This is a diagnosis of exclusion, referring to patients in whom organic causes of hemorrhage are not identified by conventional clinical and paraclinical methods. The basic rule when carrying out the treatment of dysfunctional uterine bleeding (DUB) is to proceed from the principle of a systematic approach to this problem: the need to restore the impaired cyclic regulation of the reproductive cycle through a complex effect on the woman’s body as a whole, with an emphasis on individual primary or most affected parts. When carrying out treatment of DUB, it is necessary to comply with the following fundamental principles of accounting: a) the nature of the menstrual cycle disorders and the level of damage in the hypothalamus - pituitary gland - ovaries - uterus system; b) the age of the patient; c) duration of the disease and duration of bleeding, severity of anemia; d) the presence of concomitant extragenital diseases; e) the period of the expected menstrual cycle, calculated retrospectively.

There are three main stages in the treatment of DUB. 1st stage. Venue: gynecological hospital. The main task is to stop bleeding as quickly as possible using a complex of non-hormonal and hormonal methods of influence.

All used methods of treating DUB are divided into two main groups: conservative and surgical. Conservative methods include general nonspecific therapy, non-drug treatment and surgical - curettage of the uterine cavity; vacuum aspiration of the endometrium; destruction (destruction) of the endometrium by freezing (cryosurgery), cauterization (electrocoagulation), laser vaporization; hysterectomy, ovarian transplantation, omento-ovariopexy, etc.

Conservative methods of treating DUB (pharmacotherapy)

General nonspecific therapy. Consists of the following main components: a) effects on the central nervous system (CNS); b) symptomatic treatment; c) antianemic therapy.

Effect on the central nervous system

General restorative treatment includes the following activities: elimination and prevention of negative emotions; improvement of working and living conditions; daily routine and nutrition; employment (excluding the possibility of mental and physical fatigue); conducting autogenic training, hypnosis; appointment within 3-4 weeks. sedatives, hypnotics and tranquilizers; vitamins Vitamin A (retinol) is prescribed at 50,000 units/day. or carotene (rosehip oil), sea buckthorn oil; vitamin B) (thiamine bromide) - 0.002-0.005 g 2 times a day; vitamin B2 (riboflavin) - 0.005 g 2 times a day; vitamin B5 (calcium pantothenate) - 0.1 g 4 times a child; vitamin B6 (pyridoxine) - 0.01 g 2 times a day or in the form of pyridoxal phosphate; vitamin BC (folic acid) - 5 mg 2 times a day; vitamin B]2 (cyanocobalamin) - 0.01% solution, 1 ml IM; vitamin C (ascorbic acid) - 0.3 g 3 times a day; vitamin P (rutin) - 0.02 g 3 times a day; vitamin PP (nicotinic acid) - 0.015 g 2 times a day or in the form of nicotinamide - 0.025 g 3 times a day; vitamin K (vicasol) - 0.015 g 3 times a day or 1 ml of 1% solution IM. Instead of individual drugs, it is also advisable to prescribe combination drugs (pentovit, gendevit, dicamevit, oligovit, revit, etc.) - 1-2 tablets 2-3 times a day in a continuous course for 40 days. repeating it after 3-4 months.

At the 2nd and 3rd stages of treatment, it is advisable to carry out cyclic vitamin therapy: folic acid, pentovit are prescribed in the first phase of the menstrual cycle, ascorbic acid - in the second; vitamin E (tocopherol acetate) - 0.1 g (capsules) 2 times a day or 30% oil solution - 10 drops 2 times a day or IM 1 ml for several menstrual cycles (3 -th stage of therapy).

At the same time, treatment of concomitant diseases of the liver, gastrointestinal tract, and regulation of intestinal function are carried out.

Symptomatic therapy

Uterotonic drugs are prescribed in small dosages during the period of bleeding and 3 days after hemostasis: ergotal - 0.001 g 3 times a day; ergometrine maleate - 0.2 mg (1 tablet) 3 times a day or 0.02% solution, 1 ml IM 1 time a day; methylergometrine - 0.02% solution, 1 ml IM, subcutaneous ergotamine hydrotartrate 0.05% solution, 0.5-1.0 ml IM or 0.1% - th solution 10 drops 2-3 times a day or 1 mg 3 times a day in tablets; stgaggicin (cotarnine chloride) - 0.05 g 3 times a day; hyfotocin, oxytocin, pituitrin - 0.3-1.0 ml IM every 6 hours.

Hemostatic agents that strengthen the vascular wall are: calcium gluconate - 0.5 g 3 times a day or calcium chloride - 1 tbsp. a spoonful of 10% solution orally 3 times a day after meals or 10 ml of 10% solution intravenously; epsilonaminocaproic acid (EACA) - orally at the rate of 0.1 g/kg body weight every 4 hours (daily dose 10-15 g) for 3 days. - 15.0 g and 4 days. - respectively 12.0; 9.0; 6.0; 3.0 g/day; dicinone - in tablets 0.5-0.75 g/day. or IM, IV 1-2 ml of 12.5% ​​solution; rutin, askorugin - in normal doses; medical gelatin - in the form of a 10% solution, 0.1 - 1.0 ml per 1 kg of body weight IV or 10-50 ml IM; serotonin - 0.015-0.02 g/day. IM in 5 ml of 0.5% novocaine solution 2 times a day at intervals of at least 4 hours (course of treatment is 10 days); acetylcholine chloride for hemostasis - IM or SC 0.05-0.1 g 1-3 times a day for 10-15 days (does not normalize the menstrual cycle).

Local hemostasis is carried out with a thrombin sponge, EACA, 1% adrenaline solution - a tampon is moistened and inserted into the cervix for 8 hours. The Grammaticati method is used in two versions: 1) tincture of 5% iodine is injected into the uterine cavity with a Brown syringe. Start with 0.2 ml and add 0.1 ml daily, bring to 1 ml (2-3 ml maximum); course of treatment is 20-30 days. daily or every other day; 2) loose tamponade of the uterus with a tampon generously moistened with 5-10% iodine solution; exposure 20-30 minutes (course - 1-3 procedures); histological verification of the diagnosis on the eve of treatment is mandatory.

Antianemic therapy

Includes the following components: microelements - iron preparations (hemostimulin, iron lactate, ferroceron, reduced iron, ferroplex, tardiferon, ferkoven, etc.) - average daily doses required time (until hemoglobin levels are restored); ferrum-lek - IM or IV according to the scheme (1st day - 2.5 ml IV; 2nd - 5 ml IV; 3rd - 10 ml IV slowly, then 2 ampoules (10 ml) 2 times a week).

Treatment can be guided by a special nomogram; cobalt preparations - 1% solution of coamide, 1 ml subcutaneously, course of treatment 3-4 weeks; copper preparation - 1% copper sulfate solution, 5-15 drops in milk 2-3 times a day; vitamin analogues - Vitohepat - 1-2 ml IM 1 time per day, course of 15-20 injections, repeated after 1.5-2 months; antianemin - 2-4 ml IM (mild forms) or 6-8 ml (severe forms); sirepar IM, IV - 2-3 ml once a day (50-60 injections); Campolon - 2-4 ml IM daily or every other day, 25-40 days.

Infusion therapy

Includes transfusions of erythromass, polyfer, erythroid suspension, freshly citrated blood, dextrans. It is an integral part of complex therapy for severe conditions.

Hormone therapy

An obligatory component of the first stage of treatment for DUB. Her tasks:

• implementation of hemostasis followed by pseudomenstruation;
• regulation of the menstrual cycle with prevention of recurrent bleeding (preventive goal);
• induction of ovulation and normalization of the menstrual cycle (juvenile DMC, DMC in reproductive age);
• artificial menostasis in menopause with persistent recurrent bleeding.

The goal of hormonal hemostasis is a rapid (in the first hours from the start of therapy) cessation of bleeding. The following options for hormonal hemostasis are used.

Hemostasis by estrogen

Indications: DMC in adolescence and reproductive age with reduced levels in the blood; anemia of the patient and the need for urgent hemostasis; any term and duration of bleeding. Advantages: 1) rapid onset of hemostasis; 2) is not contraindicated in weakened and anemic patients. Methods of administration: microfollin - 0.1-0.2 mg every 2-3-4 hours orally; folliculin - 10,000 units intramuscularly every 2-4 hours; synestrol - 0.1% solution, 1 ml IM every 2-4 hours (estrone - 20,000 units); estradiol benzoate - 5 mg IM every hour until hemostasis; estradiol dipropionate - 0.1% solution, 1 ml every 2-4 hours; small, gradually increasing doses of estrogen.

First, 500 units of folliculin are administered intramuscularly; in the absence of hemostasis, the next day, 1000 units of folliculin are administered intramuscularly, then 1500 units, etc. until hemostasis occurs. Once the bleeding stops, the daily dose of estrogen is reduced by 500 units per day (to a dose of 1000-1500 units) and then discontinued. For anovulatory hyperestrogenic bleeding, estrogens are administered: on the 1st day - 100,000 units 3 times (sinestrol 1% solution - 1 ml), on the 2nd - 100,000 units 2 times a day, on the 3rd - 50,000 units 2 times a day, on the 4th day - 25,000 units 2 times a day and on the 5th day - 10,000 units 2 times a day. To prevent re-bleeding from estrogen decline, treatment is continued after hemostasis - 1 ml intramuscularly for 2-3 weeks. with a gradual dose reduction by 30-50%, then prescribed - 10 mg/day. IM for 6-8 days or a single dose of 125 mg 17-OPK IM.

