Violation of the menstrual cycle - Causes, symptoms and treatment. MF.

Breaking the menstrual cycle( NMC) is one of the most common causes of a woman turning to a doctor obstetrician-gynecologist. According to different authors, in one way or another it is manifested in 35% of gynecological patients. In addition, more than 70% of women in the course of life have some manifestations( irregular cycle after menstruation, more ample monthly than normal with stress, etc.).

Irregular monthly - one of the most frequent symptoms of most gynecological diseases, also occurs with extragenital diseases in women. Another major manifestation of menstrual irregularity is bleeding, the nature and volume of which can vary greatly. Frequent bleeding in and out of menstruation does not have any organic justification - in this case they speak of discirculatory uterine bleeding. For the violation of the menstrual cycle, the following clinical manifestations are characteristic: irregular cycle, soreness and heavy bleeding.

Normally, the menstrual cycle is controlled by the release of pituitary and ovarian hormones. The first phase is dominated by FSH, a follicle-stimulating hormone that promotes the maturation of the follicle, which promotes the growth of estrogen secretion( primarily estradiol), which in turn contributes to the growth of the endometrium. When the level of estradiol rises, the level of FSH begins to fall( this mechanism is called negative feedback), and decreases as much as possible by the middle of the cycle. At the same time, under the influence of estrogens, the level of LH - luteinizing hormone begins to increase. When the level of PH reaches its peak, ovulation occurs. Together with the increase in the level of LH( a little later), there is an increase in the level of progesterone. The level of estrogen after the peak decreases and rises again only when the maximum level is reached by progesterone. If the fertilization has not occurred, progesterone and estrogen levels decrease and reach the minimum values, endometrial rejection occurs. After again FSH starts to increase and the process begins anew. Simpler it looks like this:

The duration of the monthly cycle for a woman is on average from 21 to 31 days. Typically, menstruation is set at the age of 12 to 14 years and most often almost immediately become regular. Less often they become regular after the first pregnancy. Periodic deviations from the norm are possible, within a few days / weeks. So if the monthly in a particular cycle comes a few days earlier or later, then talk about the violation is not legal. If the interval between menstrual periods is 40-60 days, or on the contrary, it is less than 21-25 days, at what, therefore, the woman's menstrual period lasts for a long time - one can speak about the irregularity of the cycle.

Why is the female monthly cycle accompanied by bleeding? The uterus, as is known, consists of three layers, of which the inner layer - the endometrium, in turn, is also divided into two parts: functional and basal. The first is the place where the fetal egg is implanted and where pregnancy begins to develop. During each monthly cycle, due to the basal layer, it increases and thickens, preparing the basis for possible implantation. In the case where the egg does not fertilize, the "magnificent" functional layer "as unnecessary" exfoliates, under the influence of a cyclically changing concentration of pituitary-ovarian hormones in the blood, causing bleeding. Bleeding is quite abundant, which is primarily due to the rich system of blood supply of the endometrium. The so-called spiral arteries penetrate the endometrium, which are damaged by the detachment of the tissue, which they actually fed. Their damage leads to dilatation( expansion) of spiral arterioles, after which the actual menstrual bleeding begins. Initially, adhesion( clumping) of platelets in the vessels of the endometrium is suppressed, but then, the damaged ends of the vessels are sealed with intravascular thrombi consisting of platelets and fibrin. Twenty hours after the onset of menstruation, when most of the endometrium has already torn off, a pronounced spasm of the spiral arterioles develops, thereby achieving hemostasis. Endometrial regeneration begins 36 hours after the onset of menstruation, despite the fact that endometrial rejection is not yet complete.

Causes of the disorder of the central cycle

What are the causes of menstrual irregularity? In principle, we can distinguish the following:

• External( physiological) - in this case there is no direct physiological effect on the process, but there are indirect factors, such as: stress, changes in the nature of nutrition, climate change, etc. Consequently, eliminating the external cause leads to a normalization of the process.
• Pathological - this can include a huge group of diseases and conditions, which will be characterized by a violation of the regularity of the cycle.
• Medication - when prescribing or canceling certain medications

What may be irregularities of the menstrual cycle by nature:

• Dysfunctional uterine bleeding - abnormal uterine bleeding without lesions of the genital organs.
• Menorrhagia - copious spotting( more than 100 ml), which occurs with a clearly defined periodicity.
• Metrorrhagia - irregular bleeding, without clear time intervals.
• Polymorrhoea - bleeding occurring with an interval of less than 21 days.
• Intermenstrual bleeding is a bleeding between menstruations. The amount of blood lost varies.
• Postmenopausal bleeding - bleeding, a year( or more) after the onset of menopause;

Pathological conditions in which the menstrual cycle is disrupted:

