Dysfunctional uterine bleeding (abbreviated DUB)- bleeding from the uterine cavity that is not associated with anatomical changes in the woman’s genital organs.

The incidence of DMC in modern gynecology is quite high - approximately 15-20% of the total number of gynecological diseases. DMC occurs in women of various age groups, but more often in the juvenile period (12-18 years) and premenopausal age (45-55 years). DUB is less common in women of reproductive age (18-45 years). This division into age groups is not accidental, because it is the hormonal fluctuations characteristic of each age that reflect the essence of the disease.

Causes of DMK

The reasons leading to the development of DMC include:

Violation of the formation and release of gonadotropic hormones that regulate the hormonal function of the ovaries. In the juvenile period, DUB occurs due to the immaturity of the gonadotropic function in girls, and in the menopausal period the same function is disrupted due to age-related involutive processes (decay of reproductive function in women);
- inflammatory diseases of the genitals, genital infections;
- frequent curettage, in particular abortions;
- endocrine diseases - diabetes mellitus, thyrotoxicosis, hypothyroidism;
- taking psychotropic drugs, frequent stress;
- a sharp change in climatic conditions, in particular, winter holidays in hot exotic countries.

Depending on the presence or absence of ovulation, DMCs are:

Ovulatory (with ovulation) - characteristic of women of the reproductive period;
- anovulatory (without ovulation) - occurs in girls of the juvenile period and premenopausal age, less often occurs in women of the reproductive period.

Ovulatory DUBs can be intermenstrual or DUBs that are caused by “persistence of the corpus luteum” (long-term functional activity of the corpus luteum).

What are intermenstrual DMCs? Normally, every woman ovulates in the middle of her cycle, after which estrogen levels decrease, but bleeding does not occur, since the corpus luteum maintains normal hormonal levels. But if there is a significant and sharp decline in hormones, then a woman may experience intermenstrual bleeding immediately after ovulation, which lasts approximately 2-3 days.

Persistence of the corpus luteum occurs due to the fact that the corpus luteum functions for too long for various reasons, for example, if there is a functional formation in the ovaries, for example, a cyst. All this leads to the fact that progesterone levels fall too slowly or insignificantly. As a result, the tone of the uterus decreases, the functional layer is rejected and prolonged bleeding occurs.

Anovulatory DUBs are divided into DUBs with absolute hyperestrogenia (against the background of “follicle persistence,” i.e., the long-term existence of an unovulated follicle) and DUBs with relative hyperestrogenism (against the background of “follicular atresia,” i.e., regression of the follicle).

Follicle persistence occurs because the menstrual cycle stops before ovulation. At the same time, the follicle, which has reached maturity, continues to produce estrogens, due to which absolute hyperestrogenism develops. A large amount of estrogens causes proliferative processes and vascular changes in the endometrium. Further, as a result of hormonal decline, bleeding occurs from the uterine cavity.

With follicular atresia, the development of follicles also stops at any stage of the menstrual cycle, then the follicles disintegrate, turning into small cysts. Relative hyperestrogenism, like absolute hyperestrogenism, leads to proliferative processes in the endometrium, and hormonal decline leads to bleeding.

Symptoms of DUB

The severity and nature of symptoms in DUB depends on changes in the ovaries. In any case, the main symptom of all types of DUB is menstrual irregularity, which can manifest itself in the following forms:

Heavy regular or irregular periods lasting more than 7 days;
- menstruation with an interval of more than 35 days or less than 21 days;
- absence of menstruation in a woman during her reproductive period for more than 6 months, if the woman is not pregnant and is not lactating.

Anovulatory DUB usually manifests itself as a delay in menstruation for more than 1.5 months, after which bleeding appears lasting more than 7 days.

Sometimes it is difficult to distinguish DUB from normal menstruation, especially if menstruation occurs on time or with a slight delay. You need to know that the normal duration of normal menstruation should be approximately 2-7 days, and menstruation should not be too heavy. The duration of the menstrual cycle as a whole is 21-35 days (you need to count from the first day of your period!).
If you have discovered that you have menstrual irregularities, you need an in-person consultation with a gynecologist.

Diagnosis of DMC includes:

- gynecological examination;
- cytological examination of aspirate from the uterine cavity;
- Ultrasound of the pelvic organs;
- study of the hormonal profile (levels of LH, FSH, Prl, progesterone and estrogen);
- study of the level of thyroid hormones (TSH, T4, T3);
- hysteroscopy (examination of the uterine cavity using a hysteroscope), if necessary, separate diagnostic curettage of the cervical canal and the uterine cavity is performed;
- histological examination of scrapings obtained from the uterine cavity and cervical canal;
- examination of the pituitary gland: radiography, computed tomography and magnetic resonance imaging of the brain.

Treatment of DUB

Treatment tactics depend on the type of DUB, the age of the patient and the concomitant gynecological pathology. Treatment can be conservative or surgical. For ovulatory DUB, conservative treatment is carried out. For anovulatory DUB, both surgical and conservative treatment are necessary. The exception is anovulatory bleeding of the juvenile period, when surgical treatment is resorted to only in emergency cases.

Conservative therapy for DUB involves the use of hormonal drugs to stop bleeding, normalize the normal menstrual cycle, restore reproductive function and prevent DUB in the future.

The main groups of hormones for the treatment of DUB:

Estrogen - progestin oral contraceptives - OK (Zhanin, Logest, Regulon, Yarina) - are suitable for girls with DMC of the juvenile period and women of reproductive age up to 35 years. The course of treatment is approximately 3 months.

If the bleeding is too heavy and leads to sudden anemia in the patient, “hormonal hemostasis” is indicated. Prescribe OK 4-6 tablets per day, then the dose is gradually reduced by one tablet per day. Hormonal hemostasis is carried out for no more than 3 weeks.
- gestagens (Utrozhestan, Duphaston, Norkolut) are prescribed from the 16th to the 26th day of the menstrual cycle for 3 months. Suitable for women of any age;
- GnRH gonadotropin releasing hormone agonists (Buserelin, Zoladex, Diferelin) are prescribed for 3-6 months. Suitable for women of perimenopausal age, especially with repeated relapses of the disease, as well as women in whom DUB is combined with uterine fibroids or endometriosis.

Surgical method of treatment for anovulatory DUB.

