Causes, symptoms and treatment of uterine bleeding. Abnormal uterine bleeding during puberty: definition and management tactics (literature review) Abnormal bleeding during puberty

Puberty uterine bleeding (PUB) - functional disorders that arise during the first three years after menarche, caused by deviations in the coordinated activity of functional systems that maintain homeostasis, manifested in the disruption of correlations between them under the influence of a complex of factors.

SYNONYMS

Uterine bleeding during puberty, dysfunctional uterine bleeding, juvenile uterine bleeding.

ICD-10 CODE
N92.2 Heavy menstruation during puberty (heavy bleeding with the onset of menstruation, pubertal cyclic bleeding - menorrhagia, pubertal acyclic bleeding - metrorrhagia).

EPIDEMIOLOGY

The frequency of manual transmission in the structure of gynecological diseases of childhood and adolescence ranges from 10 to 37.3%.
Manual transmission is a common reason why teenage girls visit a gynecologist. They also account for 95% of all uterine bleeding during puberty. Most often, uterine bleeding occurs in teenage girls during the first three years after menarche.

SCREENING

It is advisable to screen the disease using psychological testing among healthy patients, especially excellent students and students of institutions with a high educational level (gymnasiums, lyceums, professional classes, institutes, universities). The risk group for the development of manual transmission should include adolescent girls with deviations in physical and sexual development, early menarche, and heavy menstruation with menarche.

CLASSIFICATION

There is no officially accepted international classification of manual transmission.

Depending on the functional and morphological changes in the ovaries, the following are distinguished:

• ovulatory uterine bleeding;
• anovulatory uterine bleeding.

During puberty, anovulatory acyclic bleeding is most common, caused by atresia or, less commonly, persistence of follicles.

Depending on the clinical characteristics of uterine bleeding, the following types are distinguished.

• Menorrhagia (hypermenorrhea) is uterine bleeding in patients with a preserved menstrual rhythm, with bleeding lasting more than 7 days and blood loss exceeding 80 ml. In such patients, a small number of blood clots are usually observed in heavy bleeding, the appearance of hypovolemic disorders on menstrual days and signs of moderate to severe iron deficiency anemia.
• Polymenorrhea is uterine bleeding that occurs against the background of a regular shortened menstrual cycle (less than 21 days).
• Metrorrhagia and menometrorrhagia are uterine bleeding that does not have a rhythm, often occurring after periods of oligomenorrhea and characterized by periodic increased bleeding against the background of scanty or moderate blood discharge.

Depending on the level of estradiol concentration in the blood plasma, manual transmissions are divided into the following types:

• hypoestrogenic;
• normoestrogenic.

Depending on the clinical and laboratory characteristics of manual transmission, typical and atypical forms are distinguished.

ETIOLOGY

MCPP is a multifactorial disease; its development depends on the interaction of a complex of random factors and the individual reactivity of the organism. The latter is determined by both the genotype and the phenotype, which is formed during the ontogenesis of each person. Conditions such as acute psychogenia or prolonged psychological stress, unfavorable environmental conditions in the place of residence, and hypovitaminosis are most often cited as risk factors for the occurrence of manual transmission. Trigger factors for manual transmission can also be nutritional deficiency, obesity, and underweight. It is more correct to regard these unfavorable factors not as causal, but as provoking phenomena. The leading and most likely role in the occurrence of bleeding belongs to various types of psychological overload and acute psychological trauma (up to 70%).

PATHOGENESIS

An imbalance of homeostasis in adolescents is associated with the development of nonspecific reactions to stress, i.e. some circumstances (infection, physical or chemical factors, socio-psychological problems) leading to tension in the body’s adaptive resources. As a mechanism for the implementation of the general adaptation syndrome, the main axis of hormonal regulation - “hypothalamus-pituitary-adrenal glands” - is activated. A normal adaptive response to changes in the external or internal environment of the body is characterized by a balanced multiparametric interaction of regulatory (central and peripheral) and effector components of functional systems. The hormonal interaction of individual systems is ensured by correlations between them. When exposed to a set of factors that exceed the usual conditions of adaptation in intensity or duration, these connections may be disrupted. As a consequence of this process, each of the systems that ensure homeostasis begins to work to one degree or another in isolation and afferent information about their activity is distorted. This in turn leads to disruption of control connections and deterioration of effector mechanisms of self-regulation. And finally, the long-term low quality of the self-regulation mechanisms of the system, which is the most vulnerable due to any reasons, leads to its morphofunctional changes.

The mechanism of ovarian dysfunction is inadequate stimulation of the pituitary gland by GnRH and can be directly related to both a decrease in the concentration of LH and FSH in the blood, and a persistent increase in LH levels or chaotic changes in the secretion of gonadotropins.

CLINICAL PICTURE

The clinical picture of manual transmission is very heterogeneous. Manifestations depend on what level (central or peripheral) the violations of self-regulation occurred.
If it is impossible to determine the type of manual transmission (hypo, normo or hyperestrogenic) or there is no correlation between clinical and laboratory data, we can talk about the presence of an atypical form.

In the typical course of manual transmission, the clinical picture depends on the level of hormones in the blood.

• Hyperestrogenic type: outwardly, such patients look physically developed, but psychologically they can show immaturity in judgments and actions. Distinctive features of the typical form include a significant increase in the size of the uterus and the concentration of LH in the blood plasma relative to the age norm, as well as an asymmetrical enlargement of the ovaries. The greatest likelihood of developing the hyperestrogenic type of manual transmission is at the beginning (11–12 years) and end (17–18 years) of puberty. Atypical forms can occur up to 17 years of age.
• The normoestrogenic type is associated with the harmonious development of external characteristics according to anthropometry and the degree of development of secondary sexual characteristics. The size of the uterus is smaller than the age norm, therefore, with such parameters, patients are often classified as the hypoestrogenic type. Most often, this type of manual transmission develops in patients aged 13 to 16 years.
• The hypoestrogenic type is more common in teenage girls than others. Typically, such patients are of fragile constitution with a significant lag behind the age norm in the degree of development of secondary sexual characteristics, but a fairly high level of mental development. The uterus significantly lags behind the age norm in volume in all age groups, the endometrium is thin, the ovaries are symmetrical and slightly exceed normal in volume.

The level of cortisol in the blood plasma significantly exceeds the normative values. With the hypoestrogenic type, manual transmission almost always occurs in a typical form.

DIAGNOSTICS

Criteria for diagnosing manual transmission:

• the duration of vaginal bleeding is less than 2 or more than 7 days against the background of a shortening (less than 21–24 days) or lengthening (more than 35 days) of the menstrual cycle;
• blood loss more than 80 ml or subjectively more pronounced compared to normal menstruation;
• the presence of intermenstrual or post-coital bleeding;
• absence of structural pathology of the endometrium;
• confirmation of the anovulatory menstrual cycle during the period of uterine bleeding (the level of progesterone in the venous blood on days 21–25 of the menstrual cycle is less than 9.5 nmol/l, monophasic basal temperature, absence of a preovulatory follicle according to echography).

During a conversation with relatives (preferably with the mother), it is necessary to find out the details of the patient’s family history.
They evaluate the characteristics of the mother’s reproductive function, the course of pregnancy and childbirth, the course of the newborn period, psychomotor development and growth rates, find out living conditions, nutritional habits, previous diseases and operations, note data on physical and psychological stress, and emotional stress.

PHYSICAL EXAMINATION

It is necessary to conduct a general examination, measure height and body weight, determine the distribution of subcutaneous fat, and note signs of hereditary syndromes. The compliance of the patient’s individual development with age standards is determined, including sexual development according to Tanner (taking into account the development of the mammary glands and hair growth).
In most patients with manual transmission, a clear advance (acceleration) in height and body weight can be observed, but in terms of body mass index (kg/m2), a relative lack of body weight is noted (with the exception of patients aged 11–18 years).

Excessive acceleration of the rate of biological maturation at the beginning of puberty is replaced by a slowdown in development in older age groups.

Upon examination, you can detect symptoms of acute or chronic anemia (pallor of the skin and visible mucous membranes).

Hirsutism, galactorrhea, enlarged thyroid gland are signs of endocrine pathology. The presence of significant deviations in the functioning of the endocrine system, as well as in the immune status of patients with manual transmission, may indicate a general disturbance of homeostasis.

It is important to analyze the girl’s menstrual calendar (menocyclogram). Based on its data, one can judge the development of menstrual function, the nature of the menstrual cycle before the first bleeding, the intensity and duration of bleeding.

The onset of the disease with menarche is more often observed in the younger age group (up to 10 years), in girls 11–12 years after menarche before bleeding, irregular menstruation is more often observed, and in girls over 13 years old, regular menstrual cycles are observed. Early menarche increases the likelihood of developing manual transmission.

The development of the clinical picture of manual transmission with atresia and persistence of follicles is very characteristic. With persistence of follicles, menstrual-like or more abundant bleeding than menstruation occurs after a delay of the next menstruation by 1–3 weeks, while with follicular atresia the delay ranges from 2 to 6 months and is manifested by scanty and prolonged bleeding. At the same time, various gynecological diseases can have identical bleeding patterns and the same type of menstrual irregularities. Spotting blood from the genital tract shortly before and immediately after menstruation can be a symptom of endometriosis, endometrial polyp, chronic endometritis, or GPE.

