Types and treatment of abnormal uterine bleeding. Abnormal uterine bleeding (AMB)

Abnormal uterine bleeding is general term, which includes any discharge of blood from the genital organ that does not correspond to the normal parameters of menstruation in women of the reproductive period. This pathology is considered one of the most common in medical practice and requires the immediate placement of the woman in medical institution... It is important to understand that the appearance of abnormal bleeding that occurs during the intermenstrual period is a serious threat to female body.

Features of pathology

In the event that the discharge of blood does not correspond to normal menstruation, then experts talk about abnormal uterine bleeding. With such a pathological condition of the female body, menstruation is secreted from the genital tract for a long period and in large quantities. In addition, such heavy periods cause depletion of the patient's body and provoke the development of iron deficiency anemia. Of particular concern and anxiety among specialists is blood from the genital organ, which appears in the intermenstrual period for no reason.

In most cases, the main reason for the development of such pathological condition the patient's body becomes changes in hormonal levels. It is important that a woman can independently distinguish abnormal discharge from ordinary menstruation, which will help to contact a specialist for help in a timely manner.

Young girls are often diagnosed with dysfunctional uterine bleeding, which is accompanied by menstrual irregularities. In patients of reproductive age, such discharge is often observed with the progression in the body of various inflammatory processes and endometriosis.

Dangerous for a woman's health is the appearance of abnormal uterine secretions during menopause, when the functioning of the reproductive system has already ended and menstruation has completely stopped. In most cases, the appearance of blood is considered a dangerous signal that a woman's body is progressing. dangerous disease, and even oncology. Not the last place in the development of such a pathological condition is occupied by hormonal disorders that develop due to the influence of estrogens.

Experts refer to abnormal uterine bleeding and the appearance of bleeding in a disease such as fibroids. With this pathology, menstruation becomes abundant and can occur in the middle of the menstrual cycle.

Types of pathology

There is a medical classification that distinguishes several types of abnormal blood discharge from the genital organ, taking into account the etiological factor:

Discharge of blood that is associated with the pathological state of the uterus. The reasons for the development of such uterine bleeding may be associated with pregnancy and cervical pathologies. In addition, such secretions develop with the progression in the female body of various diseases of the body of the genital organ and with dysfunction of the endometrioid tissue.
Bleeding from the uterus, which has nothing to do with the pathological state of the genital organ. The reasons for the development of such an unpleasant condition may be different. This is the progression in the female body of various diseases of the appendages of the reproductive organ, ovarian tumors of various nature and premature puberty. Taking hormonal contraceptives by a woman. Frequent anovulatory bleeding
Abnormal discharge from the uterus that develops as a result of various systemic diseases. Most often, such a pathological condition of the female body develops with pathologies of the circulatory and nervous system, as well as with violations of the liver and kidneys.
Discharge of blood from the genital organ, which are closely related to iatrogenic factors. The reasons for the development of such a pathological state of the female body are biopsy and cryodestruction. In addition, the selection a large number blood may result from ingestion neurotropic drugs and anticoagulants.
Abnormal bleeding from the uterus of unexplained etiology

Taking into account the nature of the disorder, bleeding of an abnormal nature from the genital organ may have the following manifestations:

Discharge of blood that begins with menstruation in the right time or after a slight delay.
The appearance within 1-2 months of minor bleeding or profuse blood loss, which provoke the development of anemia and require immediate medical attention.
The appearance of discharge from the genital organ with clots, which can be large.
The development of a woman's iron deficiency amenorrhea, which causes the appearance of characteristic symptoms in the form of increased pallor of the skin and an unhealthy appearance.

The development of any bleeding from the genital organ is considered a dangerous pathological condition of the female body, which can result in the death of a woman.

The appointment of a specific treatment for such an ailment is determined by:

The reasons that caused the appearance of blood from the genital organ.
The degree of blood loss.
The general condition of a woman.

With abnormal discharge from the uterus, treatment is aimed at solving the following problems:

Stopping further blood loss.
Carrying out preventive measures to prevent relapse.

In order to find out the cause of bleeding, a specialist assigns laboratory research and a procedure such as colposcopy.

In medical practice, the following methods are used to help stop further development pathological state of the body:

Conducting surgical homeostasis, which is curettage of the uterine cavity.
Appointment of hormonal homeostasis.
Treatment with hemostatic agents.

Every woman is familiar with bloody discharge 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, there are abnormal uterine bleeding. They occur when a disturbance occurs in the body. Most often, such bleeding occurs due to gynecological diseases... In most cases, they are dangerous, as they can have serious consequences.

Identifying abnormal uterine bleeding

Abnormal uterine bleeding is a condition in which the vascular wall of the body or cervix is torn. 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 between periods. Sometimes abnormal uterine bleeding occurs rarely, such as once every few months or years. Also this definition also suitable for long periods of more than 7 days. In addition, 200 ml is considered abnormal for the entire period of "critical days". This problem can occur at any age. Including in adolescents, as well as among women in menopause.

