Treatment of dysfunctional uterine bleeding

Treatment goals for dysfunctional uterine bleeding

General goals of treatment for uterine bleeding during puberty:

• stopping bleeding to avoid acute hemorrhagic syndrome;
• stabilization and correction of the menstrual cycle and the condition of the endometrium;
• antianemic therapy;
• correction of the mental state of patients and concomitant diseases.

Indications for hospitalization

Indications for hospitalization are:

• heavy (profuse) uterine bleeding that cannot be controlled by drug therapy;
• life-threatening decrease in hemoglobin (below 70-80 g/l) and hematocrit (below 20%);
• the need for surgical treatment and blood transfusion.

Drug treatment of dysfunctional uterine bleeding

There is evidence of low efficacy of etamsylate in recommended doses for stopping profuse uterine bleeding.

Stage I. In patients with uterine bleeding, it is advisable to use plasminogen to plasmin inhibitors (tranexamic or aminocaproic acid) at the first stage of treatment. The intensity of bleeding is reduced by reducing the fibrinolytic activity of blood plasma. Tranexamic acid is prescribed orally at a dose of 4-5 g during the first hour of therapy, then 1 g every hour until bleeding stops completely. Intravenous administration of 4-5 g of the drug during the first hour is possible, then drip administration of 1 g per hour for 8 hours. The total daily dose should not exceed 30 g. With high doses, the risk of developing intravascular coagulation syndrome increases, and with the simultaneous use of estrogens, the probability of thromboembolic complications is high. It is possible to use the drug at a dose of 1 g 4 times a day from the 1st to the 4th day of menstruation, which reduces the volume of blood loss by 50%.

It has been reliably proven that a significant reduction in blood loss in patients with menorrhagia occurs with the use of NSAIDs, monophasic combined oral contraceptives and danazol. Danazol is very rarely used in girls with uterine bleeding during puberty due to severe side effects (nausea, deepening of the voice, hair loss and increased greasiness, acne and hirsutism).

NSAIDs (mefenamic acid, ibuprofen, nimesulide), by suppressing the activity of cyclooxygenase types 1 and 2, regulate the metabolism of arachidonic acid, reduce the production of prostaglandins and thromboxanes in the endometrium, reducing the volume of blood loss during menstruation by 30-38%.

Ibuprofen is prescribed at 400 mg every 4-6 hours (daily dose - 1200-3200 mg) on days of menorrhagia. For mefenamic acid, the starting dose is 500 mg, then 250 mg 4 times a day. Nimesulide is prescribed at 50 mg 3 times a day. Increasing the daily dose may cause an undesirable increase in prothrombin time and lithium content in the blood serum.

The effectiveness of NSAIDs is comparable to the effectiveness of aminocaproic acid and combined oral contraceptives.

In order to increase the effectiveness of hemostatic therapy, the combined use of NSAIDs and hormonal therapy is justified and appropriate. The exceptions are patients with hyperprolactinemia, structural anomalies of the genital organs and thyroid pathology.

Methylergometrine (methylergobrevin) can be prescribed in combination with etamsylate, however, if there is or is a suspicion of the existence of an endometrial polyp or uterine fibroid, it is better to refrain from prescribing methylergometrine due to the possibility of increased bleeding and the occurrence of pain in the lower abdomen.

Preformed physical factors can be used as alternative methods: automammary gland stimulation, vibration massage of the areola, electrophoresis with calcium chloride, galvanization of the upper cervical sympathetic ganglia, electrical stimulation of the cervix with low-frequency pulsed currents, local or laser therapy, acupuncture.

Indications for hormonal hemostasis:

• lack of effect from symptomatic therapy;
• moderate or severe anemia due to prolonged bleeding;
• recurrent bleeding in the absence of organic diseases of the uterus.

Low-dose COCs with 3rd generation progestogens (desogestrel 150 mcg or gestodene 75 mcg) are the most commonly used drugs in patients with profuse and acyclic uterine bleeding. Ethinyl estradiol in COCs provides a hemostatic effect, and progestogens stabilize the stroma and basal layer of the endometrium. Only monophasic COCs are used to stop bleeding.

