Abnormal uterine bleeding (AUB)

Abnormal uterine bleeding is quite serious problem for women of any age in different countries of the world. Almost any type of menstrual cycle disorder can be called abnormal. Obstetricians-gynecologists regard bleeding as abnormal if the following signs are noted:

• its duration exceeds 1 week (7 days);
• the volume of lost blood exceeds 80 ml (normal blood loss does not exceed this figure);
• the time interval between bleeding episodes is shorter than 3 weeks (21 days).

For comprehensive assessment abnormal bleeding, such details as the frequency of their occurrence, irregularity or regularity of occurrence, the duration of the bleeding itself, the relationship with reproductive age and hormonal status are important.

All types of bleeding can be divided into 2 large groups: those associated with diseases of the reproductive system and those caused by systemic pathology. Diseases of the reproductive organs are very diverse - pathological bleeding can be caused by inflammatory, hypertrophic and atrophic changes in the uterus and genital tract. Marked changes in the balance of female sex hormones can also provoke changes menstrual cycle.

Systemic pathology, for example, blood diseases with thrombocytopenia, pathology of coagulation factors, vascular diseases, various infectious diseases(viral hepatitis, leptospirosis) affects all organs and tissues female body, therefore, abnormal uterine bleeding may be one of the signs of a serious systemic process.

PALM–COEIN classification

In domestic practice long time a classification was used that distinguished uterine bleeding according to the time of its occurrence, duration and volume of blood loss. In practice, such definitions as metrorrhagia were used (a variant of irregular uterine bleeding, the duration of which exceeds 1 week and the volume of blood loss exceeds 80-90 ml).

However, this classification option did not take into account the supposed etiology of the pathological process, which somewhat complicated the diagnosis and treatment of the woman. Concepts such as metrorrhagia, polymenorrhea and their features remained difficult to understand even for a specialist.

In 2011, an international group of experts developed the most modern version of bleeding in accordance with the expected etiology of the process, duration and volume of blood loss. Among specialists, the name PALM-COEIN is used in accordance with the first letters of the names of the main groups of pathological processes.

1. Polip – benign polypous growths.
2. Adenomyosis – pathological germination inner shell uterus into other adjacent tissues.
3. Leiomyoma (leiomyoma) – benign neoplasm formed by muscle cells.
4. Malignancy and hyperplasia are hyperplastic processes of malignant origin.
5. Coagulopathy – any variants of coagulopathy, that is, pathology of coagulation factors.
6. Ovulatory dysfunction is dysfunction associated with various ovarian pathologies (hormonal dysfunction).
7. Endometrial – disorders within the endometrium.
8. Iatrogenic (iatrogenic) – developing as a result of actions medical personnel, that is, as a complication of treatment.
9. Not yet classified is a variant of unclassified bleeding, the etiology of which has not been established.

PALM group, that is, the first 4 subgroups of diseases are characterized by pronounced morphological changes in tissues, and therefore can be visualized using instrumental methods research and, in some cases, during a bimanual examination.

The COEIN group - the second subgroup of the classification - cannot be detected during a traditional obstetric-gynecological examination; more detailed and specific diagnostic methods are required. This group of causes of abnormal uterine bleeding is less common than the PALM group and may therefore be considered secondarily.

a brief description of

Polyp

This is the proliferation of connective, glandular or muscle tissue within the endometrium only. Usually this is a small formation located on a vascular pedicle. Polypous growth rarely undergoes transformation into malignancy, but due to its shape it can easily be injured, which will be manifested by uterine bleeding.

Adenomyosis

This is the growth of the mucous (inner) lining of the uterus in uncharacteristic places. At a certain period of the menstrual cycle, the endometrium is rejected, that is, a fairly significant volume of blood is released. To date, it has not been established how closely abnormal uterine bleeding and adenomyosis are related, which requires additional and comprehensive study.

Leiomyoma

Leiomyoma is more often called uterine fibroids. As the name suggests, this is a formation of muscle tissue that is of benign origin. Fibroids rarely undergo malignant transformation. The myomatous node can be either small or very large (the uterus reaches the size of 10-12 weeks of pregnancy).

A separate point should be made about fibroids, which are located in the submucous membrane and deform the uterine wall, since it is this variant of the tumor node that most often causes abnormal uterine bleeding. In addition, any fibroid, especially a large one, is often the cause of female infertility.

Malignancy and hyperplasia

Malignant neoplasms of the uterus and genital tract can form in both the elderly and elderly, as well as in women reproductive age. The exact causes of cancer of the reproductive system are not known, however, it is noted increased risk such processes, if a woman had such diseases in her family, there were repeated abortions and terminations of pregnancy, violation hormonal levels, irregular sex life and heavy physical activity.

This is the most unfavorable cause of abnormal uterine bleeding. Systemic signs of oncological pathology (cancer intoxication) appear quite late, and bleeding itself is often not something serious for a woman, which leads to late consultation with a doctor.

Coagulopathy

A type of systemic pathology, since the cause of abnormal uterine bleeding is a deficiency of the platelet homeostasis or coagulation factors. Coagulopathies can be congenital or acquired. Treatment involves influencing the damaged part of hemostasis.

