Medicine

Disorders of menstrual function

Disorders of menstrual function. Neuroendocrine syndromes. Endometriosis: etiology, pathogenesis, classification, diagnosis, clinic, and treatment.  Pediatrics’ Gynecology.

 Prepared by Korda I.

 

disorders of menstrual function

The female menstrual cycle is determined by a complex interaction of hormones.

HeirarchyofHormones

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.

350px-MenstrualCycle2_en

 

 

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:

l opsomenorrhea — menses come extremely rarely: in 6-8 weeks

l spaniomenorrhea — the extremely long menstrual cycle, menses come
2-4 times per year

l proiomenorrhea (tachimenorrhoea) — shortened menstrual cycle, menses come in 21 days

Change of blood amount, that exudes during menses:

l hypermenorrhea — a excessive amount of blood, more than 100-150 ml

l hypomenorrhea — reduced amount of blood, less than 50 ml

Abnormal menses’ duration:

l polymenorrhea — menses’ duration is 7-12 days

l oligomenorrhea — menses duration is less than 2 days

Painful menses:

l algomenorrhea — pain during menses in genital organs region

l dysmenorrhea — general disturbances during menses (headache, nausea, anorexia, raised irritability)

l 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:

l in child age and in period of pubescence — juvenile

l in women of puberty age — bleeding of reproductive or genital period

l in climacteric period — climacteric bleeding

According to recurrence ovulative (cyclic, diphasic) disorders of menstrual cycle and anovulative (monophased).

AMENORRHEA

Amenorrhea — absence of menses in adult women within 6 months. Amenorrhea is not an independent disease, but a symptom of many diseases, causing disorders of menstrual function regulation on different levels.

Forms of amenorrhea:

Genuine — absence of cyclic changes in women’s organism, most frequently associated with acute insufficiency of sexual hormones.

Falce amenorrhea (cryptomenorrhea — latent menses) — absence of mens­trual blood excretion because of cyclic changes presence in organism. False ame­norrhea is a clinical sign of genital organs development abnormalities — athresia of hymen or vagina, when blood, having no exit, is accumulated in vagina, uterus and uterine tubes.

Primary amenorrhea is the absence of menstrual function from puberty age.

Secondary amenorrhea is the suppression of menstrual function in woman who has menstruated before.

Physiological amenorrhea is absence of menses before puberty period, during pregnancy and lactation, in menopause period.

The pathological amenorrhea can be provoked by many causes, especially by general state changes, most frequently by endocrine diseases.

There are different forms of pathological amenorrhea: hypothalamic, pitu­itary, ovarian and uterine ones according to the level of menstrual function regulation disturbance.

The hypothalamic amenorrhea

Psychogenic amenorrhea appears as a result of stress situations and psy­chic traumas (“student’s” amenorrhoea during exams especially, ame­norrhea of war period). Excessive secretion of Corticotropin within stress blocks pro­duction of releasing hormones by hypothalamus. The production of Lutropin and Folitro­pin is inhibited, the maturing of follicles is stopped, the cyclic changes in uterus regress. Atrophic changes in sexual organs at short duration of disease are absent or expressed insignificantly.

Treatment. Menstrual cycle is mostly spontaneously restored after stress factors managing. If amenorrhea continues, therapy is performed by two stages:

I stage. Psychotherapy, balanced feeding are indicated, physical and mental overload must be avoided. Drug therapy: sedative remedies are applied — extract of Vale­ri­anne, 1-2 tab. per day and Novopassitum 2-3 times per day, Vitamin E, 100 mg per day for 20 days, Ascorbic acid 0,15 g/day, Folic acid.

Physiotherapy to be applied: the endonasal electrophoresis with 2% vitamin В1 solution, jugular-facial galvanisation with 0,25% Novocain solution, 2% Sodium bromide solution.

II stage. At absence of menses after 2-3 months of treatment Thyroidin
0,05 g per day during 4-5 days and vitamin E are prescribed.

If psychogenic amenorrhea is combined with genital infantilism, hormone therapy is prescribed for stimulation of uterus growth and development of secondary sexual signs.

Amenorrhea at false pregnancy appears in women, who are eager or very afraid to become pregnant. Nausea, morning vomiting (probable preg­nancy signs, that arise as an auto-suggestion influence), swelling of breasts, some enlarging and softening of uterus can appear. Biological reactions for preg­nancy are negative. At US examination fetus in uterus is not found.

Amenorrhea at nervous anorexia is found in girls and young women with non-stabile nervous system in period of pubescence, at nervous or physical over­load, as a result of irrational diets, directed on becoming thin, at uncontrolled using of remedies, that reduce appetite. Typical is body mass loss, hypotension, hypoglycemia.

Treatment consists of sufficient feeding and prescribing of light sedative remedies.

Amenorrhea attached to adiposogenital dystrophy (Pehrants-Babinsky-Frelikh syndrome) develops in period of pubescence. Obesity with de­po­sition of adipose tissue on thighs, abdomen, face, growth delay, hypoplasia of genitalia and intellect reduction are typical.

Etiology is a tumor or trauma of hypothalamic region. Disease can start after neu­roinfection, epidemic parotitis, flu. Secretion of Luliberin, Folitropin and Lutropin decreases. It causes the hypophysis-ovaries system dysfunc­­tio­n and finaly it leads to genitals hypoplasia.

Diagnosis is based on clinical data. During gynecological examination absence of hairity on external genitals is found, or it is slightly expressed, vagina is narrow, uterus is considerably reduced in size.

Laboratory research expresses great FSH, LH, estrogens and Pregnandione lowering. In vaginal smear the intermediate cells prevail. There are 30-40% of basal and parabasal cells. superficial cells are solitary. Basic metabolism is decreased.

If disease is caused by tumor of pituitary body then dilation of turkish saddle is visualized on X-ray report. rise of intracranial pressure, headache, symptoms of visual nerves compression appear. Unlike the Lorence-Moon-Barde-Bidle syndrome, intellect is not affected in such patients, or it is insignificantly lowered.

Treatment. At tumular etiology the treatment consists of ablation of tumor or in X-ray therapy. After operation replacement hormonal therapy is used.

Amenorrhea at the Lorence-Moon-Barde-Bidle syndrome (hereditary di­encephal-retinal degeneration with autosome-recessive type of inheritance). Clinical symptoms are like the clinic of the Pekhrant-Babinsky-Frelix syndrome. however, the main peculiarity of the patients is presence of drastic mental retard­ness (oligophreny), defects of development (polydactily, syndactily, pigmental reti­nitis). The patients have poor eyesight (sometimes total blindness), lowering of hearing or total deafness, skull anomalies, excessive development of fatty cellular tissue.

Treatment. for body weight lowering a diet with limitation of fats, carbo­hydrates, liquid, and also medical physical training are recommended. Medicinal the­rapy includes using of Thyreoidin — 0,05-0,2 g per day for 4-5 days per month. The patients take the gonadothropic hormones — choriogonin 500 IU for 2-4 days per month. afterwards cyclic hormone therapy is held at first by Estrogens (Microfollinum 0,01 mg 2 times a day) or Folliculin 5-10 th. units daily during 20 days. If uterine enlargement and appearance of secondary sexual signs begins in 3-6 months, hormone therapy by estro­gens and Progesterone should be applied.