It is necessary to clarify the patient’s psychological state through psychological testing and consultation with a psychotherapist. It has been proven that signs of depressive disorders and social dysfunction play an important role in the clinical picture of typical forms of MCPP. The presence of a relationship between stress and the hormonal metabolism of patients suggests the possibility of primacy of neuropsychiatric disorders.

A gynecological examination also provides important information. When examining the external genitalia, the growth lines of the pubic hair, the shape and size of the clitoris, labia majora and minora, the external opening of the urethra, features of the hymen, the color of the mucous membranes of the vaginal vestibule, and the nature of discharge from the genital tract are assessed.

Vaginoscopy allows you to assess the condition of the vaginal mucosa, estrogen saturation and exclude the presence of a foreign body in the vagina, condylomas, lichen planus, neoplasms of the vagina and cervix.

Signs of hyperestrogenism: pronounced folding of the vaginal mucosa, juicy hymen, cylindrical cervix, positive pupil symptom, abundant streaks of mucus in the blood discharge.

Signs of hypoestrogenemia: the vaginal mucosa is pale pink, the folding is weak, the hymen is thin, the cervix is ​​subconical or conical, bleeding without mucus.

LABORATORY RESEARCH

Patients with suspected manual transmission undergo the following studies.

• Complete blood count with determination of hemoglobin level, platelet count, reticulocyte count. A hemostasiogram (aPTT, prothrombin index, activated recalcification time) and assessment of bleeding time will help exclude gross pathology of the blood coagulation system.
• Determination of βhCG in blood serum in sexually active girls.
• Smear microscopy (Gram stain), bacteriological examination and PCR diagnosis of chlamydia, gonorrhea, mycoplasmosis, ureaplasmosis in scrapings of the vaginal walls.
• Biochemical blood test (determination of glucose, protein, bilirubin, cholesterol, creatinine, urea, serum iron, transferrin, calcium, potassium, magnesium levels) alkaline phosphatase, AST, ALT activity.
• Carbohydrate tolerance test for polycystic ovary syndrome and overweight (body mass index 25 and above).
• Determination of the level of thyroid hormones (TSH, free T4, AT to thyroid peroxidase) to clarify the function of the thyroid gland; estradiol, testosterone, DHEAS, LH, FSH, insulin, Speptide to exclude PCOS; 17-OP, testosterone, DHEAS, circadian rhythm of cortisol to exclude CAH; prolactin (at least 3 times) to exclude hyperprolactinemia; progesterone in the blood serum on the 21st day of the cycle (with a menstrual cycle of 28 days) or on the 25th day (with a menstrual cycle of 32 days) to confirm the anovulatory nature of uterine bleeding.

At the first stage of the disease in early puberty, activation of the hypothalamic-pituitary system leads to periodic release of LH (primarily) and FSH, their concentration in the blood plasma exceeds normal levels. In late puberty, and especially with recurrent uterine bleeding, the secretion of gonadotropins decreases.

INSTRUMENTAL RESEARCH METHODS

X-rays of the left hand and wrist are sometimes taken to determine bone age and predict growth.
Most patients with manual transmission are diagnosed with advanced biological age compared to chronological age, especially in younger age groups. Biological age is a fundamental and multifaceted indicator of the pace of development, reflecting the level of the morphofunctional state of the organism against the background of the population standard.

X-ray of the skull is an informative method for diagnosing tumors of the hypothalamic-pituitary region that deform the sella turcica, assessing cerebrospinal fluid dynamics, intracranial hemodynamics, osteosynthesis disorders due to hormonal imbalance, and previous intracranial inflammatory processes.

Echography of the pelvic organs allows you to clarify the size of the uterus and endometrium to exclude pregnancy, the size, structure and volume of the ovaries, uterine defects (bicornuate, saddle-shaped uterus), pathology of the uterine body and endometrium (adenomyosis, MM, polyps or hyperplasia, adenomatosis and endometrial cancer, endometritis , intrauterine synechiae), assess the size, structure and volume of the ovaries, exclude functional cysts and space-occupying formations in the uterine appendages.

Diagnostic hysteroscopy and curettage of the uterine cavity in adolescents are rarely used and are used to clarify the condition of the endometrium when echographic signs of endometrial or cervical canal polyps are detected.

Ultrasound of the thyroid gland and internal organs is performed according to indications in patients with chronic diseases and endocrine diseases.

DIFFERENTIAL DIAGNOSTICS

The main goal of the differential diagnosis of uterine bleeding during puberty is to clarify the main etiological factors that provoke the development of uterine bleeding.

Differential diagnosis should be carried out with a number of conditions and diseases.

• Complications of pregnancy in sexually active adolescents. Complaints and medical history data to exclude interrupted pregnancy or bleeding after an abortion, including in girls who deny sexual contact. Bleeding occurs more often after a short delay of more than 35 days, less often when the menstrual cycle is shortened to less than 21 days or at a time close to the expected menstruation. The history, as a rule, contains indications of sexual intercourse in the previous menstrual cycle. Patients note engorgement of the mammary glands and nausea. Bloody discharge is usually profuse with clots, pieces of tissue, and often painful. The results of pregnancy tests are positive (determination of βhCG in the patient’s blood serum).
• Defects of the blood coagulation system (von Willebrand disease and deficiency of other plasma hemostasis factors, Werlhoff disease, Glanzmann thromboasthenia, Bernard-Soulier, Gaucher). In order to exclude defects in the blood coagulation system, family history (tendency to bleeding in parents) and life history (nosebleeds, prolonged bleeding time during surgical procedures, frequent and causeless occurrence of petechiae and hematomas) are ascertained. Uterine bleeding that develops against the background of diseases of the hemostatic system, as a rule, has the character of menorrhagia with menarche. Examination data (pallor of the skin, bruises, petechiae, yellowness of the palms and upper palate, hirsutism, stretch marks, acne, vitiligo, multiple birthmarks, etc.) and laboratory research methods (hemostasiogram, general blood test, thromboelastogram, determination of the main coagulation factors ) allow you to confirm the presence of pathology of the hemostatic system.
• Other blood diseases: leukemia, aplastic anemia, iron deficiency anemia.
• Polyps of the cervix and uterine body. Uterine bleeding is usually acyclic with short light intervals, the discharge is moderate, often with strands of mucus. An echographic examination often diagnoses GPE (the thickness of the endometrium against the background of bleeding is 10–15 mm), with hyperechoic formations of various sizes. The diagnosis is confirmed using hysteroscopy and subsequent histological examination of distant endometrial formation.
• Adenomyosis. Manual transmission against the background of adenomyosis is characterized by severe dysmenorrhea, prolonged spotting with a brown tint before and after menstruation. The diagnosis is confirmed using ultrasound data in the 1st and 2nd phases of the menstrual cycle and hysteroscopy (in patients with severe pain and in the absence of the effect of drug therapy).
• PID As a rule, uterine bleeding is acyclic in nature and occurs after hypothermia, unprotected sexual intercourse in sexually active adolescents, against the background of exacerbation of chronic pelvic pain and discharge. Patients complain of pain in the lower abdomen, dysuria, hyperthermia, profuse pathological leucorrhoea outside of menstruation, which acquires a sharp unpleasant odor due to bleeding. During a rectoabdominal examination, an enlarged softened uterus is palpated, the pastiness of the tissues in the area of ​​the uterine appendages is determined, the examination is usually painful. Bacteriological examination data (Gram smear microscopy, PCR diagnosis of vaginal discharge for the presence of STIs, bacteriological culture from the posterior vaginal fornix) help clarify the diagnosis.
• Trauma to the external genitalia or foreign body in the vagina. Diagnosis requires mandatory clarification of anamnestic data and vulvovaginoscopy.
• PCOS. With MCPP, girls with PCOS, along with complaints of delayed menstruation, excess hair growth, simple acne on the face, chest, shoulders, back, buttocks and thighs, have indications of late menarche with progressive menstrual irregularities such as oligomenorrhea.
• Hormone-producing formations. MCPP may be the first symptom of estrogen-producing tumors or tumor-like formations of the ovaries. Verification of the diagnosis is possible after determining the level of estrogen in the venous blood and ultrasound of the genital organs with clarification of the volume and structure of the ovaries.
• Thyroid gland dysfunction. MCPPs usually occur in patients with subclinical or clinical hypothyroidism. Patients with manual transmission on the background of hypothyroidism complain of chilliness, swelling, weight gain, memory loss, drowsiness, and depression. In hypothyroidism, palpation and ultrasound with determination of the volume and structural features of the thyroid gland can reveal its enlargement, and examination of patients reveals the presence of dry subecteric skin, puffiness of the face, glossomegaly, bradycardia, and an increase in the relaxation time of deep tendon reflexes. The functional state of the thyroid gland can be clarified by determining the content of TSH and free T4 in the venous blood.
• Hyperprolactinemia. To exclude hyperprolactinemia as a cause of manual transmission, it is necessary to examine and palpate the mammary glands with clarification of the nature of the discharge from the nipples, determine the content of prolactin in the venous blood, an X-ray examination of the skull bones with a targeted study of the size and configuration of the sella turcica or MRI of the brain is indicated.
• Other endocrine diseases (Addison's disease, Cushing's disease, postpubertal form of CAH, adrenal tumors, empty sella syndrome, mosaic variant of Turner syndrome).
• Systemic diseases (liver disease, chronic renal failure, hypersplenism).
• Iatrogenic causes (errors in taking medications containing female sex hormones and glucocorticoids, long-term use of high doses of NSAIDs, antiplatelet agents and anticoagulants, psychotropic drugs, anticonvulsants and warfarin, chemotherapy).