Ovulatory dysfunction

This is a complex of hormonal disorders that are associated with the function corpus luteum. Hormonal disorders in this case, they are very complex and serious, directly related to the hypothalamic-pituitary system and the thyroid gland. Ovulatory dysfunction can also be caused by excessive sports activity, sudden weight loss, or stress.

Endometrial dysfunction

Currently, deep biochemical disorders leading to dysfunction of the endometrium are quite difficult to diagnose, so they should be considered after excluding other, more common causes of abnormal uterine bleeding.

Iatrogenic bleeding

They are the result of drug or instrumental intervention. Among the most common reasons Iatrogenic abnormal bleeding is known:

• anticoagulants and antiplatelet agents;
• oral contraceptives;
• certain types of antibiotics;
• glucocorticosteroids.

Even a highly qualified specialist may not always suspect the possibility of iatrogenic bleeding.

Diagnostic principles

The use of any method of laboratory or instrumental diagnostics must be preceded by a thorough collection of the patient’s medical history and an objective examination. Often the information obtained allows us to reduce to a minimum the required range of further research.

Among the most informative methods instrumental diagnostics are known:

• saline infusion sonohysterography;
• magnetic resonance or positron emission tomography;
• endometrial biopsy.

Plan required laboratory diagnostics is compiled individually depending on the patient’s health status. Experts consider it advisable to use:

• general clinical blood test with platelets;
• hormonal panel (thyroid hormones and female reproductive hormones);
• tests characterizing the blood coagulation system (prothrombin index, coagulation and bleeding time);
• tumor markers;
• pregnancy test.

Only as a result of a comprehensive examination can a final specialist opinion be given on the cause of abnormal uterine bleeding, which is the basis for further treatment patients.

Treatment of abnormal uterine bleeding

The cause of the bleeding is determined. Treatment can be conservative and surgical. The PALM group is most often eliminated by surgical intervention. When COEIN group bleeding is detected, conservative tactics are more often practiced.

Surgical intervention can be organ-preserving or, conversely, radical in case of invasive formations. Conservative therapy includes the use of non-steroidal anti-inflammatory drugs, antifibrinolytics, hormonal agents (oral progestins, combined contraceptives, danazol, injectable progestin, hormone releasing hormone antagonists).

Abnormal uterine bleeding in a woman of any age is a reason for an unscheduled visit to the gynecologist. The disease is much easier to cure at its early stage.

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

Inability to detect any histological pathology in 20% of specimens removed during hysterectomy indicates that the cause of such bleeding may be potentially treatable hormonal or medical conditions.

Every gynecologist should strive to find the most appropriate, cost-effective and successful method of treating uterine bleeding (UB). Accurate diagnosis and adequate treatment depend on knowledge of the most likely causes of uterine bleeding (UB). and the most common symptoms that express them.

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

Usually to abnormal uterine bleeding(AUB) refers to bleeding originating from the cervix or fundus of the uterus, and since they are clinically difficult to distinguish, both options must be taken into account in case of uterine bleeding. Abnormal bleeding can also occur in childhood and after menopause.

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

The total volume of blood loss for normal menstrual period is no more than 80 ml, although the exact volume is difficult to determine clinically due to the high content in menstrual flow rejected endometrial layer. Normal menstruation does not cause serious pain and does not require the patient to change it sanitary pad or a tampon more often than 1 time per hour. There are no visible clots in normal menstrual flow. Therefore, abnormal uterine bleeding (AUB) is any uterine bleeding that goes beyond the above parameters.

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

Oligomenorrhea - menstruation occurring less than 9 times a year (that is, with an average interval of more than 40 days).
Hypomenorrhea - menstruation, insufficient (scanty) in terms of the volume of discharge or its duration.
Intermenstrual bleeding is uterine bleeding between obvious periods.
Amenorrhea is the absence of menstruation for at least 6 months, or only three menstrual cycles per year.
Postmenopausal uterine bleeding is uterine bleeding 12 months after the cessation of menstrual cycles.

Such classification of abnormal uterine bleeding(AUB) can be helpful in establishing its cause and diagnosis. However, due to the existing differences in the presentation of abnormal uterine bleeding (AUB) and the frequent existence of multiple causes, the clinical picture of AUB alone is not sufficient to exclude a number of common diseases.

Dysfunctional uterine bleeding- an outdated diagnostic term. Dysfunctional uterine bleeding is a traditional term used to describe excessive uterine bleeding when uterine pathology cannot be identified. However, a deeper understanding of the issue of pathological uterine bleeding and the advent of improved diagnostic methods have made this term obsolete.

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

In many cases that in the past would have been classified as dysfunctional uterine bleeding, modern medicine, using new diagnostic methods, identifies uterine and systemic disorders such categories:
causing anovulation (for example, hypothyroidism);
caused by anovulation (in particular hyperplasia or cancer);
accompanying bleeding during anovulation, but can be either associated with abnormal uterine bleeding (AUB) or unrelated (for example, leiomyoma).

From a clinical point of view, treatment will always be more effective if it can be determined cause of uterine bleeding(MK). Because grouping different cases of uterine bleeding (UB) into one ill-defined group does not contribute to the diagnostic and treatment processes, the American Consensus Panel recently announced that the term “dysfunctional uterine bleeding” no longer appears to be necessary for clinical medicine.

