Polymenorrhea ICD code 10. Menorrhagia
A number of diseases consisting of a deviation in the frequency, duration of the menstrual cycle and (or) a decrease (oligomenorrhea) or an increase (polymenorrhea, dysfunctional uterine bleeding) in the amount of discharge during menstruation. The causes of these diseases are two groups of factors: extragenital, including various kinds of disturbances on the part of central hormonal regulation, and genital factors, including disorders on the part of the genital organs: the main of these causes include disturbances in the hormonal activity of the ovaries and hormonopoiesis. The objectives of laser therapy are to optimize endocrine homeostasis and restore metabolism and microcirculatory hemodynamics of the pelvic organs. When performing laser therapy, it is necessary to focus on the periodicity of the hormonal cycle: the most favorable period for treatment is from the 4-5th to 15-17th days of the menstrual cycle. The action plan includes endovaginal irradiation of the uterus, ovaries (through the lateral vaginal fornix), percutaneous effects on the uterus and ovaries, effects on the segmental innervation of the genital organs in the Th10-L2 projection, modulation of the activity of the pelvic nerve plexus by irradiating it through the sacral openings, a general energizing effect through irradiation of the abdominal aorta and ulnar artery, effects on the suboccipital area. Additionally, the impact is performed on the receptor zone of the pelvic organs in the projection of the inner surface of the thigh and lower leg. The listed activities not only have a positive effect in the area of direct laser irradiation, but also indirectly affect the activity of the hypothalamic-pituitary system due to the activation of homeostatic regulation mechanisms implemented by the body when exposed to LILI factors. The cervical-hypothalamic-pituitary reflex, induced by direct LILI irradiation of the cervix, plays an extremely important role. Based on this, one should not exclude endovaginal irradiation from the plan of tactical measures for this group of diseases, performed using specialized attachments or by defocused irradiation of the cervix when applying vaginal speculum, usually performed using red continuous lasers. The use of the latter method of exposure requires the use of special non-glare gynecological instruments for the procedure. In the presence of concomitant inflammatory diseases of the pelvic organs, their mandatory therapy is carried out according to the appropriate criteria for choosing therapeutic laser treatment modes. It should be noted that in order to prevent suppression of the functional activity of the ovaries, it is necessary to avoid their simultaneous irradiation in one procedure using endovaginal and cutaneous techniques. Irradiation regime for projection zones in the treatment of menstrual disorders
| Irradiation zone | Emitter | Power | frequency Hz | Exposure, min | Nozzle |
| ILBI, Fig. 130, pos. "1" | NIR-ILBI | 4 mW | - | 12-15 | KIVL |
| NLBI of the ulnar vessel, Fig. 130, pos. "1" | BIC | 15-20 mW | - | 8-10 | KNS-Up, No. 4 |
| Ovaries endovaginally | B2 | 14 W | 1500 | 2-4 | LONO, R1 |
| Projection of the ovaries, cutaneously, Fig. 130, pos. "2" | B2 | 14 W | 150-600 | 4-8 | MH30 |
| Projection of the uterus, cutaneously, Fig. 130, pos. "3" | B2 | 14 W | 600-1500 | 2-4 | MH30 |
| Projection of the sacrum, Fig. 130, pos. "5" | BIM | 35 W | 150-300 | 4 | - |
| Spine Th10-L2, Fig. 130, pos. "4" | BIM | 25 W | 150-300 | 4 | - |
| Receptor zone | BIM | 20 W | 150 | 4 | - |
Bleeding from the genital tract is considered normal, which appears at intervals of 21-35 days and lasts from three to six days. If the regularity or volume changes, then there must be a pathological reason for the cycle failure. Metrorrhagia is the occurrence of bleeding from the genital tract outside of normal menstruation. This symptom can appear at any age - in adolescents, women of reproductive age, during menopause.
The ICD-10 code for metrorrhagia corresponds to several categories. N92 includes heavy, irregular and frequent menstruation, and N93 other abnormal bleeding from the uterus that may occur after coitus (N93.0) or for unspecified reasons (N93.8-9).
What is metrorrhagia, causes of pathology
The most common causes of metrorrhagia are hormonal disorders, inflammatory diseases and problems with the blood coagulation system. But each age has its own characteristics.
In teenagers
The appearance of spotting not associated with menstruation in adolescents is called juvenile uterine bleeding. It is often explained by the immaturity of hormonal structures, but groups of factors have been identified that can contribute to the appearance of an unpleasant symptom.
- Antenatal period. During intrauterine development, a girl develops genital organs and several million eggs. Some of them will be atretic in the future, and the rest will form the ovarian reserve for life. Unlike men, who produce sperm constantly, women do not produce new eggs. Therefore, any negative influences during intrauterine development can lead to pathology of the reproductive system in the future.
- Mental trauma. Stress and heavy physical activity affect the production of hormones along the hypothalamus-pituitary-adrenal cortex chain. This leads to disruption of the secretion of gonadotropic hormones, persistence of the follicle and changes in the synthesis of sex hormones.
- Hypovitaminosis. The lack of vitamins C, E, K affects, which leads to fragility of blood vessels, impaired hemostasis and the secretion of prostaglandins, as well as a decrease in the process of platelet adhesion during the formation of blood clots.
- Infections. Girls with NMC of the metrorrhagia type often experience chronic tonsillitis, influenza, acute respiratory infections and other infections. Tonsillogenic infectious processes have a particular impact on the hypothalamic region.
- Increased function of the pituitary gland. The secretion of FSH and LH in girls with bleeding is erratic. The maximum release can occur at intervals of one to eight days, and the concentration is several times higher than that in healthy people. Bleeding at this age is often anovulatory.
- Blood clotting disorders. Often these are hereditary pathologies of the hemostatic system. With them, juvenile bleeding is observed in 65% of cases. Often these are thrombocytopathy, von Willebrand syndrome, idiopathic thrombocytopenic purpura.
Bleeding in adolescents can be of three types:
- hypoestrogenic;
- normoestrogenic;
- hyperestrogenic.
