Vaginal bleeding in gynecologyVaginal bleeding in gynecology

Professor of obstetrics and gynecology Professor of obstetrics and gynecology

GP TMA, MDGP TMA, MD Karimov Ahmad HashimovichKarimov Ahmad Hashimovich

Reproductive organsReproductive organs

Menstrual cycleMenstrual cycle

Duration from 21 to 35 days:Duration from 21 to 35 days:- Anteponiruyuschy 21-25- Anteponiruyuschy 21-25- Normoniruyuschy 28- Normoniruyuschy 28- Postponiruyuschy 30 and more- Postponiruyuschy 30 and moreClinically distinguished:Clinically distinguished:- Postmenstrual period- Postmenstrual period- Premenstrual- Premenstrual- Menstrual period- Menstrual period

Regulation of the menstrual cycleRegulation of the menstrual cycle

Regulation of the menstrual Regulation of the menstrual cyclecycle

Regulation of the menstrual Regulation of the menstrual cyclecycle

Estrogens are Estrogens are allocated:allocated:

Granulosa cells of the Granulosa cells of the follicle;follicle;Luteal cells of the Luteal cells of the corpus luteum;corpus luteum;Suprarenal;Suprarenal;Ekstraglandulyarny Ekstraglandulyarny steroidogenesis in steroidogenesis in adipose tissue;adipose tissue;Stroma of teka interna Stroma of teka interna - estrone and - estrone and androgens.androgens.

Allocation of progesterone and of progesterone and androgenandrogen

progesterone:progesterone:- Luteum - luteal cells- Luteum - luteal cells- Reticular zone of adrenal- Reticular zone of adrenal

androgens:androgens:- Reticular zone of adrenal- Reticular zone of adrenal- Sertolievymi and Leydigovymi ovary - Sertolievymi and Leydigovymi ovary cells.cells.

Ovarian morphologyOvarian morphology

Ovarian morphologyOvarian morphology

Four stages of development of Four stages of development of the corpus luteumthe corpus luteum

1st stage of 1st stage of proliferation and proliferation and vascularizationvascularizationStage 2 of the Stage 2 of the glandular glandular metamorphosismetamorphosisStage 3 peakStage 3 peak4 stage reverse 4 stage reverse developmentdevelopment

OvaryOvary

Tests of functional Tests of functional diagnosticsdiagnostics

basal temperaturebasal temperature

symptom of "pupil“symptom of "pupil“

symptom crystallizationsymptom crystallization

symptom relief of mucussymptom relief of mucus

kariopiknotichesky indexkariopiknotichesky index

endometrial histologyendometrial histology

Basal temperatureBasal temperature

Symptom relief mucusSymptom relief mucus

CPI is the ratio of cells with pyknotic nucleus CPI is the ratio of cells with pyknotic nucleus of the cells without pyknosis, the more of the cells without pyknosis, the more

estrogen, the higher the% of KPI. On day estrogen, the higher the% of KPI. On day

14, 40 - 50%.14, 40 - 50%.

EtiologyEtiology

Mental stress, stressMental stress, stressAbnormal development of the reproductive Abnormal development of the reproductive systemsystemInfantilismInfantilismacute infectionsacute infectionschronic infectionschronic infectionsMalnutritionMalnutritionDiseases of the endocrine glandsDiseases of the endocrine glands

Uterine bleeding divided:Uterine bleeding divided: Functionality: Functionality:

Dysfunctional uterine bleedingDysfunctional uterine bleeding

Organic:Organic:

Fibroids;Fibroids;

Endometriosis; Endometriosis;

Polyposis endometrial;Polyposis endometrial;

Inflammatory disease.Inflammatory disease.

Classification of Classification of disturbancesdisturbances menstrual cyclemenstrual cycle

1. Amenorrhea 1. Amenorrhea 2. Cyclical disturbances.2. Cyclical disturbances.- Under the "+"- Under the "+"     - menorrhagia (heavy)     - menorrhagia (heavy)     - polimenoreya (long and heavy periods,      - polimenoreya (long and heavy periods, turning in meno-and metrorrhagia)turning in meno-and metrorrhagia)     - giperpolimenoreya     - giperpolimenoreya  - Under the sign "-"  - Under the sign "-"     - gipomenoreya (scanty menses)     - gipomenoreya (scanty menses)     - oligomenorrhea - (short menstrual period      - oligomenorrhea - (short menstrual period (less than 2 days)(less than 2 days)     - gipooligomenoreya     - gipooligomenoreya

Menstruation to change the Menstruation to change the tempo and rhythm:tempo and rhythm:

