Treatment of dysfunctional uterine bleeding

The goals of treatment of dysfunctional uterine bleeding

The general goals of treatment of pubertal uterine bleeding:

• stop bleeding in order to avoid acute hemorrhagic syndrome;
• stabilization and correction of the menstrual cycle and the state of the endometrium;
• anti-anemic therapy;
• correction of the mental state of patients and concomitant diseases.

Indications for hospitalization

Indications for hospitalization are:

• profuse (uterus) uterine bleeding, not suppressed by drug therapy;
• a life-threatening decrease in hemoglobin (below 70-80 g / l) and hematocrit (below 20%);
• the need for surgical treatment and blood transfusion.

Drug treatment for dysfunctional uterine bleeding

There is evidence of low efficacy of etamzilate at recommended doses for stopping profuse uterine bleeding.

I stage. In patients with uterine bleeding at the first stage of treatment, it is advisable to use inhibitors of the transition of plasminogen to plasmin (tranexamic or aminocaproic acid). The intensity of bleeding is reduced due to a decrease in the fibrinolytic activity of the blood plasma. Tranexamic acid is administered orally at a dose of 4-5 g during the first hour of therapy, then 1 g every hour until the bleeding stops completely. Possible intravenous administration of 4-5 g of the drug during the first hour, then drip introduction of 1 g per hour for 8 hours. The total daily dose should not exceed 30 g. At high doses, the risk of developing the syndrome of intravascular coagulation 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 in girls with uterine bleeding puberty is used very rarely due to severe adverse reactions (nausea, coarsening of the voice, loss and increase of greasiness of the hair, the appearance of acne and hirsutism).

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

Ibuprofen is prescribed 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 50 mg 3 times a day. An increase in the daily dose may cause an undesirable increase in the prothrombin time and the lithium content in the serum.

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

In order to improve the effectiveness of hemostatic therapy, the combined use of NSAIDs and hormone therapy is justified and appropriate. Exception is made by patients with hyperprolactinemia, structural abnormalities of the genital organs and pathology of the thyroid gland.

Methylergometrin (methylergobrevin) can be prescribed in combination with etamzilate, however, if there is or if there is a suspected existence of an endometrial polyp or uterine fibroids from the appointment of metargergometrin, it is better to refrain because of the possibility of increasing blood discharge and pain in the lower abdomen.

Alternate methods can be used preformed physical factors: autoammonization, vibromassage of the nasal zone, electrophoresis with calcium chloride, galvanization of the region of the upper cervical sympathetic ganglia, electrostimulation of the cervix by pulsed currents of low frequency, local or laser therapy, acupuncture.

Indications for hormonal hemostasis:

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

Low-dose COCs with progestogens of the third generation (desogestrel 150 μg or gestodene 75 μg) are the most commonly used drugs in patients with profuse and acyclic uterine bleeding. Ethinyl estradiol in the COC provides a haemostatic effect, and progestogens - stabilization of the stroma and basal layer of the endometrium. To stop bleeding use only monophasic COCs.

There are many schemes of using COC for haemostatic purposes in patients with uterine bleeding. The most popular is the following scheme; 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 the bleeding for the purpose of regulating the menstrual cycle, COCs are prescribed for 3 cycles of 1 tablet per day (21 day of taking, 7 days off). The duration of hormonal therapy depends on the severity of the initial iron deficiency anemia and the rate of recovery of hemoglobin. The use of COC in this mode 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 anti-anemic therapy.

High efficiency of low-dose monophasic COCs (marvelon, regulon, rigevidon, janin) on a half-tablet every 4 h before full hemostasis is proved. This is based on the data that the maximum concentration of COC in the blood is reached 3-4 hours after taking the drug inside and significantly reduced in the next 2-3 hours. The total haemostatic dose of ethinyl estradiol ranges from 60 to 90 μg, which is more than 3 times less than the traditionally used dose of this drug. In the following days, the daily dose of COC is reduced by 1/2 tablets per day. With a decrease in the daily dose to 1 tablet, it is advisable to continue taking the drug taking into account the level of hemoglobin. As a rule, the duration of the first cycle of taking COC should not be less than 21 days, counting from the first day from the beginning of hormonal hemostasis. In the first 5-7 days of COC administration, a temporary increase in the thickness of the endometrium is possible, which is refreshed without bleeding while continuing treatment.