Abnormal uterine bleeding: causes of appearance

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

Diseases of the uterus. Among them: inflammatory processes, ectopic pregnancy or the threat of termination, fibroids, polyps, endometriosis, tuberculosis, cancer, etc.
Pathologies associated with the secretion of hormones by the ovaries. These include: cysts, oncological processes of the appendages, early puberty. Also, bleeding can occur due to dysfunction. thyroid gland, stressful situations taking contraceptives.
Pathologies of the blood (thrombocytopenia), liver or kidneys.
Iatrogenic causes. Bleeding caused by surgery on the uterus or ovaries, the introduction of the IUD. In addition, the use of anticoagulants and other drugs is among iatrogenic reasons.
Their etiology is not completely clear. These bleeding are not associated with diseases of the genital organs and are not caused by any of the other reasons listed. They are believed to arise from a violation hormonal regulation in the brain.

The mechanism of development of bleeding from the genital tract

The pathogenesis of abnormal bleeding depends on what kind of cause they were caused. The mechanism of development in 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). An ectopic pregnancy can proceed as an abortion or tube rupture. 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 the endometrial vessels. When the hormonal function of the ovaries or the brain is disturbed, changes occur in the menstrual cycle. As a result, there may be several ovulations instead of one, or, on the contrary, a complete absence. Taking oral contraceptives has the same mechanism. may cause mechanical damage 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, and the amount of fluid lost (mild, moderate, and severe). By etiology, there are: uterine, ovarian, iatrogenic and dysfunctional bleeding. DMKs differ in character Among them:

Anovulatory uterine bleeding. They are also called single-phase DMC. They arise as a result of short-term persistence or follicular atresia.
Ovulatory (2-phase) DMC. These include hyper- or hypofunction corpus luteum... Most often, this is an abnormal uterine bleeding of the reproductive period.
Polymenorrhea. Blood loss occurs more often than every 20 days.
Promenorrhea. The cycle is not broken, but "critical days" last more than 7 days.
Metrorrhagia. This type of disorder is characterized by erratic bleeding, without a specific interval. They are not related to the menstrual cycle.

Symptoms of uterine bleeding

In most cases, it is impossible to immediately establish the cause of the appearance of blood from the genital tract, since the symptoms are almost the same for all DMC. These include lower abdominal pain, dizziness, and weakness. Also, with constant blood loss, there is a decrease in blood pressure and pallor of the skin. To distinguish DMC among themselves, 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 period 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 have menometrorrhagia. In the climacteric period, bleeding is profuse, prolonged. The interval is 6-8 weeks.

Diagnosis of bleeding from the uterus

To detect abnormal uterine bleeding, it is important to monitor your menstrual cycle and visit your gynecologist periodically. If given diagnosis still confirmed, it is necessary to be examined. To do this, take general analyzes urine and blood (anemia), a smear from the vagina and cervix, 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.

Why are bleeding from the uterus dangerous?

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

How is uterine bleeding treated?

Treatment for abnormal uterine bleeding should be started immediately. First of all, hemostatic therapy is needed. This applies to profuse blood loss. An ice bladder is applied to the uterus area, an erythrocyte mass is injected intravenously or. Surgical treatment is also performed (most often the removal of one of the appendages). With non-abundant bleeding, conservative therapy is prescribed. It depends on the cause of the DMK. In most cases, these are hormonal medicines(drugs "Jess", "Yarina") and hemostatic medicines (solution "Dicinon", tablets "Calcium gluconate", "Ascorutin").

Abnormal uterine bleeding (AMB) - according to modern ideas is an all-encompassing term that refers to any uterine bleeding (i.e. bleeding from the body and cervix) that does not meet the parameters of normal menstruation in a woman of reproductive age.

Parameters of normal menstruation (menstrual cycle). So, by modern views, its duration ranges from 24 to 38 days. The duration of the menstrual phase is normal - 4.5 - 8 days. An objective study of blood loss during menstruation showed that a volume of 30-40 ml should be considered normal. Its upper limit is considered to be 80 ml (which is equivalent to a loss of about 16 mg of iron). It is this hemorrhage that can lead to a decrease in the level of hemoglobin, as well as to the appearance of other signs of iron deficiency anemia.

The frequency of AMK increases with age. So, in the general structure of gynecological diseases, juvenile uterine bleeding is 10%, AMC in the active reproductive period - 25 - 30%, in the late reproductive age- 35 - 55%, and in menopause - up to 55 - 60%. The special clinical significance of AMCs is determined by the fact that they can be a symptom of not only benign diseases, but also precancer and endometrial cancer.

AMK reasons:

not associated with the pathology of the uterus: diseases of the uterine appendages (bleeding after ovarian resection or oophorectomy, uterine bleeding with ovarian tumors, premature sexual maturation), AMC on the background hormone therapy(combined oral contraceptives, progestins, hormone replacement therapy), anovulatory bleeding (menarche, perimenopause, polycystic ovary disease, hypothyroidism, hyperprolactinemia, stress, disorders eating behavior);

systemic pathology: diseases of the blood system, liver diseases, renal failure, congenital hyperplasia of the adrenal cortex, Cushing's syndrome and disease, diseases of the nervous system;

iatrogenic factors: bleeding after resection, electro-, thermo- or cryodestruction of the endometrium, bleeding from the biopsy zone of the cervix, while taking anticoagulants, neurotropic drugs;

AMK of unexplained etiology.

