The gynecologist is often faced with the task of diagnosis and treatment (AMC). Complaints about abnormal uterine bleeding(AUB) make up more than a third of all those presented during a visit to the gynecologist. The fact that half of the indications for hysterectomy in the United States are abnormal uterine bleeding (AUB) indicates how serious this problem can be.
Inability to detect any histological pathology in 20% of specimens removed during hysterectomy indicates that the cause of such bleeding may be potentially treatable hormonal or medical conditions.
Every gynecologist should strive to find the most appropriate, cost-effective and successful method of treating uterine bleeding (UB). Accurate diagnosis and adequate treatment depend on knowledge of the most probable causes uterine bleeding (UB). and the most common symptoms that express them.
Anomalous(AUB) is a general term used to describe uterine bleeding that goes beyond the parameters of normal menstruation in women of childbearing age. Abnormal uterine bleeding (AUB) does not include bleeding if its source is located below the uterus (for example, bleeding from the vagina and vulva).
Usually to abnormal uterine bleeding(AUB) refers to bleeding originating from the cervix or fundus of the uterus, and since they are clinically difficult to distinguish, both options must be taken into account in case of uterine bleeding. Abnormal bleeding may also occur in childhood and after menopause.
What is meant by normal menstruation, is somewhat subjective, and often differs from one woman to another, and even more so from one culture to another. Despite this, normal menstruation (eumenorrhea) is considered to be uterine bleeding after ovulation cycles, occurring every 21-35 days, lasting for 3-7 days and not being excessive.
The total volume of blood loss for normal menstrual period is no more than 80 ml, although the exact volume is difficult to determine clinically due to the high content of the rejected endometrial layer in the menstrual fluid. Normal menstruation does not cause serious pain and does not require the patient to change a sanitary pad or tampon more than once an hour. There are no visible clots in normal menstrual flow. Therefore, abnormal uterine bleeding (AUB) is any uterine bleeding that goes beyond the above parameters.
For description abnormal uterine bleeding(AMC) often use the following terms.
Dysmenorrhea is painful menstruation.
Polymenorrhea - frequent menstruation at intervals of less than 21 days.
Menorrhagia - excessive menstrual bleeding: the volume of discharge is more than 80 ml, the duration is more than 7 days. At the same time, regular ovulatory cycles are maintained.
Metrorrhagia is menstruation with irregular intervals between them.
Menometrorrhagia - menstruation with irregular intervals between them, excessive in volume of discharge and/or duration.
Oligomenorrhea - menstruation occurring less than 9 times a year (that is, with an average interval of more than 40 days).
Hypomenorrhea - menstruation, insufficient (scanty) in terms of the volume of discharge or its duration.
Intermenstrual bleeding is uterine bleeding between obvious periods.
Amenorrhea is the absence of menstruation for at least 6 months, or only three menstrual cycles per year.
Postmenopausal uterine bleeding is uterine bleeding 12 months after the cessation of menstrual cycles.
Such classification of abnormal uterine bleeding(AUB) can be helpful in establishing its cause and diagnosis. However, due to the variations in the presentation of abnormal uterine bleeding (AUB) and the frequent existence of multiple causes for a single clinical picture BUN is not sufficient to exclude a number of common diseases.
Dysfunctional uterine bleeding- an outdated diagnostic term. Dysfunctional uterine bleeding is a traditional term used to describe excessive uterine bleeding when uterine pathology cannot be identified. However, a deeper understanding of the issue of pathological uterine bleeding and the advent of improved diagnostic methods have made this term obsolete.
In most cases uterine bleeding, not related to uterine pathology, are associated with the following reasons:
chronic anovulation (PCOS and related conditions);
use of hormonal drugs (for example, contraceptives, HRT);
hemostasis disorders (for example, von Willebrand disease).
In many cases that in the past would have been classified as dysfunctional uterine bleeding, modern medicine, using new diagnostic methods, identifies uterine and systemic disorders of the following categories:
causing anovulation (for example, hypothyroidism);
caused by anovulation (in particular hyperplasia or cancer);
accompanying bleeding during anovulation, but can be either associated with abnormal uterine bleeding (AUB) or unrelated (for example, leiomyoma).
From a clinical point of view, treatment will always be more effective if it can be determined cause of uterine bleeding(MK). Because grouping different cases of uterine bleeding (UB) into one ill-defined group does not contribute to the diagnosis and treatment processes, the American Consensus Panel recently announced that the term “dysfunctional uterine bleeding” no longer appears necessary for clinical medicine.
Abnormal uterine bleeding
Relevance of the problem.
Classification of violations menstrual cycle.
Etiology.
Diagnostic criteria for NMC.
Tactics, principles of conservative and surgical treatment.
Prevention, rehabilitation.
