Abnormal uterine bleeding (AMK)

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These are bleeding other than the usual menstruation in duration and blood loss and / or frequency volume. Normally durability menstrual cycle Various from 24 to 38 days, the duration of menstrual bleeding is 4-8 days, the total blood loss ranges from 40 to 80 ml. At the reproductive age, the AMK is 10 - 30%, in the perimenopause reaches 50%.

AMK is one of the main causes of iron deficiency anemia, reduce the performance and quality of women's life. AMK occupies a 2nd place among the reasons for the hospitalization of women in gynecological hospitals, serve as an indication for 2/3 of the endometrium hystrecoma and ablants produced.

Causes of occurrence

Causes of AMK have age peculiarities. Young girls AMK is more likely associated with hereditary hematasis disorders and infections. Approximately 20% of adolescents and 10% of female reproductive age with abundant menstruation have blood disease (coagulopathy), such as Willebrand's disease, thrombocytopenia, less often than spicy leukemia, as well as liver disease.

In the reproductive age among the causes of the AMC, organic disorders of endo- and miometrium (submucosic mioma of uterus, adenomyosis, polyps, hyperplasia and endometrial cancer), as well as inorganic pathology (violation of blood coagulation system, intrauterine device, chronic endometritis, ovulatory dysfunction, reception medicinal preparations - Some antibiotics, antidepressants, tamoxifen, corticosteroids). In many cases, the cause is endocrinopathy and neuropsychic stress (for example, polycystic ovarian syndrome, hypothyroidism, hyperprolactinemia, obesity, anorexia, a sharp weight loss or extreme sports training). Bleeding "breakthrough" on the background of reception hormonal drugs More often observed in smoking women, which are associated with a decrease in steroid levels in the bloodstream due to the strengthening of their metabolism in the liver.

In Perimenopause, the AMK arises against the background of annovation and various organic pathology of the uterus. With age, the likelihood of malignant lesions of endo and myometrium increases.

Clinical manifestations

Depending on the nature of violations allocate various symptoms AMK:

Irregular, long-term uterine bleeding (menometromragia);

Excessive (more than 80 ml) or long-term menstruation (more than 8 days) with a regular interval of 24-38 days (menorragia (hypermetrian);

Irregular, intermenstrual bleeding from the uterus, as a rule (more often than intensive nature) (metrragia);

Frequent menstruation with an interval of less than 24 days (polymenorrhea)

Diagnosis of abnormal uterine bleeding

Inspection of the gynecologist-endocrinologist, evaluating patient complaints. Many women incorrectly interpret the magnitude of blood loss during menstruation. For example, 50% of women with normal menstrual blood loss are treated with complaints of reinforced bleeding. In order to clarify the presence of AMK, the patient is given the following questions:

Laboratory examination is necessary for anemia, hemostasis pathology. Transvaginal ultrasound of the small pelvis organs is considered as a diagnostic procedure of the 1st line to estimate the state of the endometrium. High diagnostic significance has a son-modelography, is carried out with insufficient informativeness of transvaginal ultrasound to clarify focal intrauterine pathology. Hysteroscopy and biopsy Endometrial continues to be considered as "golden" standard for the diagnosis of intrauterine pathology, primarily for the exclusion of precancerous lesions and endometrial cancer. It is recommended for suspected endometrial pathology, the presence of risk factors of the body cancer (obesity, SPKA, diabetes mellitus, burdened by a family history of a fat intestine cancer), in patients with AMK after 40 years.

The MRI is recommended to be carried out in the presence of multiple mioma of the uterus to clarify the topography of nodes to the planned momectomy, embolization of the uterine arteries, computers, and in suspected adenomyosis or in cases of poor visualization of the uterine cavity to estimate the endometrium state.

Methods for the treatment of abnormal uterine bleeding

Treatment of AMK in the center of obstetrics, gynecology and perinatology. IN AND. Kulakova Ministry of Health of Russia is carried out on the basis of modern international and Russian clinical recommendationsIn the development of which researchers took an active part departments of Gynecological Endocrinology. The principles of AMK therapy pursue 2 main objectives: stopping the bleeding and prevention of his recurrence. In each case, when prescribing drug therapy, not only the effectiveness of drugs, but also possible side effects, the age of a woman, interest in pregnancy or contraception is taken into account. With AMK, non-organic pathology, non-surgical treatments are used.

The most common and heavy forms of violation of the sexual system during puberty in girls include juvenile uterine bleeding. Such a term is called dysfunctional bleeding aged 10-18 years from the beginning of the first monthly and to the age of majority.

This gynecological pathology occurs about 10-20% of all girls of this age category. Abundant and frequent bleeding can cause a significant decrease in blood hemoglobin levels, exacerbating hormonal disorders, and in the future to cause infertility. In addition, the uterine bleeding in adolescents adolescently affect the psychological state of children, causing closure, uncertainty in themselves, fear for their health and even life.

Causes of violations

The main reason is disorders in the work of the hypothalamic-pituitary system. The hormonal failure provokes a single-phase ovarian cycle with a delayed monthly and further bleeding. More often dysfunctional uterine bleeding of the puberty period is found during the first two years after.

There is no direct link between this pathology and the development of other secondary penis. In general, sexual ripening girl passes without disorders. In more than a third of patients, the disease may be complicated by the appearance of acne rashes and fatty seborrhea.

The emergence of uterine bleeding in girls of older ages is celebrated with early menarche (7-12 years). It is diagnosed with more than 60% of patients. With a late appearance of the first monthly (after 15-16 years), such pathology arises rarely - no more than 2% of cases.

The main causes of the pathological condition of adolescents:

• pathology of the blood coagulation system;
• the formation of tumors of ovarian hormonal origin;
• acute and chronic infectious diseases (ORVI, pneumonia, chronic tonsillitis, chickenpox, rubella);
• diseases of the endocrine system (pancreas, adrenal glands);
• tuberculosis of genital organs;
• malignant bowls of body and cervix;
• accommodation in adverse conditions, excessive physical and psychological loads;
• poor nutrition that does not provide the body with the necessary vitamins and microelements.