The surgical method of treatment for anovulatory DUB is a separate therapeutic and diagnostic curettage of the uterine cavity and cervical canal with hysteroscopy. This method allows you to reliably diagnose intrauterine pathology and quickly stop bleeding by curettage of the uterine mucosa. The scraping is sent for histological examination. If there are no contraindications, hormonal therapy is prescribed after curettage. If a woman is premenopausal and, based on the results of histological examination, there is a suspicion of oncological pathology (endometrial cancer or atypical hyperplasia), then removal of the uterus is indicated.

During the rehabilitation period, general strengthening measures are carried out for a quick recovery of the patient: after heavy DMK, iron supplements (Sorbifer, Ferroplex) are necessarily prescribed to correct hemoglobin levels and serum iron levels. Nutrition should be complete; the diet must include meat dishes - beef, liver, as well as legumes and fruits.

For scanty and moderate bleeding, you can use traditional and alternative medicine as an addition to the main treatment. Nettle tinctures are widely used; the plant has a tonic and general strengthening effect, contains vitamin C, B vitamins, and iron salts. Regular use of the tincture helps increase hemoglobin levels and normalizes iron levels in the blood.

A popular trend in alternative medicine - vumbilding - training of vaginal muscles deserves special attention. Wumbuilding exercises using special vaginal simulators improve blood supply to the pelvic organs, which has a beneficial effect on the functioning of the ovaries. As a result, menstruation becomes painless and less abundant, and the cyclicity of discharge is regulated.

Complications of DMC:

Infertility during reproductive age; Pregnant women with a history of DUB are more likely to have early miscarriages than healthy pregnant women;
- chronic anemia; in case of acute bleeding and untimely consultation with a doctor, a state of shock with a fatal outcome may develop;
- with long-term anovulatory DUBs caused by hyperplastic processes, the development of endometrial cancer is possible.

Prevention of DMC:

- regular observation by a gynecologist;
- taking hormonal contraceptives;
- refusal of abortion;
- regular sex life, wumbling activities;
- exercise, weight control;
- correction of concomitant endocrine disorders.

Questions and answers from an obstetrician-gynecologist on the topic of DMC.

1. Can I have heavy periods due to the IUD?
The copper IUD can provoke increased menstrual flow; for women with heavy periods, hormone-containing IUDs such as Mirena or oral contraceptives are more suitable.

2. My period always comes a couple of days late. Is this a pathology?
No, if menstruation is delayed for more than 5 days, only then can we talk about ovarian dysfunction.

3. How can you tell if your periods are heavy or not?
If the discharge is clotted and you change pads or tampons at intervals of less than 2 hours, then your periods are heavy and this is a reason to contact a gynecologist.

4. Is it possible for a 16-year-old virgin to undergo curettage for DMC?
Usually in such cases, hormonal hemostasis is prescribed, but if the situation is urgent and the blood loss is large, it is necessary to perform curettage of the uterus. To avoid ruptures, the hymen is injected with novocaine.

5. After a diagnostic curettage for DUB, I was prescribed Norkolut. While taking the drug, menstruation has lengthened even more and my periods have been going on for more than 10 days. What to do? Does this mean Norkolut is not suitable for me?
While taking gestagens, in this case Norkolut, prolonged blood spotting is possible. This is not an indication for discontinuation of the drug.

6. I had a 2-week delay, then spotting bleeding appeared. What could it be?
Take a pregnancy test and see a gynecologist. Perhaps this is a threat of miscarriage or DUB.

7. How long does it take for a girl to have regular menstruation?
Within 1.5 - 2 years after the first menstruation, there may be acyclic bleeding. This is a normal option if the discharge is not too abundant. If the cycle is not established within this time, a consultation with a gynecologist is indicated.

8. Is it necessary to perform hysteroscopy for DUB, or can only curettage of the uterine cavity be done?
It is advisable to perform curettage with hysteroscopy, since it allows you to assess the condition of the uterine cavity and identify concomitant pathologies (myomatous nodes, polyps, endometriotic ducts, and so on). All this is important to know for a more accurate diagnosis and determination of treatment tactics.

Obstetrician-gynecologist, Ph.D. Christina Frambos.

Differential diagnosis, identification of causes, treatment of dysfunctional uterine bleeding (DUB) - all this presents certain difficulties, despite the fairly high development of the obstetric and gynecological branch of medicine. This is explained by common symptoms and often similar clinical and histological manifestations for different causes of pathology. Among gynecological diseases, DMK accounts for approximately 15-20%.

Causes of dysfunctional uterine bleeding

DUBs are acyclic abnormal (heavy, frequent and/or prolonged) bleeding that occurs as a result of dysregulation of the function of the reproductive system and is manifested by morphological changes in the mucous membrane of the uterus (endometrium). They are not associated with diseases of the genital organs themselves or with any systemic diseases of the whole body.

Mechanisms of regulation of the menstrual cycle

The menstrual cycle is a very complex biological process that is regulated by the nervous and hormonal systems of the body. Its external manifestation is regular menstrual bleeding from the genital tract, which occurs as a result of rejection of the surface membrane (functional layer) of the uterine mucosa.

The essence of the menstrual cycle is the release of a mature egg from the follicle, ready to merge with a sperm, and the formation of the luteal (yellow) body in the ovary in its place. The latter produces the female sex hormone progesterone.

Regulation of ovarian function is carried out by the anterior lobe of the pituitary gland through the synthesis and secretion into the blood of a group of gonadotropic hormones:

1. Follicle-stimulating hormone (FSH), which affects the processes of growth and maturation of the next follicle and the ovulatory process. FSH, together with luteinizing hormone (LH), stimulates the production of estrogen. In addition, it helps to increase the number of receptors that perceive the action of LH. They are found in the layer of granulosa cells of the follicle, which develop into the corpus luteum.
2. Luteinizing hormone, which controls the formation of the luteal body.
3. Prolactin, involved in the synthesis of the hormone progesterone by the corpus luteum.

The amount of estrogen and progesterone is not constant. It changes depending on the activity of the luteal body and corresponds to the phases of the menstrual cycle: during the follicular phase, the amount of all sex hormones increases, but mainly estrogens, and during ovulation and before the onset of menstruation, more progesterone is produced.

The production of FSH and LH by the pituitary gland occurs in a constant biological clock rhythm, which is ensured by the appropriate functioning (in this mode) of the cells of the nuclei of the hypothalamic part of the brain. The latter secrete gonadoliberins, or gonadotropin-releasing hormones (GnRH).