Amenorrhea at the Morghani-Stuart syndrome. It is rarely found. In patho­geny one can find affection of hypothalamo-pituitary allotment as a result of procrasti­nation of Calcium salts in the region of turkish saddle (internal frontal hypero­stosis).

Clinical features: headache, paroxysms of convulsions, psychic violations, obesity, virilism.

Treatment is symptomatic.

Amenorrhea at persistent lactation syndrome (the Kiary-Frommel synd­rome). In disease basis is lesion of hypothalamic centres, producing Prolactin inhibiting releasing-factor. It causes the rise of Prolactin secretion that inhibits FSH production in its turn. The consequence of this is lowering of estrogens amount, amenorrhea, and further — atrophy of external and internal genitalia. More frequently the disease appears in postnatal period (after pathological deli­very) or after abortion.

The basic symptom is: galactorrhea that begins after delivery. High level of Prolactin in patient causes persistent lactation. After stopping of baby feeding milk secretion continues. There is hypertrophy of breasts with expressed vas­cular pattern. Genital organs atrophy appears. Disorders of carbohydrate and fatty metabolism are developed, arterial pressure becomes unsteady.

Diagnosis is based on symptomatics. For exclusion of the pituitary tumors X-ray examination of turkish saddle, axial computered tomo­graphy, determination of acuity and field of vision is made.

During determining of sexual hormones amount in blood, there is found rising of Prolactin level, lowering of Folitropin level. The amount of estrogens in blood and urine decrease. 17-ketosteroids excretion is not changed.

Tests of functional diagnostics show monophase basal temperature: 36,5-36,8°С. Pupil and fern symptoms are negative during the whole cycle.

Cytological research of vaginal smear allows to find lowering of estrogens amount. in smear there are found out up to 50% parabasal cells, KI is lower than 5%.

Treatment. Hormone therapy, directed on inhibiting of lactation and regu­lation of menstrual function is applied. The most effective remedy for treatment of galactorrhea is a Prolactin inhibitor. Patient should take 2,5-5 mg of Parlodel per day during 6 months. For lo­wering of Prolactin level also grinded Camphora is used — 0,1 g three times a day orally, or 20% solution — 2 ml twice a day; Bromcampho­ra — 0,25-0,5 g 2-3 times a day orally.

The pituitary amenorrhea

Amenorrhea at pituitary nanism. Disease develops in prenatal period or during the first months of life due to infectious diseases or traumatic da­mages of anterior part of pituitary. insufficiency of all its hor­mones including somatotropin appears as a result.

Treatment mainly is in an endocrinologist’s competence. One should begin treatment in childhood with growth stimulation. further replacement hormonal therapy is indicated.

Amenorrhea at gigantism and acromegalia. Diseases are caused by So­ma­to­tropin hyperproduction, production of gonadothropic hormones is decreased. Amenorrhea has a secondary character.

Treatment. At pituitary tumors rhoentgenotherapy is indicated. For pa­tients with gigantism estrogen therapy for stopping of excessive growth is pre­scribed.

Amenorrhea at Itsenko-Kushing’s disease is caused by excessive produc­tion of Corticothopin. The disease develops at age of 20-40. The earliest symp­tom is body weight increasing with expansion of fatty tissue predominantly on face, neck and trunk. Skin and skeleton changes appear, arterial blood pressure rises, cardioscle­rosis and nephrosclerosis develop. There develops osteoporosis due to bones’ deminera­lization and hirsutism (hair grows on unusual for a woman places — face, breasts, abdomen). The tension stripes, eruption of acne vulgaris type, hyperpigmentation of external genitals, appear on skin.

Treatment is provided by endocrinologist. it consists of Khlo­ditan — the inhibitor of adrenals’ cortex hormones synthesis prescribing. If there is no effect there is performed rhoentgenotherapy of hypothalamus and pituitary region or adrena­l­ectomy with the following replacement therapy by Prednisolone.

Amenorrhea at Shikhane syndrome develops after pathological delivery or septic diseases and is associated with hemorrhage into pituitary and following necrosis of its anterior, and sometimes also posterior part. Necrosis size determines severity of disease course.

Clinic. in woman after recent difficult delivery there appears headache, giddiness, weakness and anorexia. Later asthenia, body weight de­creasing, ame­norrhea and mixedema develops. Head and pubis grow bald. Arterial blood pres­sure and body temperature decrease. Difficult form of the Shikhane’s synd­rome manifests in panhypopityitarism. It is a deficit of gonadothropic hor­mones that causes persistent amenorrhea, hypotrophy of genitals and breasts; deficiency of TTH — mixedema, growing bald, somnolence, worsening of me­mory; АCТH — hypotension, adynamy, weakness, intensive skin pigmentation. Typical is per­sistent anemia, that is resistant to treatment.

Diagnosis. in anamnesis there is septic shock or bleeding during delivery or abor­tion. Hormonal investigation data shows different degree of gonadotropins, TTH, ACTH decreasing in blood, in urine a level of 17-CS and 17-ОCS is also decreased. There is hypoglycemia and a hypoglycemic type of sugar curve at glucose loading.

Treatment is directed to improve general patient’s state. Food rich in calories and vitamins are used. At expressed asthenia anabolic hormones are taken. Replacement therapy is using of Pred­nisolon 5 mg per day during 2-3 weeks once for 3 months, Thyreoidin, estrogens and Progesterone in cycles. For patients after 40 years androgens are prescribed, taking into account their high anabolic effect: Methyltestosteronum 5 mg per day. Vitamin therapy is recommended. vitamin B, C, РР, biostimulators are used.

 

The ovarian amenorrhea

The causes of ovarian amenorrhea are: congenital gonades’ dysgenesia (disease appears as a result of sexual chromosomes anomaly), the Shereshevsky-Terner’s syndrome and syndrome of scleropolycystic ovaries (the Shtein-Levental syndrome).

Shereshevsky-Terner’s syndrome is a complex of genetic defects, connec­ted with chromosomes anomaly (one Х-chromosome is absent), that causes tissue inability to development and damage mesodermal rudiments of muscular and osseous tissue in embryonic period. Ovarian tissue also suffers due to harmful influence at the period of genital glands’ differentiation period, that causes death of secretory epithelium and its replacement by connective tissue.

After birth children have low body mass, later they grow slowly. They growth does not exceed 140 cm. Special body building is typical. These children have disproportionate tubby thorax, short neck with wing-like folds, squint, ptosis, the ears are lowly placed and have wrong shape. There appear plural bone structure violations — osteoporosis. degenerative-dystrophic changes and changes in vertebrae bodies and shape of the tubular bones also appear.

In puberty period secondary sexual signs do not appear. Breasts are under­developed. Hairity is absent completely or insignificant, external genital organs, vagina, uterus are abruptly underdeveloped (fig. 68). primary amenorrhea is typical. menses appear in patients on condition that treatment was begun in time.

 

 

Diagnosis. Research of chromosomes shows a wide spectrum of chromo­some anomalies: ХО/ХХ; ХО/ХХХ; ХО/ХХmosaicism is also typical.

