Abnormal bleeding in gynecology. Abnormal uterine bleeding

– pathological bleeding from the uterus associated with impaired production of sex hormones by the glands internal secretion. Distinguish juvenile bleeding(during puberty) menopausal bleeding(in the stage of fading ovarian function), bleeding reproductive period. It is expressed by an increase in the amount of blood lost during menstruation or an increase in the duration of menstruation. May manifest as metrorrhagia - acyclic bleeding. Characterized by alternating periods of amenorrhea (from 6 weeks to 2 or more months) with subsequent bleeding different strengths and duration. Leads to the development of anemia.

General information

Dysfunctional uterine bleeding(accepted abbreviation - DMK) serve as the main manifestation of ovarian dysfunction syndrome. Dysfunctional uterine bleeding is characterized by acyclicity, prolonged delays in menstruation (1.5-6 months) and prolonged blood loss (more than 7 days). There are dysfunctional 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 common hormonal pathologies of the female genital area.

Juvenile dysfunctional uterine bleeding is usually caused by the immaturity of the cyclic function of the hypothalamus-pituitary-ovaries-uterus departments. IN childbearing age common causes of ovarian dysfunction and uterine bleeding are inflammatory processes of the reproductive system, diseases endocrine glands, surgical termination of pregnancy, stress, etc., in menopause - dysregulation of the menstrual cycle due to the extinction of hormonal function.

Based on the presence or absence of ovulation, ovulatory and anovulatory uterine bleeding are distinguished, with the latter accounting for about 80%. For clinical picture Uterine bleeding at any age is characterized by prolonged bloody issues appearing after a significant delay in menstruation and are accompanied by signs of anemia: pallor, dizziness, weakness, headaches, fatigue, decreased blood pressure.

DMK development mechanism

Dysfunctional uterine bleeding develops as a result of a violation hormonal regulation functions of the ovaries by the hypothalamic-pituitary system. Violation of the secretion of gonadotropic (follicle-stimulating and luteinizing) hormones of the pituitary gland, which stimulate follicle maturation and ovulation, leads to disruptions in folliculogenesis and menstrual function. In this case, the follicle in the ovary either does not mature (follicular atresia) or matures, but without ovulation (follicle persistence), and, therefore, the corpus luteum does not form. In both cases, the body is in a state of hyperestrogenism, that is, the uterus is influenced by estrogen, since 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 heavy and prolonged uterine bleeding.

The duration and intensity of uterine bleeding are influenced by hemostasis factors (platelet aggregation, fibrinolytic activity and vascular spasticity), which are disrupted in DUB. Uterine bleeding can stop on its own after an indefinitely long period of time, but, as a rule, it occurs again, so the main therapeutic goal is to prevent the recurrence of DUB. In addition, hyperestrogenism during dysfunctional uterine bleeding is a risk factor for the development of adenocarcinoma, uterine fibroids, fibrocystic mastopathy, endometriosis, and breast cancer.

Juvenile DMK

Causes

In the juvenile (pubertal) 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 trauma, disadvantaged living conditions, overwork, hypovitaminosis, dysfunction of the adrenal cortex and/or thyroid gland. Childhood infections (chickenpox, measles, mumps, whooping cough, rubella), acute respiratory infections, chronic tonsillitis, complicated pregnancy and childbirth in the mother, etc. also play a provoking role in the development of juvenile uterine bleeding.

Diagnostics

When diagnosing juvenile uterine bleeding, the following are taken into account:

• anamnesis data (date of menarche, last menstruation and onset of bleeding)
• development of secondary sexual characteristics, physical development, bone age
• hemoglobin level and blood clotting factors ( general analysis blood, 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 with a gynecologist, endocrinologist, neurologist, ophthalmologist
• indicators basal temperature in the period between menstruation (single-phase menstrual cycle characterized by 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 who are sexually active). An echogram of the ovaries with juvenile uterine bleeding shows an increase in the volume of the ovaries during the intermenstrual period
• the state of the regulatory hypothalamic-pituitary system according to radiography of the skull with a sella turcica projection, echoencephalography, EEG, CT or MRI of the brain (to exclude tumor lesions of the pituitary gland)
• Ultrasound of the thyroid and adrenal glands with Dopplerometry
• Ultrasound monitoring of ovulation (for the purpose of visualizing atresia or persistence of the follicle, mature follicle, ovulation, formation of the corpus luteum)

Treatment

The primary task in the treatment of uterine bleeding is to carry out hemostatic measures. Further treatment tactics are aimed at preventing repeated uterine bleeding and normalizing the menstrual cycle. Modern gynecology has in its arsenal several ways to stop dysfunctional uterine bleeding, both conservative and surgical. The choice of hemostatic therapy method is determined general condition patient and the amount of blood loss. For anemia medium degree(with hemoglobin above 100 g/l), symptomatic hemostatic (menadione, etamsylate, ascorutin, aminocaproic acid) and uterine contracting (oxytocin) drugs are used.

