Treatment of uterine bleeding

Uterine bleeding is the discharge of blood from the vagina, characterized by abundance and duration. This pathological condition poses a danger to the life and health of a woman and is a sign of serious diseases of the reproductive system. To save the patient, it is important to immediately provide her with first aid and find out the cause of the bleeding. Natural bleeding from the vagina is called menstruation. Menstrual bleeding is characterized by cyclicity and repeats at regular intervals. The period between menstruation usually lasts 25–30 days. Blood from the vagina should not be released longer than 8 days, otherwise we can talk about pathology. Menstrual irregularities are a reason to immediately consult a gynecologist. The doctor will find out the cause of the pathological phenomenon and help get rid of the disease at an early stage, before complications arise.

Causes of uterine bleeding

The likelihood of uterine bleeding depends on the age of the patient. In girls from 12 to 18 years old, copious discharge of blood from the vagina is a consequence of hormonal imbalance. And hormonal imbalances at a young age arise due to:

physical injury or emotional distress;
deterioration of the functioning of the endocrine glands;
poor nutrition, deficiency of vitamins in the body;
pregnancy with complications, difficult childbirth;
genital tuberculosis;
bleeding disorders;
suffered severe infectious diseases.

In mature women, uterine bleeding is a rare occurrence, usually associated with impaired ovarian function. In this case, the provocateurs of the pathological condition are:

stress, overwork, nervous tension, mental disorders;
uterine fibroids;
endometriosis;
advanced endometritis;
uterine polyps;
oncology of the uterus or cervix;
tumor formations in the ovaries;
ectopic pregnancy, miscarriage, medical or instrumental abortion;
infectious diseases of the reproductive organs;
climate change, unfavorable environmental situation in the place of residence, harmful working conditions;
taking medications that can disrupt the systemic functioning of the hypothalamus and pituitary gland.

Uterine bleeding is often observed in women during menopause. This is due to a decrease in the synthesis of gonadotropin by the pituitary gland. As a result, the level of sex hormones in the female body begins to jump, the menstrual cycle is disrupted, and the formation of follicles in the ovaries is disrupted. Frequent causes of bleeding from the uterus at the age of decline of reproductive function are:

Diagnosis of the causes of menorrhagia and metrorrhagia

The gynecologist determines the cause of bleeding based on test results and ultrasound.

A gynecological examination in a chair will show whether there is prolapse of the genital organs, neoplasms or erosion on the cervix. During pregnancy, cervical insufficiency is clearly visible. Also, already at this stage, injuries from the spiral, after sexual intercourse, etc. are visible;
Colposcopy. A gynecologist conducts an examination with a device equipped with magnifying glasses. Using a colposcope, internal pathologies of the cervix are identified, and the nature and stage of erosion is determined.
An ultrasound of the uterus will determine whether there are injuries, neoplasms, or inflammation of the female internal organs.
Smears for microflora and cytology show STI infections (STDs), precancerous conditions, and cancer.
A blood test for hormones will determine whether there is a hormonal imbalance.

If this is not enough, you will have to undergo an MRI (tomography) to obtain images of the organs in 3D format at high magnification.

Symptoms of uterine bleeding

weakness;
fainting;
dizziness;
nausea;
paleness of the skin;
cardiac tachycardia;
lowering blood pressure.

copious bleeding from the vagina;
presence of clots in blood discharge;
change the pad every 2 hours, even more often;
duration of bleeding more than 8 days;
increased bleeding after sexual intercourse;
painless bleeding when the pathology is of dysfunctional origin;
discrepancy between the onset of bleeding and the period of menstruation.

The duration of menstruation normally does not exceed 8 days, and bleeding that persists longer than normal is pathological. Vaginal bleeding should be considered unhealthy if the period between which is less than 21 days. During menstruation, 80–120 ml of blood flows per day; with uterine bleeding, the daily blood volume is more than 120 ml.

Heavy periods: when to take hemostatic pills

Hemostatic tablets for heavy periods help cope with large amounts of discharge. However, you should not self-medicate; only a doctor can select the appropriate drug.

Read the popular article on the site: Menopause in women: symptoms, age-related characteristics, treatment with effective methods.

The menstrual cycle without pathological abnormalities should last no more than 7 days , and the amount of discharge should not exceed 80 ml per day. Anything that is released in excess of the norm is considered heavy menstruation.

Hemostatic pills for heavy periods - we will look at the best ones below

You can check the norm by the number of hygiene products used. It is necessary to change the pad 2-3 times a day; if this number increases and the hygiene product is changed every 2 hours, then we are talking about a deviation from the norm and the occurrence of heavy discharge.

Heavy periods are dangerous for a woman; the reasons for their occurrence may be associated with hormonal disorders and stress.

Therefore, it is necessary to take a hemostatic drug.

It is important to know! Medications for this purpose are selected taking into account the individual characteristics of the woman, which can only be done by a specialist. Self-medication can cause the condition to worsen.

Types of uterine bleeding

Bleeding from the uterus, depending on the age of the patient, is divided into five types.

During infancy. In the first week of life, a newborn girl may experience slight bleeding from the vagina. This is not a pathological phenomenon; the child does not require medical intervention. Infant bleeding is caused by a sharp change in hormonal levels in a newborn girl and disappears on its own.
During the period before puberty. During this period, vaginal bleeding in girls is rare. The cause of the pathological condition is most often a hormone-dependent ovarian tumor, due to which the gonad synthesizes too many hormones. As a result, the girl experiences false maturation of the reproductive system.
During puberty. Uterine bleeding during puberty, which occurs between 12 and 18 years of age, is called juvenile bleeding.
During the reproductive period. Bleeding from the uterus, observed between 18 and 45 years, can be organic, dysfunctional, breakthrough, or caused by pregnancy and childbirth.
During menopause. During the period of decline of reproductive function, bleeding from the vagina is most often associated with pathologies of the genital organs or with a decrease in the synthesis of hormones.