The functioning of the hypothalamus and the frequency of secretion of hormones into the blood, in turn, depend on the influence of biologically active substances, neurotransmitters (endogenous opiates, biogenic amines) secreted by higher structures of the brain. In addition, the regulation of the secretion of all hormones is also carried out according to the type of universal negative feedback: the higher the concentration of ovarian hormones in the blood, the more they inhibit the release of corresponding stimulating hormones by the pituitary gland and hypothalamus, and vice versa.

Schematic representation of feedback mechanisms

Causes and mechanism of DMC

Thus, the regular menstrual cycle is a complex biological process consisting of many links. A pathological factor can influence any link. However, as a rule, as a result of its influence, the entire chain (hypothalamus - pituitary gland - ovaries - uterus) of the regulatory mechanism is involved in the pathological process. Therefore, disturbances in any of its areas lead to dysfunction of the reproductive system of the woman’s body as a whole.

Adolescent or juvenile dysfunctional uterine bleeding of an anovulatory nature occurs in 20-25%. They usually occur in the first two years after the start of menstruation. But sometimes abundant ovulatory DUBs occur at the end of adolescence as polymenorrhea (8 days each with a break of 3 weeks), which is due to the inferiority of the corpus luteum or insufficient secretion of LH.

Such disorders are explained by the insufficiently complete formation of the adolescent’s hormonal system and its instability. In this regard, any, even minor pathological or simply negative impact can lead to pronounced dysfunctional disorders. With heavy bleeding lasting more than a week, girls quickly develop anemia, accompanied by pale skin, weakness and lethargy, headaches, loss of appetite, and rapid heart rate.

In the involutive period, the hormonal regulation system is disrupted due to the extinction of endocrine organs and is easily susceptible to breakdowns. Both during adolescence and at the stage of decline, she is also easily influenced by negative factors. Anovulatory dysfunctional uterine bleeding during menopause occurs in 50-60%. It occurs due to age-related changes in the hypothalamic region of the brain. As a result, the cyclical secretion of gonadotropin-releasing hormones is disrupted, which means that the maturation and function of the follicles are disrupted.

Bleeding in women of this period of life is often associated with cancer of the genital area. Therefore, differential diagnosis with DUB and treatment must be carried out in a gynecological hospital.

The remaining 15-20% of cases are dysfunctional uterine bleeding of the reproductive period. They develop against the background of persistent follicles with excessive secretion of estrogen and progesterone deficiency, which contributes to the development of glandular-cystic growth of the endometrium.

So, both the insufficiently formed and already “fading” hormonal regulation systems represent an easily vulnerable background for unfavorable factors that provoke DUB.

Causes and provoking factors

Among all the causative and provoking factors of DUB, the main ones are:

1. Occupational hazards, intoxications, general infectious and inflammatory diseases.
2. Inflammatory processes of the pelvic organs, as well as taking antipsychotic drugs. All this leads to dysfunction of the ovarian receptor apparatus.
3. Mental or physical fatigue.
4. Frequent psychological stress and stressful conditions.
5. Poor nutrition associated with a lack of proteins, vitamins and microelements.
6. Rapid change (moving) of location in areas with different time and climate zones.
7. Dysfunction of endocrine organs due to the presence of brain tumors, hyper- or hypothyroidism, Itsenko-Cushing's disease or syndrome, the presence of ectopic hormone-secreting tumors, etc.
8. Pregnancy and abortions with complications.
9. Restructuring of the endocrine system during puberty and involution;
10. Genetic diseases of the endocrine and reproductive systems.

Disorders of the regulatory system function lead to disruption of the cyclicity and rhythm of rejection and restorative-secretory processes in the endometrium of the uterus. Estrogen stimulation with prolonged and excessive secretion of this hormone contributes to an increase in uterine contractile activity, uneven blood supply and nutrition to the mucous membrane due to spastic contractions of the walls of its vessels.

The latter causes practically continuous and non-simultaneous damage and rejection of different parts of the intrauterine layer of the endometrium, accompanied by heavy and long-lasting bleeding from the uterus.

In addition, an increased concentration of estrogen increases the rate of cell division, which causes hyperplasia - proliferation and increase in thickness of the mucous membrane, polyposis, adenomatosis and atypical cell transformation.

The ovulatory phase of the menstrual cycle is the most vulnerable link in the regulatory mechanism of the neuroendocrine system. For this reason, dysfunctional uterine bleeding can occur:

• against the background of the absence of maturation and release of the egg from the follicle () - in most cases; this is associated with the lack of ovulation; in some women, the dominant (prepared) follicle still reaches the required degree of maturity, but does not ovulate and continues to function (persists), secreting estrogens and progesterone constantly and in large quantities;
• in other cases, one or more follicles, not reaching full maturity, become overgrown (atresia) and undergo reverse development (atretic follicles); they are replaced by new follicles, which also undergo atresia; all these corpus luteum secrete moderate amounts of progesterone and estrogens, but for a long time;
• against the background of normally occurring ovulation, DUB occurs due to premature rejection of the functional endometrium due to a short-term decrease in the production and secretion of sex hormones;
• before the start of the usual period of menstruation, which is evidence of insufficient functioning of the corpus luteum;
• prolonged menstrual bleeding due to follicle deficiency.

Thus, anovulatory bleeding occurs due to changes in the ovaries of two types - the persistence type and the atresia type. In most cases, both options are characterized by delayed menstruation with subsequent bleeding. In the case of follicle persistence, the delay in menstruation ranges from 1 to 2 months, and in case of atresia - up to 3-4 or more months. The duration of bleeding ranges from 2-4 weeks to 1.5-3 months, and with a persistent follicle they are shorter and more abundant. Ovulatory bleeding is manifested mainly by blood smearing before and after the end of menstruation.

Principles of treatment

Complex treatment of dysfunctional uterine bleeding should take into account the severity of symptoms, age, the cause of the disease, if it can be established, and the mechanism of development of the disease. Treatment tactics consist of three stages:

1. Stop bleeding and conduct hemostatic and restorative therapy.
2. Restoration of the menstrual cycle.
3. Stimulation of ovulation or surgical treatment.

Stop bleeding

In reproductive age and in menopausal women, the uterine cavity is scraped out to stop bleeding, which also has diagnostic value. In adolescent patients, the method of treating bleeding is intensive hormonal therapy. For these purposes, estrogens are prescribed by injection (estradiol dipropionate) or a course of tablets (otestrol). If the bleeding is moderate, without signs of anemia, then after estrogen therapy, progesterone is prescribed for a week in a daily dose of 10 ml.