AMK can manifest with regular, heavy (more than 80 ml) and prolonged (more than 7 - 8 days) menstruation - heavy menstrual bleeding(this type of bleeding was referred to as menorrhagia before the introduction of the new classification system). Common causes these bleeding adenomyosis, submucous uterine myoma, coagulopathy, functional disorders of the endometrium. AMK can manifest itself as intermenstrual discharge (previously called metrorrhagia) against the background of a regular cycle. This is more common for endometrial polyps, chronic endometritis, ovulatory dysfunction. AMK is also clinically manifested by irregular, prolonged and (or) profuse bleeding (menometrorrhagia), which often occurs after a delay in menstruation. This type of menstrual irregularity is more common in hyperplasia, precancer, and endometrial cancer. AMK is classified as chronic or acute (FIGO, 2009). Chronic bleeding is uterine bleeding, abnormal in volume, regularity and (or) frequency, observed for 6 months or more, as a rule, does not require immediate medical intervention. Acute bleeding is an episode of profuse bleeding that requires urgent intervention in order to prevent further blood loss. Acute AMK may occur for the first time or against the background of an already existing chronic AMK.

When making a diagnosis of AMK, the first stage of the diagnostic search is to establish the truth of the patient's complaints regarding the presence of bleeding. It should be noted that in 40 - 70% of women who complain of heavy menstruation, an objective assessment does not always determine the amount of blood loss in excess of the norm. In such cases, patients need rather psychological assistance and conducting outreach activities. Conversely, about 40% of patients with menometrorrhagia do not consider their periods heavy. Hence, it is very difficult to give qualitative assessment given clinical symptom based only on the patient's complaints. In this regard, for objectification clinical picture it is advisable to use the method for assessing blood loss developed by Jansen (2001). Women are encouraged to complete a special visual table counting the number of pads or tampons used in different days menstruation with a point assessment of the degree of their getting wet (the maximum point for pads - 20, for tampons - 10). It should be noted that the count corresponds to the standard sanitary material ("normal", "regular"). However, very often patients with menorrhagia use "maxi" or "super" tampons or pads, and sometimes even double their number, and therefore the actual blood loss may exceed the volumes calculated using the unified table. The score of 185 and above is regarded as a metrorrhagia criterion.

The second stage of diagnosis is the establishment of the actual AMK diagnosis after excluding systemic diseases, coagulopathies and organic pathology of the pelvic organs, which can be the cause of bleeding. At this stage, given the difficulties of diagnosis, there can be no trifles in the work of a doctor. So, when interviewing a patient, it is necessary to collect a "menstrual history":

taking medications that cause metrorrhagia: derivatives of steroid hormones (estrogens, progestins, corticosteroids), anticoagulants, psychotropic drugs (phenothiazine series, tricyclic antidepressants, MAO inhibitors, tranquilizers), as well as digoxin, propranolol;

the presence of an IUD in the uterine cavity;

the presence of other diseases: a tendency to bleeding, hypertension, liver disease, hypothyroidism;

previous operations: splenectomy, thyroidectomy, myomectomy, polypectomy, hysteroscopy, diagnostic curettage;

clinical factors combined with metrorrhagia, subject to targeted identification (differential diagnosis with systemic pathology): nosebleeds, bleeding gums, bruising and bruising, bleeding after childbirth or surgery, family history.

In addition to collecting anamnesis and gynecological examination, determination of the concentration of hemoglobin, platelets, von Willebrand factor, clotting time, platelet function, thyroid-stimulating hormone, ultrasound examination (ultrasound) of the pelvic organs are considered important for the diagnosis of AMK. Hysterography is performed in unclear cases, with insufficient information content of transvaginal ultrasound (does not have 100% sensitivity) and the need to clarify focal intrauterine pathology, localization and size of lesions.

MPT is not recommended as a 1st-line diagnostic procedure for AMC (benefits versus cost should be weighed). It is advisable to perform MRI in the presence of multiple uterine fibroids to clarify the topography of the nodes before the planned myomectomy. before embolization uterine arteries, before endometrial ablation, if adenomyosis is suspected, in cases of poor visualization of the uterine cavity to assess the state of the endometrium.

The gold standard for the diagnosis of intrauterine pathology - diagnostic hysteroscopy and endometrial biopsy, which is done primarily to exclude precancerous lesions and endometrial cancer. This study is recommended if there is a suspicion of endometrial pathology, the presence of risk factors for cancer of the uterine body (with excessive exposure to estrogens - PCOS, obesity) and in all patients with AMK after 45 years. To diagnose the causes of AMK, office hysteroscopy is preferred and aspiration biopsy as less traumatic procedures. Endometrial biopsy is informative for diffuse lesions and adequate material sampling.

The main goals of AMK therapy are:

prevention of relapses: restoration of normal functioning of the hypothalamic-pituitary-ovarian system, restoration of ovulation; replenishment of the deficiency of sex steroid hormones.

Today, the implementation of hemostasis is possible both through conservative measures and by surgery. It is advisable to carry out medical hemostasis mainly to women of early and active reproductive age who do not belong to the risk group for the development of hyperproliferative processes of the endometrium, as well as to patients in whom diagnostic curettage was carried out no more than 3 months ago, and it was not revealed pathological changes in the endometrium.