In the basis of primary and secondary disorders of the menstrual cycle, the main role belongs to hypothalamic factors, according to the scheme: puberty is the process of establishing the rhythm of luliberin secretion from its complete absence (in premenarche), followed by a gradual increase in the frequency and amplitude of impulses until the rhythm of an adult woman is established. In the initial stage, the level of RG-GT secretion is insufficient for the onset of menarche, then for ovulation, and later for the formation of a full-fledged corpus luteum. Secondary forms of menstrual irregularities in women, occurring as corpus luteum deficiency, anovulation, oligomenorrhea, amenorrhea, are considered as stages of one pathological process, the manifestations of which depend on the secretion of luliberin (Leyendecker G., 1983). In maintaining the rhythm of HT secretion, the leading role belongs to estradiol and progesterone.
Thus, the synthesis of gonadotropins (GT) is controlled by hypothalamic GnRH and peripheral ovarian steroids through a positive and negative feedback mechanism. An example of negative feedback is the increased release of FSH at the beginning of the menstrual cycle in response to decreased estradiol levels. Under the influence of FSH, the growth and maturation of the follicle occurs: proliferation of granulosa cells; synthesis of LH receptors on the surface of granulosa cells; synthesis of aromatases involved in the metabolism of androgens into estrogens; promoting ovulation together with LH. Under the influence of LH, androgens are synthesized in the theca cells of the follicle; synthesis of estradiol in granulosa cells of the dominant follicle; stimulation of ovulation; synthesis of progesterone in luteinized granulosa cells. Ovulation occurs when the maximum level of estradiol is reached in the preovulatory follicle, which, through a positive feedback mechanism, stimulates the preovulatory release of LH and FSH by the pituitary gland. Ovulation occurs 10-12 hours after the LH peak or 24-36 hours after the estradiol peak. After ovulation, granulosa cells undergo luteinization to form the corpus luteum, under the influence of LH, which secretes progesterone.
Structural Formation of the corpus luteum is completed by the 7th day after ovulation, during this period there is a continuous increase in the concentration of sex hormones in the blood.
After ovulation, in phase II of the cycle, the concentration of progesterone in the blood increases 10 times compared to the basal level (4-5 days of the menstrual cycle). To diagnose reproductive function disorders, the concentration of hormones in the blood is determined in phase II of the cycle: progesterone and estradiol; the combined action of these hormones ensures the preparation of the endometrium for blastocyst implantation; sex steroid binding globulins (SSBG), the synthesis of which occurs in the liver under the influence of insulin, testosterone and estradiol. Albumin takes part in the binding of sex steroids. The immunological method for studying blood hormones is based on determining the active forms of steroid hormones that are not bound to proteins.
Abnormalities of menstrual function are the most common form of dysfunction of the reproductive system.
Abnormal uterine bleeding (AUB) is usually called any bloody uterine discharge outside of menstruation or pathological menstrual bleeding (more than 7-8 days in duration, more than 80 ml in terms of blood loss for the entire period of menstruation).
AUB can be symptoms of various pathologies of the reproductive system or somatic diseases. Most often, uterine bleeding is a clinical manifestation of the following diseases and conditions:
Pregnancy (uterine and ectopic, as well as trophoblastic disease).
Uterine fibroids (submucous or interstitial fibroids with centripital growth of the node).
Oncological diseases (uterine cancer).
Inflammatory diseases of the genital organs (endometritis).
Hyperplastic processes (endometrial and endocervix polyps).
Endometriosis (adeiomyosis, external genital endometriosis)
Use of contraceptives (IUD).
Endocrinopathies (chronic anovulation syndrome - PCOS)
Somatic diseases (liver diseases).
10. Blood diseases, including coagulopathy (thrombocytopenia, thrombocytopathy, von Willebrand disease, leukemia).
11. Dysfunctional uterine bleeding.
Dysfunctional uterine bleeding (DUB) - violations menstrual function, manifested by uterine bleeding (menorrhagia, metrorrhagia), in which no pronounced changes in the genitals are detected. Their pathogenesis is based on functional disorders of the hypothalamic-pituitary regulation of the menstrual cycle, as a result of which the rhythm and level of hormone secretion changes, anovulation and disruption of the cyclic transformations of the endometrium are formed.
Thus, DUB is based on a disturbance in the rhythm and production of gonadotropic hormones and ovarian hormones. DUB is always accompanied by morphological changes in the uterus.
DMC is always a diagnosis of exclusion
In the general structure of gynecological diseases, DMK accounts for 15-20%. Most cases of DUB occur 5-10 years before menopause or after menarche, when the reproductive system is in an unstable state.
Menstrual function is regulated by the cerebral cortex, suprahypothalamic structures, hypothalamus, pituitary gland, ovaries and uterus. This is a complex system with double feedback; for its normal functioning, the coordinated work of all links is necessary.
The main point in the mechanism of functioning of the endocrine system that regulates the menstrual cycle is ovulation; most DUBs occur against the background of anovulation.