It is necessary to distinguish between manual transmission and uterine bleeding syndrome in adolescents. Uterine bleeding syndrome can be accompanied by almost the same clinical and parametric attributes as with MCPP. However, uterine bleeding syndrome is characterized by pathophysiological and clinical specific signs, which must be taken into account when prescribing treatment and preventive measures.

INDICATIONS FOR CONSULTATION WITH OTHER SPECIALISTS

Consultation with an endocrinologist is necessary if thyroid pathology is suspected (clinical symptoms of hypo or hyperthyroidism, diffuse enlargement or nodules of the thyroid gland on palpation).

Consultation with a hematologist - at the debut of manual transmission with menarche, indications of frequent nosebleeds, the occurrence of petechiae and hematomas, increased bleeding during cuts, wounds and surgical manipulations, identification of prolongation of bleeding time.

Consultation with a phthisiatrician - in case of manual transmission on the background of long-term persistent low-grade fever, acyclic bleeding, often accompanied by pain, the absence of a pathogenic infectious agent in the discharge of the urogenital tract, relative or absolute lymphocytosis in a general blood test, positive results of a tuberculin test.

Consultation with a therapist - for manual transmission against the background of chronic systemic diseases, including diseases of the kidneys, liver, lungs, cardiovascular system, etc.

Consultation with a psychotherapist or psychiatrist is indicated for all patients with manual transmission to correct the condition, taking into account the characteristics of the traumatic situation, clinical typology, and the individual’s reaction to the disease.

EXAMPLE OF FORMULATION OF DIAGNOSIS

N92.2 Heavy menstruation during puberty (heavy bleeding with menarche or pubertal menorrhagia
or pubertal metrorrhagia).

TREATMENT GOALS

The general goals of treating pubertal uterine bleeding are:

• stopping bleeding to avoid acute hemorrhagic syndrome;
• stabilization and correction of the menstrual cycle and endometrial condition;
• antianemic therapy;
• correction of the mental state of patients and concomitant diseases.

INDICATIONS FOR HOSPITALIZATION

Patients are hospitalized for the following conditions:

• profuse (profuse) uterine bleeding that cannot be controlled by drug therapy;
• life-threatening decrease in hemoglobin (below 70–80 g/l) and hematocrit (below 20%);
• the need for surgical treatment and blood transfusion.

DRUG TREATMENT

In patients with uterine bleeding, at the first stage of treatment it is advisable to use inhibitors of the transition of plasminogen to plasmin (tranexamic acid or aminocaproic acid). The drugs reduce the intensity of bleeding by reducing the fibrinolytic activity of blood plasma. Tranexamic acid is prescribed orally at a dose of 4–5 g during the first hour of therapy, then 1 g every hour until bleeding stops completely. Intravenous administration of 4–5 g of the drug is possible over 1 hour, then drip administration of 1 g per hour for 8 hours. The total daily dose should not exceed 30 g. When taking large doses, the risk of developing intravascular coagulation syndrome increases, and with simultaneous use estrogen there is a high probability of thromboembolic complications. It is possible to use the drug in a dosage of 1 g 4 times a day from the 1st to the 4th day of menstruation, which reduces the amount of blood loss by 50%.

It has been reliably proven that with the use of NSAIDs, monophasic COCs and danazol, blood loss in patients with menorrhagia is significantly reduced. Danazol is used very rarely in girls with manual transmission due to severe adverse reactions (nausea, deepening of the voice, hair loss and increased greasiness, acne and hirsutism). NSAIDs (ibuprofen, nimesulide), by suppressing the activity of COX1 and COX2, regulate the metabolism of arachidonic acid, reduce the production of PG and thromboxanes in the endometrium, reducing the amount of blood loss during menstruation by 30–38%.

Ibuprofen is prescribed 400 mg every 4-6 hours (daily dose - 1200-3200 mg) on ​​days of menorrhagia. Nimesulide is prescribed 50 mg 3 times a day. Increasing the daily dosage may cause an undesirable increase in prothrombin time and an increase in the lithium content in the blood serum.

The effectiveness of NSAIDs is comparable to that of aminocaproic acid and COCs.

In order to increase the effectiveness of hemostatic therapy, the simultaneous administration of NSAIDs and hormonal therapy is justified and advisable. The exception is patients with hyperprolactinemia, structural abnormalities of the genital organs and pathology of the thyroid gland.

Methylergometrine can be prescribed in combination with ethamsylate, but if you have or suspect an endometrial polyp or MM, it is better to refrain from prescribing methylergometrine due to the possibility of increased bleeding and pain in the lower abdomen.

Physiotherapy procedures can be used as alternative methods: automammonia, vibromassage of the isola, calcium chloride electrophoresis, galvanization of the area of ​​the upper cervical sympathetic ganglia, electrical stimulation of the cervix with low-frequency pulsed currents, local or laser therapy, acupuncture.

In some cases, hormonal therapy is used. Indications for hormonal hemostasis:

• lack of effect from symptomatic therapy;
• moderate or severe anemia due to prolonged bleeding;
• recurrent bleeding in the absence of organic diseases of the uterus.

Low-dose COCs containing 3rd generation progestogens (desogestrel or gestodene) are the most commonly used drugs in patients with profuse and acyclic uterine bleeding. Ethinyl estradiol in COCs provides a hemostatic effect, and progestogens provide stabilization of the stroma and basal layer of the endometrium. To stop bleeding, only monophasic COCs are used.

There are many schemes for using COCs for hemostatic purposes in patients with uterine bleeding. The most popular is the following: 1 tablet 4 times a day for 4 days, then 1 tablet 3 times a day for 3 days, then 1 tablet 2 times a day, then 1 tablet a day until the end of the second package of the drug. Outside of bleeding for the purpose of regulating menstrual flow cycle COCs are prescribed for 3 cycles 1 tablet per day (21 days of use, 7 days off). Duration hormonal therapy depends on the severity of the initial iron deficiency anemia and the rate of restoration of the level hemoglobin. The use of COCs in this regimen is associated with a number of serious side effects: increased blood pressure, thrombophlebitis, nausea, vomiting, allergies.

The use of low-dose monophasic COCs has been proven to be highly effective (Marvelon©, Regulon ©, Rigevidon ©, Janine ©) 1/2 tablet every 4 hours until complete hemostasis occurs. Appointment under this scheme is based on evidence that the maximum concentration of COCs in the blood is achieved 3-4 hours after oral administration drug and decreases significantly in the next 2–3 hours. The total hemostatic dose of ethinyl estradiol with This ranges from 60 to 90 mcg, which is less than the dose traditionally used. In the following days, a decrease is carried out daily dose of the drug is 1/2 tablet per day. As a rule, the duration of the first cycle of COC use should not be be less than 21 days, counting from the first day from the beginning of hormonal hemostasis. The first 5–7 days of taking COCs is possible a temporary increase in endometrial thickness, which regresses without bleeding with continued treatment.

In the future, in order to regulate the rhythm of menstruation and prevent recurrence of uterine bleeding, the drug prescribed according to the standard regimen for taking COCs (courses of 21 days with breaks of 7 days between them). In all patients, Those who took the drug according to the described regimen showed good tolerability with no side effects. If it is necessary to quickly stop a patient’s life-threatening bleeding with first-line drugs are conjugated estrogens administered intravenously at a dose of 25 mg every 4–6 hours until complete stop bleeding if it occurs during the first day. Can be used in tablet form conjugated estrogens 0.625–3.75 mcg every 4–6 hours until bleeding stops completely with gradual reducing the dose over the next 3 days to 1 tablet (0.675 mg) per day or drugs containing natural estrogens (estradiol), according to a similar scheme with an initial dose of 4 mg per day. After stopping the bleeding Progestogens are prescribed.

Outside of bleeding, in order to regulate the menstrual cycle, 1 tablet of 0.675 mg per day is prescribed for 21 days from mandatory addition of gestagens for 12–14 days in the second phase of the simulated cycle.

In some cases, especially in patients with severe adverse reactions, intolerance or contraindications to the use of estrogens, it is possible to prescribe progestogens.

In patients with heavy bleeding, taking high doses of progestogens (medroxyprogesterone 5–10 mg, micronized progesterone 100 mg or dydrogesterone 10 mg) every 2 hours or 3 times a day for 24 hours until stopping bleeding. For menorrhagia, medroxyprogesterone can be prescribed 5–20 mg per day for the second phase (in cases of NLF) or 10 mg per day from the 5th to the 25th day of the menstrual cycle (in cases of ovulatory menorrhagia).