E. B. Rudakova, A. A. Luzin, S. I. Mozgovoy

In recent years, an increase in the frequency of uterine bleeding has been noted, which may be due to an increase in the total number of menstrual cycles in modern women throughout life, as well as an increase in the intergenetic interval. In Russia, menstrual irregularities, manifested by bleeding, are in second place among gynecological problems associated with the referral of women to hospitalization. Every year, one third of visits to a gynecologist in the USA and Great Britain are associated with abnormal uterine bleeding (AUB). In reproductive age, this is the most common indication for emergency hospitalization; in addition, AUB is an indication for 300,000 hysterectomies performed annually in the United States, in one third of cases anatomical reasons Uterine bleeding is not detected. The highest frequency of uterine bleeding is observed in the next 5-10 years after menarche and 5-10 years before the upcoming menopause.

It is generally accepted that the main form of functioning reproductive system According to the mature fertile type, there is an ovulatory, adequately hormonally provided menstrual cycle. The menstrual cycle is a manifestation of a complex biological process in a woman’s body, characterized by cyclic changes in the function of the reproductive, endocrine, cardiovascular, nervous and other systems. The reproductive system, in turn, is a supersystem, the functional state of which is determined by the reverse afferentation of its constituent subsystems. A prospective study based on the analysis of 275,947 menstrual cycles found that average duration The menstrual cycle at the age of 20 years is 28.9 ± 2.8 days, at the age of 40 years - 26.8 ± 2.0 days. Based on the criteria for a normal menstrual cycle, the diagnosis of AUB is made when the duration of bleeding increases for more than 7 days, blood loss exceeds 80 ml, and the cyclicity of bleeding is disrupted. In one fifth of women, the average menstrual blood loss exceeds 60 ml, its value can vary by 40% from cycle to cycle.

The frequently used term AUB refers to all cyclic and acyclic bleeding from the uterus, regardless of their genesis. The term “dysfunctional uterine bleeding” is no less often used in the literature, defining it as bleeding from the endometrium not associated with pregnancy, organic diseases of the uterus and systemic disorders. A number of publications are devoted to the problem of unifying international terminology on issues of uterine bleeding recent years.

Depending on the nature of the disorders, various symptoms of AUB are distinguished:

• hypermenorrhea (menorrhagia) - excessive (more than 80 ml) or long periods(more than 7 days) at regular intervals of 21-35 days;
• metrorrhagia - irregular, intermenstrual bloody issues;
• menometrorrhagia - irregular, prolonged uterine bleeding;
• polymenorrhea - frequent menstruation with an interval of less than 21 days.

The most accepted classifications are those based on the genesis of bleeding, taking into account the characteristics of hormonal levels and the age of their onset: organic, dysfunctional, iatrogenic. In terms of age, they distinguish juvenile bleeding, bleeding of reproductive age, peri- and postmenopause. Bleeding in the juvenile period and perimenopause is anovulatory in nature. In this case, the occurrence of anovulation in the juvenile period is due to the immaturity of the hypothalamic-pituitary system, the absence of a formed circhoral rhythm of luliberin, and in perimenopause - a decrease in ovarian function.

The heterogeneity of the group of patients with AUB is explained by a wide range of causes of bleeding. During reproductive age, about 25% of uterine bleeding is due to organic causes, the rest are a consequence of functional disorders in the hypothalamus-pituitary-ovarian system (dysfunctional uterine bleeding - DUB). The main cause of DUB is chronic anovulation, which occurs in 55-82% within 2 years after menarche, in 20% within 5 years. Although the presence of an ovulatory cycle also does not exclude DMC, as, for example, with Halban syndrome - persistence of the corpus luteum, manifested as amenorrhea after 6-8 weeks of menstrual irregularities. According to E. G. Chernukh, ovulatory bleeding is often observed against the background of organic pathology, and anovulatory bleeding often has a substrate in the form of hyperplastic endometrium.

The ratio of frequent and rare causes AUB in different age periods is shown in. Organic causes of abnormal uterine bleeding are: pathology of the uterus (trauma, foreign body uterine cavity, chronic and acute endometritis, inflammatory diseases of the pelvic organs, uterine tumors, adenomyosis, endometrial polyps), ovaries (hormone-producing tumors), coagulopathy, medications (anticoagulants, tricyclic antidepressants, serotonin reuptake inhibitors, tamoxifen, contraceptives), somatic diseases(Cushing's syndrome, diabetes mellitus, systemic lupus erythematosus, Crohn's disease and so on).

The inflammatory genesis of AUB is sometimes not given due attention, but according to a number of authors, the frequency of chronic endometritis in reproductive age can reach 80-90%, varying in the structure of intrauterine pathology in the range of 0.2-66.3%. Moreover, based on our comprehensive microbiological research, the frequency of pathogen detection in the endometrium of patients with AUB is 42.1%, and the frequency of chronic endometritis in this group of patients is 31.5%.