Chronic tonsillitis with regular exacerbation periods is recognized as the most significant provocation factor. There is a certain relationship between the disease in girls and how pregnancy proceeded by her mother. Late toxicosis, chronic intrauterine, premature aging or discontinuation of the placenta, asphyxia of the child at birth could be provoking factors.

Symptoms of the disease

Many girls have a regular monthly cycle restored immediately after Menarche, but only for half a year - two years. Menstruation can take place with a delay in two or three months, and sometimes six months. The uterine bleeding occurs more often after menstruation delay up to 2 weeks or one and a half months.

In some cases, it may arise a week or two after Menarche or occur in the intermenstrual period. The main symptoms of pathology include:

• abundant (more than 100 ml per day) and long-term (over 7 days) bleeding;
• allocations arising 2-3 days after the end of menstruation;
• monthly, which are repeated with the interval less than 21 days;
• dizziness, drowsiness, nausea as a consequence of anemia;
• pallor of skin, dry mouth;
• pathological desire to eat inadequate products (for example, chalk);
• oppressed state, irritability, fast physical fatigue.

Very often the girl and even her more experienced mom cannot determine the violation and regard it as ordinary monthly. The girl can continue to lead her lifestyle to her, thereby postponing the treatment, which should begin immediately, and exacerbating the problem. It should be remembered that any abundant dischargeYes, even with clots, require close attention. Abyard is considered monthly when the gasket or tampon has to be changed at least than every hour.

Since pathology can be caused by various reasons, in addition to the mandatory inspection of a children's gynecologist, consultation of an endocrinologist, a neuropathologist, oncologist is needed.

Diagnostics

For diagnostics use general and special methods of researching violations. The general includes a gynecological and general inspection of the patient, the study of the state internal organs, analysis of the physique and the ratio of growth and weight, the presence of secondary sexual signs. From the conversation, the gynecologist will learn about the date of the beginning of the first monthly, regularity of the menstrual cycle, previously transferred diseases and the general health status.

Patients prescribe a number of laboratory studies: common urine and blood tests, blood biochemical analysis, sugar analysis and hormonal screening to determine the hormonal level. To clarify the diagnosis, the abodes of the small pelvis are carried out.

Abnormal uterine bleeding of a puberty should be differentiated from others pathological conditionswhich may be accompanied by bleeding, namely:

• diseases of the blood system;
• hormone-producing ovarian tumors, endometriosis, cervical cancer;
• inflammatory diseases of the genital organs;
• injuries of vagina and external organs of the sexual sphere;
• starting abortion during pregnancy;
• polycystic ovarian syndrome.

In case of diseases of the blood system, patients often observe bleeding from the nose, the appearance of a hematoma on the body. In contrast to inflammatory diseases of the genital organs, dysfunctional uterine bleeding is rarely accompanied by snatch-like pain at the bottom of the abdomen. If there is a tumor suspected of a different nature, their presence will be established after the ultrasound and other specific diagnostic methods.

Treatment

With abundant bleeding and poor health, girls need to cause ambulance. Before her arrival, the child is placed in bed, provide full peace and apply a bag with ice to the stomach. Patient need to give a lot of sweet drink, preferably tea. Even if the bleeding was able to stop independently, it should not be a reason for complacency, since such pathologies are prone to relapses.

The main task of therapy is a complete cessation of the discharge and normalization of the menstrual cycle in the future. When choosing methods and preparations for treatment, the intensity of bleeding, the degree of severity of anemia, data of laboratory tests, the general physical and sexual development of the patient are taken into account.

For treating and stopping, adolescents are held in exceptional cases. They are shown only when pathology threatens the patient's life. In other cases, drug therapy is limited.

Preparations used in uterine bleeding in adolescents

With the general satisfactory condition of the girl and the absence of signs of severe anemia, treatment can be carried out at home using hemostatic, sedatives and vitamins.

If the patient's condition is severe and there are all signs of anemia (low hemoglobin, dizziness, pallor of the skin) is necessary hospitalization.

To stop the bleeding and normalization of the menstrual cycle, the following drugs are prescribed:

• cutting uterus - oxytocin, ergotal, water pepper extract;
• hemostatic drugs - vikasol, transcases, ascorutin, ditinon, aminocaproic acid;
• combined - Rugulon, non-Ovlon, Zhanin;
• sedatives - bromine or valerian preparations, latter tincture, Seduksen, Tazepam;
• preparations for adjusting the menstrual cycle - Utrezhastan, Duphaston, which are accepted from the 16th to the 25th day of the cycle;
• vitamins - groups B, including folic acid, C, E, K.

With an elevated level, the girls are prescribed Tourinal, Nigolut for three cycles with a three-month break with a further repetition of the drug reception scheme. At the reduced level, sex hormones are prescribed in cyclic mode. Hormonal therapy is not the main method of preventing new bleeding.

As auxiliary treatment methods use physiotherapy - electrophoresis with novocaine or vitamin B1 and needleflexotherapy. The second procedure is prescribed with blood loss without a threat to the development of anemia, in the absence of a pronounced hormonal imbalance.

If bleeding is provoked by diseases of the endocrine system organs, appropriate specific treatment and drugs of iodine are prescribed.

For the purpose of the sedative effect and the normalization of the processes of excitation and inhibition of the central structures of the brain, nootropyl, Veroshpiron, Asparkov, Glycine can be appointed. Comprehensive treatment and measures to restore the menstrual cycle include the exercise of therapeutic physical education and psychocorrect classes with a psychologist.

Clinical recommendations for the uterine bleeding of a puberty include compliance with the beddown during treatment, the application of the cold to the bottom of the abdomen, abundant drinking to replenish the fluid loss by the organism. It is forbidden to apply a warm height, take a hot bath, spend douching or take hemostatic means without consulting a doctor.

It is important to eliminate the symptoms of iron deficiency anemia, which is most often complicated in uterine bleeding. For treatment, such iron preparations are prescribed such as Ferrum Lek, Malto, Hematogen, Totem, Sorbifer Durouples. Preparations are accepted in the form of tablets, injection will be more efficient. In the future, the girl must comply with a diet, which includes products rich in iron: red meat, liver, bird meat, seafood, spinach, beans, grenades, brown rice, dried fruits, peanut butter.

After discharge from the hospital, the girl should be registered with the children's gynecologist.