Dysfunctional bleeding

This type of uterine bleeding observed during the reproductive period is the most common. The pathological condition is diagnosed in both girls and older women during menopause. The cause of dysfunctional bleeding is a failure in the synthesis of sex hormones by the endocrine glands. The endocrine system, including the pituitary gland, hypothalamus, ovaries and adrenal glands, controls the production of sex hormones. If the operation of this complex system malfunctions, the menstrual cycle is disrupted, the duration and abundance of menstruation changes, and the likelihood of infertility and spontaneous abortion increases. Therefore, if there are any changes in the menstrual cycle, you should immediately contact a gynecologist. Dysfunctional uterine bleeding can be ovulatory or anovulatory. Ovulatory bleeding is manifested by a change in the duration and abundance of blood discharge during menstruation. Anovulatory bleeding is observed more often and is caused by the lack of ovulation due to impaired synthesis of sex hormones.

Organic bleeding

Such bleeding is caused either by severe pathologies of the reproductive organs, or by blood diseases, or by serious disturbances in the functioning of internal organs.

Breakthrough bleeding

Such uterine bleeding is also called iatrogenic. They are diagnosed after exceeding the dosage and course of taking certain medications, frequent use of hormonal contraceptives, as well as after surgery to install an IUD and after other surgical manipulations on the organs of the reproductive system. When taking hormonal medications, scanty bleeding is usually observed, which means that the body is adapting to synthetic hormones. In this situation, it is recommended to consult a doctor about changing the dosage of the medication. In most cases, with breakthrough bleeding, gynecologists advise patients to increase the dosage of the hormonal drug for a certain time. If after this measure the amount of blood released does not decrease, but increases, then you need to urgently undergo a medical examination. In this case, the cause of the pathological condition may be a serious disease of the reproductive system. If uterine bleeding occurs after the installation of the IUD, then the contraceptive device most likely injured the walls of the uterus. In this situation, you should immediately remove the IUD and wait for the uterine walls to heal.

Bleeding due to pregnancy and childbirth

In the first months of pregnancy, bleeding from the uterus is a sign of either a threatened spontaneous abortion or an ectopic fetus. In these pathological conditions, severe pain in the lower abdomen is noted. A pregnant woman who has started uterine bleeding should immediately consult a supervising doctor. If a spontaneous abortion begins, the fetus can be saved if proper treatment is started in time. In the last stages of a miscarriage, you will have to say goodbye to the pregnancy; in this case, curettage is prescribed. With an ectopic pregnancy, the embryo develops in the fallopian tube or cervix. Menstruation is delayed, some symptoms of pregnancy are noted, but no embryo is found in the uterus. When the embryo reaches a certain stage of development, bleeding occurs. In this situation, the woman requires urgent medical attention.

In the third trimester of pregnancy, uterine bleeding is deadly for both the mother and the developing child in the womb.

The causes of the pathological condition in the late stages of gestation are placental previa or placental abruption, rupture of the uterine walls. In these cases, the woman urgently needs medical attention; a caesarean section is usually performed. Patients who are at high risk of the above pathologies should be kept in conservatory care. Uterine bleeding can also occur during childbirth. In this case, its causes may be the following pathological conditions:

placenta previa;
blood clotting disorder;
low contractility of the uterus;
placental abruption;
afterbirth stuck in the uterus.

If bleeding from the uterus occurs a few days after birth, you should immediately call an ambulance. The young mother will require emergency hospitalization.

Danger

Dysfunctional uterine bleeding is not a harmless disease. During the juvenile period it can lead to:

anemia;
hormonal disorders;
infertility;
endometriosis.

In women of reproductive age, the disease can be caused by:

infertility;
anemia;
endometrial cancer, breast cancer;
fibrocystic mastopathy;
uterine fibroids.

In premenopausal and menopausal patients, dysfunctional uterine bleeding can cause anemia, cancer, and also cause the growth of existing tumors into neighboring organs. from a gynecology clinic at the first symptoms of the disease.

First emergency aid before doctors arrive

Heavy bleeding from the vagina must be stopped or at least reduced before doctors arrive. This is a matter of life and death for a woman. In most cases, with proper first aid, bleeding stops, but in 15% of cases the pathological process ends in death.

Every woman should know how to help herself before the doctors arrive, what she can do and what she can’t do.

A sick woman, while waiting for doctors at home, should do the following:

lie on your back, remove the pillow from under your head;
place a high cushion made of towels or a blanket under your shins;
Place a cold water bottle or an ice-filled heating pad on your stomach;
drink cold still water.

It is strictly prohibited:

be in a standing and sitting position;
lie with your legs pressed to your stomach;
take a hot bath;
do douching;
put a heating pad on your stomach;
drink hot drinks;
take any medications.

Hemostatic drugs for nosebleeds

To stop nosebleeds of various etiologies, packing should be done. For these purposes, a gauze, foam rubber or pneumatic base can be used. Hemostatic medications previously applied to the tampon will help enhance the effect. Such drugs are:

Etamsylate;
Dicynone;
Epsilon-aminocaproic acid;
Calcium chloride;
Vikasol.

The most common cause of nosebleeds is arterial hypertension, so it is important to ensure a rapid hypotensive effect. It involves lowering blood pressure through medication. Drugs that are designed for long-term use are not suitable for emergency treatment of nosebleeds.

Drug therapy

Treatment of diseases that cause bleeding from the uterus is carried out in a hospital setting. Additionally, the doctor prescribes medications to the patient to help stop bleeding. Hemostatic medications are taken only on the recommendation of a medical specialist; taking medications at your own discretion is strictly prohibited. Below is a list of medications most commonly used to stop bleeding.

