Juvenile uterine bleeding in adolescents. Juvenile uterine bleeding

JUMK (juvenile uterine bleeding) is blood loss of an inorganic nature that occurs in puberty. Juvenile bleeding most often occurs due to a delay in menstruation due to disruption of the interaction of the ovaries with endocrine glands. In this case, the volume of discharge exceeds the norm during menstruation, and in the absence of treatment, symptoms such as pale skin, dizziness, chronic fatigue, feeling of weakness, etc.

Causes

JMC have a polyetiological origin and appear as a result of many factors, both external and internal. The most common cause of juvenile bleeding in girls is dysfunction reproductive system during the formation of the menstrual cycle. As a result of this disorder, the concentration of estrogen and progesterone changes, which becomes the cause uterine bleeding. Factors that provoke the appearance of juvenile uterine bleeding:

• blood diseases (including von Willebrand-Diana disease);
• heredity;
• excessive physical activity;
• strong emotional experiences and regular stress (problems at school, quarrels with parents or peers, etc.);
• vitamin imbalance in the body;
• chronic and acute infectious pathologies;
• disruption of the endocrine system;
• liver dysfunction.

JMC also depend on the physiology of a teenage girl. In the medical field, there are three types of disorders:

• hyperestrogenic: most often observed in children with psychological immaturity and excessive physiological and sexual development;
• normoestrogenic: occurs in young girls and adolescents with normal development and an underdeveloped uterus;
• hypoestrogenic: this type of disorder is encountered by young girls with a well-developed psyche, whose secondary sexual characteristics are poorly developed.

Classification and forms

According to the degree of blood loss, there are three types of juvenile uterine bleeding in adolescents:

• metrorrhagia - develops against the background of the absence of scanty menstrual flow and is not cyclical;
• menorrhagia - with this type of bleeding, the menstrual cycle is not disrupted, but blood loss lasts longer than 7 days and exceeds 80 ml/day;
• polymenorrhea - the menstrual cycle persists, but lasts no longer than 3 weeks.

Experts have found that JMC is most often encountered by children whose mothers suffered from infectious diseases during pregnancy.

Clinical manifestations

JMCs occur between the first menstruation and the next two years. Signs of violation:

• high or low blood pressure;
• systematic dizziness;
• constant feeling thirst;
• pale skin;
• increased fatigue and feeling tired;
• sudden mood swings;
• bleeding is observed between menstruation;
• the cycle lasts less than 3 weeks;
• discharge lasts longer than 15 days;
• heavy blood loss continues for more than a week.

If you suspect JMC, you should pay attention to the duration, volume and cyclicity of bleeding. If you feel unwell or have any abnormalities, you should seek help from a specialist.

Diagnostics

Sometimes it is extremely difficult to distinguish menstrual flow from JMC, and only a doctor can accurately diagnose the problem. Basic diagnostic methods:

• interviewing the patient to identify the presence of congenital or chronic pathologies;
• study of anamnesis;
• visual examination, which can help identify deviations in puberty (the size of the mammary glands, the presence of vegetation on the pubis and in the axillary recesses);
• blood test for hormones to determine the level of estradiol, prolactin, progesterone, FSH and LH;

After stopping the bleeding, you need to additionally undergo:

• echography of the adrenal glands and thyroid gland;
• secondary ultrasound examination of the pelvic organs;
• electroencephalogram;
• X-ray of the skull;
• CT scan of the brain;
• echoencephalogram.

To confirm/exclude the diagnosis, you should consult an oncologist, neurologist, endocrinologist and hematologist.

Treatment

If there is heavy bleeding, you should call an ambulance. Additionally, the following measures need to be taken:

• the teenager needs to take a horizontal position;
• on bottom part Apply an ice pack wrapped in a soft towel to the abdomen for 10-15 minutes;
• the child needs to be provided with plenty of fluids in the form of sweetened tea or water;
• It is advisable to give the girl 1 tablet or capsule of vitamin C.

You should consult a doctor even if the bleeding stops on its own. Timely diagnosis and pathology therapy will help avoid negative consequences.

For juvenile bleeding in teenage girls, treatment is carried out in two stages.

To begin with, the doctor sets himself the task of stopping the bleeding. If the pathology is severe, then classical means to stop bleeding may be ineffective. In such situations, hormonal therapy is prescribed by taking gestagens and estrogens.

If the bleeding can be stopped, then medications are prescribed to stabilize it. menstrual cycle. In this case, drugs are selected depending on the causes of the disorder and the characteristics of the patient’s body.

In addition, female patients may be prescribed vitamin complexes, physiotherapeutic procedures and a special schedule of physical activity. At this stage, the physician also pays attention to psychological condition female patients. Sometimes repeated JMC are observed after stress.

If the bleeding poses a threat to life, then in this case, surgical intervention is prescribed, in which the uterine cavity is curetted. After this, a scheme is selected drug treatment.

Average term therapy - 12 months. During this period, the menstrual cycle is established, and irregularities no longer occur.

Complications and consequences

JMC in girls can cause the development of anemia and associated complications. IN severe cases anemia affects many systems and internal organs, which poses a threat not only to health. but also for the life of a teenage girl.

Untimely and improper exfoliation of endometrial tissue can lead to inflammation of the uterus, which can lead to the development of tumors, endometriosis and cysts, which can cause infertility.

Therefore, in case of any deviations, you should consult a doctor.

Prevention

The state of the reproductive and reproductive systems of girls is formed at an early age. After the birth of a child, parents need to not only constantly monitor his hygiene, but also teach him a healthy lifestyle and daily routine. Balanced, saturated diet useful microelements and vitamins, regular walks outside and moderate physical activity - all this will allow the child to develop correctly and prevent many gynecological pathologies.

In addition, to prevent juvenile uterine bleeding in girls, viral and infectious diseases should be promptly treated and regularly visited by a gynecologist.

A mother should definitely inform her daughter about the importance of menstruation. It is also advisable for her to monitor this process until the end of puberty.