Treatment with folk remedies

People's medicine known many herbs, infusions and decoctions of which have a hemostatic effect. However, they can not be completely replaced medicia treatment. Decorations and tinnitus of herbs can be used as an additional method of treatment.

Among the most effective plants should be allocated:

• highlanded kidney - contains acetic and apple acid, tannin, vitamins K and C, strengthens the walls of the vessels, increases blood viscosity;
• water pepper - tannin, organic acids, vitamin k in the composition stabilize the activity of the smooth muscles of the uterus, increase blood coagulation;
• shepherd bag - contains alkaloids, organic acids, vitamin C, tannin, riboflavin, which contribute to the decrease in blood discharge;
• nettle - the most famous plant to stop bleeding, regulates the menstrual cycle, saturates the body with vitamins K, C, A, V.

To prepare ragners, the grass of plants are crushed, poured boiling water and withstand 15-20 minutes in the water bath. After the filping, take several times a day. The duration of reception and dosage should be clarified by the doctor.

Prevention of bleeding

Since juvenile bleeding arise mainly in hormonal disorders, specific prevention measures does not exist. However, compliance with certain recommendations will help reduce the risk of their appearance:

1. Timely treatment of infectious and viral diseasesespecially those who take chronic character (tonsillitis, bronchitis, ORVI).
2. Regular observation of pregnant women at the obstetrician-gynecologist, starting with the early period of gestation in order to identify and correct the early and late, edema of pregnant women, intrauterine disorders of the development of the fetus, premature genera, fetal hypoxia.
3. Compliance with the girl-adolescent principles of proper nutrition is to eat food products rich in vitamins, the elimination of fast food, the failure to "diets", which suggest long-term fasting.
4. Machining a menstrual calendar, which will help draw attention to deviations when they first appear.
5. Reception sedative medicines In order to strengthen the vessels and the nervous system (according to the prescription of the doctor).
6. Refusal of bad habits, compliance after the day, full sleep, regular physical exercise, sports.
7. Notification of the girl about the dangers of early sexual relations.

Separately, it should be said about the need to visit a children's gynecologist. Many mothers consider it superfluous until the girl becomes sex life. A visit to the children's gynecologist with a prophylactic goal, especially after the advent of menstruation, should be the same norm as visiting other doctors.

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About 65% of the women of reproductive ages are treated for women's consultation on the bleeding seals from the genital tract. In fact, uterine bleeding is not a diagnosis, but a symptom having a place with different obstetric and gynecological and other pathologies.

According to modern ideas, the term "dysfunctional uterine bleeding" went into the past. Currently, all obstetrician-gynecologists of the world use a single terminology, according to which another name is used - anomalous uterine bleeding, or AMK.

Anomalous uterine bleeding is any bleeding that does not correspond to the parameters of the normal menstrual function in women of reproductive age.

Recall normal physiology.

Menarche (first menstruation) comes an average of 12-14 years. After about 3-6 months, a normal menstrual cycle is installed. It fluctuates within 21-35 days. Menstruation itself lasts from 3 to 7 days, blood loss is from 40 to 80 ml. About 45-50 years old comes the menopausal period, which with the last menstruation passes during menopause.

Deviations from the norm that fall under the determination of abnormal uterine bleeding:

• During the formation of menstruation.
• Between menstruation.
• After delayed menstruation.
• For more than 7 days, with blood loss over 80 ml.
• In Klimakse or in menopause.

If you have noticed blood on underwear, and monthly should not appear - contact a specialist. This may be a sign of serious pathologies.

Causes and classification

These classifications are applied after 2010 by all the gynecologists of the world. Consider two modern classifications - for reasons of bleeding and by their species. The basis of the first classification was the causes of pathology:

1. AMK associated with the pathology of the uterus and appendages.
2. AMK associated with violation of the ovulation process.
3. AMK arising from various systemic pathology (blood disease, pathology of adrenal glands, illness or syndrome of Itsenko-Cushing, hypothyroidism).
4. Yatrogenic forms of AMK, that is, associated with those or other medical influences. For example, resulting from violations in the hemostasis system (blood coagulation) after or during the reception of a number of medicines (anticoagulants, hormones, tricyclic antidepressants, tranquilizers, adrenal cortex hormones, etc.). This group includes AMK, which emerged after medical manipulations. For example, bleeding after taking biopsy, after performing the cryodestruction of hyperplasned endometrial.


5. AMK of unexplained etiology (reasons).

Clarification of the causes of bleeding is the basis of the choice of treatment tactics.

The second classification determines the types of uterine bleeding:

• Heavy. The degree of gravity is determined by the subjective state of the woman.
• Irregular menstrual bleeding.
• Long.

Obviously, the classification includes bleeding, having their source only the body, neck of the uterus and appendages. Blood allocations in women from vulva, the walls of the vagina to AMK does not apply.

Consider more reasons for dysfunctional uterine bleeding.

Pathology of uterus and appendages

We will analyze the Read more AMK, arising in connection with diseases of the uterus.

Directly in the body of the uterus can be detected by moman nodes, as the most common cause of bleeding. Other reasons include:

• Endometrial polyps.
• Adenomyosis.
• Endometrial hyperplasia.
• Endometriosis.
• Cancer body uterus.
• Sarcoma.
• Chronic endometritis.

Internal bleeding with clots in women may be with the following diseases of the cervix:

1. Atrophic cervicitis.
2. Cervical erosion.
3. Polyp canal cervical.
4. Myomatous nodes located in the neck.

For reasons also include oncological diseases cervix. With this pathology, as a rule, contact bleeding, that is, emerging after sexual contact or douching.

Internal uterine bleeding can occur when pregnancy is complicated. Spontaneous miscarriage, placental polyp, ectopic pregnancy and placenta detachment are accompanied by very significant blood loss with clots. Bleeding from the uterus can be a symptom of rupture organ on the header from the transferred operation.

Injuries of the uterus of non-hatrogenic origin also lead to the emergence of uterine bleeding.

Disorders ovulation

Anguulatory uterine bleeding occurs after Menarche, during the formation of menstruation. Possible in the perimenopausal period when the menstrual function is fading. In violation of the process of ovulation of bleeding, reproductive women are also often observed in the practice of gynecologists.