DUB are the most common pathology of menstrual function, characterized by a recurrent course, leading to impaired reproductive function and the development of hyperplastic processes in the uterus and mammary glands. Recurrent DUBs lead to a decrease in social activity and a deterioration in a woman’s quality of life, accompanied by mental (neuroses, depression, sleep disturbances) and physiological abnormalities (headaches, weakness, dizziness due to anemia).
DMC are a polyetiological disease, which is a special type of response of the reproductive system to the influence of damaging factors.
Uterine bleeding, depending on the age of the woman, is distinguished:
1. Juvenile or pubertal bleeding - in girls during puberty.
2. Premenopausal bleeding at the age of 40-45 years.
3. Menopausal – 45-47 years;
4. Postmenopausal - bleeding in menopausal women a year or more after menopause, the most common cause is uterine tumors.
According to the state of menstrual function:
Menorrhagia
Metrorrhagia
Menometrorrhagia
Etiology and pathogenesis of DUB complex and multifaceted.
Causes of DMK:
psychogenic factors and stress
mental and physical fatigue
acute and chronic intoxications and occupational hazards
pelvic inflammatory processes
dysfunction of the endocrine glands.
In pathogenesis Uterine bleeding involves the following mechanisms:
1. violation of the contractile activity of the uterus with fibroids, endometriosis, inflammatory diseases;
disturbances in the vascular supply of the endometrium, the causes of which may be hyperplastic processes of the endometrium, hormonal disorders;
impaired thrombus formation in patients with defects in the hemostatic system, especially in the microcirculatory-platelet unit, with the formation of a smaller number of blood clots compared to normal endometrium, as well as as a result of activation of the fibrinolytic system;
Impaired endometrial regeneration due to decreased hormonal activity of the ovaries or due to intrauterine causes.
There are 2 large groups of uterine bleeding:
Ovulatory ( caused by a decrease in progesterone) . Depending on the changes in the ovaries, the following 3 types of DUB are distinguished:
A. Shortening the first phase of the cycle;
b. Shortening of the second phase of the cycle - hypoluteinism;
V. Extension of the second phase of the cycle - hyperluteinism.
Anovulatory uterine bleeding, caused by a decline in estrogen ( persistence of follicles and follicular atresia) .
Uterine bleeding always occurs against the background of a decline in the level of steroid hormones.
Clinic for ovulatory uterine bleeding:
maybe bleeding leading to anemia;
there may be bleeding before menstruation;
spotting after menstruation;
there may be spotting in the middle of the cycle;
miscarriage and infertility.
Dysfunctional uterine bleeding- bleeding due to pathology of endocrine regulation, not associated with organic causes, most often occurring in connection with anovulatory cycles (90% of DUB). Provided that at least 2 years have passed since menarche, regular menstrual cycles with heavy bleeding lasting more than 10 days are considered DUB; menstrual cycle less than 21 days and irregular menstrual cycle. As a rule, DUB is accompanied by anemia.
The frequency is 14-18% of all gynecological diseases. Predominant age: 50% of cases are over 45 years of age (premenopausal and menopausal periods), 20% are adolescents (menarche).
Etiology:
Spotting in the middle of the cycle is a consequence of decreased estrogen production after ovulation;
Frequent menstruation is a consequence of shortening the follicular phase, caused by inadequate feedback from the hypothalamic-pituitary system;
Shortening of the luteal phase - premenstrual spotting or polymenorrhea due to a premature decrease in progesterone secretion; the result of insufficiency of the functions of the corpus luteum;
Prolonged activity of the corpus luteum is a consequence of constant production of progesterone, which leads to prolongation of the cycle or prolonged bleeding;
Anovulation - excess production of estrogen, not associated with the menstrual cycle, not accompanied by the cyclic production of LH or the secretion of progesterone by the corpus luteum;
Other causes - damage to the uterus, leiomyoma, carcinoma, vaginal infections, foreign bodies, ectopic pregnancy, hydatidiform mole, endocrine disorders (especially dysfunction thyroid gland), blood dyscrasia. Pathomorphology. Depends on the cause of DMC. Pathohistological examination of endometrial preparations is mandatory.
Protocol code:
Abbreviations used in the protocol:
DUB - dysfunctional uterine bleeding
LH – luteinizing hormone
CNS - central nervous system
Ultrasound – ultrasound examination
ECG - electrocardiography
Date of development of the protocol: April 2013
Protocol users: obstetrician-gynecologists
Clinical picture
Symptoms, course
Diagnostic criteria: bleeding from the genital tract, anemia.
Complaints for bleeding from the genital tract, weakness, malaise
Physical examination: pale, sunken face, pointed nose, pale blue nails, anemic skin, tachycardia, sharp decline blood pressure, readiness for hemorrhagic shock.