In patients with anovulatory uterine bleeding, it is advisable to prescribe progestogens in the second phase menstrual cycle against the background of constant use of estrogen. It is possible to use micronized progesterone in a daily dose of 200 mg 12 days a month against the background of continuous estrogen therapy. For the purpose of subsequent regulation of the menstrual cycle gestagens (natural micronized progesterone 100 mg 3 times a day, dydrogesterone 10 mg 2 times a day) is prescribed in the second phase of the cycle for 10 days. Continued bleeding against the background of hormonal hemostasis is an indication for hysteroscopy to clarification of the condition of the endometrium.

All patients with manual transmission are prescribed iron supplements to prevent and prevent the development of iron deficiency anemia. The use of iron sulfate in combination with ascorbic acid has been proven to be highly effective acid, ensuring that the patient’s body receives 100 mg of ferrous iron per day (Sorbifer Durules©).

The daily dose of ferrous sulfate is selected taking into account the level of hemoglobin in the blood serum. As a criterion correct selection and adequacy of ferrotherapy for iron deficiency anemia, presence of reticulocyte crisis, those. A 3 or more fold increase in the number of reticulocytes on the 7th–10th day of taking an iron-containing drug.

Antianemic therapy is prescribed for a period of at least 1–3 months. Iron salts should be used with caution patients with concomitant gastrointestinal pathology. In addition, Fenyuls may be an option©, Tardiferon ©, Ferroplex ©, FerroFolgamma ©.

SURGERY

Separate curettage of the mucous membrane of the body and cervix under the control of a hysteroscope in girls is performed very rarely. Indications for surgical treatment may include:

• acute profuse uterine bleeding that does not stop with drug therapy;
• the presence of clinical and ultrasound signs of endometrial and/or cervical canal polyps.

In cases where it is necessary to remove an ovarian cyst (endometrioid, dermoid follicular or yellow cyst) body, persisting for more than three months) or clarifying the diagnosis in patients with a mass formation in the area of the uterine appendages, therapeutic and diagnostic laparoscopy is indicated.

APPROXIMATE DURATION OF DISABILITY

In an uncomplicated course, the disease does not cause permanent disability. Possible periods of incapacity from 10 to 30 days may be determined by the severity of clinical manifestations iron deficiency anemia due to prolonged or heavy bleeding, as well as the need for hospitalization for surgical or hormonal hemostasis.

FOLLOW-UP

Patients with uterine bleeding during puberty require constant dynamic monitoring once per month until the menstrual cycle stabilizes, then it is possible to limit the frequency of control examinations to 1 time per month 3–6 months Ultrasound examination of the pelvic organs should be carried out at least once every 6–12 months.

Electroencephalography after 3–6 months. All patients should be trained in the rules of maintaining a menstrual calendar and assessing the intensity of bleeding, which will allow assessing the effectiveness of the therapy. Patients should be informed about the advisability of correction and maintenance of optimal body weight (as with
deficiency, and with excess body weight), normalization of the work and rest regime.

INFORMATION FOR THE PATIENT

To prevent the occurrence and successful treatment of uterine bleeding during puberty, the following is necessary:

• normalization of work and rest regimes;
• good nutrition (with the obligatory inclusion of meat, especially veal);
• hardening and physical education (outdoor games, gymnastics, skiing, skating, swimming, dancing, yoga).

FORECAST

Most girls-adolescents respond favorably to drug treatment, and within the first year they have full ovulatory menstrual cycles and normal menstruation are formed. Forecast for manual transmission, associated with pathology of the hemostatic system or with systemic chronic diseases, depends on the degree of compensation for existing disorders. Girls, who remain overweight and have relapses of manual transmission in aged 15–19 years should be included in the risk group for developing endometrial cancer.

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Every woman is familiar with bleeding from the genital tract. They appear regularly and last for several days. Monthly bleeding from the uterus is observed in all healthy women of fertile age, that is, capable of giving birth to children. This phenomenon is considered normal (menstruation). However, abnormal uterine bleeding also exists. They occur when disturbances occur in the body. Most often, such bleeding occurs due to gynecological diseases. In most cases, they are dangerous because they can have serious consequences.

Determination of abnormal uterine bleeding

Abnormal uterine bleeding is a condition in which a tear occurs in the vascular wall of the body or cervix. It is not associated with the menstrual cycle, that is, it appears independently of it. Bloody discharge may occur frequently. In this case, they occur in the period between menstruation. Sometimes abnormal uterine bleeding occurs infrequently, such as once every few months or years. This definition is also suitable for long menstruation lasting more than 7 days. In addition, 200 ml for the entire period of “critical days” is considered abnormal. This problem can occur at any age. Including in adolescents, as well as among women undergoing menopause.

Abnormal uterine bleeding: causes

The reasons for the appearance of blood from the genital tract can be different. However, this symptom is always a reason to urgently seek medical help. Often abnormal uterine bleeding occurs due to oncological pathologies or diseases preceding them. Due to the fact that this problem is one of the reasons for removing the reproductive organ, it is important to identify the cause in time and eliminate it. There are 5 groups of pathologies that may cause bleeding. Among them:

1. Diseases of the uterus. Among them: inflammatory processes, ectopic pregnancy or threatened miscarriage, fibroids, polyps, endometriosis, tuberculosis, cancer, etc.
2. Pathologies associated with the secretion of hormones by the ovaries. These include: cysts, oncological processes of the appendages, early puberty. Bleeding can also occur due to dysfunction of the thyroid gland, stressful situations, or taking contraceptives.
3. Pathologies of the blood (thrombocytopenia), liver or kidneys.
4. Iatrogenic causes. Bleeding caused by surgery on the uterus or ovaries, or insertion of an IUD. In addition, iatrogenic causes include the use of anticoagulants and other medications.
5. Their etiology is not completely clear. These bleedings are not associated with diseases of the genital organs and are not caused by other listed reasons. They are thought to occur due to hormonal imbalances in the brain.

The mechanism of development of bleeding from the genital tract

The pathogenesis of abnormal bleeding depends on what exactly caused it. The mechanism of development for endometriosis, polyps and oncological processes is similar. In all these cases, it is not the uterus itself that bleeds, but pathological elements that have their own vessels (myomatous nodes, tumor tissue). Ectopic pregnancy can occur as an abortion or a ruptured tube. The latter option is very dangerous for a woman’s life, as it causes massive intra-abdominal bleeding. Inflammatory processes in the uterine cavity cause tearing of endometrial vessels. When the hormonal function of the ovaries or brain is disrupted, changes occur in the menstrual cycle. As a result, several ovulations may occur instead of one or, conversely, a complete absence. The same mechanism applies to oral contraceptives. can cause mechanical damage to the organ, thereby leading to bleeding. In some cases, the cause cannot be established, so the mechanism of development also remains unknown.

Abnormal uterine bleeding: classification in gynecology

There are a number of criteria according to which uterine bleeding is classified. These include the cause, frequency, period of the menstrual cycle, as well as the amount of fluid lost (mild, moderate and severe). Based on etiology, there are: uterine, ovarian, iatrogenic and dysfunctional bleeding. DMKs vary in nature. Among them are:

1. Anovulatory uterine bleeding. They are also called single-phase DMKs. They arise due to short-term persistence or atresia of the follicles.
2. Ovulatory (2-phase) DMC. These include hyper- or hypofunction of the corpus luteum. Most often, this is how abnormal uterine bleeding occurs during the reproductive period.
3. Polymenorrhea. Blood loss occurs more often than once every 20 days.
4. Promenorrhea. The cycle is not broken, but the “critical days” last more than 7 days.
5. Metrorrhagia. This type of disorder is characterized by random bleeding without a certain interval. They are not related to the menstrual cycle.

Symptoms of uterine bleeding

In most cases, it is impossible to immediately determine the cause of the appearance of blood from the genital tract, since the symptoms are almost the same for all DUB. These include pain in the lower abdomen, dizziness and weakness. Also, with constant blood loss, a decrease in blood pressure and pale skin are observed. To distinguish between DMKs, you need to calculate how many days it lasts, in what volume, and also set the interval. To do this, it is recommended to mark each menstruation in a special calendar. Abnormal uterine bleeding is characterized by a duration of more than 7 days and an interval of less than 3 weeks. Women of fertile age usually experience menometrorrhagia. During menopause, bleeding is profuse and prolonged. The interval is 6-8 weeks.

Diagnosis of bleeding from the uterus

To identify abnormal uterine bleeding, it is important to monitor your menstrual cycle and periodically visit your gynecologist. If this diagnosis is still confirmed, it is necessary to be examined. To do this, general urine and blood tests (anemia), a smear from the vagina and cervix are taken, and a gynecological examination is performed. It is also necessary to do an ultrasound of the pelvic organs. It allows you to determine the presence of inflammation, cysts, polyps and other processes. In addition, it is important to get tested for hormones. This applies not only to estrogens, but also to gonadotropins.

What are the dangers of bleeding from the uterus?

Abnormal bleeding from the uterus is a rather dangerous symptom. This sign may indicate a disturbed pregnancy, tumor and other pathologies. Massive bleeding leads not only to loss of the uterus, but even to death. They occur in diseases such as ectopic pregnancy, torsion of the tumor stalk or myomatous node, and ovarian apoplexy. These conditions require immediate surgical attention. Minor short-term bleeding is not so scary. However, their reasons may be different. They can lead to malignancy of the polyp or fibroids, and infertility. Therefore, examination is extremely important for women of any age.