1. Ovarian pathology - disorders of the functional connection of the pituitary-ovary, damage to the ovarian tissue, iatrogenic( medicamentous) effect, oncological degeneration of the ovaries. It is necessary to mention such a pathology as insufficiency of the yellow body of the ovary( in place of the follicle from which the egg "leaves" the egg for fertilization normally develops a yellow body that is capable of producing progesterone necessary for the implantation of the fetal bladder) - an insufficient amount of progesterone is not able to support the process at a normal level. This is one of the main causes of menstrual irregularities.
2. Pathology of the hypothalamic-pituitary system - the normal regulation of the cycle is disrupted, due to inadequate release of FSH and other hormones;oncological degeneration of tissue.
3. The pathology of the adrenal glands and other estrogen secretion tissues - the normal synthesis of estrogens is disrupted, the process "does not start."Here it is possible to carry tumors of adrenals.
4. Endometrial polyp
5. Chronic inflammatory diseases of the uterus - there is no normal growth of the endometrium and its timely maturation.
6. Endometriosis( genital and ectragenital) - is considered separately, due to the fact that the causes of its origin have been poorly studied.
7. Oncology - the appearance of pathological hormone-secreting tissue can also lead to the occurrence of regularity disorders.
8. Abortion and scraping of the uterine cavity - can be accompanied by both mechanical damage and possible attachment of inflammatory processes.
9. Operated ovary - after operation on the ovaries, especially with the use of coagulation, may develop failure of the organ function, manifested primarily in the irregularity of menstruation.
10. Diseases of the liver - as a rule for cirrhotic degeneration of liver tissue characterized by a violation of conjugation of estrogens. As a result, the estrogen level rises and menstrual bleeding becomes more frequent( and more abundant).
11. Dysfunctional uterine bleeding - without organic damage to organs and systems. In 20% of cases occur immediately after puberty, in 50% of women older than 40 years. The diagnosis is made when other pathologies are disconnected.
12. Disturbance of coagulating blood system - can cause long-term bleeding and without disrupting the regularity of the cycle.
13. Other causes - surgical interventions, long-term diseases, etc.

In addition, it is necessary to allocate irregular monthly, associated with taking medications. This includes: drugs for hormone replacement therapy, corticosteroids, anticoagulants, tranquilizers, antidepressants, digitalis preparations, dilantine and intrauterine spirals. Therefore, the appointment of any of these drugs should be done only by the doctor, as well as their cancellation. If necessary, consult a specialist who prescribes the drug.

Diagnosis of menstrual disorders

In view of the huge number of reasons, diagnostic search should start from simple to complex:

1. Medical history - the doctor should find out about the patient's medications, about the history of her recent pregnancy( after pregnancy, menstrual can not only normalize, as mentioned above, butand violated), of all external factors that may contribute to the disruption of the cycle. Pay attention to the state of the patient's psyche.
2. Inspection of a woman - draws attention to the depletion of the patient, discoloration of the skin, mucous and sclera of the patient, the presence of manifestations of extragenital pathology( enlargement of the liver, thyroid gland, appearance of discharge from the nipple not related to pregnancy, etc.).
3. Gynecologic examination - pay attention to the appearance of soreness when viewed, especially when palpation of the cervix, the nature of the discharge and their number, the presence of voluminous formations in the small pelvis and infiltrates.
4. Taking all the smears - allows you to exclude the infection, a long persistence which can also cause irregularity of the cycle.
5. Ultrasound of the pelvis or abdominal cavity - pay attention first of all to the condition of the uterus and ovaries, in the absence of pathology in them - ultrasound of all organs and systems, sighting of the thyroid ultrasound( for possible hypophysial cause) and liver. When examining the ovaries pay attention to their size, the presence of follicles and their size, the blood supply of tissue, etc.
6. Clinical and biochemical blood tests, coagulogram - is necessary for differentiation with pathological conditions of the hematopoietic tissue and the pathology of blood clotting.
7. Determining the level of hormones in the blood is an important factor. Norms:
   Estradiol - 0,17 ± 0,1 nmol / l - folliculin phase, 1,2 ± 0,13 nmol / l-ovulation, 0.57 ± 0.01 nmol / l - luteal phase. Progesterone - 1.59 ± 0.3 nmol / l - folliculin phase, 4.77 ± 0.8 nmol / l - ovulation, 29.6 ± 5.8 nmol / l - luteal phase
   LH - folliculin phase - 1.1 - 11.6 mIU / l,ovulation 17 - 77 mIU / l, luteal phase 0 -14.7 mIU / l
   FSH - folliculin phase-2,8-11,3 mIU / l, ovulation - 5,8 - 21 mIU / l, luteal phase - 1, 2 - 9.0 mIU / L
8. MRI is a method by which a patient can be examined in detail, for the purpose of neoplasms and pathological changes in tissues. Expensive, rarely used.
9. Hysteroscopy - allows to study in detail the state of the endometrium, the presence or absence of the polyp. Allows after examination to make a curettage for sending the material to the histological examination. Of the minuses - the cost and need to give anesthesia.

The combination of the history, clinical manifestations and methods of laboratory and instrumental examinations makes it possible to determine the cause of the irregularity of the menstrual cycle, pain and pathological bleeding and eliminate them.