The mechanisms of AUB development also remain not entirely clear. In addition to the classic “hormonal” concept of menstrual (uterine) bleeding by Markee (1940), there is an “inflammatory” hypothesis by Finn (1986). According to it, menstrual (uterine) bleeding is a sign that an “infection has been detected” in the endometrium. The hypothesis was based on certain changes in the endometrium in the late secretion phase: tissue edema, migration of leukocytes and the presence of decidual cells with signs of tissue fibroblasts.

L. A. Salamonsen et. al. (2002) put forward a different concept, according to which menstrual (uterine) bleeding is an active process under the control of matrix metalloproteinases and dependent on their activity. The fall in progesterone concentration in the late secretory phase is key point, changing the balance of metalloproteinase inhibitors - matrix metalloproteinases (MMPs) towards the latter. These proteolytic enzymes (MMP-1, MMP-3, MMP-9) degrade the extracellular matrix and promote shedding of the upper two-thirds of the endometrium. Proinflammatory cytokines (IL-1, IL-8, TNF-alpha) are indirectly involved in this process, influencing the processes of angiogenesis, endometrial remodeling and attraction of leukocytes, which in turn also produce MMPs.

The occurrence of uterine bleeding is determined not only by the level of sex steroid hormones, but also by the local production of other biologically active molecules: prostaglandins (PGs), cytokines, growth factors. A shift in the ratio between the endometrial content of the vasoconstrictor PG F2a and the vasodilator PG E2 may be one of the causes of ovulatory DUB, while an increase in the concentration of prostaglandins with a decrease in progesterone levels may increase blood loss during menstruation.

The endometrium expresses angiogenesis inducers and most angiogenesis blocking factors. It has been suggested that impaired angiogenesis may be a cause of AUB. For example, increased levels of estrogen induce the synthesis of vascular endothelial growth factor (VEGF), which promotes angiogenesis in the endometrium, as well as nitric oxide (endothelial relaxing factor), which affects excess menstrual blood loss. Endometrial endothelins are powerful vasoconstrictors; a lack of their production can increase the duration of bleeding and thus contribute to the occurrence of menorrhagia.

Estrogens also stimulate fibrinolysis, and progesterone inhibits this process by increasing the concentration of fibrinolysis inhibitors. Excessive activation of the fibrinolytic system can disrupt the balance of the hemostatic system, leading to uterine bleeding. Normally, primary hemostasis in the endometrium is achieved not only through the formation of small blood clots in the spiral arterioles, but also through their spasm.

About 19-28% of patients of reproductive age hospitalized for AUB have disturbances in the hemostatic system. Approximately 80-85% hereditary disorders in the hemostatic system are associated with hemophilia A (factor VIII deficiency), von Willebrand disease and hemophilia B (factor IX deficiency). Approximately 15% of congenital disorders of hemostasis are associated with deficiency of fibrinogen, prothrombin, factors V, VII, X, XI, XIII, as well as combined deficiency of factors V and VIII. About 20-30% of patients in this category with AUB of the menorrhagia type have platelet disorders. Bleeding caused by pathology of the hemostatic system is characterized by disturbances in the form of menorrhagia, starting from the period of menarche, accompanied by a decrease in hemoglobin levels, the presence of a characteristic history (hemorrhages and postoperative bleeding) and family predisposition.

The diagnostic algorithm for AUB is widely covered in domestic and foreign literature (). Although, due to the heterogeneity of the causes of AUB, the list diagnostic procedures has differences.

Morphological verification of the cause of AUB is quite complex, since the material obtained during therapeutic and diagnostic curettage of the endometrium may be inadequate for the interpretation, for example, of signs of chronic endometritis or glandular hyperplasia due to the presence of numerous artificial changes caused by tissue destruction and massive amounts of blood in the material .

Verification during subsequent research may have its own characteristics with consideration of such issues as the preferred period of the ovarian-menstrual cycle for sampling diagnostic material, interpretation of morphological findings taking into account gynecological history, taking hormonal drugs, and is the subject of clinical and morphological comparisons.

An experienced doctor, even by the nature of menstrual dysfunction, can guess its genesis. For example, the regularity of bleeding, the presence of premenstrual syndrome and dysmenorrhea suggest the presence of ovulation. Heavy, irregular and painless menstrual bleeding, especially in the middle of the reproductive period, suggests an ovulation disorder. In any case, it is necessary to exclude organic causes of uterine bleeding. Thus, the presence of anteponing, postponing scanty discharge“rusty” character (against the background of cyclic pain associated with the cycle) suggests the presence of adenomyosis. Hypermenorrhea is often one of the symptoms of endometrial polyp or submucous uterine fibroids. Uterine bleeding against the background of follicular atresia is prolonged, not abundant and occurs after 6-8 weeks of delayed mensis. Against the background of persistence of the follicle, bleeding is usually profuse, with clots, occurring after delayed mensis.

The principles of therapy for uterine bleeding are built in accordance with the reasons that cause them, as well as the degree of blood loss, the patient’s condition and have two main goals: stopping bleeding and preventing its recurrence.

There is a therapeutic approach based on the tactics of managing uterine bleeding depending on hematocrit and blood hemoglobin. So, in case of anemia mild degree and the established fact of anovulation is indicated: antianemic therapy, antifibrinolytic and nonsteroidal anti-inflammatory drugs (NSAIDs); hormonal drugs used for moderate to severe anemia. In the latter case, the use of surgical hemostasis is also indicated.

