Abnormal bleeding during puberty. Profuse menses during puberty. Stage I. Stopping bleeding

Abnormal uterine bleeding

The urgency of the problem.

Classification of menstrual irregularities.

Etiology.

Diagnostic criteria of the NMC.

Tactics, principles of conservative and surgical treatment.

Prevention, rehabilitation.

At the heart of primary and secondary menstrual irregularities, the main role belongs to hypothalamic factors, according to the scheme: puberty is the process of the formation of the rhythm of luliberin secretion from its complete absence (in the premenarch), followed by a gradual increase in the frequency and amplitude of impulses until the rhythm of an adult woman is established. In the initial stage, the level of RG-HT secretion is insufficient for the onset of menarche, then for ovulation, and later for the formation of a full-fledged corpus luteum. Secondary forms of menstrual irregularities in women, proceeding according to the type of corpus luteum insufficiency, anovulation, oligomenorrhea, amenorrhea, are considered as stages of one pathological process, the manifestations of which depend on the secretion of luliberin (Leyendecker G., 1983). In maintaining the rhythm of HT secretion, the leading role belongs to estradiol and progesterone.

Thus, the synthesis of gonadotropins (HT) is controlled by hypothalamic GnRH and peripheral ovarian steroids by the mechanism of positive and negative feedback. An example of negative feedback is the increase in FSH secretion at the beginning of the menstrual cycle in response to a decrease in estradiol levels. Under the influence of FSH, follicle growth and maturation occurs: proliferation of granulosa cells; synthesis of LH receptors on the surface of granulosa cells; synthesis of aromatases involved in the metabolism of androgens to estrogens; promoting ovulation in conjunction with LH. Under the influence of LH, androgens are synthesized in the theca cells of the follicle; synthesis of estradiol in the granulosa cells of the dominant follicle; stimulation of ovulation; synthesis of progesterone in luteinized granulosa cells. Ovulation occurs when the maximum level of estradiol in the preovulatory follicle is reached, which, through a positive feedback mechanism, stimulates the preovulatory release of LH and FSH by the pituitary gland. Ovulation occurs 10-12 hours after the LH peak or 24-36 hours after the estradiol peak. After ovulation, granulosa cells undergo luteinization with the formation of a corpus luteum, under the influence of progesterone-secreting LH.

The structural formation of the corpus luteum is completed by the 7th day after ovulation, during this period there is a continuous increase in the concentration of sex hormones in the blood.

After ovulation in phase II of the cycle, there is an increase in the concentration of progesterone in the blood compared to the basal level (4-5th day of the menstrual cycle) 10 times. To diagnose reproductive dysfunctions, the concentration of hormones in the blood is determined in phase II of the cycle: progesterone and estradiol, the combined action of these hormones provides the preparation of the endometrium for blastocyst implantation; sex steroid-binding globulins (PSGS), the synthesis of which occurs in the liver under the influence of insulin, testosterone and estradiol. Albumin is involved in the binding of sex steroids. The immunological method for the study of blood hormones is based on the determination of active forms of steroid hormones that are not associated with proteins.

Menstrual anomalies are the most common form of reproductive disorders.

Abnormal uterine bleeding (AMB) - it is customary to call any bloody uterine discharge outside of menstruation or pathological menstrual bleeding (more than 7-8 days for a duration of more than 80 ml in terms of blood loss for the entire period of menstruation).

AMK can be symptoms of various pathologies of the reproductive system or somatic diseases. Most often, uterine bleeding is a clinical manifestation of the following diseases and conditions:

Pregnancy (uterine and ectopic, as well as trophoblastic disease).

Uterine myoma (submucous or interstitial myoma with centripital node growth).

Oncological diseases (cancer of the uterus).

Inflammatory diseases of the genital organs (endometritis).

Hyperplastic processes (polyps of the endometrium and endocervix).

Endometriosis (adeiomyosis, external genital endometriosis)

Contraceptive use (IUD).

Endocrinopathies (chronic anovulation syndrome - PCOS)

Somatic diseases (liver disease).

10. Diseases of the blood, including coagulopathy (thrombocytopenia, thrombocytopathy, von Willebrand disease, leukemia).

11. Dysfunctional uterine bleeding.

Dysfunctional uterine bleeding (UBH) - violations of menstrual function, manifested by uterine bleeding (menorrhagia, metrorrhagia), in which there are no pronounced changes in the genitals. Their pathogenesis is based on functional disorders of the hypothalamic-pituitary regulation of the menstrual cycle, as a result of which the rhythm and level of hormone secretion changes, anovulation and disruption of the cyclic transformations of the endometrium are formed.

Thus, DMC is based on a violation of the rhythm and production of gonadotropic hormones and ovarian hormones. DMC is always accompanied by morphological changes in the uterus.

DMC is always a diagnosis of exclusion

In the general structure of gynecological diseases, DMK is 15-20%. Most cases of DMC occur 5-10 years before menopause or after menarche, when the reproductive system is unstable.

Menstrual function is regulated by the cerebral cortex, supra-hypothalamic structures, hypothalamus, pituitary gland, uterus ovaries. This is a complex system with double feedback; for its normal functioning, well-coordinated work of all links is required.

The main point in the mechanism of functioning of the endocrine system that regulates the menstrual cycle is ovulation, most of the DMC occur against the background of anovulation.

DMC are the most common pathology of menstrual function, are characterized by a recurrent course, lead to impaired reproductive function, the development of hyperplastic processes in the uterus and mammary glands. Recurrent DMC lead to a decrease in social activity and a deterioration in the quality of life of a woman, accompanied by mental (neuroses, depression, sleep disturbance) and physiological abnormalities (headaches, weakness, dizziness due to anemia).

DMK is a polyetiological disease, which is a special type of response of the reproductive system to the impact of damaging factors.

Uterine bleeding, depending on the age of the woman, is distinguished:

1. Juvenile or pubertal bleeding - in girls during puberty.

2. Pre-menopausal bleeding at the age of 40-45 years.

3. Menopause - 45-47 years old;

4. Postmenopausal - bleeding in women of menopause a year or more after menopause, the most common cause is uterine tumors.

By the state of menstrual function:

Menorrhagia

Metrorrhagia

Menometrorrhagia

Etiology and pathogenesis of DMC complex and multifaceted.

Causes of DMC:

psychogenic factors and stress

mental and physical fatigue

acute and chronic intoxication and occupational hazards

inflammatory processes of the small pelvis

dysfunction of the endocrine glands.

In pathogenesis the following mechanisms are involved in uterine bleeding:

1. violation of the contractile activity of the uterus with myoma, endometriosis, inflammatory diseases;

disturbances in the vascular supply of the endometrium, the causes of which may be hyperplastic processes of the endometrium, hormonal disorders;

violation of thrombus formation in patients with defects in the hemostasis system, especially in the microcirculatory-platelet link, with the formation of a smaller number of thrombi compared with the normal endometrium, as well as as a result of activation of the fibrinolytic system;

Disruption of endometrial regeneration with a decrease in the hormonal activity of the ovaries or due to intrauterine reasons.

There are 2 large groups of uterine bleeding:

Ovulatory ( due to a decline in progesterone) . Depending on the changes in the ovaries, the following 3 types of DMC are distinguished:

a. Shortening the first phase of the cycle;

b. Shortening of the second phase of the cycle - hypoluteinism;

v. The lengthening of the second phase of the cycle is hyperluteinism.

Anovulatory uterine bleeding caused by a decline in estrogen ( follicular persistence and follicular atresia) .

Uterine bleeding always occurs against the background of a decline in the level of steroid hormones.

Clinic for ovulatory uterine bleeding:

may be bleeding leading to anemia;

there may be bleeding before menstruation;

spotting after menstruation;

there may be spotting in the middle of the cycle;

miscarriage and infertility.

Gynecology: textbook / BI Baisov et al.; ed. G. M. Savelyeva, V. G. Breusenko. - 4th ed., Rev. and add. - 2011 .-- 432 p. : ill.

Chapter 6. Uterine bleeding of the pubertal period

Uterine bleeding of the pubertal period (Uterine bleeding) - pathological bleeding caused by deviations of endometrial rejection in adolescent girls with impaired cyclic production of steroid hormones from the moment of the first menstruation to 18 years. Manual transmissions account for 20-30% of all gynecological diseases of childhood.