Depending on the situation may arise:

• Against the background of absolute increase in estrogen levels, if a persistent follicle arose.
• Against the background of the relative increase in estrogen with a decrease in the production of the Gestagen (Follicle Atresia).

The clinical signs of these hormonal abnormalities are manifested in the form of a follicular cyst and a yellow bodies.

Irregular periods with interruptions in a few months are characteristic of the ovarian polycystosis.

Against the background of the reception of combined oral contraceptives (COC), especially at the beginning of the course, breakthrough bleeding may appear. This is due to the fact that the body adapts to the formation of a thinner layer of endometrial. That is why, at the end of the reception, there will be no menstruation as such, but a more scarcable menstrual-like reaction.

In other cases, the appearance of breakthrough bleeding indicates that there are signs of ineffectiveness of Kok. This is possible if the woman simultaneously takes antibiotics or moved food poisoning, during which there was vomiting.

In practice, there were cases when smoking could be called - so sometimes nicotine affects the body of a woman.

Systemic pathology

Signs of violations in the hemostasis system may appear before the start of menstruation. For example, after the removal of the tooth of the hole is long bleeding or blood after getting small injuries, it is impossible to stop the cuts for a long time. Usually someone from relatives are noted similar symptoms. Violation of blood coagulation factors is detected with a detailed laboratory study.

Liver diseases affect the synthesis of many hormones and biologically active substances, which can also have adverse effects and on blood coagulation processes and on the processes of the menstrual cycle regulation.

Natrogenation

This term means a negative effect on the patient's health as a result of a doctor's actions. It will not be wrong to understand it as a malicious effect of the health worker. None of doctors want to harm the patient.

Such a situation may occur, for example, during the fulfillment of a medical abortion in a renignant woman who has many abortions in history, and even complicated by endometritis. The fact is that the operation is carried out blindly with a sharp tool. And with an excessive supple and thinned wall of the uterus, perforation can occur, that is, damage stacks of the uterus with an exit to the abdominal cavity. If large vessels are damaged during perforations, then there may be internal bleeding.

Or another example. The doctor suspecting the oncological process on the cervix, takes a piece of neck tissue for histological examination, that is, simply jests his sharp tool. By virtue of the existing changes in the tissues of the affected neck, the site from which biopsy is taken can be bleeded with clots.

It can also affect blood clotting treatment with Digoxin preparations that the doctor discharges the cardiologist according to the testimony. One of side Effects There will be a possible decrease in the number of platelets.

Symptoms

Bleeding symptoms depend on what causes its causes. The main manifestation is bleeding out or during menstruation.

The intensity of uterine bleeding may be different. Often there is a profound bleeding with clots. Moreover, the subjective well-being of a woman depends not only on the amount of lost blood, but also on the speed, the intensity of blood loss.

Profuse bleeding is dangerous in that compensatory, protective mechanisms do not have time to turn on. This creates a risk of developing hemorrhagic shock. Signs of shock:

1. The pallor of the skin, the coldness of them to the touch.
2. Weakness, right up to loss of consciousness.
3. A sharp decline arterial pressure With simultaneous tachycardia. The pulse is weak, thread-shaped.
4. With severely rare urination.
5. Hemoglobin, red blood cells reduced.
6. The volume of circulating fluid is sharply reduced.

This situation requires immediate resuscitation measures with compulsory replenishment of blood loss.

In less dangerous cases, there are bleeding from the genital paths of moderate intensity, sometimes with clots. In some situations, bleeding can be accompanied by pain.

During spontaneous miscarriage, abundant bleeding with bunches are accompanied by pronounced grasp pain. When interrupted ectopic pregnancy, against the background of a minor delay of menstruation and acute pain At the bottom of the abdomen, there are signs of pronounced internal bleeding.

Internal bleeding is very dangerous for the patient's life. After breaking in pregnant pumping pipe In the abdominal cavity can be up to a liter of liquid blood with clots. In this case, emergency operational treatment is shown.

With a premature detachment of a normally located placenta of outer bleeding may not be. If the detachment goes on the central section of the placenta, then there is an internal uterine bleeding. That is, the blood accumulates between the pocent and the wall of the uterus, impregnating the latter. There is a so-called sweller uterus. In this case, the doctor in the interests of salvation of the mother's life is forced to send a patient to remove the uterus.

Diagnostics

Determine the degree of blood loss, the level of reduction of hemoglobin, erythrocytes, platelets, the state of the coagulation system is relatively simple. To clarify the reasons to assign proper and timely treatment required additional methods Research. First of all, it is a vaginal inspection and inspection of cervix in mirrors, transvaginal ultrasound.

To confirm the extragnenital pathology, it is required:

• Ultrasound of the thyroid gland, abdominal organs and retroperitoneal space.
• Biochemical analyzes.
• Study of the level of hormones.
• Inspection from other specialists.

It is also necessary to carefully study the data for the reception of drugs that can cause violations in the hemostasis system, family history to identify hereditary blood coagulation anomalies. Extremely useful information about the obstetric and gynecological history and produced shortly before the bleeding of operational interventions.

It is important to find out in a patient, as the formation of menstruation passed whether problems were noted during menstrual-strokes.

Treatment

Treatment pursues two goals: stop bleeding, and prevent recurrence in the future. But before proceeding with treatment, it is necessary to clearly determine its cause. Spontaneous miscarriage, placental polyp, the resulting myomatous node require surgical intervention. Ectopic pregnancy, uterus break, placenta detachment, ovarian breakdown or cysts - operations with entry into the abdominal cavity.

The treatment of annevulatory AMK is carried out in 2 stages. We will look at them in more detail.

Stage I. Stop bleeding

The choice of tactics depends on the age of the patient. Girls and young women should begin treatment with non-flammable treatment. In order to stop bleeding, antifibrinolytic drugs and non-steroidal anti-inflammatory drugs are conducting therapy.

The "gold standard" in the appointment of antifibrinolithics is the transcamic acid. It suppresses fibrinolysin protein, which prevents normal blood coagulation, makes it more fluid. Also has anti-inflammatory, anti-allergic and painkillers, which is especially important during menstruation.

The drug is appointed by a doctor, the application scheme is individual. Treatment of over 3 menstrual cycles is not recommended.