There are many schemes for using COCs for hemostatic purposes in patients with uterine bleeding. The most popular scheme is as follows: 1 tablet 4 times a day for 4 days, then 1 tablet 3 times a day for 3 days, then 1 tablet 2 times a day, then 1 tablet a day until the end of the second package of the drug. Outside of bleeding, COCs are prescribed for 3 cycles to regulate the menstrual cycle, 1 tablet per day (21 days of use, 7 days of break). The duration of hormonal therapy depends on the severity of the initial iron deficiency anemia and the rate of recovery of the hemoglobin level. The use of COCs in this regimen is associated with a number of serious side effects - increased blood pressure, thrombophlebitis, nausea and vomiting, allergies. In addition, there are difficulties in selecting suitable antianemic therapy.

The high efficiency of using low-dose monophasic COCs (Marvelon, Regulon, Rigevidon, Zhanin) in a dose of half a tablet every 4 hours until complete hemostasis has been proven. This is based on the data that the maximum concentration of COCs in the blood is achieved 3-4 hours after oral administration of the drug and significantly decreases in the next 2-3 hours. The total hemostatic dose of ethinyl estradiol in this case ranges from 60 to 90 mcg, which is more than 3 times less than the traditionally used dose of this drug. In the following days, the daily dose of COCs is reduced by 1/2 tablet per day. When reducing the daily dose to 1 tablet, it is advisable to continue taking the drug, taking into account the hemoglobin level. As a rule, the duration of the first cycle of COC intake should not be less than 21 days, counting from the first day from the onset of hormonal hemostasis. During the first 5-7 days of taking COCs, a temporary increase in the thickness of the endometrium is possible, which recedes without bleeding with continued treatment.

Subsequently, in order to regulate the menstrual rhythm and prevent recurrence of uterine bleeding, the drug is prescribed according to the standard regimen for taking COCs (21-day courses with 7-day breaks between them). All patients who took the drug according to the described regimen showed good tolerability with no side effects.

There is evidence of low efficiency of using low doses of gestagens against the background of profuse uterine bleeding and in the 2nd phase of the menstrual cycle with menorrhagia.

In patients with heavy bleeding, high doses of progestogens (medroxyprogesterone 5-10 mg, micronized progesterone 100 mg or dydrogesterone 10 mg) every 2 hours or 3 times a day until bleeding stops are effective. In case of menorrhagia, medroxyprogesterone can be prescribed at 5-10-20 mg per day in the 2nd phase (in cases with NLF) or 10 mg per day from the 5th to the 25th day of the menstrual cycle (in cases of ovulatory menorrhagia). In patients with anovulatory uterine bleeding, progestogens should be prescribed in the 2nd phase of the menstrual cycle against the background of continuous use of estrogens. It is possible to use micronized progesterone in a daily dose of 200 mg 12 days a month against the background of continuous estrogen therapy. For the purpose of subsequent regulation of the menstrual cycle, gestagens [progesterone (utrogestan) 100 mg 3 times a day, dydrogesterone (duphaston) 10 mg 2 times a day] are prescribed in the 2nd phase of the cycle for 10 days.

High efficiency of stopping bleeding with antihomotoxic drugs has been proven. Traumeel C (2.2 ml) and ovaryum compositum (2.2 ml) are administered in one syringe intramuscularly every 4 hours. Gyneko-hel and valerianachel are prescribed orally in the form of an alcohol solution (20 drops of each solution per 50 ml of water 3 times a day). Bleeding stops 12-18 hours after the start of using antihomotoxic drugs.

Continued bleeding against the background of hormonal hemostasis is an indication for hysteroscopy to clarify the condition of the endometrium.