If non-hormonal hemostasis is ineffective, progesterone drugs (ethinyl estradiol, ethinyl estradiol, levonorgestrel, norethisterone) are prescribed. Bloody discharge usually stops 5-6 days after stopping the medication. Heavy and prolonged uterine bleeding leading to a progressive deterioration of the condition (severe anemia with Hb less than 70 g/l, weakness, dizziness, fainting) are an indication for hysteroscopy with separate diagnostic curettage and pathomorphological examination of the scraping. A contraindication to curettage of the uterine cavity is a blood clotting disorder.

In parallel with hemostasis, antianemic therapy is carried out: iron supplements, folic acid, vitamin B12, vitamin C, vitamin B6, vitamin P, red blood cell transfusion and fresh frozen plasma. Further prevention of uterine bleeding includes taking progestin drugs in low doses (gestodene, desogestrel, norgestimate in combination with ethinyl estradiol; dydrogesterone, norethisterone). In the prevention of uterine bleeding, general hardening, rehabilitation of chronic infectious foci and proper nutrition are also important. Adequate measures for the prevention and treatment of juvenile uterine bleeding restore the cyclic functioning of all parts of the reproductive system.

DMC of the reproductive period

Causes

In the reproductive period, dysfunctional uterine bleeding accounts for 4-5% of all cases gynecological diseases. Factors causing ovarian dysfunction and uterine bleeding are neuropsychic reactions (stress, fatigue), climate change, occupational hazards, infections and intoxications, abortions, some medicinal substances, causing primary disorders at the level of the hypothalamic-pituitary system. Disturbances in the ovaries are caused by infectious and inflammatory processes that contribute to thickening of the ovarian capsule and a decrease in the sensitivity of ovarian tissue to gonadotropins.

Diagnostics

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 for diagnosing uterine bleeding (history taking, gynecological examination), hysteroscopy and separate diagnostic curettage endometrium with histological examination of the material. Further diagnostic measures the same as for juvenile uterine bleeding.

Treatment

Therapeutic tactics for uterine bleeding of the reproductive period are determined by the histological results of the scrapings taken. If recurrent bleeding occurs, hormonal and non-hormonal hemostasis is performed. In the future, to correct the identified dysfunction, it is prescribed hormonal treatment, helping to regulate menstrual function and prevent recurrence of uterine bleeding.

Nonspecific treatment of uterine bleeding includes normalization of the neuropsychic state, treatment of all underlying diseases, and removal of intoxication. This is facilitated by psychotherapeutic techniques, vitamins, sedatives. For anemia, iron supplements are prescribed. Uterine bleeding reproductive age with incorrectly chosen hormone therapy or for a specific reason, they can occur again.

DMC of menopause

Causes

Premenopausal uterine bleeding occurs in 15% of cases of gynecological pathology in menopausal women. With age, the amount of gonadotropins secreted by the pituitary gland decreases, their release becomes irregular, which causes disruption of the ovarian cycle (folliculogenesis, ovulation, development of the corpus luteum). Progesterone deficiency leads to the development of hyperestrogenism and hyperplastic growth of the endometrium. Menopausal uterine bleeding in 30% develops against the background of menopausal syndrome.

Diagnostics

Features of the diagnosis of menopausal uterine bleeding lie in the need to differentiate them from menstruation, which at this age becomes irregular and occurs as metrorrhagia. To exclude the pathology that caused uterine bleeding, it is better to perform hysteroscopy twice: before and after diagnostic curettage.

After curettage, examination of the uterine cavity can reveal areas of endometriosis, small submucous fibroids, and uterine polyps. IN in rare cases The cause of uterine bleeding is a hormonally active ovarian tumor. Reveal this pathology allows ultrasound, nuclear magnetic or CT scan. Methods for diagnosing uterine bleeding are common to their different types and are determined by the doctor individually.

Treatment

Therapy for dysfunctional uterine bleeding during menopause is aimed at suppressing hormonal and menstrual functions, i.e., inducing menopause. Stopping bleeding during uterine bleeding during menopause is done exclusively surgically - through therapeutic and diagnostic curettage and hysteroscopy. Waiting 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 DMK

Prevention of dysfunctional 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 general strengthening and general health measures, prevention or timely treatment of diseases, especially the reproductive system, and prevention of abortions.

If dysfunction and uterine bleeding do develop, then further measures should be aimed at restoring the regularity of the menstrual cycle and preventing recurrent bleeding. For this purpose, the prescription of oral estrogen-progestin contraceptives is indicated according to the scheme: the first 3 cycles - from 5 to 25 days, the next 3 cycles - from 16 to 25 days of menstrual-like bleeding. Pure gestagenic drugs (Norkolut, Duphaston) are prescribed for uterine bleeding from the 16th to 25th day of the menstrual cycle for 4 to 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 form of infertility, endometrial adenocarcinoma, cancerous tumors mammary glands. Patients with dysfunctional uterine bleeding should be monitored by a gynecologist.