Among drug methods hemostasis in AMC with proven efficacy should be noted antifibrinolytic drugs (tranexamic acid) and non-steroidal anti-inflammatory drugs (NSAIDs). However, until now the most effective among conservative methods of stopping bleeding is hormonal hemostasis with monophasic oral contraceptives containing 0.03 mg of ethinylestradiol and progestogens of the norsteroid group and having a pronounced suppressive effect on the endometrium. Much less often in clinical practice used gestagenic hemostasis, which is pathogenetically justified in anovulatory hyperestrogenic bleeding.

Surgical hemostasis is provided primarily by fractional curettage of the uterine cavity and cervical canal under hysteroscopic control. This operation pursues both diagnostic (to exclude organic pathology of the uterine cavity) and therapeutic purpose, and is the method of choice in women of late reproductive and climacteric periods, given the increase in the frequency of atypical transformation of the endometrium in these age groups. When pubertal bleeding this operation is possible only for health reasons.

Relapse prevention. General principles of anti-relapse treatment of AMK: 1. Carrying out general strengthening measures - regulation of sleep, work and rest, rational nutrition, compliance with the rules psychological hygiene... 2. Treatment of anemia (iron supplements, multivitamins and mineral remedies, v severe cases- blood substitutes and blood products). 3. Inhibitors of prostaglandin synthesis in the first 1 - 3 days of menstruation. 4. Antifibrinolytics in the first 1 - 3 days of menstruation (tranexamic acid). 5. Vitamin therapy - complex preparations containing zinc. 6. Drugs that stabilize the function of the central nervous system. Non-hormonal drugs are recommended for both ovulatory and anovulatory bleeding. 7. Hormone therapy is prescribed differentially depending on the pathogenetic variant of AMK: in the juvenile period - cyclic hormone therapy with estrogen-gestagens for 3 months, gestagens in the 2nd phase of the menstrual cycle up to 6 months; in the reproductive period - cyclic hormone therapy with estrogen-gestagens for 3 months, gestagens in the 2nd phase of the menstrual cycle up to 6 months; in the climacteric period - it is necessary to turn off the function of the ovaries (gestagens in a continuous mode - 6 months).

Most frequent indication to emergency hospitalization in gynecological practice are uterine bleeding (MC), while this pathology accounts for one third of all visits to the gynecologist. Up to 65% of women of reproductive age consult a specialist for excessive menstrual bleeding (Herve Fernandez, 2007).

Despite the achievements of modern medicine, even in developed countries the frequency of surgical interventions for MV remains high. So, in the United States, this pathology is an indication for 300,000 hysterectomies performed annually. Often, due to MC, it develops Iron-deficiency anemia, which is an extremely unfavorable footing in the presence of other somatic diseases... The importance of this problem is also due to the fact that it is an economic burden for the patient, since the average length of stay of a woman on sick leave due to menstrual disorders exceeds 10 days. This practically correlates with the disability in salpingo-oophoritis and other inflammatory diseases of the pelvic organs. Besides, material costs on hygiene products and medicines, as well as the constant expectation of bleeding create the preconditions for the psychological discomfort of women, significantly reducing their quality of life.

In 2005, in Washington, experts from 35 different countries presented reports on the problems of diagnosis, treatment, and terminology of MC. It was found that differences and diversity in the definition of the term "dysfunctional uterine bleeding" (DUH) often lead to incorrect interpretation of these scientific developments, complicate mutual understanding and training of specialists, as well as the conduct of multinational clinical research... V different countries, schools, teaching aids, clinical guidelines different definitions of DMC have been given, and clinicians different countries understand this term differently. So, in some countries (for example, in the United States), this term meant any abnormal bleeding that was regarded as a symptom, while in others (in particular in many European countries), DMK was a diagnosis that included ovulatory and anovulatory bleeding.

As a result of the discussion of the problem, the concept of the need to revise the term "dysfunctional uterine bleeding" was put forward, which received support from WHO, the International Federation of Obstetricians and Gynecologists (FIGO), the American Society for Reproductive Medicine (ASRM), the European Society for Human Reproduction and Embryology (ESHRE), National Institute US Health (NIH), American College of Obstetricians and Gynecologists (ACOG), Royal College of Obstetricians and Gynecologists of Great Britain (RCOG), European College of Obstetricians and Gynecologists (ECOG), New Zealand College of Obstetricians and Gynecologists (RANZCOG). It was recommended to move away from the terms of Greek and Latin origin and replace them with simple, clear terms that are understandable to women and men in different societies, doctors of different specialties, easily translated into any language. Thus, the overarching term "abnormal uterine bleeding" (AMB) was introduced, meaning any MC that does not meet the parameters of normal menstruation in a woman of reproductive age.

It is known that the normal menstrual cycle is characterized by regularity, lasting 24-38 days with a duration of menstrual bleeding for 4-8 days and blood loss of no more than 80 ml (Table 1).

AMK includes terms such as heavy menstrual bleeding (HMB), which means more volume or duration of menstruation, as well as irregular menstrual bleeding and prolonged menstrual bleeding. Moreover, anemia is not a mandatory criterion for severe MC.

The main components of severe MC are: the patient's physical, emotional, social and material discomfort.

It should be noted that AMK includes bleeding from the body and cervix, but not from the vagina and vulva.