Opsomenoreya (infrequent menstruation - a Opsomenoreya (infrequent menstruation - a cycle of 35-48 days);cycle of 35-48 days);Spaniomenoreya (significantly lengthened Spaniomenoreya (significantly lengthened menstrual cycles (2-4 times a year);menstrual cycles (2-4 times a year);Proyomenoreya (frequent and heavy periods)Proyomenoreya (frequent and heavy periods)anovulatory DUBanovulatory DUB

         - algomenoreya- algomenoreya     - dysmenorrhea     - dysmenorrhea    Acyclic uterine bleeding - metrorrhagiaAcyclic uterine bleeding - metrorrhagia

ExaminationExamination:: HistoryHistory MenogrammaMenogramma Inspection in the mirrorInspection in the mirror bimanual examinationbimanual examination Smears for cytologySmears for cytology blood testblood test Diagnostic curettageDiagnostic curettage uterine endometrial biopsy uterine endometrial biopsy Additional methods:Additional methods: Determination of hCGDetermination of hCG Pelvic ultrasoundPelvic ultrasound blood biochemistryblood biochemistry coagulationcoagulation

Differential diagnosis:Differential diagnosis:

PregnancyPregnancy

complications of oral contraceptivescomplications of oral contraceptives

genital injurygenital injury

HematopathyHematopathy

endocrine diseasesendocrine diseases

malignancies.malignancies.

DUBDUB(dysfunctional uterine (dysfunctional uterine

blooding)blooding) DUB - is bleeding not related to organic DUB - is bleeding not related to organic

changes in the genital organs, and changes in the genital organs, and depending on the disruptions and depending on the disruptions and production of gonadotropic hormones and production of gonadotropic hormones and ovarian hormones. The frequency of the ovarian hormones. The frequency of the DUB gynecological patients is 10-15%.DUB gynecological patients is 10-15%.

ETIOLOGYETIOLOGY Psychogenic factorsPsychogenic factors

Mental and physical fatigueMental and physical fatigue

Acute and chronic toxicityAcute and chronic toxicity

Inflammation of the uterusInflammation of the uterus

Impaired function of the endocrine glandsImpaired function of the endocrine glands

Poor nutrition, lack ofPoor nutrition, lack ofvitaminsvitamins

PathogenesisPathogenesis

Disruption in follicle;Disruption in follicle;

Long term effects on the estrogen;Long term effects on the estrogen;

OOvulatory failure;vulatory failure;

The absence of the corpus luteum.The absence of the corpus luteum.

DUBDUB

• Juvenile - at pubertyJuvenile - at puberty     (up to 20 years - 20-25%);     (up to 20 years - 20-25%);• Bleeding at pubertyBleeding at puberty      (from 20 to 40 years - 15-20%);      (from 20 to 40 years - 15-20%);• Menopausal bleedingMenopausal bleeding      (over 40 years before menopause - 50-60%.)      (over 40 years before menopause - 50-60%.)

Functional diagnostics tests the Functional diagnostics tests the persistence of the follicle:persistence of the follicle:

BBasal temperature – monophasic;asal temperature – monophasic;

Symptom of "pupil" - + + + + + + +;Symptom of "pupil" - + + + + + + +;

Tension of mucus - 10-12 cm;Tension of mucus - 10-12 cm;

Symptom of "fern" - + + +, + + + +;Symptom of "fern" - + + +, + + + +;

KPI 70-80%;KPI 70-80%;

Endometrial histology - hyperplasia without Endometrial histology - hyperplasia without secretory transformation.secretory transformation.

Functional diagnostic tests for Functional diagnostic tests for follicle atresia:follicle atresia:

Basal temperature – monophasic;Basal temperature – monophasic;

Symptom of "pupil" - + + +;Symptom of "pupil" - + + +;

Tension of mucus - 3-4 cm;Tension of mucus - 3-4 cm;

Symptom of "fern" - +, + +;Symptom of "fern" - +, + +;

KPI 20-30%;KPI 20-30%;

Endometrial histology - glandular-cystic Endometrial histology - glandular-cystic hyperplasiahyperplasia

Treatment of juvenile bleeding.Treatment of juvenile bleeding.