Etamzilat . This drug stimulates the synthesis of thromboplastin and changes the permeability of blood vessels. Blood clotting increases, resulting in decreased bleeding. The medication is intended for intramuscular injection.
Oxytocin . A hormonal drug often used during childbirth to improve uterine contractility. As a result of contraction of the uterine muscles, bleeding stops. The drug oxytocin is prescribed for intravenous administration with the addition of glucose and has a large list of contraindications.
Aminocaproic acid . This medicinal substance prevents blood clots from dissolving under the influence of certain factors, thereby reducing bleeding. The medicine is either taken orally or administered intravenously. Treatment of uterine bleeding with aminocaproic acid is carried out under close medical supervision.
Vikasol . The drug is based on vitamin K. With a deficiency of this vitamin in the body, blood clotting worsens. The medication is prescribed to patients who have a tendency to uterine bleeding. However, vitamin K begins to act only 10–12 hours after entering the body, so it is not advisable to use the drug to stop bleeding in emergency cases.
Calcium gluconate . The drug is prescribed for calcium deficiency in the body. Deficiency increases the permeability of vascular walls and impairs blood clotting. This medicine is also not suitable for use in emergency cases, but is used to strengthen blood vessels in patients prone to bleeding.

Types of hemostatic drugs

The range of hemostatic agents used in medicine is very wide. Modern hemostatic agents are divided into two main groups: resorptive and local action.

Resorptive drugs - the effect occurs when they enter the blood, these include specific and nonspecific hemostatic agents. Local agents - in direct contact with bleeding tissues, they are divided into mechanical, thermal and chemical drugs.

There are three types of chemical hemostatic agents:

Vasoconstrictors - narrow blood vessels and reduce blood flow.
Procoagulants - increase blood clotting.
Hygroscopic - allow you to “seal” a damaged vessel.

Combination preparations, fibrin glue, gelatin plates and collagen films, and cellulose are mainly used as chemical local hemostatic agents.

Treatment with folk remedies

To stop and prevent uterine bleeding, you can use decoctions and infusions of medicinal plants. The most popular and effective folk recipes for stopping bleeding are listed below.

Infusion of yarrow . You need to take 2 teaspoons of dried plant material and pour a glass of boiling water. The solution is infused for about an hour, then filtered. The infusion is taken a quarter glass 4 times a day before meals.
Nettle decoction . Take a tablespoon of dried nettle leaves and pour a glass of boiling water. The solution is simmered over low heat for 10 minutes, then filtered. The prepared decoction is taken one tablespoon 3 times a day before meals.
Infusion of shepherd's purse . Take a tablespoon of dried plant material and pour a glass of boiling water. The container with the solution is wrapped in a warm towel and left for an hour to infuse. The finished infusion is filtered and taken a tablespoon 3 times a day before meals.

It must be remembered that folk remedies cannot be a complete replacement for medications; they are used only as an addition to the main therapy. Before using herbal remedies, you should definitely consult a medical specialist to exclude intolerance to the medicinal plant and other contraindications.

Who is at risk?

Basically, diseases that lead to bleeding are observed in adults. Moreover, according to statistics, men are 2 times more likely than women to be diagnosed with problems with the gastrointestinal tract - the stomach, duodenum. As we noted above, ulcerative pathologies hold first place in terms of the number of diseases. The peak age for diseases is 40-45 years.

However, the problem is not limited to adults. The diagnosis associated with ulcerative lesions of the gastrointestinal tract is often made to adolescents who uncontrollably consume junk food and drinks. Cases of the formation of intestinal polyps are also common.

Gastric and intestinal bleeding is increasingly being detected even in newborns. Basically, they are caused by intestinal volvulus. In 3-year-old children, leakage can be caused by the formation of a diaphragmatic hernia, as well as abnormalities in the development of the organs of the lower gastrointestinal tract.

Ways to stop blood loss

For any bleeding, even minor bleeding, the woman should be examined by a gynecologist. A specialist doctor will order an examination to determine the cause. If the doctor considers home treatment possible, he will prescribe suitable hemostatic agents. It is necessary to follow the dosage and take the medications correctly.

With significant blood loss, there is a threat to the woman’s life. Hospitalization is mandatory.

Applicable:

intravenous drip medications;
fresh frozen plasma, red blood cells;
curettage (removal of the inner layer of mucosa).

Sometimes the only possible help is removal of the uterus.

What symptoms to look out for

Patients with the diagnoses we listed above should be especially monitored for the appearance of alarming symptoms. If you are taking medications for the liver and gastrointestinal tract, carefully monitor your well-being. If you are concerned about the changes discussed below, consult your doctor. However, knowing these signs is useful for every person, since many diseases of the lower and upper gastrointestinal tract develop without obvious painful sensations. Often their first manifestation may be the symptoms of bleeding.

Weakness

This is the main sign of any prolonged bleeding. Weakness gradually increases, the patient's skin turns pale, he feels cold sweat, a ringing in the ears, and trembling of the limbs. The weakened state may last for several minutes, after which it passes and returns periodically. If blood is bleeding actively, fainting or semi-fainting and even shock are possible.

Vomit

This symptom accompanies severe blood loss - more than 0.5 liters. If the vomit is dark cherry in color, it is most likely coming from a vein near the esophagus. If unchanged blood is clearly visible in the vomit, the integrity of the artery in the esophagus is most likely compromised. If the patient vomits so-called “coffee grounds” of brown color, the problem lies in the gastric vessels. Only a doctor can accurately determine the nature, location and intensity of blood loss.

Chair

Traces of blood in the stool may appear within a few hours or 1-2 days after the integrity of the blood vessels is damaged. With significant problems with the stomach or duodenum, as well as blood loss in a volume of more than 0.5 liters, you can observe melena - loose stools that resemble tar in color and consistency. If the blood loss is smaller, which often happens, for example, with intestinal bleeding, then the stool remains formed, but its color darkens.

Please note that darkening of the stool can occur due to eating foods that contain dark coloring substances, for example, blueberries and cherries. Dark stools are not an absolute sign of the presence of blood in the stool and problems in the upper or lower gastrointestinal tract. The diagnosis can only be made by a qualified specialist.

How to make a diagnosis

The doctor examines the patient, assessing his external condition, the shade of the skin and mucous membranes. Then he measures blood pressure - often it is low.