With heavy or prolonged mensis, 50-250 mg of iron is released into the blood. The need for iron in these women increases 2.5-3 times. This amount of iron is not absorbed even with a high content of it in food. In this case, both replenishment of latent iron deficiency and treatment of iron deficiency therapy are carried out exclusively with iron preparations. A multicentre randomized trial (Mahomed, 2004; NICE level of evidence - 1) involving 5449 pregnant and gynecological patients of reproductive age with iron deficiency anemia found that combined oral iron and folic acid supplementation was more effective than monotherapy. Deficiency of folic acid and cyanocobalamin, often observed in posthemorrhagic anemia, leads to disruption of DNA synthesis in hematopoietic organs, and their inclusion in the composition medicines, increases the active absorption of iron in the intestine, its further utilization, as well as the release of additional amounts of transferrin and ferritin. These drugs include the complex antianemic drug Ferro-Folgamma, containing 100 mg of anhydrous iron (II) sulfate, 5 mg of folic acid, 10 mcg of cyanocobalamin and 100 mg ascorbic acid. The active components of Ferro-Folgamma are located in a special neutral shell, which ensures their absorption mainly in the upper section small intestine. The absence of local irritation on the gastric mucosa contributes to good tolerability of the drug by gastrointestinal tract. As part of the treatment of uterine bleeding, it was noted positive effect applications of Ferro-Folgamma. In particular, after 4-5 weeks of treatment, hemoglobin levels and other indicators of general hemostasis were restored in 87.6-90.1% of patients with JMC who initially had mild or moderate anemia.

Within complex therapy NSAIDs are used that block prostaglandin synthetase and allow a 30-50% reduction in the volume of blood lost.

If there is no effect from symptomatic hemostatic therapy, hormonal hemostasis is performed using estrogens, progestogens or combined estrogen-progestogen drugs. A number of studies have demonstrated the effectiveness of using synthetic transdermal estrogens for hormonal hemostasis, intravenous administration equilines.

The therapy complex should include antifibrinolytic drugs that inhibit the conversion of plasminogen to plasmin, for example, tranexamic acid. Tranexamic acid is given at 20-25 mg/kg every 6-8 hours, but not more than 1.5 g per course. The use of drugs in this group for DUB leads to a reduction in menstrual blood loss by approximately 45-60%.

There are publications in foreign and domestic literature about the successful intranasal use of desmopressin (1-deamino-8-D-vasopressin acetate) as part of the complex therapy of patients with AUB. Desmopressin is a synthetic analogue of the antidiuretic hormone of the posterior lobe of the pituitary gland (vasopressin). Desmopressin increases the plasma concentration of factor VIII and von Willebrand factor by 2-6 times and indirectly affects platelets.

After stopping the bleeding, either therapy is carried out for the identified organic pathology, or therapy is aimed at forming a regular menstrual cycle. In this case, oral contraceptives and progestogens are used in the contraceptive mode. Therapy with combined estrogen-progestin drugs is usually carried out for 3-6 months, after which regular menstruation may spontaneously resume.

In case of recurrent bleeding, lack of effect from conservative therapy it is necessary to establish the rationality of the conservative treatment carried out, namely the adequacy of the dose and regimen of medications, and also to determine the degree of adherence to therapy. In the case of a true lack of effect from conservative treatment, the issue of surgical treatment is decided. In this case, along with traditional ones (hysterectomy, panhysterectomy), endoscopic techniques are successfully used: Nd-YAG laser ablation (method efficiency: 88-93% - normalization of the menstrual cycle, amenorrhea was obtained in 55.4-74%), diathermic loop ( loop)-resection and diathermic rollerball ablation. These methods have a number of advantages over hysterectomy: fewer postoperative complications, shorter recovery time and lower cost of treatment. Destruction of the endometrium requires subsequent dynamic observation with transvaginal echographic monitoring of the condition of the pelvic organs.

Adequate treatment of AUB can not only improve the quality of life of patients, but in some cases solve their reproductive problems.

For questions regarding literature, please contact the editor.

E. B. Rudakova, doctor medical sciences, Professor
A. A. Luzin
S. I. Mozgovoy, Candidate of Medical Sciences, Associate Professor
GU VPO Omsk State Medical Academy, Omsk

Presentation description: Abnormal uterine bleeding: modern treatment approaches and slides

Abnormal uterine bleeding: modern approaches treatment and prevention, obstetrician-gynecologist, 1st category, candidate of medicine. n. , assistant at the Department of Obstetrics and Gynecology No. 1, ONMed. From O. M. Kalanzhov

ABNORMAL UTERINE BLEEDING (AUB) is any uterine bleeding that does not meet the parameters of normal menstruation in a woman of reproductive age. NB! AUB includes exclusively bleeding from the body and cervix, but not from the vagina and vulva. Washington (2005) - revision of the term “MQM”. With the support of WHO, FIGO, ASRM, ACOG, RCOG, ECOG, a comprehensive term “ABNORMAL UTERINE BLEEDING” (AUB) has been introduced, which is understood in various countries, medical schools, clinical guidelines and training manuals. Dysfunctional uterine bleeding (DUB) is abnormal bleeding from the uterus, not associated with systemic diseases, organic pathology of the pelvic organs or complications of pregnancy.

