Causes of menstrual irregularities at different ages, principles of diagnosis and treatment. Physiology of the menstrual cycle

For a woman, the regularity of menstruation is of great importance. Any deviations, delays, early onset of menstruation always cause alarm.

Normally, it lasts from 21 to 35 days (for 60% of women, the average cycle length is 28 days); the duration of menstrual flow is from 2 to 7 days; amount of blood loss in menstrual days 40-60 ml (average 50 ml).

Very often, certain violations of the menstrual function of a woman are associated with the pathology of the uterus or appendages. However, this is not the case. Disorders of menstrual function should be considered as a result of the disease whole body.

They occur when one or more parts of the reproductive system are damaged. The normal menstrual cycle is the result of neurohormonal relationships between the CNS, hypothalamus, pituitary gland, ovaries, and uterus. Violations in any of these links can lead to menstrual dysfunction (IMF).

The causes of menstrual dysfunction can be different:

hereditary and genetic factors,
acute and chronic genital diseases,
acute and chronic somatic diseases,
endocrine diseases,
infection,
intoxication,
injury,
anomalies in the development of the genital organs,
malnutrition (obesity, cachexia),
diseases of the central nervous system,
stress,
mental disorders,
adverse factors external environment(radiation, environmental disturbances, occupational hazards)

Classification of menstrual disorders

Terminology

hypermenorrhea – heavy menstruation coming on time,
polymenorrhea- long (more than 7 days) menstruation;
proyomenorrhea- shortening of the duration of the menstrual cycle less than 21 days;
metrorrhagia- acyclic bleeding and intermenstrual bleeding;
hypomenorrhea- scanty menstruation, coming on time;
opsomenorrhea- rare menstruation at intervals of 36 days to 3 months;
amenorrhea- Absence of menstruation for 6 months. and more;
algomenorrhea- painful menstruation.

To find out the causes of menstrual dysfunction, a whole system of diagnostic tests is used.

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Menstrual irregularities can long time reduce the performance of women, accompanied by a deterioration in reproductive function (miscarriage, infertility), both immediate (bleeding, anemia, asthenia) and long-term (endometrial, ovarian, breast cancer) consequences and complications.

Causes of menstrual irregularities

Violation of the menstrual cycle is mainly secondary, i.e. it is a consequence of genital (damage to the regulatory system and target organs of the reproductive system) and extragenital pathology, exposure to various adverse factors on the system of neurohumoral regulation of reproductive function.

To leading etiological factors menstrual irregularities include:

violations of the restructuring of the hypothalamic-pituitary system during critical periods of development female body especially during puberty;
diseases of the female genital organs (regulatory, purulent-inflammatory, tumor, trauma, malformations);
extragenital diseases (endocrinopathy, chronic infections, tuberculosis, diseases of the cardiovascular system, hematopoiesis, gastrointestinal tract and liver, metabolic diseases, neuropsychiatric diseases and stress);
occupational hazards and environmental problems (exposure to chemicals, microwave fields, radioactive radiation, intoxication, sudden climate change, etc.);
violation of the diet and work (obesity, starvation, hypovitamia, physical fatigue and etc.);
genetic diseases.

Menstrual irregularities can also be caused by other reasons:

Hormone imbalance. A decrease in the level of progesterone in the body is often the cause of a hormonal imbalance in the body, which leads to disruption of the menstrual cycle.
stressful situations. Violation of the menstrual cycle caused by stress is often accompanied by irritability, headaches, and general weakness.
genetic predisposition. If your grandmother or mother had problems of this kind, it is quite possible that you inherited such a disorder.
Lack of vitamins, minerals in the body, exhaustion of the body, painful thinness.
Climate change.
Acceptance of any medicines can provide side effect as a violation of the menstrual cycle.
Infectious diseases of the genitourinary system.
Alcohol abuse, smoking.

It should be emphasized that by the time the patient goes to the doctor. The action of the etiological factor may disappear, but its consequence will remain.

Phases of the menstrual cycle

Follicular phase

The menstrual phase includes the period of menstruation itself, which in total can be from two to six days. The 1st day of menstruation is considered the beginning of the cycle. With the onset of the follicular phase, menstrual flow stops and the hormones of the hypothalamus-pituitary gland system begin to be actively synthesized. The follicles grow and develop, the ovaries produce estrogens, which stimulate the renewal of the endometrium and prepare the uterus to accept the egg. This period lasts about fourteen days and stops when hormones are released into the blood, which inhibit the activity of follitropins.

ovulatory phase

During this period, the mature egg leaves the follicle. This is due to the rapid increase in the level of luteotropins. Then it penetrates into the fallopian tubes, where fertilization takes place directly. If fertilization does not occur, the egg dies within twenty-four hours. On average, the ovulatory period occurs on the 14th day of the MC (if the cycle lasts twenty-eight days). Small deviations are considered the norm.

luteinizing phase

The luteinizing phase is the last phase of the MC and usually lasts about sixteen days. During this period, a corpus luteum appears in the follicle, producing progesterone, which promotes the attachment of a fertilized egg to the uterine wall. If pregnancy does not occur, the corpus luteum ceases to function, the amount of estrogen and progesterone decreases, which leads to rejection of the epithelial layer, as a result of increased prostaglandin synthesis. This completes the menstrual cycle.

The processes in the ovary that occur during the MC can be represented in the following way: menstruation → maturation of the follicle → ovulation → development of the corpus luteum → completion of the functioning of the corpus luteum.

Regulation of the menstrual cycle

The cerebral cortex, the hypothalamus-pituitary-ovaries system, uterus, vagina, fallopian tubes take part in the regulation of the menstrual cycle. Before proceeding with the normalization of the MC, you should visit a gynecologist and pass all necessary tests. With concomitant inflammatory processes and infectious pathologies, antibiotic treatment, physiotherapy can be prescribed. To strengthen immune system need to take vitamin and mineral complexes, balanced diet, rejection of bad habits.

Failure of the menstrual cycle

Failure of the menstrual cycle most often occurs in adolescents in the first year or two after the onset of menstruation, in women in the postpartum period (up to the end of lactation), and is also one of the main signs of the onset of menopause and the completion of the ability to fertilize. If the failure of the menstrual cycle is not associated with any of these reasons, then such a disorder can be triggered by infectious pathologies of the female genital organs, stressful situations, hormonal disorders in the body.

Speaking about the failure of the menstrual cycle, one should also take into account the duration and intensity of menstrual flow. So, excessively abundant discharge can signal the development of a neoplasm in the uterine cavity, and can also be the result of negative impact intrauterine device. A sharp decrease in the contents released during menstruation, as well as a change in the color of the discharge, may indicate the development of a disease such as endometriosis. Any abnormal bloody discharge from the genital tract can be a sign of an ectopic pregnancy, so if you experience any irregularities in your monthly cycle, it is strongly recommended to consult a doctor.

Delayed menstrual cycle

If menstruation has not occurred within five days of the expected date, this is considered to be a delay in the menstrual cycle. One of the reasons for the non-occurrence of menstruation is pregnancy, so a pregnancy test is the first thing to do if your period is late. If the test turns out to be negative, the cause should be sought in diseases that may have affected the MC and caused its delay. Among them are diseases of a gynecological nature, as well as diseases of the endocrine, cardiovascular system, neurological disorders, infectious pathologies, hormonal changes, lack of vitamins, trauma, stress, overstrain, etc. In adolescence, a delay in the menstrual cycle in the first year or two after the onset of menstruation is a very common phenomenon, since hormonal background at this age is still not stable enough.

