Causes and consequences of juvenile uterine bleeding. Heavy menstruation during puberty Abnormal uterine bleeding during puberty

Abnormal uterine bleeding of puberty (AUB)

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Abnormal uterine bleeding of puberty (AUB)

Uterine bleeding can occur in a teenage girl, starting with her first menstruation. In the world, the frequency of this disease varies from 8 to 30% among teenage girls in different countries; in Russia, abnormal uterine bleeding accounts for almost 50% of all gynecological diseases of adolescents.

Uterine bleeding can be excessively profuse in terms of the volume of blood lost, and can manifest itself in the form of prolonged moderate or bloody discharge from the genital tract. The danger of uterine bleeding lies in the development of such serious complications as a state of shock with loss of consciousness due to the loss of a large volume of blood. Continued bleeding for up to 2 weeks or more causes inflammation of the uterus and the development of moderate or severe anemia, accompanied by severe weakness, apathy, lack of appetite and interest in life. Late diagnosis of serious diseases that cause uterine bleeding is also dangerous.

Causes

Endometrial/cervical polyp
Adenomyosis
Uterine fibroids
Neoplasms of the vagina, cervix, uterus
Blood diseases
Disorders of the ovulation process: functional ovarian cysts, polycystic ovary syndrome, hypothyroidism, hyperprolactinemia, sudden changes in body weight, excessive physical/mental stress, stress
Endometritis
Vascular malformations
Taking medications (estrogens, gestagens, corticosteroids, antipsychotics, etc.)

Clinical manifestations

copious bleeding from the genital tract (soaking a hygiene product with “normal” absorbency in less than 2 hours)
presence of blood clots larger than 3 cm in heavy blood discharge from the genital tract
prolonged bleeding from the genital tract (more than 8 days)
frequent bleeding from the genital tract (more often than after 21 days)
intermenstrual bleeding from the genital tract lasting more than 2 days

Diagnostics

assessment of menocyclogram, profuse bleeding
gynecological examination with vaginoscopy
blood type, Rh factor
clinical blood test with determination of ESR
biochemical blood test + C-reactive protein
determination of iron content in blood serum + ferritin + transferrin
hemostasiogram
determination of the concentration of blood hormones (LH, FSH, Estradiol, Prolactin + thyroid hormones (according to indications) + androgenic fractions of blood hormones (according to indications))
Ultrasound of the pelvic organs (during initial treatment and over time during treatment)
Microscopic examination of vaginal contents
PCR examination of vaginal contents
Ultrasound of the mammary glands (if indicated)
Ultrasound of the thyroid gland (if indicated)
Microbiological examination of vaginal contents with determination of sensitivity to antibacterial agents (according to indications)
Diagnostic liquid hysteroscopy without anesthesia (according to indications)
Consultation with a pediatrician (if indicated)
Consultation with a hematologist (if indicated)
Consultation with an endocrinologist (if indicated)
Consultation with a medical psychologist (if indicated)

Description of the invasive diagnostic method

Recurrent (repeated) uterine bleeding in most cases is a consequence of the inflammatory process in the uterus (endometritis). The cause of uterine bleeding may be adenomyosis, a disease in which cells similar in structure to the cells of the inner lining of the uterus are detected in tissues atypical for their location. Sometimes the cause of prolonged bleeding from the genital tract is a polyp of the body or cervix.

In order to more accurately determine all possible causes of the disease, if indicated, in our department, girls undergo an examination of the walls and contents of the uterine cavity - liquid diagnostic hysteroscopy. This study is highly informative, is carried out under local anesthesia with a special gel, and is easily tolerated by adolescents. The data obtained from such a comprehensive examination allows the patient to be treated with the highest possible efficiency.

Treatment methods

Comprehensive treatment is carried out taking into account the causes of uterine bleeding identified during the examination. Treatment includes:

Hemostatic (hemostatic) therapy
Infusion therapy
Antianemic therapy (iron-containing drugs)
Anti-inflammatory therapy, including physical therapy
Use of drugs containing clotting factors
If necessary, hormonal hemostatic therapy is selected individually.