In this case, there are characteristic changes in the ovaries and endometrium according to ultrasound. With hypoestrogenism, the thickness of the endometrium is reduced, and there are small cystic changes in the ovaries. With the hyperestrogenic type, the endometrium cannot grow up to 2.5 cm, which significantly exceeds the norm. At this time, cystic formations from 1 to 3.5 cm are visualized in the ovaries.
In potential mothers
Metrorrhagia during the reproductive period may be associated with the following conditions:
- hormonal pathologies;
- tumors;
- pathological conditions of the cervix;
- for complications of pregnancy.
Hormonal pathologies include non-inflammatory diseases of the reproductive organs:
- endometrial hyperplasia;
- myoma;
- endometriosis.
In this case, a state of relative hyperestrogenia is noted. The thickness of the endometrium increases significantly, and if there is a malnutrition, bleeding can begin in the middle of the cycle. With endometriosis, the cause of bleeding may be the emptying of endometrioid foci, which form cavities in the body of the uterus.
Dysfunctional bleeding often occurs during the reproductive period. They occur when the hormonal functions of the ovaries are disrupted. Triggering factors can be:
- infection;
- stress;
- injury;
- unfavorable environment;
- metabolic syndrome.
Metrorrhagia usually appears after a long delay in menstruation, sometimes up to three months. The bleeding itself can last up to seven days, releasing a large amount of blood with clots, which leads to anemia.
The release of blood during ovulation may be physiological in nature. It is also called “breakthrough” and is explained by a sharp jump in sex hormones. Also, spotting bleeding sometimes occurs in women who have started taking combined oral contraceptives. However, it is considered normal only during the period of adaptation to the drug in the first three months.
Cervical erosion may be accompanied by postcoital bleeding. Also, bleeding may occur with endometritis.
A woman may not be aware of her pregnancy in the early stages. Especially if she has an irregular menstrual cycle, delays often occur. Therefore, metrorrhagia may be associated with early miscarriage. But even with a diagnosed pregnancy, bleeding from the genital tract speaks in favor of an abortion that has begun.
In the later stages, metrorrhagia is a sign of bleeding from the placenta previa or abruption of a normally located placenta. In this case, pain may appear in the lower back and lower abdomen. In each of these cases, emergency medical attention is required. The consequences of delay in such a situation are intrauterine fetal death.
Over 45 years old
Menopausal metrorrhagia can be cyclical or acyclic in nature. Its origin may be different:
- organic - associated with pathology of the cervix, endometrium, myometrium, ovaries or vagina;
- inorganic - in connection with atrophic processes in the endometrium and anovulation;
- iatrogenic - due to taking medications for replacement therapy;
- extragenital- associated with pathology of other organs.
Metrorrhagia in premenopause is often associated with endometrial polyps. For women aged 45-55 years, the main reason is endometrial hyperplasia. Based on structural changes, it can be without cell atypia and atypical, which can develop into oncology.
Women aged 55-65 years have a peak incidence of endometrial cancer. Therefore, metrorrhagia in postmenopause always makes one think about a tumor.
Pre- and postmenopause are characterized by bleeding due to fibroids located submucosally (in the muscular layer of the uterus) and myosarcoma. Before menopause, adenomyosis may be the cause. Pathology of the ovaries, cervix, atrophic processes in the vagina lead to metrorrhagia less often.
In postmenopausal women, metrorrhagia often occurs in the absence of menstruation and in women who do not take hormone replacement therapy.
Diagnostic methods
When examining a teenager, a conversation is held with her mother. The doctor pays attention to the course of pregnancy and childbirth, the presence of diabetes mellitus in the mother, and endocrine pathologies that can affect the girl’s health. An external examination reveals the following signs that are associated with hypothalamic dysfunction:
- light stretch marks on the skin;
- excess hair growth;
- hyperpigmentation in the armpits, neck and elbows.
Girls are often obese or overweight.
Laboratory tests include:
- blood chemistry- reflects the state of metabolism of proteins, fats and carbohydrates;
- fasting blood glucose- tendency to diabetes;
- sex steroids in urine- analysis of hormone metabolism;
- blood hormones - LH, FSH, estriol, progesterone, testosterone, EDHEA, cortisol.
Additionally, TSH, T3 and T4 are examined. Antibodies to thyroid peroxidase are also determined. In some cases, registration of circadian rhythms of LH, prolactin, and cortisol is used.
Instrumental diagnostic methods for teenagers are as follows:
- Ultrasound through the vagina;
- MRI of the pelvis;
- X-ray of the brain;
- osteometry of the hands;
When choosing a diagnostic method for women of reproductive age, the doctor is guided by the existing clinical picture. In case of metrorrhagia caused by an interrupted pregnancy, determination of the level of sex or pituitary hormones is not necessary. In such a situation, general clinical blood tests and pelvic ultrasound are sufficient.
In older women, bleeding can be a symptom of many gynecological diseases. Diagnosis is aimed at establishing not only the cause, but also the location of bleeding: from the uterus, vagina, ovaries, cervix. The following examination methods are used:
- taking anamnesis;
- verbal assessment of blood loss;
- in premenopause, determination of beta-hCG;
- blood chemistry;
- general blood analysis;
- coagulogram;
- hormones: LH, FSH, estriol, progesterone;
- thyroid hormones;
- markers CA-125, CA-199;
- Transvaginal pelvic ultrasound;
- Doppler mapping;
- MRI of the pelvis;
- smear for oncocytology;
- endometrial biopsy;
- hysteroscopy;
- separate diagnostic curettage.
It is not necessary that the entire list of diagnostic techniques will be used for every woman. Some of them are performed when indicated.
Tactics for choosing therapy
Treatment of metrorrhagia depends on the patient's age, her general condition and the cause of the bleeding. Therapeutic measures can be conservative and surgical.
For young girls
In adolescence, conservative hemostatic therapy is more often used during bleeding present at the time of treatment. For this purpose, combined hormonal contraceptives are used, but they are not taken one tablet per day, but according to a specific regimen, which may include from four tablets per day. To avoid recurrent bleeding, COCs continue to be used after it has stopped, but as usual.
Curettage of the uterine cavity is not used in girls. Manipulation is allowed only in cases of severe endometrial hyperplasia or polyp. In this case, the hymen is injected with lidase, and all manipulations are carried out with special baby mirrors.