Etiology and pathogenesis. At the heart 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 in the ovaries is disrupted and, as a result, uterine bleeding occurs.

Against the background of dyshormonal changes in the ovary, the growth and maturation of several follicles begin, which undergo atresia. In the process of their growth in the body, relative hyperestrogenism, those. the level of estrogen does not exceed normal levels, but the corpus luteum is absent, so the uterus is under the influence of only estrogens. Hormonal dysfunction can also lead to the persistence of one follicle, and therefore the corpus luteum is not formed. At the same time, the level of estrogens, which have an effect on the endometrium, is significantly higher than normal - absolute hyperestrogenism.

Follicular cysts are often formed in the ovaries (82.6%), less often - cysts of the corpus luteum (17.4%). Regardless of the relative or absolute hyperestrogenism, the mucous membrane of the uterus is not rejected in a timely manner (on the days of menstruation) and undergoes hyperplastic transformation - glandular-cystic hyperplasia develops. There is no secretion phase in the mucous membrane, its excessive growth leads to malnutrition and rejection. Rejection may be accompanied by profuse bleeding or stretch over time.

With recurrent manual transmission, atypical hyperplasia is possible.

Impaired hormonal regulation in girls with manual transmission is promoted by mental and physical stress, overwork, unfavorable living conditions, hypovitaminosis, dysfunction of the thyroid gland and (or) the adrenal cortex. Both acute and chronic infectious diseases (measles, whooping cough, chickenpox, mumps, rubella, acute respiratory viral infections and especially frequent tonsillitis, chronic tonsillitis) are of great importance in the development of manual transmission. In addition, complications in the mother during pregnancy may be important.

pregnancy, childbirth, infectious diseases of parents, artificial feeding.

Clinical picture consists in the appearance of bleeding from the genital tract after a delay in menstruation for a period from 14-16 days to 1.5-6 months. Such menstrual irregularities sometimes appear immediately after menarche, sometimes within the first 2 years. In 1/3 girls, they can be repeated. Bleeding can be profuse and lead to anemia, weakness, and dizziness. If such bleeding continues for several days, a blood clotting disorder of the type of disseminated intravascular coagulation may occur for the second time, and then the bleeding increases even more. In some patients, bleeding may be moderate, not accompanied by anemia, but last 10-15 days or more.

Manual transmission does not depend on the correspondence of the calendar and bone age, as well as on the development of secondary sexual characteristics.

Diagnostics 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 history data (delayed menstruation) and the appearance of bleeding from the genital tract. The presence of anemia and the state of the blood coagulation system are determined by laboratory research (clinical blood test, coagulogram, including platelet count, activated partial thromboplastic time, bleeding time and coagulation time; biochemical blood test). The level of hormones (FSH, LH, prolactin, estrogens, progesterone, cortisol, testosterone, TSH, T 3, T 4) is determined in the blood serum, and functional diagnostics tests are carried out. It is advisable to consult a specialist - a neurologist, endocrinologist, ophthalmologist (fundus condition, determination of color fields of view). Between menstrual periods, it is recommended to measure basal temperature. With a single-phase menstrual cycle, the basal temperature is monotonous.

To assess the condition of the ovaries and endometrium, ultrasound is performed, with an intact hymen - using a rectal sensor.

For those who are sexually active, the method of choice is the use of a vaginal probe. On the echogram in patients with manual transmission, a slight tendency to an increase in the volume of the ovaries in the period between bleeding is revealed. Clinical and echographic signs of a 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 bleeding, it is necessary to find out as accurately as possible the predominant lesion of the regulatory system of reproduction. For this purpose, the development of secondary sexual characteristics and bone age, physical development are assessed, X-ray of the skull with a projection of the Turkish saddle is used; EchoEG, EEG; according to indications - CT or MRI (to exclude a pituitary tumor); echography of the adrenal glands and thyroid gland.

Ultrasound, especially with Doppler, is advisable to be carried out in dynamics, since it is possible to visualize atretic and persistent follicles, a mature follicle, ovulation, and the formation of a corpus luteum.

Differential diagnosis The manual transmission is carried out primarily with a started and incomplete abortion, which is easy to exclude with the help of ultrasound. Uterine bleeding during puberty is not only functional; they can also be symptoms of other diseases. One of the first places is occupied by idiopathic autoimmune thrombocytopenic purpura (Werlhof's disease). Formed in the body autoantibodies against platelets destroy the most important factors of blood coagulation and cause bleeding. This congenital pathology occurs with periods of remission and deterioration. Girls with Werlhof's disease, from early childhood, suffer from nosebleeds, bleeding from cuts and bruises, after tooth extraction. The very first menstruation in patients with Werlhof's disease turns into bleeding, which serves as a differential diagnostic sign. On the skin of patients, as a rule, multiple bruises, petechiae are visible. The history and appearance of patients help in establishing the diagnosis of Werlhof's disease. The diagnosis is clarified on the basis of blood tests: a decrease in the number of platelets<70-100 г/л, увеличение времени свертывания крови, длительность кровотечения, изменение показателей коагулограммы. Иногда определяется не только тромбоцитопения (пониженное число тромбоцитов), но и тромбастения (функциональная неполноценность тромбоцитов). При выявлении болезни Верльгофа и других заболеваний крови лечение осуществляется совместно с гематологами. Используемые при этом большие дозы дексаметазона могут приводить к аменорее на период лечения.

MKPP can be the result of inflammatory changes in the internal genital organs, including tuberculous lesions of the endometrium, cancer of the cervix and uterine body (rare).

Treatment uterine bleeding is carried out in 2 stages. At the 1st stage, hemostasis is carried out, at the 2nd - therapy aimed at preventing recurrence of bleeding and regulating the menstrual cycle.

When choosing a method of hemostasis, it is necessary to take into account the general condition of the patient and the amount of blood loss. Patients with mild anemisation (Hb level> 100 g / l, hematocrit> 30%) and the absence of endometrial hyperplasia according to ultrasound examination are treated with symptomatic hemostatic therapy. Prescribe uterine-reducing agents: oxytocin, hemostatic drugs (etamzilate, tranexamic acid, Ascorutin ♠). A good hemostatic effect is provided by the combination of this therapy with physiotherapy - applied sinusoidal modulated currents to the area of the cervical sympathetic nodes (2 procedures per day for 3-5 days), as well as with acupuncture or electropun-ktura.

If symptomatic hemostatic therapy is ineffective, hormonal hemostasis is performed with monophasic combined estrogen-progestational drugs (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 discharge

after stopping the intake of estrogen-progestogens, they are moderate and end within 5-6 days.

With prolonged and profuse bleeding, when there are symptoms of anemia and hypovolemia, weakness, dizziness, with Hb levels<70 г/л и гематокрите <20% показан хирургический гемостаз - раздельное диагностическое выскабливание под контролем гистероскопии с тщательным гистологическим исследованием соскоба. Во избежание разрывов девственную плеву обкалывают 0,25% раствором прокаина с 64 ЕД гиалуронида-зы (лидаза *). Пациенткам с нарушением свертывающей системы крови раздельное диагностическое выскабливание не проводится. Гемостаз осуществляют комбинированными эстроген-гестагенными препаратами, при необходимости (по рекомендации гематологов) - в сочетании с глюкокор-тикостероидами.

Simultaneously with conservative or surgical treatment, it is necessary to carry out a full-fledged antianemic therapy: iron preparations (maltofer ♠, fenuls ♠ inside, venofer ♠ intravenously); cyanocobala-min (vitamin B 12 ♠) with folic acid; pyridoxine (vitamin B 6 ♠) inside, ascorbic acid (vitamin C ♠), rutoside (rutin ♠). As a last resort (Hb level<70 г/л, гематокрит <25%) переливают компоненты крови - свежезамороженную плазму и эритроцитную массу.