Restoration of menstruation

Restoration of the menstrual cycle in juvenile age is carried out by a course of progesterone administration at a normal estrogen background, and at a reduced level - progesterone in combination with estrogen.

Women of reproductive age are usually prescribed combined oral contraceptives for 1 year, and during menopause - continuous use of prolonged progesterone.

Ovulation stimulation

Clomiphene is used to stimulate ovulation during reproductive age. If premenopausal patients recur despite treatment, or if adenomatous polyps, focal adenomatosis, or atypical endometrial cell hyperplasia are detected, uterine hysterectomy (amputation) or extirpation is recommended.

If pathology is detected in the brain, etc., appropriate treatment or elimination of provoking factors that led to dysfunctional uterine bleeding is carried out.

• Which doctors should you contact if you have Dysfunctional Uterine Bleeding?

What is Dysfunctional Uterine Bleeding?

Dysfunctional uterine bleeding (DUB) is caused by a violation of the cyclic production of ovarian hormones. With DUB, there are no anatomical changes in the reproductive system that could cause bleeding. Functional changes as a cause of uterine bleeding are possible at any level of regulation of menstrual function: in the cerebral cortex, hypothalamus, pituitary gland, adrenal glands, thyroid gland, ovaries. DUBs recur and often lead to reproductive dysfunction, the development of hyperplastic processes up to precancer and endometrial cancer.

There are DMK of the juvenile period - at 12-18 years; DMC of the reproductive period - at 18-45 years; menopausal bleeding - at 45-55 years.

Dysfunctional uterine bleeding of the reproductive period

DUBs account for about 4-5% of gynecological diseases of the reproductive period and remain the most common hormonal pathology of the female reproductive system.

What causes dysfunctional uterine bleeding

Etiological factors affecting the cortex-hypothalamus-pituitary-ovary-uterus system can be: stressful situations, climate change, mental and physical fatigue, occupational hazards, unfavorable material and living conditions, hypovitaminosis, intoxication and infections, disturbances of hormonal homeostasis after abortion, taking certain medications.

In addition to primary disorders in the cortex-hypothalamus-pituitary system, primary disorders are possible at the ovarian level. The cause of ovulation disorders can be inflammatory and infectious diseases: in 75% of cases with inflammatory diseases of the uterine appendages, various menstrual dysfunctions develop. Under the influence of inflammation, thickening of the tunica albuginea of ​​the ovary, disruption of blood supply and a decrease in reactive sensitivity to gonadotropic hormones are possible.

Disorders of the hypothalamic-pituitary system lead to functional and morphological changes in the ovaries and uterus. Depending on the pathogenetic mechanisms and clinical and morphological features, DMC are divided into anovulatory and ovulatory.

Anovulatory DMK:

• against the background of persistence of the follicle (absolute hyperestrogenia);
• against the background of follicular atresia (relative hyperestrogenism).

Ovulatory DMCs:

• intermenstrual;
• caused by the persistence of the corpus luteum.

In the reproductive period, the end result of hypothalamic-pituitary disorders is anovulation and anovulatory bleeding, which is based on the absence of ovulation and the luteal phase. With DUB during reproductive age, a mature follicle exists in the ovaries for a longer period than normal - persistence of the follicle occurs and a progesterone deficiency state develops. Persistence of the follicle is a kind of stoppage of the normal menstrual cycle at a time close to ovulation: the follicle, having reached maturity, does not undergo further physiological transformations and continues to secrete estrogens (absolute hyperestrogenism). When the follicle persists, as in the middle of the menstrual cycle, the follicle in the ovary is well developed. The level of estrogen hormones is sufficient. Long-term exposure to elevated levels of estrogen causes excessive growth of the endometrium with proliferation of stromal glands and blood vessels. Prolongation and intensification of proliferative processes in the endometrium lead to the development of hyperplastic processes and the risk of developing atypical hyperplasia and endometrial adenocarcinoma. Due to the absence of ovulation and the corpus luteum, the secretion of progesterone for the secretory transformation of the proliferative endometrium and its normal rejection does not occur. The mechanism of bleeding is associated with vascular changes in response to a decline in hormone levels: congestive plethora with a sharp expansion of capillaries in the endometrium, circulatory disorders, tissue hypoxia are accompanied by dystrophic changes and the appearance of necrotic processes against the background of blood stasis and thrombosis, which leads to prolonged and uneven rejection of the endometrium. The morphological structure of the mucous membrane is variegated: along with areas of decay and rejection, foci of regeneration appear. Rejection of the functional layer is also difficult due to the formation of a dense mesh-fibrous structure that penetrates the mucous membrane of the uterine body in the form of a kind of frame at the border of the basal and functional layers.

Anovulatory bleeding may result from relative hyperestrogenism. In the ovary, one or more follicles stop at any stage of development, without undergoing further cyclic transformations, but also without stopping functioning until a certain time, and subsequently atretic follicles disintegrate or turn into small cysts. The level of estrogen in follicular atresia may be low, but they act on the endometrium for a long time and cause hyperplasia (relative hyperestrogenism). Bleeding in such cases is associated with a drop in hormonal levels as a result of follicular atresia. Based on the morphology of the functional layer of the endometrium, it is possible to determine the phase in which follicular atresia occurred.

Ovulatory DMCs account for about 20% of all DMCs during the reproductive period. There are intermenstrual DUBs and DUBs caused by the persistence of the corpus luteum. Violations of ovarian function associated with pathology of the corpus luteum are possible in sexually mature women of any age; they are somewhat more common after the age of 30 and account for 5-10% of all DUBs.

In the middle of the menstrual cycle, after ovulation, there is normally a slight decrease in estrogen levels, but this does not lead to bleeding, since the general hormonal level is maintained by the corpus luteum, which is beginning to function. With a significant and sharp decline in hormone levels after the ovulatory peak, intermenstrual DUBs are observed for 2-3 days. There is a temporary inhibition of the cycle at the stage of the bursting follicle.

DUBs due to dysfunction of the corpus luteum are much less common than bleeding as a result of impaired follicular development. Dysfunction of the corpus luteum lies in its long-term functional activity - persistence of the corpus luteum. As a result, the level of gestagens does not fall quickly enough or last long enough. Uneven rejection of the functional layer causes prolonged menstrual bleeding. A decrease in uterine tone under the influence of increased levels of progesterone in the blood also contributes to bleeding. In this case, the corpus luteum either has no signs of reverse development at all, or, along with the luteal cells, which are in a state of reverse development, there are areas with pronounced signs of functional activity. The persistence of the corpus luteum is indicated by a high level of pregnanediol during bleeding, whereas normally the secretion of pregnanediol ceases on the eve of menstruation or simultaneously with its onset.

