Uterine hemorrhages of puberty (ICIE) are pathological bleeding caused by abnormalities of the endometrium in adolescent girls with violations of the cyclic production of steroid hormones from the time of the first menstruation to 18 years. Manual transmission is 20-30% among all gynecological diseases of childhood.
Etiology and pathogenesis. The basis of the manual transmission is a violation of the cyclic functioning of the hypothalamic-pituitary-ovarian system. As a result, the rhythm of secretion of releasing hormones, FSH and LH changes, folliculogenesis is disturbed in the ovaries and, as a result, uterine bleeding occurs.
Against the background of dyshormonal changes in the ovary, the growth and maturation of several follicles that undergo atresia begin. In the process of their growth in the body, there is a relative hyperestrogenism, i.e. estrogen levels do not exceed normal levels, but the corpus luteum is absent, so the uterus is influenced only by estrogens. Hormonal dysfunction can also lead to the persistence of a single follicle, and therefore a yellow body does not form. At the same time, the level of estrogen, which has an effect on the endometrium, is significantly higher than the norm – absolute hyperestrogenism.
Often follicular cysts form in the ovaries (82.6%), less often – corpus luteum cysts (17.4%). Regardless of the relative or absolute hyperestrogenism, the uterine mucosa does not reject in time (on menstruation days) and undergoes hyperplastic transformation — glandular cystic hyperplasia develops. In the mucous membrane there is no secretion phase, its excessive proliferation leads to malnutrition and burning off. Rejection may be accompanied by heavy bleeding or stretch in time.
When recurrent manual transmission possible atypical hyperplasia.
Mental and physical stress, overwork, adverse living conditions, vitamin deficiencies, and dysfunction of the thyroid gland and (or) the adrenal cortex contribute to the violation of hormonal regulation in girls with manual transmission. Of great importance in the development of MCPG1 are both acute and chronic infectious diseases (measles, whooping cough, chicken pox, mumps, rubella, acute respiratory viral infections and especially frequent sore throats, chronic tonsillitis). In addition, maternal complications during pregnancy, childbirth, infectious diseases of parents, and artificial feeding may be important.
The clinical picture is the appearance of blood discharge from the genital tract after a delay of menstruation for a period of 14-16 days to 1.5-6 months. Such menstrual irregularities sometimes appear immediately after menarche, sometimes during the first 2 years. In ‘/ 3 girls, they can be repeated. Bleeding can be profuse and lead to anemia, weakness, dizziness. If such bleeding lasts for several days, a violation of blood coagulation by type of DIC may occur for the second time, and then the bleeding increases. In some patients, the bleeding may be moderate, not accompanied by anemia, but last 10-15 days or more.
The manual transmission does not depend on the compliance of the calendar and bone age, as well as on the development of secondary sexual characteristics.
Diagnosis of manual transmission is carried out after hemostasis on the basis of determining the level and nature of changes in the reproductive system.
Diagnosis is based on anamnesis (delayed menstruation) and the appearance of blood discharge from the genital tract. The presence of anemia and the state of the blood coagulation system are determined by laboratory testing (clinical blood analysis, coagulogram, including platelet count, activated partial thromboplastic time, bleeding time and clotting time; biochemical blood test). In the serum determine the level of hormones (FSH, J1 G, prolactin, estrogen, progesterone, cortisol, testosterone, TSH, T3, -T4), conduct tests of functional diagnostics. It is advisable to consult specialists – a neurologist, an endocrinologist, an ophthalmologist (the state of the fundus, determination of color fields of vision). In the intermenstrual gap is recommended to measure the basal temperature. With a single-phase menstrual cycle, the basal temperature is monotonic.
To assess the state of the ovaries and endometrium, ultrasound is performed, and in the case of an undisturbed hymen, using a rectal probe.
In sex workers, the method of choice is to use a vaginal sensor. On the echogram in patients with manual transmission, there is a slight tendency to an increase in the volume of the ovaries between the bleeding periods. Clinical and echographic signs of persistent follicle: echo-negative formation of a rounded shape with a diameter of 2 to 5 cm, with clear contours in one or both ovaries.
After stopping the bleeding, it is necessary to clarify as accurately as possible the preferential defeat of the regulatory system of reproduction. For this purpose, the development of secondary sexual characteristics and bone age, physical development are evaluated, an x-ray of the skull with a projection of the Turkish saddle is used; Echo EEG, EEG; according to indications – CT or MRI (to exclude a pituitary tumor); echography of the adrenal glands and thyroid gland. Ultrasound, especially with Doppler, should be carried out in dynamics, since it can visualize atretic and persistent follicles, mature follicle, ovulation, formation of the corpus luteum.