Symptoms of menstrual disorders

Hypomenapral syndrome is a violation of the menstrual cycle, which is characterized by a decrease in the volume and duration of menstruation until they stop. Occurs in both preserved and broken cycles.

Allocate the following forms hypomenstrual syndrome:

Hypomenorrhea - scanty and short periods.
Oligomenorrhea - delay in menstruation from 2 to 4 months.
Opsomenorrhea - delay of menstruation from 4 to 6 months.
Amenorrhea - extreme form hypomenstrual syndrome, is the absence of menstruation for 6 months. and more in the reproductive period.

Physiological amenorrhea occurs in girls before puberty, in pregnant and breastfeeding women, and in postmenopausal women.

Pathological amenorrhea is divided into primary, when menstruation does not appear in women over 16 years of age, and secondary, when MC does not recover within 6 months. in a previously menstruating woman.

Different types of amenorrhea differ in their causes and the level of damage in the reproductive system.

Primary amenorrhea

Violation of the menstrual cycle, which is a lack of factors and mechanisms that ensure the launch of the menstrual function. The examination needs 16-year-old (and possibly 14-year-old) girls who by this age do not develop mammary glands. In girls with normal MC, the mammary gland should have an unchanged structure, regulatory mechanisms (hypothalamic-pituitary axis) should not be disturbed.

Secondary amenorrhea

The diagnosis is made in the absence of menstruation for more than 6 months (except pregnancy). As a rule, this condition is caused by disturbances in the activity of the hypothalamic-pituitary axis; the ovaries and endometrium are rarely affected.

Oligomenorrhea

This menstrual irregularity occurs in women with irregular sex life when regular ovulation does not occur. In the reproductive period of life, the cause is most often polycystic ovary syndrome.

menorrhagia

Profuse blood loss.

Dysmenorrhea

Painful menses. 50% of women in the UK complain of painful periods, 12% very painful.

Primary dysmenorrhea- painful menstruation in the absence of organic cause. This menstrual irregularity occurs after the onset of the ovarian cycle shortly after menarche; pains are cramping in nature, radiating to the lower back and groin, the maximum severity in the first 1-2 days of the cycle. Excessive production of prostaglandins stimulates excessive contraction of the uterus, which is accompanied by ischemic pain. To reduce the production of prostaglandins and, as a result, pain leads to the use of prostaglandin inhibitors, such as mefenamic acid, at a dose of 500 mg every 8 hours orally. Pain can be relieved by suppressing ovulation by taking combined contraceptives(dysmenorrhea may be the reason for prescribing contraceptives). Pain is relieved somewhat after childbirth by stretching the cervical canal, but surgical stretching can cause cervical leakage and is not currently used as a treatment.

Secondary dysmenorrhea due to pathology of the pelvic organs, such as endometriosis, chronic sepsis; occurs in late age. It is more constant, observed throughout the period and often combined with deep dyspareuia. The best way to treat is to treat the underlying disease. When using viutriuterine contraceptives (IUDs), dysmenorrhea increases.

Intermenstrual bleeding

Menstrual irregularity that occurs in response to the production of estrogen in the middle of the cycle. Other causes: cervical polyp, ectropion, carcinoma; vaginitis; hormonal contraceptives(locally); Navy; pregnancy complications.

Bleeding after intercourse

Causes: trauma of the cervix, polyps, cervical cancer; vaginitis of various etiologies.

Bleeding after menopause

Menstrual irregularity that occurs 6 months after the last menstrual period. The cause, until proven otherwise, is believed to be endometrial carcinoma. Other causes: vaginitis (often atrophic); foreign bodies, such as pessaries; cancer of the cervix or vulva; polyps of the endometrium or cervix; estrogen withdrawal (with hormone replacement therapy for ovarian tumors). The patient may confuse bleeding from the vagina and from the rectum.

Pain syndrome with a saved cycle

Pain syndrome with a preserved cycle - cyclic pain observed during ovulation, the luteal phase of the MC and at the beginning of menstruation, can be caused by a number of pathological conditions.

Ovarian Hyperstimulation Syndrome - pain syndrome found in hormonal medical stimulation ovaries, which in some cases requires emergency care.

Types of menstrual dysfunction

The degree of menstrual disorders is determined by the level and depth of violations of the neurohormonal regulation of the MC, as well as changes in the target organs of the reproductive system.

There are various classifications of menstrual disorders: according to the level of damage to the reproductive system (CNS - hypothalamus - pituitary gland - ovaries - target organs), according to etiological factors, according to the clinical picture.

Menstrual disorders are divided into the following groups:

Algodysmenorrhea, or painful periods, is more common than other disorders, can occur at any age and occurs in about half of women. With algomenorrhea, pain during menstruation is combined with headache, general weakness, nausea, and sometimes vomiting. The pain syndrome usually persists from several hours to two days.
Dysmenorrhea. Such a violation is characterized by the instability of the MC - menstruation can either be significantly delayed or begin earlier than expected.
Oligomenorrhea is a violation of the menstrual cycle, which is characterized by a reduction in the duration of menstruation to two or less days. Menstrual flow is usually scanty, the duration of the intermenstrual period can be more than thirty-five days.
Amenorrhea is the absence of menstruation for several cycles.

Treatment of menstrual irregularities

Treatment of menstrual disorders is diverse. It can be conservative, surgical or mixed. Often, the surgical stage is followed by treatment with sex hormones, which performs a secondary, corrective role. This treatment can be worn as radical, pathogenetic character, completely restoring the menstrual and reproductive functions of the body, and play a palliative, replacement role, creating an artificial illusion of cyclic changes in the body.

Correction organic disorders target organs of the reproductive system, as a rule, is achieved surgically. Hormone therapy is used here only as aid, for example, after removal of the synechia of the uterine cavity. In these patients, the most commonly used oral contraceptives(OK) in the form of cyclic courses for 3-4 months.

Surgical removal of gonads containing male germ cells is mandatory in patients with gonadal dysgenesis with a 46XY karyotype due to the risk of malignancy. Further treatment is carried out in conjunction with an endocrinologist.

Hormone replacement therapy (HRT) with sex hormones is prescribed at the end of the patient's growth (closure of bone growth zones) at the first stage only with estrogens: ethinylestradiol (microfollin) 1 tablet / day - 20 days with a break of 10 days, or estradiol dipropionate 0.1% solution 1 ml intramuscularly - 1 time in 3 days - 7 injections. After the appearance of menstrual-like discharge, they switch to combined therapy with estrogens and gestagens: microfotlin 1 tablet / day - 18 days, then norethisterone (norcolut), duphaston, lutenil 2-3 tablets / day - 7 days. Since this therapy is carried out for a long time, for years, breaks of 2-3 months are allowed. after 3-4 cycles of treatment. Similar treatment can also be carried out with OK with a high level of estrogen component - 0.05 mg of ethinylestradiol (non-ovlon), or with HRT preparations for menopausal disorders (femoston, cycloproginova, divin).

Tumors of the pituitary-hypothalamic region (sellar and suprasellar) are subject to surgical removal or undergo radiation (proton) therapy followed by replacement therapy with sex hormones or dopamine analogs.

Hormone replacement therapy is indicated for patients with hyperplasia and tumors of the ovaries and adrenal glands with increased production of sex steroids of various origins in isolation or as a postoperative stage of treatment, as well as in postovariectomy syndrome.