CHARACTERISTICS OF THE MENSTRUAL CYCLE characteristics regularity (days) frequency (days) duration (days) volume of blood loss norm regular ± 5 24 -38 4.5 -8 normal (80.0 -120.0 ml) deviation option 1 (polymenorrhea) more than ± 20 8 excessive variant of deviations 2 (opsomenorrhea) absent > 38< 4, 5 сниженный

Hypothalamus Pituitary gland (anterior lobe) Ovaries Gonadotropic releasing hormones (Gn. RG) Gonadotropic hormones (FSH, LH) Uterus Cyclic changes in the endometrium. Regulation of the menstrual cycle Steroid hormones(E, Pg, A, inhibin)

Frequency of occurrence of AUB in the structure of gynecological diseases, taking into account the age gradation of women: 1. Juvenile uterine bleeding - 10% 2. AUB in active reproductive age - 25 -30% 3. AUB in late reproductive age - 35 -55% 4. AUB in postmenopause − 55 -60%

Classification of AUB based on the etiological factor (Malcolm Murno - XIX FIGO Congress) 1. AUB caused by uterine pathology: endometrial dysfunction (ovulatory bleeding, chronic endometritis); diseases of the uterine body (uterine fibroids, endometrial polyp, adenomyosis, endometrial hyperplastic processes, endometrial cancer, endometritis, genital TVS, arteriovenous anomaly of the uterus); diseases of the cervix (cervical endometriosis, endocervical polyp, cervical cancer, atrophic cervicitis, uterine fibroids - cervical variant); associated with pregnancy (spontaneous abortion, placental polyp, trophoblastic disease, impaired ectopic pregnancy).

Classification of AUB based on the etiological factor (Malcolm Murno - XIX FIGO Congress) 2. AUB not associated with uterine pathology: anovulatory bleeding (in puberty or perimenopause, polycystic ovaries, thyroid dysfunction, hyperprolactinemia, stress, eating disorders); diseases of the uterine appendages (bleeding after ovarian resection, oophorectomy); on the background hormone therapy(COCs, progestins, HRT).

Classification of AUB, based on the etiological factor (Malcolm Murno - XIX FIGO Congress) 3. AUB, due to systemic pathology: (diseases of the blood system, liver, kidneys, nervous system). 4. AUB associated with iatrogenic factors: (resection, electrical or cryodestruction of the endometrium; bleeding from the cervical biopsy area, taking anticoagulants). 5. AUB of unknown etiology.

AUB of a functional nature 2. Associated with ovarian dysfunction 1. Not associated with organic or systemic pathology OMT Anovulatory bleeding Ovulatory bleeding Estrogenic bleeding Progestin bleeding Breakthrough bleeding Withdrawal bleeding - absolute hyperestrogenia (follicle persistence) - profuse acute bleeding - relative hyperestrogenia (follicular atresia) - long-term bleeding - bilateral oophorectomy - withdrawal of estrogen drugs - irradiation of mature follicles - high progesterone/estrogen ratio (taking long-acting gestagens, low-dose COCs with low estrogen levels) - sharp decrease in progesterone levels (normal menstruation, discontinuation of progesterone use - test for amenorrhea )

Anovulatory estrogenic breakthrough bleeding Hyperestrogenic anovulation FOLLICLE PERSISTENCE One or more follicles reach a certain stage of maturity, but ovulation does not occur and the corpus luteum does not form. Progesterone is not synthesized. The follicle exists from several days to several months, producing a significant amount of estrogens. High level of estrogen (absolute hyperestrogenism) + Progesterone deficiency Hypoestrogenic anovulation FOLLICULAR ATRESIA With follicular atresia, estrogens are produced for a long time, but in relatively small quantities Low (below normal), but constant level of estrogen (relative hyperestrogenism) + Progesterone deficiency

Ovulatory AMK Shortening of the 2nd phase of MC, according to basal temperature data (< 10 дней) Уменьшение параметров желтого тела, по данным УЗИ, на 21 -23 день МЦ 1. Недостаточность лютеиновой фазы (НЛФ) Уменьшение концентрации прогестерона и эстрогена на 7 -8 день после овуляции Недолгосрочное и минимальное действие гестагенов 2. Недостаточная секреторная трансформация эндометрия Скудные кровянистые выделения, возникающие за 7 -10 дней до предполагаемой менструации Heavy bleeding against the background of a shortened (less often elongated) MC 3. Inadequate endometrial rejection

Diagnosis of AUB Confirmation of the presence of bleeding based on assessing the truth of complaints of metrorrhagia (Jansen’s method) Stage 1 Conducting a differential diagnostic search and establishing a diagnosis of AUB: - medical history (somatic history, menstrual history, exclusion of EGP and coagulopathies); — assessment of thyroid function; -examination in mirrors, cytological examination cervix, ultrasound of the pelvic organs, hysteroscopy, hysteroscopy of the endometrium (exclusion of organic pathology OMT) 2nd stage Establishment of the clinical and pathogenetic variant of AUB 3rd stage