Your child should be seen for the first time at the gynecologist during their first period.

Thereafter, a gynecological consultation should be sought every six months until adulthood.

The baby's body weight also affects the menstrual cycle. It is necessary to ensure that the child is not overweight or underweight. If necessary, you can additionally consult with a nutritionist on this issue. The specialist will select a nutrition plan for the teenager, help get rid of weight problems and prevent the recurrence of juvenile bleeding in the future.

In addition, mothers should discuss issues with their daughters that explain the dangers and consequences of early sexual intercourse.

Puberty is individual for each child, so you should not self-medicate and try to solve the problem of JMC on your own. It's better to contact medical specialist, who identifies the deviation and prescribes adequate therapy

Juvenile bleeding is uterine bleeding that occurs during puberty in girls as a result of dysfunction. This pathology occurs quite often. It accounts for approximately 20% of all sexually transmitted diseases in adolescent and childhood girls.

The occurrence of juvenile bleeding is associated with hormonal imbalances and improper balance of hormones of the hypothalamus, pituitary gland and ovaries. This leads to a violation of the ratio of secretion of the hormones LH and FSH. As a result, the normal formation of follicles is disrupted and menstrual function is disrupted. Several follicles grow in the ovaries every month, but there is no dominant one among them. The amount of estrogen in the body is small, and corpus luteum No. All these hormonal imbalances can lead to the formation follicular cysts or corpus luteum cysts against the background of hyperestrogenism. In this case, the uterine mucosa is not rejected during menstruation, but is transformed, which is why hyperplasia develops, that is, excessive growth of the mucosa. Over time, the mucous membrane is rejected, which is accompanied by severe prolonged bleeding.

In most cases, juvenile bleeding develops in the first couple of years after the start of menstruation in girls.

Juvenile bleeding: classification

All juvenile bleeding is divided into anovulatory and ovulatory. The first type of pathology is characterized by cycle disruptions, large blood loss, loss of appetite, drowsiness and weakness. It can be recognized by the clinical picture of the course during a gynecological examination, during ultrasound and other laboratory tests.

Ovular bleeding is similar in its symptoms to normal monthly bleeding in women. Their distinctive feature is their duration; they are also noted scanty discharge throughout the entire month and too short or too long periods between menstruation.

Juvenile bleeding: symptoms

The main symptom of juvenile bleeding is discharge of blood from the genitals, which occurs after a delay in menstruation for a period of 2 weeks to 2 months. Many girls experience this phenomenon again. Bleeding is usually profuse and accompanied by weakness, dizziness and other signs of anemia. In some cases, with this disorder, bleeding of moderate intensity is observed, but there are no signs of blood loss; such juvenile bleeding can last up to two weeks or more.

Diagnosis of juvenile bleeding

For the diagnosis of juvenile bleeding, the main importance is the pronounced clinical picture. Methods used to confirm the absence of ovulation functional diagnostics. This disorder must be differentiated from blood diseases, which may cause increased bleeding, hormonal tumors of the ovaries and uterus, spontaneous miscarriage, cervical cancer and other pathologies.

To accurately diagnose juvenile bleeding, ultrasound examinations of the ovaries and uterus can be used, which can help determine changes in the structure and size of these organs.

Juvenile bleeding: treatment

Therapy for these bleedings involves two stages, the first of which is to stop the bleeding, and the second is to prevent the recurrence of the pathology. Choice suitable treatment Juvenile bleeding depends on the patient's condition.

In severe cases (with severe anemia, pale skin and a decrease in hemoglobin to a level of 80 g/l and below), if bleeding continues, it is indicated surgery. It consists of curettage of the uterus with removal of the mucous membrane and subsequent laboratory examination of part of the scraping. To avoid damage to the hymen, doctors use baby vaginal speculums. Among other things, the patient is prescribed B vitamins and ascorbic acid, as well as iron supplements. Nutrition during the recovery period should be high in calories.

If the patient's condition is assessed as moderate severity or satisfactory, then conservative treatment is carried out. It includes taking hormonal and vitamin-containing medications.

With timely, comprehensive treatment, the prognosis for the development of the disease is favorable. If the necessary measures are not taken in time, then infertility may develop.

Prevention of juvenile bleeding

Preventive measures for juvenile bleeding are aimed at the formation regular cycle in a woman. For this purpose, hormonal drugs such as oral contraceptives can be used. In the prevention of juvenile bleeding, acupuncture is used, which stimulates ovulation and increases the regularity of the cycle. Of particular importance is maintaining general health body: sanitation of the oral cavity and other possible foci of infection, proper nutrition, physical activity, vitamin therapy, hardening, etc.

Definition of the concept. Juvenile uterine bleeding (JUB) includes acyclic bleeding that occurs during puberty. JMC is often called dysfunctional

national uterine bleeding, less often - puberty or adolescence.

Frequency. JMC is one of the most common forms of menstrual irregularities during puberty. In the population of teenage girls, menstrual cycle disorders of the JMC type, according to some authors, occur with a frequency of 2.5 to 10%, according to other data, much more often - from 10-15 to 52%.

Etiology and pathogenesis. The etiological factors contributing to the occurrence of JMC are extremely diverse. In the literature one can find indications that an unfavorable course of the antenatal period of development can contribute to the predisposition of girls’ bodies both to some endocrinopathies and to the development of a number gynecological diseases, in particular juvenile bleeding. Therefore, when considering the etiology and pathogenesis of JMC, it is necessary to clarify the features of the course of the antenatal period of ontogenesis in each specific case.

Many authors report on the role of mental trauma and physical stress in the genesis of JMC. Stressful influences are accompanied by activation of the hypothalamic-adenohypo-adrenal cortex system, as a result of which the secretion of GL and, accordingly, gonadotropic hormones is disrupted. As a result, persistence of the follicles occurs, leading to changes in the production of sex hormones. With vitamin C deficiency, the strength of the vascular walls decreases and the microcirculatory link of hemostasis is disrupted, which is also observed in JMC. With vitamin E deficiency, the function of the hypothalamus, the biosynthesis of prostaglandins involved in blood clotting, and platelet aggregation processes are disrupted. With vitamin K deficiency, hepatocyte function is impaired.