The greatest difficulty in therapy various forms amenorrhea presents primary lesion ovaries (ovarian amenorrhea). Therapy of the genetic form (premature ovarian failure syndrome) is exclusively palliative in nature (cyclic HRT with sex hormones). Until recently, a similar scheme was proposed for ovarian amenorrhea of autoimmune origin (ovarian resistance syndrome). The frequency of autoimmune oophoritis is, according to various authors, from 18 to 70%. At the same time, antibodies to ovarian tissue are determined not only in hypergonadotropic, but also in 30% of patients with normogonadotropic amenorrhea. Currently, to remove the autoimmune block, the use of corticosteroids is recommended: prednisolone 80-100 mg / day (dexamethasone 8-10 mg / day) - 3 days, then 20 mg / day (2 mg / day) - 2 months.

The same role can be played by antigonadotropic drugs (gonadotropin-releasing hormone agonists) prescribed for up to 8 months. In the future, with an interest in pregnancy, ovulation stimulants (clostilbegit) are prescribed. In patients with hypergonadotropic amenorrhea, the effectiveness of such therapy is extremely low. For the prevention of estrogen deficiency syndrome, they are shown the use of HRT drugs for menopausal disorders (femoston, cycloproginova, divin, trisequence, etc.).

Diseases of the most important endocrine glands organisms, secondary to sexual dysfunction, require treatment first of all by an endocrinologist. Therapy with sex hormones is often not required or is of an auxiliary nature. At the same time, in some cases, their parallel administration allows for faster and more stable compensation of the underlying disease (diabetes mellitus). On the other hand, the use of ovarian TFD allows, at the appropriate stage of treatment, to select the optimal dose of the drug for pathogenetic effects both for restoring menstrual and reproductive functions and for compensating for the underlying disease.

Therapy of milder than amenorrhea stages of hypomenstrual syndrome is closely related to the degree of MC hormonal insufficiency. For the conservative hormone therapy violations of menstrual function, the following groups of drugs are used.

Menstrual disorders: treatment

In violation of the menstrual cycle, which is associated with hormonal imbalance and progesterone deficiency, use the drug cyclodinone. The drug is taken once a day in the morning - one tablet or forty drops one time, without chewing and drinking water. General course treatment is 3 months. In the treatment of various menstrual disorders, such as algomenorrhea, amenorrhea, dysmenorrhea, as well as menopause, the drug remens is used. He promotes normal functioning systems "hypothalamus-pituitary-ovaries" and aligns hormonal balance. On the first and second days, the drug is taken 10 drops or one tablet eight times a day, and starting from the third day - 10 drops or one tablet three times a day. The duration of treatment is three months.

Modern drugs for drug correction of menstrual dysfunction

Drug group	A drug
Gestagens	Progesterone, 17-hydroxyprotesterone capronate (17-OPK), uterogestan, duphaston, norethistron, norcolut, acetomepregenol, orgametril
Estrogens	Estradiol dipropionate, ethinylestradiol (microfollin), estradiol (estradiol-TTC, Climara), estriol, conjugated estrogens
Oral contraceptives	Non-ovlon, anteovine, triquilar
Antiandrogens	Danazol, cyproterone acetate (Diane-35)
Antiestrogens	Clostilbegit (clomiphene citrate), tamoxifen
Gonadotropins	Pergonal (FSH+LH), Metrodin (FSH), Profazi (LH) Choriogonin
Gonadotropin-releasing hormone agonists	Zoladex, buserelin, decapeptyl, decapeptyl depot
dopamine agonists	Parlodel, norprolact, dostinex
Analogues of hormones and other endocrine glands	Thyroid and antithyroid drugs, corticosteroids, anabolics, insulins

In patients with endocrine infertility, additional application ovulation stimulants.

As the first stage of treatment of patients with infertility, it is possible to prescribe combined OCs (non-ovlon, triquilar, etc.) in order to achieve a rebound effect (withdrawal syndrome). OK is used according to the usual contraceptive scheme for 2-3 months. If there is no effect, you should switch to direct ovulation stimulants.

Antiestrogens - the mechanism of action of AE is based on a temporary blockade of the LH-RH receptors of gonadotrophs, the accumulation of LH and FSH in the pituitary gland, followed by the release of their increased amount into the bloodstream with stimulation of the growth of the dominant follicle.

In the absence of the effect of treatment with clostilbegit, stimulation of ovulation with gonadotropins is possible.

Gonadotropins have a direct stimulating effect on the growth of follicles, their production of estrogen and egg maturation.

Violation of the menstrual cycle is not treated with gonadotropins in the following cases:

hypersensitivity to the drug;
ovarian cysts;
uterine fibroids and anomalies in the development of the genital organs, incompatible with pregnancy;
dysfunctional bleeding;
oncological diseases;
pituitary tumors;
hyperprolactinemia.
Gn-RH analogs - zoladex, buserelin, etc. - are used to imitate the natural impulse secretion of LH-RH in the body.

It should be remembered that in the event of an artificially induced pregnancy, against the background of the use of ovulation stimulants, pregnancy requires the obligatory appointment of preserving hormonal therapy at its early, pre-placental stage (progesterone, uterogestan, duphaston, turinal).

Menstruation is an essential aspect of the lives of all women and girls. The menstrual cycle begins at about 10 years of age and continues for 30-40 years. During this time, 70% of women have any disturbances in the functioning of this system. But few people know why menstrual irregularities occur. What are the symptoms of pathology, and what is the prevention and treatment of NMC?

Menstruation: norm and pathology

The menstrual cycle consists of three phases:

This process enables a woman to conceive a child. The cycle is controlled by the pituitary gland, ovaries, uterus and nervous system. The duration of the cycle is from 28 to 35 days. There may be deviations from this period for several days and even a week. Most of the time this is the norm.

Violation of the menstrual cycle in gynecology is characterized by:

delay in menstruation by more than 10 days;
too much short cycle(less than 21 days);
heavy bleeding for more than 7 days;
cycle irregularity;
soreness.

It is important if you have one of these symptoms, seek help from a doctor to establish the causes of the deviation and start treatment on time.

Some of the diseases that cause violations in women monthly cycle, can lead to infertility or even the development of cancerous tumors.

Types of NMC

There is such a classification of menstrual irregularities:

Features of NMC at a young age

Menstruation begins in girls at the age of 10-14 years. A constant menstrual cycle is established for about a year. In adolescents, it ranges from 20 to 40 days. Menstruation at this time is not plentiful and lasts 3-7 days. Anxiety should cause too much bleeding during menstruation, strong pain, lack of menstruation for more than six months. With such symptoms, you should consult a doctor.

These disorders occur in girls during puberty, since the reproductive system during this period is particularly sensitive to the influence of adverse factors. The most common causes of NMC in adolescents are:

poor nutrition;
stress;
bulimia and anorexia;
infectious and colds.

Types of NMC found in girls:

Oligomenorrhea.
Metrorrhagia.
Menorrhagia.

Diseases that cause violations of the monthly cycle in adolescent girls:

Causes of violations and diagnostic methods

The functioning of the menstrual system can be affected by such factors:

Irregular menstruation can be a symptom of many diseases, these include:

It's pretty serious illness therefore, when NMC appears, it is necessary to consult a gynecologist to establish a diagnosis.

To determine the cause of NMC, the doctor first collects anamnesis data from the patient. All the details are important here:

After questioning the patient, gynecological examination to detect abnormalities in the internal and external genital organs. The doctor also examines the chest and checks if the liver and thyroid gland are enlarged.