In mature women
To properly stop bleeding, the main thing is to identify the cause. If it is an abortion or dysfunctional uterine bleeding, endometrial hyperplasia, then the main treatment method is curettage.
Medicines to stop bleeding can also be used:
- "Dicynon";
- aminocaproic acid;
- calcium gluconate.
Hormonal hemostasis is rarely used, only in women under 30 years of age with minor bleeding due to ovarian dysfunction. Subsequently, they are recommended to take monophasic hormonal contraceptives “Yarina”, “Zhanin”, “Marvelon”.
Against the background of existing endometriosis and fibroids, as well as endometrial hyperplasia, women who do not plan to have children in the coming years are recommended to install the Mirena hormonal system.
Removal of the uterus as a method of stopping bleeding during reproductive age is used extremely rarely. Usually only when combined with fibroids, severe endometriosis, and with severe contraindications to hormonal therapy.
During menopause
The first stage of treatment is to stop the bleeding. For this purpose, curettage, hysteroscopy, and resectoscopy are used. In severe cases, especially if there is oncology, a hysterectomy is performed.
Technically speaking, a woman is a rather complex mechanism. If a problem arises with any organ, it will entail a lot of others.
The female genital organs are a very complex system, so you need to pay attention to even the little things, since they sometimes play a key role. Ignoring gynecological diseases can lead to infertility.
Very often, during menstruation, a woman experiences discomfort. Of course, there is nothing pleasant about menstruation, but some women experience severe pain. This disease is called algodismenorrhea.
The cause of pain is most often the incorrect position of the uterus, or its very small size, endometriosis, and inflammation of the reproductive organs can also affect the pain.
As a rule, the disease has several symptoms - abdominal pain, headache, nausea, dizziness. All symptoms disappear as soon as menstruation begins.
Algodismenorrhea has two types - primary and secondary. Usually primary is not related to anatomy; it appears in girls with their very first menstruation. Although there are cases when it appears in women. The pain is very severe, so you cannot do without analgesics or tranquilizers. In nature, it resembles contractions; anyone who has given birth will understand how painful it is!
Secondary algodismenorrhea, unfortunately, is usually a manifestation of another disease. As a rule, it is a symptom of fibroids or uterine anteflexion, inflammatory processes. Sometimes this disease occurs after a difficult birth or abortion.
ICD-10 codes
N94.0 Pain in the middle of the menstrual cycle;
N94.1 Dyspareunia;
N94.2 Vaginismus;
N94.3 Premenstrual tension syndrome;
N94.4 Primary dysmenorrhea;
N94.5 Secondary dysmenorrhea;
N94.6 Dysmenorrhea, unspecified;
N94.8 Other specified conditions associated with the female genital organs and the menstrual cycle;
N94.9 Conditions associated with the female genital organs and the menstrual cycle, unspecified.
Treatment
It is generally accepted that secondary algodysmenorrhea will go away if the underlying disease is treated, since it is a symptom. However, you should not endure terrible pain. It is necessary to use anti-inflammatory drugs a couple of days before your period. You can also try medicinal preparations and hardware physiotherapy. Primary algodysmenorrhea most often goes away after the first birth; until this point, the woman takes analgesics and anti-inflammatory drugs.
In any case, the help of an experienced gynecologist is simply necessary! When it comes to gynecological problems, self-medication can lead to infertility, which is a terrible diagnosis for any woman. Therefore, it is better not to take risks without a reason!
Puberty uterine bleeding (PUB) - functional disorders that arise during the first three years after menarche, caused by deviations in the coordinated activity of functional systems that maintain homeostasis, manifested in the disruption of correlations between them under the influence of a complex of factors.
SYNONYMS
Uterine bleeding during puberty, dysfunctional uterine bleeding, juvenile uterine bleeding.
ICD-10 CODE
N92.2 Heavy menstruation during puberty (heavy bleeding with the onset of menstruation, pubertal cyclic bleeding - menorrhagia, pubertal acyclic bleeding - metrorrhagia).
EPIDEMIOLOGY
The frequency of manual transmission in the structure of gynecological diseases of childhood and adolescence ranges from 10 to 37.3%.
Manual transmission is a common reason why teenage girls visit a gynecologist. They also account for 95% of all uterine bleeding during puberty. Most often, uterine bleeding occurs in teenage girls during the first three years after menarche.
SCREENING
It is advisable to screen the disease using psychological testing among healthy patients, especially excellent students and students of institutions with a high educational level (gymnasiums, lyceums, professional classes, institutes, universities). The risk group for the development of manual transmission should include adolescent girls with deviations in physical and sexual development, early menarche, and heavy menstruation with menarche.
CLASSIFICATION
There is no officially accepted international classification of manual transmission.
Depending on the functional and morphological changes in the ovaries, the following are distinguished:
- ovulatory uterine bleeding;
- anovulatory uterine bleeding.
During puberty, anovulatory acyclic bleeding is most common, caused by atresia or, less commonly, persistence of follicles.
Depending on the clinical characteristics of uterine bleeding, the following types are distinguished.
- Menorrhagia (hypermenorrhea) is uterine bleeding in patients with a preserved menstrual rhythm, with bleeding lasting more than 7 days and blood loss exceeding 80 ml. In such patients, a small number of blood clots are usually observed in heavy bleeding, the appearance of hypovolemic disorders on menstrual days and signs of moderate to severe iron deficiency anemia.
- Polymenorrhea is uterine bleeding that occurs against the background of a regular shortened menstrual cycle (less than 21 days).
- Metrorrhagia and menometrorrhagia are uterine bleeding that does not have a rhythm, often occurring after periods of oligomenorrhea and characterized by periodic increased bleeding against the background of scanty or moderate blood discharge.
Depending on the level of estradiol concentration in the blood plasma, manual transmissions are divided into the following types:
- hypoestrogenic;
- normoestrogenic.
Depending on the clinical and laboratory characteristics of manual transmission, typical and atypical forms are distinguished.