Abnormal uterine bleeding (AUB) - according to modern concepts - is a comprehensive term that implies any uterine bleeding (i.e. bleeding from the body and cervix) that does not meet the parameters of normal menstruation in a woman of reproductive age.

Parameters of normal menstruation (menstrual cycle). So, according to modern views, its duration ranges from 24 to 38 days. The normal duration of the menstrual phase is 4.5 - 8 days. An objective study of blood loss during menstruation showed that a volume of 30 - 40 ml should be considered normal. Its upper acceptable limit is considered to be 80 ml (which is equivalent to a loss of approximately 16 mg of iron). It is this hemorrhage that can lead to a decrease in hemoglobin levels, as well as to the appearance of other signs of iron deficiency anemia.

The incidence of AUB increases with age. Thus, in the general structure of gynecological diseases, juvenile uterine bleeding accounts for 10%, AUB in the active reproductive period - 25 - 30%, in late reproductive age - 35 - 55%, and in menopause - up to 55 - 60%. The particular clinical significance of AUB is determined by the fact that they can be a symptom not only of benign diseases, but also of precancer and endometrial cancer.

Causes of AMC:

not related to uterine pathology: diseases of the uterine appendages (bleeding after ovarian resection or oophorectomy, uterine bleeding due to ovarian tumors, premature puberty), AUB during hormonal therapy (combined oral contraceptives, progestins, hormone replacement therapy), anovulatory bleeding (menarche , perimenopause, polycystic ovary syndrome, hypothyroidism, hyperprolactinemia, stress, eating disorders);

systemic pathology: diseases of the blood system, liver diseases, renal failure, congenital adrenal hyperplasia, Cushing's syndrome and disease, diseases of the nervous system;

iatrogenic factors: bleeding after resection, electrical, thermal or cryodestruction of the endometrium, bleeding from the cervical biopsy area, while taking anticoagulants, neurotropic drugs;

AUB of unknown etiology.

AUB can manifest itself as regular, heavy (more than 80 ml) and prolonged (more than 7-8 days) menstruation - heavy menstrual bleeding (this type of bleeding before the introduction of the new classification system was designated as menorrhagia). Common causes of these bleedings are adenomyosis, submucous uterine fibroids, coagulopathies, and functional disorders of the endometrium. AUB can manifest as intermenstrual bleeding (formerly called metrorrhagia) during a regular cycle. This is more typical for endometrial polyps, chronic endometritis, and ovulatory dysfunction. AUB is also clinically manifested by irregular, prolonged and (or) heavy bleeding (menometrorrhagia), most often occurring after delayed menstruation. This type of menstrual irregularities is more typical for hyperplasia, precancer and endometrial cancer. AUB is classified into chronic and acute (FIGO, 2009). Chronic bleeding is uterine bleeding that is abnormal in volume, regularity and (or) frequency, observed for 6 months or more, usually not requiring immediate medical intervention. Acute bleeding is an episode of heavy bleeding that requires urgent intervention to prevent further blood loss. Acute AUB may occur for the first time or against the background of pre-existing chronic AUB.

When diagnosing AUB, the first stage of the diagnostic search is to establish the truth of the patient’s complaints regarding the presence of bleeding. It should be noted that in 40 - 70% of women who complain of heavy menstruation, an objective assessment does not always determine the amount of blood loss that exceeds the norm. In such cases, patients rather need psychological help and educational activities. Conversely, about 40% of patients with menometrorrhagia do not consider their menstruation to be heavy. Consequently, it is very difficult to give a qualitative assessment of this clinical symptom based only on the patient’s complaints. In this regard, to objectify the clinical picture, it is advisable to use the method of assessing blood loss developed by Jansen (2001). Women are asked to fill out a special form visual table with counting the number of used pads or tampons on different days of menstruation with a score for the degree of their wetting (the maximum score for pads is 20, for tampons - 10). It should be noted that the count corresponds to standard sanitary material (“normal”, “regular”). However, very often, patients with menorrhagia use “maxi” or “super” tampons or pads, and sometimes even double the amount of them, and therefore actual blood loss may exceed the volumes calculated using a unified table. A score of 185 and above is regarded as a criterion for metrorrhagia.

