DISORDERS OF MENSTRUAL FUNCTION
Regulation of menstrual function is an extraordinarily complicated and intricate
neurohumoral process, violation of which at any level (CNS — hypothalamus —
hypophisis — ovaries — uterus) causes disorders of menstrual cycle in that or other
form. Causes giving rise to menstrual function disorders, are nervous and mental
affections, stresses, psychic traumas, sexual infantilism, serious and protracted chronic
diseases, chronic intoxications, feeding violations (exhaustion or obesity), endocrine
diseases, gynecological diseases.
CLASSIFICATION OF MENSTRUAL FUNCTION VIOLATIONS
Amenorrhea — absence of menses.
Violation of menses rhythm:
 opsomenorrhea — menses come extremely rarely: in 6-8 weeks
 spaniomenorrhea — the extremely long menstrual cycle, menses come 2-4
times per year
 proiomenorrhea (tachimenorrhoea) — shortened menstrual cycle, menses
come in 21 days
Change of blood amount, that exudes during menses:
 hypermenorrhea — a excessive amount of blood, more than 100-150 ml
 hypomenorrhea — reduced amount of blood, less than 50 ml
Abnormal menses' duration:
 polymenorrhea — menses' duration is 7-12 days
 oligomenorrhea — menses duration is less than 2 days
Painful menses:
 algomenorrhea — pain during menses in genital organs region
 dysmenorrhea — general disturbances during menses (headache, nausea,
anorexia, raised irritability)
 algodysmenorrhea — a combination of local pain and general state
disturbance
Menorrhagia—the cyclic uterine bleeding, associated with menstrual cycle, lasting
more than 12 days.
Methrorrhagia — acyclic uterine bleeding that is not associated with menstrual
cycle.
There
are
distinguished
hypomenstrual
syndrome
(opsomenorrhea,
oligomenorrhea, hypomenorrhea) and the hypermenstrual syndrome (proiomenorrhea,
hypermenorrhea, polymenorrhea).
According to the woman's age the bleeding is classified:
 in child age and in period of pubescence —juvenile
 in women of puberty age — bleeding of reproductive or genital period
 in climacteric period — climacteric bleeding
According to recurrence ovulative (cyclic, diphasic) disorders of menstrual cycle
and anovulative (monophased).
DYSFUNCTIONAL
UTERINE BLEEDING
A dysfunctional uterine bleeding (DUB) is the bleeding, not associated with
organic diseases of women's genitals, interrupted pregnancy or systemic diseases of the
organism. The dysfunctional uterine bleeding can appear at any age. Depending on the
time of their onset juvenile bleeding (at child age and in period of pubescence), bleeding
of reproductive period, climacteric bleeding are classified. DUB are the manifestations
of initial stages of neuroendocrinological diseases, especially of blood diseases. Most
frequently the dysfunctional uterine bleeding appear in young women during the
formation of menstrual and reproductive function. In early reproductive phase as a
damaging factor are frequently the situations, connected with mental and physical
overload. Chronic stress and diseases of adaptation are the pathological background on
which the lesions of hormonal status develop.
In women of reproductive age the basic cause of dysfunctional uterine bleeding are
inflammatory diseases. Late reproductive phase, or premenopause, comes in women at
the age over 35. At this age even moderate irritants, which earlier were not the reasons
of menstrual function disorders, can become starting mechanism for development of
cyclic system activity dysfunction.
Disease etiology is associated with unfavourable affects of environment, psychic
stresses, lesions of the ovaries' and other endocrine glands function.
Dysfunction of hypothalamus-pituitary-ovaries-uterus system cause violation of
follicle maturing. Depending on the fact that ovulation comes or not, the bleeding can
be ovulative and anovulative.
Classification of dysfunctional uterine bleeding according to pathogeneses:
I. Ovulative (two-phased) according to the type of:
 hypoestrogeny
 hypogestageny
 hyperestrogeny
II. Anovulative (monophased) according to the type of:
 hypoestrogeny
 hyperestrogeny
According to onset time: cyclic (those, that come in term of next menses, but
differ from it with amount of lost blood and duration); non-cyclic (appear out of menses
or continue with interruptions during all the cycle).
