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According to patient's age
The prolonged follicle persistence
Ovulatory dysfunctional uterine bleeding
According to hypogestageny type
According to hypergestageny type
The juvenile bleeding
Clinic and diagnostics
In patients with hypoestrogenic type
In patients with hyperestrogeny
Management of anaemia
Haemostasis by synthetic Progestins
Correcting hormone therapy
Principles of conservative treatment of dysfunctional uterine bleeding
Method of realization
2. Haemostasis by gestagens.
DISORDERS OF MENSTRUAL FUNCTION
Regulation of menstrual function is an extraordinarily complicated and intricate neurohumoral process, violation of which at any level (CNS — hypothalamus — hypophisis — ovaries — uterus) causes disorders of menstrual cycle in that or other form. Causes giving rise to menstrual function disorders, are nervous and mental affections, stresses, psychic traumas, sexual infantilism, serious and protracted chronic diseases, chronic intoxications, feeding violations (exhaustion or obesity), endocrine diseases, gynecological diseases.
CLASSIFICATION OF MENSTRUAL FUNCTION VIOLATIONS
Amenorrhea — absence of menses.
Violation of menses rhythm:
Change of blood amount, that exudes during menses:
Abnormal menses' duration:
Menorrhagia—the cyclic uterine bleeding, associated with menstrual cycle, lasting more than 12 days.
Methrorrhagia — acyclic uterine bleeding that is not associated with menstrual cycle.
There are distinguished hypomenstrual syndrome (opsomenorrhea, oligomenorrhea, hypomenorrhea) and the hypermenstrual syndrome (proiomenorrhea, hypermenorrhea, polymenorrhea).
According to the woman's age the bleeding is classified:
According to recurrence ovulative (cyclic, diphasic) disorders of menstrual cycle and anovulative (monophased).
A dysfunctional uterine bleeding (DUB) is the bleeding, not associated with organic diseases of women's genitals, interrupted pregnancy or systemic diseases of the organism. The dysfunctional uterine bleeding can appear at any age. Depending on the time of their onset juvenile bleeding (at child age and in period of pubescence), bleeding of reproductive period, climacteric bleeding are classified. DUB are the manifestations of initial stages of neuroendocrinological diseases, especially of blood diseases. Most frequently the dysfunctional uterine bleeding appear in young women during the formation of menstrual and reproductive function. In early reproductive phase as a damaging factor are frequently the situations, connected with mental and physical overload. Chronic stress and diseases of adaptation are the pathological background on which the lesions of hormonal status develop.
In women of reproductive age the basic cause of dysfunctional uterine bleeding are inflammatory diseases. Late reproductive phase, or premenopause, comes in women at the age over 35. At this age even moderate irritants, which earlier were not the reasons of menstrual function disorders, can become starting mechanism for development of cyclic system activity dysfunction.
Disease etiology is associated with unfavourable affects of environment, psychic stresses, lesions of the ovaries' and other endocrine glands function.
Dysfunction of hypothalamus-pituitary-ovaries-uterus system cause violation of follicle maturing. Depending on the fact that ovulation comes or not, the bleeding can be ovulative and anovulative.
Classification of dysfunctional uterine bleeding according to pathogeneses:
I. Ovulative (two-phased) according to the type of:
II. Anovulative (monophased) according to the type of:
According to onset time: cyclic (those, that come in term of next menses, but differ from it with amount of lost blood and duration); non-cyclic (appear out of menses or continue with interruptions during all the cycle).
^ : juvenile, of reproductive age, climacteric, menopausal bleeding.
Non-ovulate uterine bleeding
Follicle atresia is a disorder of menstrual cycle, that manifests in cyclic uterine bleedings through regular time intervals, but ovulations are absent. Follicle begins its development, reaches some maturity degree, but ovulation does not come, Luteal body does not appear, follicle undergoes reverse development. There is no regular hormones' excretion (oestrogens-progesteron), secretory changes do not come in endometrium. Disease is followed by hypoestrogeny.
Clinic. Menses loose regular rhythm, intensity and duration. In response to follicle atresia and decreasing of hormones amount, in 8-16 days after bleeding onset menstrual-like reaction comes. Its mechanism is connected with blood transsudation from superficial endometrium layer vessels, where hemorrhages and regions of necrosis appear. Absence of ovulation causes infertility, that is frequently a basic patients' complaint. The anovulate cycles can alternate with ovulate ones.