ETIOLOGY
MCPP is a multifactorial disease; its development depends on the interaction of a complex of random factors and the individual reactivity of the organism. The latter is determined by both the genotype and the phenotype, which is formed during the ontogenesis of each person. Conditions such as acute psychogenia or prolonged psychological stress, unfavorable environmental conditions in the place of residence, and hypovitaminosis are most often cited as risk factors for the occurrence of manual transmission. Trigger factors for manual transmission can also be nutritional deficiency, obesity, and underweight. It is more correct to regard these unfavorable factors not as causal, but as provoking phenomena. The leading and most likely role in the occurrence of bleeding belongs to various types of psychological overload and acute psychological trauma (up to 70%).
PATHOGENESIS
An imbalance of homeostasis in adolescents is associated with the development of nonspecific reactions to stress, i.e. some circumstances (infection, physical or chemical factors, socio-psychological problems) leading to tension in the body’s adaptive resources. As a mechanism for the implementation of the general adaptation syndrome, the main axis of hormonal regulation - “hypothalamus-pituitary-adrenal glands” - is activated. A normal adaptive response to changes in the external or internal environment of the body is characterized by a balanced multiparametric interaction of regulatory (central and peripheral) and effector components of functional systems. The hormonal interaction of individual systems is ensured by correlations between them. When exposed to a set of factors that exceed the usual conditions of adaptation in intensity or duration, these connections may be disrupted. As a consequence of this process, each of the systems that ensure homeostasis begins to work to one degree or another in isolation and afferent information about their activity is distorted. This in turn leads to disruption of control connections and deterioration of effector mechanisms of self-regulation. And finally, the long-term low quality of the self-regulation mechanisms of the system, which is the most vulnerable due to any reasons, leads to its morphofunctional changes.
The mechanism of ovarian dysfunction is inadequate stimulation of the pituitary gland by GnRH and can be directly related to both a decrease in the concentration of LH and FSH in the blood, and a persistent increase in LH levels or chaotic changes in the secretion of gonadotropins.
CLINICAL PICTURE
The clinical picture of manual transmission is very heterogeneous. Manifestations depend on what level (central or peripheral) the violations of self-regulation occurred.
If it is impossible to determine the type of manual transmission (hypo, normo or hyperestrogenic) or there is no correlation between clinical and laboratory data, we can talk about the presence of an atypical form.
In the typical course of manual transmission, the clinical picture depends on the level of hormones in the blood.
- Hyperestrogenic type: outwardly, such patients look physically developed, but psychologically they can show immaturity in judgments and actions. Distinctive features of the typical form include a significant increase in the size of the uterus and the concentration of LH in the blood plasma relative to the age norm, as well as an asymmetrical enlargement of the ovaries. The greatest likelihood of developing the hyperestrogenic type of manual transmission is at the beginning (11–12 years) and end (17–18 years) of puberty. Atypical forms can occur up to 17 years of age.
- The normoestrogenic type is associated with the harmonious development of external characteristics according to anthropometry and the degree of development of secondary sexual characteristics. The size of the uterus is smaller than the age norm, therefore, with such parameters, patients are often classified as the hypoestrogenic type. Most often, this type of manual transmission develops in patients aged 13 to 16 years.
- The hypoestrogenic type is more common in teenage girls than others. Typically, such patients are of fragile constitution with a significant lag behind the age norm in the degree of development of secondary sexual characteristics, but a fairly high level of mental development. The uterus significantly lags behind the age norm in volume in all age groups, the endometrium is thin, the ovaries are symmetrical and slightly exceed normal in volume.
The level of cortisol in the blood plasma significantly exceeds the normative values. With the hypoestrogenic type, manual transmission almost always occurs in a typical form.
DIAGNOSTICS
Criteria for diagnosing manual transmission:
- the duration of vaginal bleeding is less than 2 or more than 7 days against the background of a shortening (less than 21–24 days) or lengthening (more than 35 days) of the menstrual cycle;
- blood loss more than 80 ml or subjectively more pronounced compared to normal menstruation;
- the presence of intermenstrual or post-coital bleeding;
- absence of structural pathology of the endometrium;
- confirmation of the anovulatory menstrual cycle during the period of uterine bleeding (the level of progesterone in the venous blood on days 21–25 of the menstrual cycle is less than 9.5 nmol/l, monophasic basal temperature, absence of a preovulatory follicle according to echography).
During a conversation with relatives (preferably with the mother), it is necessary to find out the details of the patient’s family history.
They evaluate the characteristics of the mother’s reproductive function, the course of pregnancy and childbirth, the course of the newborn period, psychomotor development and growth rates, find out living conditions, nutritional habits, previous diseases and operations, note data on physical and psychological stress, and emotional stress.
PHYSICAL EXAMINATION
It is necessary to conduct a general examination, measure height and body weight, determine the distribution of subcutaneous fat, and note signs of hereditary syndromes. The compliance of the patient’s individual development with age standards is determined, including sexual development according to Tanner (taking into account the development of the mammary glands and hair growth).
In most patients with manual transmission, a clear advance (acceleration) in height and body weight can be observed, but in terms of body mass index (kg/m2), a relative lack of body weight is noted (with the exception of patients aged 11–18 years).
Excessive acceleration of the rate of biological maturation at the beginning of puberty is replaced by a slowdown in development in older age groups.
Upon examination, you can detect symptoms of acute or chronic anemia (pallor of the skin and visible mucous membranes).
Hirsutism, galactorrhea, enlarged thyroid gland are signs of endocrine pathology. The presence of significant deviations in the functioning of the endocrine system, as well as in the immune status of patients with manual transmission, may indicate a general disturbance of homeostasis.
It is important to analyze the girl’s menstrual calendar (menocyclogram). Based on its data, one can judge the development of menstrual function, the nature of the menstrual cycle before the first bleeding, the intensity and duration of bleeding.
The onset of the disease with menarche is more often observed in the younger age group (up to 10 years), in girls 11–12 years after menarche before bleeding, irregular menstruation is more often observed, and in girls over 13 years old, regular menstrual cycles are observed. Early menarche increases the likelihood of developing manual transmission.
The development of the clinical picture of manual transmission with atresia and persistence of follicles is very characteristic. With persistence of follicles, menstrual-like or more abundant bleeding than menstruation occurs after a delay of the next menstruation by 1–3 weeks, while with follicular atresia the delay ranges from 2 to 6 months and is manifested by scanty and prolonged bleeding. At the same time, various gynecological diseases can have identical bleeding patterns and the same type of menstrual irregularities. Spotting blood from the genital tract shortly before and immediately after menstruation can be a symptom of endometriosis, endometrial polyp, chronic endometritis, or GPE.
