Comprehensive diagnostics of cycle disorders
Assessment of the reproductive system begins with bimanual examination of the uterus and appendages. A comprehensive approach is applied for an accurate diagnosis:
- Functional diagnostic tests (FDT): help differentiate follicular persistence from atresia. In persistence, the karyopyknotic index (KPI) reaches 70–80%, mucus stringing exceeds 10 cm, and the "pupil" phenomenon is strongly pronounced. In atresia, the KPI is 20–30%, and mucus stretches for no more than 4 cm. Basal body temperature during bleeding is typically monophasic.
- Laboratory studies: include blood tests for pituitary, ovarian, and adrenal hormones. It is extremely critical to evaluate thyroid function, as hyperthyroidism (decreased TSH with elevated T3/T4) frequently triggers uterine bleeding.
- Instrumental methods: serial ultrasound to assess ovarian structure and M-echo thickness, as well as MRI or sella turcica radiography to rule out hypothalamic-pituitary region pathology.
- Histological examination: is a crucial stage. Fractional diagnostic curettage (FDC) of the uterine mucosa and cervical canal under hysteroscopic guidance serves both diagnostic and therapeutic-hemostatic purposes. A typical finding in dysfunction is endometrial hyperplasia without signs of secretion.
Management of dysfunctional uterine bleeding (DUB)
Patient management tactics directly depend on their age and the severity of clinical symptoms.
In the reproductive period:
- Stage one (surgical hemostasis): performing therapeutic and diagnostic hysteroscopy and FDC to rapidly stop bleeding. Hormonal hemostasis is used as an exception because it acts slowly. It is permissible only if fresh histological data are available and ultrasound shows no hyperplasia.
- Stage two (hormone therapy): in case of estrogen excess, progestins or combined medications are prescribed in the luteal phase. In hypoestrogenism, cyclic estrogen-progestin therapy is indicated.
- Rehabilitation: ovulation is stimulated with clomifene under strict ultrasound monitoring to restore fertility.
In the premenopausal period (45–55 years): Climacteric bleeding occurs against the background of anovulation, hyperestrogenism, and prolonged shedding of hyperplastic endometrium.
- Therapy always begins with FDC to strictly rule out organic and malignant processes.
- Conservative treatment includes normalizing central nervous system function, combating anemia (iron supplements, vitamins C, P, K, E), and metabolic correction.
- Synthetic progestins are used to prevent recurrences. If hormone therapy is ineffective or contraindicated, the patient is indicated for endometrial ablation (laser, thermal, or electrosurgical).
Dysmenorrhea: pathogenesis and management tactics
Dysmenorrhea is a cyclic pain syndrome accompanying endometrial shedding. The condition is divided into two major groups:
Primary (functional) dysmenorrhea Occurs in young girls (often of asthenic build) 1–1.5 years after menarche. Pain is caused by high levels of prostaglandins, which trigger pronounced vasospasm, local ischemia, and calcium salt accumulation in the myometrium. The condition is frequently accompanied by nausea, fainting, and spastic headaches. Treatment: prostaglandin synthesis inhibitors (NSAIDs in suppositories), antispasmodics, combined oral contraceptives (COCs), sedatives, and vitamin E.
Secondary (organic) dysmenorrhea Typical for women over 30 with a burdened gynecological history. Pain is associated with anatomical changes in the pelvis. Main causes:
- Endometriosis: aching pain radiating to the rectum, worsening before menstruation.
- Intrauterine contraception: increases the concentration of macrophages and prostaglandins (the exception being hormone-releasing intrauterine devices).
- Submucosal myoma: sharp cramp-like pain as the "birthing" node is expelled.
- Pelvic varicosities and malformations.
Treatment of the secondary form aims to eliminate the root cause and frequently requires surgical intervention (laparoscopy, hysteroscopy). It is important to remember: prolonged use of analgesics with an unclarified diagnosis is strictly contraindicated, as it may mask the presentation of acute surgical pathology.
To memorize the main causes of secondary dysmenorrhea, use the acronym "EMIP": Endometriosis, Myoma (submucosal), Intrauterine contraception, Malformations.
Class and exam questions
What is the difference between persistence and follicular atresia according to functional diagnostic tests?
In persistence, the "pupil" phenomenon is strongly pronounced, and the karyopyknotic index reaches 70–80%. In atresia, the "pupil" phenomenon is weak, and the index is only 20–30%.
Why is curettage mandatory in climacteric bleeding?
This is necessary to rapidly stop bleeding (surgical hemostasis) and obtain tissue samples for histology to reliably rule out organic diseases and malignant tumors.
How is primary dysmenorrhea treated?
A comprehensive approach is used: prostaglandin synthesis inhibitors (NSAIDs), antispasmodics, combined oral contraceptives, as well as sedatives and vitamin E.
What else to study on this topic
- Differential diagnosis of DUB with uterine myoma and endometriosis
- Regimens of hormonal hemostasis and strict conditions for its administration
- The role of endogenous opiates in shaping the pain threshold in dysmenorrhea
- Methods of surgical endometrial ablation for recurrent bleeding
- Features of climacteric syndrome in premenopausal DUB
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