Abnormal uterine bleeding (AUB)

0 RUB

This is bleeding that differs from normal menstruation in duration and volume of blood loss and/or frequency. Normally, the duration of the menstrual cycle varies from 24 to 38 days, the duration of menstrual bleeding is 4-8 days, total blood loss ranges from 40 to 80 ml. In reproductive age, BUN is 10 - 30%, in perimenopause it reaches 50%.

AUB are one of the main causes of iron deficiency anemia and reduce the performance and quality of life of women. AUB ranks second among the reasons for hospitalization of women in gynecological hospitals and serves as an indication for 2/3 of hysterectomies and endometrial ablations.

Causes

The causes of AUB have age-related characteristics. In young girls, AUB is more often associated with hereditary disorders of the hemostatic system and infections. Approximately 20% of adolescents and 10% of women of reproductive age with heavy menstruation have blood diseases (coagulopathies), such as von Willebrand disease, thrombocytopenia, and less commonly, acute leukemia, and liver disease.

In reproductive age, the causes of AUB include organic disorders of the endo- and myometrium (submucous uterine fibroids, adenomyosis, polyps, hyperplasia and endometrial cancer), as well as inorganic pathology (disorders of the blood coagulation system, intrauterine devices, chronic endometritis, ovulatory dysfunction, medicines- some antibiotics, antidepressants, tamoxifen, corticosteroids). In many cases, the cause is endocrinopathies and neuropsychic stress (for example, polycystic ovary syndrome, hypothyroidism, hyperprolactinemia, obesity, anorexia, sudden weight loss or extreme sports training). “Breakthrough” bleeding while taking hormonal drugs is more often observed in smoking women, which is associated with a decrease in steroid levels in the bloodstream due to increased metabolism in the liver.

In perimenopause, AUB occurs against the background of anovulation and various organic pathologies of the uterus. With age, the likelihood of malignant lesions of the endo- and myometrium increases.

Clinical manifestations

Depending on the nature of the violations, there are various symptoms AMK:

Irregular, prolonged uterine bleeding (menometrorrhagia);

Excessive (more than 80 ml) or long periods(more than 8 days) at regular intervals of 24-38 days (menorrhagia (hypermenorrhea);

Irregular, intermenstrual bleeding from the uterus, usually (often not intense) (metrorrhagia);

Frequent menstruation less than 24 days apart (polymenorrhea)

Diagnosis of abnormal uterine bleeding

Examination by a gynecologist-endocrinologist, assessment of patient complaints. Many women misinterpret the amount of blood loss during menstruation. For example, 50% of women with normal menstrual blood loss complain of increased bleeding. In order to clarify the presence of AUB, the patient is asked the following questions:

A laboratory examination is necessary to determine the presence of anemia and hemostasis pathology. Transvaginal ultrasound of the pelvic organs is considered as diagnostic procedure 1st line for assessing the condition of the endometrium. Sonohysterography has high diagnostic significance; it is performed when transvaginal ultrasound is insufficiently informative to clarify focal intrauterine pathology. Hysteroscopy and endometrial biopsy continue to be considered as the “gold” standard for diagnosing intrauterine pathology, primarily to exclude precancerous lesions and endometrial cancer. It is recommended for suspected endometrial pathology, the presence of risk factors for uterine cancer (obesity, PCOS, diabetes mellitus, family history of colon cancer), in patients with AUB after 40 years.

MRI is recommended in the presence of multiple uterine fibroids to clarify the topography of the nodes before planned myomectomy, embolization uterine arteries, FUS ablation, as well as in cases of suspected adenomyosis or in cases of poor visualization of the uterine cavity to assess the condition of the endometrium.

Treatment methods for abnormal uterine bleeding

Treatment of AUB at the Center for Obstetrics, Gynecology and Perinatology named after. IN AND. Kulakov of the Ministry of Health of Russia is carried out on the basis of modern international and Russian clinical recommendations, in the development of which researchers took an active part Department of Gynecological Endocrinology. The principles of treatment for AUB pursue 2 main goals: stopping bleeding and preventing its relapse. In each specific case, upon appointment drug therapy Not only the effectiveness of the drugs is taken into account, but also possible side effects, the woman’s age, interest in pregnancy or contraception. For AUB not associated with organic pathology, they are used non-surgical methods treatment.

Article publication date: 06/28/2017

Article updated date: 12/21/2018

From this article you will learn about dysfunctional uterine bleeding. Similar diagnosis is among the top three in terms of visits to gynecologists in all countries of the world, along with vaginal discharge and pain syndrome. Today we will talk about the causes, nature, symptoms, diagnosis and treatment of this phenomenon.

Dysfunctional uterine bleeding, or DUB, is a wide group of uterine bleeding that, in terms of frequency, duration and volume of blood loss, exceeds the limits of normal menstruation in women of reproductive age (from 18 to 49 years). Modern medicine suggests using the term “abnormal uterine bleeding,” or AUB. If we are talking about such bleeding in adolescents under 18 years of age, then uterine bleeding is called juvenile uterine bleeding, or JUB. In older women on the threshold of menopause, uterine bleeding is called perimenopausal.