Non-steroidal anti-inflammatory drugs are also very positively established in the treatment of AMK. Ibuprofen, Naproxen, Sulindak, Medehenamic Acid are successfully used. In addition to anti-inflammatory action, they reduce the volume of lost blood due to the inhibition of the synthesis of thrombooxane and prostacyclin.

If during this stage fails to reach cessation of bleeding, then the uterine instantly resort to the scanning of the uterus or go to the second stage.

Stage II. Hormonal treatment

For young women, COC with an increased estrogen content (desogestrel, gestodene), sometimes combining with in / in the introduction of estrogen. Also prescribed according to the testimony of the Gestagen (MedroxyProgesterone, micronized progesterone uremines).

In the polls you should begin with the scraping of the uterine.

Currently, it is proved the inability to stop the bleeding by oxytocin.

Anti-relapse complex

Anomalous uterine bleeding after treatment can be repeated. That is why it is very important to spend on time preventive treatmentTo prevent the AMK repetition during the following menstruation. It includes the following activities:

1. Lowing means (iron preparations, vitamins).
2. Antifibrinolytic preparations (transcamic acid, aminocaproic acid, vitamin C, zinc drugs).
3. Antiprostaglandine tools (mefenamic acid).
4. Stabilization of the Function of the CNS (Glycine, Trental, Cinnarizin).
5. Hormonal correction. Appointment in the 2nd phase: Marvelon, Regulon, Riguevidon. Gestagen Dofaston is also recommended (with ovulatory menstruation from 15 to 25 days, when anneviation from 11 to 25 days).
6. If pregnancy is not planned, then discharged COC with a reduced estrogen component (for example, three-mercy in cyclic mode). If a woman wants to be pregnant in the near future - it is better to apply the drug Fermoston.

Often on the forums you can read: "There is no time to go to the doctor, 10 days bleeding. Advise what to drink. " You are represented by many reasons for AMK, and while the doctor does not initiate a diagnosis, we categorically not recommended to use drugs that helped to stop the bleeding of the girlfriend, neighbor, etc. Your visit to the doctor is obligatory!

The uterine bleeding of a puberty period (manual transmission) - pathological bleeding, due to the deviations of the endometrium rejection in teenage girls with impaired cyclic products of sex steroid hormones from the moment of the first menstruation up to 18 years.

Code of the ICD-10

N92.2 abundant menstruation in the pubistered period

N93.8 Other refined anomalous bleeding from uterus and vagina

Epidemiology

The frequency of the uterine bleeding of a puberty period in the structure of gynecological diseases of children's and youthful age varies from 10 to 37.3%. Over 50% of all applications of adolescent girls to the gynecologist associated with the uterine bleeding of a puberty period. Almost 95% of all vaginal bleeding of a puberty period is due to the MCPP. The most often uterine bleeding occurs in adolescent girls during the first 3 years after Menarche.

Causes of uterine bleeding of a puberty period

The main cause of the uterine bleeding of a puberty is the immaturity of the reproductive system at the age of age, close to Menarche (up to 3 years). In teenage girls with uterine bleeding, there is a defect of the negative feedback of the ovaries and the hypothalamic-pituitary area of \u200b\u200bthe CNS. Characteristic for the period of puberty, an increase in the level of estrogen does not lead to a decrease in the secretion of FSH, which in turn causes stimulation of growth and development of several follicles at once. Saving a higher than normal, secretion of FSH serves as a factor inhibiting the choice and development dominant follicula From a variety of simultaneously ripening stripe follicles.

The absence of ovulation and subsequent production of progesterone with a yellow body leads to the constant influence of estrogen on target organs, including on endometrium. When the proliferating endometrium overwhelms the uterus cavity, trophic disorders occur in separate areas with subsequent local rejection and bleeding. Bleeding is supported increased education Prostaglandins in a long proliferating endometrial. The protracted lack of ovulation and the influence of progesterone significantly increases the risk of uterine bleeding of the puberty period, while even one random ovulation is enough to temporarily stabilize the endometrium and more complete rejection without bleeding.

Symptoms of the uterine bleeding of a puberty period

The following criteria of the uterine bleeding of a puberty period are distinguished.

• The duration of blood discharge from the vagina is less than 2 or more than 7 days on the background of shortening (less 21-24 days) or elongation (more than 35 days) of the menstrual cycle.
• The blood loss is more than 80 ml or subjectively more pronounced compared to conventional menstruation.
• The presence of intermenstrual or post-cellular blood discharges.
• Lack of structural pathology endometrial.
• Confirmation of the anoint menstrual cycle during the occurrence of uterine bleeding (progesterone concentration in venous blood On the 21-25th day of the menstrual cycle of less than 9.5 nmol / l, monophasic basal temperature, the absence of the preventive follicle according to the echography).

Forms

The officially adopted international classification of the uterine bleeding of the puberty period is not developed. When determining the type of uterine bleeding in adolescent girls, as well as women of reproductive age, take into account clinical features Uterine bleeding (polymenia, metrragia and menometromragia).

• Menorragia (hypermenia) is called uterine bleeding in patients with preserved rhythm of menstruation, in which the duration of blood secretions exceeds 7 days, blood loss is more than 80 ml and noted a small number of blood clots in abundant blood discharges, the appearance of hypovolemic disorders in the menstrual days and the presence of iron deficiency anemia and severe.
• Polymenorrhea - uterine bleeding arising against the background of a regular shortened menstrual cycle (less than 21 days).
• Metrragia and menometricragia - uterine bleeding, not having a rhythm, often arising after the gaps of oligomenogenios and characterized by periodic bleeding amplification against the background of scarce or moderate blood discharge.

Diagnosis of uterine bleeding of a puberty

The diagnosis of uterine bleeding of a puberty period after the elimination of the diseases listed below.

