Dysfunctional uterine bleeding: treatment

In the treatment of dysfunctional uterine bleeding 2 problems are posed:

1. stop the bleeding;
2. to prevent his relapse.

Solving these problems, you can not act according to the standard, stereotyped. The approach to treatment should be purely individual, taking into account the nature of bleeding, the age of the patient, the state of her health (the degree of anemia, the presence of concomitant somatic diseases).

Arsenal of medical measures, which a practical doctor can have, is quite diverse. It includes both surgical and conservative methods of treatment. 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 methods of treatment is also very wide. It includes non-hormonal (medicamentous, preformed physical factors, different kinds of reflexotherapy) and hormonal methods of action.

Rapid arrest of bleeding can be ensured only by scraping the uterine mucosa. In addition to the therapeutic effect, this manipulation, as noted above, is of great diagnostic significance. Therefore, the first time dysfunctional uterine bleeding in patients with reproductive and premenopausal periods is rationally stopped, resorting to this method. With relapse of bleeding to scraping resorted only in the absence of the effect of conservative therapy.

Juvenile bleeding requires a different treatment approach. Scraping of the mucous membrane of the uterus body in girls is carried out only for vital indications: with heavy bleeding against the background of sharp anemisation of patients. In girls it is advisable to resort to scraping endometrium not only for life indications. Oncological vigilance dictates the need for a diagnostic-therapeutic curettage of the uterus, if bleeding, even mild, often recur for 2 years or more.

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

Surgical removal of the uterus for dysfunctional uterine bleeding is rare. LG Tumilovich (1987) believes that the relative indication for surgical treatment is the recurrent ferruterous-cystic endometrial hyperplasia in women with obesity, diabetes, hypertension, that is, in patients at risk of endometrial cancer. Unconditional surgical treatment includes 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 tekamatosis.

Stop bleeding can be a conservative way, affecting the reflexogenic zone of the cervix or posterior vaginal vault. Electrostimulation of these regions by a complex neurohumoral reflex leads to an increase in the neurosecretion of the Gn-RG in the hypophysitropic zone of the hypothalamus, the end result of which are secretory transformations of the endometrium and stopping of bleeding. Strengthening the effect of electrostimulation of the cervix is facilitated by physiotherapeutic procedures that normalize the function of the hypothalamic-pituitary region: indirect electrical stimulation with pulsed currents of low frequency, longitudinal induction of the brain, galvanic collar over the Scherbak, cervico-facial. Galvanization according to Kellat.

You can achieve hemostasis using various methods of reflexotherapy, including traditional acupuncture, or exposure to acupuncture points with helium-neon laser radiation.

It is very popular with practical doctors for hormonal hemostasis , it can be used in patients of different ages. However, it should be remembered that the scale of hormonal therapy in adolescence should be maximally limited, since the introduction of exogenous sex steroids can cause the disabling of the functions of the endocrine glands and the centers of the hypothalamus. Only in the absence of the effect of non-hormonal methods of treatment in girls and girls of puberty, it is advisable to use synthetic combined estrogen-progestational medications (non-vellon, ovidone, rigevidon, anovlar). These funds quickly lead to secretory transformations about endometrium, and then to the development of the so-called phenomenon of glandular regression, due to which the withdrawal of the drug is not accompanied by significant blood loss. Unlike adult women, they are prescribed for hemostasis not more than 3 tablets of any of these drugs per day. Bleeding stops within 1-2-3 days. Before the stop of bleeding, the dose of the drug is not reduced, and then gradually reduced to 1 tablet per day. The duration of hormone intake is usually 21 days. After 2-4 days after discontinuation of the drug, menstrual bleeding occurs.