Click on photo to enlarge

The concept " normal menstruation“is extremely unsteady and subjective, it is difficult to place it in any rigid framework. The nature of menstruation changes throughout a woman’s life, depending on nationality and family history women.

On average, the concept of “normality” fits into the following framework:

• Regularity of menstruation - that is, a woman should be able to predict her menstruation.
• The duration of the menstrual cycle from the first day of the current and the first day of the previous menstruation takes from 21 to 35 days. The upper limit of this segment is arbitrary - sometimes in completely healthy women who have had successful pregnancies, the menstrual cycle takes 40–45 days or even more.
• The duration of menstrual bleeding is from 3 to 7 days.
• Blood loss during menstruation is about 80–100 ml, but this is the second extremely arbitrary value. Firstly, it is very difficult to measure the actual volume of blood. Secondly, menstrual blood consists not only of blood itself, but also of fragments of the uterine mucosa, fibrin clots, which form peculiar “clots” even with a small volume of menstruation.
• Menstruation should not bring a woman any physical or psychological discomfort. Pain syndrome is acceptable on the first day of menstruation in mild form, which does not require medication and does not interfere with a woman’s ability to work.

If we are talking about dysfunctional, or abnormal, uterine bleeding, then it is enough that at least one of the specified parameters does not fit into the specified framework. It is very important to take into account the presence and absence of ovulation, as well as a woman’s ability to conceive and carry a child. Therefore, conditionally, AUB of the reproductive period can be divided into:

• Ovulatory - that is, ovulation occurs during the cycle, and the woman is capable of conceiving.
• Anovulatory – for several consecutive cycles the process of releasing an egg does not occur, which is the cause of infertility in the patient.

Dysfunctional uterine bleeding can be a consequence of both gynecological diseases and systemic disorders of the body. It is important to understand that the source of such bleeding lies in the uterine cavity or cervix, without taking into account the causes in the vagina or lower sections genital area.

Some women for a long time They do not go to doctors, considering too frequent or heavy menstruation to be “the female part.” Others often end up in gynecological hospitals due to profuse and truly life-threatening bleeding. Still others suffer for a long time from prolonged “spotting” bleeding, which does not threaten the patient’s life, but significantly disrupts psychological and sexual comfort.

The disease can and should be cured completely, since AUB disrupts a woman’s quality of life and her psychological comfort. Treatment, its duration and nature directly depend on the root cause of bleeding, which we will talk about below.

The problem of abnormal uterine bleeding is dealt with directly by an obstetrician-gynecologist. In some cases, the gynecologist resorts to the help of endocrinologists, hematologists and even oncologists, depending on the initial cause of the condition.

Causes of abnormal uterine bleeding

So, we list the main causes of AUB in women of reproductive age.

Gynecological diseases

This is a broad group of diseases, including:

1. Inflammatory diseases of the genital area: salpingitis, salpingoophoritis, endometritis - disrupt the hormonal function of the ovaries and uterus, causing various options uterine bleeding. Very often combined with anovulation.
2. Volumetric formations of the uterus: fibroids, endometrial polyps, endometrial hyperplasia and internal endometriosis - adenomyosis. Ovarian function and ovulation in this case are most often preserved, but pregnancy may be absent for other reasons - unstable hormonal levels, deformation of the uterine cavity, endometrial deficiency.
3. Volumetric formations of the ovaries - cysts and tumors of various nature, including precancerous and cancerous.
4. Various diseases of the cervix - chronic cervicitis, cervical mass formations, precancerous and cancerous diseases of the cervix.
5. Malignant processes of the uterus and cervix are very, very often combined in abnormal bleeding, therefore, if there are such complaints, the first thing you need to do is carefully check and exclude oncological diseases.

Blood coagulation disorders

Uterine bleeding is stopped according to the same principles as all other bleeding. Therefore, any disturbances in the blood coagulation or hemostasis system clearly affect the nature of menstruation. We list the main disorders of the hemostatic system:

• Decreased platelet levels – thrombocytopenia. Platelet levels drop due to lack of folic acid, malnutrition, against the background of taking various antitumor drugs, antiviral drugs and some antibiotics. Thrombocytopenia also fits into various blood diseases - purpura, leukemia and others.
• Congenital blood diseases – various shapes hemophilia, deficiencies of blood clotting factors.
• Acquired disorders of the coagulation system - against the background of liver diseases, with autoimmune diseases.
• While taking certain medications - warfarin, heparin, aspirin and other non-steroidal anti-inflammatory drugs (ibuprofen, paracetamol) with regular use.