When carrying out hemostasis with estrogen, the first day of the cycle is conventionally taken as the time of bleeding cessation. The mechanism of hemostasis is based on the principle of feedback in the body to the introduction of large doses of estrogens. In this case, the following processes occur: inhibition of the synthesis and release of follitropin by the pituitary gland, stimulation of the secretion of lutropin; increased endometrial proliferation; increasing the density of the walls of blood vessels, slowing down fibrinolysis in them.

Disadvantages: the need to use relatively high doses that block ovulation; the incidence of so-called breakthrough bleeding with rapid dose reduction; the menstrual-like reaction after hemostasis is abundant and prolonged.

Hemostasis by gestagens

The mechanism of action is based on: secretory transformation and rejection of proliferatively changed endometrium (“medical”, “hormonal” curettage); the effect of the drug on the hypothalamic centers that regulate the gonadotropic function of the pituitary gland, and on the vascular wall; an increase in the number of platelets and proconvertin.

Indications: 1) initial period of uterine bleeding (duration no more than 10 days); 2) the absence of anemia in the patient and the need for urgent hemostasis. The hemostatic effect of gestagens is determined by the daily and total dose of the administered drug (for complete rejection of the endometrium, at least 70-90 mg of progesterone is required) and the duration of use of the drug.

Clinical course of hemostasis with gestagens: a) bleeding stops or sharply decreases during the period of progesterone administration for 3-5 days, and then intensifies again and continues for another 8-9 days, often profusely; b) after 3-4 injections, bleeding increases sharply and, despite the treatment, continues for another 7-8 days; c) bleeding does not stop during treatment, intensifies after its completion and lasts 15-16 days.

Methods of carrying out: progesterone - 10 mg/day. IM for 6-8 days. contract; progesterone - 1% solution, 3-5 ml for 3 days. consecutively or 100 mg 1 time per day; pregnin - 2 tablets. (0.02 g) under the tongue 3 times a day; water-soluble progesterone - 20 mg IV; 12.5% ​​solution 17-OPK - 2 ml IM. Instead of 17-OPK, you can use hormofort, proluton-depot, primolutin. Disadvantages: lack of rapid hemostasis; worsening anemia of the patient due to possible increased bleeding; Possibility of use only in the first days of bleeding; restriction of use in cases of follicle persistence.

Hemostasis by androgens

The mechanism of the hemostatic effect of androgens is due to their influence on: the hypothalamus and pituitary gland (suppression of their function in the form of a decrease in the secretion of gonadotropins); ovary (blockade of folliculogenesis); endometrium (suppression of proliferation - direct antiestrogenic effect); blood estrogens (their blockade); uterine vessels (vasoconstrictor effect); myometrium (increased contractile activity).

Indications: 1) DUB with high and prolonged hyperestrogenia in menopause; 2) DUB with contraindications to estrogens (history of genital or extra-genital tumor processes; small uterine fibroids; mastopathy; individual intolerance); A relative contraindication to androgens is a woman's age under 45 years.

Methods of carrying out: testosterone propionate - 1 ml of 1% solution intramuscularly 2-3 times a day for 2-3 days, then progesterone - 10 mg/day. IM for 6 days; testosterone propionate for hemostasis - 1 ml of 5% solution IM 2 times a day for 2-3 days, then the dose is reduced to 2 times a week for 6-8 weeks. Next, methyltestosterone is prescribed - 15 mg/day. within 2-3 months; methyltestosterone for hemostasis - at least 250-300 mg (50 mg per day for 5-8 days). When bleeding decreases, the dose is reduced to 25 mg daily or every other day, then to 10 mg/day. after 1-2 days, or replace with 1 ml of Sustanon-250, Omnadren.

You can carry out hemostasis with androgens according to the following scheme: on the 1st day - 1 ml 3 times a day, on the 2nd - 1 ml 2 times a day, on the 3rd - 0.5 ml 2 times a day, on the 4th day - 0.25 ml 2 times a day, on the 5th day - 0.25 ml 1 time a day IM. After hemostasis (48-60 hours), it is advisable to continue treatment with gradually decreasing doses or prescribe 50 mg of androgens intramuscularly daily (every other day) until hemostasis occurs (2-3 injections), and then 25 mg 2-3 times a week i/m. In the absence of recurrent bleeding, maintenance therapy is indicated - 10 mg every other day or orally 10 mg of methyltestosterone sublingually 2 times a day.

When carrying out treatment with androgens, the following basic rules should be adhered to: the period of active treatment is at least 1 month, more often no more than 2 and in rare cases no longer than 3 months; after eliminating acute disorders, maintenance doses are prescribed - from 50 to 150 mg per month; the choice of dose and duration of therapy is strictly individual. Impact therapy is considered to be the use of 25 mg of the drug every 4 days, and maintenance therapy is the administration of the same dose every 10 or 7 days. The drug of choice is testosterone propionate, which has no side effects. When treating with androgens, preference is given to androgens with a non-virilizing effect. Disadvantages of androgen therapy: can only be prescribed to older women before artificial menostasis; impossibility (lack of conditions) for long-term use due to virilization and anabolic effect.

Hemostasis with synthetic progestins (SPP)

The mechanism of action is as follows:

• blocking the hypothalamic-pituitary system and thereby reducing the secretion of folliberin and luliberin;
• cancellation of SPP promotes the onset of the rebound phenomenon in the hypothalamic-pituitary-ovarian system. The pituitary gland is freed from prolonged inhibition, conditions are created for the production of its own gonadotropins;
• the positive therapeutic effect of SPP is associated with the hemostatic effect of estrogens and secretory transformations of the endometrium under the influence of gestagens.

Indications- DMK at any age. Features of hemostasis of SPP: their use in the treatment of DUB makes it possible to give an answer about the occurrence or absence of hemostasis in the interval from 5 to 96 hours, as this is evidence of the hormonal genesis of bleeding and the possibility of simulating artificial menstrual cycles by treatment, imitating the natural biological rhythm of a woman; the speed of onset of hemostasis with different morphological states of the endometrium confirms the fact that the mechanism of hemostasis is not directly related to the transition of the endometrium to the secretory phase; a positive reaction to taking SPP also indicates the pathogenetic significance of luteal insufficiency of varying severity in this bleeding; the absence of hemostasis indicates that the bleeding is not hormonal in nature or that it is of multifactorial origin (hormonal, inflammatory, tumor, mechanical, traumatic, etc.); the effect of SPP is a differential diagnostic auxiliary treatment for DM K. When using SPP hemostasis, simultaneous treatment is necessary to relieve the patient of side effects (vitamin B6, hepatoprotectors).

Methods of carrying out:

1) one of the available monophasic SPPs necessary for the woman is prescribed in decreasing doses, starting from 4-6 tablets/day. until hemostasis. Then gradually over 10 days. the dose is reduced by 1/2 tablet, brought to 2 tablets/day and switched to a maintenance dose (1 tablet/day). The duration of the course is 21 days, starting from taking the first tablet or from the first day of hemostasis. After discontinuation of the drug, a menstrual-like reaction occurs. Scheme: 1st day use 6 tablets. (after 4 hours), 2nd - 5 tablets. (after 6 hours), 3rd - 4 tablets. (after 6 hours), 4th - 3 tablets. (after 8 hours) and from the 5th to the 21st day - 2(1) tablets/day;

2) to reduce the frequency of negative side effects of SPPs, which often occur when using the first method, they are prescribed 1 table. orally 3 times a day at regular intervals for 2-3 days. Then the dose is reduced to 2 tablets. within 2 days. and switch to maintenance (1 table) for 7-14 days. Disadvantages of SPP hemostasis: a relatively high frequency of side effects, mainly due to the estrogen component; the presence of a large number of absolute ones (hormone-dependent tumors, acute diseases of the liver and biliary tract, acute thrombophlebitis, thromboembolic diseases, hemostatic disorders, Itsenko-Cushing's disease, hypopituitarism, genetic diseases of the gallbladder) and relative (thrombophlebitis, chronic diseases of the liver and biliary tract, epilepsy, severe sclerosis, otosclerosis, hypertension, rheumatic carditis, diabetes mellitus, tetany, migraine, chronic pyelonephritis) contraindications.

Hemostasis by a combination of estrogens and gestagens

The most optimal and widespread estrogen-progesterone ratio is 1:10 or 1:20, 1:25.

Indications- DMK at any age.

Methods of carrying out: estrogens - 0.1% solution, 1 ml in combination with 1 ml of 1% progesterone solution in one syringe IM for 3 days. contract; estrogens in the same dose intramuscularly for 10 days. or hormofort - 2 ml (250 mg) intramuscularly on days 10, 11, 12 of treatment, or sinestrol - 0.1% solution, 1 ml in combination with 2 ml of 0.5% progesterone solution IM; estradiol benzoate - 10 mg IM in combination with 200 mg progesterone or estradiol benzoate at a dose of 10-20 mg in combination with 1-2-3 ml (125-250-375 bw) 12.5% ​​solution 17-OPK (primosiston) IM in one syringe. It is possible to use 17 mg of estradiol valerianate in combination with 6 mg of ethinylnortestosterone IM or linestrol at a dose of 10 mg in combination with mestranol at a dose of 0.3 mg for 3 days, followed by a dose reduction for 3 days. up to 5 mg and 0.15 mg of drugs, respectively.