In order to prevent recurrence of bleeding after complete hemostasis against 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 tablet 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 once a day, thiamine (vitamin B 1 ♠) - 5% solution, 1 ml intramuscularly. For the regulation of menstrual function, endonasal electrophoresis of lithium, pyridoxine, procaine, electrophoresis is also used. Prevention of bleeding after hormonal hemostasis consists in taking monophasic combined estrogen-progestational drugs (novinet *, mersilon *, logest *, jess *) - 1 tablet each, starting from the 1st day of the menstrual cycle (within 21 days), or gestagens - dydrogesterone (dyufa-ston *) 10-20 mg per day from the 16th to the 25th day for 2-3 months, followed by cyclic vitamin therapy. Patients with hyperplastic processes of the endometrium after curettage, as well as after hormonal hemostasis, should be prevented from relapse. For this, estrogen-progestogen drugs or pure progestogens are prescribed (depending on changes in the ovary - atresia or follicle persistence). Measures of general health improvement, hardening, good nutrition, sanitation of foci of infection are of great importance.

Uterine bleeding of the pubertal period (Uterine bleeding) - pathological bleeding caused by deviations of endometrial rejection in adolescent girls with impaired cyclic production of sex steroid hormones from the moment of the first menstruation to 18 years.

ICD-10 code

N92.2 Profuse menses during puberty

N93.8 Other specified abnormal uterine and vaginal bleeding

Epidemiology

The frequency of uterine bleeding during puberty in the structure of gynecological diseases of childhood and adolescence varies from 10 to 37.3%. Over 50% of all adolescent girls' visits to a gynecologist are associated with uterine bleeding during puberty. Almost 95% of all vaginal bleeding during puberty is due to manual transmission. Most often, uterine bleeding occurs in adolescent girls during the first 3 years after menarche.

Causes of uterine bleeding during puberty

The main cause of uterine bleeding during puberty is the immaturity of the reproductive system at an age close to menarche (up to 3 years). Adolescent girls with uterine bleeding have a negative feedback defect of the ovaries and the hypothalamic-pituitary region of the central nervous system. The increase in estrogen levels characteristic of puberty does not lead to a decrease in FSH secretion in them, which in turn stimulates the growth and development of many follicles at once. Maintaining a higher than normal secretion of FSH serves as a factor inhibiting the selection and development of a dominant follicle from a multitude of simultaneously maturing cavity follicles.

The lack of ovulation and the subsequent production of progesterone by the corpus luteum leads to a constant effect of estrogens on target organs, including the endometrium. When the proliferating endometrium overflows the uterine cavity, trophic disturbances occur in some areas, followed by local rejection and bleeding. Bleeding is supported by increased production of prostaglandins in the long-term proliferating endometrium. The prolonged absence of ovulation and the effect of progesterone significantly increases the risk of uterine bleeding during puberty, while even one accidental ovulation is enough to temporarily stabilize the endometrium and more complete its rejection without bleeding.

Symptoms of uterine bleeding during puberty

The following criteria are distinguished for uterine bleeding during puberty.

The duration of bleeding from the vagina 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 of more than 80 ml or subjectively more pronounced compared to normal menstruation.
Presence of intermenstrual or postcoital bleeding.
Lack of structural pathology of the endometrium.
Confirmation of anovulatory menstrual cycle during the onset of uterine bleeding (the concentration of progesterone in the venous blood on the 21-25th day of the menstrual cycle is less than 9.5 nmol / l, monophasic basal temperature, absence of preovulatory follicle according to echography).

Forms

An officially accepted international classification of uterine bleeding during puberty has not been developed. When determining the type of uterine bleeding in adolescent girls, as well as in women of reproductive age, the clinical features of uterine bleeding (polymenorrhea, metrorrhagia and menometrorrhagia) are taken into account.

Menorrhagia (hypermenorrhea) is called uterine bleeding 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 amount of blood clots in abundant bleeding, the appearance of hypovolemic disorders on menstrual days and the presence of moderate iron deficiency anemia and severe.
Polymenorrhea - 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 intervals of oligomenorrhea and are characterized by a periodic increase in bleeding against the background of scant or moderate bleeding.

Diagnosis of uterine bleeding during puberty

The diagnosis of uterine bleeding during puberty is made after excluding the diseases listed below.

Spontaneous termination of pregnancy (in sexually active girls).
Diseases of the uterus (fibroids, endometrial polyps, endometritis, arterio-venous anastomoses, endometriosis, the presence of an intrauterine contraceptive, extremely rarely adenocarcinoma and uterine sarcoma).
Pathology of the vagina and cervix (trauma, foreign body, neoplastic processes, exophytic warts, polyps, vaginitis).
Ovarian diseases (polycystic ovaries, premature exhaustion, tumors and tumor-like formations).
Diseases of the blood [von Willebrand's disease and deficiency of other plasma factors of hemostasis, Werlhof's disease (idiopathic thrombocytopenic purpura), thrombasthenia of Glyantsman-Negeli, Bernard-Soulier, Gaucher, leukemia, aplastic anemia, iron deficiency anemia].
Endocrine diseases (hypothyroidism, hyperthyroidism, Addison's or Cushing's disease, hyperprolactinemia, postpubertal form of congenital adrenal hyperplasia, adrenal tumors, empty Turkish saddle syndrome, mosaic version of Turner's syndrome).
Systemic diseases (liver disease, chronic renal failure, hypersplenism).
Iatrogenic reasons - application errors: non-compliance with the dosage and administration regimen, unreasonable prescription of drugs containing female sex steroids, and long-term use in high doses of non-steroidal anti-inflammatory drugs (NSAIDs), antiplatelet agents and anticoagulants, psychotropic drugs, anticonvulsants and warfarin, chemotherapy.

History and physical examination

Collecting anamnesis.
Physical examination.
- Comparison of the degree of physical development and puberty according to Tanner with age standards.
- Vaginoscopy and examination data make it possible to exclude the presence of a foreign body in the vagina, warts, lichen planus, neoplasms of the vagina and cervix. Assess the state of the vaginal mucosa, estrogen saturation.
  - Signs of hyperestrogenism: pronounced folding of the vaginal mucosa, succulent hymen, cylindrical shape of the cervix, positive pupil symptom, abundant streaks of mucus in the blood discharge.
  - Hypoestrogenemia is characterized by a pale pink mucous membrane of the vagina; its folding is poorly expressed, the hymen is thin, the cervix is subconical or conical in shape, bleeding without mucus.
Assessment of the menstrual calendar (menocyclogram).
Clarification of the patient's psychological characteristics.

Laboratory research

A general blood test to determine the concentration of hemoglobin, the number of platelets is performed in all patients with uterine bleeding during puberty.
Biochemical blood test: a study of the concentration of glucose, creatinine, bilirubin, urea, serum iron, trans-ferrin in the blood.
Hemostasiogram (determination of activated partial thromboplastin time, prothrombin index, activated recalcification time) and assessment of bleeding time allow to exclude gross pathology of the blood coagulation system.
Determination of the β-subunit of chorionic gonadotropin in the blood in sexually active girls.
Study of the concentration of hormones in the blood: TSH and free T to clarify the function of the thyroid gland; estradiol, testosterone, dehydroepiandrosterone sulfate, LH, FSH, insulin, C-peptide to exclude PCOS; 17-hydroxyprogesterone, testosterone, dehydroepiandrosterone sulfate, circadian rhythm of cortisol secretion to exclude congenital adrenal hyperplasia; prolactin (at least 3 times) to exclude hyperprolactinemia; serum progesterone on day 21 (with a 28-day menstrual cycle) or on day 25 (with a 32-day menstrual cycle) to confirm the anovulatory nature of uterine bleeding.
Carbohydrate tolerance test for PCOS and overweight (body mass index is 25 kg / m 2 and above).

Instrumental research

Microscopy of a smear from the vagina (Gram staining) and PCR of the material obtained by scraping from the walls of the vagina is carried out in order to diagnose chlamydia, gonorrhea, mycoplasmosis.
Ultrasound of the pelvic organs allows you to clarify the size of the uterus and the state of the endometrium to exclude pregnancy, uterine malformation (two-horned, saddle uterus), pathology of the uterine body and endometrium (adenomyosis, uterine myoma, polyps or hyperplasia, adenomatosis and endometrial cancer, endometritis, endometrial receptor defects, etc. intrauterine synechiae), assess the size, structure and volume of the ovaries, exclude functional cysts (follicular, corpus luteum cysts, provoking menstrual irregularities by the type of uterine bleeding, both against the background of shortening the duration of the menstrual cycle, and against the background of a preliminary delay of menstruation up to 2-4 weeks with cysts of the corpus luteum) and volumetric formations in the uterine appendages.
Diagnostic hysteroscopy and curettage of the uterine cavity in adolescents is rarely used and is used to clarify the state of the endometrium when ultrasound signs of endometrial polyps or the cervical canal are detected.