Rapid hemostasis can be achieved by the administration of estrogenic preparations: 0.5-1 ml of a 10% solution of synestrol, or 5000-10 000 units of folliculin administered intramuscularly every 2 hours until the bleeding stops, which usually occurs on the first day of treatment due to the proliferation of the endometrium. In subsequent days, gradually (not more than a third) reduce the daily dose of the drug to 1 ml of synestrol at 10,000 units of folliculin, introducing it first into 2, then into 1 reception. Estrogenic drugs are used for 2-3 weeks, while seeking to eliminate anemia, then switch to gestagens. Every day for 6-8 days intramuscularly injected 1 ml of 1% solution of progesterone or every other day 3-4 injections of I ml of a 2.5% solution of progesterone, or once 1 ml of 12.5% solution of 17a-hydroxyprogesterone kapronate. 2-4 days after the last administration of progesterone or 8-10 days after injection of 17a-OPC, menstrual bleeding occurs. As a gestagenic preparation, it is convenient to use tableted norkolut (10 mg per day), turinal (in the same dosage) or acetomeredigenol (0.5 mg per day) for 8-10 days.

In women of reproductive age, with favorable results of histological examination of the endometrium, carried out 1-3 months ago, with repeated bleeding, there may be a need for hormonal hemostasis if the patient has not received appropriate anti-relapse therapy. To this end, synthetic estrogen-progestational drugs (non-ovolone, rigevidon, ovidon, anovlar, etc.) can be used. Hemostatic effect usually occurs at large doses of the drug (6 and even 8 tablets per day). Gradually reducing the daily dose to 1 tablet. Continue to receive a total of up to 21 days. Choosing a similar method of hemostasis, we must not forget about possible contraindications: liver and biliary tract diseases, thrombophlebitis, hypertension, diabetes, uterine fibroids, glandular-cystic mastopathy.

If the recurrence of bleeding occurs on a high estrogen background and duration is low, then for hormonal hemostasis, pure gestagens can be used: 1 ml of a 1% solution of progesterone intramuscularly administered for 6-8 days. 1 % solution of progesterone can be replaced with 2.5% solution and injected every other day, or a prolonged-release preparation is used - 12.5% solution of 17a-OPK once in an amount of 1-2 ml, it is also possible enterocolic reception of 10 mg or 10 mg of norkolut or acetomepregenol but 0.5 mg for 10 days. When choosing such methods of stopping bleeding, it is necessary to exclude possible anemization of the patient, because with the withdrawal of the drug, a marked menstrual bleeding occurs.

With confirmed hypoestrogenism, as well as the repulsion of the yellow body to stop bleeding, you can use estrogens followed by a transition to gestagens according to the scheme given for the treatment of juvenile bleeding.

If the patient after curettage of the mucous membrane of the uterus body received adequate therapy, the relapse of bleeding requires a more precise diagnosis, rather than hormonal hemostasis.

In the pre-menopausal period, estrogenic and combination drugs should not be used. Pure gestagens are recommended for use 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 removing negative emotions, physical and mental fatigue, the elimination of infection and / or intoxication, and the treatment of concomitant diseases. Part of the complex treatment is psychotherapy, taking sedatives, vitamins (C, B1, VB, B12, K, E, folic acid), reducing the uterus means. It is mandatory to include gemostimulating (gemostimulin, ferrum Lek, ferroplex) and hemostatic drugs (dicinone, sodium ethamidate, vikasol).

Stopping bleeding completes the first stage of treatment. The task of the second stage is to prevent repeated bleeding. In women under 48 years this is achieved by the normalization of the menstrual cycle, in patients of older age - by suppression of menstrual function.

Girls during puberty with a moderate or increased level of estrogen saturation of the body. Determined by tests of functional diagnostics, appoint gestagens (turinal or norcolut 5-10 mg from 16th to 25th day of the cycle, acetomerepreghenol 0.5 mg on the same days) for three cycles with a 3-month break and a repeated course from three cycles. In the same regime, combined estrogen-progestational medications can be administered. Girls with low estrogen levels are advisable to appoint sex hormones in a cyclic mode. For example, ethinylestradiol (microfodlin) to 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, the intake of vitamins by cycle is recommended (in the I phase - vitamins B1 and B6, folic and glutamic acids, in the II phase - vitamins C, E, A), desensitizing and hepatotropic drugs.

At girls and teenagers hormonal therapy is not the basic method of the prevention of relapse of bleedings. It is preferable to prefer reflexive methods of action, for example, electrostimulation of the mucous membrane of the posterior vaginal vault on the 10th, 11th, 12th, 14th, 16th, 18th days of the cycle or various methods of acupuncture.

