Anovulatory uterine bleeding is uterine bleeding during a single-phase (anovulatory) menstrual cycle. As a rule, it appears after a delay in menstruation, differs from normal menstrual bleeding by a longer duration and the amount of blood loss. It can provoke anemia. Anovulatory uterine bleeding occurs against the background of infantilism, malformations, chronic intoxication, infections, endocrine disorders, stress and poor nutrition. They are diagnosed on the basis of complaints, anamnesis, gynecological examination and the results of special studies. Treatment – pharmacotherapy, elimination of the underlying pathology.
N93.8 Other specified abnormal bleeding from the uterus and vagina
Anovulatory uterine bleeding is a dysfunctional bleeding that occurs against the background of an anovulatory cycle. It is provoked by harmful effects, observed against the background of certain diseases and congenital anomalies. It occurs due to atresia of an immature follicle or follicle persistence, entailing a violation of the cyclic development of the surface layer of the endometrium and the proliferation of this layer with its subsequent rejection. Anovulatory uterine bleeding is more often detected at puberty or preclimacteric age. They differ from normal menstruation by irregularity, longer duration and the amount of blood loss. Combined with infertility caused by the absence of ovulation. They can provoke secondary iron deficiency anemia. Treatment of anovulatory uterine bleeding is carried out by specialists in the field of clinical gynecology.
The immediate cause of anovulatory bleeding is single-phase cycles, which can occur as a result of a violation of the pituitary gland and a decrease in the amount of follicle-stimulating or luteinizing hormone, as well as hormonal balance disorders (changes in the ratio of estrogens, androgens, LH). Single-phase cycles accompanied by anovulatory uterine bleeding are provoked by:
- malformations of development;
- metabolic disorders;
- vitamin deficiency;
- chronic intoxication;
- infectious diseases;
- severe stress.
Single-phase cycles are not always evidence of pathology, and menorrhagia in such cycles are not always regarded as anovulatory uterine bleeding. Normally, such cycles occur within 1-2 years after menarche, premenopause and during breastfeeding. In addition, in some women, anovulatory cycles alternate with ovulatory ones. The diagnosis is made only when single-phase cycles are accompanied by profuse bleeding with a violation of the general condition and working capacity.
The normal menstrual cycle consists of two phases. The first phase begins on the 1st day of menstruation. The old inner layer of the endometrium is rejected, then proliferation begins – the formation of a new inner layer ready to receive a fertilized egg. At the same time, egg maturation occurs in the ovary under the influence of follicle-stimulating hormone. After the egg matures, the anterior pituitary gland releases a peak amount of luteinizing hormone into the blood, which initiates ovulation – the rupture of the mature follicle and the release of the egg into the fallopian tube. After that, the second phase of the menstrual cycle begins.
In place of the follicle, a yellow body is formed that produces progesterone. The activity of endometrial proliferation decreases, the height of the surface layer increases, optimal conditions for egg implantation are created. A few days before the start of menstruation, the growth of the endometrium stops. The yellow body regresses, progesterone levels decrease. Blood circulation in the surface layer of the endometrium is disrupted, the cells necrotize. Vascular spasm is replaced by their paralytic expansion, and dead cells come out with menstrual blood.
With an anovulatory cycle, there is no second phase. Ovulation does not occur, fertilization is impossible. There may be a reverse development of the follicle (atresia) or continued growth of the follicle with the formation of a cyst-like formation (persistence). The yellow body does not form, progesterone levels do not increase, endometrial cells continue to proliferate. Due to the lag in vascular growth, the nutrition of the surface layer worsens, dystrophic changes occur in it. Rejection of necrotic epithelium is accompanied by opening of blood vessels and profuse bleeding.
There are three variants of anovulatory uterine bleeding:
- with atresia of multiple follicles;
- with short-term rhythmic persistence of follicles;
- with long-term persistence of follicles.
Atresia of multiple follicles is diagnosed in adolescence. Anovulatory uterine bleeding begins after a delay in menstruation for a period of half a month to six months, can be moderate, but prolonged (more than 10-15 days) or very abundant, quickly leading to the development of anemia. In severe cases, secondary clotting disorders are possible, further aggravating anovulatory uterine bleeding.
Short-term rhythmic persistence of follicles can be observed at any age, but is more often detected in the reproductive period. It is accompanied by menstrual-like anovulatory uterine bleeding, usually occurring after a delay in menstruation for a period of several days to several weeks.