Blood loss during menstruation is limited by prostaglandins with different properties: prostaglandin E2 and prostacyclin are vasodilators and antiplatelet agents, prostaglandin F2 and thromboxane are vasoconstrictors and aggregation stimulators.

The production of prostaglandins is regulated by estrogens and progesterone: progesterone acts as an inhibitor of prostaglandin synthesis in the endometrium, and a decrease in its level increases the production of prostaglandins.

In addition to prostaglandins, many other cellular regulators, growth factors, and cytokines that affect the vascular and stromal components of the endometrium, regeneration and proliferation of the endometrium are involved in the mechanisms of menstrual bleeding.

Symptoms of Dysfunctional Uterine Bleeding

Clinical manifestations are usually determined by changes in the ovaries. The main complaint of patients with DUB is irregular menstrual rhythm.

Persistence of the follicle can be short-term, within the normal menstrual cycle. With the reverse development of a persistent follicle and the associated drop in hormone levels, uterine bleeding in intensity and duration does not differ from normal menstruation. Anovulatory menstrual cycles occur throughout life, but more often the persistence of the follicle is much longer and bleeding occurs after some delay in menstruation (the delay can be 6-8 weeks). Bleeding often begins as moderate, periodically decreases and increases again and continues for a very long time. The functional layer of the endometrium may gradually collapse down to the basal layer. Estrogen saturation also gradually decreases. Prolonged bleeding can lead to anemia and weakening of the body.

DUB due to persistence of the corpus luteum - menstruation occurring on time or after some delay. With each new cycle it becomes longer and more profuse, turning into bleeding that lasts up to 1-1.5 months.

Impaired ovarian function in patients with DUB can lead to infertility, but due to the alternation of ovulatory and anovulatory cycles, this infertility is relative.

Diagnosis of dysfunctional uterine bleeding

The cause of uterine bleeding in reproductive age can be various organic diseases of the reproductive system: benign and malignant diseases of the genitals, endometriosis, uterine fibroids, genital injuries, inflammatory processes of the uterus and appendages, interrupted uterine and ectopic pregnancy, remnants of the fertilized egg after an artificial abortion or spontaneous miscarriage , placental polyp after childbirth or abortion. Uterine bleeding occurs with extragenital diseases: diseases of the blood, liver, cardiovascular system, endocrine pathology. In patients with DUB during the reproductive period, it is necessary to identify or exclude organic lesions of the cerebral cortex, hypothalamus, pituitary gland, ovaries, uterus, thyroid gland, adrenal glands, as well as extragenital pathology. The examination should include the study of functional disorders in the hypothalamus-pituitary-ovary-uterus system using publicly available and, if necessary, additional examination methods. Examination methods for DMC:

• clinical (medical history; objective examination - general and gynecological examination);
• examination using functional diagnostic tests (measurement of basal temperature, “pupil” symptom, symptom of cervical mucus tension, calculating the karyopyknotic index);
• radiography of the skull (sella turcica), EEG and echo-EG, REG;
• determination of hormone content in blood plasma and urine (hormones of the pituitary gland, ovaries, thyroid gland and adrenal glands);
• Ultrasound, hydrosonography, hysterosalpingography;
• hysteroscopy with separate diagnostic curettage and morphological examination of scrapings;
• examination by a therapist, ophthalmologist, endocrinologist, neurologist, hematologist, psychiatrist.

A thorough analysis of anamnestic data helps to clarify the causes of bleeding and allows for differential diagnosis with diseases that have similar clinical manifestations. As a rule, DMCs occur against an unfavorable background: after infectious diseases, inflammatory processes of the uterine appendages, in patients with late menarche. Irregularity of menstruation from the period of menarche, juvenile DUB indicate instability of the reproductive system. If the generative function is impaired during the reproductive period (recurrent miscarriage, infertility), anovulatory bleeding and ovarian hypofunction with luteal phase deficiency can indirectly be assumed. Indications of cyclic bleeding - menorrhagia indicate organic pathology (uterine fibroids with a submucosal node, endometrial pathology). Painful bleeding is characteristic of adenomyosis.

During a general examination, attention is paid to the condition and color of the skin, the distribution of subcutaneous fatty tissue with increased body weight, the severity and prevalence of hair growth, stretch marks, the condition of the thyroid gland and mammary glands.

With a special gynecological examination, signs of hyper- or hypoestrogenism can be detected. With hyperestrogenic DUB, the mucous membranes of the vagina and cervix are juicy, the uterus is slightly enlarged, and the symptoms of the “pupil” and tension of the cervical mucus are sharply positive. With hypoestrogenic bleeding, the mucous membranes of the vagina and cervix are dry, pale, the symptoms of the “pupil” and tension of the cervical mucus are weakly positive. With a two-handed examination, the condition of the cervix, the size and consistency of the body and appendages of the uterus are determined.

The next stage of the examination is to assess the functional state of various parts of the reproductive system. Hormonal status is studied using functional diagnostic tests over 3-4 menstrual cycles outside the bleeding period, i.e. after bleeding has stopped or after diagnostic curettage. Basal temperature in DMB is almost always monophasic. The pronounced phenomenon of the “pupil” remains positive throughout the entire period of delayed menstruation with persistence of the follicle. With follicular atresia, the “pupil” phenomenon is quite pronounced, but persists for a long time. With persistence of the follicle, there is a significant predominance of keratinizing cells (CPI 70-80%), tension of the cervical mucus is more than 10 cm, with atresia there are slight fluctuations in the CI from 20 to 30%, tension of the cervical mucus is not more than 4 cm.

In clinical practice, to assess the patient’s hormonal status, hormonal studies are carried out: studying the secretion of pituitary gonadotropic hormones (FSH, LH, Prl); estrogen excretion, progesterone content in blood plasma; determine T3, T4, TSH, testosterone and cortisol in blood plasma and 17-CS in urine.

Determination of estrogens indicates long-term, monotonous excretion and the predominance of their most active fraction (predominance of estradiol over estrone and estriol). Levels of pregnanediol in urine and progesterone in the blood indicate luteal phase deficiency in patients with anovulatory DUB.