Among the etiological factors of SMC, the leading place is occupied by infectious diseases. Many authors point to a high infectious index in girls with JMC, and among the provoking diseases are usually frequent sore throats, flu, chronic tonsillitis, acute respiratory infections, as well as chicken pox, rubella, rheumatism and mumps. Currently, there is a consensus on the distinct influence of an infectious agent on the hypothalamic region during puberty, with chronic tonsillitis having a particularly adverse effect.

infection. With chronic tonsillitis, according to our data, the body's immune reserve is also reduced. Yu. A. Krupko-Bolshova discovered pronounced changes in the endometrium and ovaries in animals infected with the influenza virus and a culture of hemolytic streptococcus.

Thus, infectious diseases in JMC can have an adverse effect on both the hypothalamus and the ovaries. The possibility of an effect on the target organ of estrogen - the uterus - cannot be ruled out.

The study of the secretion of gonadotropins in JMC indicates various deviations from the norm: acyclic monotonic low or increased level LH excretion. In the hypoestrogenic form of JMC, the excretion of LH and FSH is, as a rule, reduced, and in the hyperestrogenic form, along with a decrease in LH excretion, a constantly increased release of FSH was noted. According to V.F. Kokolina et al. , JMC are not associated with hyperproduction of estrogen, but, on the contrary, with a decrease in the functional activity of the follicle, which is caused by FSH deficiency.

According to our data, the excretion of FSH and LH in JMC is chaotic, with maximum emissions of these hormones synchronized in time or with intervals between maximums of 1-8 days. The level of the highest FSH excretion in girls aged 13-16 years with JMC is significantly higher than in healthy girls of the same age. At older ages, there is a decrease in FSH excretion. The average values ​​of maximum LH emissions in patients with JMC exceeded the age norm of cyclic LH production only in the group of 12-13 year olds, while in other age groups they were decreased in all observations below the ovulation peak in women of childbearing age.

The data obtained suggest that in sick girls with acyclic anovulatory bleeding, during the period of formation of menstrual function (up to 13 years), there is an increased gonadotropic function of the pituitary gland, and then its gradual suppression occurs. In this case, first of all, the function of the links that ensure the cyclic secretion of LH is reduced. By the age of 17, a decrease in gonadotropic function occurs to a level that ensures cyclic secretion of FSH. In the vast majority of girls with JMC, we found manifestations of dysfunction

Chapter 3. Pathology of the reproductive system during its formation

subcortical structures of the brain, and the picture of typical diencephalic changes was recorded on electroencephalograms mainly with a high infectious index and the presence of chronic tonsillitis. An increase in TSH levels may also play a certain role in the pathogenesis of bleeding.

The fairly frequent occurrence of JMC in girls is explained by the special vulnerability of the hypothalamus-pituitary-ovary-uterus system during puberty. As is known, it is in the puberty period that the morphological maturity of the structures of the hypothalamic region, which ensure hypothalamic-pituitary activity, begins, and the cyclical release of hormones is formed and consolidated. At this age, the hypothalamic-pituitary system is especially sensitive to adverse effects. It is believed that in most cases of JMC there is functional immaturity of the hypothalamic centers. Dysfunction of the anterior hypothalamus can manifest itself as a lack of cyclic production of liberins, which ensure the secretion of pituitary hormones. Regardless of the primary or secondary nature of the pathological changes in the hypothalamic-pituitary system, there is no cyclic release of gonadotropins, therefore there is no ovulation and, as a consequence, the maturation of the follicle is disrupted by the type of persistence, and more often - atresia.

Follicular atresia is accompanied by wave-like secretion of estrogens with small fluctuations in the overall high level, which creates long-lasting estrogenic effects. This long-term exposure to estrogens, both in large (with persistence) and in relatively small (with atresia) quantities, ultimately leads to the same results - hyperplastic processes in the endometrium. With the reverse development of follicles, bleeding occurs as a reaction to a decline in hormones. The mechanism of bleeding is not well understood, but, according to most authors, highest value has a relationship between changes in hormonal levels and fluctuations in vascular tone.

As a result of a decrease in the secretion of sex hormones, congestive plethora of the endometrium occurs with dilation of capillaries and circulatory disorders, leading to hypoxia and changes in metabolism in the tissue. Dystrophic areas and necrosis appear, followed by prolonged and uneven rejection of the endometrium. In addition to changes in blood vessels, the appearance of blood

3.2. Juvenile uterine bleeding

flows is facilitated by an increase in the sensitivity of the endometrium to estrogens while simultaneously reducing the contractility of the uterus, which is observed especially often during puberty. Rejection of the endometrium is sometimes difficult due to the compaction of the argyrophilic mesh-fibrous structure of the uterine body mucosa.

In the mechanism of uterine bleeding, the main role, as a rule, is given to disruption of hormonal regulation and trophism of the basal layer of the endometrium. However, there are observations that bleeding can occur without a drop in hormone levels. Apparently, the mechanism of development of uterine bleeding is much more complex and not all of its components have been sufficiently studied.

New research methods that have emerged in recent years are helping to clarify the genesis of JMC. Thus, our studies indicated, in particular, the possibility of a combination in JMC of both disorders in the reproductive system and primary changes in the hemostatic system. Among the contingent of patients with JMC who were in the gynecology department of childhood and adolescence, in 40% of cases disorders of only the reproductive system were found (isolated form of YuMC), and in 60% of patients there is a combination of disorders of the reproductive system and changes in the hemostatic system (combined form of JMC).