How to treat uterine bleeding?

Treatment of abnormal uterine bleeding should begin immediately. First of all, hemostatic therapy is necessary. This applies to heavy blood loss. An ice pack is placed on the uterine area and red blood cells are injected intravenously. Surgical treatment is also performed (most often, removal of one of the appendages). For mild bleeding, conservative therapy is prescribed. It depends on the cause of DMC. In most cases, these are hormonal drugs (drugs "Jess", "Yarina") and hemostatic drugs (solution "Ditsinon", tablets "Calcium Gluconate", "Ascorutin").

In modern society, improving the reproductive health of women of all age groups is an important task for the formation of future generations of healthy people capable of living a full life and creative self-expression. The reproductive health of women is significantly affected by gynecological pathology of the puberty period (puberty), in particular, uterine bleeding. Women who have had uterine bleeding during puberty are subsequently at risk for menstrual irregularities and generative function, and hormonally caused diseases.

Uterine bleeding during puberty occurs in 22.5-37% of girls and belong to the category of dysfunctional uterine bleeding.

Considering the trend towards an increase in the number of adolescents with uterine bleeding during this period, as well as the increase in the number of recurrent bleeding and the tendency for a protracted course of the disease, in practical terms, the choice of a rational method of treating the disease is very important.

Treatment of uterine bleeding during puberty should be comprehensive and include both stopping bleeding and normalizing the menstrual cycle.

The main generally accepted method of treating uterine bleeding is the sequential use of symptomatic, conservative hemostatic therapy and the immediate elimination of anemia, followed by correction of the physical and mental status and prevention of recurrence of uterine bleeding.

Conservative symptomatic therapy is effective only in 45-55% of patients. Non-hormonal hemostatic therapy is recommended by many researchers for patients with uterine bleeding who do not have hyperplastic changes in the endometrium and complications of uterine bleeding at the start of treatment.

The traditional and most common method of hemostasis is the administration of hormonal drugs in various modes and doses.

Treatment of patients with uterine bleeding during puberty, despite a wide arsenal of hormonal drugs, presents certain difficulties in prescribing these drugs in children due to the frequent presence of diseases of the gastrointestinal tract, cholecystitis, biliary dyskinesia, allergies, and chronic tonsillitis. The use of high doses of hormonal drugs by such patients is not always well tolerated due to concomitant extragenital pathology, therefore, in pediatric practice, the use of low doses of hormonal drugs is justified, both at the stage of stopping bleeding and preventing it.

For the treatment of uterine bleeding during puberty, split doses of COCs are used, containing ethinyl estradiol in small doses for hemostasis. The total hemostatic dose of ethinyl estradiol ranges from 60 to 90 mcg, which is more than three times less than the dose traditionally used in adult gynecology for the treatment of dysfunctional uterine bleeding. Using this regimen, not only optimal bleeding control was achieved, but also side effects were significantly reduced.

The hormonal method allows you to quickly stop bleeding, which is a significant advantage compared to other drugs.

If hormonal therapy is ineffective, recurrent and anemic bleeding is indicated for the purpose of hemostasis and diagnosis of pathological conditions of the endometrium, curettage of the uterine mucosa under the control of hysteroscopy.

Many doctors do not pay enough attention to the presence of existing iron deficiency, up to iron deficiency anemia. The main causes of iron deficiency anemia are nutritional deficiency and the increased need for iron in the body of girls during the period of intense physical and biochemical processes of puberty, including from the moment of the onset of menstrual bleeding. The basis of pathogenetic therapy is the administration of iron preparations, ensuring early intake and accumulation of iron in the body of patients with uterine bleeding.

Despite the wide range of drug treatment methods, non-drug methods of treatment are now being widely introduced, which are non-invasive and have no side effects. In recent years, various physiotherapeutic methods have been successfully used to treat uterine bleeding during puberty:

• laser puncture,
• electrical stimulation,
• acupuncture,
• acupuncture,
• magnetotherapy.

An integral component in the treatment of uterine bleeding in adolescence should be a successful period of rehabilitation, which begins with the restoration of the rhythm of menstruation and ends with the transition to a mature type of functioning of the reproductive system. The total duration of the rehabilitation period ranges from 2 to 6 months, during which the causes of uterine bleeding are eliminated and normalization of the function of the hypothalamic-pituitary-ovarian system is achieved. For the purpose of rehabilitation, all patients with uterine bleeding of this period, regardless of the treatment, are recommended to be prescribed cyclic vitamin therapy, sedative therapy, nootropic and microcirculation-improving drugs, herbal medicine, and diet therapy.

Sibirskaya Elena Viktorovna,

d etsky-gynecologist of the highest category, Ph.D. honey. sciences

Literary Fund Children's Clinic

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In the last decade, the relevance of the problem of protecting the reproductive health of children and adolescents, the prevention and treatment of gynecological diseases in childhood has increased sharply. One of the most common forms of dysfunction of the reproductive system during puberty is uterine bleeding (UB) during puberty, which often subsequently leads to persistent disturbances of menstrual and generative function, hormonally caused diseases.

The issues of treatment and rehabilitation of patients with MK are very relevant, since relapses of diseases worsen the prognosis for generative function, which is a social and economic problem.

It is difficult to establish the true cause of MK, which is due to the rare and often late referral of parents or the girl herself to specialists, as well as underestimation of this problem by local doctors in children's clinics and antenatal clinics. The functional state of higher nervous activity, which controls the mechanisms of regulation of the reproductive system, is unstable during puberty; the receptor apparatus of the uterus and ovaries is imperfect. Exogenous and endogenous stimuli can easily disrupt the regulatory mechanisms of the reproductive system, which can clinically manifest as MC. With prolonged and heavy bleeding, posthemorrhagic anemia develops, which affects performance and study. Patients complain of weakness, fatigue, dizziness. There are often deviations in the parameters of the blood coagulation and anticoagulation systems. Identifying the causes of urticaria in teenage girls plays an important role, making it possible to prevent relapses in the future, and solve problems of reproductive health in marriage.

Pubertal MC (MPP) is pathological bleeding caused by deviations in endometrial rejection in adolescent girls with disturbances in the cyclic production of steroid hormones from the moment of the first menstruation to 18 years.

There is no officially accepted international classification of MC during puberty. When determining the type of bleeding in teenage girls, their clinical characteristics (polymenorrhea, metrorrhagia and menometrorrhagia) are taken into account.

Menorrhagia is called MK in patients with a preserved rhythm of menstruation, in whom the duration of bleeding exceeds 7 days, blood loss is more than 80 ml and there is a small number of clots in heavy bleeding, the appearance of hypovolemic disorders on menstrual days and the presence of moderate and severe iron deficiency anemia.

Polymenorrhea is uterine bleeding that occurs against the background of a regular shortened menstrual cycle (less than 21 days).

Metrorrhagia and menometrorrhagia are urticaria that do not have a rhythm, often occurring after periods of oligomenorrhea and characterized by periodic increased bleeding against the background of scanty or moderate blood discharge.

Clinical features

The main complaint upon admission to the hospital is bleeding from the genital tract of varying intensity and duration. The majority of those examined (60.3%) were characterized by the presence of moderate bleeding, less often - copious (18.7%) and prolonged, spotting (21%).

Moderate bleeding, as a rule, is not accompanied by a change in general condition, since the body compensatory copes with minor blood loss, while with heavy bleeding, signs of secondary posthemorrhagic anemia are often observed: dizziness, general weakness, short-term loss of consciousness in the form of fainting. 13.4% of the subjects complained of pain in the lower abdomen; 38.7% of patients were admitted without concomitant complaints.

A more detailed study of the nature of bleeding revealed that the majority of those examined (71.5%) were admitted for the first time and only 28.5% were admitted again.

In 2/3 of patients, bleeding lasted 20-30 days, in 1/3 - within 10 days, in 20% - more than 30 days. The duration of bleeding varies from 10 to 91 days.

According to the results of the gynecological examination, it was revealed that 69.6% of the subjects had not been previously treated; 30.4% were treated before admission to the hospital, of which 20.7% were outpatient, 9.8% were inpatient; non-hormonal drugs - 19.1%, hormonal - 11.3%.

Chronic diseases of parents, relatively high age of parents, violation of the daily routine and nutrition of girls can be considered as factors of increased risk of developing MC.

Ultrasound parameters of the condition of the internal genital organs and hysteroscopy data

Ultrasound examination is an important method in assessing the internal genital organs in girls suffering from urticaria. According to the results of ultrasound, their vagina and uterus were the same in shape, echostructure and location in the pelvic cavity as in healthy people. The echographic dimensions of the uterus did not undergo significant changes during dynamic observation. Of particular interest is an echographic study of the dynamics of the development of the ovaries and follicles in them in patients with MC. The results of the study indicate changes in the average volume of the ovaries during the course of the disease. There is a slight tendency towards an increase in ovarian volume in the period between bleeding and the first menstruation after hemostasis in all age groups. On echograms, in 13.5% of patients with MC, one or two round cystic formations of various diameters with clear contours were visualized, located in one or both ovaries. In 15.3% of patients with urticaria, ultrasound revealed an echo-negative formation in one of the ovaries with a diameter of 3 to 6 cm, with clear contours and a high level of sound conductivity. These formations are regarded as follicular cysts.

