Dysfunctional uterine bleeding

Dysfunctional uterine bleeding (DMK) is one of the forms of menstrual dysfunction caused by a violation of the cyclic production of ovarian hormones. DM K can manifest as meno-, metro- or menometrorrhagias. Functional changes leading to uterine bleeding can be at any level of regulation of menstrual function: in the cerebral cortex, hypothalamus, pituitary, adrenal glands, thyroid, ovaries. DM K recurs and often leads to impaired reproductive function, and hormonal imbalances in DM K lead to the development of hyperplastic processes up to pre-cancer and endometrial cancer.
Depending on the period of life, women emit:
• DM By the juvenile period – 12-17 years (see section “Pediatric gynecology”);• DM By the reproductive period – 18-45 years;
• MQM premenopausal period – 46-55 years

Dysfunctional uterine bleeding of the reproductive period

DM K is about 4-5% gynecological diseases of the reproductive period and remain the most common pathology of the reproductive system of women.

Etiology and pathogenesis. Etiological factors can be stressful situations, climate change, mental and physical overwork, occupational hazards. Along with the great importance of primary disorders in the cortex-hypothalamus-pituitary system, primary disorders at the ovarian level play a smaller role. The cause of the ovulation disorder can be inflammatory and infectious diseases, under the influence of which the thickening of the ovarian tunica, changes in the blood supply and reduced sensitivity of the ovarian tissue to gonadotropic hormones are possible. Depending on the pathogenetic mechanisms and the clinical and morphological features of the DM of the reproductive period, they are divided into apovulatory and ovulatory.

In the reproductive period, the end result of the hypothalamic-pituitary disorders is anovulation, which can be based on both persistence and follicle atresia. With DM K at reproductive age, the persistence of the follicle with excess estrogen production occurs more often in the ovaries. Since ovulation does not occur and the corpus luteum does not form, a progester-deficient state is created and absolute hyperestrogenism occurs. The persistence of the follicle is like stopping the normal menstrual cycle on time, close to ovulation: the follicle, reaching maturity, does not undergo further physiological transformations, continuing to secrete estrogens. Anovulatory bleeding can be on the background of atresia of the follicle as a result of relative hyperestrogenism. In the ovary, one or more follicles stop at any stage of development, not being subjected to further cyclic transformations, but not ceasing to function until a certain time. Subsequently, the atresisable follicles undergo a reverse development or turn into small cysts. At atresia, the estrogen follicles are few, but due to anovulation, the corpus luteum and the release of progesterone are absent – a state of relative hyperestrogenism develops.

Prolonged exposure to elevated levels of estrogen in the uterus causes excessive growth of the endometrium. An increase in the duration and intensity of proliferative processes in the endometrium leads to hyperplasia with the risk of developing atypical hyperplasia and endometrial adenocarcinoma. Due to the lack of ovulation and the corpus luteum, there is not enough progesterone needed for secretory transformation and normal rejection of the proliferative endometrium. The mechanism of bleeding is associated with vascular changes: congestive, plethora with a sharp expansion of capillaries in the endometrium, disruption of the wound, tissue hypoxia accompanied by dystrophic changes in the uterine mucosa and the appearance of necrotic processes against the background of blood stasis and thrombosis. All of the above leads to prolonged and uneven rejection of the endometrium. The morphological structure of the mucous membrane is variegated: along with the sites of disintegration and rejection there are foci of regeneration.

Ovulatory DMK are usually caused by the persistence of the corpus luteum, which is more often observed after the age of 30 years. Violation of the function of the yellow body is its long-term functional activity. As a result of the persistence of the corpus luteum, the level of gestagens does not fall fast enough or remains at the same level for a long time. Uneven rejection of the functional layer causes prolonged menometrorrhagia. Reducing the tone of the uterus under the influence of elevated levels of progesterone in the blood also contributes to bleeding. At the same time, the corpus luteum does not have signs of reverse development, or along with luteal cells that are in a state of reverse development, there are areas with pronounced signs of functional activity. The persistence of the corpus luteum is indicated by high levels of progesterone in the blood and an echographic picture of the ovaries.

During hemorrhage in the endometrium, the content of prostaglandin F2 is lowered, which enhances vascular contraction, and the content of prostaglandin E2 is increased, which prevents platelet aggregation.

Ovulatory bleeding can also be in the middle of the menstrual cycle, after ovulation. Normally, in the middle of the menstrual cycle, there is a slight decrease in the level of estrogen, but it does not lead to bleeding, since the general hormonal level is maintained by the corpus luteum that begins to function. With a significant and sharp decline in the level of hormones after an ovulatory peak, blood discharge from the genital tract is observed within 2–3 days.