Diagnostics
List of basic and additional diagnostic measures:
Basic diagnostic measures:
General blood test (6 parameters)- counting shaped elements blood detection of anemia
Determination of capillary blood clotting time
General urine analysis
Coagulogram (prothrombin time, fibrinogen, thrombin time, aPT, plasma fibrinolytic activity, hematocrit)- state of the blood coagulation system
Determination of total protein- blood biochemistry
Determination of glucose- blood biochemistry
Determination of bilirubin- state of liver function
Determination of creatinine- condition of the urinary system
Examination of smears for gonorrhea, trichomoniasis and yeast fungus- degree of vaginal cleanliness
Ultrasound of female genital organs— identification of space-occupying formations of the pelvic organs
ECG- state of the cardiovascular system
Consultation with an anesthesiologist— identification of the degree of anesthetic risk
Consultation with a general practitioner— identification of extragenital pathology
histological examination of scraping- tissue examination
Additional diagnostic measures:
Immunoradiometric determination of triiodothyronine, thyroxine or antibodies to thyroglobulin
Ultrasound of the thyroid gland- to exclude thyroid pathology
ELISA - HBsAg— Order of the Ministry of Health of the Republic of Kazakhstan No. 404 dated 08/15/97
Blood test for HIV— Order of the Ministry of Health of the Republic of Kazakhstan No. 575 dated 11.07.02
Immunoradiometric determination of cortisol, estradiol, progesterone or testosterone- hormonal status
Immunoradiometric determination thyroid-stimulating hormone - hormonal status
Consultation with a gynecological oncologist- exclusion of oncopathology
Minimum examination before hospitalization:
Wasserman reaction, HIV;
Determination of blood group and Rh factor, presence of antibodies;
General blood test (6 parameters);
General urine analysis;
Examination of smears for gonorrhea, trichomoniasis and yeast fungus;
- Ultrasound of the pelvic organs.
Differential diagnosis
Differential diagnosis:
- decubital ulcer;
- abortion;
- trophoblastic disease.
Treatment
Treatment goals: stopping bleeding from the uterus and vagina, normalizing the menstrual cycle.
Treatment tactics: All treatment methods are divided into conservative and surgical:
- Diagnostic hysteroscopy and curettage of the uterine cavity;
- Antianemic therapy;
- Hormone therapy.
Non-drug treatment: —
Drug treatment:
Clinical tactics:
This is a diagnosis of exclusion, referring to patients in whom organic causes of hemorrhage are not identified by conventional clinical and paraclinical methods. The main rule when conducting therapy is to proceed from the principle of a systematic approach to this problem: the need to restore the impaired cyclic regulation of the sexual cycle through a complex effect on the woman’s body as a whole, with an emphasis on individual primary or most affected parts. When carrying out treatment, the following fundamental accounting provisions must be observed:
1) the nature of the menstrual cycle disorders and the level of damage in the hypothalamus - pituitary gland - ovaries - uterus system;
2) age of the patient;
3) duration of the disease and duration of bleeding, severity of anemia;
4) the presence of concomitant extragenital diseases;
5) the period of the expected menstrual cycle.
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 comes menopause, which with the last menstruation enters 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 the causes of bleeding and by their types. The first classification was based on the causes of pathology:
- AUB associated with pathology of the uterus and appendages.
- AUB associated with disruption of the ovulation process.
- AUB that occurs in various systemic pathologies (blood diseases, adrenal pathology, Cushing's disease or syndrome, hypothyroidism).
- 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 manipulation. For example, bleeding after taking a biopsy, after performing cryodestruction of hyperplastic endometrium.
- 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 cervix:
- Atrophic cervicitis.
- Cervical erosion.
- Polyp of the cervical canal.
- Myomatous nodes located in the neck.
Causes also include cervical cancer. With this pathology, as a rule, there are contact bleedings, that is, those that occur 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. When the ovulation process is disrupted, bleeding in reproductive women is 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 the woman is simultaneously taking antibiotics or has had food poisoning, during which there was vomiting.
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 on 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. The doctor, suspecting an oncological process on the cervix, takes a piece of cervical tissue for histological examination, that is, he simply plucks it off with a sharp instrument. Due to existing changes in the tissues 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 the side effects will be a possible decrease in 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 and protective mechanisms do not have time to turn on. This creates a risk of developing hemorrhagic shock. Signs of shock:
- Pallor skin, their coldness to the touch.
- Weakness, up to loss of consciousness.
- A sharp decrease in blood pressure with simultaneous tachycardia. The pulse is weak, thread-like.
- In severe cases, urination is rare.
- Hemoglobin and red blood cells are reduced.
- 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 an interrupted ectopic pregnancy, against the background of a slight delay in menstruation and acute pain in the lower abdomen, signs of severe internal bleeding are observed.
Internal bleeding is very dangerous for the patient's life. After a pregnant fallopian tube ruptures in abdominal cavity There may be up to a liter of liquid blood with clots. In this case, emergency surgical treatment is indicated.
