Dysfunctional uterine bleeding
Dysfunctional uterine bleeding – the pathological bleedings from a uterus connected with violation of production of sex hormones endocrine glands. Distinguish juvenile bleedings (during puberty), climacteric bleedings (in a stage of fading of function of ovaries), bleedings of the reproductive period. It is expressed by increase in amount of the lost blood during periods or lengthening of duration of periods. It can be shown by a metrorragiya – acyclic bleeding. Alternation of the periods of an amenorea (from 6 weeks to 2 and more months) with the subsequent bleedings of various force and duration is characteristic. Leads to development of anemia.
Dysfunctional uterine bleeding
Dysfunctional uterine bleedings (the accepted abbreviation - DMK) serve as the main manifestation of a syndrome of yaichnikovy dysfunction. Dysfunctional uterine bleedings differ in acyclicity, long delays of periods (1,5-6 months) and long blood loss (more than 7 days). Distinguish dysfunctional uterine bleedings juvenile (12-18 years), reproductive (18-45 years) and climacteric (45-55 years) the age periods. Uterine bleedings are one of the most frequent hormonal pathologies of a female genital.
Juvenile dysfunctional uterine bleedings are usually caused by not formation of cyclic function of departments a hypothalamus-hypophysis-ovaries-uterus. The frequent reasons causing dysfunction of ovaries and uterine bleedings serve in childbearing age inflammatory processes of a reproductive system, a disease of endocrine glands, surgical termination of pregnancy, stresses, etc., in climacteric – violation of regulation of a menstrual cycle in connection with fading of hormonal function.
On the basis of existence of an ovulation or its absence distinguish ovulyatorny and anovulyatorny uterine bleedings, and the last make about 80%. The long bloody allocations which are appearing after a considerable delay of periods and followed by symptoms of anemia are characteristic of a clinical picture of uterine bleeding at any age: pallor, dizziness, weakness, headaches, fatigue, lowering of arterial pressure.
Mechanism of development of DMK
Dysfunctional uterine bleedings develop as a result of violation of hormonal regulation of function of ovaries gipotalamo-hypophysial system. Violation of secretion gonadotropny (follikulostimuliruyushchy and lyuteiniziruyushchy) the hormones of a hypophysis stimulating maturing of a follicle and an ovulation leads to failures in a follikulogenenza and menstrual function. At the same time in an ovary the follicle or does not grow ripe (a follicle atresia), or grows ripe, but without ovulation (a follicle persistention), and, therefore, also the yellow body is not formed. In either case the organism is in a condition of a giperestrogeniya, i.e. the uterus comes under influence of estrogen since in lack of a yellow body progesterone is not produced. The uterine cycle is broken: there is long on time, an excessive growth of endometrium (giperplaziya), and then its rejection that is followed by plentiful and long uterine bleeding.
Hemostasis factors (aggregation of platelets, fibrinolytic activity and spastic ability of vessels) which are broken at DMK exert impact on duration and intensity of uterine bleeding. Uterine bleeding can stop and independently through vaguely long time, but, as a rule, arises again therefore the main therapeutic objective is a prevention of a retsidivirovaniye of DMK. Besides, the giperestrogeniya at dysfunctional uterine bleedings is risk factor of development of an adenocarcinoma, myoma of a uterus, fibrous and cystous mastopathy, endometriosis, cancer of mammary glands.
In the juvenile (pubertatny) period uterine bleedings meet more often other gynecologic pathology – almost in 20% of cases. Violation of formation of hormonal regulation at this age is promoted by physical and mental injuries, unsuccessful living conditions, overfatigue, hypovitaminoses, dysfunction of bark of adrenal glands and/or a thyroid gland. A provocative role in development of juvenile uterine bleedings is played by also children's infections (chicken pox, measles, epidemic parotitis, whooping cough, a rubella), ORZ, chronic tonsillitis, the complicated pregnancies and childbirth at mother etc.