All patients with uterine bleeding during puberty are prescribed iron preparations to prevent and prophylactically prevent the development of iron deficiency anemia. High efficiency of iron sulfate in combination with ascorbic acid, which provides the patient with 100 mg of divalent iron per day (Sorbifer Durules), has been proven. The daily dose of iron sulfate is selected taking into account the level of hemoglobin in the blood serum. The criterion for the correct selection and adequacy of ferrotherapy for iron deficiency anemia is the presence of a reticulocyte crisis, i.e. an increase in the number of reticulocytes by 3 times or more on the 7-10th day of taking an iron-containing drug. Antianemic therapy is prescribed for a period of at least 1-3 months. Iron salts should be used with caution in patients with concomitant gastrointestinal pathology. In addition, other options include fenuls, tardiferon, ferroplex, ferro-folgamma, maltofer.

In case of recurrent or prolonged (more than 2 months) uterine bleeding, detection of pathogenic microflora or opportunistic microflora in unacceptable concentrations after separate diagnostic curettage, antibacterial therapy is carried out taking into account the sensitivity of the vaginal or cervical canal flora to antibiotics. Macrolide group: roxithromycin (rulid) 150 mg 2 times a day for 7-10 days, josamycin (vilprofen) 150 mg 2 times a day for 7-10 days, or fluoroquinolone group: ofloxacin 200 mg

2 times a day for 7-10 days, or a group of cephalosporins: ceftriaxone (lendacin) 1 g 2 times a day for 5 days, or a group of penicillins: amoxiclav 625 mg

3 times a day for 7 days, or metronidazole (Metrogil) 0.5% 100 ml intravenously by drip once a day for 3 days. In addition, it is necessary to prescribe antiprotozoal or antifungal agents [fluconazole (Diflucan, Mycosyst) 150 mg once, nystatin 500,000 IU 4 times a day for 10-14 days, ketoconazole (Nizoral) 200 mg per day for 7 days]. Alternative therapy may include

Complex antihomotoxic drugs should be used (Gynecohel 3 times a day, 10 drops for 3-6 months, Traumeel C 1 tablet 3 times a day for 3 months, Mucosa compositum 2.2 ml intramuscularly 2 times a week for 3 months, Metro-Adnex-Injel 2.2 ml intramuscularly 2 times a day for 3 months.

Stage II of treatment of uterine bleeding during puberty includes therapy aimed at regulating the menstrual cycle and preventing recurrence of bleeding, correction of physical and mental disorders taking into account individual characteristics, types and forms of uterine bleeding during puberty.

• Correction of eating behavior (caloric and varied nutrition in sufficient quantities).
• Compliance with the work and rest regime, hardening.
• Posture correction (if necessary).
• Sanitation of infection foci.
• Non-drug anti-relapse therapy: acupuncture, magnetotherapy, electropuncture.
• Vitamin therapy.
• Complex antihomotoxic therapy.
• Therapy aimed at improving the functions of the central nervous system.

Vitamin therapy: vitamin and mineral complex; cyclic vitamin therapy: glutamic acid 0.5-1 g 2-3 times a day daily, vitamin E 200-400 mg per day daily, folic acid 1 mg 3 times a day for 10-15 days in the expected 2nd phase of the cycle, ascorbic acid 0.5 g 3 times a day for 10-15 days in the expected 2nd phase of the cycle, magnesium B6 1 tablet 2-3 times a day for 3 months 2 times a year.

Complex antihomotoxic therapy. It is carried out taking into account the definition of the regulatory system that plays a leading role in pathogenesis, regulatory systems involved in the pathogenesis of the disease in a specific patient, and the distribution of pathological symptoms between these systems, as well as the identification of the main "drainage" system that is impaired to the greatest extent.

Coenzyme compositum, ubiquinone compositum, tonsilla compositum, ovarium compositum, 2.2 ml intramuscularly 2 times a week for 2.5-3 months, gynecohel 10 drops 3 times a day, gormel SN 10 drops 3 times a day.

In case of impaired drainage function of the gastrointestinal tract (constipation, diarrhea, flatulence and other symptoms - Nux Vomica-Homaccord 10 drops 3 times a day, Mucosa Compositum 2.2 ml intramuscularly 2 times a week, mainly in case of impaired colon function; Duodenohel - in case of impaired small intestine function; Gastricumel - in case of impaired stomach function. In case of impaired drainage function of the kidneys: Populus Compositum SR, Renel, Berberis-Homaccord, Solidago Compositum S, Aesculus Compositum. In case of impaired drainage function of the liver: Hepel, Hepar Compositum, Curdlipid, Cheledonium Homaccord, Nux Vomica-Homaccord, Leptandra Compositum. In case of impaired drainage function of the skin: PsoriNohel H, Traumeel S, Cutis Compositum. The leading antihomotoxic drug for removing homotoxins from the pathological focus by controlling humoral interstitial transport and restoring the normal state of the lymphatic system is lymphomyosot, 10 drops 3 times a day.