Indications for consulting other specialists

Consultation with an endocrinologist is indicated if there is a suspicion of thyroid pathology (clinical symptoms of hypothyroidism or hyperthyroidism, diffuse enlargement or nodules of the thyroid gland on palpation).
Consultation with a hematologist is necessary at the onset of uterine bleeding during puberty with menarche, indications of frequent nosebleeds, the occurrence of petechiae and hematomas, increased bleeding with cuts, wounds and surgical manipulations, when an increase in bleeding time is detected.
Consultation with a phthisiatrician is indicated for uterine bleeding during puberty against the background of prolonged persistent subfebrile condition, acyclic bleeding, often accompanied by pain, in the absence of a pathogenic infectious agent in the urinary tract discharge, relative or absolute lymphocytosis in the general blood test, positive tuberculin samples.
Consultation of a therapist should be carried out for uterine bleeding during puberty against the background of chronic systemic diseases, including diseases of the kidneys, liver, lungs, cardiovascular system, etc.

Differential diagnosis

The main purpose of the differential diagnosis of uterine bleeding during puberty is to clarify the main etiological factors that provoke the development of the disease. Listed below are the diseases from which uterine bleeding during puberty should be differentiated.

Complications of pregnancy in sexually active adolescents. First of all, complaints and anamnesis data are clarified, allowing to exclude interrupted pregnancy or bleeding after an abortion, including in girls who deny sexual contacts. Bleeding occurs more often after a short delay in menstruation for more than 35 days, less often when the menstrual cycle is shortened by less than 21 days or at times close to the expected menstruation. In the history, as a rule, there are indications of sexual intercourse in the previous menstrual cycle. Patients report complaints of engorgement of the mammary glands, nausea. Blood discharge, usually copious, clotted, with pieces of tissue, often painful. Positive pregnancy tests (determination of the β-subunit of chorionic gonadotropin in the patient's blood).
Defects of the blood coagulation system. To exclude defects in the blood coagulation system, family history (a tendency to bleeding in parents) and life history (nosebleeds, prolonged bleeding time during surgical procedures, frequent and unreasonable occurrence of petechiae and hematomas) are ascertained. Uterine bleeding, as a rule, has the character of menorrhagia, starting with menarche. Examination data (pallor of the skin, bruising, petechiae, icteric coloration of the palms and upper palate, hirsutism, striae, acne, vitiligo, multiple birthmarks, etc.) and laboratory research methods (coagulogram, complete blood count, thromboelastogram, concentration determination the main factors of blood coagulation) allow to confirm the pathology of the hemostasis system.
Polyps of the cervix and uterine body. Uterine bleeding is usually acyclic, with short, light-colored gaps; discharge is moderate, often with strands of mucus. Ultrasound often reveals endometrial hyperplasia (endometrial thickness against a background of 10-15 mm bleeding) with hyperechoic formations of various sizes. The diagnosis is confirmed by the data of hysteroscopy and subsequent histological examination of the remote endometrial formation.
Adenomyosis. Uterine bleeding of puberty against the background of adenomyosis is characterized by severe dysmenorrhea, prolonged spotting bleeding with a characteristic brown tint before and after menstruation. The diagnosis is confirmed by the results of ultrasound in the 1st and 2nd phases of the menstrual cycle and hysteroscopy (in patients with severe pain syndrome and in the absence of the effect of drug therapy).
Inflammatory diseases of the pelvic organs. As a rule, uterine bleeding is acyclic in nature, occurs after hypothermia, unprotected, especially accidental or promiscuous (promiscuity) sexual intercourse in sexually active adolescents, against the background of exacerbation of chronic pelvic pain. Disturbed by pain in the lower abdomen, dysuria, hyperthermia, profuse pathological leucorrhoea outside menstruation, acquiring a sharp, unpleasant odor against the background of bleeding. When a recto-abdominal examination reveals an enlarged softened uterus, pasty tissues in the region of the uterine appendages; the research being done is usually painful. Bacteriological examination data (microscopy of smears with Gram stain, examination of the vaginal discharge for the presence of a sexually transmitted infection using PCR, bacteriological examination of material from the posterior fornix of the vagina) help to clarify the diagnosis.
Injury to the vulva or a foreign body in the vagina. For diagnosis, anamnesis data and results of vulvovaginoscopy are required.
Polycystic ovary syndrome. With uterine bleeding during puberty in patients with developing PCOS, along with complaints of delayed menstruation, excessive hair growth, acne on the face, chest, shoulders, back, buttocks and thighs, there are indications for later menarche with progressive menstrual irregularities of the oligomenorrhea type.
Hormone-producing formations of the ovaries. Uterine bleeding during puberty may be the first symptom of estrogen-producing tumors or ovarian tumors. Clarification of the diagnosis is possible after ultrasound of the genitals with the determination of the volume and structure of the ovaries and the concentration of estrogen in the venous blood.
Thyroid dysfunction. Uterine bleeding during puberty occurs, as a rule, in patients with subclinical or clinical hypothyroidism. Patients complain of chilliness, swelling, weight gain, memory loss, drowsiness, 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 - the presence of dry subicteric skin, pasty tissues, puffiness of the face, enlarged tongue, bradycardia, an increase in the relaxation time of deep tendon reflexes. To clarify the functional state of the thyroid gland, it is possible to determine the content of TSH, free T 4 in the blood.
Hyperprolactinemia. To exclude hyperprolactinemia as a cause of uterine bleeding during puberty, examination and palpation of the mammary glands with clarification of the nature of discharge from the nipples, determination of prolactin content in the blood, X-ray of the skull bones with a targeted study of the size and configuration of the Turkish saddle or MRI of the brain are shown. Trial treatment with dopaminomimetic drugs in patients with uterine bleeding during puberty, resulting from hyperprolactinemia, helps to restore the rhythm and nature of menstruation within 4 months.

Treatment of uterine bleeding during puberty

Indications for hospitalization:

Abundant (profuse) uterine bleeding that does not stop with drug therapy.
Life-threatening decrease in hemoglobin concentration (below 70–80 g / l) and hematocrit (below 20%).
The need for surgical treatment and blood transfusion.

Non-drug treatment of uterine bleeding during puberty

There are no data confirming the advisability of non-drug therapy in patients with uterine bleeding during puberty, except for situations requiring surgical intervention.

Drug therapy for uterine bleeding during puberty

The general goals of drug treatment for uterine bleeding during puberty are:

Stopping bleeding to avoid acute hemorrhagic syndrome.
Stabilization and correction of the menstrual cycle and the state of the endometrium.
Antianemic therapy.

The following drugs are used:

At the first stage of treatment, it is advisable to use inhibitors of the transition of plasminogen to plasmin (tranexamic and aminocaproic acids). The intensity of bleeding decreases due to a decrease in the fibrinolytic activity of blood plasma. Tranexamic acid is prescribed orally at a dose of 5 g 3-4 times a day with profuse bleeding until the bleeding stops completely. Perhaps intravenous administration of 4-5 g of the drug during the first hour, then drip administration of drugs at a dose of 1 g / h for 8 hours. The total daily dose should not exceed 30 g. the use of estrogens, the likelihood of thromboembolic complications is high. It is possible to use the drug in a dose of 1 g 4 times a day from the 1st to the 4th day of menstruation, which reduces the volume of blood loss by 50%.

A significant decrease in blood loss in patients with menorrhagia is observed with the use of NSAIDs, monophasic COCs and danazol.