In the clinic, the patient undergoes a general blood test. Using it you can quickly get an idea of the level of hemoglobin and the volume of other blood cells. Additionally, the diagnosis is made by biochemical analysis, but it is usually prescribed several days after the onset of blood loss, since the chemical composition of the blood changes only over time.

The main diagnosis concerns the detection of the very cause of the violation of the integrity of blood vessels. To do this, doctors use the following hardware examinations.

Endoscopy - examination of the esophagus, stomach, duodenum using a flexible tube with a miniature camera allows you to quickly detect a problem area;
Contrast radiography - an effective method for detecting bleeding in the gastrointestinal tract involves injecting a safe contrast solution into the organ, followed by an X-ray;
Magnetic resonance imaging is a modern method that allows you to obtain comprehensive information about the condition of all tissues of a particular organ of the gastrointestinal tract.

The issues of the effectiveness of therapy for uterine bleeding during puberty (UMB), prevention of recurrence and restoration of normal menstrual, and subsequently reproductive functions, are extremely relevant.

Despite many years of close attention of doctors to this problem, some subtle mechanisms of the pathogenesis of manual transmission, questions about the clinical and pathogenetic definition of manual transmission, namely the primacy and severity of changes in the hemostatic system, and the characteristics of the state of various parts of the reproductive system at different stages of the disease remain unspecified. .

Probably, these circumstances lead to the fact that researchers give different statistics on the frequency of manual transmission both in the population and in the structure of gynecological morbidity (from 2.5 to 30.0%).

By definition, true MCPPs are dysfunctional MCs that arise during the formation of menstrual function in the absence of anatomical changes in the reproductive system caused by the presence of organic diseases or developmental anomalies, as well as systemic diseases - blood diseases.

Etiology of manual transmission

Etiological factors predisposing to the appearance of manual transmission are not specific.

Factors contributing to the emergence of dysfunctional MCs include:

unfavorable course of the perinatal period (threat of miscarriage, gestosis, inflammatory diseases of the mother during pregnancy, leading to fetoplacental insufficiency and intrauterine hypoxia of the fetus, complications during childbirth, birth injuries, which may result in hemorrhages in the brain structure, posthypoxic encephalopathy, intracranial hypertension);
chronic and acute severe infectious diseases in childhood (chronic tonsillogenic infection, acute purulent-inflammatory diseases of the ENT organs, acute viral neuroinfections);
chronic somatic diseases (chronic diseases of the liver, gastrointestinal tract, kidney disease and cardiovascular system);
dysfunction of the endocrine glands (thyroid gland);
childhood and actual psychogenic disorders (unfavorable psychological climate in the family or school, loss of relatives, change of place of residence, excessive mental stress - parallel studies in several schools);
hypovitaminosis, nutritional factors (with poor or poor nutrition, helminthic infestations, diseases of the gastrointestinal tract, dysbacteriosis);
harmful environmental factors (living in an environmentally unfavorable area);
bad habits (smoking, drinking alcohol);
dysfunction of the immune system, including those accompanied by the development of autoimmune diseases (polyvalent allergies, bronchial asthma, neurodermatitis, psoriasis);
congenital connective tissue dysplasia.

Any pathological influence on the mechanisms of neurohumoral regulation of menstrual function can contribute to the appearance of MMPP. Of the listed etiological factors, some are rare and even very rare, while others occur to varying degrees of severity in almost all patients.

These most significant etiological factors include the unfavorable course of the perinatal period, acute and chronic inflammatory diseases of the ENT organs, autoimmune dysfunctions (which in turn are most often a consequence of perinatal hazards and previous inflammatory diseases), congenital connective tissue dysplasia, and psychotraumatic factors.

Pathogenesis of manual transmission

The pathogenesis of MCPP is based on disturbances in the normal rhythm of secretion of hypothalamic, pituitary and ovarian hormones against the background of failure of the neuroreceptor apparatus of various parts of the reproductive system during the period of its age-related functional immaturity. In the vast majority of cases, MCPP are anovulatory and occur against the background of persistence or atresia of immature follicles.

Often (83–85%) in girls with manual transmission, changes in the structure of the endometrium are detected, which are characterized as hyperplasia. However, the appearance of hyperplastic changes in the endometrium is generally not associated with true, absolute hyperestrogenism (the level of estrogen in the blood plasma usually corresponds to average normative values or is even reduced). Endometrial hyperplasia in patients with manual transmission is a so-called phenomenon. relative hyperestrogenism. Namely, with a low level of estrogen in the blood plasma and with progesterone deficiency caused by anovulation, the ratio of epithelial and mesenchymal elements in the structure of the endometrium is disrupted, which is histologically characterized as hyperplasia. These changes are associated with disturbances in hormonal homeostasis and are aggravated by an inadequate response of the uterus as a target organ to stimulation with sex steroids.

The immediate trigger for bleeding is fluctuations in the level of sex hormones, leading to disruption of the blood supply to the endometrium, the appearance of foci of congestive plethora, ischemia, hypoxia, necrosis and its uneven rejection.

The previously listed etiological factors contribute to disruption of the neurohumoral regulation of the menstrual cycle (MC) and the development of bleeding through a combination of a number of mechanisms.

The primary factors in the genesis of manual transmission are certainly disturbances of hormonal homeostasis. However, they are aggravated by age-related failure of the neuroreceptor apparatus of the uterus, as well as very often by low contractile activity of the myometrium, functional failure of the hemostatic system, caused by congenital mesenchymal failure. A detailed examination of most girls, especially with recurrent MCPP, reveals clinical symptoms of congenital connective tissue dysplasia in various combinations: juvenile osteochondrosis and postural disorders, joint hypermobility, increased skin extensibility, venous insufficiency, mitral valve prolapse, accessory chord of the left ventricle, nephroptosis, deformity gallbladder, biliary dyskinesia, visual impairment, etc.