Diagnosis of thyroid pathology is based on the results of a comprehensive clinical and laboratory examination. Uterine bleeding usually results from increased thyroid function - hyperthyroidism. An increase in the secretion of T3 or T4 and a decrease in TSH allow the diagnosis to be verified.

To identify organic diseases of the hypothalamic-pituitary region, as well as their radiological features, radiography of the skull and sella turcica and magnetic resonance imaging are used.

Ultrasound, as a non-invasive and practically safe research method, can be used dynamically; it allows you to diagnose myomatous nodes, endometrial pathology, endometriosis, pregnancy and, most importantly, ovarian tumors. In recent years, hydrosonography (ultrasound with a contrast agent) has been used to identify intrauterine pathology.

The most important stage of diagnosis is histological examination of the material from separate curettage of the uterus and cervical canal. The most informative are scrapings a few days before the expected menstruation, but they are not always possible to obtain, since in some patients scraping for diagnostic and, at the same time, hemostatic purposes must be carried out at the height of bleeding. Separate diagnostic curettage is performed under hysteroscopy control.

Treatment of dysfunctional uterine bleeding

Treatment of patients with DUB during the reproductive period depends on the clinical manifestations. It is necessary to take into account the nature of menstrual dysfunction, the condition of the endometrium, the duration of the disease, and the severity of anemia.

When a patient with DUB presents, a hysteroscopy and separate diagnostic curettage are performed. This stops the bleeding, and based on the results of histological examination of scrapings, therapy is determined.

In case of recurrent bleeding, hormonal hemostasis is possible, but only if information about the state of the endometrium was received no later than 2-3 months ago. There are several methods of hormonal hemostasis using estrogens, gestagens, and synthetic progestins. To quickly stop bleeding, estrogens are widely used, which in large doses have an inhibitory effect on the hypothalamus and pituitary gland, suppressing the release of follitropin, and increasing the secretion of lutropin. Most often, shock doses of estrogens are used at regular intervals until the bleeding stops: folliculin 10 thousand units or sinestrol 0.1% solution 1 ml 3-4 times every 1.5-2 hours. Then the daily dose of estrogens is reduced and treatment is continued with minimal doses until the 12-14th day, and then gestagens are added (progesterone 10 ml for 6-8 days or prolonged gestagen oxyprogesterone capronate - 17-OPK 12.5% ​​-125 mg). After the withdrawal of gestagens, menstrual-like discharge appears.

Hemostasis with gestagens is based on their ability to cause desquamation and complete rejection of the endometrium. However, progestational hemostasis does not provide a quick effect.

The next stage of treatment is hormone therapy, taking into account the characteristics of the structure of the endometrium, the nature of ovarian dysfunction and the level of blood estrogen. Goals of hormone therapy:

• normalization of menstrual function;
• rehabilitation of impaired reproductive function with decreased fertility or infertility;
• prevention of bleeding.

In case of hyperestrogenism (persistence of the follicle), treatment is carried out with gestagens in the second phase of the menstrual cycle (progesterone, norkolut, duphaston, uterozhestan) for 3-4 cycles, estrogen-gestagens with a high content of gestagens (rigevidon, microgynon, celeste) for 4-6 cycles .

For hypoestrogenism (follicular atresia), cyclic therapy with estrogens and gestagens for 3-4 cycles in combination with vitamin therapy (in the first phase - folic acid, in the second - ascorbic acid) against the background of anti-inflammatory therapy is indicated.

Preventive therapy is carried out in intermittent courses (3 months of treatment - 3 months break). Repeated courses of hormone therapy are prescribed according to indications, depending on the effectiveness of the previous course. The absence of an adequate response to hormone therapy at any stage should be considered an indication for a detailed examination of the patient.

In order to rehabilitate impaired reproductive function, ovulation is stimulated with clomiphene from the 5th to the 9th day of the menstrual reaction to progestins after endometrial curettage. The control of the ovulatory cycle is basal temperature, the presence of a dominant follicle and endometrial thickness on ultrasound.

General nonspecific therapy is aimed at relieving negative emotions, physical and mental fatigue, eliminating infections and intoxications and consists of effects on the central nervous system (psychotherapy, autogenic training, hypnosis, sedatives, hypnotics and tranquilizers, vitamins) and antianemic therapy.

DUB in the reproductive period with inadequate therapy are prone to relapses. Recurrent bleeding is possible due to the ineffectiveness of hormone therapy or an incorrectly identified cause of bleeding. In addition, disturbances in hormonal homeostasis in DMB become the background for the development of hormonal-dependent diseases and complications of the menopausal period. All this increases the risk of developing breast cancer and endometrial adenocarcinoma.

Dysfunctional uterine bleeding- This is a sign of ovarian dysfunction syndrome. It is characterized by prolonged delays in menstruation (up to six months), acyclicity and prolonged blood loss (up to 7 days). In gynecology, the disease is usually classified into:

• dysfunctional uterine bleeding of the juvenile period - between the ages of 12 and 18 years;
• dysfunctional uterine bleeding of reproductive age - develops in women 18-45 years old;
• dysfunctional uterine bleeding of the premenopausal (menopausal) period - occurs during menopause (45-55 years).

According to the criterion of the presence of ovulation or its absence, dysfunctional bleeding is:

• ovulatory;
• anovulatory (80% of cases).

According to statistics, uterine bleeding is the most common pathology of the female reproductive system.

Causes of dysfunctional uterine bleeding

Dysfunctional uterine bleeding is a consequence of a violation of the hormonal regulation of ovarian function by the hypothalamic-pituitary system. Due to impaired secretion of luteinizing and follicle-stimulating hormones of the pituitary gland, which are responsible for follicle maturation and ovulation, disruptions in folliculogenesis and menstrual function are observed. In this case, the ovary can either ripen, but without ovulation, or not ripen, that is, the corpus luteum does not form in any case.

As a result of these pathological processes, the female body is in a state of hyperestrogenism - progesterone is not synthesized in the absence of the corpus luteum, and the uterus is exposed to estrogen. A disruption of the uterine cycle occurs when the endometrium grows greatly (hyperplasia), and then is rejected. Because of this, uterine bleeding becomes severe and prolonged. Dysfunctional uterine bleeding may stop on its own, but usually reappears after some time. Therefore, it is very important to exclude recurrence of the disease.