• Spontaneous interruption of pregnancy (sexually active girls).
• The diseases of the uterus (mioma, endometrial polyps, endometritis, arterio-venous anastomoses, endometriosis, the presence of an intrauterine contraceptive agent, extremely rare adenocarcinoma and sarcoma of the uterus).
• Pathology of vagina and cervix (injury, foreign body, neoplastic processes, exophytic conglishers, polyps, vaginites).
• Ovarian diseases (polycystic ovary, premature exhaustion, tumors and tumor education).
• Blood Diseases [disease von Willebrand and a shortage of other plasma hemostasis factors, Vergood disease (idiopathic thrombocytopenic purple), thrombaster of glossman-Nemeli, Bernard-Sulie, Gauche, Leukemia, Aplastic anemia, iron-ficit anemia].
• Endocrine diseases (hypothyroidism, hyperthyroidism, Addison or Cushing disease, hyperprolactinemia, postpubertate form of congenital hyperplasia of adrenal cortex, adrenal tumors, empty Turkish saddle syndrome, mosaic version of Turner syndrome).
• Systemic diseases (liver disease, chronic renal failure, hyperplanism).
• Yatrogenic reasons - application errors: non-compliance with the dosing and reception mode, unreasonable purpose of drugs containing female sex steroids, and long-term use in high doses of non-steroidal anti-inflammatory funds (NSAIDs), disaggregants and anticoagulants, psychotropic drugs, anticonvulsants and warfarin, chemotherapy.

History and physical examination

• Collect anamnesis.
• Physical examination.
  • Comparison of the degree of physical development and puberty on a tanner with age standards.
  • Vaginoscopy and inspection data make it possible to eliminate the presence of a foreign body into the vagina, the wig, the red flat depriving, the neoplasms of the vagina and the cervix. Assess the condition of the mucous membrane of the vagina, estrogen saturation.
    • Signs of hyperstroyment: pronounced folding of the mucous membrane of the vagina, juicy virgin, cylindrical shape of the cervix, positive symptom of "pupil", abundant residence of mucus in blood discharge.
    • For hypo estrogenemia, the mucous membrane of the vagina is characterized by a pale pink; Its folding is poorly pronounced, hymen thin, cervix subconic or conical shape, blood discharge without impurities of mucus.
• Evaluation of the menstrual calendar (menocyclic).
• Clarification of the psychological characteristics of the patient.

Laboratory research

• The overall analysis of blood with the determination of the concentration of hemoglobin, the number of platelets is carried out by all patients with uterine bleeding of a puberty period.
• Biochemical blood test: study of the concentration of glucose, creatinine, bilirubin, urea, serum, trans-ferrine in the blood.
• The hemostasiogram (definition of activated partial thromboplastin time, prothrombin index, activated recalcification time) and the estimate of the bleeding time makes it possible to exclude the coarse pathology of the coagulation system of blood.
• Definition in the blood of β-subunit of chorionic gonadotropin in sexually active girls.
• Study of the concentration of hormones in the blood: TSH and free t to clarify the function of the thyroid gland; estradiol, testosterone, dehydroepiandrosterone sulfate, LH, FSH, insulin, C-peptide to exclude PCS; 17-hydroxyprogesterone, testosterone, dehydroepiderosterone sulfate, daily rhythm of cortisol secretion to exclude congenital hyperplasia of adrenal cortex; prolactin (at least 3 times) to eliminate hyperprolactinemia; Progesterone in blood serum on the 21st day (with a 28-day menstrual cycle) or on the 25th day (with a 32-day menstrual cycle) to confirm the annevoral nature of the uterine bleeding.
• Test tolerance to carbohydrates with PCC and overweight (body weight index is 25 kg / m 2 and higher).

Instrumental research

• Microscopy smear from the vagina (painting in gram) and PCR material obtained from the scraping from the walls of the vagina, are carried out in order to diagnose chlamydia, gonorrhea, mycoplasmosis.
• Ultrasound of the small pelvis organs allows you to clarify the size of the uterus and the endometrium state to eliminate pregnancy, the viciousness of the uterus (twin, saddot uterus), the pathology of the bodies of the uterus and endometrial (adenomyosis, myoma of the uterus, polyps or hyperplasia, adenomatosis and endometrial cancer, endometritis, endometrial receptors and endometrial Intrauterine syneficias), estimate the size, structure and volume of ovaries, eliminate functional cysts (follicular, yellow-body cysts, provoking disorders of the menstrual cycle by type of uterine bleeding, both against the background of shortening the duration of the menstrual cycle and on the background of the preliminary delay of menstruation up to 2-4 weeks With the cysts of the yellow body) and volume formations in the subdivities of the uterus.
• The diagnostic hysteroscopy and the scraping of the uterine cavity in adolescents are rarely used and used to clarify the status of the endometrium when detected ultrasonic signs Endometrial polyps or cervical channel.

Indications for consultation of other specialists

• The consultation of the endocrinologist is shown in suspected the pathology of the thyroid gland (clinical symptoms of hypothyroidism or hyperthyroidism, diffuse increase or nodal formation of the thyroid gland during palpation).
• The consultation of the hematologist is necessary when debuting the uterine bleeding of a puberty period with menarche, indications of frequent nasal bleeding, the occurrence of petechia and hematoma, increased bleeding during cuts, injuries and operational manipulations, when lengthening the bleeding time.
• The consultation of the phthisiart is shown in the uterine bleeding of the pubertal period against the background of a long resistant subfebilite, the acyclic character of bleeding, often accompanied by painful syndrome, In the absence of a pathogenic infectious agent in the separated urinary tract, relative or absolute lymphocytosis in the overall blood test, positive tuberculin samples.
• Consultation of the therapist should be carried out in the uterine bleeding of the pubertal period against the background of chronic systemic diseases, including diseases of the kidneys, liver, lung, cardiovascular system, etc.

Differential diagnosis

The main goal differential diagnosis The uterine bleeding of the puberty period is the clarification of the main etiological factors provoking the development of the disease. The following diseases are listed on which the uterine bleeding of a puberty should be differentiated.