Hormonal homeostasis in manual transmission does not have clearly specific features; it can have different options, depending on menstrual age and duration of the disease. The levels of follicle-stimulating (FSH) and luteinizing (LH) hormones are often within the normative range, but there are disturbances in the LH/FSH ratio: at the first stage of the disease there may be a tendency to activate the gonadotropic function of the pituitary gland; with recurrent bleeding there is a tendency to decrease gonadotropic function. Prolactin levels are often normal. In 15% of cases, there may be transient hyperprolactinemia (not requiring specific therapy with dopamine agonists).

Sex steroid levels correspond to the following indicators:

estradiol often corresponds to the average values of the mid-follicular phase;
progesterone corresponds to the indicators of the follicular phase or slightly exceeds the normative indicators for the follicular phase (always lower than the indicators for the luteal phase of normal ovulatory MC);
testosterone, androstenedione, dehydroepiandrosterone are normal.

Features of hormonal homeostasis determine the choice of both hemostatic and corrective hormonal therapy. Namely, the use of only gestagens for the purpose of hemostasis or in a cyclic mode for the correction of MC in patients with manual transmission is usually not enough (estrogen-containing drugs are indicated).

Clinical symptoms

Manual transmission, often acyclic (rarely cyclic), can be plentiful, but can also be scanty, such as “bleeding”, lasting up to 1.0–1.5 months or more, and sometimes erratic (scanty, such as “blooding” with periodic cessation of bleeding for several days or their intensification to heavy doses).

The clinical symptoms of manual transmission have their own characteristics at different stages of the disease and depend on the presence and severity of complications, as well as concomitant pathology.

On this basis, the following clinical forms of manual transmission can be distinguished:

Uncomplicated form - MK is the main or even the only clinical symptom, there is no posthemorrhagic anemia, secondary pathological changes in the hemostatic system and the reproductive system.
Complicated forms are characterized by the presence of posthemorrhagic anemia, hypoxemia; secondary bacterial endomyometritis; secondary disorders in the hemostasis system (consumptive thrombocytopenia; changes in hemocoagulation, fibrinolysis, disorders of intrauterine hemostasis; latent protracted chronic forms of DIC [disseminated intravascular coagulation syndrome]).
The combined form is characterized by the appearance of urticaria in girls with irregular urinary tract in combination with diseases of the hemostatic system and specific inflammatory diseases of the reproductive system.

Differential diagnosis

Differential diagnosis of MCPP, especially recurrent ones, is carried out with a number of diseases in which MC may appear, such as primary defects in the hemostatic system, thrombocytopenia, thrombasthenia, aplastic anemia, hereditary disorders of coagulation hemostasis (von Willebrand disease, hemophilia C, etc.), hemorrhagic vasculitis . In these cases, MK are one of the clinical symptoms of hemorrhagic syndrome.

The clinical feature of MC as a symptom of hemorrhagic syndrome is the preservation of regular MC, the presence of clinical manifestations of hemorrhagic syndrome (bleeding of other localization). In such cases, urticaria often appears with menarche, less often with the second or third menstruation and is of the nature of menorrhagia or hyperpolymenorrhea. The appearance of MC in girls suffering from blood diseases against the background of MC disorders indicates their combined genesis. The presence of defects in the hemostatic system is confirmed (or excluded) by anamnesis data, clinical symptoms of hemorrhagic syndrome, and the results of a hemostasiological study.

MK can be a symptom of organic diseases of the reproductive system, such as anomalies of its development, genital infantilism, genital endometriosis (adenomyosis), hormone-producing ovarian tumors, tumors and tumor-like diseases of the vagina, cervix and uterine body. The presence of organic changes in the reproductive system is confirmed (or excluded) by data from a gynecological examination (including vaginoscopy), colposcopy, and ultrasound examination of the pelvic organs; results of hormonal examination; laparoscopic examination data (only according to indications – if organic diseases of the pelvic organs are suspected).

Inflammatory diseases of the reproductive system (such as genital tuberculosis, gonorrhea, colpitis of viral or mixed origin) may also be accompanied by the appearance of bloody discharge from the genital tract.

The presence of specific inflammatory diseases of the reproductive system is confirmed (or excluded) by data from bacterioscopic, bacteriological, serological, and cultural research methods. Traumatic injuries to the reproductive system (the appearance of which is possible during coitus, masturbation using various objects, injuries) are confirmed (or excluded) by data from a gynecological examination, including vaginoscopy, and anamnesis data.

Data from a pregnancy test, gynecological examination and pelvic ultrasound make it possible to exclude or confirm the presence of a pregnancy complicated by a miscarriage.

The presence of concomitant neurological symptoms, especially with persistently recurrent bleeding, is an indication to exclude organic lesions of the central nervous system (tumors of the pituitary gland, hypothalamus, etc.).

A comprehensive examination includes an X-ray of the skull, magnetic resonance imaging, echoencephalography, electroencephalography, Doppler ultrasound of the vessels of the head and neck, and possibly additional hormonal testing (if organic changes in the central nervous system are suspected based on the results of a previous examination).

The combined genesis of urticaria (dysfunctional bleeding due to primary defects of hemostasis, specific inflammatory diseases of the reproductive system) is confirmed (or excluded) by anamnesis data, features of clinical symptoms, results of hemostasiological, gynecological examination, results of examination for specific inflammatory diseases.

Treatment of patients with manual transmission

Treatment of patients with manual transmission can be divided into two stages: the first - hemostatic therapy during the period of bleeding and the second stage - prevention of recurrent bleeding, normalization of the function of the hypothalamic-pituitary-ovarian system.

Hemostatic therapy during bleeding includes the following measures:

provision of medical and protective regime;
non-hormonal hemostatic therapy (uterotonic drugs; drugs that increase the contractile activity of the myometrium, vitamin therapy, stimulation of blood coagulation potential, phyto-, reflexology, physiotherapy);
hormonal hemostatic therapy: hemostasis is most often carried out with combined estrogen-progestogen drugs; hemostasis with pure gestagens is possible with scanty bleeding, sufficient proliferative changes in the endometrium, or if endometrial hyperplasia is suspected according to ultrasound data;
surgical hemostasis - diagnostic curettage.