Therapy aimed at improving CNS functions: vinpocetine (cavinton) 1-2 mg/kg per day, cinnarizine in a daily dose of 8-12.5 mg 1-2 times per day, pentoxifylline (trental) 10 mg/kg per day, glycine 50-100 mg 2-3 times per day for 1-2 months, piracetam (nootropil) 50-100 mg 1-2 times per day from 2-3 weeks to 2 months, phenytoin (diphenin) 1-2 tablets per day for 3-6 months, carbamazepam (finlepsin) 1/2 tablet 2 times per day for 2-4 weeks.

Antihomotoxic drugs: valerianachel, 10 drops 3 times a day - if symptoms of psychoemotional agitation predominate, nervochel - if depression predominates, 1 tablet 3 times a day, cerebrum compositum 2.2 ml intramuscularly 2 times a week for 3 months, vertigochel, 10 drops 3 times a day.

Evaluation of the effectiveness of treatment for dysfunctional uterine bleeding

An equally important component of the conducted therapy of uterine bleeding is the assessment and identification of the nature of the low efficiency of the proposed treatment methods. When assessing possible variants of clinical outcomes in the follow-up, the most acceptable of them is considered to be not only the cessation of bleeding, but also the establishment of regular menstrual cycles.

Evidence was obtained that the highest probability of relapses was observed in cases where bleeding occurred in patients against the background of hypoestrogenism. The highest assessment of the therapeutic solution was obtained when prescribing non-hormonal therapy, in which the probability of the most favorable outcomes (according to follow-up data) is from 75% to 90% for all types of uterine bleeding in the pubertal period.

The clinical significance of hormonal therapy is demonstrated at a sufficient level only when taking COCs and only with the hyperestrogenic type in the absence of relapses. In patients with normoestrogenism, this type of therapy shows the highest risk of irregular menstrual cycles. In patients with hypoestrogenism, at late stages after COC treatment, there is a high probability of irregular cycles and relapses.

The least successful treatment for patients with different types of functional disorders of the menstrual cycle in the pubertal period was the use of progestogens. The highest probability of relapses was noted in the group of patients with hyperestrogenism.

Taking into account typical and atypical forms of uterine bleeding in the pubertal period, there is evidence that in patients with atypical forms, the probability of recurrence of bleeding was low. In the case of non-hormonal therapy, not only was there no recurrence, but also no cases of irregular cycles were detected. The effectiveness of COCs and progestogens was also quite high.

In the case of the typical form of uterine bleeding, the effectiveness of all types of treatment was significantly reduced compared to the atypical form. The least effective was the use of progestogens (high probability of relapse). Remote results of the use of COCs showed the highest probability of irregular cycles.

Negative and not entirely satisfactory effects of the conducted therapy are associated not only with the use of specific therapeutic measures. From a clinical point of view, it may be ineffective due to random uncontrolled factors that may well determine the patient's resistance to the selected treatment methods. At the same time, it cannot be denied that, when assessing his own experience, the doctor must clarify the impact on the quality of treatment of factors that can be controlled, including factors associated with incomplete knowledge of the causes and mechanisms of development of this pathology, as well as factors based on an erroneous interpretation of clinical manifestations and "generally accepted" misconceptions about the use of a particular treatment method. Some of the factors that can be controlled are clinical and paraclinical signs that determine the type of uterine bleeding in the pubertal period. In accordance with the general principles of the formation of functional disorders, the use of agents with a specific effect on any of the elements of the "dysregulated" functional system is inappropriate. Any procedure for restoring self-regulation should interact organically with all components of the system, and not selectively with any of them. Even a specific external effect necessarily causes a non-specific systemic reaction, and it is also possible to obtain an effect that aggravates the disruption of the coordinated activity of the entire system. That is why restorative measures should begin with the use of the least specific effects that have a positive effect on the entire body. In practice, the doctor must solve a dual problem. When uterine bleeding occurs that threatens to cause serious complications, the clinician must first of all eliminate the cause of this "target symptom" using specific methods. However, in the future, even if the treatment method turned out to be highly effective for hemostasis, its use is rather not entirely justified. A clear illustration of the advantage of a non-specific approach is the conducted analysis of the probability of outcome options for various types and forms of uterine bleeding in the pubertal period in cases of using various therapeutic approaches.