Danazol is used very rarely in patients with uterine bleeding during puberty due to severe adverse reactions (nausea, coarsening of the voice, hair loss and increased greasiness, the appearance of acne and hirsutism).
NSAIDs (ibuprofen, diclofenac, indomethacin, nimesulide, etc.) affect the metabolism of arachidonic acid, reduce the production of prostaglandins and thromboxanes in the endometrium, reducing the volume of blood loss during menstruation by 30–38%. Ibuprofen is prescribed at a dose of 400 mg every 4–6 hours (daily dose 1200–3200 mg) on the days of menorrhagia. However, an increase in the daily dose can cause an undesirable increase in prothrombin time and the concentration of lithium ions in the blood. The effectiveness of NSAIDs is comparable to that of aminocaproic acid and COCs. In order to increase the effectiveness of hemostatic therapy, the combined use of NSAIDs and hormonal therapy is justified. However, this type of combination therapy is contraindicated in patients with hyperprolactinemia, structural abnormalities of the genital organs and thyroid pathology.
Low-dose oral contraceptives with modern progestogens (desogestrel at a dose of 150 mcg, gestodene at a dose of 75 mcg, dienogest at a dose of 2 mg) are more often used in patients with profuse and acyclic uterine bleeding. Ethinylestradiol in the composition of COCs provides a hemostatic effect, and progestogens stabilize the stroma and the basal layer of the endometrium. To stop bleeding, only monophasic COCs are prescribed.
- There are many schemes for the use of COCs for hemostatic purposes in patients with uterine bleeding. The following scheme is often recommended: 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 2nd package of the drug. Outside of bleeding, in order to regulate the menstrual cycle, COCs are prescribed for 3-6 cycles, 1 tablet per day (21 days of admission, 7 days off). The duration of hormone therapy depends on the severity of the initial iron deficiency anemia and the rate of recovery of the hemoglobin content. The use of COCs in this mode is associated with a number of serious side effects: increased blood pressure, thrombophlebitis, nausea and vomiting, allergies. In addition, difficulties arise in the selection of an appropriate antianemic therapy.
- An alternative can be considered the use of low-dose monophasic COCs in a dose of half a tablet every 4 hours before the onset of complete hemostasis, since the maximum concentration of the drug in the blood is reached 3-4 hours after oral administration of the drug and significantly decreases in the next 2-3 hours. this ranges from 60 to 90 mcg, which is more than 3 times less than with the traditionally used treatment regimen. On the following days, the daily dose of COCs is reduced - by half a tablet a day. With a decrease in the daily dose to 1 tablet, it is advisable to continue taking the drug, taking into account the hemoglobin concentration. As a rule, the duration of the first cycle of COC intake should not be less than 21 days, counting from the 1st day from the onset of hormonal hemostasis. In the first 5–7 days of taking the drug, a temporary increase in the thickness of the endometrium is possible, which regresses without bleeding with continued treatment.
- In the future, in order to regulate the rhythm of menstruation and prevent recurrence of uterine bleeding, COCs are prescribed according to the standard scheme (21-day courses with 7-day breaks between them). In all patients who took the drugs according to the described scheme, there was a cessation of bleeding within 12-18 hours from the start of admission and good tolerance in the absence of side effects. Pathogenetically, the use of COCs in short courses is not justified (10 days each in the 2nd phase of a modulated cycle or in a 21-day regimen for up to 3 months).
If it is necessary to accelerate the arrest of life-threatening bleeding, the first-line drugs of choice are conjugated estrogens administered intravenously at a dose of 25 mg every 4–6 hours until the bleeding stops completely, which occurs during the first day. It is possible to use a tablet form of conjugated estrogens at a dose of 0.625-3.75 μg every 4-6 hours until the bleeding stops completely with a gradual dose reduction over the next 3 days to a dosage of 0.675 mg / day or estradiol according to a similar scheme with an initial dose of 4 mg / day ... After stopping bleeding, progestogens are prescribed.
Outside of bleeding, in order to regulate the menstrual cycle, conjugated estrogens are prescribed orally at a dose of 0.675 mg / day or estradiol at a dose of 2 mg / day for 21 days with the obligatory addition of progesterone for 12-14 days in the 2nd phase of the modulated cycle.
In some cases, especially in patients with severe adverse reactions, intolerance or contraindications to the use of estrogens, it is possible to prescribe only progesterone. Low efficacy of low doses of progesterone was noted against the background of profuse uterine bleeding, primarily in the 2nd phase of the menstrual cycle with menorrhagia. Patients with heavy bleeding are shown high doses of progesterone (medroxyprogesterone acetate 5-10 mg, micronized progesterone 100 mg, or dydrogesterone 10 mg), or every 2 hours for life-threatening bleeding, or 3-4 times a day for heavy bleeding. but not life-threatening bleeding until the bleeding stops. After stopping bleeding, the drugs are prescribed 2 times a day, 2 tablets for no more than 10 days, since prolongation of administration can cause repeated bleeding. The reaction of withdrawal of progestogens, as a rule, is manifested by profuse bleeding, which often requires the use of symptomatic hemostasis. In order to regulate the menstrual cycle in menorrhagias, medroxyprogesterone can be prescribed at a dose of 5-10-20 mg / day, dydrogesterone - at a dose of 10-20 mg per day, or micronized progesterone - at a dose of 300 mg per day in the second phase (in case of luteal insufficiency phases), or at a dose of 20, 20 and 300 mg / day, respectively, according to the type of drug from the 5th to the 25th day of the menstrual cycle (with ovulatory menorrhagia). In patients with anovulatory uterine bleeding, progestogens should be prescribed in the 2nd phase of the menstrual cycle against the background of constant use of estrogens. It is possible to use progesterone in micronized form in a daily dose of 200 mg for 12 days a month against the background of continuous estrogen therapy.

Continued bleeding against the background of hormonal hemostasis is an indication for hysteroscopy to clarify the state of the endometrium.

All patients with uterine bleeding during puberty are shown iron supplements to prevent the development of iron deficiency anemia. The high efficiency of the use of ferrous sulfate in combination with ascorbic acid at a dose of 100 mg of ferrous iron per day has been proven. The daily dose of ferrous sulfate is selected taking into account the concentration of hemoglobin in the blood. The criterion for the correct selection of iron preparations for iron deficiency anemia is the development of a reticulocytic crisis (a 3-fold increase in the number of reticulocytes 7-10 days after the start of administration). Antianemic therapy is carried out for at least 1–3 months. Iron salts should be used with caution in patients with concomitant gastrointestinal pathology.

Uterine bleeding during puberty (MCB) - functional disorders that occur during the first three years after menarche, caused by deviations in the coordinated activity of functional systems that maintain homeostasis, manifested in the violation 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 in puberty (profuse bleeding with the onset of menstruation, pubertal cyclical bleeding - menorrhagia, pubertal acyclic bleeding - metrorrhagia).

EPIDEMIOLOGY

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

SCREENING

It is advisable to conduct screening of the disease with the help of 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, heavy menstruation with menarche.

CLASSIFICATION

There is no officially accepted international classification of the ICIE.

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

ovulatory uterine bleeding;
anovulatory uterine bleeding.

In puberty, the most common anovulatory acyclic bleeding caused by atresia or, less often, persistence of the follicles.

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

Menorrhagia (hypermenorrhea) - uterine bleeding in patients with a preserved rhythm of menstruation, with a duration of bleeding for more than 7 days and blood loss above 80 ml. In such patients, a small number of blood clots in abundant blood secretions, the appearance of hypovolemic disorders on menstrual days and signs of moderate to severe iron deficiency anemia are usually observed.
Polymenorrhea - 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 a periodic increase in bleeding against the background of scant or moderate bleeding.

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

hypoestrogenic;
normoestrogenic.

Depending on the clinical and laboratory features of the manual transmission, there are typical and atypical forms.

ETIOLOGY

MKPP 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 in the process of ontogenesis of each person. As risk factors for the occurrence of manual transmission, most often called conditions such as acute psychogenias or prolonged psychological stress, unfavorable environmental conditions in the place of residence, hypovitaminosis. Alimentary insufficiency, obesity, and body weight deficiency can also serve as trigger factors for manual transmission. 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 kinds of psychological overload and acute psychological trauma (up to 70%).