Table 1.
Characteristics of the menstrual cycle

Rice. 1. AMK as a result of ovarian dysfunction

At the XIX World Congress of obstetrics and gynecology of the International Federation of Obstetricians and Gynecologists (FIGO) Malcolm Mumo proposed the MK classification, which was published in the book Abnormal Uterine Bleeding (2010). According to this classification, based on the etiological factor, AMK is isolated:

1.Due to the pathology of the uterus:

pregnancy-related (spontaneous abortion, placental polyp, trophoblastic disease, impaired ectopic pregnancy);
diseases of the cervix (cervical endometriosis, atrophic cervicitis, endocervical polyp, cervical cancer and other neoplasms of the cervix, uterine myoma with a cervical node);
diseases of the uterine body (uterine myoma, endometrial polyp, internal endometriosis of the uterus, hyperplastic processes of the endometrium and endometrial cancer, sarcoma of the uterine body, endometritis, genital tuberculosis, arteriovenous uterine anomaly);
endometrial dysfunction (this also includes ovulatory bleeding and bleeding against the background of chronic endometritis).

2.Not associated with uterine pathology:

diseases of the uterine appendages (bleeding after ovarian resection or ovariectomy, MK with ovarian tumors and against the background of inflammatory processes of the appendages, premature puberty);
against the background of hormonal therapy (COCs, progestins, HRT);
anovulatory bleeding (in puberty or perimenopause, polycystic ovary, thyroid dysfunction, hyperprolactinemia, stress or eating disorders, etc.).

3. Due to systemic pathology: diseases of the blood system, liver diseases, renal failure, congenital hyperplasia of the adrenal cortex, Cushing's syndrome and disease, diseases of the nervous system.

4. Associated with iatrogenic factors: after resection, electro-, thermo- or cryo-destruction of the endometrium, bleeding from the biopsy zone of the cervix, while taking anticoagulants, neurotropic drugs, etc.

5. Unexplained etiology.

For many years of studying this pathology, various theories of the mechanisms of development of uterine bleeding have been put forward. In addition to the classic “hormonal” concept of menstrual bleeding by Magkee, there is an “inflammatory” hypothesis by Finn (1986), which is based on certain changes in the endometrium in the late secretion phase: tissue edema, migration of leukocytes and the presence of decidual cells with signs of tissue fibroblasts. L.A. Salamonsen et al. (2002) put forward a different concept, according to which MK is an active process under the control of matrix metalloproteinases and depending on their activity. A decrease in the concentration of progesterone in the late secretory phase is a key factor that changes the equilibrium in the ratio of metalloproteinase inhibitors and matrix metalloproteinases (MMP) themselves towards the latter. These proteolytic enzymes (MMP-1, MMP-3, MMP-9) destroy the extracellular matrix and promote rejection of the upper two-thirds of the endometrium. Proinflammatory cytokines (interleukins types 1 and 8, tumor necrosis factor-alpha) are indirectly involved in this process, influencing the processes of angiogenesis, endometrial remodeling and the recruitment of leukocytes, which also produce MMPs.

The emergence of MC is determined not only by the level of sex steroid hormones, but also by the local production of other biologically active molecules: prostaglandins, cytokines, growth factors. A shift in the ratio between the endometrial content of the prostaglandin F2a vasoconstrictor and the prostaglandin E2 vasodilator may be one of the causes of ovulatory AMC. At the same time, an increase in the concentration of prostaglandins with a decrease in progesterone levels can increase blood loss during menstruation. The endometrium expresses inducers of angiogenesis and most of the factors that block angiogenesis. Experts have suggested that the cause of AMC may be pathology at the level of angiogenesis. For example, relative hyperestrogenism induces the synthesis of vascular endothelial growth factor, which promotes angiogenesis in the endometrium, as well as nitric oxide (an endothelial relaxing factor), which affects excess menstrual blood loss. Endometrial endothelin is a powerful vasoconstrictor. The lack of their production can increase the duration of bleeding and thus contribute to the occurrence of menorrhagias.

Given the variety of causes and mechanisms of AMK development, therapy and their prevention should be complex and selected individually depending on the severity of bleeding, the woman's age, reproductive history and, most importantly, the etiology of bleeding. Understanding the mechanisms of AMK development helps in the correct selection of therapy during the correction of hormonal dysfunction (Fig. 1, 2).

DMC or, according to the latest terminology, AMK of a functional nature are divided into ovulatory and anovulatory. Anovulatory estrogenic breakthrough bleeding occurs with prolonged exposure to low doses of estrogen with follicle atresia, i.e. relative hyperestrogenism against a background of low estrogen content or with persistence of the follicle, leading to absolute hyperestrogenism.

Anovulatory estrogenic withdrawal bleeding occurs with estrogen withdrawal or after bilateral ovariectomy.

Breakthrough gestagenic bleeding occurs with the use of prolonged hestagenic drugs (normoplant, depot-pro-vera, etc.) or with prolonged administration of oral gestagens. In this case, there is an increase and decidualization of the endometrial stroma with underdevelopment of the glands, which leads to uneven focal rejection of the endometrium and the appearance of bleeding.

Progestogen withdrawal bleeding occurs after a decrease in the concentration of progesterone, for example, during a progesterone test for amenorrhea. MC therapy ultimately comes down to solving two main problems: stopping bleeding and preventing its recurrence (Table 2) and can be carried out both with the use of surgical interventions and medication.