From the analyzes can appoint:

general and biochemical analysis of blood and urine;
smear from the vagina;
analysis of the level of hormones in the blood;
coagulogram (blood clotting test).

to install accurate diagnosis, use methods functional diagnostics:

radiography;
Ultrasound of the pelvic organs or other organs (depending on the specific case);
hysteroscopy;
computed tomogram;
MRI.

Based on all these data, the doctor will make a diagnosis and prescribe treatment. If the causes of NMC are not in gynecology, then consultation of other specialists will be required, for example: an endocrinologist, psychiatrist or therapist.

Menstrual cycle- cyclic hormonal changes in the body of a woman at the level of the cortex - the hypothalamus - the pituitary gland - the ovaries, accompanied by cyclic changes in the uterine mucosa and manifested by menstrual bleeding; it is a complex rhythmic repetitive biological process preparing a woman's body for pregnancy.

Cyclic menstrual changes begin at puberty. First menses (menarche) appear at 12-14 years of age and continue into childbearing age(up to 45 - 50 years). Fertilization occurs in the middle of the menstrual cycle after ovulation, the unfertilized egg quickly dies, the uterine mucosa, prepared for egg implantation, is rejected, and menstrual bleeding occurs.

The duration of the menstrual cycle is counted from the first day of the past to the first day of the last menstruation. Normal length of the menstrual cycle from 21 to 35 days, duration of menstruation on average 3-4 days, up to 7 days, amount of blood loss 50-100 ml. The normal menstrual cycle is always ovulatory.

Cyclic functional changes in the hypothalamus-pituitary-ovaries system are conditionally combined into ovarian cycle, and cyclic changes in the uterine mucosa - into the uterus. At the same time, cyclic shifts occur throughout the woman's body ( menstrual wave), which are periodic changes in the activity of the central nervous system, metabolic processes, functions of the cardiovascular system and thermoregulation.

According to modern ideas menstrual function is regulated by the neurohumoral pathway with the participation of:

1. cerebral cortex- regulates the processes associated with the development of menstrual function. Through it, the influence of the external environment on the underlying parts of the nervous system involved in the regulation of the menstrual cycle is carried out.

2. subcortical vegetative centers located primarily in the hypothalamus- it concentrates the influence of CNS impulses and hormones of peripheral endocrine glands, its cells contain receptors for all peripheral hormones, including estrogens and progesterone. Neurohormones of the hypothalamus that stimulate the release of tropic hormones in the anterior pituitary gland are releasing factors (liberins) that inhibit the release of tropic hormones - statins.

The nerve centers of the hypothalamus produce 6 releasing factors that enter the blood, the system of cavities of the third ventricle of the brain, into cerebrospinal fluid, are transported by nerve fibers into the pituitary gland and lead to the release in the anterior lobe of its corresponding tropic hormones:

1) somatotropic releasing factor (SRF) or somatoliberin

2) adrenocorticotropic releasing factor (ACTH-RF) or corticoliberin

3) thyrotropic releasing factor (TRF) or thyreoliberin

4) follicle-stimulating releasing factor (FSH-RF) or folliberin

5) luteinizing releasing factor (RLF) or luliberin

6) prolactin-releasing factor (LRF) or prolactoliberin.

FSH-RF, LRF and PRF are related to menstrual function, which release the corresponding gonadotropic hormones in the adenohypophysis.

Of the statins, only somatotropin inhibitory factor (SIF) or somatostatin and prolactin inhibitory factor (PIF) or prolactinostatin are currently known.

3. pituitary gland- its anterior lobe (adenohypophysis) synthesizes adrenocorticotropic (ACTH) hormone, somatotropic (STH), thyrotropic (TSH), follicle-stimulating (FSH), luteinizing (LH), prolactin (lactotropic, PRL). In the regulation of menstrual function, the last three hormones take part - FSH, LH, PRL, united under the name of pituitary gonadotropic hormones:

FSH causes the development and maturation of the primary follicle. The rupture of the mature follicle (ovulation) occurs under the influence of FSH and LH, then the corpus luteum is formed under the influence of LH. Prolactin stimulates the synthesis and secretion of progesterone, turns a non-functioning corpus luteum into a functioning one. In the absence of prolactin, the reverse development of this gland occurs.

4. Ovary- perform hormonal(formation of estrogen and progesterone) and generative(follicle maturation and ovulation) functions.

In the first phase (follicular) of the menstrual cycle, under the influence of FSH of the pituitary gland, the growth of one or several follicles begins, but usually one follicle reaches the stage of full maturation. Other follicles, the growth of which began along with the normally developing, undergo atresia and reverse development. The process of maturation of the follicle takes the first half of the menstrual cycle, i.e., with a 28-day cycle, it lasts 14 days. In the process of development of the follicle, all its constituent parts undergo significant changes: the egg, the epithelium, the connective tissue membrane.

Ovulation- this is a rupture of a large mature follicle with the release of an egg surrounded by 3-4 rows of epithelium in abdominal cavity and then into the ampulla of the fallopian tube. Accompanied by hemorrhage into the walls of the bursting follicle. If fertilization does not occur, the egg is destroyed after 12-24 hours. During the menstrual cycle, one follicle matures, the rest undergo atresia, the follicular fluid is resorbed, and the follicle cavity is filled connective tissue. During the entire reproductive period, about 400 eggs ovulate, the rest undergo atresia.

Luteinization- transformation of the follicle after past ovulation into the corpus luteum. In some pathological conditions, luteinization of the follicle is possible without ovulation. The corpus luteum is the multiplied cells of the granular layer of the follicle that has undergone ovulation, which turn yellow due to the accumulation of lipochromic pigment. Cells of the inner zone also undergo luteinization, turning into theca-luteal cells. If fertilization does not occur, corpus luteum exists 10-14 days, passing during this time the stages of proliferation, vascularization, flourishing and regression.

In the ovary, biosynthesis of three groups of steroid hormones occurs - estrogen, progestogen and androgens.

a) estrogen- are secreted by the cells of the inner membrane of the follicle, are also formed in a small amount in the corpus luteum and adrenal cortex. The main estrogens of the ovary are estradiol, estrone and estriol, and the first two hormones are predominantly synthesized. These hormones provide specific action on the female genital organs:

Stimulate the development of secondary sexual characteristics

Cause hypertrophy and hyperplasia of the endometrium and myometrium, improve blood supply to the uterus

Contribute to the development of the excretory system of the mammary glands, the growth of secretory epithelium in the milk ducts

b) gestagens- secreted by luteal cells corpus luteum, as well as luteinizing cells of the granular layer and membranes of the follicles, the cortical substance of the adrenal glands. Action on the body:

Suppress estrogen-induced endometrial proliferation

Transform the lining of the uterus into the secretion phase

In the case of fertilization, the eggs suppress ovulation, prevent uterine contractions, and contribute to the development of alveoli in the mammary glands.

c) androgens- are formed in the interstitial cells, the inner membrane of the follicles (in a small amount) and in the reticular zone of the adrenal cortex. Action on the body:

Stimulate the growth of the clitoris, cause hypertrophy of the labia majora and atrophy of the minor

In women with a functioning ovary, they affect the uterus: small doses cause pregravid changes in the endometrium, large doses - its atrophy, suppress lactation

IN large doses cause masculinization

In addition, inhibins are synthesized in the ovary (inhibit the release of FSH), oxytocin, relaxin, prostaglandin.

5. uterus, fallopian tubes and vagina containing receptors that respond to the action of ovarian sex hormones.