During laboratory investigation of hormones amount they determine con­siderable increasing of FSH level. Level of 17-CS excretion is rather decreased.

The US examination shows the expressed hypoplasy of uterus or presence of connective tissue instead of internal genitals. Sometimes uterus is absent at all.

In vaginal smear during cytological research basal and parabasal cells are found.

Treatment. In childhood cure is directed foremost to growth stimulation. The­rapy with hormones is recommended not earlier than at the age of 15, because  earlier beginning of cure with estrogens causes closing of epiphysis zones of the bones and a complete growth stop.

The aim of hormones replacement therapy (at first only with estrogens) is the forming of figure for woman’s type and correction of body disproportion. To improve hormones’ reception Thyreoidin 0,1 mg and Folic acid, 10-20 mg daily 20 days per month are prescribed. At the same time a patient takes Ethynilestradiol or Microfollin in dose of 0,05-0,1 mg for 20 days, then makes a 10 days’ inter­val. Therapy continues for 3-4 months and causes the development of secondary sexual signs and menstrual-like reaction. Then 3-phase combined estrogen-gestagen medicines are taken according a scheme: Microfollin “forte” 0,05 mg per day from the 1st till the 20st day of artificially formed mens­trual cycle and Pregnin 0,01 g three times a day, the 21st till the 26th day.

The polycystic ovarian syndrome (the Shtein-Levental’s syndrome, POS) is a clinical complex of symptoms, that is characterized by enlargening and cystic changes of ovaries and disorders of menstrual cycle. Endocrine disturbances manifest with increasing of LH, Androstendiol and Testosterone level. Contem­po­rary gynecological endocrinology conception about pathogenesis of polycystic ovaries’ syndrome is considerably broadened. A typical form with ovarian hyperandrogeny, that was described by Shtein and Levental, a central form with expressed violations of hypothalamic-hypophysar system and a combined form, caused by ovarian and adrenal hyperandrogeny are differed.

For typical POS form a break of sexual hormones’ biosynthesis processes in ovary tissue is the main characteristic. As a result of the broken hormonal effect. albuminous ovarian membrane thickens, with fibrosis of underlying layers. Theca interna is also thickened. in subcortical layer there are found many cysts and athresed follicles.

Clinical course of the polycystic ovaries’ syndrome manifests in period of pu­bescence, sometimes later, at the age of 20-30 years. Basic symptoms are ame­norrhea (hypomenorrhea), hirsutism, obesity, infertility, enlarged and cysti­cally altered ovaries. Disturbances of menstrual cycle are expressed in form of anovu­latory cycles, hypomenstrual syndrome, amenorrhea, more rare — as uterine bleeding. Due to unovulation infertility appears. Hirsutism is one of per­ma­nent signs of polycystic ovaries’ syndrome and is expressed in hair growing on face, on extremities, on anterior abdominal wall and around nipples. Obesity is found approximately in 1/3 of patients and is combined with signs of hypo­thalamic-pituitary dysfunction: tension stripes on abdominal wall and thighs, incre­asing of intracranial pressure.

 

Diagnosis. During bimanual examination that is found uterus of normal size or slightly reduced. ovaries are enlarged, dense and mobile. In patients with obesity it is hard to estimate an ovaries size by palpation, that’s why additional  methods of investigation are necessary. The US examination gives a possibility to find a degree of ovaries enlargening and many cysts of different size (fig. 70).

Processing laboratory research on amount of hormones, a LH concentration can vary from insignificantly increased significantly, a FSH level does not exceed norm. Excretion of 17-CS is on the top norm or it is just increased.

Tests of functional diagnostics: basal temperature is monophased (36,5-36,8°C). pupil and fern symptoms are negative. These are the signs of anovulative cycle. Cytological investigation of vaginal discharge allows to find lowering of estrogens amount.

For specification of diagnosis and differential diagnostics with other pa­thological processes in ovaries it is necessery to perform laparoscopy, the biopsy of ovaries when there are indications.

Treatment. Basic principles of polycistic ovaries’ syndrome therapy are: conservative treatment, directed to normalize menstrual cycle induce, ovulation  and renew reproductive function with medicinal methods. Surgical treatment takes into consideration the newest achievements of endoscopic surgery.

The aim of conservative therapy at primary polycystosis (scleropolycystosis) is to normalize the function of hypothalamus-pituitary-ovarian system, steroids biosynthesis and mechanism of ovulation, that must induce restoring of the repro­ductive function. A method of treatment is determined according to the clinical and pathogenetic variant of the disease, patient’s age, continuation and dysfunction degree in reproductive system, expressence of morphological changes in ovaries and uterus.

Treatment effectiveness criteria: restoring of menstrual function and ovu­lation, coming of pregnancy, decreasing of hirsutism.

Hormone therapy, directed to normalization of menstrual function is ne­ces­sary to control permanently with use of functional diagnostics tests, and with determination of sexual hormones’ level that allow to diagnose ovulation.

If polycistic ovaries’syndrome becomes apparent in period of pubescence,  one should begin therapy with restorative and vitamin therapy. It is undesirable to prescribe hormonal therapy for girls before 18. For normalization of sexual hor­mones metabolism they prescribe Glutamin acid 1 tabl. twice a day, Calcium panto­­thenat 1 tabl. 2 times a day from the first day of menstrual cycle (at ame­norrhea the first day is considered to be the first day of a remedy taking) during 20 days, Galascorbin 1 tabl. 2 times a day, vitamin E once (in the evening) from the 14th day of a cycle during 15 days. Such therapy is taken for 3-6 months. if men­­­st­­rual cycle is not normalized, a therapy by 2-component gestagen-estro­gen preparations with minimum amount of sexual hormones: preparations pre­scribe in dose of 1 tabl. per day during 21 days (cure starts to on 5th day of men­strual cycle) should be applied, after a 7-day break the course should be repeated, therapy lasts 3-4 months.

They use Clostylbegit (Clomipheni citras, Clomid, Tamoxyphene (according to the scheme) during 3 months. At the end of each cycle after reception of the last dose of the medicine 500-1500 IU of Choriogonin (ChG) for 3-5 days is prescribed.

At the therapy of secondary polycistic ovaries on the background of adrenal hyperand­rogeny it is recommended to combine glucocorticoids with Clomiphen.

For hirsutism treatment they use Cytotheroni acetate 100-200 mg per day from the 5th till the 14th day of menstrual cycle. When moderate hirsutism the combined estrogen-gestagen preparation with antiandrogenic action “Diane-35” 1 tabl. from the 5th till the 26th cycle day are prescribed. Effect comes commonly in 10-12 months of the reception.

Surgical treatment is the most effective method of renewing of menstrual and generative function. Depending on influence on ovaries there are following types of operative treatment: laparotomy with a wedge-shaped ovaries resection, demedullation, decapsulation, decortication. Perspective is the method of endo­scopic ovaries’ resection, electropuncture (pierce cystic formations with needle-shaped electrode), thermocauterization (after ovaries fixation thermo­cauter is inserted into the gland tissue till the immersion into the medullar layer in 6-10 places), laser vaporization (they use carbon surgical laser, make evaporation of all cystous formations under the video monitor control). Advan­tages of endo­scopic interventions are the absence of adlusions possi­bility for, ovaries and ute­rine tubes visualization exclusion of other causes of infertility and possi­bility of making accretions dissection in small pelvis, de­creasing of bleeding risk during operation.