According to patient's age: juvenile, of reproductive age, climacteric, menopausal
bleeding.
Non-ovulate uterine bleeding
Follicle atresia is a disorder of menstrual cycle, that manifests in cyclic uterine
bleedings through regular time intervals, but ovulations are absent. Follicle begins its
development, reaches some maturity degree, but ovulation does not come, Luteal body
does not appear, follicle undergoes reverse development. There is no regular hormones'
excretion (oestrogens-progesteron), secretory changes do not come in endometrium.
Disease is followed by hypoestrogeny.
Clinic. Menses loose regular rhythm, intensity and duration. In response to follicle
atresia and decreasing of hormones amount, in 8-16 days after bleeding onset
menstrual-like reaction comes. Its mechanism is connected with blood transsudation
from superficial endometrium layer vessels, where hemorrhages and regions of necrosis
appear. Absence of ovulation causes infertility, that is frequently a basic patients'
complaint. The anovulate cycles can alternate with ovulate ones.
Diagnostics. For making diagnosis a continued observation of a woman and
research of functional diagnostics tests indexes are necessary. Basal temperature is
monophased, line is beneath 37°, the "fern" and "pupil" phenomena are weakly
expressed or they are absent at all even in the middle of menstrual cycle. The
colpocytological examination shows a moderate or insignificant saturation of organism
with estrogens. The histological investigation proves that there are no secretory
transformations of endometrium, uterine mucous membrane is in proliferation phase
with tissue oedema.
Treatment. At lowered estrogen saturation the cyclic therapy with estrogens and
gestagens for normalization of menstrual cycle and methods for ovulation stimulating
are prescribed. The course lasts for 3-6 months.
The prolonged follicle persistence (hemorrhage methropathy, Shredder's disease).
It is developed as a result of extremely long follicle existence.
Pathogenesis. During first phase of menstrual cycle a follicle grows and develops
for extremely long time. Ovulation does not come. Luteal body does not form. Tere is
no progesterone production, that's why secretion phase in endometrium does not come.
Follicle grows to significant size, sometimes a follicle cyst (a retentive formation 3 and
more cm in diameter) is formed. This causes estrogens hyperproduction under the effect
of which the pathological endomethrium proliferation with polyp excrescence
phenomena takes place in uterus. As a result of endometrium thickening the destructive
changes develop in it. Necrosis and irregular desquamation appear. They are
accompanied by continued bleeding, because the absence of secretory changes in uterus
does not allow the functional layer of endometrium to exfoliate, as it happens during
normal menses. The histological picture shows the stagnant plethora with dilation of
capillaries in endometrium, blood circulation is disturbed, vessels' permeability
increases, tissual hypoxia and other dysmetabolic process develop.
Clinic. Basic sign of hemorrhage methropathy is bleeding after 1,5-2 months of
amenorrhea. Period of amenorrhea corresponds to follicular development, and bleeding
onset corresponds to the beginning of necrotic changes in endometrium. In such patients
appears infertility, associated with absence of ovulation.
Diagnosis. Diagnosis is made on the basis of analyzing patient's complaints. For
definition of hormonal status research of ovarian function: basal temperature is lower
37°, "fern" and "pupil" phenomena are positive during the whole period of amenorrhea
without cyclic variations. Colpocytological researches show an excessive saturation of
the organizm with estrogens, cary-opicnotic index is 60-80%. During investigation of
hormones excretion with urine they find a considerable lowering of Pregnandiol
excretion. During the histological research of endomethrium there is diagnosed absence
of secretory transformations before expectative menses, uterine mucous membrane is in
the phase of pathological proliferation, glandular-cystic hyperplasia of endometrium
with necrosis, thrombosis and dystrophy phenomena is typical.
Treatment. Management the uterine bleeding arrest and normalization of
menstrual cycle. Patient's age is taken into account while choosing the treatment
methods. In reproductive age and in menopause treatment begins from uterine
curretage. This operation has a diagnostic and medical sense, because abrasion of the
mucous membrane arrests bleeding, and histological research allows to exclude
malignant tumor as a bleeding source. The curretage day is conditionally considered the
first day of artificially created menstrual cycle. Later the contra-inflammatoty treatment
(for prevention of post-operative infection development in uterus) should be applied and
menstrual cycle made regular. With this aim synthetic progestines during the three
months period are taken.