The mechanism of the therapeutic effect of the combination of estrogens and gestagens is due to:

• the action of estrogens, which, by increasing the reduced level of estrogens, promote hemostasis;
• secretory transformation of hyperplastic endometrium;
• mechanical action, known in the literature as “hormonal curettage”.

Advantages of hemostasis: the possibility of use for DUB at any age and the relative duration of hemostasis (hours or even days).

Hemostasis by estrogens, gestagens, androgens

The mechanism of hemostasis is associated, in addition to the above, with the dual effect of androgens in large doses: inhibition of the secretion of gonadotropins and estrogens, as well as a progesterone-like effect on the endometrium. As a result of this influence of the complex, rest is provided to the hypothalamus-pituitary-ovary system and a therapeutic effect is achieved.

Indications- DUB of anovulatory nature with persistence of the follicle.

Methods of carrying out: synestrol - 1 ml of 2% solution in combination with 1 ml of 0.5% progesterone solution and 1 ml of 5% testosterone propionate solution intramuscularly in one syringe; estrogens - 3 mg in combination with 20 mg of progesterone and 25 mg of testosterone; folliculin - 3000 units in combination with 30 mg of progesterone and 50 mg of testosterone propionate IM in one syringe; estrone (estradiol benzoate) - 1.6 mg in combination with 25 mg of progesterone and 25 mg of testosterone propionate intramuscularly for 5 days, or estrone - 6 mg in combination with 25-50 mg of progesterone and 25 mg of testosterone propionate IM for 5 days. Basic rules for hemostasis: the mixture is administered intramuscularly in one syringe; the specified ratio is not constant; It is mandatory to take into account the patient’s age and endocrine ovarian function (individual approach); a “triad” of steroid hormones is administered every other day; course of treatment - 4-10 injections, depending on the degree and duration of anemia of the patient; the day of reduction in blood loss is considered the beginning of the next cycle. This type of hemostasis is contraindicated in anovulatory DUB with hypoestrogenism (follicular atresia) in adolescence and in young women (under 35 years).

The main disadvantages of the method: relatively low therapeutic efficacy, relapse rate.

Hemostasis by gestagens and androgens

The mechanism of hemostasis is associated with secretory changes in the endometrium (due to progesterone) and the influence of androgens on target organs in the periphery (uterus) and a decrease in hyperplastic processes in them.

Indications- DUB in combination with small size and (or) (i.e. hyperhormonal DUB).

Methods of carrying out: progesterone - 30-75 mg per day in combination with 1 ml of 5% testosterone propionate solution intramuscularly for 3 days. (progesterone); androgens - until hemostasis, followed by a decrease in testosterone doses to 50 ml once every 5-7 days, and then once every 7-10 days; testosterone propionate - 25 mg in combination with 10 mg of progesterone IM daily for 5 days. contract. Typically, hemostasis occurs during the 3rd, 4th and 5th injections; 17-OPK - 250-375 mg of 12.5% ​​solution with 1 ml of Sustanon-250 (omnadren) or 1 ml of 10% testenate solution IM at the time of bleeding. The technique is more effective and convenient due to the prolonged action of the drugs.

Hemostasis with gonadotropins

The mechanism of hemostasis is associated with the effect on the follicle, its luteinization, the onset of ovulation, the development of the corpus luteum, and the release of progesterone, which contributes to hemostasis and regulation of the menstrual cycle.

Indications- anovulatory bleeding (hyperestrogenism, NLF) in adolescence and young reproductive age.

Methods of carrying out: choriogonin - 1000-2000 units intramuscularly until hemostasis occurs; 1500 units every other day (5-6 injections in total); also used for 12 days: every next 3 days - 1500 IU, 1000, 500, 250 IM; 1000-2000 units intramuscularly until hemostasis occurs, then 500 units every other day intramuscularly for 14 days. Choriogonin at a dose of 2000 units is administered intramuscularly in combination with 25 mg of testosterone propionate for 5-10 days, or choriogonin at a dose of 3000-4500 units intramuscularly is prescribed every other day, with a total dose of 10,000-12,000 units. Typically, hemostasis occurs within the first 28-40 hours from the start of treatment. Next 2 weeks. treatment normalizes the cycle, and after 3-5 days. menstrual-like bleeding occurs. Disadvantages - relatively weak hemostatic effect due to the indirect effect on the endometrium. The method is more acceptable at the stage of preventing recurrent bleeding in young women and girls.

Clinical picture of hormonal hemostasis

Includes the following main points: cessation of bleeding is the first clinical manifestation of the action of the hormonal drug; clean days when carrying out hormonal hemostasis cover the period after the cessation of bleeding until the appearance of pseudomenstrual bleeding; pseudomenstrual bleeding is the physiological end of hemostasis.

Non-drug treatment of DUB

For this purpose, AFT, reflexology, gynecological massage, and spa treatment are used. APT is carried out by influencing the central mechanisms of regulation of the menstrual cycle, pelvic organs and influence through the mammary gland.

Impact on the central mechanisms of regulation of the menstrual cycle. The most commonly used AFT is: cervico-facial (according to G. A. Kellat) through a 1% solution of zinc chloride, 2-3% solution of sodium bromide or 2-3% solution of sulfate magnesia; procedures are carried out daily or every other day, a total of 12-15 sessions with an exposure of 8-12 minutes; endonasal galvanization or endonasal electrophoresis with 10% calcium chloride solution - for bleeding due to inflammatory processes; with vitamin B1 - for anovulatory hypo-estrogenic bleeding; with 0.25-0.5% novocaine solution - for anovulatory hyperestrogenic bleeding; a total of 12-15 procedures per course daily or every other day; indirect electrical stimulation of the hypothalamic-pituitary region (according to S. N. Davydov) begins with ongoing uterine bleeding - the first three days of the procedure are performed daily for 10 minutes, then three sessions every other day.

If after 6 procedures hemostasis does not occur, other methods of therapy are indicated; longitudinal head and ionogalvanization (according to A.E. Shcherbak) - the location of the electrodes is frontoccipital, exposure is 20 minutes, the galvanic collar is carried out through a 1% sodium bromide solution, alternating with diathermy, the number of procedures is 6, the course of treatment is 2 week; impact on the area of ​​the cervical superior sympathetic ganglia (procaine blockade - 10-15 ml of 0.5% novocaine solution; electrophoresis - with a 1% novocaine solution on the supracervical area, exposure - 15 minutes, course - 8-10 sessions).

Impact on the pelvic organs: electrical stimulation of the uterus (indicated for hemostasis in case of recurrent bleeding after repeated curettage in the past, after curettage of the uterus and insufficient hemostasis; with heavy blood loss after hormonal hemostasis; with juvenile bleeding. The total duration of the procedure is 8 minutes, the course of treatment is 2 -5 days); thermal effects on the cervix (carried out by douching with hot water - 35 ° C and above with an interval of 1-2 hours or irrigation with chlorethyl); vacuum stimulation of the cervix (created by an electric pump in the form of negative pressure at the cervix, exposure - 5-10 minutes, course of treatment - 5-6 procedures); electrical stimulation of the cervix (according to S. Ya. Davydov) (carried out with pulsed currents, course - 6 sessions), most often used for recurrent bleeding for prophylactic purposes, used from the 14th day after curettage, and in subsequent cycles - from the 14th day the th day after the next menstruation for three days, exposure - 10 minutes; (15-20 sessions every other day); ultratone (from the 5th day of the menstrual cycle daily or every other day, up to 20 sessions in total); ; electrophoresis with galvanic or pulsed current through various medicinal substances, taking into account the existing concomitant gynecological pathology; laser therapy (use helium-neon laser - GNL, wavelength - 632.8 nm, power density - up to 200 mW/cm2). The area of ​​influence is the cervix, vaginal vaults, reflexogenic zones of Zakharyin-Gsda, projectionally connected with the ovaries, active points of the meridians of the kidneys, urinary and gall bladder, liver, pancreas, spleen, anterior median meridian. Method of influence: remote, contact (through a light guide). The course of treatment is 8-9 procedures.

Effect on menstrual function through the mammary gland

The automammification method is based on an indirect (through the mammary gland) reduction in the estrogen-producing function of the ovaries. The following methods of automammification are distinguished: a) diathermy (inductothermy) of the right mammary gland (procedures - every other day, duration - 15-20 minutes); b) electrophoresis with a 5-10% solution of calcium chloride on the area of ​​the mammary glands (exposure - 20 minutes, sessions - daily or every other day, 10-12 sessions in total), exposure from 5 to 20 minutes is possible, gradually increasing ; c) the area of ​​the right mammary gland (exposure - 5 minutes, sessions - daily, 10 in total).