In case of a complicated course of manual transmission, antianemic and anti-inflammatory therapy (antibacterial, detoxification) is additionally prescribed, and post-hemorrhagic coagulopathies are prevented and treated. In case of MCPP of combined genesis, hemostasis correction of primary hemorrhagic disorders is carried out, and in case of specific inflammatory diseases, appropriate antibacterial therapy is carried out.

Creating a therapeutic and protective regime includes conducting a psychotherapeutic conversation, removing physical and mental stress, normalizing the sleep-wake schedule, prescribing a rational diet, sedatives (tincture or decoction of valerian root, motherwort, peony, bromine preparations). Hospitalization is indicated for patients with a complicated course of manual transmission.

Non-hormonal hemostatic therapy

All patients with manual transmission are prescribed non-hormonal hemostatic therapy, which, if effective, is carried out for 5–7 days. Uterotonic drugs: oxytocin, hyfotocin or others, administered intramuscularly at 0.5-1.0 ml 2-4 times a day or less often intravenously in a 5-10% glucose solution.

Drugs that increase the contractile activity of the myometrium are used: ATP (1%, 1.0 ml intramuscularly 1 time per day), co-carboxylase (50–100 mg intramuscularly 1 time per day), mexamine (50 mg 3 times per day) , 10% calcium chloride solution (10 ml intravenously or 1 tablespoon 3 times a day) or 10% calcium gluconate solution (intravenously or 0.5 g 3 times a day).

Vitamin therapy is carried out: ascorbic acid (0.1 g 3 times a day or a 5% solution of 3–5 ml intramuscularly or intravenously), rutoside or Ascorutin (1 tablet 3 times a day), vitamin E (100– 200 mg/day), vitamin B1 (2–5 mg/day), vitamin B6 (2 mg/day), vitamin B12 (100 mcg intramuscularly for no more than 5–7 days), vitamin K (1.0 ml intramuscularly or 1 tablet 3 times/day for no more than 3 days).

Stimulation of the coagulation potential of the blood is carried out using tranexamic acid (250-500 mg 2-3 times a day), ACC (5% solution 20 ml orally 3-5 times a day), etamsylate (2.0 ml intramuscularly 1–2 times a day or 1–2 tablets 2–3 times a day), adrenochrome monosemicarbazone (0.025% solution 1.0 ml intramuscularly or intravenously 1–2 times a day), aminomethylbenzoic acid (1 tablet 3 times a day), diclofenac (1 suppository rectally 1 time a day) or mefenamic acid (500 mg 3 times a day).

Herbal medicine includes lagochilus, nettle (fresh), mountain arnica, parva sedge, shepherd's purse, yarrow, burnet, horsetail, snake knotweed, wild strawberry, cinquefoil erect, viburnum bark, water pepper, cat's paws, corn silk, etc. There are ready-made hemostatic charges.

The following methods of reflexology are used: electropuncture (ELAP-1B device according to the method of N.V. Kobozeva, P.N. Krotin), acupuncture, exposure to reflexogenic zones with monochromatic laser light.

Physiotherapy consists of electrical stimulation of the cervix (according to the method of N.V. Kobozeva, N.I. Egorova), solar plexus diathermy, magnetic therapy, endonasal or nuchal electrophoresis with calcium, endonasal electrophoresis of vitamin B1.

If non-hormonal hemostatic therapy does not have an effect, hormonal therapy may be prescribed in combination with hepatoprotectors, choleretic and cholesterol-lowering drugs.

Hormonal hemostatic therapy

Indications for hormonal hemostatic therapy are:

complicated form of manual transmission: continued heavy bleeding and the presence of anemia (decrease in hemoglobin level to 100–90 g/l, hematocrit to 30–25%) or the presence of bacterial endomyometritis;
lack of effect from non-hormonal hemostatic therapy for 7 days (even if the bleeding is scanty and there is no anemia);
combined form of manual transmission (for underlying diseases of the hemostatic system);
recurrent manual transmission;
signs of hyperplastic changes in the endometrium, according to ultrasound (endometrium larger than 12 mm), the presence of fluid inclusions in the ovaries with a diameter greater than 25 mm (according to ultrasound), the presence of pronounced polycystic changes in the ovaries, according to ultrasound (ovarian dimensions greater than 35 × 30 mm with many follicles with a diameter of 7–8 mm or more).

Contraindications to hormonal therapy are:

the presence of hypercoagulation, according to hemostasiological studies. If it is impossible to conduct such a study at the first stage, you can focus on the clotting time (according to Lee-White) and the duration of bleeding (from the earlobe);
severe liver dysfunction (acute or chronic persistent hepatitis);
rheumatism, active phase.

Hormonal drugs are prescribed with caution for Gilbert's disease, idiopathic hypercholesterolemia and biliary dyskinesia.

The drugs of choice for hormonal hemostatic therapy are combined estrogen-progestogen monophasic low-dose contraceptives. On the first day, the drugs are usually prescribed 1-3 tablets every 1-3 hours. After obtaining a hemostatic effect, the dose of hormonal drugs is reduced by no more than a third per day; The maintenance dose of hormonal drugs should be at least 1 tablet per day. The total duration of the course of hemostatic therapy can be from 6 to 21 days, the course dose is at least 10 tablets.

An approximate scheme of hormonal hemostatic therapy for heavy bleeding may include the following measures:

Regulon or Marvelon (desogestrel + ethinyl estradiol) or Microgynon or Rigevidon (levonorgestrel + ethinyl estradiol), etc., 1 tablet every 1–1.5–2 hours under the tongue (from 3 to 6 tablets per day);
dynamic observation;
with a significant decrease in bleeding, the final daily dose is determined.

For scanty bleeding, the drugs are prescribed 1 tablet 1-2 times a day.

At the first stage, with heavy bleeding and increasing anemia, high-dose drugs containing 50 mcg of ethinyl estradiol (for example, Ovidone in a dose of up to 4 tablets per day) can be used. However, it should be borne in mind that the use of low-dose drugs provides more opportunities for individual selection of the required dose of the drug to obtain a hemostatic effect with minimal side effects.