Clinical and echographic signs of persistent follicles in patients with MC are:

• pronounced estrogenization;
• slight enlargement of the ovary;
• echo-negative, round-shaped formation from 1.5 to 2.5 cm in diameter, with clear contours, in one or both ovaries.

The presence of follicular cysts in patients with MC is characterized by:

• unexpressed estrogenization;
• ovarian enlargement;
• echo-negative formation of a round shape, with a clear contour, in one of the ovaries, with a diameter of 3 to 6 cm (according to ultrasound results).

In addition, follicular cysts can be detected during follow-up for 6-16 weeks. Persistent follicles persist for up to 4-6 weeks. Under the influence of hormonal therapy, persistent follicles and follicular cysts undergo reverse development, which can be used as a diagnostic sign.

Endometrial ultrasound data were confirmed by hysteroscopy. Various hyperplastic processes have been identified in patients with MC:

• glandular cystic endometrial hyperplasia;
• endometrial polyp;
• adenomyosis.

Features of hormonal status

The physiological state during puberty changes significantly from year to year, so it is of interest to analyze the hormonal status of girls with MC depending on age. These studies will contribute to the improvement of pathogenetically based therapy. An attempt to elucidate the causes of manual transmission required an assessment of the functional activity of the pituitary gland, ovaries and adrenal glands.

The concentration of progesterone in patients with manual transmission at prepubertal and pubertal age (10-13 years) does not differ from that in healthy girls of the corresponding age in phase II of the anovulatory cycle. A different picture is observed in girls aged 14-16 years. Here, progesterone production is significantly reduced compared to that in healthy girls of the same age, which may be evidence of a decrease in the functional activity of the ovaries.

All patients, depending on the level of the FSH/LH ratio (follicle-stimulating hormone/luteinizing hormone), were divided into 3 groups - with a high, low and normal FSH/LH ratio.

Group 1 - patients suffering from urticaria with a high FSH/LH ratio. A characteristic feature of this group is that the pituitary gland produces more FSH than LH. Even if the absolute level of hormones in such girls is higher than in healthy peers, the predominance of FSH indicates that LH is not enough for ovulation to occur. The ovarian follicles begin to persist, producing large amounts of estrogens. The estradiol/progesterone ratio increases. A high estradiol/progesterone ratio is not only the result of an increase in blood estrogen levels, but also a consequence of insufficient function of the corpus luteum, expressed in low progesterone levels in the blood.

Patients of group 2 had a reduced FSH/LH ratio compared to healthy peers. Analysis of the hormonal profile data of girls in this group allows us to conclude that at the initial stages of the formation of menstrual function, there is immaturity of central regulatory mechanisms, namely: the pituitary gland produces more LH than FSH. In the ovaries, under the influence of such hyperactivity of the pituitary gland, the production of estrogen increases, which leads to a state of hyperestrogenism with insufficient production of progesterone (insufficiency of corpus luteum function), and with increased production of progesterone - to a state with a reduced estradiol/progesterone ratio - hypoestrogenism. In this case, MC proceeds according to the type of follicular atresia and inferior function of the corpus luteum.

The data we presented on the relative level of hormones showed that with normal pituitary function (based on the FSH/LH ratio), both hypo- and hyperestrogenism are observed equally often.

The state of the blood coagulation and anticoagulation system in girls with urticaria

Bleeding during puberty may be caused by a violation of the formation of regulatory mechanisms in the hypothalamus-pituitary-ovary-uterus system or be the first clinical manifestation of the primary pathology of the hemostatic system.

The data available in the literature indicate that a violation of the blood coagulation system plays a certain role in the pathogenesis of MK.

The mechanism of bleeding has not been sufficiently studied and, according to most authors, the most important is the relationship between changes in hormonal levels with fluctuations in vascular tone and disturbances in the trophism of the basal layer of the endometrium. In addition to changes in blood vessels (dilation of capillaries, hypoxia, metabolic disorders), the occurrence of bleeding is facilitated by an increase in the sensitivity of the endometrium to estrogens, while simultaneously reducing the contractility of the uterus, which is especially often observed during puberty.

It is known that ovarian steroid hormones are vasoactive, that is, they can have an effect on blood vessels. The basal arterioles of the endometrium are relatively insensitive to steroid hormones, while the vessels of the functional layer change under their action; estrogens cause a decrease in the resistance of the uterine vessels and, as a result, an increase in urinary function. This effect disappears in the presence of progesterone.

In girls with manual transmission, increased blood flow in the endometrium is observed, associated with an increase in the number of estrogen receptors and an increased effect of estradiol. The level of the latter especially increases in the premenstrual period and with endometrial hyperplasia. During bleeding, exfoliated endometrial cells are mixed with the blood, converting profibrinolysin into fibrinolysin, which lyses the formed fibrin clots, which contributes to the occurrence of bleeding. To avoid this, Betty (1980) recommends removing degenerated and pathologically hyperplastic endometrium to achieve hemostasis and weaken local fibrinolysis.

Changes in the functional state of the hemostatic system during a normal cycle are natural: during ovulation, the activity of hemostasis increases - blood clotting, adhesiveness and platelet aggregation increase, fibrinolytic activity decreases. In the middle of the second phase of the cycle, there is a decrease in the activity of the hemostatic system, which reaches a maximum on the 1st day of menstrual bleeding. In the following days, the coagulation potential of the blood is gradually restored.

With hypercoagulation of the blood, prolonged light bleeding is observed, with hypocoagulation - heavy bleeding, leading to severe anemia. The changes observed in the hemostatic system are determined by the amount of blood loss and the severity of the caused hemodynamic and metabolic disorders. The recorded deficiency of coagulation factors can be caused, on the one hand, by blood loss, on the other, by their consumption as a result of the developing syndrome of disseminated intravascular coagulation (DIC).

Very quickly after blood loss, the first portions of thrombin appear, which, acting on the membranes of blood cells, changes their functional state, which contributes to the reaction of releasing erythrocyte and platelet coagulation factors. With prolonged and heavy bleeding, oxygen starvation of tissues develops, which leads to disruption of biochemical processes in the body, promotes damage to cell membranes and the release of lysokinases, which may be one of the reasons for additional activation of fibrinolysis, leading to disruption of hemodynamic balance in the hemostasis system.

Violations of the dynamic balance between the coagulation and anticoagulation systems of the blood lead to the development of thrombosis or bleeding. All this indicates the important role of the functional activity of the coagulation and anticoagulation systems of the blood in the pathogenesis of urticaria, and also indicates the possibility of the development of microcirculatory disorders.

Diagnostics

A thorough examination of teenage girls with manual transmission should be carried out in the presence of intermenstrual or postcoital bleeding, if its duration is less than 2 or more than 7 days against the background of a shortening (less than 21-24 days) or lengthening (more than 35 days) of the menstrual cycle; if blood loss is more than 80 ml or subjectively more pronounced compared to normal menstruation. This examination should include:

• taking anamnesis;
• assessment of physical and sexual development;
• gynecological examination: examination data, vaginoscopy, two-handed examination, rectal-abdominal examination can exclude the presence of a foreign body in the vagina, condylomas, neoplasms in the vagina and on the cervix. The condition of the vaginal mucosa and estrogen saturation are assessed. Signs of hyperestrogenism: pronounced folding of the vaginal mucosa, juicy hymen, cylindrical shape of the cervix, positive “pupil” symptom, abundant streaks of mucus in the blood discharge. Hypoestrogenism is characterized by pale pink vaginal mucosa, its folding is weakly expressed, the hymen is thin, the cervix is ​​subconical or conical in shape, blood discharge without mucus;
• clarification of the patient’s psychological characteristics;
• laboratory research:

- clinical blood test with hemosyndrome;
- biochemical blood test - study of the concentrations of glucose, creatinine, bilirubin, urea, serum iron, transferrin;
- study of hormone concentrations in the blood - determination of the concentration of TSH and free T4, to clarify the function of the thyroid gland, estradiol, testosterone, DEAs, the daily rhythm of cortisol secretion to exclude congenital adrenal hyperplasia, prolactin (at least 3 times) to exclude hyperprolactinemia, progesterone in blood serum (on the 21st day with a 28-day menstrual cycle or on the 25th day with a 32-day menstrual cycle) to confirm the anovulatory nature of MK;
— carbohydrate tolerance test for polycystic ovary syndrome (PCOS) and excess body weight (body mass index is 25 kg/m2 and above);

• instrumental research methods:

— vaginal smear for flora, PCR diagnostics to exclude urogenital infection;
— vaginoscopy, colposcopy;
— radiography of the skull with a projection of the sella turcica;
— magnetic resonance imaging (MRI) of the brain if a brain tumor is suspected;
— electroencephalogram (EEG), rheoencephalography (REG);
— Ultrasound of the pelvic organs — allows you to clarify the size of the uterus, the condition of the endometrium to exclude pregnancy, malformations of the uterus and vagina, pathology of the uterine body and endometrium (adenomyosis, polyps or endometrial hyperplasia, endometritis), assess the size and structure, volume of the ovaries, exclude functional cysts - follicular, corpus luteum cysts, exclude space-occupying formations of the uterine appendages;
- hysteroscopy, separate diagnostic curettage of the uterine mucosa.