The uterus is the main target organ for the ovarian sex hormones. Changes in the structure and function of the uterus under the influence of sex hormones are called the uterine cycle and include a succession of four phases of changes in the endometrium: 1) proliferation 2) secretion 3) desquamation 4) regeneration. First two phase main, so the normal menstrual cycle is considered two-phase:

A) proliferation phase- lasts 12-14 days, characterized by the restoration of the functional layer of the uterine mucosa due to the growth of the remnants of the glands, vessels and stroma of the basal layer under the increasing action of estrogen

b) secretion phase- with a 28-day menstrual cycle, it starts on the 14-15th day and continues until the onset of menstruation. The secretion phase is characterized by the fact that under the action of progestogens, the endometrial glands produce a secret, the endometrial stroma swells, and its cells increase in size. IN glandular epithelium endometrium accumulates glycogen, phosphorus, calcium and other substances. Conditions are created for implantation and development of the egg. If pregnancy does not occur, the corpus luteum undergoes regression, the growth of a new follicle begins, which leads to sharp decline blood levels of progesterone and estrogen. This causes necrosis, hemorrhage and shedding of the functional mucosal layer and the onset of menstruation (desquamation phase). The regeneration phase begins during the period of desquamation and ends by 5-6 days from the onset of menstruation, occurs due to the growth of the epithelium of the remnants of the glands in the basal layer and by the proliferation of other elements of this layer (stroma, vessels, nerves); due to the influence of estrogens of the follicle, the development of which begins after the death of the corpus luteum.

In the fallopian tubes, the vagina also has receptors for sex steroid hormones, but cyclic changes in them are less pronounced.

In the self-regulation of menstrual function, an important role is played by feedback type between the hypothalamus, adenohypophysis and ovaries, there are two types:

a) negative type- the production of releasing factors and gonadotropic hormones of the pituitary gland is suppressed by a large amount of ovarian hormones

b) positive type- The production of neurohormones and gonadotropins is stimulated by a low content of ovarian sex hormones in the blood.

Menstrual disorders:

a) depending on age period woman's life:

1) during puberty

2) during puberty

3) in premenopause

b) depending on clinical manifestations:

1) amenorrhea and hypomenstrual syndrome

2) menstrual disorders associated with bleeding

3) algomenorrhea

38. Primary amenorrhea: etiology, classification, diagnosis and treatment.

Amenorrhea- Absence of menstruation for 6 months or more.

A) false amenorrhea- a condition in which cyclic processes in the hypothalamus - pituitary gland - ovaries - uterus occur during the menstrual cycle, but the torn endometrium and blood do not find their way out

b) true amenorrhea- a condition in which there are no cyclic changes in the hypothalamus - pituitary - ovaries - uterus system, there is no menstruation. Happens:

1) physiological- observed: in girls before puberty; in women during pregnancy, lactation, postmenopause

2) pathological

1. primary- lack of menstrual function in girls 15-16 years of age and older

2. secondary- cessation of menstruation after they have been at least once

Classification of primary amenorrhea depending on the etiology and level of damage:

1. Amenorrhea due to dysfunction of the gonads (ovarian form)

a) gonadal dysgenesis (Shereshevsky-Turner syndrome)

b) testicular feminization

c) primary ovarian hypofunction

2. Amenorrhea due to extragonadal causes:

a) hypothalamic (as a result of exposure to adverse factors on the central nervous system)

b) pituitary (damage to the adenohypophysis due to tumors or dystrophic processes associated with circulatory disorders in this area)

c) uterine (anomalies in the development of the uterus, changes in the endometrium of varying degrees - from a decrease in the sensitivity of its receptors to the effects of sex hormones to the complete destruction of the endometrium)

d) amenorrhea due to congenital hyperplasia of the adrenal cortex (adrenogenital syndrome)

e) amenorrhea due to dysfunction thyroid gland(hypothyroidism)

Clinical picture determined by the nature of the disease that led to amenorrhea. The prolonged existence of amenorrhea leads to secondary emotional and mental disorders and vegetative-vascular disorders, which is manifested by general weakness, irritability, memory impairment and disability, unpleasant sensations in the region of the heart, pathological sweating, hot flashes, headache, etc.

Diagnostics:

1. History taking

2. Examination of the patient: physique, the nature of fat deposition, the nature of hair growth, the state of the thyroid gland, the development of secondary sexual characteristics, pigmentation, etc.

3. Gynecological examination

4. Laboratory and instrumental research methods - the volume depends on the alleged cause of amenorrhea, includes:

a) functional diagnostic tests

b) determination of the level of hormones in blood plasma (FSH, LH, prolactin, etc.) and in urine

c) hormonal tests (with progesterone, combined estrogen-progesterone, dexamethasone, ACTH, choriogonin, FSH, releasing factor)

d) radiological research methods: radiography of the skull and sella turcica, pelviography, pneumoperitoneography

e) endoscopic research methods: colposcopy, cervicoscopy, hysteroscopy, culdoscopy

e) Ultrasound of the pelvic organs

g) biopsy of gonadal tissues

h) determination of sex chromatin and karyotype

i) study of patency of the fallopian tubes - pertubation, hydrotubation, hysterosalpingography

j) other additional research methods if necessary

Treatment: depends on the identified level of damage, should be etiological, aimed at treating the underlying disease. If the cause of the disease could not be identified, then the treatment, if possible, should be pathogenetic, aimed at restoring the function of the impaired link of the functional systems that regulate menstrual function.

With amenorrhea of the central genesis, the correct organization of the rest regimen, rational nutrition, physical exercise, climatotherapy, sedatives and anxiolytics, vitamin therapy, physiotherapy treatment (collar according to Shcherbakov, indirect electrical stimulation of the hypothalamic-pituitary system with a low-frequency impulse current, endonasal electrophoresis, etc.).

In amenorrhea caused by functional hyperprolactinemia, drugs that suppress the secretion of prolactin (bromocriptine) are used; if a pituitary tumor is detected, patients are subject to special treatment.

With underdevelopment of the genital organs against the background of ovarian hypofunction, therapy with hormonal drugs (estrogens, cyclic hormonal therapy with estrogens and progesterones, courses of hormone replacement therapy) is indicated.

39. Secondary amenorrhea: etiology, classification, diagnosis and treatment.

Classification of secondary amenorrhea depending on the etiology and level of damage:

1. Hypothalamic(associated with impaired CNS function)

a) psychogenic - develops as a result of stressful situations

b) combination of amenorrhea with galactorrhea (Chiari-Frommel syndrome)

V) " false pregnancy"- in women with severe neurosis due to the desire to have a child

G) anorexia nervosa- in girls on the ground mental trauma

e) amenorrhea due to debilitating diseases and intoxications (schizophrenia, manic-depressive psychosis, diabetes mellitus, diseases of the cardiovascular system, liver, etc.)

2. Pituitary(more often due to organic lesions of the pituitary gland):

a) amenorrhea due to necrotic changes in the tissue of the adenohypophysis (Sheehan's syndrome - postpartum hypopituitarism, Simmonds disease)

b) amenorrhea caused by a pituitary tumor (Itsenko-Cushing's disease, acromegaly)

3. Ovarian:

a) premature ovarian failure early menopause) - menstruation stops at 30-35 years

b) sclerocystic ovaries (Stein-Leventhal syndrome) - steroidogenesis in the ovaries is disturbed, which leads to hyperproduction of androgens and suppression of estrogen production.

c) amenorrhea associated with androgen-producing ovarian tumors

d) amenorrhea, due to exposure to ionizing radiation on the ovarian tissue, after removal of the ovaries (post-castration syndrome)

4. Royal- due to pathology primarily occurring in the endometrium, the cause of which may be:

a) tuberculous endometritis

b) traumatic injury endometrium after curettage of the uterine cavity during abortion or after childbirth

c) exposure to the uterine mucosa of chemical, radioactive and other substances

Diagnostics and clinical picture : see question 38.