Treatment of menstrual disorders

First of all, it is necessary to include removal of all external factors of influence. Since the general interest of many women with weight loss can be the main cause of menstrual irregularity, it is necessary to choose the right diet for patients and recommend them to give up excessive sports.

In case of heavy bleeding, after excluding the pathology of the blood coagulation system, it is necessary to start symptomatic treatment. This includes:

1. Hemostatic preparations - vikasol, etamzilate, troneksam. In a hospital, they are usually administered intramuscularly( vikasol, etamzilate) or drip( tranexam) + in tablet form to enhance the effect( as a rule 2 tablets 3 times a day - the prone tones, 2 tablets twice a day, vikasol and etamzilate).
2. ε-Aminocaproic acid - reduces the level of bleeding in 60% of women
3. In cases of heavy bleeding - compensation of blood loss due to plasma infusion, and sometimes( in rare cases) blood.
4. Surgical treatment is an extreme method of treatment, for example, with heavy bleeding, over the age of 40, with persistent anemization of the patient, when the cause of the bleeding can not be established reliably. Possible:
   - Scraping the uterine cavity.
   - Endometrial ablation - burning of the endometrium with a laser.
   - Endometrial balloon ablation( enter a balloon with a liquid into the uterine cavity, which is then heated to 87.5 degrees).
   - Hysterectomy( removal of the uterus).
5. Compulsory combination with hormonal drugs, primarily oral contraceptives. This not only makes it possible to enhance the haemostatic effect, but it can also become the first, and sometimes the main, therapy for irregular menstruation. As a rule, use a combination drug that contains high doses of estrogens and progesterone.
   One of the most popular progesterone preparations in Russia, used in the treatment of menstrual irregularities, are Dufaston and Utrozestan. As a rule, their appointment depends on the hospital, there is no real proof of the advantage of one before another. Dose appointments depend on the situation, on average: Duphaston - 1 tab 1-2 times a day from 11 to 25 day cycle, Utrozestan 1 capsule 2-3 times a day.

In addition, the following drugs can be assigned to hormonal treatment:

• Norethisterone - oral progesterone, 5 mg 3 times a day from 5 to 26th day of the cycle.
• Medroxyprogesterone acetate - 10 mg per day from 5 to 26 days.

6. With all the advantages of these drugs, there are a number of contraindications, moreover, with prolonged use or the abolition of oral contraceptives, hormonal disorders often occur. The duration and periodicity of menstruation is reduced or increased, and the discharge can become too scarce or abundant, accompanied by pains in the lower abdomen. Beneficially affects the functions of the female reproductive system of a complex of biologically active substances - "Time Factor."In its composition, extracts of medicinal plants, vitamins B9, C, E and PP, minerals Fe, Mg and Zn - reduce muscle spasms, painful sensations during menstruation and participate in the restoration of the hormonal balance, including against or after the use of contraceptives.

In women, over 40 years of age, it is permissible to use drugs that completely or partially "turn off" menstruation. These include:

• Danazol - 200-400 mg / day. Reduces the amount of blood lost with each menses by 87%.
• Gestrinone - one capsule of 2.5 mg twice a week. It leads to atrophy of the endometrium.
• Gonadoliberin agonotes - cause a complete cessation of menstrual, amenorrhea. Treatment should be limited to 6 months to prevent osteoporosis. They are used rarely and quite expensive.

However, is the main treatment for menstrual irregularity is the cure for the underlying disease. Without the elimination of the main focus, it is impossible to achieve a complete cure. For example, if an endometrial polyp is detected, it is necessary to perform diagnostic scraping of the uterine cavity, in case of a chronic inflammatory process, the appointment of antibiotics, etc. Again, in most cases, a menstrual disorder is only a symptom of a major pathological process, and its treatment should be more prevalent. Only after removal of the main focus and the most acute clinical manifestations, it is possible to deal with the restoration of the disordered cycle.

Complications of menstrual irregularities

It is not worth considering violations of the menstrual cycle as a minor problem. Here are at least several reasons why it is worthwhile to contact a doctor:

An irregular cycle can be accompanied by persistent anovulation, hence leading to infertility

Frequent intermenstrual bleeding can cause serious complications - from fatigue to total disability.

Late diagnosis of many pathologies, the first symptom of which is a disorder of the menstrual cycle can lead to a lethal outcome from a pathology that could be cured with timely access to a doctor.

Self-medication is permissible, but only under the supervision of an experienced specialist. Be sure to observe the gynecologist. The cause of irregular periods may be severe endocrine pathologies, endocrinologist consultation may be necessary. With extragenital pathology, specialist consultation is necessary.

In women with menstrual disorders it is very important to choose the right diet. It is necessary to include as much as possible in the diet products rich in iron and protein, primarily meat. Extremely contraindicated exhausting diets and training. Necessarily consultation with a dietician.

Doctor gynecologist-endocrinologist Kupatadze D.D.