Heredity analysis showed that in patients with JMC of the combined form, family manifestations of hemorrhagic syndrome and diagnosed defects of the hemostatic system were present in 65% of cases, while in families of patients with JMC and isolated pathology of the reproductive system - in 10-25% of cases , which is only slightly higher than for the population as a whole (10-12%). A history of extragenital manifestations of hemorrhagic syndrome in the combined form of JMC was observed in every 2nd patient. As for menstrual function, in the group with the combined form of JMC, in 60% of cases complications such as bleeding or an increase in the duration of the 1st menstruation for more than 10 days were detected, while in girls with JMC without impaired hemostasis, such complications were observed 2.5 times less often. In patients with hemostasis disorders, a seasonal dependence of the first manifestations (bleeding at menarche) and relapses of the disease was also revealed. The identified violations are due to de-

Chapter 3. Pathology of the reproductive system during its formation

effects of microcirculatory hemostasis: thrombocytopathies (69%), idiopathic thrombocytopenic purpura (2.7%), von Willebrand syndrome (23%).

The diagnosis of JMC, according to the definition of this pathology, is not easy. To set it up, in addition to analyzing the pedigree, clinical data, using additional research methods such as clinical anthropometry, vaginoscopy, ultrasound, X-ray methods, EEG, determining the concentration of hormones and the state of the hemostatic system, etc., it is necessary to conduct a differential diagnosis.

During a general examination of girls and young women with JMC, the majority have certain deviations in somatic development.

According to our survey data of 350 girls with JMC, in 5% of cases some features of somatic development are found. An anthropometric study most often (37%) shows an intersex morphotype; infantile physique and a morphotype ahead of the norm were identified in 19 and 16% of cases, respectively, normoskelia - in 15%. It is characteristic that among girls with JMC at the age of 11-14 years, the sexual morphotype that is ahead of the norm predominates, while at an older age (15-17 years), intersex and infantile morphotypes dominate.

Anthropometric data corresponded to the degree of development of secondary sexual characteristics and age of menarche. Thus, at the age of 12 years, the intensity of development exceeded the age norm, and from the age of 15 there was a tendency to lag behind age norms. It is characteristic that girls with JMC often experience menarche earlier than in the general population.

The degree of biological maturation (according to bone age) is usually ahead of calendar age.

When performing mammography, most girls with JMC are diagnosed with fibrocystic mastopathy of varying severity.

Thus, patients with JMC during puberty, as a rule, differ from healthy peers in their physical and sexual development. Excessive acceleration of the rate of biological maturation at the beginning of puberty is replaced by a slowdown in development in older age groups with chronic,

3.2. Juvenile uterine bleeding

recurrent nature of JMC. This phenomenon appears to be based on pathological changes processes of steroidogenesis and worsening shifts in the ratio of estrogens and androgens towards an increase in the proportion of the latter as the disease progresses.

Based on the condition of the external genitalia and vaginoscopy data, one can judge type of bleeding. For patients with hypoestrogenic types of JMC, it is mainly characteristic proper development external genitalia, pale pink coloration of the vulvar mucosa, thin hymen. According to vaginoscopy, the mucous membrane is pale Pink colour, folding is weakly expressed (especially in young patients), the cervix is ​​subconical or conical in shape, the pupil phenomenon is “±” or “+”, the discharge is light, bloody, without mucus. A rectoabdominal examination usually reveals a typically located uterus, the angle between the body and the cervix is ​​not expressed sufficiently, the size of the uterus corresponds to age, and the ovaries are not palpable.

In patients with hyperestrogenic types of bleeding, the correct development of the external genitalia, the juiciness of the vulva, and a fringed, juicy hymen are noted. During vaginoscopy (in the absence of severe anemia), the vaginal mucosa is pink, the folds are well expressed, the cervix is ​​cylindrical in shape, the pupil phenomenon is “++”, “+++” or “++++”, the discharge is copious, bloody, mixed with mucus. .

During a rectoabdominal examination, an enlarged uterus is palpated (sometimes to the size of a 5-week pregnancy), the angle between the body and the cervix is ​​well defined, and ovaries that are slightly enlarged in size are often palpated.

Enough full information An ultrasound of the pelvic organs gives information about the condition of the internal genitalia. According to our observations, ultrasound data correspond to the nature of the dysfunction of the ovaries and may indirectly indicate the type of bleeding. With the hyperestrogenic type of bleeding, the size of the uterus exceeds the age norm, and changes in the ovaries are noted. With JMC, the volume of the ovaries is 2-2.5 times greater than in healthy peers.

The thickness of the endometrium and cystic inclusions in the ovaries vary depending on the type of bleeding: with follicular atresia (hypoestrogenic type of bleeding), the thickness of the endometrium at the time of bleeding is 0.8-1.0 cm, in the ovaries cystic

Chapter 3. Pathology of the reproductive system during its formation

inclusions reach a diameter of 0.3-0.6 cm or a small cystic transformation of both ovaries is detected. With the hyperestrogenic type of bleeding, the thickness of the endometrium reaches 1.2-2.5 cm; in this case, cystic formations ranging from 1.0 to 2.2-3.5 cm in diameter are detected in one or both ovaries.

Data hormonal studies with JMC are contradictory. Most authors note a decrease in the level of estrogen excretion in the urine. With regard to the content of progesterone, all researchers unanimously note its decrease in JMC.

Hysteroscopy in patients with JMC of the hyperestrogenic type reveals mucous membrane of uneven thickness, hyperplasia, and polyps; according to hysterosalpingography (HSG), the uterine cavity has jagged contours, small round filling defects (with hyperplasia and endometrial polyps); according to functional diagnostic tests - monophasic basal temperature, KPI - 50-80%; pull length cervical mucus- 7-8 cm. In the hypoestrogenic type of JMC, the data from hysteroscopy and radiological methods are similar, functional diagnostic tests reveal a monophasic basal temperature, CPI - 20-40%, mucus tension length - 3-4 cm.

Important diagnostics is based on histological examination of the endometrium. For a very long time (in some clinics still) there was a point of view that curettage of the endometrium in girls can only be done for vital indications. With many years of experience in diagnosing and treating JMC, we believe that diagnostic curettage in patients with frequent relapses of juvenile bleeding, it is advisable to carry out, but for this purpose it is necessary to use special children's speculums with preliminary injection of the hymen with lidase. According to our data, the vast majority of girls with frequently recurrent bleeding (in 87% of cases) develop hyperplastic processes in the endometrium. Atypical hyperplasia and adenomatous polyps are often detected, and we found endometrial cancer in 2 patients aged 16 and 18 years.