The duration of courses of hormonal hemostatic therapy is up to 21 days for severe anemia; with “thin” endometrium before the start of therapy (endometrium up to 7 mm according to ultrasound) – up to 21 days; if hyperplastic changes in the endometrium are suspected according to ultrasound data - from 10 to 6 days; in the presence of single large fluid inclusions or polycystic changes in the ovaries - from 10 to 21 days.

Progestational hemostasis can be used only in cases of scanty bleeding (such as bleeding). Heavy or even moderate bright spotting and the presence of anemia are contraindications for progestational hemostasis due to the risk of increased bleeding. Duphaston (dydrogesterone) is usually prescribed at a dose of 10 mg/day for 10 days (or Norkolut - norethisterone).

For the period of menstrual-like bleeding after a course of hormonal therapy, symptomatic hemostatic therapy is prescribed: herbal medicine, tranexamic acid 250 mg 2 times a day, vitamin therapy (Ascorutin 1 tablet 3 times a day), calcium gluconate 1 tablet 3 times a day, sodium ethamsylate 1 tablet 2-3 times a day.

Surgical hemostasis

Surgical hemostasis - diagnostic curettage, is rarely performed, only according to strict indications: continued heavy bleeding with increasing anemia (decrease in hemoglobin level below 90-70 g/l and hematocrit below 25%), lack of effect from complex conservative hemostatic therapy, recurrence of MMPP and suspicion of pronounced organic changes in the endometrium (polyps, endometrial polyposis).

The issue of expanding the indications for diagnostic curettage in manual transmission remains controversial to this day. Many years of experience in the pediatric and adolescent gynecology service in St. Petersburg indicate the sufficient effectiveness of complex conservative hemostatic therapy, which makes it possible in the vast majority of cases not to use surgical hemostasis. Diagnostic curettage must be performed in a hospital setting under general anesthesia, using hysteroscopy if possible. The use of vacuum aspiration is irrational. Control diagnostic curettage is performed only in the presence of adenomatosis, adenomatous polyps or atypical hyperplasia, according to the previous examination. Control diagnostic curettage is performed after 2–3 courses of corrective hormonal therapy on the 24–26th day of MC.

Antianemic therapy and assessment of blood loss volume

The volume of antianemic therapy depends on the degree of anemia in patients with manual transmission. For mild anemia (hemoglobin 100 g/l or more, red blood cell count 3 million or more), infusion therapy is not performed. To stimulate hematopoiesis, iron preparations are prescribed (Totema - iron gluconate 1 ampoule 1-4 times a day, Ferlatum or Ferlatum Fol - iron protein succinylate 1 bottle per day, Maltofer - iron [III]hydroxide polymaltosate 1 tablet per day, Sorbifer Durules - iron sulfate + ascorbic acid, 1 tablet per day, Ferrum Lek - iron [III]-hydroxide polyisomaltose, 1 tablet 2-3 times a day, etc.) and vitamin therapy. It should be remembered that with recurrent bleeding, 85–87% of patients, along with iron deficiency, have a deficiency of other hematopoietic factors, in particular folic acid and vitamin B12. This must be taken into account when choosing iron-containing drugs.

In case of anemia of moderate severity (blood loss up to 15% - 700 ml), blood transfusions are not performed, only blood products are transfused: cryoplasma (5 ml / kg body weight per day), albumin (5-, 10 or 20% solution in a dose of 400- 200 or 100 ml/day), to completely restore circulating blood volume (CBV), colloid and crystalloid solutions are transfused. In case of severe anemia (blood loss - 15% or more, specific density of blood - less than 1053 g/cm3, hemoglobin - below 70 g/l, hematocrit - less than 38%), blood transfusion of red blood cells, erythrocyte suspension in combination with blood products (cryoplasma, albumin, protein).

To determine the volume of blood loss, methods for determining the volume of blood loss according to G.A. are used. Barashkov (Table 1), shock index (M. Algover and K. Burri, 1967).

Shock index is the ratio of heart rate to systolic blood pressure. Its normal value is about 0.5. Shock and accompanying blood loss are characterized by higher index values. The ratio of the index value and the volume of blood loss is presented in table. 2.

Determination of the volume of blood loss by the shock index should be carried out before the start of infusion therapy, since infusion of solutions sharply reduces the diagnostic value of the method.

Along with the described methods, when assessing the volume of blood loss, diagnosing hemorrhagic shock and the degree of its severity, it is necessary to take into account clinical symptoms. A severe degree of blood loss is indicated by tachycardia, decreased systolic, increased diastolic and decreased pulse pressure, pronounced pallor of the skin and mucous membranes, acrocyanosis, decreased temperature of the skin and mucous membranes, cold sweat, dry mouth, thirst, decreased hourly diuresis (to oliguria with diuresis 50–30 ml/h, anuria – less than 30 ml/h).

The volume of infusion therapy must be strictly individual to avoid hemodilution when transfusing inappropriately large volumes of fluid and at the same time sufficient for rapid, complete restoration of blood volume and restoration of normal hemodynamic parameters. For patients with severe blood loss, hospitalization in the intensive care unit is indicated.

Anti-inflammatory and detoxification therapy

Anti-inflammatory therapy includes metronidazole drugs, which, along with an antibacterial effect, have an immunostimulating effect. Antibiotics for manual transmission are prescribed only for clearly substantiated indications.

Detoxification therapy for inflammatory changes in the reproductive system includes intravenous administration of sodium thiosulfate, Reopolyglucin - dextran, glucose solution with insulin (1 IU per 5 g of dry glucose), albumin solution, etc.