Gynecological massage

This is one of the components of complex therapy for DUB. It is carried out mainly in the second and third stages of treatment. Indications: DUB in combination with general and genital infantilism, uterine hypoplasia and genital hypotrophy; DUB in combination with a chronic inflammatory process (residual effects); anovulatory DUB with hypoestrogenism; ovulatory DMC with insufficiency of both phases of the cycle. In the absence of bleeding, it is advisable to combine gynecological massage with thermal procedures and balneotherapy. The purpose of the massage: stretching and resorption of scars and adhesions, improving blood supply to the hypoplastic uterus. Conditions: technical training of personnel; separate room with a gynecological chair, rubber gloves; normal body temperature; blood parameters: leukocytosis no more than 6.0-109 g/l, ESR no more than 15 mm/h; I-III degree of vaginal cleanliness; bowel and bladder emptying. The duration of the massage session is from 3 to 10 minutes, the course of treatment is 30-40 days. The technique is described in the relevant manuals.

Reflexology

It is carried out in several options (acupuncture, laser puncture, etc.).

Acupuncture (IRT)

For DMC, the inhibitory IRT method is used. First, a general strengthening irritation is applied, then after 2-3 sessions special action points are connected, 3-5 TAs per procedure. The most commonly used corporal points: V22, Ш, У1, VA1, TA, L9, K23, ViA, HO, 720, 721, VB20, RPIQ, R1, IZ, RP6, 76, R9, R3, G14. Auricular points: endocrine glands - 22MV, sympathetic - 51 NNP3, pituitary gland - 28PC, Uterus - 58TY. For hypermenorrhea, treatment is carried out during the menstrual cycle. The procedures begin with the legs, then move to the lower abdomen or lower back. An approximate version of an acupuncture prescription: 1st session: TA 720, K43 (symmetrical, calming method); 2nd session: VB20, C14 (symmetrical); 3rd session: 719, RP6, (calming method).

For polymenorrhea, treatment begins 2-3 days before the start of menstruation. The course of treatment is 10 days. The method of influence is inhibitory. Approximate combination of points: 1st session: R9, RP6, /4, V23; 2nd session: R6, TA, V32, ViA (symmetrical); 3rd session: RP6 (symmetrical); 4th session: 74, V23, VTI (symmetrical, calming method 1-2 hours after acupressure of medium strength); 5th session: RPb, VA1 (symmetrically, acupressure of medium strength with light vibration; after 15 minutes of rest, continue acupressure in TA/6, JA, EL, RP10); 6th session: VB2Q, L9, VG21, V32, VIQ (symmetrical, braking method).

Laser puncture

Carry out using fiberglass optics and a helium-neon laser at therapeutic power densities (10-100 mW/cm2). Currently, a differentiated approach is used in the use of reflexology for endogenous stimulation of the gonads. In the first phase of the menstrual cycle, the effect is aimed at stimulating the function of the parasympathetic nervous system. To do this, starting from the 5th day of menstruation, GNL is applied to the points of the meridians of the pericardium, heart, kidneys, liver, and anterior median meridian. In the second phase of the cycle, laser or other RT exposure is aimed at stimulating the function of the sympathetic nervous system. To do this, starting from the day of ovulation, they influence the acupuncture points of the meridians of the bladder, colon, and posterior median meridian.

Phytotherapy

It is symptomatic. They use infusions and decoctions of nettle, shepherd's purse, water pepper, yarrow, and lagochilus. You can also use pure extracts from water pepper, red viburnum, lagochilus (25-40 drops 3-4 times a day). The most commonly used fees: Collection 1. Nettle grass - 10.0, yarrow grass - 10.0. Pour the collection into 400 ml of boiling water, leave for 20 minutes, take 50 ml 3 times a day. Collection 2. Horsetail grass - 5.0, shepherd's purse grass - 5.0. Pour the mixture into 300 ml of boiling water, leave for 20 minutes, take 50 ml 3 times a day. Collection 3. Liquid burnet extract - 50.0 ml. Sterilize. Inject intrauterinely 3-5 ml daily until bleeding stops. Collection 4. Oak bark - 2.0, shepherd's purse grass - 3.0, yarrow grass - 3.0, cinquefoil erect root - 3.0. Mix, boil for 5 minutes in 500 ml of boiling water, leave for 20 minutes, take 50 ml 3-4 times a day.

Hyperbaric oxygen therapy (HBO)

It is carried out in the complex treatment of DMB from the moment the patient is admitted to the hospital, in the absence of heavy bleeding. A single pressure chamber "OKA-MT" with hyperbaric oxygenation is used at a pressure mode of 2 atm and exposure time of 40-60 minutes. The course of treatment is 6-10 procedures. Bleeding usually stops after the third session.

A relatively new method of non-drug treatment of DUB is the use of electrical stimulation of the cervix in combination with dosed local hyperthermia. The technique is most indicated for anovulation after suffering from chronic inflammatory processes of the uterus and appendages, and for rehabilitation in case of infertility. Treatment begins immediately after the end of menstruation and continues until the next one. It includes 16-18 sessions of dosed local hyperthermia. The temperature increases from 38 °C (1 °C daily) to 43 °C with a maximum on the 11-12th day of the cycle. After this, it is maintained at the same level until the 24-25th day and decreases to 39 "C by the 28th day. The temperature regime may vary depending on the duration of the menstrual cycle. During the period of expected ovulation (taking into account functional diagnostic tests) against the background dosed local hyperthermia, electrical stimulation of the cervix is ​​carried out for 4-6 days.

Often, with gynecological diseases, it is necessary to examine the endometrium of the uterus to confirm the diagnosis. The most important processes occurring in the organs of the reproductive system depend on its condition and development. Cleaning is also prescribed for medicinal purposes. How the procedure goes, how painful it is, what the consequences may be, worries many women who are faced with the need to perform curettage of the uterine cavity. The risk of complications is minimal if after the procedure the patient strictly follows the doctor’s recommendations.

Content:

What is curettage and why is it done?

The uterus is lined from the inside with a membrane (endometrium), consisting of 2 layers. One of them borders directly on the muscles of the wall. On top of it there is another layer, the thickness of which regularly changes in accordance with the functioning of the ovaries and the production of female sex hormones. Curettage is the complete removal of the functional layer. This procedure allows you to diagnose pathological neoplasms, as well as clean the organ cavity.

Types of procedure

There are several methods for carrying out such cleaning.

Normal cleaning consists of removing the mucous membrane only inside the cavity.

Separate differs in that the mucous membrane is first removed from the cervix, and then from its cavity. Selected materials are collected in different containers and examined separately. This allows us to clarify the nature of the pathology in each part of the organ.

An improved method is curettage simultaneously with hysteroscopy. Using a special optical device (hysteroscope), the uterus is illuminated from the inside, and the image of its surface is magnified. Thus, the doctor does not act blindly, but purposefully. Hysteroscopy allows you to perform a preliminary examination of the cavity and act more accurately. This significantly reduces the risk that endometrial particles will remain in the uterus and complications will arise after surgery.

Indications for cleaning for diagnostic purposes

It is used as an independent procedure, as well as as an auxiliary one, allowing one to assess the nature of the tumors and the volume of the upcoming abdominal surgery to remove tumors.

For diagnostic purposes, curettage is performed in the presence of the following pathologies:

• endometrial hyperplasia - a condition in which it thickens excessively, neoplasms appear in it, and their nature requires clarification (the anomaly is first detected using ultrasound);
• endometriosis (spread of the endometrium outside the uterus);
• cervical dysplasia (a separate diagnostic procedure is carried out if there is doubt about the benign nature of the pathology);
• menstrual irregularities.

Therapeutic purposes of cleansing

Indications for curettage for therapeutic purposes are:

1. Presence of polyps. It is possible to get rid of them only by complete rejection and removal of the entire layer of the mucous membrane. Most often, after such a procedure there are no relapses.
2. Heavy bleeding during or between periods. Emergency cleaning can prevent major blood loss. It is carried out regardless of the day of the cycle.
3. Infertility in the absence of obvious hormonal disorders and gynecological pathologies.
4. Uterine bleeding in postmenopausal women.
5. The presence of adhesions in the uterine cavity.

Obstetric curettage

Carried out in the following cases:

• during an abortion (artificial termination of pregnancy is performed in this way for a period of no more than 12 weeks);
• after a miscarriage, when it becomes necessary to remove the remains of the fertilized egg and placenta;
• in case of a frozen pregnancy (it is necessary to remove the dead fetus and completely clean the uterus to prevent inflammatory processes);
• if heavy bleeding occurs in the postpartum period, which indicates incomplete removal of the placenta.

Video: Indications for separate diagnostic uterine curettage

Contraindications for cleaning

Planned curettage is not carried out if a woman has infectious diseases or acute inflammatory processes in the genitals. In emergency cases (if, for example, bleeding occurs after childbirth), the procedure is carried out in any case, since it is necessary to save the patient’s life.

Cleaning is not performed if there are cuts or tears in the uterine wall. This method is not used to remove malignant tumors.

Carrying out the procedure

Curettage is usually performed in the last days of the cycle before the onset of menstruation. During this period, the cervix is ​​most elastic and easier to dilate.

Preparation

Before the procedure, a woman must undergo a general blood and urine test for the presence of inflammatory processes. A blood clotting test is performed. Tests are taken for syphilis, HIV and hepatitis.

Before the procedure, a microscopic analysis of a smear from the vagina and cervix is ​​performed to determine the composition of the microflora.