Patients’ rehabilitation after operation includes:

l systematic menses calendar keeping

l measuring of basal temperature during 3-6 months

l making colpocytological research at 7, 11, 14, 21, 25th cycle day, at absence of menses they take 5 smears with 5-day interval

l control examination in 3 months after operation and later on control exami­nation every three months during the first year, during the following year — twice a year, then — once a year

l if a woman becomes pregnant she must come for consultation and regi­stration as soon as possible

l if pregnancy does not come in 6 months after operation, prescribing of com­bined hormone therapy is indicated. A patient takes Norcolut from the 16th till the 26th day of mens­trual cycle during 2 months. Then stimulation of the ovulation by Clo­miphen is performed

The uterine form of amenorrhea

The uterine form of amenorrhea can be primary (as a result of uterus deve­lopment anomalies) and secondary, that appears as a result of inflammatory pro­cess with formation of synechyas (accretions) in uterine cavity; endometrium traumas during abortion or diagnostic currettage, when a structure of basal layer is damaged, after the tuberculosis of endomethrium or Iodine introduction into ute­rus. Tests of functional diagnostics inform about ovaries’ functions. During hysteroscopy there is found thinning or atrophy of endomethrium and presence of synechias in uterine cavity.

Treatment. Dissection of synechias in uterine cavity is performed as endo­scopic ope­ration. 2-3 courses of cyclic hormone therapy allow to restore menstrual function in the majority of patients, however the reproductive function is restored rarely.

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:

l hypoestrogeny

l hypogestageny

l hyperestrogeny

II. Anovulative (monophased) according to the type of:

l hypoestrogeny

l 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 endo­methrium 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, cary­opicnotic 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 contra­inflammatoty 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 (fig. 71).

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 20-25 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 (fig. 72).

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 50-80% 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:

l general treatment

l prescribing of haemostatics and contractors

l hormonal therapy

l 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:

l bleeding stop

l 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 estro­gen-gestagen 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:

l effect on central nervous system

l symptomatic therapy

l antianaemic therapy

1. 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.

2. 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; a-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 0,5-0,75 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:

l haemostasis

l regulation of menstrual cycle

l bleeding relapse prophylaxis

l 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 Methyltesto­sterone 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 pro­gesterone-like 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.

Basic preparations of sex hormones

Estrogenic hormones:

Rр.: Sol. Folliculini oleosae 0,05% 1 ml

D.t.d.N. 10 in amp.

S. 2 ml intramuscularly.

#

Rр.: Sol. Synoestroli oleosae 0,1% 1 ml

D.t.d.N. 6 in amp.

S. 1 ml intramuscularly.

#

Rр.: Sol. Oestradioli dipropionatis oleosae 0,1% 1 ml

D.t.d.N. 6 in amp.

S. 1 ml intramuscularly.

#

Rр.: Oectoestroli 0,001

D.t.d.N. 10 in tab.

S. 1 tablet once per day.

#

Rр.: Tab. “Microfollin-forte” N. 20 in tab.

D.S. 1-2 tablets 1-2 times per day.

#

Rр.: Synoestroli 0,001

D.t.d.N. 10 in tab.

S. 1-2 tablets 1-2 times per day.

#

Rр.: Tab. “Clomiphen citratis” 0,05 N. 20.

D.S. 1 tablet before going to bed, from the 5th till 10th day of a cycle.

Gestagenic preparations:

Rр.: Sol. Progesteroni oleosae 1% 1 ml

D.t.d.N. 10 in amp.

S. 1 ml intramuscularly, from the 15th till 25th day of a cycle.

#

Rр.: Sol. Oxyprogesteroni capronici oleosae 12,5% 1 ml

D.t.d.N. 10 in amp.

S. 0,5-2 ml intramuscularly, once a week.

 

#

Rр.: Tab. “Norcolut” N. 20.

D.S. 2-3 tablets a day, from the 15th till 25th day of a cycle.

#

Rр.: Tab. “Praegnini” 0,01 N. 20.

D.S. 1-2 tablets 1-3 times a day, sublingually.

Combined estrogen-gestagenic remedies:

Rр.: Tab. “Bisecurini” N. 21.

D.S. 1 tablet a day, from the 5th day of menstruation beginning, during

21 day. After a 7-day break — begin the next course.

#

Rр.: Dragee “Non-Ovlon” N. 21.

D.S. 1 dragee per day, from the 5th day of menstruation beginning,

during 21 day. After a 7-day break — begin the next course.

#

Rр.: Tab “Norinyl” N. 63.

D.S. 1 tablet per day, from the 5th day of menstruation beginning,

during 21 day. After a 7-day break — begin the next course.

#

Rр.: Tab “Ovidon” N. 21.

D.S. 1 tablet per day, from the 5th day of menstruation beginning,

during 21 day. After a 7-day break — begin the next course.

#

Rр.: Dragee “Minisiston” N. 21.

D.S. 1 dragee per day, from the 5th day of menstruation beginning,

during 21 day. After a 7-day break — begin the next course.

#

Rр.: Dragee “Femoden” N. 21.

D.S. 1 dragee per day, from the 1st day of menstruation beginning,

during 21 day. After a 7-day break — begin the next course.

#

Rр.: Dragee “Microgynon” N. 28.

D.S. 1 dragee per day, from the 1st day of menstruation beginning.

#

Rр.: Dragee “Diane-35” N. 21.

D.S. 1 dragee per day, from the 1st day of menstruation beginning,

during 21 day. After a 7-day break — begin the next course.

#

Rр.: Tab “Silest” N. 21.

D.S. 1 tablet per day, from the 1st day of menstruation beginning, during

21 day. After a 7-day break — begin the next course.

#

Rр.: Tab “Marvelon” N. 21.

D.S. 1 tablet per day, from the 1st day of menstruation beginning, during

21 day. After a 7-day break — begin the next course.

#

Rр.: Tab “Rigevidon” N. 21.

D.S. 1 tablet per day, from the 5th day of menstruation beginning,

during 21 day. After a 7-day break — begin the next course.

#

Rр.: Tab “Logest” N. 21.

D.S. 1 tablet per day, from the 1st day of menstruation beginning,

during 21 day. After a 7-day break — begin the next course.

#

Rр.: Tab “Anteovin” N. 21.

D.S. 1 tablet per day, from the 5th day of menstruation beginning,

during 21 day. After a 7-day break — begin the next course.

#

Rр.: Dragee “Tricvilar” N. 21.

D.S. 1 dragee per day, from the 1st day of menstruation beginning,

during 21 day. After a 7-day break — begin the next course.

#

Rр.: Tab “Tri-Regol” N. 21.

D.S. 1 tablet per day, from the 5th day of menstruation beginning,

during 21 day. After a 7-day break — begin the next course.

#

Rр.: Dragee “Trisiston” N. 21.

D.S. 1 dragee per day, from the 1st day of menstruation beginning, during 21 day. After a 7-day break — begin the next course.