Correction of hemostasis disorders

In case of combined genesis of bleeding, hemostasis correction of primary hemostasis disorders is carried out (under the supervision of a hematologist and constant monitoring of the hemostasiogram). For von Willebrand disease, antihemophilic plasma or cryoprecipitate is administered at a dose of 15 U/kg body weight once every 1–2 days. For diseases of mild and moderate severity, the effectiveness of e-AKK solution at a dose of 0.2 g/kg body weight per day has been proven. However, the simultaneous use of cryoprecipitate, e-ACC and combined estrogen-progestogen drugs should be avoided. According to some reports, the use of adrenochrome monosemicarbazone and burnt magnesia has a positive effect.

For thrombasthenia, tranexamic acid or e-AKK, vitamins C, A, P (vitamin B6 is contraindicated), herbal medicine (yarrow, nettle, plantain, St. John's wort, burnet, corn silk, strawberry leaf), ATP solution intramuscularly in combination with magnesium thiosulfate ( 0.5 g 3 times a day), etamzilate. Blood transfusions and plasma transfusions are ineffective.

Own observations

In 2010, 234 patients came to the Yuventa State Children's Clinical Center with a diagnosis of MCPP, which accounted for 6% of the structure of MC disorders. The diagnosis of MCPP was made in patients under 18 years of age with a menstrual age of up to 3 years, who had no history of pregnancy and no specific gynecological inflammatory diseases at the time of bleeding. In all patients, upon presentation, the duration of bleeding was more than 8 days, the amount of blood loss exceeded normal menstruation, or the bleeding was erratic.

After consultation and examination, 15 patients were sent for treatment and further observation to district children's gynecologists and youth clinics, 14 patients were hospitalized in the pediatric gynecology department of Children's Hospital No. 5. Indications for hospitalization were primarily complicated forms of manual transmission with severe anemia (hemoglobin less than 70 g/l). Along with this, patients who lived in remote areas of the city or in unfavorable social and living conditions were hospitalized, as well as upon their first appearance at the Center in the evening, before weekends or holidays. 205 patients were observed at the State Clinical CDC with a diagnosis of MCPP and received treatment in 2010. In the structure of the dispensary group with menstrual disorders, manual transmission made up 23.9%.

At the first stage of treatment for MCPP, hemostatic therapy during the period of bleeding was carried out in 57 patients in the day hospital of the State Clinical Clinical Center. In the absence of indications for infusion therapy and stay in a day hospital, 38 patients (out of 205) received treatment on an outpatient basis under the supervision of a gynecologist-endocrinologist.

In the day hospital, all patients, regardless of the results of ultrasound of the pelvic organs, began treatment with complex symptomatic hemostatic therapy. At the first stage (days 1–3), all patients showed a decrease in blood loss during therapy. Only two patients were transferred to a permanent hospital due to increased bleeding during therapy and severe anemia; 31 patients were prescribed hormonal hemostatic therapy due to insufficient clinical effect and lack of complete hemostasis.

A set of therapeutic measures carried out for patients with manual transmission in a day hospital:

Reamberin (meglumine sodium succinate) 200–400 ml per day intravenously for 3–5 days;
oxytocin 10 units; 0.9% sodium chloride solution 200 ml intravenously for 3 days;
Tranexam (tranexamic acid) 1000 mg per day orally;
Dicynone (etamsylate) 4 intravenously for 5 days;
ascorbic acid 5% 6.0 ml intravenously for 3–5 days;
10% calcium gluconate solution 10 ml intravenously for 3–5 days;
Metrogyl (metronidazole) 100 ml per day intravenously for 5 days;
ceftriaxone 1.0 g per day or ciprofloxacin 200 mg/day intravenously for 5 days (according to indications);
herbal medicine (hemostatic collection, individual);
physiotherapeutic treatment – endonasal electrophoresis of vitamin B1 – for 5–7 days;
acupuncture;
iron preparations for hemoglobin levels below 120 g/l: Ferrum Lek or Sorbifer Durules, or Ferlatum (see above).

If within 5-7 days the effect of non-hormonal hemostatic therapy was absent or insufficient, patients were prescribed hormonal hemostasis: Rigevidon 1 tablet per day (rarely 2-3 tablets per day) 21 days or with scanty bleeding and Suspected endometrial hyperplasia Norkolut 1-2 tablets per day for 6-10 days.

During hormonal therapy, a hemostatic effect was achieved in all patients. Due to the lack of indications for surgical hemostasis, diagnostic curettage of the uterine cavity was not performed.

When analyzing cases of ineffectiveness of symptomatic hemostatic therapy and the need to use hormonal hemostatic therapy, it was noted that unsatisfactory results when using non-hormonal hemostatic therapy were most often observed:

in young patients with underweight or obesity;
in patients who have signs of endometrial hyperplasia according to ultrasound data (especially if the thickness of the endometrium is more than 12 mm);
in patients who, according to ultrasound, have ovarian cysts with a diameter of more than 20 mm or ultrasound signs of polycystic ovaries.

Currently, all patients are under dispensary observation at the second (outpatient) stage of management of MCPP - they receive complex therapy to prevent relapses. During 12 months of observation, recurrent bleeding was noted in 2 cases during treatment and in 4 patients when rehabilitation conditions were violated. In all cases of relapse, hemostasis was achieved using hormonal drugs.

Conclusion

Management of patients with manual transmission in a day hospital allows one to obtain a hemostatic effect when carrying out complex conservative hemostatic therapy in 99% of patients, and in almost 80% of cases without the use of hormonal drugs. When choosing a treatment method to reduce the time to obtain a hemostatic effect and reduce the number of relapses, you should pay attention to the features of the clinical course of the disease, ultrasound data of the pelvic organs and the complexity of the therapeutic effect.

Information about the authors: Irina Nikolaevna Gogotadze – Candidate of Medical Sciences, Associate Professor of the Department of Pediatric Gynecology and Female Reproductology of the Faculty of Pedagogical Training and PP of the St. Petersburg State Pediatric Medical Academy. Email; Krotin Pavel Naumovich – Doctor of Medical Sciences, Professor, Chief Physician of the St. Petersburg State Healthcare Institution “City Consultative and Diagnostic (Reproductive Health)”. Email