Reducing funds uterus oxytocin pituitrinReducing funds uterus oxytocin pituitrin  - Calcium chloride 10% -10.0 in /  - Calcium chloride 10% -10.0 in /  - Menadione 2.0 f / m  - Menadione 2.0 f / mAntianaemia drugs: Ferrum-lek vitogepat, Antianaemia drugs: Ferrum-lek vitogepat, ferkayl, kosmofer, Venofer, apofer, ferkayl, kosmofer, Venofer, apofer, tardiferon, ginotardiferon etc.tardiferon, ginotardiferon etc.Vitamin therapy.Vitamin therapy.Sedatives.Sedatives.In the absence of the effect of this therapy In the absence of the effect of this therapy is the next stepis the next step

HORMONAL HEMOSTASISHORMONAL HEMOSTASIS Progesterone - in the absence of anemia - in shock Progesterone - in the absence of anemia - in shock doses (30 mg for 3 consecutive days). This so-called doses (30 mg for 3 consecutive days). This so-called hormonal curettage: a few days later rejected by the hormonal curettage: a few days later rejected by the mucous starts and you have to be prepared.mucous starts and you have to be prepared.Estrogens - folliculin 10 thousand / m in 2-3 hours, Estrogens - folliculin 10 thousand / m in 2-3 hours, but not more than 50 thousand per day, to stop but not more than 50 thousand per day, to stop bleeding.bleeding.After stopping the bleeding, the dose of estrogen After stopping the bleeding, the dose of estrogen decrease of 10 thousand daily and adjusted to 5 decrease of 10 thousand daily and adjusted to 5 thousand continuing to introduce it to 14 day cycle.thousand continuing to introduce it to 14 day cycle.Progesterone 1% -1.0 V / m from 12 to 26 day cycle.Progesterone 1% -1.0 V / m from 12 to 26 day cycle.

DUB treatment of DUB treatment of reproductive agereproductive age

Surgical hemostasis;Surgical hemostasis;

From 5 to 26 day cycle, hormonal - 2-3 From 5 to 26 day cycle, hormonal - 2-3 cycles.cycles.

Inflammatory and resolution therapyInflammatory and resolution therapy

Physiotherapy and balneotherapyPhysiotherapy and balneotherapy

SStimulation of ovulationtimulation of ovulation

DUB treatment of DUB treatment of climacteric ageclimacteric age

Separate diagnostic curettage of the uterine cavity.Separate diagnostic curettage of the uterine cavity.To save the cycle is assigned a long-acting drug To save the cycle is assigned a long-acting drug oksiprogesteron kapronat 17 (17 DIC), 12.5% oksiprogesteron kapronat 17 (17 DIC), 12.5% solution. He is assigned cyclically for 17-19 day solution. He is assigned cyclically for 17-19 day cycle with 1-2 ml of 6-12 months. Woman gradually cycle with 1-2 ml of 6-12 months. Woman gradually enters menopause.enters menopause.      To suppress the cycle used testosterone.To suppress the cycle used testosterone.When gistoanalize:When gistoanalize:          cancer of the cervix or uterus - is sent to a cancer of the cervix or uterus - is sent to a specialized hospital.specialized hospital.          Endometrial hyperplasia - the suppression of the Endometrial hyperplasia - the suppression of the menstrual cycle or hormone replacement therapy.menstrual cycle or hormone replacement therapy.

PREVENTIONPREVENTION

All patients with a history of postmenopausal uterine All patients with a history of postmenopausal uterine bleedingbleeding recommend the following scheme of the recommend the following scheme of the rehabilitation period (2-6 months):rehabilitation period (2-6 months):

1. Adherence of the day, a balanced diet, moderate 1. Adherence of the day, a balanced diet, moderate physical activity (the best version of sports events - the physical activity (the best version of sports events - the swimming pool). swimming pool).

2. Correction of traumatic situations at home or school 2. Correction of traumatic situations at home or school with a psychologist (if it existed), sedation for 2-3 months. with a psychologist (if it existed), sedation for 2-3 months.

3. Remediation of foci of chronic infection. 3. Remediation of foci of chronic infection.

4. Normalization of body weight at a deviation from the 4. Normalization of body weight at a deviation from the norm.norm.

PREVENTIONPREVENTION5. Girls 10-13 years - cyclic vitamin for three menstrual cycles: folic 5. Girls 10-13 years - cyclic vitamin for three menstrual cycles: folic acid, 1 tablet a day with a 5-day cycle for 10 days, vitamin E, 1 acid, 1 tablet a day with a 5-day cycle for 10 days, vitamin E, 1 capsule per day for 10 days, vitamin C 0.5 g 3 times a day for 10 days capsule per day for 10 days, vitamin C 0.5 g 3 times a day for 10 days with a 16-day menstrual cycle. with a 16-day menstrual cycle.