Clinical and pathogenetic variants of AUB Parameters Ovulation Anovulation NLF Hypoestrogenic (relative hyperestrogenism) Hyperestrogenic (absolute hyperestrogenism) Characteristics of MC regular irregular Duration of MC (days) 22 -30 35 Endometrial thickness on days 21 -23 MC (mm)< 10 14 Максимальный диаметр фолликула (мм) 16 -18 25 Уровень прогестерона на 21 -23 день МЦ (нмоль/л) 15 -20 < 15 Уровень эстрадиола на 21 -23 день МЦ (пг/мл) 51 -300 301 Histological examination endometrium Incomplete secretory transformation Atrophic or proliferative changes Hyperplastic processes

Treatment of AUB Hippocrates: “You cannot treat until you have made a diagnosis” NB! Treatment of various clinical and pathogenetic variants of AUB should be strictly individual Stage I - stopping bleeding (HEMOSTASIS) Stage II - anti-relapse therapy and its tasks: 1. restoration of the HPA system 2. restoration of ovulation 3. restoration of deficiency of sex steroid hormones

Stage I - stopping bleeding (HEMOSTASIS) hemostasis 3. Surgical hemostasis 2. Hormonal hemostasis 1. Non-hormonal hemostasis

Stage I - stopping bleeding (NON-HORMONAL HEMOSTASIS) antifibrinolytic drugs (plasminogen - plasmin) NSAIDs (inhibit PG synthetase, PG balance F 2 a/E 2)

Stage I - stopping bleeding (HORMONAL HEMOSTASIS) gestagens BUT...!!! the effect is achieved more slowly (3 -5 tablets / day - until hemostasis, reducing the dose by 1 tablet - every 3 days, the total duration of use is at least 10 days, withdrawal of gestagens, after MP bleeding - the formation of a new MC) monophasic COCs (4 -6 tab/d - until hemostasis, 3 tab/d - 3 days, 2 tab/d - 3 days, 1 tab/d - up to 21 days)

Stage I - stopping bleeding (SURGICAL HEMOSTASIS) - hysteroscopy - FDV of the cervical canal and uterine cavity METHOD OF CHOICE IN PATIENTS: PUBERTY (profuse uterine bleeding, life-threatening, secondary anemia - hemoglobin 70 g/l and below, endometrial polyp according to ultrasound) LATE REPRODUCTIVE AGE CLIMACTERIC PERIOD!!! DAMAGE TO UTERUS RECEPTORS – HORMONE-RESISTANT AUB

Stage II - anti-relapse therapy for AUB. Principles of therapy for AUB. Pathogenetic approach - anovulatory, AUB - ovulatory AUB. Consideration of risk factors for the occurrence of gestagen intolerance syndrome. Identification and recording of endocrine diseases and metabolic disorders. Reproductive intentions

Combined oral contraceptives (COCs) (monophasic) Therapeutic effect for AUB: decrease in hormonal activity of the ovaries, suppression of endometrial growth Undesirable effects: suppression of gonadotropin secretion

Progestogens Therapeutic effect in AUB: Progestogenic effect on the endometrium Stopping estrogen-induced endometrial growth Stabilization of endometrial vascularization and stopping uncontrolled vascular growth Initiation of the coagulation cascade Hemostatic and antifibrinolytic effect Inhibition of the activity of matrix metalloproteinases Undesirable effects: systemic effect of gestagens and their metabolites on the woman’s body - intolerance syndrome gestagens

IUD - LNG Therapeutic effect for AUB: reversible severe suppression of endometrial growth, up to amenorrhea Undesirable effects: intermenstrual bleeding of ovarian cysts

AGONISTS – Mr. RG Therapeutic effect in AUB: decreased sensitivity of adenohypophysis receptors to Gn. RG - decrease in the synthesis of gonadotropins by the pituitary gland - hypoestrogenia Undesirable effects: drug-induced menopause (hot flashes, hypertension, dyspareunia, osteoporosis) high price drugs

Progestins Available for patients Easy monitoring of the therapeutic effect Effective timely correction of therapy is acceptable at any stage of treatment Long-term use is acceptable

Long-term use of gestagen (dydrogesterone) is possible due to: 1. Maximum binding to progesterone receptors 2. Selective antiestrogenic activity in relation to the endometrium 3. Non-hepatotoxic No mutagenic, teratogenic and carcinogenic potential

Progestogen intolerance syndrome Psychopathological disorders Metabolic disorders Physical manifestations Anxiety Irritability Aggression Panic attacks Depression Attention problems Forgetfulness Mood lability Lethargy Excess weight Lipid metabolism disorders Glucose/insulin disorders Acne Seborrhea Flatulence Edema Dizziness Headaches Mastalgia

Morphological transformation of the endometrium against the background of taking gestagens Dydrogester on Progesterone 100% - the optimal level of the morphological state of the endometrium in the secretory phase* Without progesterone Norethisterone Levonogestr ate MPA!!! in women of reproductive age.