In the future, in order to regulate the rhythm of menstruation and prevent relapse of uterine bleeding, the drug is prescribed according to the standard scheme of COC (21-day courses with 7-day intervals between them). All patients who took the drug according to the described scheme, noted good tolerability in the absence of side effects.

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

In patients with heavy bleeding, high doses of progestogens are effective (medroxyprogesterone 5-10 mg, micronized progesterone 100 mg or dydrogesterone 10 mg) every 2 hours or 3 times a day until bleeding ceases. In case of menorrhagia, medroxyprogesterone may be prescribed 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 are advisable to be assigned to the 2nd phase of the menstrual cycle against the background of the constant use of estrogens. It is possible to use micronized progesterone in a daily dose of 200 mg 12 days a month on the background of continuous therapy with estrogens. For the purpose of the subsequent regulation of the menstrual cycle, the gestagens [progesterone (morning)), 100 mg 3 times a day, dydrogesterone (dufaston) 10 mg twice a day] are assigned to the second phase of the cycle for 10 days.

The high effectiveness of stopping bleeding with the help of anti-motoxic drugs has been proven. Traumeel C (2.2 ml) and ovarium compositum (2.2 ml) are injected intramuscularly in a single syringe every 4 h. Internally, gineko-gel and valerianacle are administered as an alcohol solution (20 drops of each solution per 50 ml of water 3 times day). The bleeding stops after 12-18 hours from the beginning of the use of antihomotoxic drugs.

Continuation of bleeding on the background of hormonal hemostasis is an indication for hysteroscopy with a view to clarifying the state of the endometrium.

All patients with uterine bleeding of the pubertal period showed the appointment of iron preparations to prevent and prevent the development of iron deficiency anemia. The high effectiveness of the use of iron sulfate in combination with ascorbic acid, which ensures the intake of a patient with 100 mg of ferrous iron per day (sorbifer durules) is proved. 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 in iron deficiency anemia is the presence of a reticulocytic crisis, i.e. Increase in the number of reticulocytes 3 times or more on the 7-10th day of taking iron-containing drug. Antianemic therapy is prescribed for a period of at least 1-3 months. Caution should be used iron salts in patients with concomitant pathology of the gastrointestinal tract. In addition, the choice may be fenules, tardiffon, ferroplex, ferro-folgamma, maltofer.

With recurrent or prolonged (more than 2 months) uterine bleeding, the detection of pathogenic microflora or conditionally pathogenic microflora at unacceptable concentrations after separate diagnostic curettage, antibacterial therapy is carried out taking into account the sensitivity of the vaginal flora or cervical canal to antibiotics. Macrolide group: roxithromycin (rolid) 150 mg twice a day 7-10 days, josamycin (wilprofen) 150 mg twice a day 7-10 days, or a group of fluoroquinolones: ofloxacin at 200 mg

2 times a day 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 (metrogyl) 0.5% 100 ml intravenously drip once a day for 3 days. In addition, mandatory prescription of antiprotozoal or antifungal agents [fluconazole (diflucan, mycosyst) 150 mg once, nystatin 500 000 units 4 times a day 10-14 days, ketoconazole (nizoral) 200 mg per day 7 days]. As an alternative therapy,

Be used complex antihomotoxic drugs (ginekohel 3 times a day for 10 drops 3-6 months, Traumeel C 1 tablet 3 times a day for 3 months, mucoza compositum 2.2 ml intramuscularly 2 times a week 3 months, metro-adnex-inel 2.2 ml intramuscularly 2 times a day 3 months.

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

• Correction of eating behavior (high-calorie and varied nutrition in sufficient quantity).
• Observance of the regime of work and rest, hardening.
• Correction of posture (if necessary).
• Sanitation of foci of infection.
• Non-medicamental anti-relapse therapy: acupuncture, magnetic therapy, electropuncture.
• Vitaminotherapy.
• Complex antihomotoxic therapy.
• Therapy, aimed at improving the functions of the central nervous system.