3 days before cleaning, the patient must stop using vaginal medications, and also stop douching and abstain from sexual intercourse. The procedure is carried out on an empty stomach.

How is the operation performed?

Curettage of the uterine cavity is carried out exclusively in a hospital, under conditions of maximum sterility. Pain relief is carried out by using a mask with nitrogen dioxide or intravenous administration of novocaine. Sometimes general anesthesia is used.

During the procedure, the uterus is expanded with special devices, and its internal size is measured. The upper mucous membrane of the organ is scraped out using a curette. If diagnostics are necessary, the material is sent for histological examination.

When performing an abortion or cleansing after a miscarriage, frozen pregnancy, or childbirth, the aspiration method is used. The contents of the uterine cavity are removed using a vacuum. In the same way, blood is removed from it in case of dysfunctional uterine bleeding or stagnation inside the uterus. This method is more gentle than curettage, since there is no risk of damage to the cervix or uterine wall.

During hysteroscopic curettage, a tube with a video camera is inserted into the uterus to examine the surface. After removing the top layer of the endometrium, make sure that the mucous membrane is completely removed.

After the procedure, ice is placed on the lower abdomen. The patient remains in the hospital for several hours so that doctors can be completely sure that there is no risk of bleeding.

After operation

Immediately after the anesthesia wears off, the woman may feel quite severe abdominal pain for 2-4 hours. Then, for another 10 days, feelings of mild nagging pain persist. The discharge of blood in the first hours is strong and contains blood clots. Then they become spotting and may appear for another 7-10 days after surgery. If they stop too quickly, and at the same time the woman’s temperature rises, this indicates the occurrence of blood stagnation (hematometra) and an inflammatory process. Treatment is carried out with oxytocin, which increases uterine contractility.

To eliminate pain, painkillers and antispasmodics (no-spa) are prescribed to help speed up the removal of residual blood. Antibiotics are taken for several days to prevent inflammation in the uterus.

2 weeks after cleaning, a control ultrasound examination is performed to ensure that the procedure was successful. If the study shows that the endometrium has not been completely removed, cleaning must be repeated. The result of a histological examination of the cells of the removed material is ready in about 10 days, after which the doctor will be able to make a conclusion about the need for further treatment.

After cleaning, your period will begin in 4-5 weeks. The frequency of their onset is restored after approximately 3 months.

Warning: You should consult a doctor immediately if blood in the discharge does not disappear after 10 days, and the abdominal pain intensifies. The appearance of elevated temperature a few days after curettage should alert you. It is imperative to visit a doctor if menstruation after cleansing the uterus becomes too heavy or very scanty, and their pain also increases.

After the operation, until its consequences completely disappear, it is necessary to avoid douching, inserting tampons into the vagina, and medications not prescribed by the doctor. You should not put a hot heating pad on your stomach, visit a sauna, take a bath, or stay in a hot room or in the sun for a long time.

Do not take aspirin or other anticoagulants for 2 weeks after cleansing. Sexual relations can be resumed 3-4 weeks after curettage, when the pain and risk of infection disappear.

Pregnancy after curettage

Curettage that takes place without complications usually does not affect the course of pregnancy and childbirth. A woman can become pregnant within a few weeks, but doctors recommend planning her pregnancy no earlier than 3 months after cleansing.

Video: Is pregnancy possible after cleaning the uterus?

Possible complications

After a qualified curettage procedure, complications occur extremely rarely. Sometimes, due to impaired muscle contractility, a condition such as hematometra occurs - stagnation of blood in the uterus. The inflammatory process begins.

During the procedure, the neck may be torn by instruments. If it is small, then the wound will quickly heal on its own. Sometimes you have to stitch it.

When performing a blind operation, damage to the uterine wall may occur. In this case, the gap needs to be sutured.

Damage to the basal (inner layer of the endometrium, from which the superficial functional layer is formed) is possible. Sometimes restoration of the endometrium becomes impossible because of this, which leads to infertility.

If polyps are not completely removed, they may grow again and require repeated curettage.

Content

Curettage (curettage, cleaning) of the uterus is the removal of the functional upper layer of the endometrium using a curette. Curettage can be used for therapeutic and diagnostic purposes. In the latter case, it makes it possible to obtain tissue samples for subsequent histological examination.

Curettage is practiced when it is necessary to remove altered endometrium and various neoplasms from the uterine cavity, as well as in the case of artificial termination of pregnancy.

Indications

For diagnostic purposes, curettage is prescribed to verify the diagnosis when certain symptoms are detected in women, indicating the development of uterine pathologies. It can be:

• bloody vaginal discharge that appears between two menstruation;
• irregular cycle;
• prolonged and heavy menstruation, accompanied by pain;
• menstruation that began during menopause;
• difficulties with bearing a child;
• suspicion of infertility.

Curettage may be prescribed if symptoms are present, indicating the development of cancer pathology.

During diagnostic curettage, all material collected from the uterine cavity is transferred to the laboratory for histological examination. Based on the results obtained, treatment will be prescribed.

Curettage, performed for therapeutic purposes, can be used both as a primary and as an additional method of treatment.

Cleaning of the uterine cavity is prescribed upon diagnosis.

• Submucosal fibroids. A benign neoplasm that forms in the muscular layer of the organ and grows into the uterine cavity. A symptom of fibroids can be heavy periods.
• Polyps. These glandular tumors develop on the walls of the uterine cavity and the lining of the cervical canal. Can cause heavy bleeding both during menstruation and in the period between two cycles. Polyposis is also characterized by spotting during the intermenstrual period, before and after menstruation. Polyps are prone to degeneration and curettage is the only way to remove them. Histological analysis of the obtained material helps determine the likelihood of developing cancer.
• Endometrial hyperplasia. The condition is a pathological thickening of the endometrial layer. In some cases, hyperplasia can cause the development of endometrial cancer, infertility, and severe bleeding.
• Endometritis. It is an inflammation of the endometrial layer of the uterus. If there is no effect from drug treatment, curettage is prescribed.

For therapeutic purposes, the procedure is prescribed in the following situations.

• Abortion. Artificial termination of pregnancy by curettage is practiced relatively rarely. Vacuum cleaning is widely used to remove the fertilized egg from the uterine cavity.
• Frozen pregnancy. A dead embryo remaining in the uterine cavity poses a serious threat to a woman. The fetus is removed after more than 5 obstetric weeks by curettage.
• Ectopic cervical pregnancy.

Postpartum curettage is practiced when it is necessary to remove fragments of the placenta and blood clots remaining in the uterine cavity. Cleaning allows you to avoid the development of serious complications - infection and massive bleeding.

Curettage technique

The purpose of diagnostic curettage is to obtain samples of the endometrial layer. Examination of the obtained tissues helps to detect pathological changes in the composition of the endometrium and begin treatment.

To obtain the necessary information, you need to take into account the day of the menstrual cycle. Cleaning the uterine cavity is carried out:

• on days 5–10 for menstrual irregularities;
• 2 - 3 days before the start of menstruation - if there is a suspicion of lack of ovulation;
• any day – if there are symptoms of an endometrial tumor and bleeding.

With the development of uterine bleeding Curettage of any intensity is carried out immediately.

Curettage of the uterine cavity is a painful procedure, so the woman receives anesthesia. It can be masked and intravenous. Epidural anesthesia is sometimes used, in which an anesthetic is injected into the spinal canal. In this case, the lower part of the body “turns off”, but the patient remains conscious. Local anesthesia - injections into the cervix - is extremely rarely practiced.

During curettage, the following gynecological instruments are used.

• Curette. It is a tool with one loop, the edge of which is carefully sharpened.
• Hegar dilators. Used to open the cervix. They have different diameters and are used as it increases.
• Bullet forceps (Muzot forceps). Used as clamps to hold the cervix in the desired position.
• Probe. An instrument in the form of a rod with centimeter divisions. Necessary for determining the length of the uterus.
• A speculum is a vaginal dilator.

Curettage is performed in several stages. The gynecologist begins the curettage itself only after complete anesthesia.

Cleaning the uterine cavity is carried out as follows:

1. A vaginal examination is performed to clarify the current position of the uterus.
2. The doctor treats the external genitalia with an antiseptic solution.
3. Using a speculum, the vagina is dilated and the cervix is ​​exposed. It is treated with antiseptics, grabbed with bullet forceps and pulled down. The position of the tool is fixed.
4. Then probing is performed, allowing the physician to determine the length of the uterus and assess the patency of the cervical canal.
5. Next, the Hegar dilators open the cervix, and the gynecologist begins curettage.
6. The doctor begins to work with the largest curette. It is inserted into the uterine cavity and removed with fast and strong movements, ensuring the removal and simultaneous removal of the endometrium. First, its back, then the front and side walls are scraped out. Cleaning is completed when a characteristic crunching sound appears.
7. Finally, the cervix and external genitalia are disinfected again.

Diagnostic curettage can be performed under the control of a hysteroscope. This is a modern device that allows the gynecologist to examine the internal surfaces of the uterus and control the curettage process.

The technique has a number of advantages:

• it provides better quality curettage;
• the doctor gets the opportunity to see the surgical field;
• the risk of injury to the walls of the uterus is reduced;
• it is possible to remove existing tumors, in particular polyps, during the procedure.