• Complications of pregnancy in sexually active adolescents. First of all, the complaints and abstract data refine the comprehensive pregnancy or bleeding after the abortion occurring, including girls who deny sexual contacts. Bleeding occurs more often after a long-term latency of menstruation over 35 days, less often in shortening the menstrual cycle less than 21 days or in terms close to the expected menstruation. In history, as a rule, there are guidance on sex in the previous menstrual cycle. Patients note complaints on the heat of the mammary glands, nausea. Blood discharge, usually abundant, with clots, with pieces of fabrics, often painful. Pregnancy tests are positive (determination of the β-subunit of chorionic gonadotropin in the blood of the patient).
• Defects of blood coagulation system. To eliminate defects of the coagulation system, the data of family history (a tendency to bleeding from parents) and the history of life (nasal bleeding, elongated bleeding time with surgical manipulations, frequent and unreasonable occurrence of petech and hematoma) are found. Uterine bleeding, as a rule, have the character of menorragia, starting with Menarche. Data inspection (pallor of skin, bruises, petechia, yellow painting palms and upper snags, girsutism, strry, acne, vitiligo, multiple birthplace spots, etc.) and laboratory methods Research (Coaga-Famogram, General Blood Analysis, Thromboelasticogram, Defining the Concentration of Basic Blood Coaling Factors) allow you to confirm the pathology of the hemostasis system.
• Polyps of cervical and body uterus. Uterine bleeding, as a rule, acyclic, short, light gaps; Allocations are moderate, often with heavy mucus. When ultrasound, endometrial hyperplasia is often detected (endometrial thickness on the background of bleeding is 10-15 mm) with hyperheogenic formations of different sizes. The diagnosis confirms the hysteroscopy data and the subsequent histological study of the remote formation of the endometrium.
• Adenomyosis. The uterine bleeding of a puberty period against the background of adenomyosis is characterized by severe dysmenorrhea, long-term brazing blood discharges with a characteristic brown tinge before and after menstruation. The diagnosis confirms the results of the ultrasound in the 1st and 2nd phase of the menstrual cycle and hysteroscopy (in patients with severe pain syndrome and in the absence of the effect of drug therapy).
• Inflammatory diseases of the small pelvis organs. As a rule, uterine bleeding has an acyclic character, arises after hypothermia, unprotected, especially random or unintelligent (promiscuits) of sexual contacts in sexually active adolescents, against the background of exacerbation of chronic pelvic pain. Worried pain at the bottom of the abdomen, dizuriy, hyperthermia, abundant pathological damage outside menstruation, acquire a sharp, unpleasant smell on the background of bleeding. Under the recalobdominal study, the invested softened uterus is found in the size, the pastosity of tissues in the area of \u200b\u200buterine appendages; The conducted study is usually painful. Data from bacteriological research (microscopy of smears with color by gram, the study of the discharge vagina for the presence of infection transmitted by sexually, using PCR, bacteriological examination of the material from the rear axle of the vagina) contribute to clarifying the diagnosis.
• The injury of external genital organs or a foreign body in the vagina. Anamnesis data and vulvo-vaginoscopy results are necessary for diagnosis.
• Polycystic ovarian syndrome. In the uterine bleeding of a puberty period in patients with the forming PCOS, along with complaints of menstruation delays, excess hair growth, acne on face, chest, shoulders, back, buttocks, and hips are indications of Menarche with progressive disorders of the menstrual cycle by type of oligomenorea.
• Hormonproductive formation of ovaries. The uterine bleeding of a puberty period may be the first symptom of estrogen-producing tumors or tumor-like ovarian formations. Clarification of the diagnosis is possible after the ultrasound of the genital organs with the determination of the volume and structure of the ovaries and the concentration of estrogen in venous blood.
• Disrupting the function of the thyroid gland. The uterine bleeding of a puberty period occurs, as a rule, in patients with subclinical or clinical hypothyroidism. Patients complain of zyabacity, swelling, increase in body weight, reduction of memory, drowsiness, depression. In hypothyroidism, palpation and ultrasound with the determination of the volume and structural features of the thyroid gland make it possible to reveal its increase, and the examination of patients - the presence of dry subicteric skin, pastosity of fabrics, causticity of the face, an increase in language, bradycardia, an increase in the relaxation time of deep tendon reflexes. Specify the functional state of the thyroid gland allows the determination of the TSH content, free T 4 in the blood.
• Hyperprolactinemia. To eliminate hyperprolactinemia as the cause of the uterine bleeding of a puberty period, inspection and palpation of the mammary glands with the refinement of the nature of the blood separated from the nipples, the determination of the blood prolactin, radiography of the skull bones with aiming study of the size and configuration of the Turkish saddle or MRI of the brain is shown. Conducting trial treatment with dopamiometric drugs in patients with uterine bleeding of a puberty period resulting from hyperprolactinemia, contributes to the restoration of the rhythm and the nature of menstruation for 4 months.

Treatment of uterine bleeding of a puberty

Indications for hospitalization:

• Abundant (profuse) uterine bleeding, not stopped during medicinal therapy.
• Life threatening decrease in hemoglobin concentration (below 70 g / l) and hematocrit (below 20%).
• Necessity surgical treatment and hemotransfusion.

Non-media treatment of uterine bleeding of a puberty

There are no data confirming the feasibility of non-drug therapy of patients with uterine bleeding of a puberty period, except for situations requiring surgical intervention.

Drug therapy of the uterine bleeding of a puberty

Common goals medicinal treatment The uterine bleeding of a puberty period are:

• Stop bleeding to avoid acute hemorrhagic syndrome.
• Stabilization and correction of the menstrual cycle and endometrial state.
• Antianamemic therapy.

Apply the following drugs:

At the first stage of treatment, it is advisable to use plasminogen transition inhibitors in plasmin (transcamic and aminocaproic acid). The intensity of bleeding is reduced due to the decrease in the fibrinolytic activity of blood plasma. The transcamic acid is prescribed in a dose of 5 g 3-4 times a day with profuse bleeding until the bleeding stop. maybe intravenous administration 4-5 g of the drug for the first hour, then drip administration of drugs at a dose of 1 g / h for 8 hours. The total daily dose should not exceed 30 g. With large doses, the risk of developing intravascular coagulation syndrome, and with the simultaneous use of estrogen is high The probability of thromboembolic complications. 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%.

A significant reduction in blood loss in patients with menorragia is observed when applying NSAIDs, monophasic Kok and Danazole.