It is necessary to clarify the patient’s psychological state through psychological testing and consultation with a psychotherapist. It has been proven that signs of depressive disorders and social dysfunction play an important role in the clinical picture of typical forms of MCPP. The presence of a relationship between stress and the hormonal metabolism of patients suggests the possibility of primacy of neuropsychiatric disorders.
A gynecological examination also provides important information. When examining the external genital organs, the growth lines of pubic hair, the shape and size of the clitoris, labia majora and minora, the external opening of the urethra, features of the hymen, the color of the mucous membranes of the vaginal vestibule, and the nature of discharge from the genital tract are assessed.
Vaginoscopy allows you to assess the condition of the vaginal mucosa, estrogen saturation and exclude the presence of a foreign body in the vagina, condylomas, lichen planus, neoplasms of the vagina and cervix.
Signs of hyperestrogenism: pronounced folding of the vaginal mucosa, juicy hymen, cylindrical cervix, positive pupil symptom, abundant streaks of mucus in the blood discharge.
Signs of hypoestrogenemia: the vaginal mucosa is pale pink, the folding is weakly expressed, the hymen is thin, the cervix is subconical or conical, bleeding without mucus.
LABORATORY RESEARCH
Patients with suspected manual transmission undergo the following studies.
- Complete blood count with determination of hemoglobin level, platelet count, reticulocyte count. A hemostasiogram (aPTT, prothrombin index, activated recalcification time) and assessment of bleeding time will help exclude gross pathology of the blood coagulation system.
- Determination of βhCG in blood serum in sexually active girls.
- Smear microscopy (Gram stain), bacteriological examination and PCR diagnosis of chlamydia, gonorrhea, mycoplasmosis, ureaplasmosis in scrapings of the vaginal walls.
- Biochemical blood test (determination of glucose, protein, bilirubin, cholesterol, creatinine, urea, serum iron, transferrin, calcium, potassium, magnesium levels) alkaline phosphatase, AST, ALT activity.
- Carbohydrate tolerance test for polycystic ovary syndrome and overweight (body mass index 25 and above).
- Determination of the level of thyroid hormones (TSH, free T4, AT to thyroid peroxidase) to clarify the function of the thyroid gland; estradiol, testosterone, DHEAS, LH, FSH, insulin, Speptide to exclude PCOS; 17-OP, testosterone, DHEAS, circadian rhythm of cortisol to exclude CAH; prolactin (at least 3 times) to exclude hyperprolactinemia; progesterone in the blood serum on the 21st day of the cycle (with a menstrual cycle of 28 days) or on the 25th day (with a menstrual cycle of 32 days) to confirm the anovulatory nature of uterine bleeding.
At the first stage of the disease in early puberty, activation of the hypothalamic-pituitary system leads to periodic release of LH (primarily) and FSH, their concentration in the blood plasma exceeds normal levels. In late puberty, and especially with recurrent uterine bleeding, the secretion of gonadotropins decreases.
INSTRUMENTAL RESEARCH METHODS
X-rays of the left hand and wrist are sometimes taken to determine bone age and predict growth.
Most patients with manual transmission are diagnosed with advanced biological age compared to chronological age, especially in younger age groups. Biological age is a fundamental and multifaceted indicator of the pace of development, reflecting the level of the morphofunctional state of the organism against the background of the population standard.
X-ray of the skull is an informative method for diagnosing tumors of the hypothalamic-pituitary region that deform the sella turcica, assessing cerebrospinal fluid dynamics, intracranial hemodynamics, osteosynthesis disorders due to hormonal imbalance, and previous intracranial inflammatory processes.
Echography of the pelvic organs allows you to clarify the size of the uterus and endometrium to exclude pregnancy, the size, structure and volume of the ovaries, uterine defects (bicornuate, saddle-shaped uterus), pathology of the uterine body and endometrium (adenomyosis, MM, polyps or hyperplasia, adenomatosis and endometrial cancer, endometritis , intrauterine synechiae), assess the size, structure and volume of the ovaries, exclude functional cysts and space-occupying formations in the uterine appendages.
Diagnostic hysteroscopy and curettage of the uterine cavity in adolescents are rarely used and are used to clarify the condition of the endometrium when echographic signs of endometrial or cervical canal polyps are detected.
Ultrasound of the thyroid gland and internal organs is performed according to indications in patients with chronic diseases and endocrine diseases.
DIFFERENTIAL DIAGNOSTICS
The main goal of the differential diagnosis of uterine bleeding during puberty is to clarify the main etiological factors that provoke the development of uterine bleeding.
Differential diagnosis should be carried out with a number of conditions and diseases.
- Complications of pregnancy in sexually active adolescents. Complaints and medical history data to exclude interrupted pregnancy or bleeding after an abortion, including in girls who deny sexual contact. Bleeding occurs more often after a short delay of more than 35 days, less often when the menstrual cycle is shortened to less than 21 days or at a time close to the expected menstruation. The history, as a rule, contains indications of sexual intercourse in the previous menstrual cycle. Patients note engorgement of the mammary glands and nausea. Bloody discharge is usually profuse with clots, pieces of tissue, and often painful. The results of pregnancy tests are positive (determination of βhCG in the patient’s blood serum).
- Defects of the blood coagulation system (von Willebrand disease and deficiency of other plasma hemostasis factors, Werlhoff disease, Glanzmann thromboasthenia, Bernard-Soulier, Gaucher). In order to exclude defects in the blood coagulation system, family history (tendency to bleeding in parents) and life history (nosebleeds, prolonged bleeding time during surgical procedures, frequent and causeless occurrence of petechiae and hematomas) are ascertained. Uterine bleeding that develops against the background of diseases of the hemostatic system, as a rule, has the character of menorrhagia with menarche. Examination data (pallor of the skin, bruises, petechiae, yellowness of the palms and upper palate, hirsutism, stretch marks, acne, vitiligo, multiple birthmarks, etc.) and laboratory research methods (hemostasiogram, general blood test, thromboelastogram, determination of the main coagulation factors ) allow you to confirm the presence of pathology of the hemostatic system.