It is also a type of diagnostic curettage - separate curettage. Initially, the gynecologist removes the endometrium from the walls of the cervical canal and then the uterine cavity. This technique helps determine the location of pathological neoplasms. The resulting samples are placed in different containers and sent to the laboratory for histology.

The results of the study will be ready in 10-14 days. Based on these, treatment is prescribed.

Contraindications

Curettage has its contraindications. The technique is not used:

• in the presence of dysfunctions of the hematopoietic system;
• for pathologies of the central nervous system;
• with severe damage to the heart and blood vessels;
• during the period of acute infectious or diagnosed malignant gynecological disease.

Cleansing is performed with caution in women who have had a negative reaction to the administration of narcotic anesthetics..

Possible complications

Performing curettage is not difficult for an experienced gynecologist and almost completely eliminates the development of complications. But in some cases, curettage of the uterine cavity may be accompanied by:

• perforation (through damage) of its walls;
• tear/complete rupture of the neck;
• infection of the uterus;
• hematometer;
• damage to the basal (germ) layer of the endometrium.

Postoperative period

The procedure for curettage of the uterine cavity is characterized by Quite heavy bleeding that stops after a few hours.

Then the discharge becomes more scanty and can last up to 14 days. This is a normal reaction of the organ to surgery.

After cleaning the uterus, periods begin on the usual dates. A delay of 1 – 3 weeks is allowed. But if it is longer, then you need to consult a gynecologist.

During the rehabilitation period (two weeks after curettage) you cannot:

• have sex;
• use sanitary tampons;
• visit baths and saunas;
• take lying baths - only showers are allowed;
• give the body significant physical activity;
• douche;
• take medications that thin the blood.

A woman should receive urgent medical care in the following cases:

• if severe bleeding develops, she is forced to change the sanitary pad once an hour or more often;
• in the absence of bleeding, this symptom indicates a hematometra - accumulation of blood in the uterine cavity caused by spasms of the cervix;
• when general health deteriorates - severe pain, increased body temperature, chills.

The uterus is ready to bear a child within a few months after curettage. But doctors recommend planning a pregnancy no earlier than 6 months after the menstrual cycle returns.

Every woman has been to a gynecologist at least once in her life. Many girls are often given a very unpleasant diagnosis after examination, in which the endometrium grows - hyperplasia. Unfortunately, according to doctors, treatment of endometrial hyperplasia almost always requires manipulation—curettage of the endometrium.

Endometrial hyperplasia is a disease where the endometrium (the inner layer covering the uterus) grows. At the same time, it increases in size and thickens. During a normal monthly cycle, under the influence of hormones, the endometrium exfoliates and the reproductive organ is cleansed. If a woman has a hormonal imbalance, this process does not occur.

Curettage is a surgical procedure that removes the endometrium. Curettage is considered both a therapeutic and diagnostic procedure, since after the procedure, the removed endometrium is examined under a microscope, after which the gynecologist prescribes the correct treatment tactics.

Endometrial hyperplasia is a disease that occurs in representatives of the fair half of humanity, regardless of age. But, in most cases, such a disease appears during adolescence and menopause, when changes in hormone levels occur in the body.

According to doctors, endometrial curettage during menopause is the only method of treating this disease.

Reviews from patients about curettage for endometrial hyperplasia

Since every girl’s body is individual, today pharmacology and modern medicine have not developed universal means and methods that equally well help women get rid of the disease.

Despite this, reviews of curettage for endometrial hyperplasia are mostly positive. Many girls claim the high effectiveness of the procedure.

You can also see reviews that after the cleansing not only positive changes occurred in the condition of the endometrium, but also the state of health improved, the hormonal balance normalized, menstruation became regular and less abundant and painful.

But, unfortunately, there are also patients who doubt the effectiveness of curettage. In such cases, girls justify their distrust of the procedure by the fact that after the first curettage, after a certain time, they have to repeat the manipulations again.

Natalya, 35 years old

“When I was 33 years old, the gynecologist diagnosed endometrial hyperplasia, prescribed a course of hormonal medications and recommended curettage. I drank the hormones and did the procedure, but after 8 months the endometrium began to grow again. Turning to the gynecologist, she advised me to cleanse myself again, saying that this happens. So what's the point of carrying out such a procedure, since then every year you have to relive it again? Maybe it’s worth informing doctors about other treatment methods for this diagnosis?”

Valeria, 57 years old

“At 49 years old, I went through menopause and my periods stopped. But, at the age of 54, I began to be bothered by spotting and turned to a gynecologist. After the examination, the doctor prescribed tests and hormonal medications, then a curettage to avoid having to remove the uterus. After the procedure, the body quickly recovered; after visiting the doctor, no formations or inflammations were found. In addition, my health has improved. Thanks to curettage, I not only got rid of the symptoms that accompany endometriosis, but also cured the disease.”

Daria, 27 years old

“I’ve had cycle disruptions all my life since the start of menstruation. But, due to a lack of consciousness, I did not pay due attention to this, thereby missing the opportunity to begin timely treatment. A year ago, after getting married, my husband and I began planning a pregnancy, but as a result, all attempts ended in disappointment. After consulting with a gynecologist, she advised me to clean the uterus. After the procedure, at just over 26 years old, I was diagnosed with hyperplasia. The gynecologist prescribed a course of antibiotics, then Janine. After 6 months, I changed the drug to Duphaston, which I also took for almost six months. After this treatment, after 1.5 years, my body returned to normal, menstruation became regular and less painful. I really hope that there will be a new addition to our family soon.”

Causes of endometrial hyperplasia

With the development of any disease, there is always a cause-and-effect relationship that entails irreversible pathological changes in the functioning of human organs and systems. Endometrial hyperplasia is no exception.

The causes of endometrial hyperplasia are as follows:

• hormonal imbalance (excess estrogen, premenopausal condition);
• hypertension, adrenal diseases, thyroid diseases, diabetes mellitus or other pathologies of the endocrine system;
• inflammation of the reproductive system;
• polycystic ovaries, fibroids or tumors (benign and malignant);
• genetic predisposition;
• abortions and miscarriages;
• use of oral contraceptives.
• obesity, metabolic disorders in the body.

To avoid endometrial hyperplasia as a result of exacerbation of chronic diseases, it is necessary to regularly visit a gynecologist for examination and lead a healthy lifestyle.

Symptoms of the disease

The main sign of endometrial hyperplasia is the presence of interruptions in the menstrual cycle. A girl may complain of unusual discharge before or after menstruation, or of discharge in large volumes during menstruation. Also during this period you may be concerned about:

• pain in the abdomen;
• weakness;
• temperature increase;
• stomach upsets;
• general malaise;
• headaches, etc.

Sometimes endometrial hyperplasia occurs without symptoms, but a woman cannot become pregnant for a long time. Therefore, if, in the absence of complaints and regular sexual activity, pregnancy does not occur for a year, you should seriously think about it and be thoroughly examined by highly qualified specialists.

Diagnostic methods

Diagnosing endometrial hyperplasia is not difficult. First, you need to collect an anamnesis, during which the patient tells all the information about her menstruation: when it started, how many days it lasts, what is the amount of discharge, how do you feel during menstruation, are there any delays, is there any discharge between periods.

The gynecologist also clarifies whether the patient has specific complaints and a predisposition to the development of genetic pathologies.

Be sure to do an ultrasound with a vaginal sensor. It is carried out in the first phase of menstruation to evaluate the endometrium in terms of thickness, structure, and homogeneity. If there is prolonged bleeding, then an ultrasound is performed regardless of the phase of the cycle. If the thickness of the layer is 7 mm or more, this indicates hyperplasia, and if it is 20 mm, this indicates a malignant process.

An analysis of hormone levels will also be informative, which will help determine the failure. In addition, mammography is done.

What exactly is removed by curettage, and how does it help?

The inner layer of the uterus has two layers - the functional and the basal layer. The first is responsible for the attachment and development of the child. If pregnancy does not occur, then it peels off and is excreted in the form of mucus during menstruation. There are vessels between the layers, and when the first layer (the spent one) is rejected, they rupture and blood is released.

With endometrial hyperplasia, the functional layer is enlarged and, naturally, menstruation becomes excessively abundant. Therefore, with this disease there is a very high risk of bleeding.

The danger of endometrial hyperplasia lies in the fact that malignant neoplasms can arise between the enlarged cells. Curettage for the diagnosis of endometrial hyperplasia is the removal of all overgrown tissue.

At the same time, during curettage, the layer in which oncology can progress is removed and the cause of bleeding is eliminated.

Is it possible to do without scraping?

It is worth noting right away that sometimes endometrial curettage can be avoided.

If a woman, before the onset of menopause, did not have heavy discharge or complaints about her health during her menstrual period, according to ultrasound or computed tomography there are no pathological changes, and an acytological smear from the cervical canal does not have atypical cells, then hormonal drugs are prescribed for treatment.

Thus, a woman can be treated with medication, but under strict control of the thickness of the functional layer and analysis of smears from the cervix.

But, during menopause, curettage is mandatory. With its help, blood loss is eliminated and endometrial hyperplasia, oncology and inflammation can be accurately differentiated.