Surgical treatment of dysfunctional uterine bleeding

Scraping of the mucous membrane of the body and cervix (separate) under the control of a hysteroscope in girls is performed very rarely. Indications for surgical treatment are:

• acute profuse uterine bleeding that does not stop despite drug therapy;
• the presence of clinical and ultrasound signs of endometrial and/or cervical canal polyps.

In case of necessity to remove an ovarian cyst (endometrioid, dermoid, follicular or corpus luteum cyst persisting for more than 3 months) or to clarify the diagnosis in patients with a volumetric formation in the area of the uterine appendages, therapeutic and diagnostic laparoscopy is indicated.

Indications for consultation with other specialists

• Consultation with an endocrinologist is necessary if thyroid pathology is suspected (clinical symptoms of hypo- or hyperthyroidism, diffuse enlargement or nodular formations of the thyroid gland upon palpation).
• Consultation with a hematologist - at the onset of uterine bleeding in the pubertal period with menarche, indications of frequent nosebleeds, the occurrence of petechiae and hematomas, increased bleeding from cuts, wounds and surgical manipulations, detection of an increase in bleeding time.
• Consultation with a phthisiatrician - in case of uterine bleeding during puberty against the background of prolonged persistent subfebrile temperature, acyclic nature of bleeding, often accompanied by pain syndrome, absence of a pathogenic infectious agent in the discharge of the urogenital tract, relative or absolute lymphocytosis in the general blood test, positive results of the tuberculin test.
• Consultation with a therapist - for uterine bleeding during puberty against the background of chronic systemic diseases, including diseases of the kidneys, liver, lungs, cardiovascular system, etc.
• Consultation with a psychotherapist or psychiatrist - for all patients with uterine bleeding during puberty for psychotherapeutic correction taking into account the characteristics of the psychotraumatic situation, clinical typology, and the individual's reaction to the disease.

Approximate periods of incapacity for work

In uncomplicated cases, the disease does not cause permanent disability. Possible periods of disability (from 10 to 30 days) may be due to the severity of clinical manifestations of iron deficiency anemia against the background of prolonged or heavy bleeding, as well as the need for hospitalization for surgical or hormonal hemostasis.

Further management

Patients with uterine bleeding during puberty require constant dynamic monitoring once a month until the menstrual cycle stabilizes, then the frequency of control examinations can be limited to once every 3-6 months. Ultrasound of the pelvic organs should be performed at least once every 6-12 months, electroencephalography - after 3-6 months. All patients should be trained in the rules of maintaining a menstrual calendar and assessing the intensity of bleeding, which will determine the effectiveness of the treatment.

Patients should be informed about the advisability of correcting and maintaining optimal body weight (both in cases of deficiency and excess body weight), and normalizing work and rest patterns.

Information for the patient

• Normalization of work and rest regime.
• A balanced diet (with the obligatory inclusion of meat in the diet, especially veal).
• Hardening and physical education (outdoor games, gymnastics, skiing, skating, swimming, dancing, yoga).

Forecast

Most adolescent girls respond favorably to drug treatment, and within the first year they develop full ovulatory menstrual cycles and normal menstruation. The prognosis for pubertal uterine bleeding in the setting of hemostatic pathology or systemic chronic diseases depends on the degree of compensation for existing disorders. Girls who remain overweight and have recurrent pubertal uterine bleeding at the age of 15-19 years should be included in the risk group for endometrial cancer.