Prolonged follicle persistence is usually detected in premenopause, but it can also occur in women of other ages. Bleeding is prolonged, abundant, repeated after 1.5-2 or more months. With prolonged persistence, anemia is observed more often than with other forms. The addition of secondary iron deficiency anemia in all forms of anovulatory uterine bleeding is accompanied by weakness, drowsiness, fatigue, dizziness, fainting, tachycardia, sweating, pallor of the skin and mucous membranes.
The diagnosis is established on the basis of patient complaints, anamnesis collection, general and gynecological examination data and special studies. In favor of this pathology, unusually abundant or prolonged bleeding appears after a delay in menstruation.
- Examination on the chair. During the gynecological examination of patients with anovulatory uterine bleeding, a positive pupil symptom is detected, which does not weaken and does not disappear in the second half of the cycle. When examining mucus from the cervical canal, a positive fern phenomenon is revealed. Rectal temperature remains stable throughout the cycle.
- Biopsy sampling. Separate diagnostic curettage for anovulatory uterine bleeding is performed at reproductive and premenopausal age. In adolescent patients, the material for histological examination is obtained by aspiration.
- Morphological examination. Histological examination of the material taken from women with rhythmic follicle persistence reveals excessive endometrial proliferation or glandular-cystic endometrial hyperplasia; in patients with prolonged follicle persistence – glandular-cystic, adenomatous, polypous or atypical endometrial hyperplasia.
- Other studies. Depending on the complaints and the results of the examination, a patient with anovulatory uterine bleeding may be referred for consultation to an endocrinologist, therapist or infectious disease specialist. The examination program includes a general blood test, a general urine test, a biochemical blood test, a blood test for hormones, ultrasound of the pelvic organs and other studies.
To determine the causes of anovulatory uterine bleeding and exclude other diseases accompanied by similar symptoms, a comprehensive examination is prescribed. Anovulatory bleeding is differentiated from:
- blood diseases;
- impaired liver function;
- diseases of the endocrine system;
- organic and inflammatory diseases of the reproductive system.
Treatment of anovulatory uterine bleeding
Treatment of this pathology can be carried out on an outpatient basis or in a gynecological department and includes three stages: stopping bleeding, normalization and regulation of the menstrual cycle. The primary task of an obstetrician-gynecologist is to reduce blood loss and stop bleeding. During the initial treatment, this task is solved at the stage of separate diagnostic curettage. In case of repeated treatment for anovulatory uterine bleeding, conservative therapy is carried out.
A prerequisite for conservative therapy is the absence of signs of endometrial hyperplasia according to the results of ultrasound and histological conclusion on the condition of the endometrium, obtained no earlier than three months before the start of treatment. With anovulatory uterine bleeding, agents are used to strengthen the vascular wall and increase blood clotting, hormonal hemostasis is carried out. With atresia of many follicles, estrogens are usually used, with regular persistence – synthetic progestins, with long–term persistence – progestins. The drugs are selected individually taking into account age, the presence or absence of anemia and other factors.
Iron preparations are used to correct secondary iron deficiency anemia resulting from anovulatory uterine bleeding. Infectious, somatic and endocrine diseases are treated. Eliminate chronic intoxication, prescribe a balanced diet. An anovulatory menstrual cycle is treated by a gynecologist-endocrinologist. Patients are prescribed gonadotropins for a period of 3-6 months between the 11th and 14th days of the cycle. 6-8 days before the start of menstruation, patients with anovulatory uterine bleeding are intramuscularly injected with progesterone.
To stimulate ovulation, endonasal electrophoresis (effect on the hypothalamic-pituitary region), electrical stimulation of the cervix and other physiotherapy procedures are used. Hormonal therapy and physiotherapy of anovulatory uterine bleeding are carried out against the background of restorative treatment. Sometimes in the first phase of the menstrual cycle, vagotropic drugs are prescribed to stimulate the maturation of the follicle. In the second phase, sympathicotropic drugs are used to increase the activity of the corpus luteum.
The main method of surgical treatment of anovulatory uterine bleeding is curettage, performed simultaneously with therapeutic and diagnostic purposes. The procedure is mandatory for all bleeding in premenopausal patients and for most anovulatory uterine bleeding in patients of reproductive age. Teenagers are scraped only for vital indications. In exceptional cases, supravaginal amputation of the uterus or hysterectomy is performed. In premenopausal patients, an indication for surgery is anovulatory uterine bleeding in combination with precancerous diseases of the cervix and atypical endometrial hyperplasia. In other cases, the removal of the uterus is carried out only with very severe bleeding that threatens the life of patients.
The prognosis depends on the cause of the development of systematic single-phase menstrual cycles and subsequent anovulatory uterine bleeding.