What is dysfunctional uterine bleeding perimenopausal period?
DQM in the perimenopausal period (aged 45 to 55 years) are called climacteric and constitute 15% of gynecological diseases. According to E.M. Vihlyaeva, 50-60% of all DMK are found in the perimenopausal period.
Causes of Dysfunctional uterine bleeding perimenopausal period
The end of the reproductive period is accompanied by a violation of cyclic processes in the reproductive system. Violation of one or more parts of the system that regulates the menstrual cycle changes hormonal homeostasis with a rhythm disturbance and the gradual cessation of menstruation.
At the heart of climacteric bleeding is a violation of the strict cyclicity of gonadotropin secretion and follicle maturation processes, leading to anovulatory ovarian dysfunction. The chaotic nature of the rhythm and the amount of gonadotropins released leads to a disturbance of the feedback mechanism. This is facilitated by the reduction of gonadotropin receptors in the ovaries. Violation of neurohumoral relationships in the perimenopausal period and contribute to the primary changes in the ovaries and uterus. As a result of these hormonal changes, steroidogenesis changes – relative hyperestrogenism is established against the background of absolute hypoprogesteronemia. Disturbances of proliferation and secretory transformation of the mucous membrane of the uterus lead to endometrial hyperplasia of varying severity. Bleeding occurs as a result of incomplete and prolonged detachment of the hyperplastic endometrium.
Symptoms of Dysfunctional uterine bleeding perimenopausal period
As a rule, patients complain of excessive bleeding from the genital tract after a delay of menstruation from 8-10 days to 4-6 weeks. Deterioration, weakness, irritability, headache are observed only during bleeding.
Uterine bleeding can be the starting point of the pathology of the neuroendocrine, cardiovascular and central nervous systems. In turn, these disorders can cause recurrent uterine bleeding. Approximately 30% of patients with menopausal bleeding have more or less pronounced metabolic and endocrine disorders. The developing symptom complex includes secondary neuroendocrine-hypothalamic disorders, primarily weight gain, fluid retention, edema, headache, sleep rhythm disturbance, unstable blood pressure, sometimes crises, accompanied by a sense of fear of death, pain in the heart, brady or tachycardia, muffled heart tones. In general examination, fat deposition is noticeable on the abdomen, back, thighs with a significant increase in body weight with skin stretching (white stretch marks).
Diagnosis of Dysfunctional uterine bleeding perimenopausal period
The main condition for effective therapy is accurate diagnosis of DMK, i.e. exclusion of organic diseases as a cause of bleeding.
A detailed, purposeful examination of the anamnesis, a thorough general examination and a pelvic exam allow us to establish a preliminary diagnosis and outline ways of examination to confirm it. When collecting history pay attention to the formation of menstrual function, reproductive function, infectious diseases in history. It should also ask the patient in detail how the interval, duration and duration of bleeding varies. The emergence of new pain may indicate the progression of the disease caused by the transition of functional disorders in organic. Climacteric bleeding recur, often accompanied by endometrial hyperplastic processes and neuroendocrine disorders. As a result of a general examination, one can get an idea of the state of the internal organs, possible endocrine disorders, and metabolic changes.
Of great practical importance is ultrasound of the genitals (abdominal and transvaginal). Ultrasound can be used in the dynamics of the survey, it allows you to diagnose myomatous nodes, foci of adenomyosis, hyperplastic uterine mucosa, ovarian tumors, polycystic ovaries. Improving transvaginal echography makes it possible to diagnose adenomyosis very accurately. In women with recurrent uterine bleeding, echography is required. For the diagnosis of intrauterine pathology more informative transvaginal ultrasound using a contrast agent (hydrosonography).
When gynecological examination should pay attention to the age of the woman and changes in the genitals.
One of the reliable and highly informative methods of examination is separate diagnostic curettage of the uterine mucosa with subsequent histological examination of the scraping. The diagnostic value of curettage significantly increases hysteroscopy, making it possible to ensure complete removal of the diseased endometrium and to visually detect intrauterine pathology. In the absence of a hysteroscope and suspected submucosal node or internal endometriosis, hysterography or hydrosonography is performed.
Hyperestrogenic uterine bleeding is also observed with hormone-active ovarian tumors (tech-, granuloscletous or mixed). These tumors do not reach the big sizes and more often arise at perimenopausal age. In these cases, additional methods of examination are used, since in a two-handed study, these tumors in obese women are difficult to determine. The diagnosis is made by ultrasound, which shows the asymmetry of the size of the ovaries, an increase in one of them and its echostructure. Computed tomography and nuclear magnetic resonance provide a clearer picture. In case of recurrent bleeding and the ineffectiveness of previous therapy, laparoscopy is of great diagnostic value, which allows not only to visualize the ovaries, but also, if necessary, to make a biopsy.
To clarify the state of the CNS, echo and electroencephalography, rheoencephalography, an overview image of the skull and the Turkish saddle, the study of color fields of view are performed. According to the testimony prescribed consultation neurologist. It is advisable to conduct an ultrasound of the thyroid gland and hormonal studies.
Treatment of Dysfunctional uterine bleeding perimenopausal period
Bleeding in the perimenopausal period is one of the first clinical symptoms of atypical hyperplasia and endometrial adenocarcinoma. In this regard, treatment begins after a complete elucidation of the essence of the pathological process, which is impossible without separate diagnostic curettage of the mucous membrane of the cervical canal and the body of the uterus under the control of hysteroscopy followed by histological examination of scrapings. Further treatment depends on the endometrial histostructure, concomitant genital pathology, endocrine diseases and metabolic disorders.
Treatment of climacteric bleeding includes general therapeutic effects, hormone therapy, and surgical intervention. In order to restore the normal functioning of the central nervous system, it is necessary to eliminate negative emotions, physical and mental overwork. Psychotherapy, physiotherapy, preparations of bromine, valerian, tranquilizers can normalize the activity of the central nervous system.
Since MQDs anemize patients, it is necessary to take iron supplements for acute and chronic anemia. Vitamin therapy includes drugs of group B, vitamin K for the regulation of protein metabolism; vitamins C and P to strengthen the endometrial capillaries, vitamin E to improve the function of the hypothalamic-pituitary region.
Hormone therapy is aimed at preventing menopausal bleeding. For this purpose, synthetic gestagens (duphaston, norcolute, premolt) are most often used. Progestins consistently lead to inhibition of proliferative activity, secretory transformation of the endometrium and cause atrophic changes in the epithelium. The dose and sequence of gestagen use depend on the age of the patient and the nature of the pathological changes in the endometrium. Women up to 48 years old can be prescribed regimens with regular menstrual cycles, older than 48 years old – with suppressed ovarian function. Derivatives of 19-norsteroids (gestrinone) and 17-ethynyl testosterone derivative (danazol) are also used. The drugs should be used for 4-6 months in a continuous mode: danazol 400 mg per day, gestrinon 2.5 mg 2 times a week. These drugs are antiestrogens, they inhibit the secretion of gonadotropins by the pituitary gland, which leads to the suppression of the synthesis of steroids in the ovaries. As a result, atrophic changes develop in the endometrium.
Combined therapy includes the correction of metabolic and endocrine disorders – primarily obesity, hyperglycemia and hypertension.
Relapse of climacteric bleeding after hormone therapy is often the result of undiagnosed organic pathology or an improperly selected drug or its dose, as well as an individual reaction to it. With recurrent uterine bleeding and the absence of data on malignant pathology, endometrial ablation (laser or electrosurgical) is possible. This treatment prevents the restoration of the endometrium by destroying its basal layer and glands.