Ovulatory dysfunctional uterine bleeding
According to hypoestrogeny type (shortening of the folliculin phase).
Bleeding appears as a result of defective follicle maturing, the first cycle phase is
shortened, ovulation takes place on the 8-10th cycle day. Menstrual cycle is shortened
to 2-3 weeks, amount of excretions can be enlarged (hypermenorrhea), menses duration
can be usual or elongated up to 7-10 days. Reproductive function is present.
Treatment. Such patients usually do not need treatment. Sometimes at
hyperpolymenorrhea uterotonics are prescribed.
According to hypogestageny type. The second place of the cycle shortens, yellow
body involutes prematury, owing this gestagens are produced in insufficient amount.
The secretory changes of endometrium are also insufficiently expressed, that's why
endometrium exfoliating is uneven.
Clinic. There are cyclic uterine bleedings, continued menses and the intervals
between menses are shortened. Before menses there are greasing blood spots discharge.
The reproductive function is lost, infertility develops.
Diagnosis. Basal temperature chart is diphasic. The first phase lasts for 2 weeks,
the second one for 3-7 days.
Treatment. Progesterone 1ml of 1% solution for 5-6 days is prescribed in second
phase of menstrual cycle. For yellow body functions enforcing vitamin E 50-60 mg and
Ascorbic acid 0,5 g daily for 10 days are indicated.
According to hypergestageny type. The first phase of menstrual cycle is of full
value and is finished with ovulation. Luteal body is generated. It persists for a long
period and excretes an excessive amount of Progesteron. The second phase lasts for 2025 days. Total duration of menstrual cycle is 35-40 days. Menses delay for a long
period, then bleeding begins. It is prolonged up to 2-4 weeks by reason of endometrium
regeneration slowing.
Diagnosis. Basal temperature chart is diphasic, the second phase (hypertermic)
lasts for a long time, the premenstrual lowering of temperature is absent. One should
make a differential diagnostics with pregnancy interruption in early terms (test on
pregnancy).
Treatment is begun from the uterine curretage. Histological research shows
secretory transformation of endometrium. Estrogens from the 1st till the 25th cycle day,
gradually decreasing a dose are indicated. Synthetic Progestines are taken according to
the scheme.
The juvenile bleeding
Non-cyclic uterine bleeding, those appear in period of pubescence, are called
"juvenile" or puberty ones. Their frequency rate is from 2,5% to 10%.
Etiology. Stress affects activation of the hypothalamus-pituitary-adrenal cortex
system, secretion of Gonadoliberin and gonadotropic hormones is broken. Follicles
persistence that leads to changing of sexual hormones production is developed.
If in the girl's organism there is a vitamin C deficiency, due to disbalanced diet,
irregular feeding, it causes increasing of vessel walls permeability. Microcirculation and
prostaglandin biosynthesis are failured. Owing this fact the blood fibrillation processes
fails too.
Among the ethiological factors the infectious diseases, especially chronic tonsillitis
is of a great importance. The tonsillogenous infection reduces immune reserve,
influences on hypothalamic region and ovaries.
For contemporary conceptions pathogenesis of juvenile uterine bleeding is
connected with synchronization violations of gonadotropic releasing factors' excretion
in blood, which affect FSH and LH production disorders. This disturbs a mechanism of
follicle maturing, ovulation and yellow body formation. The follicle development is by
persistence or atresia type, that creates conditions for hyperplastic processes in
endometrium. Bleeding appears as a reaction to decreasing of hormonal stimulation
during the follicle regress.
Dysmetabolism appears in endometrium as a result of tissues hypoxia. There are
dystrophic regions, necrosis with long and uneven exfoliating of endomethrium. It
happens due to hardening of fibroid argirophil structure of uterine mucous membrane.
In patients with JUB not only the disorders of reproductive system are present, but
the changes in hemostatic system are also frequently observed.