The clinical manifestations of dysfunctional uterine bleeding are usually determined by changes in the ovaries. The main problem in patients with DMK is a complaint about a disturbed rhythm of menstruation: bleeding occurs more often after a delay in menstruation, or menorrhagia is noted. If the persistence of the follicle is short-term, then uterine bleeding in intensity and duration does not differ from normal menstruation. Often the delay is quite long (up to 6-8 weeks), after which there is bleeding. Often, it begins as a moderate one, periodically decreases, increases again and lasts a very long time, leading to anemia and weakening of the body.
MQD due to persistence of the corpus luteum – menstruation, occurring on time or after a short delay. With each new cycle, it is becoming longer and more abundant, turning into menometerorrhagia, lasting up to 1 – 1.5 months. Impaired ovarian function in patients with DMK may lead to a decrease in fertility.

When diagnosing, it is necessary to exclude other causes of bleeding, which in reproductive return may be: benign and malignant diseases of the genital organs, endometriosis, uterine myoma, injuries of the genital organs, inflammation of the uterus and appendages, interrupted uterine and ectopic pregnancy, remnants of the ovum after an artifactual abortion or spontaneous miscarriage, placental polyp after childbirth or abortion. Uterine bleeding occurs when extragenital diseases: diseases of the blood, liver, cardiovascular system, endocrine pathology. The examination should be aimed at eliminating morphological pathology and determining functional disorders in the hypothalamus-pituitary-ovary-uterus system using publicly available, and if necessary, additional examination methods. At the 1st stage, after clinical methods (history study, objective general and gynecological examination), hysteroscopy is performed with separate diagnostic curettage and morphological examination of scrapings.

Careful analysis of anamnestic data helps to clarify the causes of bleeding and allows for differential diagnosis of diseases with similar clinical manifestations. As a rule, the appearance of MQM is preceded by a later menarche, juvenile MQM, which indicates the instability of the reproductive system. Indications of cyclical painful bleeding – menorrhagia or menometorrhagia – may indicate organic pathology (uterine myoma with submucous node, endometrial pathology, adenomyosis).

In general examination, attention is paid to the condition and color of the skin, the distribution of subcutaneous fatty tissue with increased body weight, the severity and prevalence of body hair, stretch bands, the state of the thyroid gland, and mammary glands.

In the absence of blood discharge from the genital tract with a special gynecological examination, signs of hyper- or hypoestrogenism can be detected. With absolute hyperestrogenism, the mucous membrane of the vagina and cervix is ​​juicy, the uterus is somewhat enlarged, sharply positive symptoms of “pupil” and tension of the cervical mucus. With relative hypoestrogenism, the mucous membranes of the vagina and cervix are pale, the symptoms of the “pupil” and the tension of the cervical mucus are weakly positive. In a two-handed study, determine the state of the cervix, the size and consistency of the body and uterus.

The next stage of the survey is an assessment of the functional state of various parts of the reproductive system. Hormonal status is studied with the help of functional diagnostics tests for 3-4 menstrual cycles. The basal temperature at DM K is almost always monophasic. With the persistence of the follicle, a pronounced “pupil” phenomenon is observed during the entire period of delayed menstruation. At atresia of the follicle, the phenomenon of the “pupil” is mild, but persists for a long time. With the persistence of the follicle, there is a significant predominance of orogic cells (KPP 70-80%), the tension of the cervical mucus more than 10 cm, with atresia – small fluctuations of the CAT from 20 to 30%, the tension of the cervical mucus not more than 4 cm.

To assess the patient’s hormonal status, it is advisable to determine the plasma levels of FSH, LH, Prl, estrogens, progesterone, TC, T4, TSH, DHEA and DHEA-C. The level of pregnandiol in the urine and progesterone in the blood indicates a deficiency of the luteal phase in patients with anovulatory DM K.

Diagnosis of thyroid pathology is based on the results of a comprehensive clinical and laboratory examination. An increase in thyroid function, hyperthyroidism, usually leads to the appearance of uterine bleeding. Increased secretion of T3 or T4 and a decrease in the level of TSH make it possible to verify the diagnosis. For the detection of organic diseases of the hypothalamic-pituitary region, an x-ray of the skull and turkish saddle and MRI are used. Ultrasound as a non-invasive research method can be used in dynamics to assess the state of the ovaries, the thickness and structure of the M-echo in patients with DM K, as well as for the differential diagnosis of uterine fibroids, endometriosis, endometrial pathology, pregnancy.

The most important stage of diagnosis is the histological examination of scrapings obtained by separate curettage of the uterine mucosa and cervical canal; curettage with a diagnostic and simultaneously hemostatic target often has to be carried out at the height of bleeding. Separate diagnostic curettage is performed under the control of hysteroscopy. The results of a scraping study for dysfunctional uterine bleeding indicate endometrial hyperplasia and the absence of a secretion stage.

Treatment of patients with DM to the reproductive period depends on the clinical manifestations. When treating a patient with bleeding for therapeutic and diagnostic purposes, it is necessary to perform hysteroscopy and separate diagnostic curettage. This operation stops the bleeding, and subsequent histological examination of scrapings allows you to determine the type of therapy aimed at normalizing the menstrual cycle.

local_offerevent_note February 10, 2019

account_box admin

Leave a Reply

Your email address will not be published. Required fields are marked *