Differential diagnosis of manual transmission is carried out before all with the beginning and incomplete abortion, which is easily eliminated with the help of ultrasound. Uterine bleeding in the pubertal period is not only functional; they may also be symptoms of other diseases. One of the first places is taken by idiopathic autoimmune thrombocytopenic purpura (Verlgof’s disease). Autoantibodies against platelets in the body destroy the most important hemocoagulation factors and cause bleeding. This congenital pathology proceeds with periods of remission and deterioration. Girls with Verlgof’s disease already from early childhood suffer from nosebleeds, bleeding from cuts and bruises, after the extraction of teeth. The first menstruation in patients with Verlgof’s disease turns into bleeding, which is a differential diagnostic sign. On the skin of patients, as a rule, multiple bruising, petechiae are visible. Diagnosing the diagnosis of Verlgof disease helps history and appearance of patients. The diagnosis is clarified on the basis of blood tests: a decrease in the number of platelets <70–100 g / l, an increase in blood clotting time, a bleeding time, a change in coagulogram rates. Sometimes it is determined not only thrombocytopenia (low platelet count), but also thrombasthenia (functional deficiency of platelets). In identifying Verlgof’s disease and other blood diseases, treatment is carried out jointly with hematologists. The large doses of dexamethasone used in this case can lead to amenorrhea for the period of treatment.
Manual transmission can be the result of inflammatory changes in the internal genital organs, including endometrial tuberculosis, cervical and uterine cancers (rare).
Treatment of uterine bleeding is carried out in 2 stages. At the 1st stage, hemostasis is performed, at the 2nd stage – therapy aimed at preventing recurrence of bleeding and regulation of the menstrual cycle.
When choosing a method of hemostasis, it is necessary to consider the general condition of the patient and the amount of blood loss. Patients with unexpressed anemia (Hb level> 100 g / l, hematocrit> 30%) and the absence of endometrial hyperplasia according to ultrasound data show symptomatic hemostatic therapy. Uterus-reducing agents are prescribed: oxytocin, haemostatic agents (ethamylate, tranexamic acid, Ascorutin *). A good hemostatic effect is given by the combination of the indicated therapy with physiotherapy — the applied sinusoidal modulated currents in the region of the cervical sympathetic ganglia (2 procedures a day for 3-5 days), as well as acupuncture or electroacupuncture.
With the ineffectiveness of symptomatic hemostatic therapy, hormonal hemostasis is performed using monophasic combined estrogen-progestin preparations (rigevidon *, marvelon *, regulon *, etc.), which are prescribed 1 tablet every hour (no more than 5 tablets). Bleeding stops, as a rule, within 1 day. Then the dose is gradually reduced to 1 tablet per day. The course of treatment is continued for 10 days (short course) or 21 days. Menstrual-like discharge after stopping estrogen-gestagens are moderate and ends within 5-6 days.
With prolonged and heavy bleeding, when there are symptoms of anemia and hypovolemia, weakness, dizziness, Hb level <70 g / l and hematocrit <20% shows surgical hemostasis – separate diagnostic curettage under the control of hysteroscopy with careful histological examination of scrapings. In order to avoid ruptures, the virgin chaff is cut off with a 0.25% solution of procaine with 64 U of hyaluronidase (lidazaA). For patients with impaired blood coagulation, separate diagnostic curettage is not performed.
Hemostasis is carried out with combined estrogen-progestin preparations, if necessary (as recommended by hematologists) in combination with glucocorticosteroids.
Simultaneously with conservative or surgical treatment, it is necessary to conduct a full anti-anemic therapy: drugs of iron (maltofer *, phenules * orally, venofer * intravenously); cyanocobalamin (vitamin B) with folic acid; pyridoxine (vitamin В6А) inside, ascorbic acid (vitamin O), rutin (rutin *). In extreme cases (Hb level <70 g / l, hematocrit <25%), blood components are poured over — fresh frozen plasma and red blood cell mass.
In order to prevent recurrence of bleeding after complete hemostasis on the background of symptomatic and hemostatic treatment, it is advisable to carry out cyclic vitamin therapy: for 3 months from the 5th to the 15th day of the cycle, folic acid is prescribed – 1 tablet 3 times a day, glutamic acid – 1 pill 3 times a day, pyridoxine – 5% solution 1 ml intramuscularly, vitamin E – 300 mg every other day, and from the 16th to the 25th day of the cycle – ascorbic acid – 0.05 g 2-3 times a day, thiamine (vitamin B, *) – 5% solution of 1 ml intramuscularly. For the regulation of menstrual function, endonasal electrophoresis of lithium, pyridoxine, procaine, and electrosleep is also used. Prevention of bleeding after hormonal hemostasis consists in taking single-phase combined estrogen-progestin drugs (Novinet A, Mercilon A, LogestA, JessA) – 1 tablet starting from the 1st day of the menstrual cycle (for 21 days), or gestagens – didrogesterone ( Dupha-stonA) 10–20 mg per day from the 16th to the 25th day for 2-3 months, followed by a cyclic vitamin therapy. Patients with endometrial hyperplastic processes after curettage, as well as after hormonal hemostasis, should be prevented from relapsing. For this purpose, estrogen-progestin preparations are prescribed or pure progestogens (depending on changes in the ovary, atresia or follicle persistence). Of great importance are measures of general health improvement, hardening, good nutrition, sanitation of foci of infection.
Proper and timely treatment and prevention of relapse. Manual transmissions promote the cyclical functioning of all parts of the reproductive system.