Abnormal (dysfunctional) uterine bleeding is pathological bleeding from the uterus associated with a violation of the production of sex hormones by the endocrine glands. There are juvenile bleeding (during puberty), menopausal bleeding (in the stage of extinction of ovarian function), bleeding of the reproductive period. It is expressed by an increase in the amount of blood lost during menstruation or an extension of the duration of menstruation. It may manifest as metrorrhagia – acyclic bleeding. Alternation of periods of amenorrhea (from 6 weeks to 2 months or more) with subsequent bleeding of varying strength and duration is characteristic. Leads to the development of anemia.
Abnormal uterine bleeding (the accepted abbreviation is AUB) is the main manifestation of ovarian dysfunction syndrome. Abnormal uterine bleeding is characterized by acyclicity, prolonged menstrual delays (1.5-6 months) and prolonged blood loss (more than 7 days). There are abnormal uterine bleeding of juvenile (12-18 years), reproductive (18-45 years) and menopausal (45-55 years) age periods. Uterine bleeding is one of the most frequent hormonal pathologies of the female genital area.
Juvenile abnormal uterine bleeding is usually caused by an unformed cyclic function of the hypothalamus-pituitary gland-ovaries-uterus. In childbearing age, frequent causes of ovarian dysfunction and uterine bleeding are inflammatory processes of the reproductive system, diseases of the endocrine glands, surgical termination of pregnancy, stress, etc., in menopause – a violation of the regulation of the menstrual cycle due to the extinction of hormonal function.
On the basis of the presence of ovulation or its absence, ovulatory and anovulatory uterine bleeding are distinguished, with the latter accounting for about 80%. The clinical picture of uterine bleeding at any age is characterized by prolonged bloody discharge, which appears after a significant delay in menstruation and is accompanied by signs of anemia: pallor, dizziness, weakness, headaches, fatigue, decreased blood pressure.
Mechanism of development
Abnormal uterine bleeding develops as a result of a violation of hormonal regulation of ovarian function by the hypothalamic-pituitary system. Violation of the secretion of gonadotropic (follicle-stimulating and luteinizing) hormones of the pituitary gland, stimulating follicle maturation and ovulation, leads to failures in folliculogenesis and menstrual function. At the same time, the follicle in the ovary either does not mature (follicle atresia), or it matures, but without ovulation (follicle persistence), and, consequently, a yellow body is not formed. In both cases, the body is in a state of hyperestrogenism, i.e. E. the uterus is influenced by estrogens, because in the absence of the corpus luteum, progesterone is not produced. The uterine cycle is disrupted: there is a long-term, excessive growth of the endometrium (hyperplasia), and then its rejection, which is accompanied by abundant and prolonged uterine bleeding.
The duration and intensity of uterine bleeding are influenced by hemostatic factors (platelet aggregation, fibrinolytic activity and vascular spastic ability), which are impaired in AUB. Uterine bleeding can stop on its own after an indefinite period of time, but, as a rule, it occurs again, so the main therapeutic task is to prevent recurrence of AUB. In addition, hyperestrogenism in abnormal uterine bleeding is a risk factor for the development of adenocarcinoma, uterine fibroids, fibrocystic mastopathy, endometriosis, breast cancer.
In the juvenile (puberty) period, uterine bleeding is more common than other gynecological pathology – in almost 20% of cases. Violation of the formation of hormonal regulation at this age is facilitated by physical and mental injuries, unfavorable living conditions, fatigue, hypovitaminosis, dysfunction of the adrenal cortex and / or thyroid gland. A provoking role in the development of juvenile uterine bleeding is also played by childhood infections (chickenpox, measles, mumps, whooping cough, rubella), acute respiratory infections, chronic tonsillitis, complicated pregnancy and childbirth in the mother, etc.
In the diagnosis of juvenile uterine bleeding, the following are taken into account:
- anamnesis data (date of menarche, last menstruation and the beginning of bleeding)
- the development of secondary sexual characteristics, physical development, bone age
- hemoglobin level and blood clotting factors (total blood count, platelets, coagulogram, prothrombin index, clotting time and bleeding time)
- indicators of hormone levels (prolactin, LH, FSH, estrogen, progesterone, cortisol, testosterone, T3, TSH, T4) in blood serum
- expert opinion: consultation of a gynecologist, endocrinologist, neurologist, ophthalmologist
- basal temperature indicators in the period between menstruation (a single–phase menstrual cycle is characterized by a monotonous basal temperature)
- the state of the endometrium and ovaries based on ultrasound data of the pelvic organs (using a rectal sensor in virgins or a vaginal sensor in girls living a sexual life). An echogram of the ovaries in juvenile uterine bleeding shows an increase in the volume of the ovaries in the intermenstrual period
- the state of the regulating hypothalamic-pituitary system according to skull radiography with Turkish saddle projection, echoencephalography, EEG, CT or MRI of the brain (in order to exclude tumor lesions of the pituitary gland)
- Ultrasound of the thyroid gland and adrenal glands with dopplerometry
- Ultrasound control of ovulation (in order to visualize atresia or persistence of the follicle, mature follicle, ovulation, formation of the corpus luteum)
The primary task in the treatment of uterine bleeding is to carry out hemostatic measures. Further treatment tactics are aimed at preventing recurrent uterine bleeding and normalizing the menstrual cycle. Modern gynecology has in its arsenal several ways to stop abnormal uterine bleeding, both conservative and surgical. The choice of the method of hemostatic therapy is determined by the general condition of the patient and the amount of blood loss. With moderate anemia (with hemoglobin above 100 g / l), symptomatic hemostatic (menadion, ethamzylate, ascorutin, aminocaproic acid) and uterine contractile (oxytocin) drugs are used.