PATHOGENESIS

Homeostasis imbalance in adolescents is associated with the development of nonspecific responses to stress, i.e. some circumstances (infection, physical or chemical factors, social and psychological problems), leading to the tension of the body's adaptive resources. As a mechanism for the implementation of the general adaptation syndrome, the main axis of hormonal regulation is activated - "hypothalamus-pituitary-adrenal glands". A balanced multiparametric interaction of regulatory (central and peripheral) and effector components of functional systems is characteristic of a normal adaptive response to a change in the external or internal environment of the body. Hormonal interactions between individual systems provide correlations between them. When exposed to a complex of factors, in terms of their intensity or duration, surpassing the usual conditions of adaptation, these connections can be disrupted. As a consequence of this process, each of the systems that provide homeostasis begins to work in one way or another in isolation, and the afferent information about their activity is distorted. This, in turn, leads to disruption of control connections and deterioration of the effector mechanisms of self-regulation. And, finally, the long-existing low quality of the self-regulation mechanisms of the system, the most vulnerable for any reason, leads to its morphofunctional changes.

The mechanism of ovarian dysfunction is inadequate stimulation of the pituitary gland with gonadoliberin and may be directly associated with both a decrease in the concentration of LH and FSH in the blood, and a persistent increase in the level of LH or chaotic changes in the secretion of gonadotropins.

CLINICAL PICTURE

The clinical picture of the manual transmission is very heterogeneous. Manifestations depend on the level (central or peripheral) at which self-regulation disorders have 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. The hallmarks 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 asymmetric increase in the ovaries. The greatest likelihood of developing a hyperestrogenic type of manual transmission is at the beginning (11–12 years) and the 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 signs according to anthropometric data and the degree of development of secondary sexual characteristics. The size of the uterus is less than the age norm, therefore, more often with such parameters, patients are referred to the hypoestrogenic type. Most often, this type of manual transmission develops in patients aged 13 to 16 years.
The hypoestrogenic type is most often found in adolescent girls. Usually, such patients are of a fragile constitution with a significant lag behind the age norm in the degree of development of secondary sexual characteristics, but a rather high level of mental development. The uterus lags significantly behind the age norm in all age groups, the endometrium is thin, the ovaries are symmetrical and slightly exceed normal in volume.

The level of cortisol in blood plasma is much higher than the normative values. With the hypoestrogenic type, manual transmissions almost always proceed in a typical form.

DIAGNOSTICS

Criteria for the diagnosis of manual transmission:

the duration of bleeding from the vagina 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 of more than 80 ml or subjectively more pronounced compared to normal menstruation;
the presence of intermenstrual or postoital bleeding;
lack 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 the 21-25th days of the menstrual cycle is less than 9.5 nmol / l, monophasic basal temperature, the 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 features of the mother's reproductive function, the course of pregnancy and childbirth, the course of the neonatal period, psychomotor development and growth rates, find out the living conditions, dietary habits, past diseases and operations, note data on physical and psychological stress, emotional stress.

PHYSICAL EXAMINATION

It is necessary to conduct a general examination, measure growth and body weight, determine the distribution of subcutaneous fat, note the signs of hereditary syndromes. Determine the compliance of the patient's individual development with age norms, including Tanner's sexual development (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 relative underweight is noted in terms of body mass index (kg / m2) (with the exception of patients aged 11–18 years).

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

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

Hirsutism, galactorrhea, enlargement of the 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 violation of homeostasis.

It is important to analyze the girl's menstrual calendar (menstrual cycle). According to his data, one can judge the formation of the menstrual function, the nature of the menstrual cycle before the first bleeding, the intensity and duration of bleeding.

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

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

It is necessary to clarify the psychological state of the patient with the help of 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 manual transmission. The presence of a relationship between stress and hormonal metabolism in patients suggests the possibility of primary disorders in the neuropsychic sphere.

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

Vaginoscopy allows you to assess the state of the vaginal mucosa, estrogen saturation and exclude the presence of a foreign body in the vagina, genital warts, 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 in color, the folding is poorly expressed, the hymen is thin, the cervix is subconical or conical in shape, 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 an assessment of the bleeding time will exclude a gross pathology of the blood coagulation system.
Determination of β-hCG in blood serum in sexually active girls.
Smear microscopy (Gram stain), bacteriological examination and PCR diagnostics of chlamydia, gonorrhea, mycoplasmosis, ureaplasmosis in scraping of the vaginal walls.
Biochemical blood test (determination of the level of glucose, protein, bilirubin, cholesterol, creatinine, urea, serum iron, transferrin, calcium, potassium, magnesium) activity of alkaline phosphatase, AST, ALT.
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 OHCI; prolactin (at least 3 times) to exclude hyperprolactinemia; serum progesterone 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 hypothalamo-pituitary system leads to a periodic release of LH (primarily) and FSH, their concentration in blood plasma exceeds normal levels. In late puberty, and especially with recurrent uterine bleeding, the secretion of gonadotropins decreases.

INSTRUMENTAL RESEARCH METHODS

Sometimes x-rays of the left hand and wrist are taken to determine bone age and to predict growth.
Most patients with manual transmission are diagnosed with an advance in biological age compared to chronological, especially in younger age groups. Biological age is a fundamental and multifaceted indicator of the rate of development, reflecting the level of the morphological and functional 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 hypothalamo-pituitary region, deforming the sella turcica, assessing cerebrospinal fluid dynamics, intracranial hemodynamics, osteosynthesis disorders due to hormonal imbalance, transferred 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 malformations (two-horned, saddle uterus), pathology of the body of the uterus 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 volumetric formations in the uterine appendages.

Diagnostic hysteroscopy and curettage of the uterine cavity in adolescents is rarely used and is used to clarify the state 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 manual transmission.

Differential diagnosis should be made with a variety of conditions and diseases.

Complication of pregnancy in sexually active adolescents. Complaints and anamnesis data, allowing 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 for less than 21 days or at a time close to the expected menstruation. In the history, as a rule, there are indications of sexual intercourse in the previous menstrual cycle. Patients note engorgement of the mammary glands, nausea. Blood discharge, as a rule, copious with clots, with pieces of tissue, often painful. The results of pregnancy tests are positive (determination of β-hCG in the patient's blood serum).
Defects of the blood coagulation system (von Willebrand disease and deficiency of other plasma factors of hemostasis, Werlhof's disease, Glanzmann thrombosis, Bernard-Soulier, Gaucher). In order to exclude defects in the blood coagulation system, the family history (a tendency to bleeding in parents) and life history (nosebleeds, prolonged bleeding time during surgical procedures, frequent and unreasonable occurrence of petechiae and hematomas) are ascertained. Uterine bleeding that developed 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, bruising, petechiae, yellow color of the palms and upper palate, hirsutism, striae, acne, vitiligo, multiple birthmarks, etc.) and laboratory research methods (hemostasiogram, complete blood count, thromboelastogram, determination of the main coagulation factors ) allow to confirm the presence of pathology of the hemostasis system.
Other blood diseases: leukemia, aplastic anemia, iron deficiency anemia.
Polyps of the cervix and uterine body. Uterine bleeding, as a rule, is acyclic with short light intervals, the discharge is moderate, often with cords of mucus. During echographic examination, HPE is often diagnosed (the thickness of the endometrium against the background of bleeding is 10-15 mm), with hyperechoic formations of various sizes. The diagnosis is confirmed with the help of hysteroscopy data and subsequent histological examination of the remote endometrial formation.
Adenomyosis. For manual transmission on the background of adenomyosis, severe dysmenorrhea is characteristic, prolonged spotting bleeding 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 syndrome and in the absence of the effect of drug therapy).
PID. As a rule, uterine bleeding is acyclic in nature, occurs after hypothermia, unprotected sexual intercourse in sexually active adolescents, against the background of exacerbation of chronic pelvic pain, discharge. Patients complain of pain in the lower abdomen, dysuria, hyperthermia, profuse pathological leucorrhoea outside menstruation, acquiring a sharp unpleasant odor against the background of bleeding. During recto-abdominal examination, the enlarged softened uterus is palpated, the pastiness of the tissues in the region of the uterine appendages is determined, the study is usually painful. The data of bacteriological examination (microscopy of smears according to Gram, PCR diagnostics of vaginal discharge for the presence of STIs, bacteriological culture from the posterior fornix of the vagina) help to clarify the diagnosis.
Injury to the vulva or a foreign body in the vagina. For diagnosis, it is necessary to clarify the anamnestic data and conduct vulvovaginoscopy.
PCOS. With manual transmission in girls with PCOS, along with complaints of delayed menstruation, excessive hair growth, simple acne on the face, chest, shoulders, back, buttocks and hips, there are indications of late menarche with progressive menstrual irregularities of the oligomenorrhea type.
Hormone-producing formations. MKPP may be the first symptom of estrogen-producing tumors or ovarian tumors. Verification of the diagnosis is possible after determining the level of estrogen in the venous blood and ultrasound of the genital organs with the specification of the volume and structure of the ovaries.
Thyroid dysfunction. MKPP occurs, as a rule, 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, depression. In hypothyroidism, palpation and ultrasound with the determination of the volume and structural features of the thyroid gland can reveal its enlargement, and examination of patients - the presence of dry subecteric skin, puffiness of the face, glossomegaly, bradycardia, an increase in the relaxation time of deep tendon reflexes. To clarify the functional state of the thyroid gland, it is possible to determine the content of TSH, free T4 in venous blood.
Hyperprolactinemia. To exclude hyperprolactinemia as a cause of manual transmission, it is necessary to examine and palpate the mammary glands to clarify the nature of the discharge from the nipples, to 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 Turkish saddle or MRI of the brain is shown.
Other endocrine diseases (Addison's disease, Cushing's disease, post-pubertal VHKN, adrenal tumors, empty Turkish saddle syndrome, mosaic version of Turner's syndrome).
Systemic diseases (liver disease, chronic renal failure, hypersplenism).
Iatrogenic causes (errors in taking medications containing female sex hormones and glucocorticoids, prolonged 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 manual transmission. However, the syndrome of uterine bleeding is characterized by pathophysiological and clinical specific signs, which must be taken into account when prescribing preventive measures.