Considering the need to maintain oncological vigilance for recurrent JMC in girls, we can recommend wider use of diagnostic curettage. If in some hospitals it is not possible to perform curettage without fear of breaking the hymen, you should send

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such girls are sent to specialized gynecology departments for children and adolescents.

Taking into account possible (and not uncommon) combinations of defects in the hemostasis system and the reproductive system, it is advisable to conduct a phased examination of patients to determine the level of damage and the severity of hemostasis defects.

On first stage the bleeding time and type of bleeding are determined, which, along with other results of the clinical examination, makes it possible to distinguish patients with suspected disorders of the hemostatic system and patients with pathology only of the reproductive system. These studies make it possible to exclude gross defects in the hemostatic system. Determining the platelet count at the first stage helps to exclude thrombocytopenia (thrombocytopenic purpura). Activated partial thromboplastin time (APTT), activated recalcification time (AVR), and cyclothrombin index (PTI), which characterize the total activity of plasma coagulation factors, are measured. An increase in the values ​​of the listed parameters is observed with a significant decrease in the factors of the procoagulant part of the hemostatic system or combined coagulation defects. Determination of the concentration of fibrinogen as the main substrate of blood coagulation is carried out to exclude hypofibrinogenemia, which may be a consequence of impaired fibrinogen synthesis or activation of the fibrinolytic system of the blood. Thromboelastography at the first stage is carried out to determine chronometric and structural coagulation at the time of examination.

On second stage carry out qualitative assessment plasma and microcirculatory-vascular links of the hemostasis system. When the APTT and AVR are prolonged, it is advisable to determine the thrombin time: this indicator is used for the differential diagnosis of acquired forms of coagulopathies ( acute form DIC syndrome, iatrogenic coagulopathies). An increase in thrombin time serves as a reason to determine the concentration of fibrin and fibrinogen degradation products; their elevated concentrations in combination with hypofibrinogenemia indicate thrombohemorrhagic syndrome. With an increase in the parameters APTT, AVR, PTI, qualitative reactions are performed on the content of plasma coagulation factors (VIII, X, IX, XI, XII and II, V, VII). If plasma hemostasis is normal, a qualitative

Chapter 3. Pathology of the reproductive system during its formation

a thorough assessment of the platelet component of hemostasis, determination of the adhesive activity of platelets and the formulation of qualitative reactions characterizing the functional activity of platelets with the addition of biological stimulators of aggregation. A decrease or absence of platelet adhesion and platelet aggregation upon stimulation with ristomycin is observed in von Willebrand disease and requires subsequent determination of the activity of the factor VIII antigen. A decrease in the coefficient of thromboelastographic activity of platelets to a value less than 1.0 indicates platelet hypofunction

On third stage a final assessment of the defect in the hemostatic system is carried out, with a quantitative determination of the activity of the deficiency factor and the severity of the platelet defect. First, tests are performed with strong stimulators of platelet aggregation, which makes it possible to assess the maximum ability of platelets to aggregate and characterize the release reaction of endogenous stimulants; then tests are performed with weak stimulants, which allow one to evaluate secondary platelet aggregation, the dynamics of the reaction of the release of coagulation factors, as well as primary platelet aggregation and disaggregation of platelet aggregates. This stage of the study should be carried out in specialized hemostasiology laboratories, and if gross defects in the hemostasis system are detected, patients must be transferred to hematology hospitals.

In cases of lesions of the vascular walls without a violation of the blood coagulation system (with toxic-allergic changes in the capillaries, hereditary pseudohemophilia, congenital pathology of the vascular walls), the bleeding time is prolonged, blood coagulation is normal, retraction blood clot and platelet count are also not abnormal.

To detect blood diseases great importance has an anamnesis. Gum and nose bleeding, ease of bruising since childhood, sometimes intra-articular hemorrhages, blood diseases in family members, especially in the female line, menstrual dysfunction such as menorrhagia should alert the doctor and prompt an extended hemostatic study. In cases where diagnosis is difficult, consultation with a hematologist in a specialized hospital is necessary.

3.2. Juvenile uterine bleeding

When managing patients with JMC, it is sometimes necessary to exclude pathologies of the liver, thyroid gland and dysfunction of the adrenal cortex.

If extragenital diseases are excluded, a differential diagnosis is made between diseases of the genitals. For this purpose, it is necessary to perform vaginoscopy to exclude polyposis, vaginal tumors, including vascular ones, foreign body and other sources of bleeding.

During puberty, JMC is differentiated from genital tuberculosis, which can manifest itself at this age as acyclic uterine bleeding. We should not forget about the possibility at this age of pregnancy and miscarriage, granulosa cell tumor of the ovary, cancer of the body and cervix, endometriosis and not so rare uterine fibroids. According to our data, with uterine bleeding, uterine fibroids are found in 5-7% of adolescents.

Widely used for differential diagnosis additional methods studies: vaginoscopy, colposcopy, hysteroscopy, hysterography, pneumoperitoneum; Recently, ultrasound of the pelvic organs has been increasingly used, and when indicated, laparoscopy.

Treatment of JMC should be comprehensive, individual, taking into account etiology and pathogenesis. Short-term disturbances of menstrual function, not accompanied by heavy blood loss, do not require treatment. If a girl had a single bleeding followed by spontaneous normalization of menstrual function, it is advisable to monitor further periods and not rush into prescribing therapy, especially hormonal therapy.

When identifying any common diseases in which uterine bleeding is one of the symptoms of the disease, the main focus is on treating the disease with appropriate specialists.

Treatment for JMC consists of: 1) general treatment; 2) the use of contractile and hemostatic agents; 3) hormone therapy; 4) surgical intervention.

