Obstetrics and gynecology. Menstrual disorders (lecture notes)

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Obstetrics and gynecology. Menstrual disorders (lecture notes)

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Lecture number 23. Menstrual disorders

Menstrual disorders are a manifestation of various pathological conditions associated not only with disorders in the genital area, but also with general systemic and endocrine diseases. Menstrual disorders are characterized by a change in the cyclicity, duration and volume of menstrual blood loss. Types of menstrual irregularities:

1) menorrhagia, or hypermenorrhea, - regularly occurring uterine bleeding with a volume of more than 80 ml;

2) metrorrhagia - irregular uterine bleeding that occurs at various short intervals;

3) menometrorrhagia - irregularly occurring prolonged uterine bleeding;

4) polymenorrhea - bleeding from the uterine cavity, characterized by regular occurrence after a time interval of less than 21 days;

5) intermenstrual bleeding - this is a varying degree of bleeding intensity that occurs between menstruation;

6) postmenopausal bleeding - bleeding that appeared more than a year after the last menstruation in women with insufficient ovarian function;

7) postcoital bleeding - bleeding after coition;

8) premenstrual bleeding - scanty bleeding of a smearing nature that occurs a few days before the onset of menstruation;

9) postmenstrual bleeding. It has a smearing character, scanty, lasts for several days after the end of menstruation;

10) dysmenorrhea - painful menstruation;

11) primary amenorrhea - the absence of menstruation at the age of 16 years and older;

12) secondary amenorrhea - the absence of menstruation for six months or more after menstruation;

13) oligomenorrhea - rare menstruation that occurs once every 1-2 months;

14) spaniomenorrhea - periodic onset of menstruation once every 1-6 months;

15) hypomenorrhea - scanty menstruation;

16) cystomenorrhea - latent menstruation, clinically manifested by amenorrhea due to infection of the cervical canal, malformations of the genitals or a continuous hymen.

Dysfunctional uterine bleeding

Dysfunctional uterine bleeding (DUB) is a pathological uterine bleeding caused by a violation of the secretory function of the ovaries (the synthesis of sex hormones) in the absence of pregnancy, inflammatory processes and organic changes in the genital organs, as well as systemic diseases associated with impaired blood clotting. Most often, DMC is combined with chronic anovulation, but sometimes it also occurs against the background of ovulatory menstrual cycles. Violation of the menstrual cycle can be both in the presence of ovulation and anovulation. Menstrual irregularities in the presence of ovulation are most often detected during examination of patients who have consulted a gynecologist for infertility. During the examination, the following violations are most often observed:

1) shortening of the follicular phase of the cycle in the presence of a long luteal phase;

2) shortening or inferiority of the luteal phase of the cycle with a normal or somewhat prolonged follicular phase of the cycle;

3) lengthening of the luteal phase during the normal follicular phase of the cycle.

The causes of ovulatory disorders of the menstrual cycle are pathological childbirth, abortion, inflammatory diseases in which the sensitivity of the receptor apparatus of the ovaries and uterus to normal gonadotropic stimulation is impaired. The reasons may also be the consequences of changes in the hypothalamic regulation of the gonadotropic function of the pituitary gland, in which the rhythm of FSH and LH excretion or their normal ratio necessary for ovulation is disturbed. Anovulatory cycles in women are clinically no different from the normal menstrual cycle, since the rhythm of menstruation is usually not changed. Sometimes there is a slight shortening or lengthening of the menstrual cycle, as well as a change in the intensity of blood loss. It is possible to alternate ovulatory and anovulatory cycles. In anovulatory cycles, the mechanism of their occurrence is more often associated with dysregulation of the "hypothalamus - pituitary gland - ovaries" system. With anovulatory cycles, there is no additional release of LH by the pituitary structures in the middle of the menstrual cycle. In view of this, the process of egg maturation is disrupted, ovulation does not occur. Due to the absence of ovulation, the formation of the corpus luteum in the ovaries and the secretion of progesterone in the second phase of the cycle, which is necessary for the secretory transformation of the proliferated endometrium and its normal rejection, do not occur. Anovulatory cycles may be associated with ovarian failure. DMC are anovulatory. This occurs with persistence and atresia of the follicle. With persistence, the follicle reaches the stage of maturity, but ovulation does not occur. The persistent follicle synthesizes a large amount of estrogen. This leads to hyperplasia of the endometrium, which subsequently undergoes rejection due to impaired blood supply and the occurrence of foci of necrosis. Follicular atresia is the process of reverse development of an immature follicle, accompanied by a decrease in estrogen secretion, which stimulates the release of gonadotropins, which cause the growth of a new follicle. When diagnosing pathological uterine bleeding, anamnesis data are taken into account, paying particular attention to the onset of bleeding, frequency, duration and severity, the cyclicity of these bleedings, the presence of pain, and obstetric and gynecological history. Take into account the data of objective and additional methods of examination. The task of differential diagnosis of DUB and organic causes of uterine bleeding is to exclude the presence of a complicated pregnancy (threatening abortion, abortion in progress, incomplete abortion), benign diseases of the pelvic organs (uterine fibroids, endometrial and cervical canal polyps, adenomyosis or endometriosis), malignant tumors of internal genitals. Differential diagnosis of DMC and disorders of the blood coagulation system, as well as somatic pathology, is carried out. Treatment of DMC consists of three stages.

The first stage. Its task is to stop bleeding using surgical, hormonal and non-hormonal hemostasis. Surgical hemostasis is a separate diagnostic curettage of the uterus and cervical canal. After diagnostic curettage, the bleeding stops, and based on the results of histological examination (endometrial biopsy), differential diagnosis is carried out with organic pathology of the uterus or the presence of pregnancy. Hormonal hemostasis is the main method in the treatment of DUB in women of any age. This method uses oral contraceptives with different hormone contents: combined, monophasic, oral. Non-hormonal hemostasis is the use of medications to help stop bleeding. This:

1) uterotonic agents (oxytocin, ergotal);

2) drugs that increase the contractile ability of the myometrium (calcium chloride, calcium gluconate, ATP, cocarboxylase);

3) drugs that stimulate the coagulation ability of the blood (etamsylate, transamic acid, aminomethylbenzoic acid);

4) vitamins (ascorbic acid, rutin, vikasol, vitamin E, B vitamins).

Non-hormonal hemostasis is usually used in combination with hormonal methods.

The second stage - Prevention of relapses, correction of concomitant complications. Prevention of relapses of DMC and correction of associated complications is carried out by hormonal methods, including the appointment of estrogen-progestogen drugs or pure progestogens (dydrogesterone, levonorgestrel-containing IUD, medroxyprogesterone acetate, etc.).

The third stage - preservation of fertility and the onset of ovulation in women who wish to become pregnant. Women who want to become pregnant are prescribed ovulation stimulation.

Author: Ilyin A.A.

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