General hormonal imbalances

This is a very broad group of diseases of the endocrine system. Almost any hormone imbalance affects the most complex system regulation of the menstrual cycle – hypothalamic-pituitary-ovarian. Impaired ovarian function, lack of ovulation, and impaired endometrial maturation lead to changes in the nature of the menstrual cycle, infertility and the appearance of abnormal uterine bleeding. Often the appearance of dysfunctional uterine bleeding becomes the first sign and clinical manifestation violations hormonal levels. We list the most common pathologies:

Thyroid dysfunction

The thyroid gland can rightfully be called the “second heart” human body. It regulates almost all processes of the human body, including the reproductive and sexual spheres. Decreased hormone production thyroid gland(hypothyroidism) or its excessive function (hyperthyroidism) very often become the cause of AUB and infertility.

Luteal phase deficiency of the menstrual cycle, or LPF

NLF involves a lack of the hormone progesterone produced by yellow body ovary after ovulation. Progesterone supports the development of pregnancy and prepares the mucous membrane of the uterine cavity for the implantation of the embryo. With its deficiency, the endometrium does not develop properly and can be rejected without any system - abnormal uterine bleeding occurs. AUB can occur as a long-term “smear” or “breakthrough” uterine bleeding, which is difficult to stop.

Polycystic ovary syndrome, or PCOS

This is a complex complex hormonal disorder associated with increased levels of male sex hormones, impaired sugar metabolism and impaired ovarian function. The true nature of PCOS has not yet been studied, but abnormal uterine bleeding is included in the list of them. clinical symptoms. Their peculiarity in PCOS is “breakthrough” uterine bleeding against a background of prolonged bleeding - 60–90 days or more – delays in menstruation.

Ovulatory syndrome

This is minor bleeding observed in the middle of the menstrual cycle, against the background of the release of the egg from the ovary. Ovulatory syndrome is accompanied by pain in the lower abdomen, constipation, copious mucous discharge and sometimes the appearance of bloody discharge. This is due to a slight drop in estrogen levels at the time of ovulation.

Taking hormonal medications

This point can also be attributed to hormonal imbalances, since improper use or incorrect dosage of hormonal drugs can provoke abnormal uterine bleeding. Such situations occur while taking combined oral contraceptives, mini-pills, progesterone preparations, “pure” estrogens. All these conditions can be corrected by changing the dosage or replacing the drug.

Diagnostic measures

First of all, I would like to note that any, even the healthiest, woman may experience symptoms of AUB once or twice a year - a disruption of the menstrual cycle, heavy menstruation, intermenstrual bleeding. A woman’s body is not a robot; it experiences hormonal imbalances. It is worth seeking the help of a doctor if it is repeated systematically similar symptoms– more than twice a year.

We list the required minimum examinations and tests for initial diagnosis:

• General blood tests.
• Blood test for clotting.
• Hormonal panel for thyroid hormones and sex hormones.
• Ultrasound examination of the pelvic organs to exclude certain formations of the uterus, ovaries and uterine cavity.
• A chairside examination, assessment of the condition of the cervix, and taking cytological smears to exclude malignant and precancerous diseases of the cervix are mandatory.
• If there is any suspicion of abnormal processes in the ovaries, uterine cavity or cervix, invasive interventions are indicated - scraping, biopsy of the cervix, aspiration biopsy from the uterine cavity, culdocentesis, hysteroscopy to exclude oncological processes of the genital area.

Basic principles of treatment

As we have already mentioned, treatment for AUB directly depends on the underlying cause of this condition. Modern medicine has a large arsenal of means and methods for correcting this condition, so it is completely unacceptable to ignore dysfunctional uterine bleeding.

Basic principles of treatment include:

1. Correction of the blood coagulation system with donor platelets, the introduction of artificial blood coagulation factors, and drugs to correct hemostasis.
2. Correction of hormonal levels. Many women are terrified of the word “hormones,” but correctly prescribed hormonal drugs- This is a solution in many situations.
3. Surgical treatment of gynecological diseases - removal of polyps, myomatous nodes, foci of endometriosis.
4. Timely diagnosis and treatment of sexually transmitted infections, treatment and prevention of inflammatory processes in the genital area.
5. Normalization of lifestyle, proper nutrition, sexual culture, proper pregnancy planning and preparation for it.

Prognosis for the disease

The prognosis for abnormal uterine bleeding is favorable with timely diagnosis and treatment. The main objectives in this situation are to restore the quality of life, normalize the menstrual cycle and, most importantly, restore or preserve the reproductive potential of a woman.

Abnormal uterine bleeding is general term, which includes any discharge of blood from the reproductive organ that is not appropriate normal parameters menstruation of women of the reproductive period. This pathology is considered one of the most common in medical practice and demands the woman's immediate placement in medical institution. It is important to understand that the appearance of abnormal bleeding that occurs during the intermenstrual period poses a serious threat to female body.

Features of the pathology

If blood discharge does not correspond to normal menstruation, then experts talk about abnormal uterine bleeding. With this pathological condition of the female body, menstruation is released from the genital tract for a long period and in large quantities. In addition, such heavy periods cause exhaustion of the patient’s body and provoke the development iron deficiency anemia. Specialists are especially concerned about blood from the reproductive organ, which appears during the intermenstrual period for no reason.