Vitaminotherapy: vitamin-mineral complex; cyclic vitamin therapy: glutamic acid 0.5-1 g 2-3 times a day daily, vitamin E at 200-400 mg per day daily, folic acid 1 mg 3 times a day 10-15 days in the proposed 2nd phase cycle, ascorbic acid 0.5 g 3 times a day 10-15 days in the proposed 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, the regulatory systems involved in the pathogenesis of the disease in a particular patient, and the distribution of pathological symptoms between these systems, as well as identifying the main "drainage" system that is most severely disrupted.

Coenzyme compositum, ubiquinone compositum, tonzilla compositum, ovarium compositum 2.2 ml intramuscularly 2 times a week 2.5-3 months, ginekohel 10 drops 3 times a day, hormone CH 10 drops 3 times a day.

If there is a violation of the "drainage" function of the digestive tract (constipation, diarrhea, flatulence and other manifestations - nuks vomica-homaccord 10 drops 3 times a day, mucoza compositum 2.2 ml intramuscularly 2 times a week, mainly in violation of the functions of the large intestine; duodenocel - with violation of the functions of the small intestine, gastricumel - in violation of the functions of the stomach.When there is a violation of the "drainage" function of the kidneys: Populus compositum SR, RENEL, Berberis Homaccord, Solidago Compositum C, Eskulus compositum .If the "drainage" function of the liver: hepel, gepar compositum, ku length, helomedium homaccord, nuks vomica-homaccord, leptandra compositum.When there is a violation of the drainage function of the skin: psorinochel H, traumel C, kutis compositum.The leading antihomotoxic drug for removal of homotoxins from the pathological focus due to control of humoral interstitial transport and restoration of the normal state of lymphatic The system serves lymphomyosot 10 drops 3 times a day.

Therapy aimed at improving the functions of the central nervous system: vinpocetine (cavinton) at 1-2 mg / kg per day, cinnarizine at a daily dose of 8-12.5 mg 1 -2 times a day, pentoxifylline (trental) at 10 mg / kg per day, glycine 50-100 mg 2-3 times a day 1-2 months, pyracetam (nootropil) 50-100 mg 1-2 times a day from 2-3 weeks to 2 months. Phenytoin (diphenine) 1-2 tablets per day for 3-6 months. Carbamazepam (finlepsin) 1/2 tablet 2 times a day 2-4 weeks.

Antihomotoxic drugs: valerianhal, 10 drops 3 times a day - with symptoms of psychoemotional arousal predominating, nervol - with depression dominating 1 tablet 3 times a day, cerebromum compositum 2.2 ml intramuscularly 2 times a week 3 months, vertigochel 10 drops 3 times a day.

Evaluation of the effectiveness of treatment of dysfunctional uterine bleeding

No less important component of the spent uterine bleeding therapy is the evaluation and identification of the nature of low efficacy of the proposed methods of treatment. When evaluating possible variants of clinical outcomes in a catamnesis, the most acceptable of them is not only the cessation of bleeding, but also the installation of regular menstrual cycles.

Evidence has been obtained that the greatest probability of recurrence was observed in those cases when bleeding occurred in patients with hypoestrogenism. The highest evaluation of the therapeutic solution was obtained with the appointment of non-hormonal therapy, in which the probability of the most favorable outcomes (according to the data of a catamnesis) is from 75% to 90% for all types of uterine bleeding of the pubertal period.

The clinical significance of hormonal therapy is manifested at a sufficient level only with the use of COCs and only with the hyperestrogenic type in the absence of relapses. In patients with normoesgrogenia, this type of therapy is marked by the highest risk of irregular menstrual cycles. In patients with hypoestrogeny at distant stages after COC treatment, the probability of irregular cycles and relapses is high.

The use of progestogens was the least successful for treating patients with different types of functional disorders of the menstrual cycle in the pubertal period. The greatest probability of recurrence was noted in a group of patients with hyperestrogenia.

In view of the typical and atypical forms of uterine bleeding puberty, evidence has been obtained that in patients with atypical forms the probability of recurrence of bleeding was small. In the case of non-hormonal therapy, not only did not a single relapse occur, but there were no cases of irregular cycles. The effectiveness of the use of COCs and progestogens was also quite high.