Clinic and diagnostics. The early beginning of pubescence and early menarche is
typical, but from 15-16 years a level of sexual maturity according to signs complex is
lower than in coevals. It is explained by the beginning of steroids' synthesis failure and
increasing of androgens production with progressing of disease.
In many girls with juvenile uterine bleedings the fibrous-cystic mastopathy is
found, that's why the examination of breasts in such patients is obligatory.
During the examination of external genitals its development is correct. In patients
with hypoestrogenic type of bleeding mucous membrane is pale-pink, uterine cervix is
conic in shape, "pupil" and "fern" symptoms are positive, bloody excretions are not
significant and without mucus. During the rectal-abdominal examination uterine size
corresponds to the age, an angle between the body and cervix is not expressed, ovaries
are not palpated.
In patients with hyperestrogeny type of bleeding mucous membrane of vagina is
pink coloured, the vaginal folds are well expressed, uterine cervix is cylindrical in
shape, "pupil" and "fern" symptom +++ or ++++. There are plenty of bloody excretions
with mucus admixtures. At rectal-abdominal examination uterus is slightly enlarged, an
angle between its body and cervix is clearly expressed, ovaries may be enlarged
comparing to the age norm. On sonogram the uterus exceeds an age norm, ovaries are
considerably greater, than in coeval healthy girls, there are small cysts compartments in
them. Estrogens secretion by urine is decreased, concentration of Progesterone in serum
is also decreased. Hysteroscopy shows hyperplasy and polyps of endometrium, rough
uterine contours.
Tests of functional diagnostics: monophased basal temperature chart, CPI is 5080% due to hyperestrogeny type and 20-40% due to hypoestrogeny type.
Taking into account a presence of hyperplastic processes in uterus in majority of
girls with JUB, there is a necessity of oncologic awareness, because the cases of
endometrium cancer among the girls of 16-18 years are described. The indications
owing to which uterine curretage is performed in girls, are only cases of vital necessity,
are reconsidered, and now it is recommended to make a diagnostic uterine curretage in
patients with recidivate JUB. For making the operation the special child speculum are
used, hymen previously is injected all round by Lidase, general anesthesia is used for
the operation. The blood coagulation system of the patient is estimated and she must be
consulted in specialized stationary in haematologist for revealing of possible blood
disease.
Treatment consists of:
 general treatment
 prescribing of haemostatics and contractors
 hormonal therapy
 surgical treatment
General treatment starts from creation of favourable work and rest regimen,
creation of physical and psychic calmness, correct feeding, rich in vitamins. There is
prescribed Sodium bromide and Caffeine, small doses of tranquilizers. Among
physiotherapy the most procedures effective are endonasal Calcium electrophoresis,
Novocaine electrophoresis, vibrate massage of the paravertebral zones. They use
reflexotherapy and laser accupuncture.
Management of anaemia includes prescribing of ferrum preparations, vitamins of
B group, Ascorutin, Folic acid.
Haemostatic effect is reached by using of 10% Calcium chloride solution
intravenously, Pituitrin or Mammophysin 0,3-0,5 ml i/m 2-3 times a day during
bleeding. For decreasing of blood loss they use fitopreparates — extract of Chamomile,
viburnum, hydropepper.
Hormonal therapy foresees:
 bleeding stop
 normalization of menstrual function
Hormonal therapy is prescribed on condition that the symptomatic therapy is not
effective. Estrogens or combined estrogen-gestagen remedies are indicated.
Estrogenic
haemostasis:
0,1%
solution
of
Estradiol-dipropionate
1
ml
intramuscularly in 3-4 hrs. or Folliculin 10 000-20 000 UA in 3-4 hrs are applied.
Haemostasis is gradual during 24 hours mainly. Abrupt preparations' cancellation
can cause renewing of the bleeding, that's why an estrogens dose is gradually decreased,
to 50% daily. In 5-6 days gestagens for 6-8 days are prescribed.
Haemostasis by synthetic Progestins: monophasal estrogen-gestagen remedies
(Bisecurin, Non-Ovlon, Ovulen) are taken in dose of 2-3 tabl. per day till the bleeding
stops, then the dose to 1 tabl. daily is reduced. The medicine is used for 15-20 days
more (1 tabl. per day). In 3-4 days after cancellation menstrual-like bleeding comes.