In most cases, the main reason for the development of such pathological condition The patient's body becomes affected by hormonal changes. It is important that a woman can independently distinguish abnormal discharge from normal menstruation, which will help her promptly seek help from a specialist.

Young girls are often diagnosed with dysfunctional uterine bleeding, which is accompanied by menstrual irregularities. In patients of reproductive age, such discharge is often observed during the progression of various inflammatory processes and endometriosis in the body.

Dangerous to a woman’s health is the appearance of abnormal uterine discharge during menopause, when the functioning of the reproductive system has already ended and menstruation has completely stopped. In most cases, the appearance of blood is considered dangerous signal that a woman’s body progresses dangerous disease, and even oncology. Not the least important role in the development of this pathological condition is occupied by hormonal disorders that develop due to the influence of estrogens.

Experts classify abnormal uterine bleeding as the appearance of blood discharge due to a disease such as fibroids. With this pathology, menstruation becomes profuse and can occur in the middle of the menstrual cycle.

Types of pathology

Exists medical classification, which identifies several types of abnormal bleeding from the genital organ, taking into account the etiological factor:

1. Blood discharge that is associated with the pathological condition of the uterus. The reasons for the development of such uterine bleeding may be associated with pregnancy and cervical pathologies. In addition, such discharge develops as it progresses in the female body. various diseases the body of the reproductive organ and dysfunction of endometrioid tissue.
2. Bleeding from the uterus, which is in no way related to the pathological condition of the reproductive organ. The reasons for the development of such unpleasant condition may be different. This is the progression in the female body of various diseases of the appendages of the genital organ, ovarian tumors of various nature and premature puberty. A woman taking hormonal contraceptives. Frequent anovulatory bleeding
3. Abnormal discharge from the uterus that develops as a result of various systemic diseases. Most often, this pathological condition of the female body develops with pathologies of the circulatory and nervous system, as well as for disorders of the liver and kidneys.
4. Discharge of blood from the reproductive organ, which is closely related to iatrogenic factors. The reasons for the development of such a pathological condition of the female body are biopsies and cryodestruction. In addition, highlighting large quantity blood may be the result of taking neurotropic drugs and anticoagulants.
5. Abnormal bleeding from the uterus of unknown etiology

Taking into account the nature of the disorder, abnormal bleeding from the reproductive organ may have the following manifestations:

• Discharge of blood that begins with menstruation in required period or after a slight delay.
• The appearance within 1-2 months of minor bleeding or heavy blood loss, which provoke the development of anemia and require immediate medical attention.
• The appearance of discharge from the reproductive organ with clots, which can be large in size.
• The development of iron deficiency amenorrhea in a woman, which causes characteristic symptoms in the form of increased pallor of the skin and unhealthy appearance.

The development of any bleeding from the reproductive organ is considered a dangerous pathological condition of the female body, which can result in the death of the woman.

The specific treatment for this disease is determined by:

• The reasons that caused the appearance of blood from the reproductive organ.
• The degree of blood loss.
• General condition of the woman.

For abnormal discharge from the uterus, treatment is aimed at solving the following problems:

• Stopping further blood loss.
• Carrying out preventive measures to prevent relapse.

In order to find out the cause of bleeding, a specialist prescribes laboratory research and procedures such as colposcopy.

In medical practice they are used following methods helping to stop further development pathological state of the body:

• Carrying out surgical homeostasis, which is curettage of the uterine cavity.
• Purpose of hormonal homeostasis.
• Treatment with hemostatic agents.

About 65% of women of reproductive age go to antenatal clinics regarding bleeding from the genital tract. In fact, uterine bleeding is not a diagnosis, but a symptom that occurs in various obstetric, gynecological and other pathologies.

According to modern concepts, the term “dysfunctional uterine bleeding” is a thing of the past. Currently, all obstetrician-gynecologists in the world use the same terminology, according to which they now use a different name - abnormal uterine bleeding, or AUB.

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

Let us recall normal physiology.

Menarche (first menstruation) occurs on average at 12–14 years of age. After about 3–6 months, a normal menstrual cycle is established. It ranges from 21–35 days. Menstruation itself lasts from 3 to 7 days, blood loss ranges from 40 to 80 ml. Around 45–50 years of age, the menopause begins, which with the last menstruation passes into the period of menopause.

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

• During the formation of menstruation.
• Between menstruation.
• After a missed period.
• Lasting more than 7 days, with blood loss exceeding 80 ml.
• In menopause or menopause.

If you notice blood on your underwear, and your period should not appear yet, contact a specialist immediately. This may be a sign of serious pathologies.