The second stage of diagnosis is establishing the actual diagnosis of AUB after excluding systemic diseases, coagulopathies and organic pathology of the pelvic organs, which may cause bleeding. At this stage, given the difficulties of diagnosis, there can be no trifles in the doctor’s work. So, when interviewing a patient, it is necessary to collect a “menstrual history”:

taking medications that cause metrorrhagia: derivatives of steroid hormones (estrogens, progestins, corticosteroids), anticoagulants, psychotropic drugs (phenothiazines, tricyclic antidepressants, MAO inhibitors, tranquilizers), as well as digoxin, propranolol;

presence of an IUD in the uterine cavity;

the presence of other diseases: bleeding tendency, hypertension, liver disease, hypothyroidism;

previous operations: splenectomy, thyroidectomy, myomectomy, polypectomy, hysteroscopy, diagnostic curettage;

clinical factors combined with metrorrhagia that are subject to targeted identification (differential diagnosis with systemic pathology): nosebleeds, bleeding gums, the appearance of bruises and hematomas, bleeding after childbirth or surgery, family history.

In addition to collecting an anamnesis and gynecological examination, determination of the concentration of hemoglobin, platelets, von Willebrand factor, clotting time, platelet function, thyroid-stimulating hormone, and ultrasound examination of the pelvic organs are considered significant for diagnosing AUB. Hysterography is performed in unclear cases, when transvaginal ultrasound is insufficiently informative (does not have 100% sensitivity) and the need to clarify the focal intrauterine pathology, localization and size of the lesions.

MPT is not recommended as a first-line diagnostic procedure for AUB (benefit and cost of the procedure must be weighed). It is advisable to perform MRI in the presence of multiple uterine fibroids to clarify the topography of the nodes before a planned myomectomy. before embolization of the uterine arteries, before ablation of the endometrium, if adenomyosis is suspected, in cases of poor visualization of the uterine cavity to assess the condition of the endometrium.

The gold standard for diagnosing intrauterine pathology is diagnostic hysteroscopy and endometrial biopsy, which is performed primarily to exclude precancerous lesions and endometrial cancer. This study is recommended if there is a suspicion of endometrial pathology, the presence of risk factors for uterine cancer (with excessive exposure to estrogens - PCOS, obesity) and in all patients with AUB after 45 years. To diagnose the causes of AMK, preference is given to office hysteroscopy and aspiration biopsy, as less traumatic procedures. An endometrial biopsy is informative in cases of diffuse lesions and adequate sampling of material.

The main goals of therapy for AUB are:

prevention of relapses: restoration of normal functioning of the hypothalamic-pituitary-ovarian system, restoration of ovulation; replenishment of the deficiency of sex steroid hormones.

Today, hemostasis is possible both through conservative measures and surgically. It is advisable to carry out drug hemostasis mainly for women of early and active reproductive age who are not at risk for the development of hyperproliferative processes of the endometrium, as well as for patients in whom diagnostic curettage was performed no more than 3 months ago, and no pathological changes in the endometrium were detected.

Among the medicinal methods of hemostasis for AUB with proven effectiveness, antifibrinolytic drugs (tranexamic acid) and nonsteroidal anti-inflammatory drugs (NSAIDs) should be noted. However, so far the most effective among conservative methods of stopping bleeding is hormonal hemostasis with monophasic oral contraceptives containing 0.03 mg of ethinyl estradiol and gestagens of the norsteroid group and having a pronounced suppressive effect on the endometrium. Much less often in clinical practice, progestational hemostasis is used, which is pathogenetically justified in anovulatory hyperestrogenic bleeding.

Surgical hemostasis is ensured primarily by fractional curettage of the uterine cavity and cervical canal under hysteroscopic control. This operation has both diagnostic (to exclude organic pathology of the uterine cavity) and therapeutic purposes, and is the method of choice for women of the late reproductive and menopausal periods, given the increasing frequency of atypical transformation of the endometrium in these age groups. In the case of pubertal bleeding, this operation is possible only for health reasons.