INDICATIONS FOR CONSULTING OTHER SPECIALISTS

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

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

Consultation with a phthisiatrician - with manual transmission on the background of prolonged persistent subfebrile condition, 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 the general blood test, positive results of a tuberculin test.

Consultation of a therapist - with manual transmission on 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 personality's response to the disease.

EXAMPLE FORMULATING A DIAGNOSIS

N92.2 Heavy menses during puberty (heavy bleeding with menarche or pubertal menorrhagia
or pubertal metrorrhagias).

OBJECTIVES OF TREATMENT

The general goals of treating uterine bleeding during puberty are:

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

INDICATIONS FOR HOSPITALIZATION

Patients are hospitalized with the following conditions:

profuse (profuse) uterine bleeding, which is not stopped 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.

MEDICAL 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 the bleeding stops completely. Perhaps intravenous administration of 4-5 g of the drug for 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, estrogen there is a high likelihood 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 volume 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 in girls with manual transmission is used very rarely due to pronounced side reactions (nausea, coarsening of the voice, hair loss and increased greasiness, the appearance of 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 volume of blood loss during menstruation by 30–38%.

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

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 thyroid gland pathology.

Methyl ergometrine can be prescribed in combination with ethamsylate, but if there is or if an endometrial polyp or MM is suspected, it is better to refrain from prescribing methylergometrine because of the possibility of increased blood discharge and the occurrence of pain in the lower abdomen.

As alternative methods, physiotherapy can be used: auto-mammalianization, vibromassage of the peri-ocular zone, electrophoresis with calcium chloride, galvanization of the upper cervical sympathetic ganglia region, electrical stimulation of the cervix with low-frequency pulsed currents, local or laser therapy, acupuncture.

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

lack of effect from symptomatic therapy;
moderate or severe anemia with 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. Ethinylestradiol in the composition of COCs provides a hemostatic effect, and progestogens stabilize the stroma and the basal layer of the endometrium. To stop bleeding, only monophasic COCs are used.

There are many schemes for the use of 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 bleeding for the purpose of regulating menstrual cycles of COCs are prescribed for 3 cycles of 1 tablet per day (21 days of taking, 7 days off). Duration hormone therapy depends on the severity of the initial iron deficiency anemia and the rate of recovery 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 high efficiency of the use of low-dose monophasic COCs (Marvelon©, Regulon ©, Rigevidon ©, Janine ©) 1/2 tablet every 4 hours until complete hemostasis occurs. The appointment under this scheme is based on evidence that the maximum concentration of COCs in the blood is reached 3-4 hours after oral administration the drug and significantly decreases in the next 2-3 hours. The total hemostatic dose of ethinylestradiol at this ranges from 60 to 90 mcg, which is less than the traditionally used dose. In the following days, a decrease is carried out the daily dose of the drug is 1/2 tablet per day. As a rule, the duration of the first COC cycle should not be be less than 21 days from the first day from the onset of hormonal hemostasis. The first 5-7 days of taking COCs is possible a temporary increase in the thickness of the endometrium, 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 are prescribed according to the standard scheme of taking COCs (courses for 21 days with intervals of 7 days between them). For all the sick taking the drug according to the described scheme, good tolerance was noted in the absence of side effects. If necessary, an accelerated stop of a life-threatening patient bleeding with drugs of the first line of choice are conjugated estrogens administered intravenously at a dose of 25 mg every 4-6 hours until completely stopped bleeding if it occurs during the first day. It is possible to use a 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 preparations containing natural estrogens (estradiol), according to a similar scheme with an initial dose of 4 mg per day. After stopping 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 with mandatory addition of gestagens within 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, perhaps the appointment of progestogens.

In patients with heavy bleeding, 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 a day until stopping bleeding. With menorrhagias, medroxyprogesterone can be prescribed at 5-20 mg per day on the second phase (in cases with NLF) or 10 mg per day from the 5th to the 25th day of the menstrual cycle (in cases of ovulatory menorrhagias).

In patients with anovulatory uterine bleeding, progestogens should be prescribed in the second phase. menstrual cycle against the background of constant use of estrogens. 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. With a view to follow-up regulation of the menstrual cycle progestogens (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 with the aim of clarification of the state of the endometrium.

All patients with manual transmission are shown the appointment of iron preparations to prevent and prevent the development of iron deficiency anemia. The high efficiency of the use of iron sulfate in combination with ascorbic acid has been proven. acid, providing the patient with 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 anemias, the presence of a reticulocytic crisis, those. 3 or more fold increase in the number of reticulocytes on the 7-10th day of taking the iron-containing drug.

Antianemic therapy is prescribed for a period of at least 1-3 months. Iron salts should be used with caution in patients with concomitant gastrointestinal pathology. In addition to this option, there may be Fenuls©, Tardiferon ©, Ferroplex ©, FerroFolgamma ©.

SURGERY

Separate scraping 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 can be:

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

If it is necessary to remove an ovarian cyst (endometrioid, dermoid follicular or yellow cyst body persisting for more than three months) or clarification of the diagnosis in patients with a volumetric formation in the area appendages of the uterus, diagnostic laparoscopy is indicated.

APPROXIMATE FAILURE TIME

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

FURTHER INTRODUCTION

Patients with uterine bleeding during puberty need constant follow-up 1 time in a month before the stabilization of the menstrual cycle, then it is possible to limit the frequency of the control examination to 1 time per 3-6 months Echography 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 the menstrual calendar. and assessment of the intensity of bleeding, which will assess the effectiveness of the therapy. Patients should be informed about the advisability of correction and maintenance of optimal body weight (as in
deficiency and overweight), normalization of work and rest.

PATIENT INFORMATION

For the prevention of the onset and successful treatment of uterine bleeding during puberty, it is necessary:

normalization of the work and rest regime;
good nutrition (with the obligatory inclusion in the diet 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 during the first year they have full ovulatory menstrual cycles and normal menstruation are formed. Forecast for manual transmission, associated with the pathology of the hemostasis system or with systemic chronic diseases, depends on the degree of compensation for the existing disorders. Girls, preserving excess body weight and having relapses of manual transmission in aged 15-19 should be included in the risk group for developing endometrial cancer.

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Uterine bleeding of the pubertal period (Uterine bleeding) - pathological bleeding caused by deviations of endometrial rejection in adolescent girls with impaired cyclic production of steroid hormones from the moment of the first menstruation to 18 years. They account for 20-30% of all gynecological diseases of childhood.

Etiology and pathogenesis

At the heart 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 in the ovaries is disrupted and, as a result, uterine bleeding occurs.