- Other blood diseases: leukemia, aplastic anemia, iron deficiency anemia.
- Polyps of the cervix and uterine body. Uterine bleeding is usually acyclic with short light intervals, the discharge is moderate, often with strands of mucus. An echographic examination often diagnoses GPE (the thickness of the endometrium against the background of bleeding is 10–15 mm), with hyperechoic formations of various sizes. The diagnosis is confirmed using hysteroscopy and subsequent histological examination of distant endometrial formation.
- Adenomyosis. Manual transmission against the background of adenomyosis is characterized by severe dysmenorrhea, prolonged spotting with a brown tint before and after menstruation. The diagnosis is confirmed using ultrasound data in the 1st and 2nd phases of the menstrual cycle and hysteroscopy (in patients with severe pain and in the absence of the effect of drug therapy).
- PID As a rule, uterine bleeding is acyclic in nature and occurs after hypothermia, unprotected sexual intercourse in sexually active adolescents, against the background of exacerbation of chronic pelvic pain and discharge. Patients complain of pain in the lower abdomen, dysuria, hyperthermia, profuse pathological leucorrhoea outside of menstruation, which acquires a sharp unpleasant odor due to bleeding. During a rectoabdominal examination, an enlarged softened uterus is palpated, the pastiness of the tissues in the area of the uterine appendages is determined, the examination is usually painful. Bacteriological examination data (Gram smear microscopy, PCR diagnosis of vaginal discharge for the presence of STIs, bacteriological culture from the posterior vaginal fornix) help clarify the diagnosis.
- Trauma to the external genitalia or foreign body in the vagina. Diagnosis requires mandatory clarification of anamnestic data and vulvovaginoscopy.
- PCOS. With MCPP, girls with PCOS, along with complaints of delayed menstruation, excess hair growth, simple acne on the face, chest, shoulders, back, buttocks and thighs, have indications of late menarche with progressive menstrual irregularities such as oligomenorrhea.
- Hormone-producing formations. MCPP may be the first symptom of estrogen-producing tumors or tumor-like formations of the ovaries. Verification of the diagnosis is possible after determining the level of estrogen in the venous blood and ultrasound of the genital organs with clarification of the volume and structure of the ovaries.
- Thyroid gland dysfunction. MCPPs usually occur in patients with subclinical or clinical hypothyroidism. Patients with manual transmission on the background of hypothyroidism complain of chilliness, swelling, weight gain, memory loss, drowsiness, and depression. In hypothyroidism, palpation and ultrasound with determination of the volume and structural features of the thyroid gland can reveal its enlargement, and examination of patients reveals the presence of dry subecteric skin, puffiness of the face, glossomegaly, bradycardia, and an increase in the relaxation time of deep tendon reflexes. The functional state of the thyroid gland can be clarified by determining the content of TSH and free T4 in the venous blood.
- Hyperprolactinemia. To exclude hyperprolactinemia as a cause of manual transmission, it is necessary to examine and palpate the mammary glands with clarification of the nature of the discharge from the nipples, determine the content of prolactin in the venous blood, an X-ray examination of the skull bones with a targeted study of the size and configuration of the sella turcica or MRI of the brain is indicated.
- Other endocrine diseases (Addison's disease, Cushing's disease, postpubertal form of CAH, adrenal tumors, empty sella syndrome, mosaic variant of Turner syndrome).
- Systemic diseases (liver disease, chronic renal failure, hypersplenism).
- Iatrogenic causes (errors in taking medications containing female sex hormones and glucocorticoids, long-term use of high doses of NSAIDs, antiplatelet agents and anticoagulants, psychotropic drugs, anticonvulsants and warfarin, chemotherapy).
It is necessary to distinguish between manual transmission and uterine bleeding syndrome in adolescents. Uterine bleeding syndrome can be accompanied by almost the same clinical and parametric attributes as with MCPP. However, uterine bleeding syndrome is characterized by pathophysiological and clinical specific signs, which must be taken into account when prescribing treatment and preventive measures.
INDICATIONS FOR CONSULTATION WITH OTHER SPECIALISTS
Consultation with an endocrinologist is necessary if thyroid pathology is suspected (clinical symptoms of hypo or hyperthyroidism, diffuse enlargement or nodules of the thyroid gland on palpation).
Consultation with a hematologist - at the debut of manual transmission with menarche, indications of frequent nosebleeds, the occurrence of petechiae and hematomas, increased bleeding during cuts, wounds and surgical manipulations, identification of prolongation of bleeding time.
Consultation with a phthisiatrician - in case of manual transmission on the background of long-term persistent low-grade fever, acyclic bleeding, often accompanied by pain, the absence of a pathogenic infectious agent in the discharge of the urogenital tract, relative or absolute lymphocytosis in a general blood test, positive results of a tuberculin test.
Consultation with a therapist - for manual transmission against the background of chronic systemic diseases, including diseases of the kidneys, liver, lungs, cardiovascular system, etc.
Consultation with a psychotherapist or psychiatrist is indicated for all patients with manual transmission to correct the condition, taking into account the characteristics of the traumatic situation, clinical typology, and the individual’s reaction to the disease.
EXAMPLE OF FORMULATION OF DIAGNOSIS
N92.2 Heavy menstruation during puberty (heavy bleeding with menarche or pubertal menorrhagia
or pubertal metrorrhagia).
TREATMENT GOALS
The general goals of treating pubertal uterine bleeding are:
- stopping bleeding to avoid acute hemorrhagic syndrome;
- stabilization and correction of the menstrual cycle and endometrial condition;
- antianemic therapy;
- correction of the mental state of patients and concomitant diseases.
INDICATIONS FOR HOSPITALIZATION
Patients are hospitalized for the following conditions:
- profuse (profuse) uterine bleeding that cannot be controlled by drug therapy;
- life-threatening decrease in hemoglobin (below 70–80 g/l) and hematocrit (below 20%);
- the need for surgical treatment and blood transfusion.