Women of the reproductive period of life can be given hormonal treatment according to the schemes proposed for girls suffering from juvenile bleeding. As a progestogen component, some authors suggest that intramuscularly, on the 18th day of the cycle, 2 ml of a 12.5% solution of 17α-hydroxyprogesterone caprolate. Women from the "risk" group for endometrial cancer receive this drug continuously for 2 months 2 ml 2 times a week, and then switch to cyclic mode. Combined estrogen-progestational drugs can be used in contraceptive regimens. EM Vikhlyaeva and co-authors. (1987) offer patients with late reproductive life, who have a combination of hyperplastic changes in the endometrium with myoma or internal endometriosis, appoint testosterone (25 mg on the 7th, 14th day of the 21st cycle), and norkolut (10 mg from 16 on the 25th day of the cycle).

Restoration of the menstrual cycle.

After exclusion (clinical, instrumental, histological) of inflammatory, anatomical (tumor of the uterus and ovaries), oncological nature of uterine bleeding tactics in the hormonal genesis of DMC is determined by the age of the patient and the pathogenetic mechanism of the disorder.

In adolescence and reproductive age, hormonal therapy should be preceded by the mandatory determination of serum prolactin levels, and (according to indications) hormones of other endocrine glands in the body. Hormonal research should be conducted in specialized centers after 1-2 months. After the abolition of previous hormonal therapy. Blood sampling for prolactin is performed with the saved cycle 2-3 days before the expected monthly, or with anovulation against the background of their delay. The determination of the level of hormones of other endocrine glands is not associated with the cycle.

The treatment of sex hormones proper is determined by the level of estrogen produced by the ovaries.

When the level of estrogen is insufficient: the endometrium corresponds to the early follicular phase - it is advisable to use oral contraceptives with an increased estrogen component (anteovin, non-vellon, ovidone, demulen) according to the contraceptive scheme; if the endometrium corresponds to the middle follicular phase, only gestagens are prescribed (progesterone, 17-OPK, uterine, dufaston, nor-kolut) or oral contraceptives.

With an increased level of estrogen (proliferating endometrium, especially in combination with hyperplasia of its various degrees), the usual recovery of the menstrual cycle (gestagens, COC, parlodel, etc.) is effective only in the early stages of the process. Modern approach to the treatment of hyperplastic processes of the target organs of the reproductive system (endometrial hyperplasia, endometriosis and adenomyosis, uterine fibroids, fibromatosis of the mammary glands) requires an obligatory stage of switching off menstrual function (the effect of temporary menopause for the reverse development of hyperplasia) for a period of 6-8 months. For this purpose, they are used in a continuous mode: gestagens (norkolut, 17-OPK, depot-probe), analogues of testosterone (danazol) and lylyberyrin (zoladex). Immediately after the stage of suppression, these patients show the pathogenetic restoration of a full-fledged menstrual cycle with the goal of preventing the recurrence of the hyperplastic process.

In patients of reproductive age with infertility, in the absence of the effect of sex hormones, stimulants of ovulation are additionally applied.

1. In 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 premenopausal and postmenopausal treatment is performed by special means of HRT of menopausal and postmenopausal disorders (clinonorm, cycloprogine, femoston, enema, etc.).

In addition to hormonal treatment for dysfunctional uterine bleeding, general restorative and anti-anemic therapy, immunomodulating and vitamin therapy, sedative and neuroleptic drugs, normalizing the relationship between the cortical and subcortical structures of the brain, physiotherapy (galvanic collar over the Shcherbak) are used. To reduce the influence of hormonal drugs on liver function, hepatoprotectors (essential-forte, wobenzim, festal, hofitol) are used.

The approach to the prevention of dysfunctional uterine bleeding in women of the premenopausal period of life is twofold: up to 48 years the menstrual cycle is being restored, after 48 years it is advisable to suppress menstrual function. When proceeding to regulate the cycle, it should be remembered that at this age it is undesirable to take estrogens and combined preparations, and the appointment of pure gestagens in the II phase of the cycle is desirable to be carried out by longer courses - at least 6 months. Suppression of menstrual function in women younger than 50 years, and in older - with severe hyperplasia of the endometrium, it is more expedient to carry out gestagens: 250 mg of 17a-OPK twice a week for six months.

[1], [2], [3], [4]