Against the background of dyshormonal changes in the ovary, the growth and maturation of several follicles begin, which undergo atresia. In the process of their growth, relative hyperestrogenism is observed in the body, i.e. the level of estrogen does not exceed normal levels, but the corpus luteum is absent, so the uterus is under the influence of only estrogens. Hormonal dysfunction can also lead to the persistence of one follicle, and therefore the corpus luteum is not formed. At the same time, the level of estrogens, which have an effect on the endometrium, is significantly higher than normal - absolute hyperestrogenism.

Follicular cysts are often formed in the ovaries, less often - cysts of the corpus luteum. Regardless of the relative or absolute hyperestrogenism, the mucous membrane of the uterus is not rejected in a timely manner (on the days of menstruation) and undergoes hyperplastic transformation - glandular-cystic hyperplasia develops. There is no secretion phase in the mucous membrane, its excessive growth leads to malnutrition and rejection. Rejection may be accompanied by profuse bleeding or stretch over time.

With recurrent uterine bleeding during puberty, atypical hyperplasia is possible.

Impaired hormonal regulation in girls with manual transmission is promoted by mental and physical stress, overwork, unfavorable living conditions, hypovitaminosis, dysfunction of the thyroid gland and (or) the adrenal cortex. Both acute and chronic infectious diseases (measles, whooping cough, mumps, rubella, acute respiratory viral infections and especially frequent chronic tonsillitis) are of great importance in the development of uterine bleeding during puberty. In addition, complications in the mother during pregnancy, childbirth, infectious diseases of the parents, artificial feeding may be important.

Symptoms

The clinical picture consists in the appearance of bleeding from the genital tract after a delay in menstruation for a period of 14-16 days to 1.5-6 months. Such menstrual irregularities sometimes appear immediately after menarche, sometimes within the first 2 years. In 1/3 of girls, they can be repeated. The bleeding can be profuse and lead to weakness, dizziness. If such bleeding continues for several days, a blood clotting disorder of the type of disseminated intravascular coagulation may occur for the second time, and then the bleeding increases even more. In some patients, bleeding may be moderate, not accompanied by anemia, but last 10-15 days or more.

Uterine bleeding during puberty does not depend on the correspondence of the calendar and bone age, as well as on the development of secondary sexual characteristics.

Diagnosis of uterine bleeding during puberty

It is carried out after hemostasis on the basis of determining the level and nature of changes in the reproductive system.

Diagnosis is based on history data (delayed menstruation) and the appearance of bleeding from the genital tract. The presence of anemia and the state of the blood coagulation system are determined by laboratory research (clinical blood test, coagulogram, including platelet count, activated partial thromboplastic time, bleeding time and coagulation time; biochemical blood test). The level of hormones (FSH, LH, prolactin, estrogens, progesterone, cortisol, testosterone, TSH, T3, T4) is determined in the blood serum, and functional diagnostic tests are carried out. It is advisable to consult specialists -, (condition of the fundus, determination of color fields of view). Between menstrual periods, it is recommended to measure basal temperature. With a single-phase menstrual cycle, the basal temperature is monotonous.

To assess the condition of the ovaries and endometrium, it is carried out, with an intact hymen, using a rectal sensor.

For those who are sexually active, the method of choice is the use of a vaginal probe. On the echogram in patients with uterine bleeding during puberty, a slight tendency to an increase in the volume of the ovaries in the period between bleeding is revealed. Clinical and echographic signs of a 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.

Differential diagnosis uterine bleeding during puberty is carried out primarily with the onset and incomplete, which is easy to exclude with the help of ultrasound. Uterine bleeding during puberty is not only functional; they can also be symptoms of other diseases. One of the first places is occupied by idiopathic autoimmune thrombocytopenic purpura (Werlhof's disease). Formed in the body autoantibodies against platelets destroy the most important factors of blood coagulation and cause bleeding. This congenital pathology occurs with periods of remission and deterioration. Girls with Werlhof's disease, from early childhood, suffer from nosebleeds, bleeding from cuts and bruises, after tooth extraction. The very first menstruation in patients with Werlhof's disease turns into bleeding, which serves as a differential diagnostic sign. On the skin of patients, as a rule, multiple bruises, petechiae are visible. The history and appearance of patients help in establishing the diagnosis of Werlhof's disease. The diagnosis is clarified on the basis of blood tests: a decrease in the number of platelets<70-100 г/л, увеличение времени свертывания крови, длительность кровотечения, изменение показателей коагулограммы. Иногда определяется не только тромбоцитопения (пониженное число тромбоцитов), но и тромбастения (функциональная неполноценность тромбоцитов). При выявлении болезни Верльгофа и других заболеваний крови лечение осуществляется совместно с . Используемые при этом большие дозы дексаметазона могут приводить к аменорее на период лечения.

Uterine bleeding during puberty can be the result of inflammatory changes in the internal genital organs, including tuberculous lesions of the endometrium, cancer of the cervix and uterine body (rare).

Treatment

Treatment of uterine bleeding is carried out in 2 stages. At the 1st stage, hemostasis is carried out, at the 2nd - therapy aimed at preventing recurrence of bleeding and regulating the menstrual cycle.

When choosing a method of hemostasis, it is necessary to take into account the general condition of the patient and the amount of blood loss. Patients with mild anemization (Hb level> 100 g / l, hematocrit> 30%) and the absence of endometrial hyperplasia according to ultrasound data are treated with symptomatic hemostatic therapy. Prescribe uterine-reducing agents: oxytocin, hemostatic drugs (etamzilate, tranexamic acid, Ascorutin). A good hemostatic effect is provided by a combination of this therapy with physiotherapy - applied sinusoidal modulated currents to the area of cervical sympathetic nodes (2 procedures per day for 3-5 days), as well as with acupuncture or electropuncture.

If symptomatic hemostatic therapy is ineffective, hormonal hemostasis is performed with monophasic combined estrogen-progestational drugs (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 discharge after stopping the intake of estrogen-progestogens is moderate and ends within 5-6 days.

With prolonged and profuse bleeding, when there are symptoms of anemia and hypovolemia, weakness, dizziness, with Hb levels<70 г/л и гематокрите <20% показан хирургический гемостаз — раздельное диагностическое выскабливание под контролем гистероскопии с тщательным исследованием соскоба. Во избежание разрывов девственную плеву обкалывают 0,25% раствором прокаина с 64 ЕД гиалуронидазы (лидаза). Пациенткам с нарушением свертывающей системы крови раздельное диагностическое выскабливание не проводится. Гемостаз осуществляют комбинированными эстроген-гестагенными препаратами, при необходимости (по рекомендации гематологов) — в сочетании с глюкокортикостероидами.

Simultaneously with conservative or surgical treatment, it is necessary to carry out a full-fledged antianemic therapy: iron preparations (maltofer, fenuls inside, venofer intravenously); cyanocobalamin (vitamin B12) with folic acid; pyridoxine (vitamin B6) by mouth, ascorbic acid (vitamin C), rutoside (rutin). As a last resort (Hb level<70 г/л, гематокрит <25%) переливают компоненты крови — свежезамороженную плазму и эритроцитную массу.

In order to prevent recurrence of bleeding after complete hemostasis against 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 tablet 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 day, thiamine (vitamin B1) - 5% solution, 1 ml intramuscularly. For the regulation of menstrual function, endonasal electrophoresis of lithium, pyridoxine, procaine, electrophoresis is also used. Prevention of bleeding after hormonal hemostasis consists in taking monophasic combined estrogen-progestational drugs (novinet, mersilon, logest, jess) - 1 tablet each, starting from the 1st day of the menstrual cycle (within 21 days), or progestogens - dydrogesterone (dyufaston) 10-20 mg per day from the 16th to the 25th day for 2-3 months, followed by cyclic vitamin therapy. Patients with hyperplastic processes of the endometrium after curettage, as well as after hormonal hemostasis, should be prevented from relapse. For this, estrogen-progestogen drugs or pure progestogens are prescribed (depending on changes in the ovary - atresia or follicle persistence). Measures of general health improvement, hardening, good nutrition, sanitation of foci of infection are of great importance.

Correct and timely therapy and prevention of recurrence of uterine bleeding during puberty contribute to the cyclic functioning of all parts of the reproductive system.

The article was prepared and edited by: surgeon