To stop the AMK, both surgical and conservative methods... At the first stage of the stop acute bleeding in most cases, surgical hemostasis, or hysteroscopy, or separate diagnostic curettage of the cervical canal and the uterine cavity, in combination with symptomatic therapy, is used. For the purpose of complex hemostatic therapy of AMK, it is recommended to use non-steroidal anti-inflammatory drugs that block prostaglandin synthetase and allow to achieve a 30-50% reduction in the volume of lost blood, as well as antifibrinolytic drugs (tranexamic acid) that inhibit the conversion of plasminogen into plasmin.

Rice. 2. Anovulatory bleeding

As for hormonal hemostasis, its use is pathogenetically justified in dyshormonal disorders, primarily in juvenile bleeding, the cause of which is most often anovulation, due to the immaturity of the hypothalamic-pituitary system and the absence of the formed circhoral rhythm of luliberin. The use of hormonal hemostasis at reproductive age is acceptable in the treatment of young nulliparous patients in whom organic pathology is excluded, as well as in women who underwent a histological examination of the endometrium no more than three months ago, and no precancerous or neoplastic endometrial processes were detected.

Treatment methods
Surgical		Conservative
Radical	Minimally invasive
Hysterectomy Myomectomy	Uterine artery embolization, laparoscopic uterine artery occlusion Cryo / radio / U3-ablation of endometrium or fibroid nodes Hysteroscopic resection of endometrium or nodes, polyps Endometrial thermoablation	Gestagens Local hormone therapy (pevonorgestrel releasing intrauterine system [LAN]) Selective progesterone receptor modulators Agonists / antagonists of gonadotropic riping hormones Antiestrogens, androgens Fibrinolysis inhibitors Cyclooxygenase inhibitors

Table 2.
AMK treatment methods

Options	NLF	Anovulation
Options	NLF	Hypoestrogenic	Hyperestrogenic
MC characteristic	Regular	Irregular	Irregular
MC duration (days)	22-30	< 22 и/или 35	> 35
Endometrial thickness on the 21-23rd day of MC (mm)	< 10	< 8	> 14
Follicle maximum diameter (mm)	16-18	< 7	> 25
Progesterone, 21-23 day MC (nmol / l)	15-20	< 15	< 15
Estradiol, 21-23 day MC (pg / l)	51-300	< 50	> 301
Histological examination of the endometrium	Inadequate secretory transformation	Atrophic or proliferative changes	Hyperplastic processes

Table 3.
principles of diagnosis of NLF hyper and hypoestrogenic anovulation
MC * -menstrual cycle

Considering that the growth of the epithelium of the endometrial glands is provided by estrogens, the fastest hemostatic effect is achieved when using hormonal drugs with an estrogenic component. For hormonal hemostasis, monophasic COCs containing 30-50 μg of ethinyl-estradiol are successfully used, according to a special hemostatic scheme with a gradual decrease in the dose of hormones: 4 tab. a day before hemostasis and then 3 tablets. 3 days, 2 tab. 3 days and then 1 table. up to 21 days of admission (LE: 11-1, B). Gestagenic hemostasis is achieved more slowly than when using COCs, therefore, its use is advisable only in cases of contraindications to estrogens. Therapy with gestagens is usually carried out at the second stage of AMK treatment - to prevent relapses. Preparations of the gestagenic group are especially indicated in cases ovulatory bleeding caused by luteal phase insufficiency (LF) (level of evidence H-3, B).

The main tasks of anti-relapse therapy are: normalization of the hypothalamic-pituitary-ovarian system, restoration of ovulation, replenishment of the deficiency of sex steroid hormones. Therefore, it is extremely important to correctly understand the type of bleeding, which will ensure correct selection and the dose of drugs (Table 3).

Pathogenetic therapy in young patients is to restore the menstrual cycle. The Federation of Obstetrician-Gynecological Societies of India (FOGSI) guidelines for the treatment of AMK in young girls provide recommendations for cyclic progestagen therapy (3 consecutive cycles) for 14 days, starting on the 11th day of the menstrual cycle. With the development of anovulatory AMK in a hypoestrogenic type, COCs are prescribed in a cyclic mode (if contraception is necessary) or HRT drugs with a minimum content of estradiol and adequate - progesterone. With anovulatory AM K of the hyperestrogenic type, due to hormonal dysfunction, the processes of proliferation and secretory transformation of the endometrium are disrupted, which lead to endometrial hyperplasia, which is the substrate of bleeding. That is why oral and intravaginal forms of gestagens are used to prevent this kind of disorders. selective action in cyclic mode or gestagens in the form of local action in continuous mode (LAN).

Gestagens induce regular rejection of the uterine mucosa, reduce the mitotic activity of myometrial cells, prevent the proliferation of the endometrium and cause its complete secretory transformation, as well as increase the number of platelets and reduce the level of prostaglandins in endometrial cells.

With ovulatory AMK, most often associated with NLF, bleeding occurs due to insufficient secretory transformation of the endometrium due to a weak or reduced time of action of gestagens. Therefore, in such cases, it is progestins that are the most pathogenetically justified method of treating AMK, contributing to the full-fledged secretory transformation of the endometrium for 12-14 days and, accordingly, its adequate rejection.