Causes of juvenile dysfunctional uterine bleeding

During puberty, dysfunctional bleeding occurs more often than other gynecological pathologies (in 20% of cases). Their reasons are:

• mental/physical trauma;
• overwork;
• dysfunction of the thyroid gland/adrenal cortex;
• childhood infections (measles, chicken pox, rubella, whooping cough);
• ARI, chronic tonsillitis.

Causes of dysfunctional uterine bleeding during reproductive age

In women of reproductive age, the disease occurs less frequently - in 5% of cases. Its development is led by:

• climate change;
• intoxication poisoning;
• infectious diseases;
• harmful working conditions;
• abortions;
• medications that cause disorders at the level of the hypothalamic-pituitary system.

Causes of dysfunctional uterine bleeding in the premenopausal period

During menopause, dysfunctional uterine bleeding occurs in 15% of cases from other gynecological pathologies. Gynecologists explain their occurrence by the fact that with age, the pituitary gland produces fewer gonadotropins and does so irregularly. This, in turn, causes disturbances in the egg cycle (formation of the corpus luteum, ovulation, folliculogenesis). Due to a lack of progesterone, the endometrium begins to grow. Its rejection leads to severe uterine bleeding.

The best doctors for the treatment of dysfunctional uterine bleeding

Prevention

Prevention of dysfunctional uterine bleeding consists of:

• regular visits to a gynecologist;
• submitting a smear once a year for oncocytology;
• competent treatment of gynecological diseases;
• exclusion of abortion;
• reduction of psycho-emotional and physical stress;
• maintaining a menstrual calendar;
• proper nutrition.

This article is posted for educational purposes only and does not constitute scientific material or professional medical advice.

Normal menstrual function is an important aspect of women's health. It is maintained thanks to the coordinated work of various parts of the neuroendocrine regulation of the ovarian and uterine cycles. Despite the multifactorial nature of changes in the rhythm of menstruation, clinically this most often manifests itself in two diametrically opposed options: weakening (absence) of menstruation or, conversely, their intensification. The latter can be so prevalent in symptoms that it is even classified as an independent nosological unit - dysfunctional uterine bleeding (DUB).

This pathology accounts for one fifth of all gynecological diseases. It includes only functional disorders at any level of regulation of the menstrual cycle, and bleeding that occurs against the background of organic damage to the internal genital organs is not included here. And women who are faced with a similar problem should understand why menstruation disorder occurs, how it manifests itself and what needs to be done to normalize the functioning of the body. But this is possible only after medical consultation and appropriate diagnosis.

Causes and mechanisms

Disorders in the female reproductive system have many causes. Menstrual function depends on the proper functioning of parts of the brain (cortex, hypothalamus and pituitary gland), ovaries and uterus. Therefore, disturbances in any part of the regulatory system can affect the nature of menstruation and lead to bleeding. Factors of menstrual dysfunction include both external adverse effects and internal disorders. The following can increase menstruation and provoke uterine bleeding:

• Psycho-emotional stress.
• Physical fatigue.
• Climate change.
• Occupational hazards.
• Hypovitaminosis.
• Hormonal imbalances.
• Infectious diseases.
• Various intoxications.
• Frequent abortions.
• Use of medications.

Under the influence of these factors, the neurohumoral regulation of the female cycle is disrupted. The main changes concern the “higher” links, i.e. the cortex, hypothalamus and pituitary gland, which changes the production of gonadoliberins and tropic hormones. But ovarian dysfunction, which occurs against the background of inflammatory processes, is also of great importance. This provokes thickening of the tunica albuginea of ​​the organ, deterioration of blood flow and trophic disorders, and the receptors become less sensitive to pituitary influences.

Menstrual function is also sensitive to other hormonal substances. Therefore, uterine bleeding can occur in patients with thyroid pathology, obesity and diabetes mellitus. And when making a diagnosis, you need to pay attention not only to changes in the reproductive sphere.

Dysfunctional uterine bleeding can be provoked by various factors affecting the female body - external or internal.

Cycle without ovulation

In the ovary, the processes of folliculogenesis, ovulation and the formation of the corpus luteum are disrupted, which entails maladaptation of the endometrium with corresponding disorders of proliferation, secretion and desquamation. Hypothalamic-pituitary dysfunction in most cases ends in anovulation, i.e., a situation when the egg is not released. And two mechanisms are involved in this: persistence and atresia of the follicle. The first is observed much more often and is accompanied by excessive production of estradiol (absolute hyperestrogenism). The follicle has matured and stopped developing, but progesterone is not released, since in the absence of ovulation the corpus luteum is not formed. The situation with atresia is different. In this case, the follicle freezes at any stage without reaching its peak. Consequently, there is little estradiol, but progesterone is still not produced (relative hyperestrogenism).

Excessive concentration of estrogen triggers proliferative processes in the uterus. And due to a lack of progesterone, the endometrium cannot enter the secretory phase. Then bleeding occurs, the main mechanisms of which will be:

1. Stagnation of blood.
2. Expansion of capillaries.
3. Tissue hypoxia.
4. Thrombosis and foci of necrosis.

Therefore, the endometrium is rejected unevenly, more in areas that have undergone dystrophic changes. This process takes longer than normal menstruation and has no known cyclicity. In addition, excessive growth of the endometrium is associated with the risk of atypical hyperplasia, i.e., a tumor process (precancer and cancer).

Cycle with ovulation

In women over 30 years of age, uterine bleeding often has a different explanation. The ovulation process is not affected, but the development of the corpus luteum is disrupted. We are talking about its persistence, in other words, long-term functional activity. In this case, the production of progesterone increases, the level of which remains high for a long time or decreases, but very slowly. The endometrium is delayed in the secretory phase, and therefore is rejected unevenly, causing prolonged bleeding.

The appearance of menometrorrhagia is also facilitated by relaxation of the uterus, which is a consequence of excessive levels of gestagens. In addition, the content of prostaglandin F2, responsible for vasoconstriction, decreases in the endometrium. But its biological opponent, prostaglandin E2, on the contrary, is more active, which simultaneously entails a decrease in platelet aggregation. Such bleeding can also occur in the middle of the menstrual cycle, which is due to a sharp decline in estrogen production immediately after ovulation.

With changes in regulatory influences at the level of the hypothalamus-pituitary gland, ovarian function is disrupted, which is manifested by disorders of ovulation, follicular and luteal phases of the cycle.