At diagnosis of juvenile uterine bleedings are considered:
- data of the anamnesis (date of menarche, last periods and beginning of bleeding)
- development of secondary sexual characteristics, physical development, bone age
- level of hemoglobin and the curtailing blood factors (the general blood test, platelets, koagulogramm, protrombinovy index, time of folding and time of bleeding)
- indicators of level of hormones (Prolactinum, LG, FSG, estrogen, progesterone, cortisol, testosterone, T3, TTG, T4) in blood serum
- conclusion of experts: consultation of the gynecologist, endocrinologist, neurologist, ophthalmologist
- indicators of basal temperature during the period between periods (the single-phase menstrual cycle is characterized by monotonous basal temperature)
- condition of endometrium and ovaries on the basis of data of ultrasonography of bodies of a small pelvis (with use of the rectal sensor for virgins or vaginal – at the girls leading sex life). The echogram of ovaries at juvenile uterine bleedings shows increase in volume of ovaries during the intermenstrual period
- condition of the regulating gipotalamo-hypophysial system according to a skull X-ray analysis with a projection of the Turkish saddle, an ekhoentsefalografiya, brain EEG, KT or MRT (for the purpose of an exception of tumoral damages of a hypophysis)
- Ultrasonography of a thyroid gland and adrenal glands with a dopplerometriya
- Ultrasonography control of an ovulation (for the purpose of visualization of an atresia or a persistention of a follicle, a mature follicle, an ovulation, formation of a yellow body)
Priority at treatment of uterine bleeding is holding haemo static actions. Further tactics of treatment is directed to prevention of repeated uterine bleedings and normalization of a menstrual cycle. The modern gynecology has in the arsenal several ways of a stop of dysfunctional uterine bleeding, both conservative, and surgical. The choice of a method of styptic therapy is defined by the general condition of the patient and size of blood loss. At anemia of average degree (at hemoglobin higher than 100 g/l) are applied symptomatic haemo static (, etamsylate, , aminocaproic acid) and the medicines reducing a uterus (oxytocin).
In case of inefficiency of a non-hormonal hemostasis progesterone medicines are appointed (the ethenylestradiol, an ethenylestradiol, levonorgestret, ). Bloody allocations usually stop in 5-6 days after the end of administration of drugs. The plentiful and long uterine bleeding leading to the progressing deterioration in a state (the expressed anemia with Hb less than 70 g/l, weaknesses, dizziness, to unconscious states) are the indication to carrying out hysteroscopy with a separate diagnostic scraping and a patomorfologichesky research of scrape. A contraindication to carrying out a scraping of a cavity of a uterus is violation of coagulability of blood.
In parallel with a hemostasis protivoanemichesky therapy is performed: iron medicines, folic acid, B12 vitamin, vitamin C, B6 vitamin, vitamin P, transfusion of eritrotsitarny weight and freshly frozen plasma. Further prevention of uterine bleeding includes reception of gestagenny medicines in low doses (, dezogestret, in a combination with etinilestradioly; , ). In prevention of uterine bleedings also general hardening, sanitation of the chronic infectious centers and healthy nutrition are important. Adequate measures of prevention and therapy of juvenile uterine bleedings restore cyclic functioning of all departments of a reproductive system.
DMK of the reproductive period
In the reproductive period dysfunctional uterine bleedings make 4-5% of cases of all gynecologic diseases. As the factors causing dysfunction of ovaries and uterine bleedings serve psychological reactions (stresses, overfatigue), change of climate, professional harm, the infections and intoxications, abortions, some medicinal substances causing primary violations at the level of system a hypothalamus hypophysis. In ovaries lead the infectious and inflammatory processes promoting a thickening of the capsule of an ovary and decrease in sensitivity of yaichnikovy fabric to gonadotrophins to violations.