In our clinic, we studied the effectiveness of anti-relapse therapy with gestagens in 30 young women with reproductive plans with DMC, which corresponds to the term AMC of the ovulatory type against the background of NLF. The average age of women is 36.3 ± 3.8 years. The concentration of progesterone in plasma on the 21st day of the cycle averaged 3.96 ± 1.2 ng / ml, estradiol - 281.56 ± 21.2 pg / ml, which characterized their hormonal status as relative hypoluteinism. As the first stage of treatment, all subjects underwent fractional curettage of the uterine cavity. Histological examination of the endometrium revealed no atypical changes. This group included women with morphological features insufficient secretory transformation of the endometrium and the absence of hyperplastic processes in the endometrium. For the purpose of secondary prevention of AMK development, women after surgery were prescribed dydrogesterone (Dufaston®) 10 mg twice a day from the 11th to the 25th day of the menstrual cycle for 6 months.

The appointment of dydrogesterone to this contingent of women was due to the fact that it binds almost exclusively to progesterone receptors and does not show affinity for androgenic, estrogenic, glucocorticoid and mineralocorticoid receptors, i.e. has no estrogenic, androgenic or adenocorticoid effects, cannot be converted to estrogens and has selective antiestrogenic activity against the endometrium. In addition, di-drogesterone does not affect blood coagulation indicators, blood lipids and glucose / insulin parameters, is not hepatotoxic and does not cause an increase in body temperature, and does not significantly affect the water-electrolyte balance. Preclinical studies have shown that dydrogesterone has no mutagenic, teratogenic, or carcinogenic potential. In addition, the difference between dydrogesterone and other gestagens is its lack of antigonadotropic activity, as a result of which there is no inhibition of ovulation and the synthesis of endogenous progesterone. This property makes it possible to prescribe the drug from the 11th day of the menstrual cycle without blocking ovulation. Thus, the optimal duration of the gestagenic effect (14 days) is achieved, which is necessary for a full-fledged secretory transformation of the endometrium, which is not accompanied by suppression of ovarian function.

Patients in our study were monitored after 3 and 6 months of anti-relapse therapy. The main complaint of patients before treatment in 93.3% of cases was disturbances in the rhythm of menstruation with a tendency to delays, as well as an increase in the profusion and duration of bleeding, which was accompanied by symptoms in 36.7% of cases. general weakness, decreased performance, drowsiness. An objective study of the indicators of menstrual bleeding revealed their reliable stabilization after 3 months of treatment. Normalization of the duration of the menstrual cycle (29 ± 2.4 days) was noted by all the subjects already at the first monitoring. Average duration periods decreased from 9.4 ± 1.7 to 5.3 ± 0.8 days after 3 months and to 4.5 ± 0.7 for after 6 months of therapy (p1 -2, p1 -3< 0,05). Объем менструальных кровопотерь (по шкале Янсена) также достоверно снизился с 245 ± 50 до 115 ± 30 баллов через 3 мес и до 95 ± 20 баллов к концу исследования (р1-2, р1-3 < 0,05). Наши данные согласуются с результатами ряда исследований по применению Дуфастона в лечении и secondary prevention AMK (DMK).

The efficacy of dydrogesterone in the treatment of DMK has been proven in several randomized trials. So, in 2002, a prospective study was conducted with the participation of 100 patients of reproductive and perimenopausal age with menstrual irregularities in the form of irregular, prolonged and heavy menstruation, in whom organic pathology was excluded. All women took dydrogesterone during the second phase of the menstrual cycle for 3-6 months. As a result of therapy, 85 patients restored the regularity of the menstrual cycle, decreased the volume and duration of menstrual bleeding, which averaged 4.5 days. In addition, a decrease in the intensity of pain during menstruation and a good tolerability of dydrogesterone therapy were noted.

The results of an open, prospective multicenter study, in which 352 patients participated, also indicate the effectiveness of dydrogesterone in the treatment of DMC when administered at a dose of 10 mg from the 11th to the 25th day of the cycle for three menstrual cycles. The general assessment by doctors of the effectiveness of dydrogesterone treatment was excellent and good in 84.84% of patients with polymenorrhea, 81% with oligomenorrhea, and 73.6% with metrorrhagia. In patients with polymenorrhea, a statistically significant decrease in the duration of bleeding and normalization of the duration of the menstrual cycle were observed from the third cycle of therapy and persisted during the observation period after discontinuation of treatment.

Similar results were also obtained in studies by Saldanha et al. , which showed that the use of dydrogesterone at a dose of 10 mg from the 11th to the 25th day of the menstrual cycle for three cycles helps to normalize the menstrual cycle in 91.6% of women with menstrual irregularities.

Dydrogesterone has a pronounced progestogenic and antiestrogenic effect on the endometrium in women. King and Whitehead note in their publication that dydrogesterone 10 mg produces effects equivalent to or superior to changes in the secretory phase of the normal ovulatory cycle, and Lane et al. report the antiestrogenic effect of dydrogesterone.

As for relapses of AMK and the lack of effect of conservative therapy, in this case, the possibility of surgical treatment should be considered. In this situation, along with the traditional ones (hysterectomy, pangisterectomy), modern medicine successfully uses endoscopic technologies: №: UV laser thermal and cryoablation, diathermic rollerball and radio wave ablation, and even, if necessary, endometrial resection. These methods allow you to preserve the organ and avoid hysterectomy caused only by bleeding, and are also minimally invasive methods that provide a short duration of anesthesia and hospitalization, the possibility of outpatient, a decrease in the incidence of postoperative complications, a shortening of the recovery time and a decrease in the cost of treatment.