Prevention of relapse. General principles of anti-relapse treatment of AUB: 1. Carrying out general strengthening measures - regulation of sleep, work and rest, rational nutrition, compliance with the rules of psychological hygiene. 2. Treatment of anemia (iron supplements, multivitamin and mineral supplements, in severe cases - blood substitutes and blood products). 3. Inhibitors of prostaglandin synthesis in the first 1 - 3 days of menstruation. 4. Antifibrinolytics in the first 1 - 3 days of menstruation (tranexamic acid). 5. Vitamin therapy – complex preparations containing zinc. 6. Drugs that stabilize the function of the central nervous system. Non-hormonal drugs are recommended for both ovulatory and anovulatory bleeding. 7. Hormonal therapy is prescribed differentially depending on the pathogenetic variant of AUB: in the juvenile period - cyclic hormone therapy with estrogen-gestagens for 3 months, gestagens in the 2nd phase of the menstrual cycle for up to 6 months; in the reproductive period - cyclic hormone therapy with estrogen-gestagens for 3 months, gestagens in the 2nd phase of the menstrual cycle for up to 6 months; in the menopausal period - it is necessary to turn off the ovarian function (gestagens in continuous mode - 6 months).

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

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

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

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

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

PALM–COEIN classification

In domestic practice, a classification has been used for a long time that distinguishes uterine bleeding in accordance with the time of its occurrence, duration and volume of blood loss. In practice, such definitions as metrorrhagia were used (a variant of irregular uterine bleeding, the duration of which exceeds 1 week and the volume of blood loss exceeds 80-90 ml).

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

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

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

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

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

a brief description of

Polyp

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

Adenomyosis

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

Leiomyoma

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

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

Malignancy and hyperplasia

Malignant neoplasms of the uterus and genital tract can form both in the elderly and in women of reproductive age. The exact reasons for the development of cancer of the reproductive system are not known, however, there is an increased risk of such processes if a woman has such diseases in her family, there have been repeated abortions and terminations of pregnancy, hormonal imbalance, irregular sex life and heavy physical activity.

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

Coagulopathy

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

Ovulatory dysfunction

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

Endometrial dysfunction

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

Iatrogenic bleeding

They are the result of drug or instrumental intervention. Among the most common causes of iatrogenic abnormal bleeding are:

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

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

Diagnostic principles

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

Among the most informative methods of instrumental diagnostics are the following:

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

The plan for the necessary laboratory diagnostics is drawn up individually depending on the patient’s health condition. Experts consider it advisable to use:

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

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

Treatment of abnormal uterine bleeding

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

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

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

The most common and severe forms of dysfunction of the reproductive system during puberty in girls include juvenile uterine bleeding. This term refers to dysfunctional bleeding at the age of 10-18 years from the beginning of the first menstruation until adulthood.

This gynecological pathology occurs in approximately 10-20% of all girls in this age category. Heavy and frequent bleeding can cause a significant decrease in the level of hemoglobin in the blood, aggravate hormonal disorders, and in the future cause infertility. In addition, uterine bleeding in adolescents negatively affects the psychological state of children, causing isolation, self-doubt, fear for their health and even life.

Reasons for violations

The main reason is disturbances in the functioning of the hypothalamic-pituitary system. Hormonal imbalance provokes a single-phase ovarian cycle with a delay in menstruation and further bleeding. More often, dysfunctional uterine bleeding of puberty occurs during the first two years after.

There is no direct connection between this pathology and the development of other secondary sexual characteristics. In general, the girl’s puberty proceeds without disturbances. In more than a third of patients, the disease can be complicated by the appearance of acne and oily seborrhea.

The appearance of uterine bleeding in older girls is noted at early menarche (7-12 years). It is diagnosed in more than 60% of patients. With the late appearance of the first menstruation (after 15-16 years), this pathology occurs rarely - no more than 2% of cases.

The main causes of the pathological condition in adolescents:

pathologies of the blood coagulation system;
formation of ovarian tumors of hormonal origin;
acute and chronic infectious diseases (ARVI, pneumonia, chronic tonsillitis, chicken pox, rubella);
diseases of the endocrine system (pancreas, adrenal glands);
tuberculosis of the genital organs;
malignant neoplasms of the body and cervix;
living in unfavorable conditions, excessive physical and psychological stress;
poor nutrition that does not provide the body with necessary vitamins and microelements.