With premature abruption of 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 additional research methods are required. 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 cyst - 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 a high estrogen content (Desogestrel, Gestoden) are recommended, sometimes combined with IV 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 on time preventive treatment to prevent recurrence of AUB during the next menstruation. It includes the following activities:
- General strengthening agents (iron supplements, vitamins).
- Antifibrinolytic drugs (tranexamic acid, aminocaproic acid, vitamin C, zinc preparations).
- Antiprostaglandin agents (mefenamic acid).
- Stabilization of central nervous system function (Glycine, Trental, Cinnarizine).
- 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).
- 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!
DOI: 10.17749/2313-7347.2015.10.1.123-128
ABNORMAL UTERINE BLEEDING (AUB) - MODERN POSSIBILITIES FOR OPTIMIZING TREATMENT TACTICS
Tabakman Yu.Yu.1, Solopova A.G.1, Bishtavi A.Kh.2, Smirnova S.O.2., Kocharyan A.A.2
1GBOU VPO “First Moscow State Medical University named after IM. Sechenov" of the Ministry of Health of the Russian Federation, Moscow 2 State Budgetary Educational Institution of Higher Professional Education "Moscow State Medical and Dental University
them. A.I. Evdokimov" of the Ministry of Health of the Russian Federation
Abnormal uterine bleeding is one of the most common manifestations of diseases of the female genital organs and the cause of 2/3 of all hysterectomies. Moreover, the results of a study of surgical material show that in 40-69% of patients no organic changes are detected. In these cases, hysterectomy can be considered an unnecessary intervention, which leads to an unnecessary increase in the cost of treatment and the risk of complications. It seems important to determine the optimal volume of diagnostic procedures necessary to exclude and/or reduce the number of unnecessarily radical operations in patients with AUB, taking into account the modern nomenclature of AUB - “PALM-COEIN”.
Abnormal uterine bleeding, nomenclature and classification "PALM-COEIN", methods of diagnosis and treatment for AUB.
Article received: 01/15/2016; in revised form: 02/26/2016; accepted for publication: March 17, 2016 Conflict of interest
Tabakman Yu.Yu., Solopova A.G., Bishtavi A.Kh., Smirnova S.O., Kocharyan A.A. Abnormal uterine bleeding (AUB) - modern possibilities for optimizing treatment tactics. Obstetrics, gynecology and reproduction. 2016; 1: 123-128.
ABNORMAL UTERINE BLEEDING (AUB) - MODERN POSSIBILITIES OF OPTIMIZATION OF TACTICS OF TREATMENT
Tabakman Yu.Yu.1, Solopova A.G.1, Bishtavi A.Kh.2, Smirnova S.O.2, Kocharian A.A.2
1 First Moscow State Medical Sechenov University of the Ministry of Health Russian Federation
2 Moscow State University of Medicine and Dentistry
Abnormal uterine bleeding is one of the most frequent manifestations of diseases of female genital organs and cause 2/3 of all hysterectomies. The results of the study of the surgical specimens show that 40-69% of patients not detected no organic changes. In these cases, hysterectomy may be considered excessive interference that leads to an unjustified increase the cost of treatment and risk of complications. It is very important to determine the optimal volume of diagnostic procedures necessary to exclude and/or reduce the number of unnecessarily radical surgery in patients with AUB according to the modern nomenclature AUB.
Abnormal uterine bleeding, nomenclature and classification of causes of abnormal uterine bleeding "PALM-COEIN", methods of diagnosis and treatment at AUB.
Received: 01/15/2016; in the revised form: 02/26/2016; accepted: 03/17/2016. Conflict of interests
The authors declared that they do not have anything to disclose regarding funding or conflict of interests with respect to this manuscript.
All authors equally contributed to this article. For citation
Tabakman Yu.Yu., Solopova A.G., Bishtavi A.Kh., Smirnova S.O., Kocharian A.A. Abnormal uterine bleeding (AUB) - modern possibilities of optimization of tactics of treatment. Akusherstvo, ginekologiya i reproduktsiya / Obstetrics, gynecology and reproduction. 2016; 1: 123-128 (in Russian).
Corresponding author
Address: ul. Baumanskaya, 17/1, Moscow, Russia, 105005. E-mail address: [email protected](Tabakman Yu.Yu.).
Abnormal uterine bleeding (AUB) is a common gynecological condition that represents one of the most common reasons for hospitalization and often requires surgical treatment. At the same time, the results of a study of surgical material show that in 40-60% of patients no organic changes are detected. This is a consequence of an insufficiently complete examination to determine the causes of AUB. In these cases, hysterectomy can quite reasonably be considered an overtreatment, which is associated with the risk of complications and an unjustified increase in the cost of treatment. Therefore, an urgent task is to develop standards for examination and treatment of patients with AUB. Until recently, solving this problem was complicated by the lack of a unified terminology and a universal classification system for the causes of uterine bleeding.