#

Rр.: Tab “Synphasic” N. 21.

D.S. 1 tablet per day, from the 5th day of menstruation beginning,

during 21 day. After a 7-day break — begin the next course.

Androgenic remedies:

Rр.: Sol. Testosteroni propionatis oleosae 1% 1 ml

D.t.d.N. 10 in amp.

S. 1 ml intramuscularly.

#

Rр.: Tab “Methylandrostendioli” 0,01 N. 20.

D.S. 1-2 tablets 1-2 times per day, sublingually.

#

Rр.: Tab “Methyltestosteroni” 0,005 N. 20.

D.S. 1-2 tablets 1-2 times per day, sublingually.

#

Rр.: Tab “Methylandrostenoloni” 0,001 N. 20.

D.S. 1-2 tablets 1-2 times per day.

#

Rр.: Sustanon 250 — 1 ml

D.t.d.N. 2 in amp.

S. 1 ml intramuscularly.

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.

 

 

Background: Dysmenorrhea is one of the most common gynecologic complaints in young women who present to clinicians (Jamieson, 1996).

The term dysmenorrhea is derived from the Greek words dys, meaning difficult/painful/abnormal, meno, meaning month, and rrhea, meaning flow. Dysmenorrhea is defined as difficult menstrual flow or painful menstruation. The optimal management of this symptom depends on an understanding of the underlying cause. Dysmenorrhea is classified as primary (spasmodic) or secondary (congestive) (Dawood, 1985).

Primary dysmenorrhea is defined as menstrual pain not associated with macroscopic pelvic pathology (ie, absence of pelvic disease). It typically occurs in the first few years after menarche (Koltz, 1995) and affects up to 50% of postpubescent females (Dawood, 1988).

Secondary dysmenorrhea is defined as menstrual pain resulting from anatomic and/or macroscopic pelvic pathology (Dawood, 1990; Koltz, 1995), such as that seen in women with endometriosis or chronic pelvic inflammatory disease. This condition is most often observed in women aged 30-45 years.

The following risk factors have been associated with more severe episodes of dysmenorrhea (Harlow, 1996):

1.     Earlier age at menarche

2.     Long menstrual periods

3.     Heavy menstrual flow

4.     Smoking

5.     Positive family history

Obesity and alcohol consumption were found to be associated with dysmenorrhea in some (not all) studies (Andersch, 1982; Sundell, 1990; Parazzini, 1994). Physical activity and the duration of the menstrual cycle do not appear to be associated with increased menstrual pain (Andersch, 1982).

Pathophysiology: The etiology and pathophysiology of dysmenorrhea have not been fully elucidated. Nonetheless, the following may be involved.

Primary dysmenorrhea

Growing evidence suggests that the pathogenesis of primary dysmenorrhea is due to prostaglandin F2alpha (PGF2alpha), a potent myometrial stimulant and vasoconstrictor, in the secretory endometrium (Willman, 1976). The response to prostaglandin inhibitors in patients with dysmenorrhea supports the assertion that dysmenorrhea is prostaglandin mediated. Substantial evidence attributes dysmenorrhea to prolonged uterine contractions and decreased blood flow to the myometrium.

Elevated prostaglandin levels were found in the endometrial fluid of dysmenorrheic women and correlated well with the degree of pain (Helsa, 1992; Eden, 1998). A 3-fold increase in endometrial prostaglandins occurs from the follicular phase to the luteal phase, with a further increase occurring during menstruation (Speroff, 1997; Dambro, 1998). The increase in prostaglandins in the endometrium following the fall in progesterone in the late luteal phase results in increased myometrial tone and excessive uterine contraction (Dawood, 1990).

Leukotrienes have been postulated to heighten the sensitivity of pain fibers in the uterus (Helsa, 1992). Significant amounts of leukotrienes have been demonstrated in the endometrium of women with primary dysmenorrhea that does not respond to treatment with prostaglandin antagonists (Demers, 1984; Rees, 1987; Chegini, 1988; Sundell, 1990; Nigam, 1991).

The posterior pituitary hormone vasopressin may be involved in myometrial hypersensitivity, reduced uterine blood flow, and pain in primary dysmenorrhea (Akerlund, 1979). Vasopressin's role in the endometrium may be related to prostaglandin synthesis and release.

A neuronal hypothesis has also been advocated for the pathogenesis of primary dysmenorrhea. Type C pain neurons are stimulated by the anaerobic metabolites generated by an ischemic endometrium.

Primary dysmenorrhea has also been attributed to behavioral and psychological factors. Although these factors have not been convincingly demonstrated to be causative, they should be considered if medical treatment fails.

Secondary dysmenorrhea

A number of factors may be involved in the pathogenesis of secondary dysmenorrhea. The following pelvic pathologies can lead to the condition:

  • Endometriosis
  • Pelvic inflammatory disease
  • Ovarian cysts and tumors
  • Cervical stenosis or occlusion
  • Adenomyosis
  • Fibroids
  • Uterine polyps
  • Intrauterine adhesions
  • Congenital malformations (eg, bicornate uterus, subseptate uterus)
  • Intrauterine contraceptive device
  • Transverse vaginal septum
  • Pelvic congestion syndrome
  • Allen-Masters syndrome

Almost any process that can affect the pelvic viscera can produce cyclic pelvic pain (Smith, 1993).

Frequency:

  • In the US: Dysmenorrhea may affect more than half of menstruating women. The prevalence of dysmenorrhea can be quite variable. A survey of 113 patients in a family practice setting showed a prevalence of dysmenorrhea of 29-44% (Sobczyk, 1978). With the availability of oral contraceptives (OCs) and nonsteroidal anti-inflammatory drugs (NSAIDs), both of which are effective in relieving symptoms of primary dysmenorrhea, the actual prevalence rate may be higher.

The peak incidence of primary dysmenorrhea occurs in late adolescence and the early 20s (Fraser, 1992). The incidence of dysmenorrhea in adolescents is reportedly as high as 92% (Andersch, 1982). The incidence falls with increasing age and with increasing parity. The prevalence and severity of dysmenorrhea in parous women were significantly lower (Andersch, 1982). No significant difference with respect to prevalence and severity of dysmenorrhea was found between nulligravid women and those in whom pregnancy had been terminated by either spontaneous or induced abortion.

In an epidemiologic study of an adolescent population (aged 12-17 y), Klein and Litt reported a prevalence of dysmenorrhea of 59.7%. Of patients reporting pain, 12% described it as severe; 37%, as moderate; and 49%, as mild. Dysmenorrhea caused 14% of patients to miss school frequently. Although black adolescents reported no increased incidence of dysmenorrhea, they were absent from school more frequently (23.6%) than whites (12.3%), even after adjusting for socioeconomic status.