The most significant provoking factor is chronic tonsillitis with regular periods of exacerbation. There is a definite connection between the disease in girls and how her mother’s pregnancy proceeded. Provoking factors could be late toxicosis, chronic intrauterine pregnancy, premature aging or placental abruption, asphyxia of the child at birth.

Symptoms of the disease

For many girls, the regular monthly cycle is not restored immediately after menarche, but only over the course of six months to two years. Menstruation may be delayed by two to three months, and sometimes even six months. Uterine bleeding most often occurs after a delay of menstruation of up to 2 weeks or a month and a half.

In some cases, it may occur a week or two after menarche or occur during the intermenstrual period. The main symptoms of the pathology include:

copious (more than 100 ml per day) and prolonged (over 7 days) bleeding;
discharge that occurs 2-3 days after the end of menstruation;
menstruation that recurs at intervals of less than 21 days;
dizziness, drowsiness, nausea as a result of anemia;
pale skin, dry mouth;
pathological desire to eat inedible foods (for example, chalk);
depressed state, irritability, rapid physical fatigue.

Very often, a girl and even her more experienced mother cannot identify the disorder and regard it as normal menstruation. The girl can continue to lead her usual lifestyle, thereby delaying treatment, which should begin immediately, and aggravating the problem. It should be remembered that any heavy discharge, especially with clots, requires close attention. Menstruation is considered heavy when a pad or tampon has to be changed at least every hour.

Since pathology can be caused by various reasons, in addition to a mandatory examination by a pediatric gynecologist, consultation with an endocrinologist, neurologist, or oncologist is necessary.

Diagnostics

For diagnosis, general and special methods for studying the disorder are used. General ones include a gynecological and general examination of the patient, examination of the condition of internal organs, analysis of the physique and height-to-weight ratio, and the presence of secondary sexual characteristics. From the conversation, the gynecologist will learn about the date of the first period, the regularity of the menstrual cycle, previous diseases and general health.

Patients are prescribed a number of laboratory tests: general urine and blood tests, biochemical blood test, sugar test and hormonal screening to determine hormonal levels. To clarify the diagnosis, pelvic organs are also examined.

Abnormal uterine bleeding during puberty should be differentiated from other pathological conditions that may be accompanied by bleeding, namely:

diseases of the blood system;
hormone-producing ovarian tumors, endometriosis, cervical cancer;
inflammatory diseases of the genital organs;
injuries of the vagina and external genitalia;
beginning abortion during pregnancy;
polycystic ovary syndrome.

With diseases of the blood system, patients often experience nosebleeds and the appearance of hematomas on the body. Unlike inflammatory diseases of the genital organs, dysfunctional uterine bleeding is rarely accompanied by cramping pain in the lower abdomen. If tumors of various types are suspected, their presence will be determined after ultrasound and other specific diagnostic methods.

Treatment

If there is heavy bleeding and the girl is not feeling well, it is necessary to call an ambulance. Before her arrival, the child is put to bed, given complete rest and an ice pack is applied to the stomach. The patient should be given a lot of sweet drinks, preferably tea. Even if the bleeding was stopped on its own, this should not be a reason for complacency, since such pathologies are prone to relapse.

The main goal of therapy is the complete cessation of discharge and normalization of the menstrual cycle in the future. When choosing methods and drugs for treatment, the intensity of bleeding, the severity of anemia, laboratory test data, and the general physical and sexual development of the patient are taken into account.

To treat and stop discharge in adolescents, they are carried out in exceptional cases. They are indicated only when the pathology threatens the patient’s life. In other cases, they are limited to drug therapy.

Drugs used for uterine bleeding in adolescents

If the girl’s general condition is satisfactory and there are no signs of severe anemia, treatment can be carried out at home using hemostatic drugs, sedatives and vitamins.

If the patient's condition is severe and there are all signs of anemia (low hemoglobin, dizziness, pale skin), hospitalization is necessary.

To stop bleeding and normalize the menstrual cycle, the following drugs are prescribed:

uterine contractants - Oxytocin, Ergotal, water pepper extract;
hemostatic drugs - Vikasol, Tranexam, Ascorutin, Dicinone, Aminocaproic acid;
combined - Rugulon, Non-ovlon, Janine;
sedatives - bromine or valerian preparations, motherwort tincture, Seduxen, Tazepam;
drugs to regulate the menstrual cycle - Utrozhestan, Duphaston, which are taken from the 16th to the 25th day of the cycle;
vitamins – group B, including folic acid, C, E, K.