Thus, an adequate anti-relapse, pathogenetically justified treatment of AMK with the use of gestagenic therapy, aimed at eliminating progesterone deficiency, allows to restore the normal menstrual function and quality of life of patients, creates the possibility of implementing reproductive plans, ensures the prevention of hyperplastic processes and avoids volumetric surgical interventions and associated risks. The use of progestogens, in particular Dufaston, in the treatment of AMC associated with progesterone deficiency, is a pathogenetically substantiated and effective method of treating and preventing this pathology.

The list of literature in the amount of 23 sources is presented on the website www.reproduct-endo.com.ua

The gynecologist is often faced with the task of diagnosis and treatment (AMC). Complaints about abnormal uterine bleeding (AMB) account for more than a third of all complaints presented during a visit to a gynecologist. The fact that half of the indications for hysterectomy in the United States are abnormal uterine bleeding (UBH) indicates how serious the problem can be.

Inability to detect any histological pathology 20% of specimens removed during hysterectomy indicate that the cause of such bleeding may be potentially curable hormonal or somatic conditions.

Each gynecologist should strive to find the most appropriate, cost-effective and successful treatment for uterine bleeding (UH). Accurate diagnosis and adequate treatment depends on the knowledge of the most probable causes uterine bleeding (MC). and the most common symptoms that express them.

Abnormal(AMK) is an umbrella term used to describe uterine bleeding that goes beyond the parameters of normal menstruation in women of childbearing age. Abnormal uterine bleeding (AMB) does not include bleeding if its source is located below the uterus (for example, bleeding from the vagina and vulva).

Usually to abnormal uterine bleeding(AMK) refers to bleeding originating from the cervix or the fundus of the uterus, and since it is clinically difficult to distinguish between them, in uterine bleeding, both options must be taken into account. Pathological bleeding may also occur in childhood and after menopause.

What is meant by normal menstruation, is somewhat subjective, and often differs in different women, and even more so in different cultures... Despite this, normal menstruation (eumenorrhea) is considered to be uterine bleeding after ovulation, occurring every 21-35 days, lasting 3-7 days, and not excessive.

Total blood loss for period of normal menstruation is no more than 80 ml, although the exact volume is difficult to determine clinically due to great content in the menstrual flow of the rejected layer of the endometrium. Normal menstruation does not cause serious pain and does not require the patient to replace the sanitary napkin or tampon more often than 1 time per hour. There are no visible clots in normal menstrual flow. Therefore, abnormal uterine bleeding (AMB) is any uterine bleeding that goes beyond the parameters set out above.

For description abnormal uterine bleeding(AMK) the following terms are often used.
Dysmenorrhea is painful menstruation.
Polymenorrhea - frequent menstruation at intervals of less than 21 days.
Menorrhagia - excessive menstrual bleeding: the volume of discharge is more than 80 ml, the duration is more than 7 days. Moreover, regular ovulatory cycles persist.
Metrorrhagia - menses with irregular intervals between them.
Menometrorrhagia - menstruation with irregular intervals between them, excess in volume and / or duration.

Oligomenorrhea - menstruation that occurs less often than 9 times a year (that is, with an average interval of more than 40 days).
Hypomenorrhea - menstruation, insufficient (scanty) in terms of the volume of secretions or their duration.
Intermenstrual bleeding is bleeding from the uterus between manifest periods.
Amenorrhea - absence of menses for at least 6 months, or just three menstrual cycle in year.
Postmenopausal uterine bleeding - uterine bleeding 12 months after the end of menstrual cycles.

Such classification of abnormal uterine bleeding(AMK) can be helpful in establishing its cause and diagnosis. However, due to the existing differences in the manifestations of abnormal uterine bleeding (AMB) and the frequent existence of several reasons, the clinical picture of AMB alone is not enough to exclude a number of common diseases.

Dysfunctional uterine bleeding is an obsolete diagnostic term. Dysfunctional uterine bleeding is the traditional term used to describe excess uterine bleeding when the pathology of the uterus could not be identified. However, a deeper understanding of the issue of pathological uterine bleeding and the emergence of improved diagnostic methods have made this term obsolete.

In most cases uterine bleeding not associated with uterine pathology are associated with the following reasons:
chronic anovulation (PCOS and related conditions);
the use of hormonal drugs (for example, contraceptives, HRT);
disorders of hemostasis (for example, von Willebrand disease).

In many cases that in the past would have been attributed to dysfunctional uterine bleeding, modern medicine, using new diagnostic methods, identifies uterine and systemic disorders of the following categories:
causing anovulation (eg, hypothyroidism);
caused by anovulation (in particular, hyperplasia or cancer);
accompanying bleeding during anovulation, but can be both associated with abnormal uterine bleeding (AMB), and not associated with it (for example, leiomyoma).

WITH clinical point vision treatment will always be more effective if it is possible to determine cause of uterine bleeding(MK). Because the grouping of different cases of uterine bleeding (UH) into one not well-defined group is not conducive to diagnosis and treatment, the American Consensus Panel recently announced that the term "dysfunctional uterine bleeding" is no longer necessary in clinical medicine.