In 2011, an international expert group under the auspices of FIGO proposed to adopt as a formal agreement new system nomenclature of abnormal uterine bleeding in non-pregnant women of reproductive age. This
"PALM-COEIN" (The FIGO systems for nomenclature and classification of causes of abnormal uterine bleeding in the reproductive years). The system is approved by the FIGO Executive Committee and the American College of Obstetricians and Gynecologists (ACOG), and is already used in many European countries and the USA. The classification system of the causes of abnormal uterine bleeding in non-pregnant women of reproductive age makes it possible to distribute them according to their nature and etiology. The term “AUB” includes heavy menstrual bleeding, formerly called menorrhagia, and inter menstrual bleeding, formerly called metrorrhagia/menometrorrhagia.
According to etiology, nine main categories of uterine bleeding are identified: polyp; adenomyosis (adenomyosis); leiomyoma (leiomyoma); malignancy (malignancy) and hyperplasia (hyperplasia); coagulopathy (coagulopathy); ovulatory dysfunction (ovulatory dysfunction); endometrial (endometrial); iatrogenic (iatrogenic); notyetclassified (not yet classified). The abbreviation “PALM-COEIN” is made up of the first letters of the listed categories. This classification system allows you to reflect
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To consider either a single cause of AUB or a combination of them, the presence of any category is indicated by the number 1, the absence - 0. The first four categories, combined into the PALM group, reflect organic or structural changes that can be assessed using imaging methods and (or) histopathology . The leiomyoma category (L) is divided into two - submucous leiomyoma (LSM) and other forms of fibroids that do not distort the uterine cavity (L0). For this category of patients, in most cases, various types of surgical interventions are used, including hysterectomy. Other possible etiological factors are included in the COEIN group. It consists of four categories organic reasons uterine bleeding that cannot be objectified by morphological characteristics, and one category characterizing disorders that are rare and not yet classified. Example: Abnormal uterine bleeding caused by an endometrial or endocervical polyp is classified as “AUB-P.” Endometrial hyperplasia and cancer (AUB-M) are important causes of AUB, for which the generally accepted WHO or FIGO classifications should be used to assess the type of endometrial hyperplasia or the stage of endometrial cancer.
It is clear that uterine bleeding in postmenopausal women, by definition, is always abnormal, since at this age there cannot be physiological (menstrual) bleeding. Therefore, all examination methods aimed at elucidating the pathogenetic mechanisms of bleeding should be relegated to the background. The first task is a morphological (histological, cytological) examination of the endometrium in order to exclude endometrial cancer. The PALM-COEIN classification does not apply during menopause.
Determining the necessary (optimal) volume of diagnostic procedures to exclude and/or reduce the number of unnecessarily radical operations in patients with AUB is an urgent task. In a number of publications, the problem is considered in two directions: on the one hand, it is reducing the risk of complications and side effects during treatment, and on the other hand, reducing financial costs. Thus, the paper presents data from detailed studies in the USA, Germany, Great Britain, and the Netherlands, devoted to the cost-effectiveness of various combinations and sequence of use of transvaginal ultrasound, ultrasound liquid hysterography, hysteroscopy and endometrial biopsy for AUB. Of the ultrasound techniques, liquid (infusion) ultrasound hysterography is recognized as the most accurate. According to the study, the sensitivity and specificity of transvaginal ultrasonography were 44.4 and 25%; infusion sonohysterography - 88.8 and 60.7%; outpatient hysteroscopy - 100 and 77.7%, respectively
really. Thus, infusion sonohysterography is significantly more accurate than transvaginal ultrasound examination and is comparable in accuracy to hysteroscopy.
BE was considered the most effective as the main test in both parameters (cost and information content) (level of evidence 1). This refers to the establishment (or exclusion) of endometrial hyperplasia and cancer. It is clear that further diagnostic measures are required to establish other causes of AUB. First of all, this applies to the so-called structural disorders, grouped under the PALM category: polyps, adenomyosis, leiomyoma. These abnormalities are clearly identified using ultrasound and hysteroscopy. As a result of a full examination, conditions are created for optimal treatment. Even in the recent past, when ultrasound and hysteroscopy were not widely introduced into practice, the usual tactic for re-detecting endometrial polyps was to perform a hysterectomy. In this case, the preoperative diagnosis was formulated as “recurrent polyposis, suspicion of endometrial cancer.” In fact, there was not a relapse (as in the re-emergence of a polyp), but a continued growth of the polyp, which was not completely removed during diagnostic curettage. Currently, endometrial polyps are easily identified and radically removed using hysteroscopy. If, during examination in connection with AUB, hyperplasia and RE are excluded, and the main cause of AUB is adenomyosis (AUB-A), then conservative treatment is carried out: hormone therapy with progestins, gonadotropin-releasing hormone agonists, COCs. The most effective use of progestin therapy is in the form of a levonorgestrel-releasing intrauterine system (LNG-IUS). This significantly reduces blood loss, and side effects minimal. In some cases (with contraindications to hormone therapy), minimal surgical intervention in the form of endometrial ablation is possible, and the reason for radical surgical intervention in the amount of hysterectomy rarely arises. For AUB caused by uterine leiomyoma (AUB-L), it is also possible to reduce the number of radical operations due to hysteroscopic and laparoscopic resection of myomatous nodes, embolization of the uterine arteries, blocking menstrual function using hypothalamic releasing hormones, and the use of progesterone modulators.