Surgical treatment—uterine curretage is indicated in case of disease duration with
frequent relapses for more than 2 years. It is a medically-diagnostic procedure allowing
to achieve haemostasis and to examine the endomethrium (in general majority of
patients its hyperplasy is found).
Correcting hormone therapy. Taking into account a hyperestrogenic type of
bleeding with progesterone deficit and shortening of the luteal phase, for normalization
of menstrual function gestagen preparations are indicated.
The mechanism of their action is based on gestagens ability to stimulate secretion
phase in endomethrium and normal (desquamation of functional layer (gestagenic
curettage). They use 17-hydroxyprogesterone-capronate 12,5% 1 ml intramuscularly
once for 8 days before expectative menses. Such cure takes 3-4 months. After the
treatment a FSH and LH correlation can adjust, ovulatory cycles can appear.
For renewing of normal menstrual function application of combined estrogengestagen preparations during 4-6 months is prescribed. They are used after hormonal or
surgical haemostasis.
PRINCIPLES OF CONSERVATIVE TREATMENT OF DYSFUNCTIONAL
UTERINE BLEEDING
General therapy:
 effect on central nervous system
 symptomatic therapy
 antianaemic therapy
Action on central nervous system: work and rest order, that exclude a possibility
of physical and mental overloading; psychotherapy, sedatives and vitamin therapy is
prescribed.
Symptomatic therapy: uterotonics to arrest the bleeding and for 3 days after
bleeding arrest — Gifotocin, Oxytocin, Pituitrin 0,5-1 ml i/m 2-3 times per day are
used; Methylergomethrin 0,02% 1 ml i/m. Medicines there are strengthening vascular
wall and improving blood coagulation should be taken: Calcium gluconate 0,5 g three
times a day or Calcium chloride 10 ml of 10% solution i/v; α-aminocapronic acid inside
0,1 g per kg of woman's body weight in 4 hrs. (10-15 g per day) during 3 days, on the
4th day they use 12 g, further accordingly 9,0; 6,0; 3,0 g per day; Dicinon in pills 0,50,75 ml per day or 1-2 ml of 12,5% solution; Rutin, Ascorutin, Ascorbic acid.
3. Antianaemic therapy: they take Ferrum tabulated preparations or Ferrum-Lek
i/m or i/v; erythrocytes mass or fresh citrate blood is transfused when it is necessary.
Hormonal therapy. Its tasks:
 haemostasis
 regulation of menstrual cycle
 bleeding relapse prophylaxis
 ovulation induction and normalization of menstrual cycle
1. Estrogens haemostasis.
Mechanism of action: due to injecting of big doses of Estrogens into organism, a
suppression of Folithropin synthesis in pituitary gland; acceleration of endomethrium
proliferation; decreasing of vascular walls permeability; retardation of fibrinolysis takes
place by feed-back mechanism.
Method's disadvantages: necessity of using of comparatively big doses causes
ovulation blockade; the so called "break bleeding" appear at fast dose decreasing.
Indications: DUB of juvenile and reproductive age by hypoestrogeny type;
anaemia and necessity of fast haemostasis; any term and duration of bleeding.
Method of realization: Folliculin on 0,1-0,2 mg each 3-4 hrs. inside; Folliculin
10,000-20,000 UA i/m in 3-4 hours; estradiol-dipropionate 0,1% solution 1 ml in 3-4
hours. Haemostasis comes in 24 hrs. After the bleeding arrest the preparation taking
should be continued gradually decreasing the dose.
2. Haemostasis by gestagens.
Mechanism of action is based on secretory transformation of endomethrium and
desquamation of its functional layer ("medicinal", "hormonal curettage"); influence on
vascular wall; increasing of platelets and Proconvertin amount.
Indications: short bleeding duration; absence of anemia and of immediate
haemostasis necessity.
Gestagens haemostasis arrests bleeding or decreases ii after progesterone
introducing for 3-5 days, then it is increased again and continues for 8-9 days. This is
caused by hormone action mechanism. At first secretory transformation of endometrium
takes place (in this time bleeding decreases or stops), and then there is desquamation of
its functional layer (bleeding becomes stronger again).