Classification

In clinical practice, dysfunctional uterine bleeding has several varieties. Firstly, the classification takes into account the age of the woman when the pathology appeared. Accordingly, the following bleedings are distinguished:

1. Juvenile.
2. Reproductive age.
3. Premenopausal.

And according to the mechanism, they are ovulatory and anovulatory. The former are characterized by cyclicality, and such bleeding occurs mainly in the reproductive period (menorrhagia). And the absence of ovulation is more common in adolescents and during menopause (metrorrhagia).

Symptoms

The clinical picture of uterine bleeding depends on several factors. The course and nature of menstrual dysfunction is primarily determined by its cause and mechanism of development. But the general condition of the woman, the presence of concomitant diseases, and even individual sensitivity to various stimuli are of no small importance. The main complaint at the doctor’s appointment will be a change in the cyclicity and nature of menstruation:

• Delay of menstruation from 10 days to 6–8 weeks.
• Heavy and prolonged discharge (hypermenstrual syndrome).
• Intermenstrual bleeding.

Excessive menstruation gradually turns into metrorrhagia. Some bleeding lasts up to 1.5 months, which is usually characteristic of persistence of the corpus luteum. This leads to a deterioration in the woman’s condition and the appearance of the following symptoms:

• General weakness.
• Dizziness.
• Dry mouth.
• Pallor.

Bleeding often develops against the background of neuroendocrine and metabolic disorders. Patients over the age of 45 often present certain signs of menopausal syndrome: hot flashes, headaches, increased blood pressure, irritability, sweating, rapid heartbeat. Ovarian dysfunction during reproductive age is accompanied by decreased fertility. And the premenopausal period is already characterized by a low probability of pregnancy.

During a gynecological examination, you can identify some signs indicating an increase or decrease in the level of estradiol in the blood. Hyperestrogenia is manifested by increased blood supply to the mucous membranes (they are brightly colored), and the uterus itself will be slightly enlarged upon palpation.

Particular importance in case of uterine bleeding is given to oncological alertness, since endometrial hyperplasia is a risk factor for cancer, especially at menopausal age. Therefore, women should be aware of the alarming symptoms of oncology:

• Sudden bleeding after a long delay.
• Cloudy discharge with an unpleasant odor.
• Pain in the lower abdomen.

But the disease may not manifest itself in any way for a long time, which is its insidiousness. In advanced stages of cancer, general intoxication occurs.

The clinical picture of uterine bleeding consists of local symptoms and general disorders corresponding to the intensity and duration of the pathology.

Diagnostics

A prerequisite for adequate treatment of menstrual cycle pathology is to establish the source of the disorders and the mechanisms that support the pathology. Dysfunctional uterine bleeding requires careful differential diagnosis: both between individual types within the nosological unit itself, and with other gynecological diseases, especially of an organic nature (uterine fibroids, adenomyosis). To establish the state of all links of the regulatory system that supports menstrual function, doctors prescribe various methods of laboratory and instrumental monitoring. These include the following studies:

• General blood test.
• Blood biochemistry: hormonal spectrum (follitropin, lutropin, thyrotropin, prolactin, estradiol, progesterone, thyroxine, triiodothyronine), coagulogram.
• Ultrasound of the uterus with appendages, thyroid gland.
• Hysteroscopy.
• Hysterosalpingography.
• Diagnostic curettage.
• Histological analysis of the material.
• X-ray of the sella turcica.
• Tomography (computer or magnetic resonance imaging).

The patient may need to consult other specialists, and, in addition to the gynecologist, she will most often have to see an endocrinologist and a neurologist. And having determined why dysfunctional uterine bleeding occurred, you need to begin to correct it.

Treatment

There are several stages in the treatment of this pathology. First, measures are taken to immediately stop the bleeding, mainly in a hospital setting. Then correction of hormonal disorders and disturbances in the cyclicity of menstruation is necessary, which will prevent repeated menometrorrhagia. And in the end, rehabilitation is needed aimed at restoring reproductive function.

Conservative

To stop bleeding and normalize a woman's hormonal levels, various medications are used. The doctor has modern and effective tools in his arsenal that allow him to influence the symptoms, causes and mechanisms of pathology. Hormonal drugs include the following:

1. Estrogen (Estrone, Prginon).
2. Gestagen (Norkolut, Duphaston).
3. Combined (Non-Ovlon, Marvelon).

The most commonly used regimens are estrogen hemostasis or stopping menorrhagia using combined agents. But pure progestins should be used with caution, since they have a high risk of “withdrawal bleeding.” But after hemostasis, synthetic gestagens are indicated as agents that normalize the menstrual cycle. This therapy is carried out in several cycles over 3–4 months. Ovulation can be stimulated with clomiphene, which belongs to the group of anti-estrogenic substances. And hormones are often combined with vitamin therapy with folic and ascorbic acids (in the first and second phases of the cycle, respectively).

Other drugs that help stop dysfunctional uterine bleeding are hemostatic agents (Dicinone, aminocaproic acid, Vicasol, calcium gluconate) and uterotonics that promote uterine contraction (oxytocin). For prolonged metrorrhagia, antianemic drugs (Tardiferon) are indicated, and anti-inflammatory therapy is often required.

Along with hormonal correction, physiotherapy also helps restore the menstrual cycle. Most often, electrophoresis of drugs is used: copper, zinc and iodine, vitamins C, E, group B, novocaine.

Conservative treatment of uterine bleeding can eliminate their symptoms and consequences, normalize menstrual function and prevent relapses.

Surgical

Treatment of bleeding in the reproductive and menopausal periods begins with fractional curettage of the uterine cavity. This also makes it possible to stop metrorrhagia and establish the nature of changes in the endometrium, which affects further tactics. Cancer or adenomatous hyperplasia clearly requires surgical intervention. Cryodestruction of the endometrium or chemical ablation gives a good effect.

If the bleeding does not stop after drug hemostasis, but increases with the deterioration of the woman’s condition, then the doctor decides on the issue of surgical stopping. In adolescence, uterine curettage is performed. Detection of cervical pathology during reproductive age speaks in favor of hysterectomy; in other cases, supracervical or supracervical amputation is performed. In case of altered ovaries, oophorectomy (unilateral or bilateral) is also performed in parallel.

To prevent the development of menstrual dysfunction and prevent uterine bleeding, a woman should lead a healthy lifestyle, trying not to be influenced by unfavorable factors. And if any symptoms appear, then you should not wait for them to worsen, but you should immediately go to the doctor. The specialist will conduct a differential diagnosis, tell you what is causing the pathology, and prescribe the appropriate treatment.