In case of ineffectiveness of non-hormonal hemostasis, progesterone preparations (ethinyl estradiol, ethinyl estradiol, levonorgestrel, norethisterone) are prescribed. Spotting usually stops 5-6 days after the end of taking medications. Profuse and prolonged uterine bleeding leading to progressive deterioration of the condition (severe anemia with Hb less than 70 g / l, weakness, dizziness, fainting) are indications for hysteroscopy with separate diagnostic curettage and pathomorphological examination of scraping. A contraindication to curettage of the uterine cavity is a violation of blood clotting.
In parallel with hemostasis, antianemic therapy is carried out: iron preparations, folic acid, vitamin B12, vitamin C, vitamin B6, vitamin P, transfusion of erythrocyte mass and freshly frozen plasma. Further prevention of uterine bleeding includes taking gestagenic drugs in low doses (gestoden, desogestrel, norgestimate in combination with ethinyl estradiol; didrogesterone, norethisterone). In the prevention of uterine bleeding, general hardening, rehabilitation of chronic infectious foci and proper nutrition are also important. Adequate measures of prevention and therapy of juvenile uterine bleeding restore the cyclic functioning of all parts of the reproductive system.
AUB of the reproductive period
In the reproductive period, dysfunctional uterine bleeding accounts for 4-5% of cases of all gynecological diseases. The factors causing ovarian dysfunction and uterine bleeding are neuropsychic reactions (stress, fatigue), climate change, occupational hazards, infections and intoxication, abortions, some drugs that cause primary disorders at the level of the hypothalamus-pituitary system. Disorders in the ovaries are caused by infectious and inflammatory processes that contribute to the thickening of the ovarian capsule and a decrease in the sensitivity of ovarian tissue to gonadotropins.
When diagnosing uterine bleeding, organic pathology of the genitals (tumors, endometriosis, traumatic injuries, spontaneous abortion, ectopic pregnancy, etc.), diseases of the hematopoietic organs, liver, endocrine glands, heart and blood vessels should be excluded. In addition to general clinical methods of diagnosing uterine bleeding (anamnesis collection, gynecological examination), hysteroscopy and separate diagnostic endometrial scraping with histological examination of the material are used. Further diagnostic measures are the same as for juvenile uterine bleeding.
Therapeutic tactics for uterine bleeding of the reproductive period is determined by the results of the histological result of the taken scrapings. When recurrent bleeding occurs, hormonal and non-hormonal hemostasis is performed. In the future, hormonal treatment is prescribed to correct the identified dysfunction, which contributes to the regulation of menstrual function, prevention of recurrence of uterine bleeding.
Nonspecific treatment of uterine bleeding includes normalization of the neuropsychiatric state, treatment of all background diseases, removal of intoxication. This is facilitated by psychotherapeutic techniques, vitamins, sedatives. Iron preparations are prescribed for anemia. Uterine bleeding of reproductive age with improperly selected hormone therapy or for a specific reason may occur repeatedly.
AUB of the climacteric period
Premenopausal uterine bleeding occurs in 15% of cases of gynecological pathology of menopausal women. With age, the amount of gonadotropins secreted by the pituitary gland decreases, their release becomes irregular, which causes a violation of the ovarian cycle (folliculogenesis, ovulation, development of the corpus luteum). Progesterone deficiency leads to the development of hyperestrogenism and hyperplastic overgrowth of the endometrium. Menopausal uterine bleeding develops in 30% against the background of menopausal syndrome.
The features of the diagnosis of menopausal uterine bleeding are the need to differentiate them from menstruation, which at this age become irregular and proceed according to the type of metrorrhagia. To exclude the pathology that caused uterine bleeding, it is better to perform hysteroscopy twice: before and after diagnostic curettage.
After curettage, when examining the uterine cavity, it is possible to identify areas of endometriosis, small submucous fibroids, uterine polyps. In rare cases, the cause of uterine bleeding becomes a hormone-active ovarian tumor. Ultrasound, nuclear magnetic or computed tomography allows to identify this pathology. Methods of diagnosing uterine bleeding are common for their different types and are determined by the doctor individually.
Therapy of abnormal uterine bleeding in the menopausal period is aimed at suppressing hormonal and menstrual functions, i.e. at causing menopause. Stopping bleeding during uterine bleeding of the menopausal period is performed exclusively surgically – by therapeutic and diagnostic curettage and hysteroscopy. Wait-and-see tactics and conservative hemostasis (especially hormonal) are erroneous. Sometimes cryodestruction of the endometrium or surgical removal of the uterus is performed – supravaginal amputation of the uterus, hysterectomy.
Prevention of abnormal uterine bleeding should begin at the stage of intrauterine development of the fetus, i.e. during pregnancy. In childhood and adolescence, it is important to pay attention to restorative and general health measures, prevention or timely treatment of diseases, especially of the reproductive system, prevention of abortions.
If dysfunction and uterine bleeding have developed, then further measures should be aimed at restoring the regularity of the menstrual cycle and preventing recurrence of bleeding. For this purpose, the appointment of oral estrogen-progestogenic contraceptives is shown according to the scheme: the first 3 cycles – from day 5 to day 25, the next 3 cycles – from day 16 to day 25 of menstrual bleeding. Pure progestogenic drugs (norcolut, dufaston) are prescribed for uterine bleeding from the 16th to the 25th day of the menstrual cycle for 4-6 months.
The use of hormonal contraceptives not only reduces the frequency of abortions and the occurrence of hormonal imbalance, but also prevents the subsequent development of anovulatory infertility, endometrial adenocarcinoma, breast cancer. Patients with dysfunctional uterine bleeding should be registered with a gynecologist at the dispensary.