Diagnostics. For making diagnosis a continued observation of a woman and research of functional diagnostics tests indexes are necessary. Basal temperature is monophased, line is beneath 37°, the "fern" and "pupil" phenomena are weakly expressed or they are absent at all even in the middle of menstrual cycle. The colpocytological examination shows a moderate or insignificant saturation of organism with estrogens. The histological investigation proves that there are no secretory transformations of endometrium, uterine mucous membrane is in proliferation phase with tissue oedema.
Treatment. At lowered estrogen saturation the cyclic therapy with estrogens and gestagens for normalization of menstrual cycle and methods for ovulation stimulating are prescribed. The course lasts for 3-6 months.
^ (hemorrhage methropathy, Shredder's disease). It is developed as a result of extremely long follicle existence.
Pathogenesis. During first phase of menstrual cycle a follicle grows and develops for extremely long time. Ovulation does not come. Luteal body does not form. Tere is no progesterone production, that's why secretion phase in endometrium does not come. Follicle grows to significant size, sometimes a follicle cyst (a retentive formation 3 and more cm in diameter) is formed. This causes estrogens hyperproduction under the effect of which the pathological endomethrium proliferation with polyp excrescence phenomena takes place in uterus. As a result of endometrium thickening the destructive changes develop in it. Necrosis and irregular desquamation appear. They are accompanied by continued bleeding, because the absence of secretory changes in uterus does not allow the functional layer of endometrium to exfoliate, as it happens during normal menses. The histological picture shows the stagnant plethora with dilation of capillaries in endometrium, blood circulation is disturbed, vessels' permeability increases, tissual hypoxia and other dysmetabolic process develop.
Clinic. Basic sign of hemorrhage methropathy is bleeding after 1,5-2 months of amenorrhea. Period of amenorrhea corresponds to follicular development, and bleeding onset corresponds to the beginning of necrotic changes in endometrium. In such patients appears infertility, associated with absence of ovulation.
Diagnosis. Diagnosis is made on the basis of analyzing patient's complaints. For definition of hormonal status research of ovarian function: basal temperature is lower 37°, "fern" and "pupil" phenomena are positive during the whole period of amenorrhea without cyclic variations. Colpocytological researches show an excessive saturation of the organizm with estrogens, cary-opicnotic index is 60-80%. During investigation of hormones excretion with urine they find a considerable lowering of Pregnandiol excretion. During the histological research of endomethrium there is diagnosed absence of secretory transformations before expectative menses, uterine mucous membrane is in the phase of pathological proliferation, glandular-cystic hyperplasia of endometrium with necrosis, thrombosis and dystrophy phenomena is typical.
Treatment. Management the uterine bleeding arrest and normalization of menstrual cycle. Patient's age is taken into account while choosing the treatment methods. In reproductive age and in menopause treatment begins from uterine curretage. This operation has a diagnostic and medical sense, because abrasion of the mucous membrane arrests bleeding, and histological research allows to exclude malignant tumor as a bleeding source. The curretage day is conditionally considered the first day of artificially created menstrual cycle. Later the contra-inflammatoty treatment (for prevention of post-operative infection development in uterus) should be applied and menstrual cycle made regular. With this aim synthetic progestines during the three months period are taken.
According to hypoestrogeny type (shortening of the folliculin phase).
Bleeding appears as a result of defective follicle maturing, the first cycle phase is shortened, ovulation takes place on the 8-10th cycle day. Menstrual cycle is shortened to 2-3 weeks, amount of excretions can be enlarged (hypermenorrhea), menses duration can be usual or elongated up to 7-10 days. Reproductive function is present.
Treatment. Such patients usually do not need treatment. Sometimes at hyperpolymenorrhea uterotonics are prescribed.
^ . The second place of the cycle shortens, yellow body involutes prematury, owing this gestagens are produced in insufficient amount. The secretory changes of endometrium are also insufficiently expressed, that's why endometrium exfoliating is uneven.
Clinic. There are cyclic uterine bleedings, continued menses and the intervals between menses are shortened. Before menses there are greasing blood spots discharge. The reproductive function is lost, infertility develops.
Diagnosis. Basal temperature chart is diphasic. The first phase lasts for 2 weeks, the second one for 3-7 days.
Treatment. Progesterone 1ml of 1% solution for 5-6 days is prescribed in second phase of menstrual cycle. For yellow body functions enforcing vitamin E 50-60 mg and Ascorbic acid 0,5 g daily for 10 days are indicated.
^ . The first phase of menstrual cycle is of full value and is finished with ovulation. Luteal body is generated. It persists for a long period and excretes an excessive amount of Progesteron. The second phase lasts for 20-25 days. Total duration of menstrual cycle is 35-40 days. Menses delay for a long period, then bleeding begins. It is prolonged up to 2-4 weeks by reason of endometrium regeneration slowing.