History:

  • History is critical in establishing the diagnosis of dysmenorrhea and should include an assessment of the onset, duration, type, and severity of pain. A thorough menstrual history is also essential and should include the age at menarche, cycle regularity, cycle length, last menstrual period, and duration and amount of menstrual flow.
  • Determine factors that exacerbate or ameliorate the symptoms and the degree of disruption to school, work, and social activities.
  • Consider gravity and parity status, previous pelvic infections, dyspareunia, infertility, and pelvic surgeries, injuries, and procedures.
  • Also assess symptoms such as nausea, vomiting, bloating, diarrhea, and fatigue, which may be observed in patients with dysmenorrhea.
  • Consider sexual history, including the choice of contraceptive methods. If used, establish the effect of OCs on relieving or exacerbating the condition. Moreover, discuss the use of other agents that affect dysmenorrhea pain.
  • A family history may be helpful in differentiating endometriosis from primary dysmenorrhea (Malinak, 1980; Simpson, 1980). The history should include questions pertaining to sexual abuse because this is reportedly associated with dysmenorrhea and chronic pelvic pain (Jamieson, 1997).
  • In summary, a complete history should include the following:
    • Age at menarche
    • Menstrual frequency, length of period, estimate of the menstrual flow, and presence or absence of intermenstrual bleeding
    • Associated symptoms
    • Severity of pain and its relationship to the menstrual cycle
    • Impact on physical and social activity
    • Progression of symptom severity
    • Sexual history
  • Primary dysmenorrhea should be distinguished from secondary dysmenorrhea on the basis of clinical features.
    • Primary dysmenorrhea almost invariably occurs in ovulatory cycles and usually appears within a year after menarche. In classic primary dysmenorrhea, the pain begins with the onset of menstruation (or just shortly before) and persists throughout the first 1-2 days. The pain is described as spasmodic and superimposed over a background of constant lower abdominal pain, which radiates to the back or anterior and/or medial thigh.
    • Associated general symptoms, such as malaise, fatigue (85%), nausea and vomiting (89%), diarrhea (60%), lower backache (60%), and headache (45%), may be present with primary dysmenorrhea. Dizziness, nervousness, and even collapse are also associated with dysmenorrhea.
    • The clinical features of primary dysmenorrhea include the following:
      • Onset shortly after menarche
      • Usual duration of 48-72 hours (often starting several hours before or just after the menstrual flow)
      • Cramping or laborlike pain
      • Often unremarkable pelvic examination findings (including rectal)
    • A different pattern of pain is observed with secondary dysmenorrhea that is not limited to the onset of menses; this is usually associated with abdominal bloating, pelvic heaviness, and back pain. Typically, the pain progressively increases during the luteal phase until it peaks around the onset of menstruation.
    • The following may indicate secondary dysmenorrhea (Smith, 1993; Smith, 1997):
      • Dysmenorrhea occurring during the first or second cycles after menarche, which may indicate congenital outflow obstruction
      • Dysmenorrhea beginning after the age of 25 years
      • Pelvic abnormality with physical examination: Consider endometriosis, pelvic inflammatory disease, pelvic adhesions, and adenomyosis.
      • Little or no response to therapy with NSAIDs, OCs, or both

Physical:

  • A pelvic examination is indicated at the initial evaluation, which should be carefully performed in order to exclude uterine irregularities, cul-de-sac tenderness, or nodularity that may suggest endometriosis, pelvic inflammatory disease, or a pelvic mass.
  • Women with primary dysmenorrhea usually have normal findings on examination.
  • Pelvic pathology may be found during pelvic examination in women with secondary dysmenorrhea, although normal findings do not exclude the condition.
    • Women with endometriosis who present with secondary dysmenorrhea have physical findings approximately 40% of the time (Propst, 1998; Barbieri, 1999).
    • Patients presenting with secondary dysmenorrhea may have unique and specific findings on physical examination that correspond to their particular pathologies.

Causes:

  • Causes of secondary dysmenorrhea include the following:
    • Intrauterine contraceptive devices
    • Adenomyosis
    • Uterine myoma (fibroids)
    • Uterine polyps
    • Adhesions
    • Congenital malformation of the mьllerian system
    • Cervical strictures or stenosis
    • Ovarian cysts
    • Pelvic congestion syndrome
    • Allen-Masters syndrome
    • Mittelschmerz (midcycle ovulation pain)
    • Psychogenic pain

 

NEUROENDOCRINE SYNDROMS

Premenstrual syndrome is a complex of symptoms, which appears in a few days before menses and is manifested in vegetative-vascular, endocrine-metabolic and nervously-psychic disorders.

Clinic. For 2-10 days before menses there appears headache, nausea, vomiting, abrupt irritability or depression, tearfulness, tachycardia, stomach-ache, itching of skin, considerable swelling and pain in breasts. With menses beginning these pathological signs decrease and then disappear. Menstrual function is not disturbed.

Treatment. Psychotherapy, autotraining, medical physical training, poli­vitamins, diet, sedatives (preparations of Valerianne, Trioxasin, Elenium, Se­duxen). If there is edema diuretics are used.

Postcastration syndrome is a complex of pathological symptoms (nervo­usly-psychic, vegetative-vascular and endocrine-metabolic), which appear after surgical ablation of ovaries. Ovarian ectomy causes exclusion of important link in system “hypothalamus-pituitary-ovaries-uterus” and needs considerable reor­ganization of all incretion organs, especially adrenals and thyroid. Pathological sym­ptoms’ complex, that appears in the process of organism adaptation to sudden lowering of woman’s sexual hormones amount, appears in 60-80% of operated patients. The younger woman is the greater of operation volume, the more severe is the disease.

Clinic. First signs of postcastration syndrome appear in 2-3 weeks after the operation. Estrogens deficit causes neurovegetative (heat flows, sweatiness) and psychoemotional disorders (increased irritability, dizziness, sleep disorders). Endocrine-metabolic disorders contribute to development or to progressing of diseases in hormone-dependent organs and cardiac-vascular system (essential hypertension, IHD, dyshormonal cardiopathy). Obesity, osteoporosis, atrophic col­pitis, cystalgy, changes in skin — the lowering of its elasticity and alopetia can develop. Atherosclerosis and glaucoma progress. A blood coagulation process is violated.

Treatment. The treatment is held according to the stages. They take into account operation heaviness and presence of concomitant diseases. Cure includes unmedicinal therapy — medical gymnastics, walks, water procedures (shower-bath, herbage baths, cold sower), massage, accupuncture, physiotherapy, and medicinal — hormonal replacement (therapy with sexual hormones in cyclic mode or by com­bined estrogen-gestagen preparations) therapy. Hormonal therapy is pre­scribed for patients of reproductive age. From all estrogen preparations the lightest ones are used. They take Estriol daily during the period of 21 day with the following 7-day interruption. Such therapy is indicated at atrophic col­pitis, because it removes vagina dryness and decreases painful feelings during intimacy.

In women of elder age the superiority is given to non-hormonal therapy. for normalization of the central nervous system function Reserpin, Obsidan, Stugeron, vitamins В1, В6, Е are taken. Small tranquilizers and neuro­leptics (Thasepam, Frenolone) at psychoemotional disorders should be used too.

Climacteric syndrome — a complex of symptoms, that complicates a trans­itional period. Signs of pathological climacterium are observed in 40-60% of women.