Pathogenetic approaches to anti-relapse therapy of AUB Order No. 582 of the Ministry of Health of Ukraine COCs in a cyclic mode (for the purpose of contraception) HRT (minimum level of estrogen and adequate progesterone levels) Anovulatory hypoestrogenic AUB (follicular atresia) Selective gestagens (dydrogesterone) in a cyclic mode from the 11th on the 25th day of MC (10-20 mg/day) for 3-6 months Anovulatory hyperestrogenic AUB (follicle persistence) Selective gestagens (dydrogesterone) in a cyclic mode from the 11th to 25th day of MC (20 mg/day) days) for 3-6 months In case of pronounced hyperproliferative processes of the endometrium - selective gestagens from the 5th to 25th day of MC (10-20 mg/day) for 3-6 months Ovulatory AUB against the background of NLF

Pathogenetic approaches to anti-relapse therapy of AUB Order No. 582 of the Ministry of Health of Ukraine COCs in a cyclic mode Selective gestagens (dydrogesterone) in a cyclic mode from the 11th to the 25th day of MC (10-20 mg/day) for 3-6 months Juvenile uterine bleeding Selective action gestagens (dydrogesterone) in a cyclic mode from the 11th to the 25th day of MC (20 mg/day) for 3-6 months. Constant monitoring is preferable!!! IUD, agonists – Gn. RG (uterine fibroids, adenomyosis) Contraindications in the use of gestagens (TE diseases, gastrointestinal diseases in the acute stage, severe varicose veins) AUB in the premenopausal period > 45 years of age LDV in order to exclude organic pathology AUB in postmenopause

Lack of effect from conservative therapy for AUB Surgical treatment: 1. Endoscopic technologies (Nd: YAG laser thermo- and cryoablation, radio wave ablation and, if necessary, endometrial resection) 2. Hysterectomy 3. Panhysterectomy

The effectiveness of adequate, pathogenetically substantiated therapy for AUB 1. Restoration of normal MC 2. Implementation of the patient’s reproductive plans 3. Prevention of hyperplastic processes of the edometrium 4. Prevention of extensive surgical interventions

NB! Treatment of AUB associated with progesterone deficiency should be pathogenetically justified. The treatment method for AUB is highly effective in both therapy and prevention of this pathology.

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

Features of the pathology

If blood discharge does not correspond to normal menstruation, then experts speak of abnormal uterine bleeding. With this pathological condition of the female body, menstruation is released from the genital tract for a long period and in large quantities. In addition, such heavy periods cause exhaustion of the patient’s body and provoke the development iron deficiency anemia. Specialists are especially concerned about blood from the reproductive organ, which appears during the intermenstrual period for no reason.

In most cases, the main reason for the development of such pathological condition The patient's body becomes affected by hormonal changes. It is important that a woman can independently distinguish abnormal discharge from normal menstruation, which will help her promptly seek help from a specialist.

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

Dangerous to a woman’s health is the appearance of abnormal uterine discharge during menopause, when the functioning of the reproductive system has already ended and menstruation has completely stopped. In most cases, the appearance of blood is considered dangerous signal that a woman’s body progresses dangerous disease, and even oncology. Not the least important role in the development of this pathological condition is occupied by hormonal disorders that develop due to the influence of estrogens.

Experts classify abnormal uterine bleeding as the appearance of blood discharge due to a disease such as fibroids. With this pathology, menstruation becomes profuse and can occur in the middle of the menstrual cycle.

Types of pathology

There is a medical classification that identifies several types of abnormal bleeding from the reproductive organ, taking into account the etiological factor:

1. Blood discharge that is associated with the pathological condition of the uterus. The reasons for the development of such uterine bleeding may be associated with pregnancy and cervical pathologies. In addition, such discharge develops as it progresses in the female body. various diseases the body of the reproductive organ and dysfunction of endometrioid tissue.
2. Bleeding from the uterus, which is in no way related to the pathological condition of the reproductive organ. The reasons for the development of such unpleasant condition may be different. This is the progression in the female body of various diseases of the appendages of the genital organ, ovarian tumors of various types and premature puberty. A woman taking hormonal contraceptives. Frequent anovulatory bleeding
3. Abnormal discharge from the uterus that develops as a result of various systemic diseases. Most often, this pathological condition of the female body develops with pathologies of the circulatory and nervous system, as well as for disorders of the liver and kidneys.
4. Discharge of blood from the reproductive organ, which is closely related to iatrogenic factors. The reasons for the development of such a pathological condition of the female body are biopsies and cryodestruction. In addition, highlighting large quantity blood may result from ingestion neurotropic drugs and anticoagulants.
5. Abnormal bleeding from the uterus of unknown etiology

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

• Discharge of blood that begins along with menstruation at the right time or after a slight delay.
• The appearance within 1-2 months of minor bleeding or heavy blood loss, which provokes the development of anemia and requires immediate medical attention.
• The appearance of discharge from the reproductive organ with clots, which can be large in size.
• The development of iron deficiency amenorrhea in a woman, which causes characteristic symptoms in the form of increased pallor of the skin and unhealthy appearance.

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

The specific treatment for this disease is determined by:

• The reasons that caused the appearance of blood from the reproductive organ.
• The degree of blood loss.
• General condition of the woman.

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

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

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

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

• Carrying out surgical homeostasis, which is curettage of the uterine cavity.
• Purpose of hormonal homeostasis.
• Treatment with hemostatic agents.