Differential diagnosis

Bleeding from the genital tract during puberty can be caused by a number of diseases. First of all, it is necessary to carry out a differential diagnosis of MCPP against the background of blood diseases, which are supported by the following features: subcutaneous petechial hemorrhages caused by minor injuries, bleeding from the nose and gums, persistent MVs.

Manual transmission must be differentiated from the following pathological conditions:

1. Defects of the blood coagulation system, thrombocytopenia, aplastic anemia, hereditary disorders of coagulation hemostasis (Von Willebrand disease), hemorrhagic vasculitis (Henoch-Schönlein disease), thrombocytopenic purpura (Werlhoff disease). Girls with Werlhof's disease from an early age suffer from nosebleeds, increased bleeding from cuts and bruises, after tooth extraction, multiple bruises and petechiae are usually visible on the skin of patients.
2. Organic pathology in the reproductive system: abnormal development of the genital organs, hormone-producing ovarian tumors, endometriosis, adenomyosis, cervical and uterine cancer (rare). MK against the background of adenomyosis is characterized by severe dysmenorrhea, prolonged spotting with a characteristic brown tint before and after menstruation. The diagnosis is confirmed by the results of ultrasound and hysteroscopy.
3. In inflammatory diseases of the genital organs, urolithiasis, as a rule, is acyclic in nature. Patients are concerned about pain in the lower abdomen and profuse leucorrhoea outside of menstruation.
4. Trauma to the external genitalia and vagina.
5. Pregnancy with incipient and incomplete abortion.
6. PCOS: with manual transmission with developing PCOS, along with complaints of delayed menstruation, there are excess hair growth, acne on the face, chest, shoulders, back, buttocks and thighs, there are indications of late menarche with progressive menstrual irregularities such as oligomenorrhea.
7. Thyroid gland dysfunction. MCPPs usually occur in patients with subclinical or clinical hypothyroidism. Patients complain of chilliness, swelling, weight gain, memory loss, drowsiness, and depression. In case of hypothyroidism, palpation and ultrasound of the thyroid gland can reveal its enlargement. Patients with hypothyroidism are characterized by dry subicteric skin, pasty tissue, puffiness of the face, enlarged tongue, and bradycardia. The functional state of the thyroid gland can be clarified by determining TSH and free T4 in the blood.
8. Hyperprolactinemia: to exclude hyperprolactinemia as a cause of manual transmission, examination and palpation of the mammary glands with clarification of the nature of the discharge from the nipples, determination of the prolactin content in the blood, and MRI of the brain are indicated.

Basic principles of MK therapy in adolescents

When choosing a treatment method, the intensity of bleeding, the degree of anemia, characteristics of physical and sexual development, data from laboratory examination results, heredity, and the suspected cause of bleeding are taken into account.

When a patient is admitted to a hospital, it is necessary to create a protective treatment regime and conduct a conversation with the patient and her parents aimed at removing negative emotions and fear for their lives.

The basic principles of treatment for manual transmission are:

• stopping bleeding;
• regulation of the menstrual cycle;
• prevention of recurrent bleeding.

In order to stop bleeding and normalize hemostasis, symptomatic therapy is prescribed, including:

• Hemostatic agents. At the first stage of treatment, it is advisable to use hemostatic therapy in the form of drugs that inhibit the transition of plasminogen to plasmin (tranexamic acid or epsilon-aminocaproic acid). The use of fibrinolysis inhibitors is pathogenetically justified, since bleeding that has already begun is intensified due to the fibrinolytic activity of plasmin. Tranexamic acid (Tranexam) completely suppresses the activity of plasmin, stabilizes coagulation factors and fibrin, reduces vascular permeability and gives a hemostatic effect. Tranexam is prescribed per os at a dose of 0.5-1.5 g/day, depending on the severity of metrorrhagia and the clinical effect. Duration of therapy is 3-5 days. Tranexamic acid is more active than epsilon-aminocaproic acid, which is due to its more stable and durable structure. In addition, oral use of the drug in the case of manual transmission is preferable. The antifibrinolytic activity of tranexamic acid in tissues lasts up to 17 hours. The effectiveness of hemostasis with Tranexam is comparable to that with the use of combined oral contraceptives (COCs).
• Uterine contractile agents (Oxytocin 0.5-1.0 ml 2 times a day intramuscularly, water pepper extract 20 drops 3 times a day orally, a decoction of nettle or shepherd's purse).
• Agents that strengthen the vascular wall (Ascorutin, 1 tablet 3 times a day).
• Antianemic and hemostimulating drugs (Ferro-Folgamma, Venofer, Maltofer, Fenyuls).
• Vitamins (vitamins B1 and B6 1.0 ml IM every other day for 20 days; vitamin E 1 capsule 2 times a day orally for 10 days; vitamin C 0.1 g 3 times a day orally or 5% solution 3-5 ml intravenously).
• Sedative therapy (valerian 20 drops 3 times a day orally, Glycine, Grandaxin 1 tablet 2-3 times a day orally for 2-3 months).
• Physiotherapy (endonasal electrophoresis with vitamin B1 for 10 days, acupuncture).

Acupuncture: the effect of acupuncture on both segmental and remote biologically active points of the upper, lower extremities and head. The combination of points and the method of exposure are selected individually under the control of functional diagnostics and determination of gonadotropic and sex hormones in the blood plasma. The clinical effect of acupuncture was not obtained in patients with a history of frequent recurrent diseases, hereditary urticaria in mothers, and subsequently, diseases of the blood coagulation system were identified in these patients.

Indications for acupuncture are MK without anemia and with mild anemia at 10-13 years of age, without significant hormonal imbalance at 14-17 years of age. Repeated, recurrent uterine bleeding with severe and moderate anemia, aggravated by heredity of coagulopathy (frequent nosebleeds, bleeding from the gums, the presence of ecchymosis, dysfunctional uterine bleeding (DUB) in mothers of girls) and the presence of coagulopathy in the subjects are a contraindication to the use of acupuncture.

All patients admitted with MK and identified disorders of the blood coagulation and anticoagulation systems are given specific treatment.

In case of von Willebrand's disease, for hemostatic purposes, along with symptomatic (Tranexam) and hormonal therapy, transfusion therapy is carried out: antihemophilic plasma, Cryoprecipitate.

For thromboasthenia: tranexamic acid 10 mg/kg body weight intravenously or orally for 2-4 days; patients with thrombocytopenic purpura - prednisolone at a rate of 2-8 mg/kg per day.

The use of symptomatic therapy does not have a significant effect on the endocrine status of girls with MC. However, 3 months after treatment, when symptomatic therapy is used in all age groups, the level of estradiol increases to 340 (259-468) nmol/l and progesterone to 4.1 n/mol/l, which indicates the activity of gonadal function. An increase in the level of FSH to 4.9 (0.7-36) IU/l and LH to 9.9 (1.6-58.1) IU/l was noted only in the group of older girls. Cortisol concentrations remain within limits in all age groups.

When using acupuncture, in 61.1% of subjects with manual transmission, 3 months after treatment, ovarian function increased, the cycle became ovulatory (the concentration of progesterone in the blood increased to 14.9-19.9 nmol/l).

According to ultrasound data, with hemostasis by symptomatic means, a progressive enlargement of the ovaries is noted by days 21-23 of the menstrual cycle in all patients compared to those during bleeding. The thickness of the endometrium with this type of hemostasis increases by 1.7 times by days 21-23 of the cycle. This complex is carried out for 3-5 days, depending on the effect and the initial state of the girl’s body. If the dynamics are positive, therapy is continued for another week until a hemostatic effect is achieved.

If symptomatic therapy is ineffective for 4-6 days in patients with mild anemia, 2-3 days in girls with moderate anemia and 6-12 hours in patients with severe anemia, hormonal hemostasis with combined estrogen-gestagen drugs is indicated (Marvelon, Regulon, Rigevidon), against the background of continued administration of symptomatic drugs. Two administration regimens are used: 2-3 tablets per day until hemostasis is achieved, followed by a dose reduction to 1 tablet and a course of treatment of 21 days or 2 tablets per day for 10 days. The latter treatment regimen is more often used in girls with moderate anemia, while the long regimen is used in patients with severe anemia, mainly due to the lack of compensation for blood loss in such a short period of time.

According to indications (continuing heavy bleeding, decrease in Hb below 90 g/l, Ht up to 25%, lack of effect from conservative therapy, including hormonal therapy, suspicion of organic pathology of the endometrium (increase in M-echo on ultrasound over 15 mm) , even against the background of spotting, with the consent of the parents and the patient, surgical hemostasis is performed: separate diagnostic curettage of the mucous membrane of the uterus and cervical canal under the control of hysteroscopy. The operation is performed under intravenous anesthesia. To prevent rupture of the hymen, the area of ​​the vulvar ring is injected with a 0.25% solution of Novocaine with Lidaza (64 units).

Hysteroscopy may reveal glandular cystic endometrial hyperplasia, endometrial polyp, and adenomyosis in the uterus.