Diagnosis. Basal temperature chart is diphasic, the second phase (hypertermic) lasts for a long time, the premenstrual lowering of temperature is absent. One should make a differential diagnostics with pregnancy interruption in early terms (test on pregnancy).
Treatment is begun from the uterine curretage. Histological research shows secretory transformation of endometrium. Estrogens from the 1st till the 25th cycle day, gradually decreasing a dose are indicated. Synthetic Progestines are taken according to the scheme.
Non-cyclic uterine bleeding, those appear in period of pubescence, are called "juvenile" or puberty ones. Their frequency rate is from 2,5% to 10%.
Etiology. Stress affects activation of the hypothalamus-pituitary-adrenal cortex system, secretion of Gonadoliberin and gonadotropic hormones is broken. Follicles persistence that leads to changing of sexual hormones production is developed.
If in the girl's organism there is a vitamin C deficiency, due to disbalanced diet, irregular feeding, it causes increasing of vessel walls permeability. Microcirculation and prostaglandin biosynthesis are failured. Owing this fact the blood fibrillation processes fails too.
Among the ethiological factors the infectious diseases, especially chronic tonsillitis is of a great importance. The tonsillogenous infection reduces immune reserve, influences on hypothalamic region and ovaries.
For contemporary conceptions pathogenesis of juvenile uterine bleeding is connected with synchronization violations of gonadotropic releasing factors' excretion in blood, which affect FSH and LH production disorders. This disturbs a mechanism of follicle maturing, ovulation and yellow body formation. The follicle development is by persistence or atresia type, that creates conditions for hyperplastic processes in endometrium. Bleeding appears as a reaction to decreasing of hormonal stimulation during the follicle regress.
Dysmetabolism appears in endometrium as a result of tissues hypoxia. There are dystrophic regions, necrosis with long and uneven exfoliating of endomethrium. It happens due to hardening of fibroid argirophil structure of uterine mucous membrane.
In patients with JUB not only the disorders of reproductive system are present, but the changes in hemostatic system are also frequently observed.
^ . The early beginning of pubescence and early menarche is typical, but from 15-16 years a level of sexual maturity according to signs complex is lower than in coevals. It is explained by the beginning of steroids' synthesis failure and increasing of androgens production with progressing of disease.
In many girls with juvenile uterine bleedings the fibrous-cystic mastopathy is found, that's why the examination of breasts in such patients is obligatory.
During the examination of external genitals its development is correct. ^ of bleeding mucous membrane is pale-pink, uterine cervix is conic in shape, "pupil" and "fern" symptoms are positive, bloody excretions are not significant and without mucus. During the rectal-abdominal examination uterine size corresponds to the age, an angle between the body and cervix is not expressed, ovaries are not palpated.
^ type of bleeding mucous membrane of vagina is pink coloured, the vaginal folds are well expressed, uterine cervix is cylindrical in shape, "pupil" and "fern" symptom +++ or ++++. There are plenty of bloody excretions with mucus admixtures. At rectal-abdominal examination uterus is slightly enlarged, an angle between its body and cervix is clearly expressed, ovaries may be enlarged comparing to the age norm. On sonogram the uterus exceeds an age norm, ovaries are considerably greater, than in coeval healthy girls, there are small cysts compartments in them. Estrogens secretion by urine is decreased, concentration of Progesterone in serum is also decreased. Hysteroscopy shows hyperplasy and polyps of endometrium, rough uterine contours.
Tests of functional diagnostics: monophased basal temperature chart, CPI is 50-80% due to hyperestrogeny type and 20-40% due to hypoestrogeny type.
Taking into account a presence of hyperplastic processes in uterus in majority of girls with JUB, there is a necessity of oncologic awareness, because the cases of endometrium cancer among the girls of 16-18 years are described. The indications owing to which uterine curretage is performed in girls, are only cases of vital necessity, are reconsidered, and now it is recommended to make a diagnostic uterine curretage in patients with recidivate JUB. For making the operation the special child speculum are used, hymen previously is injected all round by Lidase, general anesthesia is used for the operation. The blood coagulation system of the patient is estimated and she must be consulted in specialized stationary in haematologist for revealing of possible blood disease.
Treatment consists of:
General treatment starts from creation of favourable work and rest regimen, creation of physical and psychic calmness, correct feeding, rich in vitamins. There is prescribed Sodium bromide and Caffeine, small doses of tranquilizers. Among physiotherapy the most procedures effective are endonasal Calcium electrophoresis, Novocaine electrophoresis, vibrate massage of the paravertebral zones. They use reflexotherapy and laser accupuncture.