General treatment which should be started with, is aimed at relieving negative emotions in the patient, creating physical and mental peace and includes rational treatment of infections and

Chapter 3. Pathology of the reproductive system during its formation

intoxications, correct mode work and rest with rational nutrition, rich in vitamins. Considering the frequent central genesis YuMK for girls, they carry out a complex of psychotherapeutic measures: electrophoresis with bromine and calcium in the form of a galvanic collar, prescription of bromine preparations with caffeine, small doses of tranquilizers.

In order to normalize hemostasis and regulate menstrual function, physiotherapeutic methods are widely used. When JMC occurs against the background of influenza or tonsillitis in patients with a high infectious index and recurrent JMC, calcium electrophoresis helps well. Calcium ions penetrate the mucous membrane of the nasal passages, moving along the perineural slits of the olfactory and trigeminal nerves and enter the cerebrospinal fluid And nerve centers, increasing parasympathetic activity and tone of smooth muscles that provide vasoconstrictor effect. The effect of calcium ions in the form of local dehydration and compaction of cell membranes can play a positive role in cases of disturbances in the hypothalamic-pituitary system caused by previous infectious diseases. In rare cases of bleeding due to hyperestrogenism, endonasal electrical stimulation is considered pathogenetically justified. pulse current low frequency. Novocaine electrophoresis on the area of ​​the superior cervical sympathetic ganglia is also effective. This procedure can be carried out in the absence hypersensitivity to novocaine. Galvanization of the sinocarotid zone has proven itself well in previously untreated patients with the first episode of bleeding.

For frequently recurrent bleeding due to hypoestrogenia, vibration massage of the paravertebral zones is advisable.

To the methods of general therapeutic effects includes the fight against anemia (anti-anemic drugs, vitamins). Blood transfusion can be recommended only in cases of significant blood loss and should be treated with great caution, taking into account the risk of immediate and long-term immunological complications. It is necessary to achieve a hemostatic effect as quickly as possible, and then prescribe increased and fractional nutrition, iron supplements, and insulin therapy. In case of serious need, it is better to perform blood transfusion taking into account individual combination

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cost, choosing the patient’s closest relatives as donors. Among iron preparations, lactic acid and ferrous iron, hemostimulin, and ferroplex are recommended. Oral administration of iron sometimes causes dyspepsia, which reduces its absorption. In these cases, intramuscular or intravenous administration drugs such as fercoven, antianemin.

Among the vitamins, K and B6 are successfully used, which are involved in the regulation of protein metabolism and hemoglobin synthesis. A combination (if prescribed on more than one day) of vitamins K, B6, B12 with folic acid is indicated (B12 - 100-200 mcg intramuscularly every other day for 2-4 weeks; folic acid - 0.01 -0.03 g 2-3 times a day; Vicasol is administered 3-5 ml of a 1% solution intramuscularly and in the form of tablets of OD g 3 times a day for 3-7 days).

Sometimes used insulin(subcutaneously 4-5 (up to 8) units 1 time per day for 20-30 days). Before administering insulin, you need to give sweet tea (30-50 g of sugar per glass). It can be recommended to administer insulin subcutaneously, starting with 2 units, followed by increasing the dose by 2 units per day (up to 10 units), then gradually the dose is similarly reduced to 2 units, followed by discontinuation. Simultaneously with the insulin injection, the patient is given 2 pieces of sugar.

Reflexology is widely used for JMC. Two types of reflexology are used: electrical stimulation of cervical receptors and electropuncture. The mechanism of action of these methods is based on the stimulation of the cervical-pituitary reflex, which contributes to the normalization of processes in the hypothalamus-pituitary-ovary-uterus system.

For electrical stimulation of cervical receptors, a gynecological electrical stimulator or an ISE-01 device from the Kiev EMO plant with a bipolar electrode (inserted into the cervical canal without expansion to the internal link) is used, through which electrical impulses are applied. rectangular shape. Pulse duration - 2 ms, frequency - 80 Hz, voltage - 5 V, procedure duration - 10 minutes, course of treatment - 10 procedures. Over the course of 4-5 subsequent menstrual cycles, corrective anti-relapse therapy is carried out (from the 11th to the 15th day of the menstrual cycle). In 80% of cases, a rapid hemostatic effect was obtained (after 2-5 sessions). When studying long-term results, 62% of patients did not experience relapses of the disease.

Chapter 3. Pathology of the reproductive system during its formation

The electropuncture method makes it possible to obtain a similar effect without direct impact on the genital area, which is especially important when treating girls and adolescents.

A number of authors have identified a direct connection between some biological active points(BAT) of the skin with the genitals, the possibility of influencing the corresponding organs through them is shown. To find BAP on the surface of girls’ bodies and have a therapeutic effect on them electric shock The ELAP-1B device is used. Both segmental and distant BAPs are used on the upper and lower limbs and on the head. The course of treatment consists of 8-10 procedures. A rapid hemostatic effect was noted in 92% of cases. The duration of corrective anti-relapse treatment is from 6 to 12 months. When studying long-term results, 74% of patients showed no relapse of the disease.

Both types of reflexology should be classified as pathogenetic methods of treating JMC, since they cause not only a hemostatic effect, but also normalize the rhythm of the menstrual cycle and contribute to the transition of anovulatory menstrual cycles to ovulatory ones. However, preference should be given to the electropuncture method as it is more physiological, quite effective and psychologically more acceptable.

Monochromatic red light of a helium-neon laser is a physiological stimulant, improves metabolic processes in tissues, activates the gonadotropic function of the pituitary gland and the maturation of follicles in the ovaries. The source of coherent monochromatic radiation is an LG-44 helium-neon laser operating in continuous mode with an output power of 3 mW. This laser affects the BAP of the skin, segmentally connected to the uterus and ovaries, as well as points of general strengthening action. During 1 session of light puncture, 6 BAT are used. The total exposure of one procedure is 3 minutes. Total energy (per 1 procedure) - 0.54 J. Treatment is carried out daily for 7-12 days.

The use of laser radiation led to normalization of hemostasis in 70% of patients, best results were achieved during bleeding during the formation of menstrual function.