Causes and classification

These classifications have been used since 2010 by all obstetricians and gynecologists in the world. Let's consider two modern classifications– by reasons of bleeding and by its types. The first classification was based on the causes of pathology:

1. AUB associated with pathology of the uterus and appendages.
2. AUB associated with disruption of the ovulation process.
3. AUB that occurs in various systemic pathologies (blood diseases, adrenal pathology, Cushing's disease or syndrome, hypothyroidism).
4. Iatrogenic forms of AUB, that is, associated with certain medical influences. For example, those arising as a result of disturbances in the hemostasis system (blood clotting) after or during taking a number of medications (anticoagulants, hormones, tricyclic antidepressants, tranquilizers, adrenal hormones, etc.). This group includes AUB that occurred after medical manipulations. For example, bleeding after taking a biopsy, after performing cryodestruction of hyperplastic endometrium.
5. AUB of unknown etiology (causes).

Finding out the causes of bleeding is the basis for choosing treatment tactics.

The second classification determines the types of uterine bleeding:

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

Obviously, the classification includes bleeding that originates only from the body, cervix and appendages. Bloody discharge in women from the vulva or vaginal walls does not apply to AUB.

Let's take a closer look at the causes of dysfunctional uterine bleeding.

Pathology of the uterus and appendages

Let us examine in more detail AUB that occurs in connection with diseases of the uterus.

Myoma nodes can be found directly in the body of the uterus, as the most common cause of bleeding. Other reasons include:

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

Internal bleeding with clots in women can occur with the following diseases of the cervix:

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

Causes also include cervical cancer. With this pathology, as a rule, there are contact bleeding, that is, occurring after sexual intercourse or douching.

Internal uterine bleeding can occur as a result of pregnancy complications. Spontaneous miscarriage placental polyp, ectopic pregnancy and placental abruption are accompanied by very significant blood loss with clots. Bleeding from the uterus may be a symptom of organ rupture due to the scar from surgery.

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

Ovulation disorders

Anovulatory uterine bleeding occurs after menarche, during the formation of menstruation. They are also possible during the perimenopausal period, when menstrual function is fading. If the ovulation process is disrupted, bleeding in reproductive women are also often observed in the practice of gynecologists.

Depending on the situation, the following may occur:

• Against the background of an absolute increase in estrogen levels, if a persistent follicle has arisen.
• Against the background of a relative increase in estrogen with a decrease in progestogen production (follicular atresia).

Clinical signs of these hormonal abnormalities appear in the form of follicular cyst and corpus luteum cyst.

Irregular periods with intervals of several months are characteristic of polycystic ovary syndrome.

While taking combined oral contraceptives (COCs), especially at the beginning of the course, breakthrough bleeding may occur. This is due to the fact that the body adapts to the formation of a thinner layer of the endometrium. That is why, at the end of the dose, it is not menstruation as such that will occur, but a more scanty menstrual-like reaction.

In other cases, the appearance of breakthrough bleeding indicates that there are signs of ineffectiveness of taking COCs. This is possible if a woman is simultaneously taking antibiotics or has suffered food poisoning during which she vomited.

In practice, there have been cases when the cause could be called smoking - this is how nicotine sometimes affects a woman’s body.

Systemic pathology

Signs of disturbances in the hemostatic system may appear even before the onset of menstruation. For example, after a tooth is removed, the hole bleeds for a long time, or the bleeding after minor injuries or cuts cannot be stopped for a long time. Usually one of the relatives experiences similar symptoms. Abnormalities in blood clotting factors are detected by detailed laboratory testing.

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

Iatrogenesis

This term refers to a negative impact on a patient's health as a result of a physician's actions. It would be completely wrong to understand it as a malicious act of a health worker. None of the doctors wants to harm the patient.

This situation can occur, for example, during a medical abortion in a woman who has given birth repeatedly and who has a history of many abortions, moreover complicated by endometritis. The fact is that the operation is performed blindly with a sharp instrument. And if the uterine wall is overly pliable and thin, perforation can occur, that is, damage to the uterine wall with access to the abdominal cavity. If large vessels are damaged during perforation, internal bleeding may occur.

Or another example. Doctor suspecting oncological process on the cervix, takes a piece of cervical tissue for histological examination, that is, simply plucks it off with a sharp instrument. Due to existing changes in the tissue of the affected cervix, the area from which the biopsy was taken may bleed for a long time with clots.

Treatment with digoxin, which is prescribed by a cardiologist according to indications, can also affect blood clotting. One of side effects will possible reduction platelet count.

Symptoms

Symptoms of bleeding depend on what is causing it. The main manifestation is bleeding outside or during menstruation.

The intensity of uterine bleeding may vary. There is often profuse bleeding with clots. Moreover, a woman’s subjective well-being depends not only on the amount of blood lost, but also on the speed and intensity of blood loss.

Profuse bleeding is dangerous because compensatory, defense mechanisms they don't have time to turn on. This poses a risk of developing hemorrhagic shock. Signs of shock:

1. Pallor skin, their coldness to the touch.
2. Weakness, up to loss of consciousness.
3. A sharp decrease in blood pressure with simultaneous tachycardia. The pulse is weak, thread-like.
4. In severe cases, urination is rare.
5. Hemoglobin and red blood cells are reduced.
6. The volume of circulating fluid is sharply reduced.