DRUG TREATMENT
In patients with uterine bleeding, at the first stage of treatment it is advisable to use inhibitors of the transition of plasminogen to plasmin (tranexamic acid or aminocaproic acid). The drugs reduce the intensity of bleeding by reducing the fibrinolytic activity of blood plasma. Tranexamic acid is prescribed orally at a dose of 4–5 g during the first hour of therapy, then 1 g every hour until bleeding stops completely. Intravenous administration of 4–5 g of the drug is possible over 1 hour, then drip administration of 1 g per hour for 8 hours. The total daily dose should not exceed 30 g. When taking large doses, the risk of developing intravascular coagulation syndrome increases, and with simultaneous use estrogen there is a high probability of thromboembolic complications. It is possible to use the drug in a dosage of 1 g 4 times a day from the 1st to the 4th day of menstruation, which reduces the amount of blood loss by 50%.
It has been reliably proven that with the use of NSAIDs, monophasic COCs and danazol, blood loss in patients with menorrhagia is significantly reduced. Danazol is used very rarely in girls with manual transmission due to severe adverse reactions (nausea, deepening of the voice, hair loss and increased greasiness, acne and hirsutism). NSAIDs (ibuprofen, nimesulide), by suppressing the activity of COX1 and COX2, regulate the metabolism of arachidonic acid, reduce the production of PG and thromboxanes in the endometrium, reducing the amount of blood loss during menstruation by 30–38%.
Ibuprofen is prescribed 400 mg every 4-6 hours (daily dose - 1200-3200 mg) on days of menorrhagia. Nimesulide is prescribed 50 mg 3 times a day. Increasing the daily dosage may cause an undesirable increase in prothrombin time and an increase in the lithium content in the blood serum.
The effectiveness of NSAIDs is comparable to that of aminocaproic acid and COCs.
In order to increase the effectiveness of hemostatic therapy, the simultaneous administration of NSAIDs and hormonal therapy is justified and advisable. The exception is patients with hyperprolactinemia, structural abnormalities of the genital organs and pathology of the thyroid gland.
Methylergometrine can be prescribed in combination with ethamsylate, but if you have or suspect an endometrial polyp or MM, it is better to refrain from prescribing methylergometrine due to the possibility of increased bleeding and pain in the lower abdomen.
Physiotherapy procedures can be used as alternative methods: automammonia, vibromassage of the isola, calcium chloride electrophoresis, galvanization of the area of the upper cervical sympathetic ganglia, electrical stimulation of the cervix with low-frequency pulsed currents, local or laser therapy, acupuncture.
In some cases, hormonal therapy is used. Indications for hormonal hemostasis:
- lack of effect from symptomatic therapy;
- moderate or severe anemia due to prolonged bleeding;
- recurrent bleeding in the absence of organic diseases of the uterus.
Low-dose COCs containing 3rd generation progestogens (desogestrel or gestodene) are the most commonly used drugs in patients with profuse and acyclic uterine bleeding. Ethinyl estradiol in COCs provides a hemostatic effect, and progestogens provide stabilization of the stroma and basal layer of the endometrium. To stop bleeding, only monophasic COCs are used.
There are many schemes for using COCs for hemostatic purposes in patients with uterine bleeding. The most popular is the following: 1 tablet 4 times a day for 4 days, then 1 tablet 3 times a day for 3 days, then 1 tablet 2 times a day, then 1 tablet a day until the end of the second package of the drug. Outside of bleeding for the purpose of regulating menstrual flow cycle COCs are prescribed for 3 cycles 1 tablet per day (21 days of use, 7 days off). Duration hormonal therapy depends on the severity of the initial iron deficiency anemia and the rate of restoration of the level hemoglobin. The use of COCs in this regimen is associated with a number of serious side effects: increased blood pressure, thrombophlebitis, nausea, vomiting, allergies.
The use of low-dose monophasic COCs has been proven to be highly effective (Marvelon©, Regulon ©, Rigevidon ©, Janine ©) 1/2 tablet every 4 hours until complete hemostasis occurs. Appointment under this scheme is based on evidence that the maximum concentration of COCs in the blood is achieved 3-4 hours after oral administration drug and decreases significantly in the next 2–3 hours. The total hemostatic dose of ethinyl estradiol with This ranges from 60 to 90 mcg, which is less than the dose traditionally used. In the following days, a decrease is carried out daily dose of the drug is 1/2 tablet per day. As a rule, the duration of the first cycle of COC use should not be be less than 21 days, counting from the first day from the beginning of hormonal hemostasis. The first 5–7 days of taking COCs is possible a temporary increase in endometrial thickness, which regresses without bleeding with continued treatment.
In the future, in order to regulate the rhythm of menstruation and prevent recurrence of uterine bleeding, the drug prescribed according to the standard regimen for taking COCs (courses of 21 days with breaks of 7 days between them). In all patients, Those who took the drug according to the described regimen showed good tolerability with no side effects. If it is necessary to quickly stop a patient’s life-threatening bleeding with first-line drugs are conjugated estrogens administered intravenously at a dose of 25 mg every 4–6 hours until complete stop bleeding if it occurs during the first day. Can be used in tablet form conjugated estrogens 0.625–3.75 mcg every 4–6 hours until bleeding stops completely with gradual reducing the dose over the next 3 days to 1 tablet (0.675 mg) per day or drugs containing natural estrogens (estradiol), according to a similar scheme with an initial dose of 4 mg per day. After stopping the bleeding Progestogens are prescribed.
Outside of bleeding, in order to regulate the menstrual cycle, 1 tablet of 0.675 mg per day is prescribed for 21 days from mandatory addition of gestagens for 12–14 days in the second phase of the simulated cycle.
In some cases, especially in patients with severe adverse reactions, intolerance or contraindications to the use of estrogens, it is possible to prescribe progestogens.
In patients with heavy bleeding, taking high doses of progestogens (medroxyprogesterone 5–10 mg, micronized progesterone 100 mg or dydrogesterone 10 mg) every 2 hours or 3 times a day for 24 hours until stopping bleeding. For menorrhagia, medroxyprogesterone can be prescribed 5–20 mg per day for the second phase (in cases of NLF) or 10 mg per day from the 5th to the 25th day of the menstrual cycle (in cases of ovulatory menorrhagia).