3.2. Juvenile uterine bleeding

Reflexology with low-intensity laser radiation can be recommended for JMC both as an independent method and in combination with medications.

Drugs that stimulate uterine contractions and hemostatic agents used to reduce blood loss. Use a 10% calcium chloride solution intravenously or orally, cotarnine chloride 0.05 g 2-3 times a day, pituitrin or mammophysin 0.3 ml intramuscularly 2-3 times a day during bleeding.

The hemostatic effect by improving the contractility of the uterus is facilitated by the administration of adenosine triphosphoric acid, cocarboxylase, mexamine (50 mg 3 times a day, course 6-7 days). The latter drug often provides a sufficient hemostatic effect without combination with other drugs; it is not used in cases of significant hypovolemia. To reduce blood loss, they also use medicinal plants: nettle, viburnum, shepherd's purse, etc.

When frequently occurring expressed forms hemorrhagic syndrome (combined form of JMC), sufficient effectiveness is ensured by therapy, including hemostatic agents: dicinone, calcium gluconate, vitamins, uterotonics.

In severe forms of hemorrhagic syndrome, it is advisable to carry out treatment in a hematology hospital. However, sometimes there is still a need to carry out such therapy in a gynecological hospital, and therefore it should be remembered that in case of von Willebrand disease, replacement therapy with fresh frozen plasma is required at a dose of 5-10 U/kg body weight, when using cryoprecipitate - 15-25 U/kg body weight. For idiopathic thrombocytopenic purpura, glucocorticoids are indicated: prednisolone at a dose of 1 mg/kg body weight. After achieving hemostasis, such patients should be under the joint supervision of a hematologist and pediatric gynecologist.

Hormone therapy with anovulatory dysfunctional uterine bleeding, it pursues two goals during puberty: 1) stopping bleeding (hormonal hemostasis) and 2) normalizing menstrual function.

Indications for hormonal hemostasis are heavy bleeding with anemia and lack of effect from symptoms -

Chapter 3. Pathology of the reproductive system during its formation

tic therapy for moderate and prolonged bleeding. Contraindications: liver disease, hypercoagulation and rheumatism in the acute stage.

The method of hormonal hemostasis in girls can be the use of estrogen drugs or combined estrogen-gestagen drugs.

For estrogenic hemostasis, the patient is prescribed a 0.1% solution of estradiol dipropionate 1 ml intramuscularly every 3-4 hours, or folliculin 10,000-20,000 units at similar intervals, or ethinyl estradiol (microfollin) 0.1-0.2 mg/ days A decrease in the intensity of bleeding is usually observed within the first 24 hours from the start of administration of hormonal drugs, followed by a gradual cessation of bleeding. Depending on the nature of the response, the dose of estrogen is slowly reduced against the background of general restorative and antianemic treatment, after which they resort to prescribing progestin drugs for 6-8 days to obtain a menstrual-like reaction.

To stop bleeding, combined monophasic estrogen-progestin drugs are also used: Bise-Kurin, Nonovlon, Ovulene. Hemostasis is achieved by taking 2-3 tablets of the drug per day for the first 3 days (usually 1 day), after which the dose is gradually reduced to 1 tablet per day. Taking the drug at this dose continues for 15-25 days (depending on red blood counts). 2-4 days after discontinuation of the drug, a menstrual-like reaction occurs.

Carrying out hormonal treatment in teenage girls requires special care and systematic monitoring from the doctor hormonal status body at 3-6 month intervals. Doses of hormonal drugs during the formation of menstrual function should be rationally limited.

Surgery. For hemostasis and simultaneous diagnosis functional state endometrium resort to curettage of the mucous membrane of the uterine body. Research in recent years has shown the advisability of endometrial curettage not only for health reasons, but also for diagnostic purposes, especially in patients with frequent relapses of scanty long-term discharge with a disease duration of more than 2 years. Therapeutic and diagnostic curettage of the endometrium is optimal method hemostasis in case of heavy bleeding and the presence of data indicating hypothalamic disorders. It is advisable to perform endometrial curettage under hysteroscopic control.

3.2. Juvenile uterine bleeding

Juvenile uterine bleeding (JUB) is dysfunctional uterine bleeding in the juvenile (pubertal) period. From all gynecological diseases in childhood the frequency of JMC is 20%. This disease is associated with the immaturity of the hypothalamic-pituitary system, including an unsteady hourly (circhoral) rhythm of luliberin excretion. This leads to a violation of the proportion of LH and ACU. Which are secreted by the pituitary gland, often due to luteal phase deficiency or a single-phase ovarian cycle.

Symptoms of juvenile uterine bleeding

The clinical picture consists of emergence from the genital tract bleeding after there has been a delay in menstruation for a period of 14 to 16 days, as well as from 1.5 to 6 months. Such menstrual irregularities in some cases occur immediately after the onset of menarche, sometimes within the first two years.

In a third of girls they may recur. Bleeding may have exuberant character and lead to dizziness, weakness and anemia. When such bleeding lasts for several days, then a second disorder of the blood coagulation system may occur according to the type DIC syndrome, in this case the bleeding intensifies even more. Bleeding in some patients may be moderate and not accompanied by anemia, but may continue for 10 days or more. JMC do not depend on the correspondence of bone and calendar age, or the development of secondary sexual characteristics.

Treatment of juvenile uterine bleeding

Treatment of juvenile uterine bleeding is carried out in 2 stages.

Stage 1 – hemostasis.

Stage 2 – therapy, which is aimed at preventing recurrent bleeding and regulating menstruation.

When choosing a hemostasis method, the general condition of the patient and the amount of blood loss are taken into account. Patients with not very pronounced anemization, without signs of endometrial hyperplasia, undergo symptomatic hemostatic therapy. Drugs that contract the uterus and hemostatic drugs are indicated. An excellent hemostatic effect is achieved by combining such therapy with physiotherapy - the area of ​​symptomatic cervical nodes is treated with modulated sinusoidal currents, 2 procedures per day for 3-5 days, as well as electropuncture or acupuncture.