Treatment: see question 38 +

In Sheehan's syndrome, Simmonds' disease is indicated replacement therapy sex steroids, thyroidin, glucocorticoids, ACTH.

This material reproduces one of the lectures given by the author of this resource at advanced training courses for nursing staff.

Menstrual cycle- These are regular cyclic changes that occur in the reproductive system of a woman and indirectly cause cyclic changes throughout the body. The essence of these changes is to prepare the body for pregnancy. In the absence of fertilization, the menstrual cycle ends with bleeding, called "menstruation" - the crying of the uterus with bloody tears for a failed pregnancy.

The menstrual cycle continues from the first day of the last menstruation to the first day of the next. In most women, the cycle lasts 28 days, however, a cycle of 28 +\- 7 days with a blood loss of 80 ml can be considered normal.

Violation of the menstrual cycle is a symptom of various gynecological and endocrine diseases, sometimes leading to the loss of a woman's reproductive function or the development of precancerous and cancerous processes in the female genital organs.

The menstrual cycle may be irregular for up to 2 years after the first period and up to 3 years before menopause. If it is irregular during the rest of the reproductive period, this is a pathology and requires appropriate examination and treatment.

Currently, the issues of the etiology and pathogenesis of NMC are not well understood, and therefore rational classifications them is impossible. Numerous classifications of NMC have been proposed, but most of them are not based on the etiological and pathogenetic principle, but take into account only the clinical symptoms of a cycle disorder (amenorrhea or bleeding, preservation of a two-phase cycle or its absence, pathology of the development of the follicle or corpus luteum, disorders of the hypothalamic-pituitary system, etc.). .d.)

Factors leading to disorders of menstrual function are:

strong emotional upheavals
mental or nervous diseases(organic or functional);
malnutrition (quantitative and qualitative),
beriberi,
obesity of various etiologies;
occupational hazards (exposure to certain chemicals, physical factors, radiation);
infectious and septic diseases;
chronic diseases of organs and systems
transferred gynecological operations;
injuries of the genitourinary organs;
inflammatory diseases and tumors of the female genital organs
brain tumors;
chromosomal disorders;
congenital underdevelopment of the genital organs;
involutional restructuring of the hypothalamic centers in the menopause.

Considering that there are 5 levels of regulation of the menstrual cycle in the reproductive system, the listed factors may affect one of them. Depending on the level of damage to neurohumoral regulation, groups of these disorders are distinguished, classifying them according to the mechanism of pathogenesis:

cortical-hypothalamic
hypothalamic-pituitary
pituitary
ovarian
uterine
NMC in extragenital diseases (thyroid gland, adrenal glands, metabolism)
Genetic disorders

Classification by the nature of violations

NMC against the background of organic disorders
Functional NMC

Classification according to the content of gonadotropins

hypogonadotropic
normogonadotropic
hypergonadotropic

Classification by clinical manifestations

amenorrhea - absence of menstruation
hypomenorrhea - scanty menstruation that comes on time
hypermenorrhea or menorrhagia - heavy menstruation that comes on time
metrorrhagia - intermenstrual bleeding
polymenorrhea - prolonged menstruation for more than 6 - 7 days
oligomenorrhea - short (1-2 days), cyclical menstruation
proyomenorrhea, tachymenorrhea - shortening of the duration of the menstrual cycle (less than 21 days)
opsomenorrhea - infrequent menstruation, at intervals of 35 days to 3 months
algomenorrhea - painful menstruation
hypomenstrual syndrome - a combination of rare scanty menstruation with a shortening of their duration

Since we begin the appointment with the clarification of the patient's complaints, it is rational to start the analysis based on the classification according to clinical manifestations. Thus, the classification can be narrowed down to three groups:

Amenorrhea
Dysfunctional uterine bleeding

Amenorrhea

Amenorrhea is the absence of menstruation between the ages of 16 and 45 for 6 months or more without taking hormonal drugs.

Distinguish:

False amenorrhea - a condition in which cyclic processes in the hypothalamus-pituitary-ovaries-uterus system are normal, external excretion menstrual blood this does not occur, most often it is atresia (infection) of the vagina, cervical canal or hymen - surgical treatment
True amenorrhea, in which there are no cyclic changes in the hypothalamus - pituitary gland - ovaries - uterus, and menstruation is clinically absent. True amenorrhea can be physiological and pathological, as well as primary and secondary.

Physiological amenorrhea is observed in girls before puberty, during pregnancy, lactation, and in the postmenopausal period. Pathological primary amenorrhea - when menstruation has never been, and secondary - when, after a sufficiently long period of a regular or irregular menstrual cycle, menstruation has stopped. As a result of taking drugs (gonadotropin-releasing hormone agonists (zoladex, buserelin, triptorelin), antiestrogen (tamoxifen), gestrinone, 17-ethynyltestosterone derivatives (danazol, danol, danovan), pharmacological amenorrhea is observed.

Generally The causes of amenorrhea can be divided into two groups:

amenorrhea due to dysfunction of the gonads
1. Gonadal dysgenesis - due to genetic defects, which result in malformations of the gonads. There are 4 clinical forms of gonadal dysgenesis: typical or classic (Shereshevsky-Turner syndrome, karyotype 45X0), erased (the karyotype has a mosaic character 45XO / 46XX), pure (karyotype 46XX or 46XY (Swyer syndrome)) and mixed (karyotype 45XO / 46XY ). Gonads have a mixed structure. Diagnostics: genetic research(karyotype and sex chromatin). Treatment: in the presence of Y - surgical removal of the gonads (malignancy is possible), in other cases, HRT
2. Testicular feminization syndrome (Morris syndrome, false male hermaphroditism) - karyotype 46XY, complete (NPO female, the vagina is blind, inguinal hernia) and incomplete (NPO male) forms. Treatment - operative + HRT
3. Premature ovarian failure (syndrome of "resistant ovaries", exhausted ovary syndrome) - underdevelopment of the ovarian follicular apparatus and a decrease in their sensitivity to the action of gonadotropins. Diagnosis - determination of gonadotropins and sex steroids, laparoscopy and biopsy of the gonads. Treatment - HRT.
4. Polycystic ovary syndrome (primary polycystic ovaries-Stein-Leventhal syndrome) - a violation of steroidogenesis in the ovaries due to a lack of enzyme systems, excessive testosterone synthesis
5. Amenorrhea associated with androgen-producing ovarian tumors (ovarian androblastoma), excess testosterone.
6. Amenorrhea due to damage to the ovaries by ionizing radiation or removal of the ovaries (post-castration syndrome).
amenorrhea due to extragonadal causes
1. congenital adrenogenital syndrome(congenital hyperplasia of the adrenal cortex) - increased production of androgens. The karyotype is female, but NPO virilization is noted. At birth, a girl is mistaken for a boy. Diagnosis - ACTH, hormones of the adrenal cortex, test with glucocorticoids. CT scan of the adrenal glands. Treatment with glucocorticoids, NPO plastic surgery and the formation of the entrance to the vagina
2. hypothyroidism. Diagnosis - TSH and thyroid hormones. Treatment - thyroid medications
3. destruction of the endometrium and removal of the uterus - the uterine form of amenorrhea. Causes - tuberculosis, damage to the endometrium due to rough curettage and removal of the basal layer, damage to the endometrium due to chemical, thermal burns or cryodestruction, Asherman's syndrome (intrauterine synechia)
4. damage to the central nervous system and hypothalamic-pituitary region ( central forms amenorrhea) - wartime amenorrhea, psychogenic amenorrhea (false pregnancy), anorexia nervosa, amenorrhea with mental illness(treatment by a psychiatrist), with trauma, tumors, infectious lesions (meningoencephalitis, arachnoiditis), amenorrhea in combination with galactorrhea (Del Castillo-Forbes-Albright syndrome - amenorrhea due to mental trauma or tumor of the hypothalamic-pituitary region in nulliparous women, and Chiari-Frommel syndrome - amenorrhea and galactorrhea that occur as a complication postpartum period. Amenorrhea due to Morgagni-Stewart-Morel syndrome (frontal hyperostosis). An autosomal dominant hereditary disease is accompanied by a lesion of the hypothalamic-pituitary region as a result of calcification of the sella turcica diaphragm.
5. pituitary secondary true amenorrhea develops due to organic damage of the adenohypophysis by a tumor or circulatory disorders in it with the development of necrotic changes: Sheehan's syndrome (postpartum hypopituitarism) - the disease develops due to necrosis of the anterior pituitary gland against a background of spasm arterial vessels as a reaction to massive blood loss during childbirth or bacterial shock, Simmonds syndrome is an infectious lesion or injury, circulatory disorders or pituitary tumors. Itsenko-Cushing's disease - pituitary adenoma producing ACTH, acromegaly and gigantism - a tumor producing growth hormone.