If the level is elevated, girls are prescribed Turinal, Norkolut for three cycles with a three-month break, with further repetition of the drug regimen. If the level is low, sex hormones are prescribed in a cyclic manner. Hormone therapy is not the main method of preventing new bleeding.

Physiotherapy is used as auxiliary treatment methods - electrophoresis with novocaine or vitamin B1 and acupuncture. The second procedure is prescribed for blood loss without the threat of anemia, in the absence of pronounced hormonal imbalance.

If bleeding is caused by diseases of the endocrine system, appropriate specific treatment and iodine preparations are prescribed.

For the purpose of sedation and normalization of the processes of excitation and inhibition of the central structures of the brain, Nootropil, Veroshpiron, Asparkam, Glycine can be prescribed. Comprehensive treatment and measures to restore the menstrual cycle include performing physical therapy exercises and psychocorrective sessions with a psychologist.

Clinical recommendations for uterine bleeding during puberty include bed rest during treatment, applying cold to the lower abdomen, and drinking plenty of fluids to replenish fluid loss from the body. Do not apply a warm heating pad, take a hot bath, douche, or take hemostatic agents without consulting a doctor.

Of great importance is the elimination of the symptoms of iron deficiency anemia, which is most often a complication of uterine bleeding. For treatment, iron preparations such as Ferrum Lek, Maltofer, Hematogen, Totema, Sorbifer Durules are prescribed. The drugs are taken in tablet form; injections are more effective. In the future, the girl should follow a diet that includes foods rich in iron: red meat, liver, poultry, seafood, spinach, beans, pomegranates, brown rice, dried fruits, peanut butter.

After discharge from the hospital, the girl must be registered with a pediatric gynecologist.

Treatment with folk remedies

Traditional medicine knows many herbs, infusions and decoctions of which have a hemostatic effect. However, they cannot completely replace drug treatment. Herbal decoctions and infusions can be used as an additional treatment method.

Among the most effective plants are:

knotweed - contains acetic and malic acids, tannin, vitamins K and C, strengthens the walls of blood vessels, increases blood viscosity;
water pepper - tannin, organic acids, vitamin K in the composition stabilize the activity of the smooth muscles of the uterus, increase blood clotting;
shepherd's purse - contains alkaloids, organic acids, vitamin C, tannin, riboflavin, which help reduce blood secretions;
Nettle is the most famous plant for stopping bleeding, regulates the menstrual cycle, and saturates the body with vitamins K, C, A, B.

To prepare decoctions, plant herbs are crushed, poured with boiling water and kept in a water bath for 15-20 minutes. After straining, take several times a day. The duration of use and dosage should be checked with your doctor.

Prevention of bleeding

Since juvenile bleeding occurs mainly due to hormonal disorders, there are no specific preventive measures. However, following certain recommendations will help reduce the risk of their occurrence:

Timely treatment of infectious and viral diseases, especially those that become chronic (tonsillitis, bronchitis, ARVI).
Regular observation of pregnant women by an obstetrician-gynecologist, starting from the early stages of gestation in order to identify and correct early and late edema of pregnant women, intrauterine disorders of fetal development, premature birth, fetal hypoxia.
The teenage girl’s adherence to the principles of proper nutrition - eating foods rich in vitamins, excluding fast food, avoiding “diets” that involve prolonged fasting.
Maintaining a menstrual calendar, which will help you pay attention to deviations when they first appear.
Taking sedative medications to strengthen blood vessels and the nervous system (as prescribed by a doctor).
Giving up bad habits, following a daily routine, getting enough sleep, regular physical activity, and playing sports.
Notifying girls about the dangers of early sexual intercourse.

Separately, it should be said about the need to visit a pediatric gynecologist. Many mothers consider this unnecessary until the girl becomes sexually active. A visit to a pediatric gynecologist for preventive purposes, especially after the onset of menstruation, should become the same norm as visits to other doctors.

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.

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