The results of a study of erythrocyte aggregation activity indicate that if in girls with mild and moderate anemia after hormonal therapy the intensity of erythrocyte aggregation increases by only 3%, then in patients with severe anemia it increases 1.2 times compared to this indicator before treatment and 1.6 times compared to those in healthy people. In this case, the value of the indicator is 48% of the optical density, reaching 60-65% of the optical density in patients with the most profuse and prolonged bleeding.

The inclusion of Reopoliglucin and fresh frozen plasma in the complex of therapeutic measures for manual transmission is pathogenetically justified, as it affects both the rheological and coagulation properties of the blood of patients and the adaptive capabilities of the body.

If DIC syndrome develops against the background of MK, it is necessary to administer Heparin at the rate of 100 IU/kg per day and intravenous fresh frozen plasma up to 1 liter per day (in 2-3 doses).

All patients with manual transmission are recommended to take iron supplements to prevent iron deficiency anemia. The use of ferrous sulfate in combination with ascorbic and folic acid has been proven to be highly effective. The daily dose of ferrous sulfate is selected taking into account the concentration of hemoglobin in the blood.

Iron deficiency is one of the most common pathological conditions in the world. Among all anemias, the proportion of iron deficiency anemia (IDA) is 70-80%. According to WHO, IDA is detected in 1.8 billion inhabitants of our planet, and iron deficiency is detected in every third inhabitant of the Earth (3.6 billion people).

According to the literature, 85% of young children and more than 30% of school age suffer from iron deficiency. In teenage girls, iron deficiency is most often determined during the growth spurt (pubertal spurt), during menarche, and with the abuse of reduced diets (vegetarianism, deliberate fasting, diet depleted in iron-containing foods). In most people, especially children and women, iron deficiency occurs latently and is detected only by analyzing the electrolyte composition of the blood plasma. Iron is an essential trace element involved in oxygen transport (myoglobin, hemoglobin) and the formation of active redox enzymes (oxidases, hydroxylases, superoxide dismutases). The level of vital iron-containing depot complexes: transferrin, ferritin, hemosiderin, siderochromes and lactoferrin depends on the total iron content in the blood plasma. An imbalance or chronic deficiency of iron in the body contributes to increased accumulation of toxic metals in the nervous system.

In girls with manual transmission, iron deficiency anemia occurs during the formation of menstrual function, which requires treatment. Only iron supplements can eliminate IDA.

Prevention of relapses of manual transmission

After stopping bleeding, an integral component in the treatment of pubertal MK should be a successfully completed period of rehabilitation, which begins after effective treatment with the restoration of the rhythm of menstruation and ends with the appearance of ovulation. On average, its duration is from 2 to 6 months, during which the etiological factors of manual transmission are eliminated, and normalization of the function of the hypothalamic-pituitary-ovarian system is achieved. The following scheme for the rehabilitation period is recommended for all patients with a history of manual transmission:

1. Maintaining a daily routine, proper nutrition, moderate physical activity (the best option for sports activities is visiting the pool).
2. Correction of a traumatic situation at home or at school with the help of a psychologist (if it occurred), sedative therapy for 2-3 months.
3. Sanitation of foci of chronic infection.
4. Normalization of body weight in case of deviation from the norm.
5. Girls 10-13 years old - cyclic vitamin therapy during three menstrual cycles: folic acid 1 tablet per day from the 5th day of the cycle for 10 days; vitamin C 0.5 g 3-4 times a day for 10 days, vitamin E 1 capsule every day for 10 days from the 16th day of the menstrual cycle.
6. For girls 14-17 years old, combined estrogen-gestagen drugs are prescribed no more than three menstrual cycles: short regimen - 2 tablets for 10 days from the 16th day of the cycle, long regimen - 1 tablet per day for 21 days from the 5th day of the cycle.
7. Detection of endometriosis requires clinical observation by a gynecologist and specific conservative treatment: duphaston - 10 mg 2 times a day from 16 to 25 days of the cycle for 6 months, symptomatic therapy during menstruation (Menalgin - for pain, hemostatic drugs (Tranexam) - with hypermenorrhea).
8. If a diagnosis of manual transmission has been established, prophylactic administration of Tranexam at a dose of 0.5-1.0 g/day from the 1st to the 4th day of menstruation for 3-4 menstrual cycles is effective, which reduces the amount of blood loss by 50% and helps increase hemoglobin levels and normalization of the menstrual cycle without the use of hormonal therapy. Even long-term use of Tranexam does not increase the risk of thrombotic complications, since tranexamic acid does not have thrombogenic activity, but prolongs the dissolution of already formed blood clots. The effectiveness of treatment with tranexamic acid is also due to its anti-inflammatory effect.
9. Acupuncture: 2-3 courses of 10 sessions for girls 10-13 years old.
10. Physiotherapy: endonasal electrophoresis with vitamin B1 10 days.
11. Balneo- and thalassotherapy in the summer months without climatic temperature changes.
12. Taking into account the interest of the central regulatory mechanisms of menstrual dysfunction and the identification of pathogenetic factors of urticaria in girls, the following treatment regimen is recommended:

• glycine 0.05 g 3 times for 2 months (the effect of normalizing the processes of excitation and inhibition of the central nervous structures of the brain, sedative effect);
• vitamin E 1 capsule 2 times a day for 10 days (normalization of oxidative processes, improvement of steroidogenesis in the ovaries);
• endonasal electrophoresis with vitamin B1 for 10 days;
• vitamin B6 1 ml intramuscularly once a day for 10 days;
• Nootropil 200-400 mg 2-3 times a day for 30 days (improvement of metabolic processes in nerve cells, brain microcirculation, protective and restorative effect in case of impaired brain function due to hypoxia or intoxication);
• Veroshpiron 0.25 g daily in the morning for 3 weeks (all of the above courses of therapy, taking into account the presence of signs of increased intracranial pressure and signs of endocraniosis, were combined with periodic dehydration therapy). Veroshpiron has a mild diuretic, hypoandrogenic and potassium-sparing effect;
• Asparkam 0.05 g 3 times for 3 weeks (magnesium sedative effect, mild diuretic, hypokalemia-normalizing effect);

This complex of treatment is carried out from the 7th day of the menstrual cycle once a quarter for a year and is combined with physical therapy and psychocorrection by a psychologist. Against the background of complex treatment, in 92-93% of patients, after completion of therapy, the menstrual cycle is restored for a period of 4 to 6 months.

If hormonal abnormalities in the functioning of peripheral endocrine foci (thyroid gland, adrenal glands) are detected, correction is carried out together with an endocrinologist.

Thus, knowledge of the etiology of MCPP determines the choice of etiopathogenetic therapy aimed at eliminating the pathological effect on the central brain structures, improving the trophism of the blood supply to the brain, and normalizing the neurotransmitter link in the regulation of the patient’s basal metabolism. To correct the peripheral link of the hypothalamic-pituitary-gonadal system, it is recommended to prescribe treatment with combined estrogen-gestagen drugs (Zhanin, Diane-35, Regulon, Marvelon, Femoden, etc.), for signs of infantilism, hypoestrogenism, delayed sexual development - cyclic hormone therapy ( Cyclo-Proginova 1 tablet from 5 to 26 days of the cycle for 2-3 cycles or transdermally 2.5 g of Estrogel, when the M-echo increases to 7-8 mm, add Utrozhestan 100 mg 2 times orally for 10 days).

Thus, despite the successes achieved in the diagnosis and development of various methods of treating MCPP, the problem remains relevant.

Forecast

Most adolescent girls respond to drug therapy and develop ovulatory menstrual cycles and normal menstruation within the first year. The prognosis for MCPP associated with pathology of the hemostatic system or systemic chronic diseases depends on the degree of compensation for existing disorders. Girls who remain overweight and have relapses of urticaria at the age of 14-19 years should be included in the risk group for the development of endometrial pathology.

Literature

1. Kokolina V.F. Children's and adolescent gynecology. M.: Medpraktika-M., 2006. P. 174-228.
2. Kokolina V.F. Gynecological endocrinology of childhood and adolescence. M.: Medpraktika-M, 2005. 340 p.
3. Kulakov V.I., Uvarova E.V. Standard principles of examination and treatment of children and adolescents with gynecological diseases and disorders of sexual development. M.: Triada-X, 2004.
4. Endoscopy in gynecology / ed. G. M. Savelyeva. M.: Medicine. 1983. 200 p.
5. Savelyeva G.M. et al. Hysteroscopy. Geotar-med. 1999. pp. 120-130.
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7. Theil P.mL. Ophthlmological examination of patients in long-term treatment with tranexamic acid // Acta Ophthlmo, 1981: 59: 237-241.
8. Lethaby A., Augood C., Duckitt K. Nonsteroidal anti-inflammatory drugs for heavy menstrual bleeding // Cochrane Database Syst Rev. 2002; (1).
9. Lethaby A., Farquhar C., Cooke I. Antifibrinolytics for heavy menstrual bleeding // Cochrane Database Syst Rev. 2000; (4).

V. F. Kokolina, Doctor of Medical Sciences, Professor, Academician of the Russian Academy of Natural Sciences
D. I. Naftalieva

RGMU, Moscow