6. After stopping the bleeding for the regulation of the menstrual cycle 6. After stopping the bleeding for the regulation of the menstrual cycle and prevent rebleeding appoint utrozhestan 100 mg 2-3 times a day and prevent rebleeding appoint utrozhestan 100 mg 2-3 times a day from the 16th to the 25th day of the menstrual cycle. Utrozhestan fully from the 16th to the 25th day of the menstrual cycle. Utrozhestan fully consistent with endogenous progesterone, has a physiological consistent with endogenous progesterone, has a physiological regulator antigonadotropnym action causes secretory transformation regulator antigonadotropnym action causes secretory transformation of the endometrium, has no side effects, metabolic, does not of the endometrium, has no side effects, metabolic, does not negatively impact on the liver. negatively impact on the liver.

7. Girls 14-17 years of combined estrogen-progestin preparations 7. Girls 14-17 years of combined estrogen-progestin preparations appoint not more than three menstrual cycles: a short circuit - 2 appoint not more than three menstrual cycles: a short circuit - 2 tablets of 10 days with a 16-day cycle, the long circuit - 1 tablet a day tablets of 10 days with a 16-day cycle, the long circuit - 1 tablet a day

for 21 days with a 5-day cycle .for 21 days with a 5-day cycle .

PREVENTIONPREVENTION

8. Identification of endometriosis requires a medical check-up 8. Identification of endometriosis requires a medical check-up by a gynecologist and for specific medical treatment: by a gynecologist and for specific medical treatment: utrozhestan - 100 mg 2-3 times a day from the 16 th to the 25 utrozhestan - 100 mg 2-3 times a day from the 16 th to the 25 th day of the cycle, symptomatic therapy during menstruation. th day of the cycle, symptomatic therapy during menstruation.

9. Acupuncture: 2-3 chicken for 10 sessions for girls 10-13 9. Acupuncture: 2-3 chicken for 10 sessions for girls 10-13 years. years.

10. Physiotherapy: Endonasal electrophoresis with vitamin 10. Physiotherapy: Endonasal electrophoresis with vitamin B1 10 days. B1 10 days.

11. Given the commitment of the central regulatory 11. Given the commitment of the central regulatory mechanisms of menstrual function and isolation of the mechanisms of menstrual function and isolation of the pathogenetic factors of uterine bleeding in girls recommend pathogenetic factors of uterine bleeding in girls recommend

the following treatment groups:the following treatment groups:

PREVENTIONPREVENTION

· · Glycine 0.05 g 3 times a day for 2 months (the effect of normalization of Glycine 0.05 g 3 times a day for 2 months (the effect of normalization of excitation and inhibition of central nervous structures of the brain, sedation);excitation and inhibition of central nervous structures of the brain, sedation);· Vitamin E, 1 capsule 2 times a day for 10 days (normalization of oxidant · Vitamin E, 1 capsule 2 times a day for 10 days (normalization of oxidant processes, improvement of steroidogenesis in the ovaries);processes, improvement of steroidogenesis in the ovaries);· Endonasal electrophoresis with vitamin B1 for 10 days;· Endonasal electrophoresis with vitamin B1 for 10 days;· Nootropil 200-400 mg 2-3 times a day for 30 days;· Nootropil 200-400 mg 2-3 times a day for 30 days;· Veroshpiron to 0.25 g daily in the morning for 3 weeks (diuretic and · Veroshpiron to 0.25 g daily in the morning for 3 weeks (diuretic and gipoandrogennoe action);gipoandrogennoe action);· Asparcam of 0.05 g 3 times a day for 3 weeks (sedative effect of · Asparcam of 0.05 g 3 times a day for 3 weeks (sedative effect of magnesium, a slight diuretic effect). This complex treatment is carried out magnesium, a slight diuretic effect). This complex treatment is carried out with a 7-day menstrual cycle, one every three months during the year and is with a 7-day menstrual cycle, one every three months during the year and is combined with physical therapy and psycho-correction by a psychologist. combined with physical therapy and psycho-correction by a psychologist. Against the background of a complex treatment in 92-93% of patients after Against the background of a complex treatment in 92-93% of patients after

treatment menstrual cycle is restored for a period of 4 to 6 months.treatment menstrual cycle is restored for a period of 4 to 6 months.

PREVENTIONPREVENTION

12. In identifying the hormonal 12. In identifying the hormonal abnormalities of the peripheral endocrine abnormalities of the peripheral endocrine organs (thyroid, adrenal glands) in organs (thyroid, adrenal glands) in conjunction with the correction of an conjunction with the correction of an endocrinologist.endocrinologist.In order to prevent iodine deficiency, it is In order to prevent iodine deficiency, it is recommended the use of iodine-100 in the recommended the use of iodine-100 in the balance for 3-6 months.balance for 3-6 months.