If cancer is detected during endometrial curettage, the disease can be diagnosed at an early stage. This will allow you to immediately prescribe the correct, and most importantly timely, treatment.

What diseases require curettage?

In gynecology, there are other diseases when it is necessary to perform endometrial curettage:

• miscarriage;
• fibroids of the submucosal layer;
• polyps of the body or cervix;
• endometritis;
• childbirth with complications;
• ectopic or frozen pregnancy.

Preparing for scraping

Since endometrial curettage is a surgical procedure, it requires careful preparation (except in cases of emergency cleaning).

Firstly, you need to remember that the procedure is done on certain days of the menstrual cycle. Secondly, you need to be examined by a cardiologist, neurologist, therapist and pass a full list of necessary tests.

The list of mandatory tests before endometrial curettage includes:

• general blood test (finger prick) and urine;
• determination of blood clotting characteristics (sampling from a vein);
• blood chemistry;
• testing for antibodies to hepatitis, HIV, syphilis (RW analysis);
• microscopy of a vaginal smear to determine the degree of purity;
• secretion seeding tank;
• determination of the level of female hormones;
• electrocardiogram (ECG).

We also need two ultrasound examinations in two different cycles, which show that the thickness of the endometrium is more than 1.5 cm. The manipulation is done before the start of the expected menstruation, when the thickness of the functional layer is maximum for removal.

14 days before the intervention, the patient is advised to stop taking medications or dietary supplements, except those prescribed by the attending physician. Before curettage, thorough cleansing of the body is necessary so that rehabilitation is faster and more effective.

Important! Anticoagulants must be discontinued to avoid severe bleeding during manipulation. A week before surgery, sexual relations are limited or completely excluded, especially if contact bleeding is present. Douching is also canceled. You should avoid eating food 12 hours before the procedure, and drinking 6 hours before the procedure. In the evening, on the eve of the procedure, a cleansing enema is performed.

The only case when curettage is carried out without tests and preliminary preparation is if the patient is transported by ambulance with severe bleeding.

Features of curettage for hyperplasia

Women are always concerned about how this procedure occurs, what the consequences and risks are. Curettage is a surgical procedure that is performed in the operating room. In this case, the patient is in a comfortable position on the gynecological chair.

In most cases, the woman is given anesthesia. This is due to the fact that cleaning is a painful and unpleasant procedure. Anesthesia is not used only after childbirth or miscarriage, since the cervix is ​​already quite dilated.

The gynecologist personally chooses which method to perform the operation - blind curettage or using a hysteroscope (this is a backlit video camera that also has a channel for supplying sterile air).

Blind scraping

After the anesthesia takes effect and the patient no longer feels the internal organs, the gynecologist begins the procedure. But, no cuts are made.

First, you need to widen the cervix to gain more space for surgical manipulation. To do this, a dilator is inserted into the vagina, the walls are spread apart and access to the cervix is ​​gained.

Then, using special probes with different diameters, the cervix is ​​gradually opened. When the desired result is achieved, the uterus is checked for curvature and length.

After cleaning, the vessels that bleed are cauterized, and the removed mucosa is sent for histological examination.

Endometrial scraping takes about 30 minutes. Then the patient is taken to the ward, where she is monitored by an anesthesiologist until she awakens and feels normal.

Curettage with hysteroscope

As with blind curettage, during the procedure the patient is on a gynecological chair in a medicated sleep. The gynecologist installs a dilator, inserts a hysteroscope, and with the help of air gradually expands the uterine cavity for work.

The curette is inserted into another channel of the device, and before removal, the condition, thickness, relief and color of the layer being removed is assessed.

After removal, it is placed in a container (one or several) and also sent for histological examination. A special instrument is inserted into the hysteroscope, which is used to cauterize the vessels to stop bleeding. The operation is considered completed.

Separate curettage

There is also such a thing as separate curettage. In other words, this is diagnostic curettage. Gynecologists use it in cases where it is necessary to find out the exact cause of pathological changes or complaints (irregular, prolonged periods, bleeding during menopause, suspected infertility).

The procedure is carried out similarly to the above schemes with full preoperative preparation.

Important! Diagnostic curettage is performed only in a hospital! Like any surgical intervention, the procedure has a number of contraindications:

• relapse of infectious, bacterial or viral diseases (chlamydia, gonorrhea);
• acute foci of inflammatory nature in the pelvic organs;
• exacerbation of chronic heart, kidney or liver diseases.

Treatment of endometrial hyperplasia with drugs

After surgical intervention by a surgeon, treatment of hyperplasia must continue with medications. In the first 3-5 days, hemostatic drugs must be prescribed.

The gynecologist advises taking a course of antibiotics (5-7 days) to avoid infection. Also, if necessary, analgesics and anti-inflammatory substances are prescribed.

Further appointments depend on histological examination. If there are no malignant or pathological changes in the test material, then the patient is prescribed standard hormonal therapy. But it all depends on some nuances:

• If the pathology is detected in a teenage girl or a woman under 35 years of age, then combined oral contraceptives (COCs), which contain estrogen and gestagen, are used.

According to reviews from gynecologists, progesterone tablets are often prescribed. It stops the pathological growth of the functional layer, since it constantly affects it. If hormone therapy is chosen correctly, and the duration of taking the drug is from three to six months, then it is likely that a relapse will not occur.

• Gestagens are recommended for patients over 35 years of age and before menstruation begins. They are taken in the second phase of the menstrual cycle or two weeks after curettage. Duphaston and Utrozhestan are the most popular drugs.
• For women during menopause and postmenopause, a treatment regimen is prescribed only after a thorough examination, since at this age the disease most often occurs due to an ovarian tumor.

It is very good to add physical therapy to drug treatment - the use of ozone, reflexology, acupuncture, electrophoresis.

But if malignant formations are confirmed, then the oncologist will prescribe further recommendations.

Traditional medicine

Folk remedies for hyperplasia are also used. Herbal medicine occupies first place in folk medicine. Burdock, nettle, hogweed, and plantain cope very well with this disease.

Women who have experienced the effects of “grandmother’s remedies” note that after folk healing they feel better, bleeding becomes less heavy, the menstrual cycle is restored, and pain during menstruation decreases.

In most cases, alcohol tinctures are used, which are very easy to prepare at home. The boron uterus is dried and placed in a glass jar, into which forty-proof alcohol, vodka or cognac 0.5 liters are poured. The tincture should be infused for two weeks, stored in a place where there is no light and shaken every day.

Take one teaspoon 2-3 times a day with a glass of water. The course of treatment lasts three months. According to reviews, patients note a good effect from douching with a decoction of this plant.

Burdock must be prepared in advance. It is collected in late autumn or early spring. To prepare the medicine, you need to squeeze the juice from fresh roots. Take two teaspoons in the morning and evening before meals. The course lasts six months.

Nettle is very famous for its hemostatic properties. To treat hyperplasia, you need to brew a decoction: pour two tablespoons of the plant with boiling water (1 cup) and cook for 15 minutes, adding water to the initial volume. Take ¼ cup of decoction 3-4 times a day.

In addition, you can use herbs that are antagonists of female hormones. These include fireweed, rapeseed and jarutka.

Women who have tried traditional medicine speak positively about their effect on the body. But, despite the positive reviews, you should not abandon traditional methods of treatment; therapy should be carried out comprehensively under the supervision of the attending physician.

The most positive reviews can be found about herbal decoctions and douching, for which boron uterus is used. Patients claim that the product is completely safe, highly effective, and does not cause side effects.

Hirudotherapy

Positive reviews in the treatment of endometrial hyperplasia with leeches are also found. For gynecological problems, leeches are placed in the perineum, lower back, anus and vagina.

The hirudotherapist only places leeches on the required area of ​​the body, and they themselves move to the acupuncture point and “stick” to it. Leeches introduce useful substances into the blood of their “victim”, and generally balance out the hormonal levels.

But hirudotherapy is not suitable for everyone. It cannot be carried out if:

• there are malignant tumors;
• hemophilia was diagnosed;
• low pressure;
• the girl is pregnant;
• I am allergic to leeches.

Rehabilitation period

After surgical cleaning after endometrial curettage, it is normal for the patient to feel weak and drowsy. It is also considered normal after such manipulation to experience pain like during menstruation; it can last for quite a long time (4-5 days).

Since after the manipulation the uterus is considered a large wound, the discharge is initially copious and bloody. Over time, they become ichor, and then become watery.

Important! If bleeding lasts more than 11 days and does not decrease in volume, you should contact a gynecologist for an examination in a chair.

Doctor's advice! If you have complaints of nagging pain in the abdomen or lower back, or a fever, you should immediately consult your doctor.

To make recovery more effective and quick, you must adhere to some rules:

• do not have sex for two weeks after curettage;
• do not use vaginal tampons;
• do not douche;
• cancel intensive thermal procedures (you can get by with a hygienic shower);
• reduce physical activity and avoid lifting heavy objects;
• do not take medications that thin the blood.

Menstruation after cleansing appears at 4-5 weeks, and can be very scanty and short. It is recommended to undergo an ultrasound every month to monitor the thickness of the functional layer, which should not exceed 0.5 cm.

Important! If your period is delayed for more than 3 months, you should consult a gynecologist.