Among the causes of AUB from the COEIN category, a factor such as coagulopathy (AUB-C) is rarely diagnosed in practice, although this disorder is the main cause of heavy menstrual bleeding in 20% of patients. adolescence and in 10% of women of reproductive age. Higher frequency values for this factor are also given. Thus, researchers have found that in juveniles the cause of heavy menstrual bleeding is
regardless of the time of their first manifestation - up to two years from menarche or later, in 48% of observations various hemostatic disorders appeared, mainly platelet dysfunction (18%), von Willebrand disease (13%), deficiency of coagulation factors (12%). The frequency of these disorders did not depend on the timing of the onset of AUB from the moment of menarche. The data obtained are, according to the authors, a convincing basis for screening to identify disorders of the blood coagulation system when AUB occurs. If the nature of the hemostasis disorder is established, pathogenetic treatment can be prescribed and, thus, neither hormonal therapy nor surgical treatment will be required, which in this situation would be redundant interventions. According to R.A. Saidova and A.D. Makatsaria, based on 20 years of research, it has been established that more than half of patients suffering from AUB have congenital and/or acquired disorders of the hemostatic system with a tendency to hemorrhages (51-73%), with more than 75% being thrombocytopathies. In patients with dysfunctional uterine bleeding (AUB-O), the frequency of such disorders was: during puberty 65%, in the early reproductive period - 71.4%, in the older reproductive period - 41%. Disturbances of the hemostatic system of a hemorrhagic nature are also detected in patients with various gynecological pathologies: in patients with uterine fibroids - in 60.6% of cases; in patients with hyperplastic processes of the endometrium - in 63.3%, in patients with combined gynecological pathology - in 52.2%, in patients with endometritis - in 68.8% of observations. Only combination therapy, combining individually selected hormone therapy and nonspecific hemostatic therapy, allows not only to stop uterine bleeding, but also to restore menstrual function and significantly improve the quality of life of women at different age periods.
IN last years a subcellular component of the hemostatic process was established - cellular microvesicles - carriers of phosphatidylserine for the assembly of tenase and thrombinase complexes of the blood coagulation system, tissue factor. Microvesicles are released during activation and apoptosis of the endothelium of blood vessels and blood cells and contribute to an enhanced procoagulant effect during the initiation of blood clotting. It has been established that the intensity of microvesiculation in the blood changes cyclically, reaching a maximum in the luteal phase. An increased level of microvesicles in uterine blood reflects the process of local activation of hemostasis. Increased systemic and local levels of microvesicles correspond to an adaptive response and normalize after stopping bleeding with non-hormonal means. Reduced levels of microvesicles
corresponds to maladaptation with a tendency to normalization after stopping bleeding with hormonal agents.
Ovulatory dysfunction (AUN-O) may be associated with dysfunction of the corpus luteum. Common causes of AUB are endocrinopathies and central nervous system disorders (polycystic ovary syndrome, hypothyroidism, hyperprolactinemia, mental stress, obesity, anorexia, sudden weight loss or extreme sports training). The optimal invasive intervention may be an outpatient endometrial biopsy to exclude AUB-M, given that AGE and RE can also cause AUB in women of reproductive age. After this, additional research methods are carried out and appropriate methods of conservative therapy are prescribed.
Endometrial dysfunction (AUB-E) can be caused by various local deviations from the normal mechanisms of angiogenesis, molecular mechanisms of endometrial regeneration, inflammatory changes, and the state of hormonal receptors. Category AMK-E can be assumed after excluding other objectively detectable disorders. In cases where the bleeding is not health-threatening, non-hormonal agents such as NSAIDs (mefenamic acid 250-500 mg 3-4 times a day, ibuprofen 200-400 mg 3-4 times a day) can be used. antifibrinolytics, for example, tranexamic acid (250-500 mg per day for 4-5 days), which leads to a significant reduction in blood loss during heavy menstruation and a complete cessation of spotting not associated with menstruation (intermenstrual, postmenopausal) .
Iatrogenic causes (AUB-1) of abnormal uterine bleeding include all cases where the appearance of AUB is clearly associated with the use of drugs (hormonal drugs, anticoagulants, antibiotics or antitumor chemotherapy drugs), as well as intrauterine devices. When making adjustments to treatment tactics, all aspects of quality of life should be taken into account, since cancellation of treatment may have more serious negative consequences than the complication that has arisen - for example, in the form of minor bleeding.