Methods of realization: 1% solution of Progesterone 3-5 ml for 3 days; Pregnin
0,04 (2 tabl.) sublingually 3 times a day; Primoluton-depo, Primolut-Nor.
Disadvantages of the method: absence of fast haemostasis; impossibility of use for
anaemic patients after prolonged bleeding.
3. Haemostasis by androgens.
Mechanism of action is caused by suppression of hypothalamus and pituitary gland
function; blocking of follicle development in ovaries; antiestrogenic influence —
suppression of proliferation in endomethrium; uterine vessels contracting; in
myomethrium (increassing of contractive activity).
Indications: DUB of hyperestrogeny type in climacteric age; uterine bleeding with
contra-indications for estrogens prescribing (tumor in anamnesis, uterine fibromyoma,
mastopathy).
Methods of realization: Testosteroni propionas 1 ml of 1 % solution 2-3 times a
day i/m during 2-3 days, then Progesterone 10 mg a day i/m during 6 days; Testosteroni
propionas 1 ml of 5% solution 2 times per day i/m during 2-3 days, then dose is
decreased to 2 times per week. Later they prescribe Methyltesto-sterone 15 mg per day
during 2-3 months.
Disadvantages of the method: it can be used only for women at the age over 45
before the artificial menostase; long application gives virilyzing and anabolic effect.
4. Haemostasis by synthetic progestines (SPP).
Mechanism of action: blocking of hypothalamus-hypophysis system and
decreasing of foliberin and luliberin secretion; continuated haemostatic effect is caused
by action of estrogens and secretory transformations of endomethrium under the
influence of gestagen component of the preparations.
Indications: DUB in any age period.
Method of realizing: one of monophase SPP is prescribed in dose of 1 tabl. in 3-4
hours for hemostasis, then during the 10 days the dose is decreased 1 tabl., daily up to 2
tabl. per day and later on the support dose should be 1 tabl. per day. Therapy course is
21 day from the reception of the first pill.
Disadvantages of the method: great amount of contra-indications (hormone
sensitive tumors, acute liver and bilious pass ways diseases, acute trombophlebitis,
tuberculosis, rheumatism, chronic renal diseases).
5. Haemostasis with estrogens and gestagens combination.
Mechanism of action is caused by estrogens effect (cause endomethrium
proliferation) and gestagens effects (secretory transformation of endomethrium takes
place).
Method of realizing: estradiol-dipropionate 0,1% solution 1 ml with 1 ml of 1%
Progesterone solution in one syringe i/m for 3 days.
6. Haemostasis by estrogens, gestagens, androgens.
Mechanism of action is connected, except listed above effects, with progesteronelike influence of androgens on endometrium in big doses.
Indications: non-ovulative DUB with follicle persistence.
Method of realization: Synestrol 1 ml of 2% solution, 1 ml of 0,5% Progesterone
and 1 ml of 5% Testosterone propionate solution i/m in one syringe. Cure course
includes 4-10 injections done in a day.
The disadvantages of the method: not high therapeutic effectiveness, frequent
relapses, method is contra-indicated at DUB with follicle atresia in juvenile age and in
young women.
ALGODYSMENORRHEA
Causes giving rise to pain during menses are various. Algodysmenorrhea can be a
result of functional and organic causes. Uterine flexure, cicatrize changes causing
cervical canal constriction are the organic causes breaking menstrual blood outfrow.
Algodysmenorrhea is one of the symptoms of endomethriosis, genital infantilism,
inflammatory processes in uterus and ovaries, abnormal uterine positions and genitals'
tumors symptom. Painful menses are more frequent in girls and never delivered women,
after the first delivery algodysmenorrhea disappears or pain becomes not such intensive.
Treatment should be etiopathogenetic, directed on removal of cause bringing the
disease (resolvent, surgical, hormonal). If algodysmenorrhea is an infantilism
manifestation the restorative cure, thermal procedures, hormonal therapy should be
taken.
Symptomatic cure is the prescribing of spasmolytic remedies (Papaverin, No-spa,
Baralgin) and analgetics. Sedatives are also recommended. They are Valerian, Sibasone,
Magne-B6, Mesulidum.