Thus, amenorrhea is not a disease, it is a symptom of many diseases, from correct diagnosis on which the effectiveness of treatment depends.

Therefore, detailed complaints, anamnesis, general and special examination are in the first place. Based on the totality of these data, the direction is determined additional methods research. And only after laboratory and instrumental confirmation of the presumptive diagnosis, treatment is prescribed.

Dysfunctional uterine bleeding (DUB) is a violation of the menstrual cycle, which is based on a violation of the rhythmic secretion of sex hormones.

DMC, like amenorrhea, is a polyetiological disease, its causes are certain adverse effects that have a pathogenic effect on the reproductive system at various stages of the formation, formation and development of the female body.

The occurrence of DMC is facilitated by: unfavorable course of the perinatal period; emotional and mental stress; mental and physical stress; traumatic brain injury; hypovitaminosis and nutritional factors; abortions; transferred inflammatory diseases of the genitals; diseases of the endocrine glands and neuro-endocrine diseases (postpartum obesity, Itsenko-Cushing's disease); taking neuroleptic drugs; various intoxications; professional hazards; solar radiation; adverse environmental factors.

Depending on age, DMC are divided into:

Juvenile uterine bleeding (JUB).
DMC of reproductive age.
DMK premenopausal, postmenopausal (climacteric) period.

Dysfunctional diagnosis uterine bleeding exhibited when all other causes of bleeding (blood diseases, etc.) are excluded. The word "bleeding" should be understood as follows: even spotting spotting is also bleeding, which will only be treated differently (for example, profuse bleeding - immediately curettage in order to stop), spotting, however, requires examination according to functional diagnostic tests and planned diagnostic curettage .

So, DMK is a violation of the system of regulation of the menstrual cycle. In each case, it is important to determine the point at which the violation occurred: the hypothalamic-pituitary system, the ovary, or extragenital diseases.

Full regulation of the menstrual cycle can be only when well preserved feedback between the pituitary gland and the ovary and, the normal amount of hormones switches FSH production and LG. It is also necessary to remember in the event of DMC that all endocrine organs are very interconnected and a violation of any endocrine organ in the first place can lead to a violation of the production of gonadotropic hormones of the pituitary gland.

In the anterior lobe - the adenohypophysis, gonadotropic hormones - FSH and LH are produced, these are the most delicate structures of the pituitary gland. Moreover, a violation of the production of any other tropic hormone leads to a decrease in the production of follicle-stimulating and luteinizing hormone. For example, ACTH, if it goes increased output ACTH, then adrenal hyperplasia occurs, hyperplastic adrenal glands produce an increased amount of androgens. And of course increased content ACTH in the pituitary gland inhibits the production of FSH and LH, and increased amount androgens coming from the adrenal glands also inhibit ovarian function. As a result, we have menstrual dysfunction in the form of opsomenorrhea (rare menstruation), in some cases - amenorrhea (complete absence of menstruation).

Or take growth hormone- the same situation. Beautiful high growth, athletic physique and at the same time genital infantilism. If these women become pregnant, then their pregnancy may be accompanied by miscarriage, early termination of pregnancy, miscarriage, they may also suffer from infertility, because. somatotropic hormone depresses FSH and LH since childhood, and normal gonadotropic function is not formed. Even if they menstruate regularly, they still have a defective cycle.

The same is true for thyroid diseases. Women with thyroid disease suffer from both NMC and infertility. Pancreas - diabetes mellitus, women suffer from NMC, DMC, rare menstruation, with severe diabetes - amenorrhea. Therefore, when a woman develops DMC, especially if these bleedings are cyclical, it is necessary not only to work in the pituitary-ovary-uterus system, but also to work throughout endocrine system, because if we missed the thyroid gland, then we will not treat this woman well, i.e. there will be no etiopathogenetic treatment, and we will only carry out symptomatic treatment, which will give a temporary effect, only for the time of taking hormonal drugs, and as soon as we remove hormone therapy, the situation will repeat itself.

Diseases that must be excluded when making a diagnosis of dysfunctional uterine bleeding (differential diagnosis in reproductive age):

disturbed uterine pregnancy of early terms
ectopic pregnancy
placental polyp
hydatidiform mole
chorionepithelioma
differential diagnosis will depend on whether this bleeding first occurred or whether it is repeated. If a woman has bleeding for the first time against the background of a delay in menstruation, a differential diagnosis should be made with a disturbed uterine pregnancy or ectopic pregnancy. But if there are repeated violations of the menstrual cycle, for example, for half a year, menstruation comes with a delay of two weeks, passes more abundantly than usual, then naturally this is not a disturbed pregnancy.
inflammatory diseases of the uterus and appendages - endometritis, can give intermenstrual spotting for a long time with a clear release of menstruation. There is no pain syndrome and the woman feels practically healthy. Then think, first of all, about endometrial cancer, hyperplastic process- polyposis, o inflammatory disease- endometritis. Then anti-inflammatory treatment, diagnostic curettage, no pathological processes not in the uterus, the state of the endometrium corresponds to the phase of the menstrual cycle and leukocyte infiltration of the remaining stroma, which indicates the presence of endometritis.
Inflammatory processes of the appendages often give violations of an acyclic nature according to the type of metrorrhagia (i.e. there is a delay, and then copious spotting), then we carry out a differential diagnosis with an ectopic pregnancy, because there is pain, delayed menstruation and prolonged spotting.
submucosal uterine fibroids (very small, it practically does not affect the size of the uterus, the uterus may be slightly larger, but of normal consistency with a smooth surface), because mixed or subserous uterine fibroids, we expose immediately during the initial examination. We differentiate when a woman has cyclic disorders, heavy and prolonged menstruation, but the cycle is preserved, comes regularly and has a characteristic pain syndrome in the form of cramping pains during menstruation.
endometriosis of the uterus - we differentiate with repeated menstruation, profuse, prolonged, and there are spotting spotting and pain before and after menstruation.
With DMC, there is no pain, sometimes organic diseases occur without pain, such as endometriosis of the uterine body.
hyperplastic process of the endometrium (endometrial polyposis, atypical glandular hyperplasia - endometrial adenomatosis). The group of hyperplastic processes of the endometrium also includes glandular and glandular cystic hyperplasia, but we will say that these hyperplasia can be a manifestation of DMC, i.e. ovarian dysfunction that leads to these changes and we will expect this histological result and take this result as confirmation of DUB.
Cancer of the body of the uterus and cervix. We will immediately see the cervix, we reject it during colposcopy. Remember the old rule that any bleeding should be considered bleeding due to cancer, as long as we do not rule out its presence in any age period.
Ovarian sclerocystosis is differentiated if there is a violation of the menstrual cycle according to the type of opsomenorrhea (rare menstruation), although sclerocystosis can occur without a delay in menstruation according to the type of DMC, which can occur before the period of menstruation at first, and then, as the disease develops, opsomenorrhea is formed, which smoothly turns into amenorrhea if the woman is not treated.
Blood diseases