In the case of a typical form of uterine bleeding, the effectiveness of all treatments in comparison with the atypical form has been significantly reduced. The least effective was the use of progestogens (high probability of relapses). The long-term results of COC use showed the greatest probability of irregular cycles.

Negative and not completely satisfactory effects of the therapy are associated not only with the application of specific therapeutic measures. From a clinical point of view, it can be ineffective due to random uncontrolled factors, which can well determine the patient's resistance to the chosen methods of treatment. At the same time, one can not deny the fact that when evaluating one's own experience, the doctor should find out the influence on the quality of treatment of factors that can be controlled, including factors that are associated with incomplete knowledge about the causes and mechanisms of the development of this pathology, as well as factors , based on the erroneous treatment of clinical manifestations and "generally accepted" misconceptions about the application of a particular method of treatment. One of the factors that can be controlled is the clinical and paraclinical signs that determine the type of uterine bleeding of the pubertal period. In accordance with the general principles of the formation of functional disorders, the use of funds with a specific effect on any of the elements of a "deregulated" functional system is inexpedient. Any procedure for restoring self-regulation should organically interact with all components of the system, and not selectively with any of them. Even a specific external action necessarily causes a nonspecific systemic reaction, and it is also possible to obtain an effect that aggravates the violation of the coordinated activity of the entire system. That is why to start recovery activities should be the application of the least specific, positively affecting the entire body of the impact. In practice, the doctor must solve a two-fold problem. When there is uterine bleeding, which threatens to cause serious complications, the clinician is obliged, first of all, to use specific methods to eliminate the cause of this "target symptom". However, in the future, even if the treatment method was highly effective for hemostasis, its use is probably not entirely justified. A graphic illustration of the advantage of the non-specific approach is the analysis of the probability of outcome options for different types and forms of uterine bleeding in the pubertal period in cases of application of 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 very rare. Indications for surgical treatment are:

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

If necessary, removal of the ovarian cyst (endometrioid, dermoid, follicular or cyst of the yellow body persisting for more than 3 months) or clarifying the diagnosis in patients with volumetric education in the area of the uterine appendages treatment and diagnostic laparoscopy is indicated.

Indications for consultation of other specialists

• Consultation of the endocrinologist is necessary when suspicion of thyroid pathology (clinical symptoms of hypo- or hyperthyroidism, diffuse enlargement or nodular thyroid gland formation upon palpation).
• Consultation of the hematologist - with debut uterine bleeding puberty period with menarche, indications of frequent nasal bleeding, the emergence of petechiae and hematomas, increased bleeding with cuts, wounds and surgical manipulations, revealing the lengthening of bleeding time.
• Consultation phthisiatrician - with uterine bleeding puberty period against the background of long persistent subfebrile condition, acyclic character of bleeding, often accompanied by pain syndrome, absence of pathogenic infectious agent in the separated urogenital tract, relative or absolute lymphocytosis in the general blood test, positive tuberculin test results.
• Consultation of the therapist - with uterine bleeding puberty period against a backdrop of chronic systemic diseases, including diseases of the kidneys, liver, lungs, cardiovascular system, etc.
• Consultation of the psychotherapist or psychiatrist - all patients with uterine bleeding puberty period for psychotherapeutic correction, taking into account the characteristics of the psychotraumatic situation, clinical typology, personality response to the disease.

Approximate terms of incapacity for work

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

Further management

Patients with uterine bleeding of the pubertal period need constant dynamic observation 1 time per month before the stabilization of the menstrual cycle, then you can limit the frequency of the follow-up examination to 1 time in 3-6 months. Ultrasound of 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 for managing the menstrual calendar and assessing the intensity of bleeding, which will determine the effectiveness of the treatment.

Patients should be informed of the advisability of correcting and maintaining the optimal body weight (both in deficit and overweight), normalizing the work and rest regime.

Information for Patient

• Normalization of the regime of work and rest.
• Full nutrition (with mandatory inclusion in the diet of meat, especially veal).
• Hardening and physical training (outdoor games, gymnastics, skis, skating, swimming, dancing, yoga).

Forecast

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