The category “Unclassified abnormal uterine bleeding (AUB-M)” means that currently standard research methods do not allow AUB to be classified into the categories listed above. As new data are obtained through specific biochemical or molecular genetic studies, additional categories of AUB may be established and methods of their pathogenetic therapy may be proposed. Currently, after excluding organic causes of AUB, drug treatment is prescribed. For women of reproductive age, the goal of therapy is
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is not only a reduction in blood loss during menstruation, but also regulation of the menstrual cycle and restoration of reproductive function. In this case, NSAIDs, fibrinolysis inhibitors and drugs that reduce vascular fragility are used. Of the hormonal methods, both systemic use (COCs according to the contraceptive scheme) and in the form of an intrauterine system that releases levonorgestrel (LNG-IUS) is recommended.
In case of recurrent uterine bleeding and the presence of contraindications to hormonal therapy effective method The treatment is endometrial ablation. An indispensable condition for its implementation is the reliable exclusion of malignant changes in the genital organs. No matter how small the probability of developing EC after endometrial ablation is, it is still higher than the risk
RE in the population. Therefore, all patients with AUB after treatment should be under controlled clinical observation, the nature (scope of research) of which depends on the achieved results of the treatment, as well as on the nature of the pathological changes that caused AUB. Particular caution should be exercised in cases where patients had endometrial hyperplasia. In addition to gynecological examination and pelvic ultrasound, sono-hysterography, aspiration biopsy of the endometrium, and hysteroscopy with targeted biopsy of the endometrium are used, according to indications.
In general, it can be stated that modern methods diagnosis and treatment of AUB can significantly reduce the number of unnecessary, unnecessarily aggressive interventions in the treatment of AUB, in particular, in the scope of hysterectomy.
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to o i-2 to ■ x th a X
Tabakman Yuri Yuryevich - MD, professor, Honored Doctor of the Russian Federation, radiologist of higher education qualification category, manager laboratory of radioisotope diagnostics of the Oncological clinical dispensary No. 1 of the Moscow Health Department. Address: st. Baumanskaya, 17/1, Moscow, Russia, 105005. Tel.: +74992676672. Email: [email protected].
Solopova Antonina Grigorievna - Doctor of Medical Sciences, Professor of the Department of Obstetrics and Gynecology of the Medical and Preventive Faculty of the First Moscow State Medical University named after. THEM. Sechenov. Address: st. Zemlyanoy Val, 62, building 1, Moscow, Russia, 109004. E-mail: [email protected].
Bishtavi Alla Khaled - Candidate of Medical Sciences, Assistant at the Department of Obstetrics and Gynecology, Moscow State Medical and Dental University. A.I. Evdokimov. Address: st. Delegatskaya, 20, building 1, Moscow, Russia, 127473. E-mail: [email protected].
Smirnova Svetlana Olegovna - Candidate of Medical Sciences, Associate Professor of the Department of Obstetrics and Gynecology of the Moscow State Medical and Dental University. A.I. Evdokimov. Address: st. Delegatskaya, 20, building 1, Moscow, Russia, 127473. E-mail: [email protected]
Kocharyan Asiya Avetisovna - Candidate of Medical Sciences, Assistant of the Department of Obstetrics and Gynecology of the Moscow State Medical and Dental University named after. A.I. Evdokimov. Address: st. Delegatskaya, 20, building 1, Moscow, Russia, 127473. E-mail: [email protected]
About the authors:
Tabakman YuriyYuryevich - MD, professor, Honored Doctor of the Russian Federation, radiologist of the highest qualification category, manager radioisotope laboratory diagnostics, Cancer clinical dispensary No. 1 Department of Health of Moscow. Address: ul. Baumanskaya, 17/1, Moscow, Russia, 105005. Tel.: +74992676672. Email: [email protected].
Solopova Antonina Grigorievna - MD, professor of the Department of Obstetrics and Gynecology, Faculty of Medical and Preventive Medicine First Moscow Medical Sechenov University. Address: ul. Zemlyanoi Val, 62-1, Moscow, Russia, 109004. E-mail: [email protected].
Bishtavi Alla Khaled - PhD of medical sciences, Assistant Professor, Department of Obstetrics and Gynecology, Moscow State University of Medicine and Dentistry. Address: ul. Delegatskaia, 20/1, Moscow, Russia, 127473. E-mail: [email protected]
Smirnova Svetlana Olegovna - PhD of medical sciences, Associate Professor, Department of Obstetrics and Gynecology, Moscow State University of Medicine and Dentistry. Address: ul. Delegatskaia, 20/1, Moscow, Russia, 127473. E-mail: [email protected]
Kocharian Asia Avetisovna - PhD of medical sciences, Assistant Professor, Department of Obstetrics and Gynecology, Moscow State University of Medicine and Dentistry. Address: ul. Delegatskaia, 20/1, Moscow, Russia, 127473. E-mail: [email protected].