Ovarian dysfunction (primary, secondary due to dysfunction of the pituitary gland, but all forms of ovarian dysfunction are the same, regardless of the level of damage). As we examine these women, we will conduct differential diagnosis and at the same time identify the level of damage. Now this is done simply: the study of the level of hormones of the thyroid gland, adrenal glands and pituitary gland, (prolactin - in high doses inhibits the level of FSH and LH, therefore, in women with infertility and menstrual irregularities, it is the first to examine prolactin). Regardless of the level of damage in the primary ovary or in the pituitary gland, the forms of the disorder will be the same.

Forms of infringement.

Slow development of the next follicle. Clinic: menstruation turns into DMC and spotting occurs up to 14 days. Or menstruation has passed for 3-5 days, ended and a day later spotting began again, continues for several days and stops on its own.
Persistence (prolonged existence) of an immature follicle - a delay in menstruation or menstruation on time. Bleeding is not profuse and not too long. The main manifestation is a delay in menstruation and complaints of infertility.
The persistence of a mature follicle is the only one of all DMC, accompanied by profuse bleeding, anemic for the patient, occurs after a delay or during menstruation. Often they end up in a hospital for curettage in order to stop bleeding.
Follicle atresia (reverse development) - long delay(up to 2 - 3 months), sometimes on or before the period of menstruation. Bleeding is moderate, closer to meager
Intermenstrual spotting (a drop in hormone levels after ovulation) - spotting in the middle of the cycle, stops on its own. In abundance, they can resemble menstruation, then the woman will say that she had three menstruation in one month.
Persistence of the immature corpus luteum - bleeding before the onset of menstruation, on time or after a delay at a reduced progestogen level ( low progesterone in the second phase)
Persistence of the mature corpus luteum - bleeding on time or after a delay, not abundant, but prolonged. The reason is a stressful situation transferred in the second phase of the cycle. Very difficult to treat. If a woman does not immediately apply, then bleeding in duration with each cycle will increase all the time (2 weeks, a month, a month and a half and up to 2 months). At the same time, the woman will feel the early signs of pregnancy, and if she comes with a temperature chart, we will make the only diagnosis - a disturbed early pregnancy. This is due to the high level of gestagens. Treatment is less effective - only taking COCs
Syndrome of luteinization of the unovulated follicle - the follicle without ovulation turns into a corpus luteum. The reason is unknown. Complaints about infertility. Menstruation on time, of normal duration and intensity, a two-phase cycle according to rectal temperature. Diagnosis only by ultrasound: after ovulation, the follicle should disappear, and with this pathology we will see the follicle (liquid formation), which begins to decrease in size (it is delayed by the corpus luteum). Then laparoscopy in the second phase, after a rise in temperature: we should see the stigma of ovulation (a rounded hole with inverted edges), and we will see a yellowish formation - this will be an unovulated follicle undergoing luteinization. Treatment: ovulation stimulation
Atresia of the corpus luteum - bleeding before the period of menstruation, on time or after the delay of menstruation. The onset depends on the term of the death of the corpus luteum: sudden death - before the deadline, slow death - the temperature decreases gradually and menstruation on time, if it dies even more slowly, the temperature goes beyond 37 ° C, it stays that way for some time and only then against the backdrop of a delay bleeding starts. Normally, the temperature decreases one day before menstruation, if it decreases after large quantity days before the onset of menstruation, then the corpus luteum is atrezated

All these violations at the first admission are called (in the diagnosis we put down) NMC against the background of ... (indicate clinical manifestation, symptoms) opsomenorrhea, hyperpolymenorrhea, etc. In the future, we examine the woman by TFD, confirm them with the results of histology and reach a clinical diagnosis: DMC of the reproductive period against the background (indicate the form of the violation), for example, delayed development of the next follicle. In substantiation of the diagnosis, we write: on the basis of tests of functional diagnostics (TFD), a decrease in estrogen levels at the beginning of the cycle, a discrepancy between the histological result and the day of the menstrual cycle, this diagnosis was made.

Treatment: complex

stopping bleeding - hemostasis (medical or surgical), if operational - a mandatory histological examination of endometrial scrapings. With profuse bleeding - means aimed at increasing blood coagulability and contractility of the uterus + blood and plasma substitutes. If there is no effect, further measures are hormonal hemostasis and preparation for emergency curettage.
Surgical hemostasis in girls is used for ineffective hormonal hemostasis, as well as in cases of hypovolemic shock and severe anemia (Hb less than 70 g/l and Ht less than 20%).
On present stage surgical hemostasis should be carried out under the control of hysteroscopy to exclude organic causes of bleeding (myomatous node, polyp, etc.).
An auxiliary method for curettage of the uterine mucosa in the perimenopausal period can be endometrial cryodestruction, laser vaporization and electroextraction (ablation) of the endometrium, which give a stable healing effect. Your textbook says that such manipulations lead to the absence of the need for further hormone therapy. This is not true! It must be remembered that in addition to the endometrium, a woman has other target organs for sex steroids, therefore
therapy aimed at maintaining and normalizing menstrual function is required!
Menstrual function is not menstruation, it is a combination of the ovarian and uterine cycles, and if the uterine cycle (endometrial growth and its rejection) is eliminated, this does not mean that the ovarian cycle will be eliminated. The ovary will also continue to produce hormones that will act on target tissues, including breast tissue. There are no contraindications (except for oncopathology, and then, with some degree, one can say relative ones) to hormone therapy, there is a contraindication to a specific hormone, and it is up to the doctor to find the hormone that suits the woman.

Prevention of recurrent bleeding - depends on the cause of its cause

rational nutrition (increase in body weight),
general strengthening therapy (adaptogens) and vitamin therapy (E and C)
physiotherapy (phototherapy, endonasal galvanization), which enhances the gonadal synthesis of steroids
elimination of excessive stressors
identification of etiological (extragenital) causes of DMC and their elimination or correction (diseases of the liver, gastrointestinal tract, metabolic disorders, etc.), sanitation of foci of infection
Additional treatment for anemia
In women of reproductive age, hormone therapy with COCs before pregnancy is planned (as a prophylaxis and a method of contraception)

Uterine bleeding in postmenopause- indication for diagnostic curettage. None medical measures before scraping! Appearance spotting in postmenopause - a symptom of malignant neoplasms (adenocarcinoma or hormonally active ovarian tumor), and there may also be inflammatory changes against the background of endometrial atrophy, senile colpitis. In any case, we first exclude oncopathology.