If hemostatic symptomatic therapy is ineffective, then hormonal hemostasis is performed with synthetic progestins. Gestagenic estrogen drugs are prescribed 3-4 times a day until complete hemostasis. As a rule, bleeding stops within 24 hours. Next, the dose is gradually reduced, bringing the intake to 1 tablet per day, after which this treatment lasts for 16-18 days, but so that the course takes 21 days. Menstrual-like discharge after taking gestagens-estrogens is moderate and ends within 5-6 days.

In case of heavy and prolonged bleeding, with symptoms of hypovolemia and anemia, dizziness, weakness, low hematocrit and hemoglobin, surgical hemostasis is indicated - under the control of hysteroscopy, separate diagnostic curettage is performed with a thorough histological examination of the scraping. In order to avoid ruptures, the hymen is chipped with a solution of novocaine with lidase. Patients whose blood coagulation system is impaired do not undergo separate diagnostic curettage. Hemostasis is carried out only with synthetic progestins, if necessary, glucocorticosteroids are used.

Together with surgical or conservative treatment it is necessary to carry out complete antianemic therapy. As a last resort, transfusion of blood components - red blood cells and fresh frozen plasma - is used.

Thus, during puberty, acyclic uterine bleeding may appear, caused by a violation of the secretion of ovarian sex hormones. They are called juvenile uterine bleeding.

The causes of juvenile uterine bleeding are chronic and acute infectious diseases, hypo- and avitaminosis caused by poor diet, mental trauma, as well as mental or physical fatigue experienced stressful situations. Infectious processes that contribute to the occurrence of such bleeding include tonsillitis, influenza, chronic tonsillitis, rheumatism, pneumonia and some others, since during puberty these diseases can disrupt the function of the cerebral cortex, hypothalamus, pituitary gland and ovaries. Sometimes the cause of juvenile uterine bleeding is unfavorable heredity (for example, the mother of a girl at the same age had unstable menstrual cycle disorders).

At the age of 12-18 years, juvenile uterine bleeding is a common pathology. They make up 10-12% of all gynecological diseases detected in female patients of this age category.

Juvenile uterine bleeding is caused by congestive plethora in the uterus associated with the expansion of capillaries; the development of areas of uneven rejection of the uterine mucosa or a decrease in the contractile activity of the muscular layer of the uterus when it is underdeveloped. The disease manifests itself as long-term (more than? days), heavy bleeding, quickly leading to the development of anemia. Moreover, anemia can increase especially quickly if the bleeding is provoked by the influenza virus or severe sore throat.

Anemia accompanying juvenile uterine bleeding is accompanied by weakness and lack of appetite, fatigue, headaches, pale skin and rapid heartbeat. In laboratory studies on initial stages diseases are detected in the blood increased amount platelets, therefore increasing its coagulability. In severe anemia caused by juvenile uterine bleeding, the platelet count decreases, so the clotting time is prolonged.

It should be noted that uterine bleeding during puberty usually develops after a delay of menstruation by 1.5-6 months, but may appear 14-16 days after the onset last menstrual period. Juvenile uterine bleeding can begin within 1.5-2 years after menarche against the background of a not yet established menstrual cycle.

Since juvenile uterine bleeding is characterized by changes in the blood, to clarify the diagnosis of the disease, it is necessary to exclude diseases of the blood, liver and dysfunction of the thyroid gland.

Short-term disturbances of menstrual function in adolescence usually do not require treatment, therefore, if a single occurrence of mild uterine bleeding occurs, without prescribing drug therapy, a gynecologist monitors the further nature of menstruation.

In more complex cases, treatment is carried out in 2 stages, the first of which comes down to stopping the bleeding by prescribing hormonal drugs or curettage of the uterus. Moreover, the choice of treatment is based on the general condition of the patient and the degree of blood loss. So, girls with long and heavy bleeding, complaining of weakness, dizziness, palpitations, with low blood pressure and hemoglobin, as a rule, curettage of the uterus is performed. If the manifestations of anemia are mild (the hemoglobin level in the blood does not deviate too much from the norm), then hormonal therapy is prescribed. With the help of medications, it is possible to stop bleeding on the first day of taking hormonal drugs, so their dose is quickly reduced, but treatment continues for another 15-20 days to stabilize the patient’s general condition and restore blood loss. Often prescribed hormonal drugs cause dyspeptic disorders, expressed by nausea and vomiting. In order to prevent them, it is better to take hormones prescribed by a doctor after meals along with antihistamines (such as clemastine, chloropyramine, etc.).

Modern antihistamines have fewer side effects. Particularly pleasing is the fact that, unlike antihistamines previous generations, do not cause drowsiness and do not interfere with the normal rhythm of life.

In parallel with hormone therapy, medications are prescribed that increase the level of hemoglobin in the blood, i.e., eliminating anemia and its consequences. As a rule, treatment is carried out for 15-20 days and ends with taking hormonal medications. It includes the transfusion of blood, red blood cells, blood plasma or blood substitutes to restore the clotting properties of the blood; administration of iron supplements, vitamins B12, B6, C, P, folic acid. In addition, calcium supplements (calcium gluconate) are prescribed.

Attention is also paid to the nutrition of the sick girl. Food should be easily digestible, high in calories and varied, with sufficient protein and plenty of drink in the form of fruit and vegetable juices and fruit drinks.

The essence of the second stage of treatment is to prevent recurrence of uterine bleeding. Hormone therapy is also prescribed for this purpose. As additional treatment, acupuncture, electropuncture, and laser eruption are performed.

If a girl has uterine bleeding, then the mother must show her to the doctor, as they lead to anemia and serious consequences for the heart, blood, brain and, of course, genitals. Girls under the supervision of a gynecologist for juvenile uterine bleeding and receiving preventive treatment, are not exempt from physical education in educational institutions, because an active lifestyle, including gymnastics, swimming, running, skiing or skating, affects restorative effect on a young body.