Clinic. Most typical signs of pathological climacterium are neurovegetative features: heat “flows” to face, head and upper part of body, those are attended by redness of face and intensive sweating, palpitation, dizziness. Patients suffer from headache, irritability, decreasing of working capacity, disorders of sleep. Chronic diseases such as hepatocholecystitis, gall-stone disease, ulcerous stomach and duodenum disease,  ischemic heart disease, essential hypertension become acute, varicose disease flow becomes worse. Ecessive amount of estrogens from meta­bolic processes causes increasing of cholesterol level in blood, and lowering of gesta­gens rate causes increasing of blood coagulability and thrombosis. In patients with atherosclerosis and hypertension in clinic of climacteric disorders prevails a cerebral component — headache, dizziness, worsening of memory, insomnia. More frequently there appear hypertensive crises.  vascular complica­tions and blood effusions are possible.

Climacteric syndrome is developed in patients with vul­nerable nervous system in stress situations caused by work or home conflicts. Astheno-neurotic syndrome with hypochondriac fixation of personality with tearfulness, feeling of fear, trouble, depression can also apear. difficult depression  that almost does not respond to treatment is observed in some patients.

Estrogens and gestagens deficit causes development of methabolism and endo­crine violations. Dystrophic changes of vulva, atrophic (sometimes even ulcerous) colpitis, cystalgyas refer to urinary genital symptoms. The tonicity of pelvic floor muscles and urinary bladder sphincters is lost. It can cause inconti­nence, frequent urination even when small amount of urine in urinary bladder. Decreasing of estrogenic stimulation causes suppression of vaginal epithelium cells ripening and decreasing of glycogen amount in their cytoplasm. That’s why a vagina self-clearing process is disturbed, and afterwards it ceases. non-keeping of per­sonal hygiene rules can cause senile colpitis development. If wo­man continues sexual life, then dryness of mucous causes microtraumas and unpleasant feelings during intimacy.

dry” conjunctivitis and laryngitis those are connected with insufficient secretory ability of mucous membranes belong to extragenital Estrogen def­iciency states. On face there can appear separate wiry hair, sometimes voice timbre becomes lower. It is explained by reinforced synthesis of androgens in ova­ries and adrenals. In postmenopausal period osteoporosis develops. It is caused by Calcium and Phosphorus loss. 2/3 of patients with climacteric syndrome suffer from lipid metabolism disorders of different degree.

Treatment. The first stage of cure is unmedicinal therapy, the second one is medicinal non-hormonal therapy, the third one is hormonal therapy. At severe forms of climacteric syndrome simultaneously are used all of the three types of treatment.

It is of particular importance to convince woman in necessity to lead the heal­thy way of life, proper feeding, to keep the work and rest regimen. Morning gymnastics according to age, walk, adequate physical loading are also obligatory. In domestic conditions they take hydrotherapy — contrasting shower-bath (alternation of cold and hot water is a peculiar vessels massage and prevents progressing of vegetative-vascular manifestations), hot baths for feet, before sleep they have sedative general baths of moderate temperature with addition of medical plants. If possible, they are recommended a health-resort cure, in usual for woman climatic zone. Physiotherapy — neck and face galva­nization is also effective. Novocain electrophoresis on collar zone is taken. Procedures should be accomp­lished with massage of jugular-hu­meral allotment.

Sedative therapy — Phrenolone, Ethaperasine,Triphtasin, beginning from mini­mum doses 0,5-1 mg per day, gradually increasing it to reaching constant effect without appearance of weakness, somnolence, that testifies about prepa­ration overdosing.

Such variants of hormone therapy are possible:

l with Androgens — for patients with proliferative processes in genitals, asso­ciated with hyperestrogeny (uterine fibromyoma, mastopathy, osteo­po­rosis). Androgens are contra-indicated at virile syndrome, stabile hyperto­ny

l synthetic progestines in cyclic mode

l with combination of estrogens and androgens. Sy­nergic effect of these hor­mones on diencephal region and antagonistic effect on genitals is base of this method. Androgens decrease proliferative action of estrogens, and estro­gens decrease the virilizing androgen action

l with combination of estrogens and gestagens — imitation of menstrual cycle: in the first half they should take estrogens, in the second one — progesterone

Long using of estrogens is undesirable due to danger of hyperplastic pro­cesses development (estrogens stimulate endometrium, myometrium and also breasts’ tissues proliferation). Estrogen hormones are not considered to be cance­ro­gens, they don’t cause development of cancer. but if a tumor transforma­tion of genome has already take place in tissue, high content of estrogens hastens tumor growth.

Patients with climacteric syndrome use preparations, those decrease clinical manifestations or remove them completely, improve health state, and some of them at the same time are a prophylaxis of malignant diseases of genitalia. Following medecines are recommended: Progynova-21 — 1 dragee per day during 2-6 months, Cyclo-Progynova — 2-phase preparation, that  is used from the 5th day of mens­trual cycle till the 26th day, further a 7-day interruption. This medicine is not a contraceptive, that’s why, if menses does not come, it is necessary to make a test on pregnancy. Climen, Climonorm, Climactoplan, Ovestin, Livial, Divi­na, Divitren, Trisequense are effec­tive. Besides of tabulated forms there are offered to use transdermal gel Divigel, Extraderm and preparation of prolonged action Gynodiane-depot 1 ml of oily solution i/m once on 30 days.

Prescribing of that or other scheme of hormonal therapy is admissible only after careful examinaton of a patient. Tests of ovaries’ functional state diagnostics before cure and in its dynamics should be taking into account.

The virile syndrome. Is characterized by development of secondary mascu­line sexual signs in women. Disease can develop in any age.

Basic manifestations:

l masculine body building — skeleton, muscular system

l atrophy of breasts

l hypertrophy of the clitoris

l hairity growing according to masculine type (hypertrichosis, hirsutism)

l irregular menstrual cycle at first there appears hypomenstrual synd­rome (oligo-, hypo- and opsomenorrhoea), then — stabile amenorrhea

Causes of virile syndrome are cortex hyperplasy of adrenal glands (virile syndrome of adrenal origin); tumors of adrenal glands’ cortex (virile syndrome of tumular genesis); syndrome of sclerocystic ovaries (virile syndrome of ovarian origin), that is followed by enlarging and cystic changes of ovaries, irregular menstrual cycle, infertility and hirsutism; masculinizing ovaries’ tumor — adrenoblastoma.

Diagnostics is complicated. Except of the obligatory methods of gynecolo­gical examination it must include the estimation of patient’s hormonal status with 17-cetocteroids determination; tests with Corticotropin, Dexamethazon, Pred­nisolon; ovaries and kidneys’ sonography; computer axial tomography for tumor diagnostics. for specification of diagnosis laparoscopy with biopsy of ovaries should be performed.

Treatment is etiopathogenetic. Depending on the disease cause it is operative (tumor ablation, ovary resection) or conservative (hormonal therapy).