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

In less dangerous cases, bloody discharge from the genital tract of moderate intensity, sometimes with clots, is observed. In some situations, bleeding may be accompanied by pain.

During a spontaneous miscarriage, heavy bloody discharge with clots is accompanied by severe cramping pain. In case of interrupted ectopic pregnancy, against the background of a slight delay in menstruation and acute pain in the lower abdomen, there are signs of severe internal bleeding.

Internal bleeding is very dangerous for the patient's life. After a breakup in a pregnant woman fallopian tube V abdominal cavity There may be up to a liter of liquid blood with clots. In this case, emergency surgical treatment is indicated.

At premature detachment In a normally located placenta, there may be no external bleeding. If the abruption occurs in the central part of the placenta, then internal uterine bleeding occurs. That is, blood accumulates between the placenta and the wall of the uterus, saturating the latter. The so-called Cuveler's uterus appears. In this case, the doctor, in the interests of saving the mother’s life, is forced to send the patient to have the uterus removed.

Diagnostics

Determining the degree of blood loss, the level of decrease in hemoglobin, red blood cells, platelets, and the state of the coagulation system is relatively easy. To find out the reasons in order to prescribe the correct and timely treatment required additional methods research. First of all, this is a vaginal examination and examination of the cervix in the speculum, transvaginal ultrasound.

To confirm extragenital pathology, the following is required:

• Ultrasound of the thyroid gland, abdominal organs and retroperitoneal space.
• Biochemical tests.
• Study of hormone levels.
• Examination by other specialists.

It is also necessary to carefully study the data regarding the use of drugs that can cause disturbances in the hemostatic system, and family history to identify hereditary abnormalities of blood clotting. Information about obstetric and gynecological history and surgical interventions performed shortly before bleeding is very useful.

It is important to find out from the patient how the formation of menstruation proceeded, whether problems were noted during menstrual bleeding.

Treatment

Treatment has two goals: to stop the bleeding and to prevent relapse in the future. But before starting treatment, it is necessary to clearly determine its cause. Spontaneous miscarriage, placental polyp, formed myomatous node require surgical intervention. Ectopic pregnancy, uterine rupture, placental abruption, ovarian rupture or cysts - operations involving entry into the abdominal cavity.

Treatment of anovulatory AUB 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. In girls and young women, treatment should begin with non-hormonal treatment. To stop bleeding, therapy is carried out with antifibrinolytic drugs and non-steroidal anti-inflammatory drugs.

The “gold standard” in the prescription of antifibrinolytics is tranexamic acid. It suppresses the protein fibrinolysin, which interferes with normal blood clotting, making it more fluid. It also has anti-inflammatory, anti-allergic and analgesic effects, which is especially important during menstruation.

The drug is prescribed by a doctor, the regimen of use is individual. Treatment for more than 3 menstrual cycles is not recommended.

Nonsteroidal anti-inflammatory drugs have also proven themselves to be very positive in the treatment of AUB. Ibuprofen, Naproxen, Sulindac, and mefenamic acid have been successfully used. In addition to their anti-inflammatory effect, they reduce the volume of blood lost by inhibiting the synthesis of thromboxane and prostacyclin.

If during this stage it is not possible to achieve cessation of bleeding, then urgently resort to curettage of the uterine cavity or proceed to the second stage.

Stage II. Hormonal treatment

For young women, COCs with increased content estrogen (Desogestrel, Gestodene), sometimes combined with intravenous administration of estrogens. Progestins (Medroxyprogesterone, micronized progesterone Utrozhestan) are also prescribed according to indications.

In women who have given birth, you should start with curettage of the uterine cavity.

It has now been proven that oxytocin cannot stop bleeding.

Anti-relapse complex

Abnormal uterine bleeding may recur after treatment. That is why it is very important to carry out preventive treatment in time to prevent recurrence of AUB during the next menstruation. It includes the following activities:

1. General strengthening agents (iron supplements, vitamins).
2. Antifibrinolytic drugs (tranexamic acid, aminocaproic acid, vitamin C, zinc preparations).
3. Antiprostaglandin agents (mefenamic acid).
4. Stabilization of central nervous system function (Glycine, Trental, Cinnarizine).
5. Hormonal correction. Assignment in the 2nd phase: Marvelon, Regulon, Rigevidon. The gestagen Duphaston is also recommended (for ovulatory periods from 15 to 25 days, for anovulation from 11 to 25 days).
6. If pregnancy is not planned, then a COC with a reduced estrogen component is prescribed (for example, Tri-Mercy in a cyclic mode). If a woman wants to become pregnant in the near future, it is better to use the drug Femoston.

You can often read on forums: “No time to go to the doctor, bleeding for 10 days. Please advise what to drink." You are presented with many causes of AUB, and until the doctor makes a diagnosis, we categorically do not recommend using medications that helped stop the bleeding of a friend, neighbor, etc. Your visit to the doctor is mandatory!