• Danazole in patients with uterine bleeding of the puberty period are used very rarely due to pronounced adverse reactions (nausea, voices, loss and increased hair salinity, the appearance of acne and hirsutism).
• NSAIDs (ibuprofen, diclofenac, indomethacin, nimesulide, etc.) affect the metabolism of arachidonic acid, reduce the products of prostaglandins and thromboxanes in endometrial, reducing the volume of blood loss during menstruation by 30-38%. Ibuprofen is prescribed at a dose of 400 mg every 4-6 h (daily dose of 1200-3200 mg) in days of menorgia. However, the increase in daily dose may cause an undesirable increase in prothrombin time and the concentration of lithium ions in the blood. The effectiveness of the NSPID is comparable to the effectiveness of aminocaproic acid and COC. In order to increase the efficiency of hemostatic therapy, the combined use of NSAIDs and hormone therapy is justified. However, this type of combined therapy is contraindicated in patients with hyperprolactinemia, structural anomalies of the genital organs and the pathology of the thyroid gland.
• Oral low-volume contraceptives with modern progestainenes (desogestrel at a dose of 150 μg, gesthered at a dose of 75 μg, a dienogest at a dose of 2 mg) are often used in patients with profuse and acyclic uterine bleeding. Ethinyl estradiol in COC provides a hemostatic effect, and progestogen is the strass stabilization and the basal layer of the endometrium. Only monophazic Koks are prescribed to stop bleeding.
  • There are many schemes for the use of COC in hemostatic purposes in patients with uterine bleeding. Frequently recommended 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 per day until the end of the 2nd packaging of the drug. Out of bleeding in order to regulate the Menstrual Cycle Koks are prescribed for 3-6 cycles of 1 tablet per day (21 days of reception, 7 days break). The duration of hormone therapy depends on the severity of the initial iron deficiency anemia and the reduction rate of hemoglobin content. The use of COC in the specified mode is associated with a number of serious side effects: an increase in blood pressure, thrombophlebitis, nausea and vomiting, allergies. In addition, difficulties arise in the selection of suitable anti-diamemine therapy.
  • An alternative can be considered the use of low-volume monophase COCs in a dose of half of the tablet every 4 hours before complete hemostasis, since the maximum concentration of the drug in the blood is achieved after 3-4 hours after oral administration of the drug and significantly decreases in the following 2-3 hours. Total dose EE with It ranges from 60 to 90 μg, which is more than 3 times less than with a traditionally used treatment scheme. In the following days, the daily dose of Kok is reduced - half a pill per day. With a decrease in the daily dose to 1 tablet, it is advisable to continue the preparation of the drug, taking into account the concentration of hemoglobin. As a rule, the duration of the first taking cycle of KOC 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 taking medication, a temporary increase of endometrial thickness is possible, which regresses without bleeding during the continuation of treatment.
  • In the future, in order to regulate the rhythm of menstruation and the prevention of recycling of uterine bleeding, KOC are prescribed according to the standard diagram (21-day courses with 7-day breaks between them). In all patients who took preparations according to the described scheme, the bleeding stop is noted within 12-18 hours from the beginning of the reception and good tolerability in the absence of side effects. Pathogenetically not justified the use of Coc Short-Route (10 days in the 2nd phase of the modulated cycle or in 21 days to 3 months).
• If you need to accelerate stopping the threatening life of bleeding with the preparations of the first lines of choice, the conjugated estrogens are introduced in / c at a dose of 25 mg every 4-6 hours to a complete cessation of bleeding, which occurs during the first day. It is possible to use the tablet forms of conjugated estrogen at a dose of 0.625-3.75 μg every 4-6 hours to a complete cessation of bleeding with a gradual decrease in the dose for subsequent 3 days before the dosage of 0.675 mg / day or estradiol in a similar scheme with an initial dose of 4 mg / day . After stopping bleeding, progestogens are prescribed.
• Out of bleeding in order to regulate the menstrual cycle are prescribed inside conjugated estrogens at a dose of 0.675 mg / day or estradiol at a dose of 2 mg / day for 21 days with the obligatory addition of progesterone within 12-14 days in the 2nd phase of the modulated cycle.
• In some cases, especially in patients with severe side reactions, intolerance or contraindications to the use of estrogen, it is possible to appoint only progesterone. The low efficiency of small doses of progesterone was noted against the background of profuse uterine bleeding, first of all in the 2nd phase of the menstrual cycle under menorgia. Patients S. abundant bleeding The high doses of progesterone are shown (acetate acetate at a dose of 5-10 mg, micronized progesterone in a dose of 100 mg or a DIDROGESTERON at a dose of 10 mg), or every 2 hours with a threatening life of bleeding, or 3-4 times a day with a rich, but not dangerous For the life of bleeding to cessation of bleeding. After stopping bleeding, drugs are prescribed 2 times a day for 2 tablets no more than 10 days, since the reception prolongation may cause re-bleeding. The reaction of cancellation of progestogencies is usually manifested by abundant blood discharge, which often requires the use of symptomatic hemostasis. In order to regulate the menstrual cycle in menopragia, the medroxyprogesterone can be assigned in a dose of 5-10-20 mg / day, the DIDROGESTERON - at a dose of 10-20 mg per day, or micronized progesterone - at a dose of 300 mg per day in the second phase (when luteinic failure phases), or at a dose of 20, 20 and 300 mg / day, respectively, the type of the drug from the 5th to the 25th day of the menstrual cycle (during ovulatory menopids). In patients with annevulatory uterine bleeding progestogen, it is advisable to prescribe in the 2nd phase of the menstrual cycle against the background of the constant use of estrogen. It is possible to use progesterone in a micronized form in a daily dose of 200 mg within 12 days per month against the background of continuous therapy with estrogen.

Continuation of bleeding against the background of hormonal hemostasis serves as an indication for hysteroscopy to clarify the status of the endometrium.

All patients with uterine bleeding of a puberty period are shown iron preparations to prevent the development of iron deficiency anemia. The high efficiency of the use of iron sulfate in combination with ascorbic acid at a dose of 100 mg of bivalent iron per day is proved. The daily dose of iron sulfate is selected taking into account the concentration of hemoglobin in the blood. The criterion for the correct selection of iron preparations for iron deficiency anemia is the development of a reticulocyte crisis (an increase of 3 times and more of reticulocytes after 7-10 days after the start of reception). Antianamemic therapy is carried out for at least 1-3 months. Iron salts should be used with caution in patients with accompanying tractology of the gastrointestinal tract.