In patients with anovulatory uterine bleeding, it is advisable to prescribe progestogens in the second phase menstrual cycle against the background of constant use of estrogen. It is possible to use micronized progesterone in a daily dose of 200 mg 12 days a month against the background of continuous estrogen therapy. For the purpose of subsequent regulation of the menstrual cycle gestagens (natural micronized progesterone 100 mg 3 times a day, dydrogesterone 10 mg 2 times a day) is prescribed in the second phase of the cycle for 10 days. Continued bleeding against the background of hormonal hemostasis is an indication for hysteroscopy to clarification of the condition of the endometrium.
All patients with manual transmission are prescribed iron supplements to prevent and prevent the development of iron deficiency anemia. The use of iron sulfate in combination with ascorbic acid has been proven to be highly effective acid, ensuring that the patient’s body receives 100 mg of ferrous iron per day (Sorbifer Durules©).
The daily dose of ferrous sulfate is selected taking into account the level of hemoglobin in the blood serum. As a criterion correct selection and adequacy of ferrotherapy for iron deficiency anemia, presence of reticulocyte crisis, those. A 3 or more fold increase in the number of reticulocytes on the 7th–10th day of taking an iron-containing drug.
Antianemic therapy is prescribed for a period of at least 1–3 months. Iron salts should be used with caution patients with concomitant gastrointestinal pathology. In addition, Fenyuls may be an option©, Tardiferon ©, Ferroplex ©, FerroFolgamma ©.
SURGERY
Separate curettage of the mucous membrane of the body and cervix under the control of a hysteroscope in girls is performed very rarely. Indications for surgical treatment may include:
- acute profuse uterine bleeding that does not stop with drug therapy;
- the presence of clinical and ultrasound signs of endometrial and/or cervical canal polyps.
In cases where it is necessary to remove an ovarian cyst (endometrioid, dermoid follicular or yellow cyst) body, persisting for more than three months) or clarifying the diagnosis in patients with a mass formation in the area of the uterine appendages, therapeutic and diagnostic laparoscopy is indicated.
APPROXIMATE DURATION OF DISABILITY
In an uncomplicated course, the disease does not cause permanent disability. Possible periods of incapacity from 10 to 30 days may be determined by the severity of clinical manifestations iron deficiency anemia due to prolonged or heavy bleeding, as well as the need for hospitalization for surgical or hormonal hemostasis.
FOLLOW-UP
Patients with uterine bleeding during puberty require constant dynamic monitoring once per month until the menstrual cycle stabilizes, then it is possible to limit the frequency of control examinations to 1 time per month 3–6 months Ultrasound examination of the pelvic organs should be carried out at least once every 6–12 months.
Electroencephalography after 3–6 months. All patients should be trained in the rules of maintaining a menstrual calendar and assessing the intensity of bleeding, which will allow assessing the effectiveness of the therapy. Patients should be informed about the advisability of correction and maintenance of optimal body weight (as with
deficiency, and with excess body weight), normalization of the work and rest regime.
INFORMATION FOR THE PATIENT
To prevent the occurrence and successful treatment of uterine bleeding during puberty, the following is necessary:
- normalization of work and rest regimes;
- good nutrition (with the obligatory inclusion of meat, especially veal);
- hardening and physical education (outdoor games, gymnastics, skiing, skating, swimming, dancing, yoga).
FORECAST
Most girls-adolescents respond favorably to drug treatment, and within the first year they have full ovulatory menstrual cycles and normal menstruation are formed. Forecast for manual transmission, associated with pathology of the hemostatic system or with systemic chronic diseases, depends on the degree of compensation for existing disorders. Girls, who remain overweight and have relapses of manual transmission in aged 15–19 years should be included in the risk group for developing endometrial cancer.
BIBLIOGRAPHY
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Treatment tactics
Treatment goals: timely diagnosis of menstrual cycle disorders (MCI), taking into account the classification and age factor, etiology; identification of complications (secondary anemia, infertility, etc.).
It is necessary to exclude organic genesis of NMC, and then examine the patient’s hormonal status in order to determine the level of damage. In parallel, symptomatic therapy and hormonal hemostasis are carried out (A). If there are signs of inflammation, an infectious lesion should be excluded. If there is an IUD in the uterine cavity, remove it. In the absence of effect from conservative therapy or relapse of the disease, therapeutic and diagnostic curettage of the endometrium with histological examination is indicated (C). For bleeding in perimenopause - endometrial ablation (A).
Indications for curettage of the uterine cavity:
Prolonged bleeding due to metrorrhagia;
The woman's age is over 35 years;
In women under 35 years of age with ineffective conservative therapy for up to 3 days.
Non-drug treatment
A diet rich in proteins and vitamins, frequent small meals. Limiting physical activity (increasing rest time). Physiotherapy: endonasal electrophoresis with Ca++, Shcherbak collar. Herbal medicine (decoctions of nettle, shepherd's purse).
Drug treatment:
Etamsylate 250 mg x 2-3 times a day, for 2-3 days;
NSAIDs (not acetylsalicylic acid), mefenamic acid, naproxen, tolfenamic acid, ibuprofen;
Combined oral contraceptives (Regulon, Novinet) and transdermal therapeutic system (contraceptive patch);
Combined hormonal therapy with estrogens (for example, estradiol at a dose of 1 mg) and progestin for 7-10 days leads to the cessation of dysfunctional bleeding, but such treatment has no effect on bleeding caused by organic causes. Immediately after stopping taking hormonal drugs, “withdrawal bleeding” occurs, about which the patient should be warned in advance;
Treatment is continued with cyclic administration of progestins (norethisterone 5 mg x 3 times a day; linestrol 10 mg x 2 times a day) in a cyclic mode from days 15 to 25 of the menstrual cycle;
Menadione sodium bisulfide 0.0015 mg x 3 times a day, 3-5 days;
Oxytocin 5 units IM x 2-3 times a day, 3-5 days;
If there is no effect for up to 3 days and moderate bleeding, with endometrial hyperplasia - ethinyl etradiol 30 mcg + desogestrel 150 mcg according to the regimen.
Preventive measures (prevention of complications):
1. Prevention of infectious complications.
2. Prevention of relapse.
3. Preservation of reproductive function.
Further management:
1. Observation in the antenatal clinic.
2. Symptomatic therapy.