At diagnosis of uterine bleeding it is necessary to exclude organic pathology of genitals (tumors, endometriosis, traumatic damages, spontaneous abortion, extra-uterine pregnancy etc.), diseases of bodies of blood formation, a liver, endocrine glands, heart and vessels. Besides all-clinical methods of diagnosis of uterine bleeding (collecting the anamnesis, gynecologic survey) hysteroscopy and a separate diagnostic scraping of endometrium with carrying out a histologic research of material is applied. Further diagnostic actions same, as at juvenile uterine bleedings.
Medical tactics at uterine bleedings of the reproductive period is defined by results of histologic result of the taken scrapes. When developing recurrent bleedings the hormonal and non-hormonal hemostasis is carried out. Further for correction of the revealed dysfunction the hormonal treatment promoting settlement of menstrual function, prevention of a recurrence of uterine bleeding is appointed.
Nonspecific treatment of uterine bleedings includes normalization of a psychological state, treatment of all background diseases, removal of intoxication. It is promoted by psychotherapeutic techniques, vitamins, sedative medicines. At anemia iron medicines are appointed. Uterine bleedings of reproductive age at incorrectly picked up hormonal therapy or a certain reason can repeatedly arise.
DMK of the climacteric period
Premenopauzalny uterine bleedings meet in 15% of cases of number of gynecologic pathology of women of the climacteric period. With age the quantity of the gonadotrophins allocated by a hypophysis decreases, their emission becomes irregular that causes violation of a yaichnikovy cycle (a follikulogeneza, ovulations, development of a yellow body). Deficiency of progesterone leads to development of a giperestrogeniya and hyper plastic growth of endometrium. Climacteric uterine bleedings develop in 30% against the background of a climacteric syndrome.
Features of diagnosis of climacteric uterine bleedings consist in need to differentiate them from periods which at this age become irregular and proceed as metrorragiya. For an exception of the pathology which caused uterine bleeding, it is better to carry out hysteroscopy twice: before and after a diagnostic scraping.
After a scraping at survey of a cavity of a uterus it is possible to reveal sites of endometriosis, small submukozny myomas, uterus polyps. In rare instances the hormonal and active tumor of an ovary becomes the reason of uterine bleedings. Allows to reveal this pathology ultrasonography, a nuclear magnetic or computer tomography. Methods of diagnosis of uterine bleedings are the general for their different types and are defined by the doctor individually.
Therapy of dysfunctional uterine bleedings in the climacteric period is directed to suppression of hormonal and menstrual functions, i.e. to a menopause call. The bleeding stop at uterine bleeding of the climacteric period is made exclusively surgically by method – by a medical and diagnostic scraping and hysteroscopy. Waiting tactics and a conservative hemostasis (especially hormonal) are wrong. Cryodestruction of endometrium or surgical removal of a uterus – nadvlagalishchny amputation of a uterus, a hysterectomy is sometimes carried out.
Prevention of DMK
Prevention of dysfunctional uterine bleedings should be begun at a stage of pre-natal development of a fruit, i.e. during conducting pregnancy. In the children's and teenage periods it is important to pay attention to the all-strengthening and all-improving actions, prevention or timely treatment of diseases, in particular a reproductive system, prevention of abortions.
If dysfunction and uterine bleeding nevertheless developed, then further measures have to be directed to restoration of a regularity of a menstrual cycle and prevention of a recurrence of bleeding. Appointment oral estrogen-gestagennykh of contraceptives according to the scheme is for this purpose shown: the first 3 cycles - from 5 to 25 day, the subsequent 3 cycles - from 16 to 25 day of menstrualnopodobny bleeding. Pure gestagenny medicines (norkonut, ) are appointed at uterine bleeding from the 16th to the 25th day of a menstrual cycle within 4 — 6 months.
Application of hormonal contraceptives not only allows to reduce the frequency of abortions and emergence of a hormonal imbalance, but also to prevent in the subsequent development of an anovulyatorny form of infertility, adenocarcinoma of endometrium, cancer tumors of mammary glands. Patients with dysfunctional uterine bleedings have to be on the dispensary account at the gynecologist.