^ includes prescribing of ferrum preparations, vitamins of B group, Ascorutin, Folic acid.
Haemostatic effect is reached by using of 10% Calcium chloride solution intravenously, Pituitrin or Mammophysin 0,3-0,5 ml i/m 2-3 times a day during bleeding. For decreasing of blood loss they use fitopreparates — extract of Chamomile, viburnum, hydropepper.
Hormonal therapy is prescribed on condition that the symptomatic therapy is not effective. Estrogens or combined estrogen-gestagen remedies are indicated.
^ : 0,1% solution of Estradiol-dipropionate 1 ml intramuscularly in 3-4 hrs. or Folliculin 10 000-20 000 UA in 3-4 hrs are applied.
Haemostasis is gradual during 24 hours mainly. Abrupt preparations' cancellation can cause renewing of the bleeding, that's why an estrogens dose is gradually decreased, to 50% daily. In 5-6 days gestagens for 6-8 days are prescribed.
^ : monophasal estrogen-gestagen remedies (Bisecurin, Non-Ovlon, Ovulen) are taken in dose of 2-3 tabl. per day till the bleeding stops, then the dose to 1 tabl. daily is reduced. The medicine is used for 15-20 days more (1 tabl. per day). In 3-4 days after cancellation menstrual-like bleeding comes.
^ —uterine curretage is indicated in case of disease duration with frequent relapses for more than 2 years. It is a medically-diagnostic procedure allowing to achieve haemostasis and to examine the endomethrium (in general majority of patients its hyperplasy is found).
^ . Taking into account a hyperestrogenic type of bleeding with progesterone deficit and shortening of the luteal phase, for normalization of menstrual function gestagen preparations are indicated.
The mechanism of their action is based on gestagens ability to stimulate secretion phase in endomethrium and normal (desquamation of functional layer (gestagenic curettage). They use 17-hydroxyprogesterone-capronate 12,5% 1 ml intramuscularly once for 8 days before expectative menses. Such cure takes 3-4 months. After the treatment a FSH and LH correlation can adjust, ovulatory cycles can appear.
For renewing of normal menstrual function application of combined estrogen-gestagen preparations during 4-6 months is prescribed. They are used after hormonal or surgical haemostasis.
Action on central nervous system: work and rest order, that exclude a possibility of physical and mental overloading; psychotherapy, sedatives and vitamin therapy is prescribed.
Symptomatic therapy: uterotonics to arrest the bleeding and for 3 days after bleeding arrest — Gifotocin, Oxytocin, Pituitrin 0,5-1 ml i/m 2-3 times per day are used; Methylergomethrin 0,02% 1 ml i/m. Medicines there are strengthening vascular wall and improving blood coagulation should be taken: Calcium gluconate 0,5 g three times a day or Calcium chloride 10 ml of 10% solution i/v; ?-aminocapronic acid inside 0,1 g per kg of woman's body weight in 4 hrs. (10-15 g per day) during 3 days, on the 4th day they use 12 g, further accordingly 9,0; 6,0; 3,0 g per day; Dicinon in pills 0,5-0,75 ml per day or 1-2 ml of 12,5% solution; Rutin, Ascorutin, Ascorbic acid.
3. Antianaemic therapy: they take Ferrum tabulated preparations or Ferrum-Lek i/m or i/v; erythrocytes mass or fresh citrate blood is transfused when it is necessary.
Hormonal therapy. Its tasks:
1. Estrogens haemostasis.
Mechanism of action: due to injecting of big doses of Estrogens into organism, a suppression of Folithropin synthesis in pituitary gland; acceleration of endomethrium proliferation; decreasing of vascular walls permeability; retardation of fibrinolysis takes place by feed-back mechanism.
^ : necessity of using of comparatively big doses causes ovulation blockade; the so called "break bleeding" appear at fast dose decreasing.
Indications: DUB of juvenile and reproductive age by hypoestrogeny type; anaemia and necessity of fast haemostasis; any term and duration of bleeding.
^ : Folliculin on 0,1-0,2 mg each 3-4 hrs. inside; Folliculin 10,000-20,000 UA i/m in 3-4 hours; estradiol-dipropionate 0,1% solution 1 ml in 3-4 hours. Haemostasis comes in 24 hrs. After the bleeding arrest the preparation taking should be continued gradually decreasing the dose.
Mechanism of action is based on secretory transformation of endomethrium and desquamation of its functional layer ("medicinal", "hormonal curettage"); influence on vascular wall; increasing of platelets and Proconvertin amount.
Indications: short bleeding duration; absence of anemia and of immediate haemostasis necessity.