Possible complications

Like any surgical procedure, endometrial curettage can lead to complications. During the operation, working with a curette can damage the uterus, or rupture with a dilator or probe is possible. After the intervention there may be:

• bleeding (this often happens if the doctor performed poor-quality cleaning);
• inflammation;
• infection;
• blood accumulation;
• infertility (in case of violation of the second basal layer).

During cleaning, anesthesia in almost all cases is general (intravenous). Since the manipulation is not long, such anesthesia very rarely causes complications. But there is no pain, the patient breathes on her own and sleeps soundly.

Curettage and pregnancy with endometrial hyperplasia

Pregnancy after curettage is quite possible. If you do not take medications with hormones, pregnancy can occur 4-5 weeks after the intervention. If the patient complies with hormonal therapy and adheres to the doctor’s recommendations, then after stopping, after about 1-2 months of therapy, you can become pregnant.

In order for pregnancy to occur and proceed well, the inner lining of the reproductive organ must be sufficiently restored. Gynecologists advise avoiding pregnancy for 3-6 months.

Probability of relapse

Unfortunately, the likelihood of recurrence of endometrial hyperplasia even after curettage is quite high. After curettage, the exact cause of the disease is established, and of course you will have to work on eliminating it.

To do this, you need to take medications regularly, follow the gynecologist’s prescriptions, eat right, and exercise - then the risk of relapse will be significantly reduced.

DYSFUNCTIONAL UTERINE BLEEDING (DUB).

LECTURE No. 3 ON GYNECOLOGY
DUB - bleeding that is not associated with either organic changes in the genital organs or systemic diseases leading to disruption of the blood coagulation system. Thus, DUB is based on a disturbance in the rhythm and production of gonadotropic hormones and ovarian hormones. DUB is always accompanied by morphological changes in the uterus. In the general structure of gynecological diseases, DMK accounts for 15-20%. Menstrual function is regulated by the cerebral cortex, suprahypothalamic structures, hypothalamus, pituitary gland, ovaries and uterus. This is a complex system with double feedback; for its normal functioning, the coordinated work of all links is necessary.
Causes of DMK:
· psychogenic factors and stress
mental and physical fatigue
· acute and chronic intoxications and occupational hazards
· pelvic inflammatory processes
· dysfunction of the endocrine glands.
There are 2 large groups of uterine bleeding:
1. Ovulatory. Depending on the changes in the ovaries, the following 3 types of DUB are distinguished: a. Shortening the first phase of the cycle; b. Shortening the second phase of the cycle; in lengthening the second phase of the cycle.
2. Anovulatory uterine bleeding.
Clinic for ovulatory uterine bleeding: there may be no real bleeding leading to anemia, but there will be spotting before menstruation, spotting after menstruation, and there may be spotting in the middle of the cycle. Also, patients will suffer from miscarriage, and some of them will suffer from infertility.
DIAGNOSTICS:
· complaints and medical history of the patient
· examination using functional diagnostic tests.
Histological examination of the endometrium
TREATMENT consists in restoring the cycle based on existing disorders.
Example: The diagnosis is a shortening of the 2nd phase of the cycle, it needs to be lengthened, we prescribe gestagens progesterone.
The 1st phase of the cycle is shortened - it needs to be lengthened - we prescribe estrogens.
It must be said that ovulatory bleeding is rare and, as a rule, accompanies inflammatory adhesive processes in the pelvis.

ANOVULATORY UTERINE BLEEDING - occurs much more often. Occurs in 2 age periods:
· in juvenile age 20-25%
· at menopausal age 60%
The remaining 10% occurs during childbearing years. With anovulatory bleeding, the following disorders are observed in a woman’s body:
1. Lack of ovulation.
2. There is no second phase of the cycle (no release of progesterone).
3. The process of follicle maturation is disrupted, which can have 2 peaks: follicle atresia and follicle persistence.
4. Throughout the entire period of the cycle, only estrogens are released, which causes not proliferative, but hyperplastic processes at the level of receptor organs (glandular endometrial hyperplasia and endometrial polyposis)
If these disorders are not treated, then adenocarcinoma develops in the endometrium after 7-14 years.
Follicle persistence. During the 1st phase of the cycle, the follicle matures to maturity and is ready for ovulation. At this time, the amount of LH increases, which determines ovulation.
When the follicle persists, LH does not increase, and the follicle does not rupture, but the follicle continues to exist (persist). This means there will be pronounced hyperestrogenism in the body.
Follicular atresia. The follicle does not reach its final development, but undergoes shrinkage at the stages of the small ripening follicle. Usually in these cases, the ovary develops one rather than two follicles. They are replaced by the next 2 follicles, which then also become atretic. In this case, there is also no ovulation, there will also be estrogen, but not very pronounced.
In the hyperplastic endometrium, vascular proliferation occurs. They become brittle and susceptible to estrogenic influences. And the level of estrogen is not constant, it either increases or decreases. In response to a decrease in blood estrogens, thrombosis and necrosis form in the hyperplastic endometrium, which leads to its rejection. But the fact is that such a hyperplastic endometrium can never be completely rejected, much less accept a fertilized egg.
Thus, with anovulatory bleeding in the ovaries, there may be changes in the type of follicular atresia, in the type of follicle persistence, as a rule, in both cases a period of delayed menstruation is characteristic.
As a rule, in 70-80% of cases bleeding begins after a delay. In 20%, menstruation may begin on time, but not end on time. The main complaint is bleeding due to delay.
DIAGNOSTICS.
· Functional diagnostic tests (monophasic basal temperature both with follicular atresia and with its persistence; pupil symptom with persistence ++++, with atresia + ,++; hormonal colpocytology will in both cases indicate estrogenic influence, karyopyknotic index with atresia follicle will be low, and with persistence - high.
· Histological examination of the myometrium will show pathoproliferation in both cases.
The final diagnosis is made after curettage of the uterine cavity. Differential diagnosis is carried out with extragenital pathology, especially with systemic blood diseases (Werlhof's disease) - in juvenile age. In childbearing age - with pregnancy pathology (incipient miscarriage, ectopic pregnancy). At menopausal age there should be oncological alertness!
TREATMENT should take into account the etiology, pathogenesis and the principle according to which menstrual function is a function of the whole organism. On the other hand, treatment should be strictly individual. Consists of:
general restorative therapy.
· Symptomatic therapy.
· Hormone therapy.
· Surgical intervention.
The basis of treatment is hormone therapy. There are 3 goals:
1. Stop bleeding
2. prevention of bleeding (regulation of the menstrual cycle)
3. rehabilitation of patients
Juvenile bleeding: stopping it is usually done with the help of hormonal drugs (hormonal hemostasis). Used:
· in the absence of anemia - progesterone in loading doses (30 mg 3 days in a row). This is the so-called hormonal curettage: after a few days the mucous membrane begins to be rejected and you need to be prepared for this.
· If there is anemia, it is necessary to stop the bleeding in such a way as to delay the menstrual-like reaction, and devote the gained time to treating the anemia. In this case, they begin with the introduction of estrogens, which causes regeneration of the mucosa. Microfollin on the 1st day 5 tablets or folliculin on the first day 2 ml. After 14 days, we introduce progesterone to induce a menstrual-like reaction.
· You can use two-phase hormonal oral contraceptives (bisekurin): on the first day 5 tablets, on the second day - 4 tablets, etc. 1 tablet is given up to 21 days, then a menstrual-like reaction follows.
· Hormone therapy is used to prevent bleeding. In juvenile age, follicular atresia is more common, therefore, estrogen concentration is reduced. In this case, it is better to prescribe hormone replacement therapy - estrogen in the first part of the cycle, progesterone in the second half. If estrogen saturation is sufficient, then you can limit yourself to progesterone or human chorionic gonadotropin.
Treatment is prescribed for 3 months. Then they take a break and see if our therapy will cause a rebound effect, that is, an increase in the body’s own functions.
Rehabilitation - it is necessary to reduce the load and give the opportunity for more rest.

BLEEDING IN CHILDREN'S AGE.
Stopping bleeding at this age is carried out by curettage of the uterine cavity, which has 2 goals:
· therapeutic, that is, all hyperplastic mucosa is removed from the uterus
· diagnostic, that is, the scraping is sent for histological examination, which allows for a differential diagnosis with disorders during pregnancy.
Next, hormonal treatment is prescribed: hormonal contraceptives.

BLEEDING IN CLIMACTERIC AGE.
First of all, there must be oncological alertness. Hemostasis is carried out by separate curettage of the uterine cavity and the cervical canal, which pursues therapeutic and diagnostic purposes. If we get changes like atypical hyperplasia (precancer), then we must immediately raise the question of surgical treatment (amputation of the uterus).
If histological examination reveals only a hyperplastic process, then hormone therapy is prescribed. Here you can follow two paths: either maintaining and regulating the cycle, or suppressing it.
To maintain the cycle, a long-acting drug 17-hydroxyprogesterone capronate (17-OPK), 12.5% ​​solution, is prescribed. It is prescribed cyclically on days 17-19 of the cycle, 1-2 ml, for 6-12 months. A woman gradually enters menopause.
Testosterone is used to suppress the cycle. Rehabilitation at this age consists of the fact that in case of precancer it is necessary to raise the question of surgical treatment. The same question should be asked if there is no effect from hormone therapy.