance of usually small bloody discharge before and after the menstrual period.

According to the TFD of the ovaries, the rise in rectal temperature after ovulation is noted only for 2-7 days; cytologically and histologically, there is a lack of secretory transformations of the endometrium.

Treatment consists in prescribing the preparations of the yellow body - gestagens (progesterone, 17-OPK, dufaston, utero, norethisterone, norkolut).

• Lengthening of the luteal phase (persistence of the yellow body). It occurs when the function of the pituitary gland is disturbed, it is often associated with hyperprolactinemia. Clinically it can be expressed in a slight delay in menstruation followed by hyperpolymenoreia (meno-, menometrorrhagia).

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

Treatment begins with curettage of the mucous membrane of the uterus, which leads to a halt of bleeding (interruption of the present cycle). In the future - pathogenetic therapy with dopamine agonists (parlodel), gestagens or oral contraceptives.

[11], [12], [13], [14], [15]

Anovulatory bleeding

More often there are anovulatory dysfunctional uterine bleeding, characterized by the absence of ovulation. The cycle is single-phase, without the formation of a functionally active yellow body, or cyclicity is absent.

In the period of puberty, lactation and premenopause, often arising anovulatory cycles may not be accompanied by pathological bleeding and do not require pathogenetic therapy.

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

1. With insufficient maturation of the follicle, which later undergoes reverse development (atresia). It is characterized by an elongated cycle followed by a prolonged, prolonged bleeding; often occurs in juvenile age.
2. Prolonged persistence of the follicle (Schroeder hemorrhagic metropathy). The ripened follicle does not ovulate, continuing to produce estrogen in increased amounts, the yellow body is not formed.

The disease is characterized by often abundant, prolonged bleeding to three months, which may be preceded by a delay of monthly to 2-3 months. It occurs more often in women after 30 years with concomitant hyperplastic processes of the target organs of the reproductive system or in early premenopause. It is accompanied by anemia, hypotension, impaired function of the nervous and cardiovascular systems.

Differential diagnostics: RT - single-phase, colpocytology - reduced or increased estrogenic effect, serum E ₂ level - differently directed, progesterone - sharply reduced. Ultrasound is a linear or sharply thickened (more than 10 mm) heterogeneous endometrium. Histological examination reveals the correspondence of the endometrium to the onset of the follicular phase of the cycle or its pronounced proliferation without secretory transformations. The degree of proliferation of the endometrium ranges from glandular hyperplasia and endometrial polyps to atypical hyperplasia (structural or cellular). A severe degree of cellular atypia is considered as a preinvasive endometrial cancer (clinical stage 0). All patients with dysfunctional uterine bleeding during reproductive years suffer infertility.

[16], [17], [18]

Diagnostics of the dysfunctional uterine bleeding

The diagnosis of dysfunctional uterine bleeding is the diagnosis of an exception, it can be suspected in patients with unexplained hemorrhage from the genital tract. Dysfunctional uterine bleeding should be differentiated from disorders that cause similar bleeding: pregnancy or pregnancy-related disorders (eg, ectopic pregnancy, spontaneous abortion), anatomical gynecological disorders (eg, fibroids, cancer, polyps), foreign bodies in the vagina, inflammatory processes (eg, cervicitis) or disorders in the hemostasis system. If patients have ovulatory bleeding, then anatomical changes should be excluded.

Anamnesis and general examination focuses on finding signs of inflammation and tumor. For women of reproductive age, a pregnancy test is required. In the presence of profuse bleeding, hematocrit and hemoglobin are determined. So the level of TGG is examined. To identify anatomical changes, transvaginal ultrasonography is performed. In order to determine anovulatory or ovulatory bleeding, it is necessary to determine the level of progesterone in the blood serum; if the progesterone level is 3 ng / ml or more (9.75 nmol / L) during the luteal phase, then it is assumed that bleeding is ovulatory. In order to avoid hyperplasia or endometrial cancer, it is necessary to perform an endometrial biopsy in women over the age of 35, with obesity, in the syndrome of polycystic ovaries, with ovulatory bleeding, irregular menstruation, suggesting the presence of chronic anovulatory bleeding, with an endometrium thickness of more than 4 mm, with doubtful ultrasound data. In women, in the absence of the above situations with an endometrium thickness of less than 4 mm, including patients with irregular menstrual cycles who have a shortening of the anovulation period, no further examination is required. Patients with atypical adenomatous hyperplasia need hysteroscopy and separate diagnostic curettage.

Studies used to exclude the cause of anovulatory bleeding:

• Human chorionic gonadotropin (hCG).
• General blood analysis.
• Smear on the pap.
• Endometrial examination.
• Functional tests of the thyroid gland and prolactin.
• Functional tests of the liver.
• Coagulogram.
• Other hormonal studies.
• Histological studies.
• In obese patients and with suspicion of cancer of the ovaries or uterus, uterine fibroids are performed ultrasound of the pelvic organs.

[19], [20], [21], [22], [23]

Treatment of the dysfunctional uterine bleeding

In the presence of anovulatory dysfunctional uterine bleeding, the most effective use of oral contraceptive drugs. In severe bleeding, oral contraceptives can be prescribed in the following: 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 once a day. With very severe bleeding, estrogens can be administered at a dose of 25 mg intravenously every 6-12 hours until the bleeding is reduced. After reducing bleeding, a combination of estrogen-progestin-only oral contraceptives should be prescribed for 3 months to prevent relapse.

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

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

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

In the presence of atypical adenomatous endometrial hyperplasia medroxyprogesterone acetate is prescribed for 20-40 mg orally once a day for 36 months. If repeated endometrial biopsy reveals an improvement in the state of the endometrium with hyperplasia, a cyclic medroxyprogesterone acetate is prescribed (5-10 mg orally once a day for 10-14 days of each month). If pregnancy is desired, you can prescribe clomiphene citrate. If a biopsy shows no effect from the treatment of hyperplasia or progression of atypical hyperplasia is noted, hysterectomy is necessary. In benign cystic or adenomatous hyperplasia of the endometrium, the appointment of cyclic medroxyprogesterone acetate is necessary; a biopsy is repeated after about 3 months.