^ arrests bleeding or decreases ii after progesterone introducing for 3-5 days, then it is increased again and continues for 8-9 days. This is caused by hormone action mechanism. At first secretory transformation of endometrium takes place (in this time bleeding decreases or stops), and then there is desquamation of its functional layer (bleeding becomes stronger again).
^ : 1% solution of Progesterone 3-5 ml for 3 days; Pregnin 0,04 (2 tabl.) sublingually 3 times a day; Primoluton-depo, Primolut-Nor.
Disadvantages of the method: absence of fast haemostasis; impossibility of use for anaemic patients after prolonged bleeding.
Mechanism of action is caused by suppression of hypothalamus and pituitary gland function; blocking of follicle development in ovaries; antiestrogenic influence — suppression of proliferation in endomethrium; uterine vessels contracting; in myomethrium (increassing of contractive activity).
Indications: DUB of hyperestrogeny type in climacteric age; uterine bleeding with contra-indications for estrogens prescribing (tumor in anamnesis, uterine fibromyoma, mastopathy).
^ : Testosteroni propionas 1 ml of 1 % solution 2-3 times a day i/m during 2-3 days, then Progesterone 10 mg a day i/m during 6 days; Testosteroni propionas 1 ml of 5% solution 2 times per day i/m during 2-3 days, then dose is decreased to 2 times per week. Later they prescribe Methyltesto-sterone 15 mg per day during 2-3 months.
Disadvantages of the method: it can be used only for women at the age over 45 before the artificial menostase; long application gives virilyzing and anabolic effect.
Mechanism of action: blocking of hypothalamus-hypophysis system and decreasing of foliberin and luliberin secretion; continuated haemostatic effect is caused by action of estrogens and secretory transformations of endomethrium under the influence of gestagen component of the preparations.
Indications: DUB in any age period.
Method of realizing: one of monophase SPP is prescribed in dose of 1 tabl. in 3-4 hours for hemostasis, then during the 10 days the dose is decreased 1 tabl., daily up to 2 tabl. per day and later on the support dose should be 1 tabl. per day. Therapy course is 21 day from the reception of the first pill.
Disadvantages of the method: great amount of contra-indications (hormone sensitive tumors, acute liver and bilious pass ways diseases, acute trombophlebitis, tuberculosis, rheumatism, chronic renal diseases).
Mechanism of action is caused by estrogens effect (cause endomethrium proliferation) and gestagens effects (secretory transformation of endomethrium takes place).
Method of realizing: estradiol-dipropionate 0,1% solution 1 ml with 1 ml of 1% Progesterone solution in one syringe i/m for 3 days.
Mechanism of action is connected, except listed above effects, with progesterone-like influence of androgens on endometrium in big doses.
Indications: non-ovulative DUB with follicle persistence.
Method of realization: Synestrol 1 ml of 2% solution, 1 ml of 0,5% Progesterone and 1 ml of 5% Testosterone propionate solution i/m in one syringe. Cure course includes 4-10 injections done in a day.
^ : not high therapeutic effectiveness, frequent relapses, method is contra-indicated at DUB with follicle atresia in juvenile age and in young women.
Causes giving rise to pain during menses are various. Algodysmenorrhea can be a result of functional and organic causes. Uterine flexure, cicatrize changes causing cervical canal constriction are the organic causes breaking menstrual blood outfrow. Algodysmenorrhea is one of the symptoms of endomethriosis, genital infantilism, inflammatory processes in uterus and ovaries, abnormal uterine positions and genitals' tumors symptom. Painful menses are more frequent in girls and never delivered women, after the first delivery algodysmenorrhea disappears or pain becomes not such intensive.
Treatment should be etiopathogenetic, directed on removal of cause bringing the disease (resolvent, surgical, hormonal). If algodysmenorrhea is an infantilism manifestation the restorative cure, thermal procedures, hormonal therapy should be taken.
Symptomatic cure is the prescribing of spasmolytic remedies (Papaverin, No-spa, Baralgin) and analgetics. Sedatives are also recommended. They are Valerian, Sibasone, Magne-B6, Mesulidum.
|Topic: Disorders of the menstrual cycle. Neuroendocrine syndromes in gynecology||Module diseases of the newborn, blood disorders, and disorders of the endocrine system in children|
|Normal menstrual cycle||Acute appendicitis anatomy and function|
|Acute appendicitis anatomy and function|
move to 0-16988141
|Contents Clinical resarches|
|Local circulation disorders. Ischemia, infarction||Local disorders of circulation. Thrombosis. Embolism|
|Flow Chart Diagramme of Disorders of Puberty||Theme Mental disorders in vascular diseases|