CLIMACTERIC MENORRAHGIA

 

Lab Studies:

  • CBC count
    • The CBC count may be used as a baseline for hemoglobin and hematocrit or to rule out anemia.
    • Use the platelet count in conjunction with a peripheral smear if a coagulation defect is suspected.
  • Iron studies: Total iron-binding capacity (TIBC) and total iron are used to assess iron stores.
  • Coagulation factors: These studies are used to rule out von Willebrand disease; ITP; and factor II, V, VII, or IX deficiency. These tests should be ordered sparingly because they are expensive tests for rare disorders.
  • Human chorionic gonadotropin: Pregnancy remains the most common cause of abnormal uterine bleeding in patients of reproductive age. Bleeding usually denotes threatened abortion, incomplete abortion, or ectopic pregnancy.
  • Thyroid function tests and prolactin level: These tests can rule out hyperthyroidism or hypothyroidism and hyperprolactinemia. All of these conditions cause ovarian dysfunction leading to possible menorrhagia.
  • Liver function and/or renal function tests
    • Order liver function tests (LFTs) when liver disease is suspected, such as in persons with alcoholism or hepatitis.
    • BUN and creatinine tests assess renal function.
    • Dysfunction of either organ can alter coagulation factors and/or the metabolism of hormones.
  • Hormone assays
    • LH, FSH, and androgen levels help diagnose patients with suspected PCOS.
    • Adrenal function tests (eg, cortisol, 17-alpha hydroxyprogesterone [17-OHP]) delineate hyperandrogenism in women with suspected adrenal tumors. Congenital adrenal hyperplasia (CAH) is diagnosed primarily by testing 17-OHP.

Imaging Studies:

  • Small, focal, irregular, or eccentrically located endometrial lesions may be missed by an in-office endometrial biopsy (EMB). The findings yielded from pelvic examinations may be limited if patients are obese. These limitations can lead to further imaging studies to inspect the uterus, endometrium, and/or adnexa.
  • Pelvic ultrasound is the best noninvasive imaging study to assess uterine shape, size, and contour; endometrial thickness; and adnexal areas.
  • Sonohysterography (saline-infusion sonography): Fluid infused into the endometrial cavity enhances intrauterine evaluation. One advantage is the ability to differentiate polyps from submucous leiomyomas (ie, fibroids).

Other Tests:

  • Papanicolaou (Pap) smear test results for cervical cytology should be current.
  • Cervical specimens should be obtained if the patient is at risk for an infection.

Procedures:

  • Because routine EMB and conventional imaging studies may miss small or laterally displaced lesions, superior methods of assessment must be used in high-risk patients. In addition, performing an in-office biopsy or imaging studies may be limited by patient problems such as obesity or cervical stenosis.
  • Hysteroscopy: This can be done in the office but may require anesthesia if the patient has a low pain tolerance or adequate visualization is not obtainable.
    • This technique is used to directly visualize the endometrial cavity by close contact.
    • A biopsy sample should be taken, regardless of the endometrial appearance.
    • The histologic diagnosis is missed in less than 2% of patients who undergo hysteroscopy with directed biopsy.
  • Endometrial biopsy
    • This procedure is used in women who are at risk for endometrial carcinoma, polyps, or hyperplasia.
    • High-risk patients who should be biopsied include those with hypertension, diabetes, chronic anovulation (eg, PCOS), obesity, atypical glandular cells (AGUS) on Pap smear, new-onset menorrhagia, and those older than 70 years or any woman older than 35 years with new-onset irregular bleeding (especially if nulliparous).
    • EMB findings are used to assess the stage and proliferation of the endometrial stroma and glands. Many studies have been done to compare the results of EMB and dilatation and curettage (D&C). Both tests are accepted as equal in value and are approximately 98% accurate.

Histologic Findings: Understanding EMB results is essential for any physician treating menorrhagia.

If no tissue is returned after an EMB is performed, most likely the endometrium is atrophic and requires estrogen.

Simple proliferative endometrium is normal and does not require treatment.

Endometrial hyperplasia (except atypical adenomatous) requires progesterone on timed 12-day regimens outlined in the Treatment. Endometrial hyperplasia with atypia (especially atypical adenomatous hyperplasia) generally is considered equivalent to an intraepithelial malignancy, and hysterectomy usually is advised.

Any biopsy that reveals endometrial carcinoma should prompt immediate referral to a gynecologic oncologist for treatment outlined by current oncology protocols associated with the grade and stage of the cancer.

Medical Care: Medical therapy must be tailored to the individual. Factors taken into consideration when selecting the appropriate medical treatment include the patient's age, coexisting medical diseases, family history, and desire for fertility. Medication cost and adverse effects also are factored in because they may play a direct role in patient compliance.

  • Nonsteroidal anti-inflammatory drugs
    • Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line medical therapy in ovulatory menorrhagia.
    • Studies show an average reduction of 25-35% in menstrual blood flow.
    • NSAIDs reduce prostaglandin levels by inhibiting cyclooxygenase and increasing the ratio of prostacyclin to thromboxane.
    • NSAIDs are ingested for only 5 days of the entire cycle, limiting their most common adverse effect of stomach upset.
  • Oral contraceptive pills
    • Oral contraceptive pills (OCPs) are a popular first-line therapy for women who desire contraception.
    • Menstrual blood loss is reduced as much as 60% due to endometrial atrophy.
    • OCPs suppress pituitary gonadotropin release, preventing ovulation.
    • Common adverse effects include breast tenderness, breakthrough bleeding, nausea, and, possibly, related weight gain in some individuals.
  • Progestin therapy
    • Progestin is the most frequently prescribed medicine for menorrhagia.
    • Therapy with progestin results in a 15% reduction in menstrual blood flow when used alone.
    • If administered to a patient with an IUD, the reduction in blood loss is as high as 86%.
    • Progestin works as an antiestrogen by minimizing the effects of estrogen on target cells, thereby maintaining the endometrium in a state of down-regulation.
    • Common adverse effects include weight gain, headaches, edema, and depression.
  • Gonadotropin-releasing hormone agonists
    • These agents are used on a short-term basis due to high costs and severe adverse effects.
    • GnRH agonists are effective in reducing menstrual blood flow.
    • They inhibit pituitary release of FSH and LH, resulting in hypogonadism.
    • A prolonged hypoestrogenic state leads to bone demineralization and reduction of high-density lipoprotein (HDL) cholesterol.
  • Danazol
    • Danazol competes with androgen and progesterone at the receptor level, causing amenorrhea in 4-6 weeks.
    • Androgenic effects cause acne, decreasing breast size, and, rarely, lower voice.
  • Conjugated estrogens
    • These agents are given intravenously every 4 hours in patients with acute bleeding.
    • A D&C procedure may be necessary if no response is noted in 24 hours.
    • If menses slows, follow up with estrogen-progestin therapy for 7 days. This is followed by OCPs for 3 months.

Surgical Care: Surgical management has been the standard of treatment in menorrhagia due to organic causes (eg, fibroids) or when medical therapy fails to alleviate symptoms. Surgical treatment ranges from a simple D&C to a full hysterectomy.

  • Dilatation and curettage
    • A D&C should be used for diagnostic purposes, although studies have shown that less than 50% of the endometrium is sampled during a D&C. It is not used for treatment because it provides only short-term relief, typically 1-2 months.
    • This procedure is used best in conjunction with hysteroscopy to evaluate the endometrial cavity for pathology.
    • It is contraindicated in patients with known or suspected pelvic infection. Risks include uterine perforation, infection, and Asherman syndrome.
  • Transcervical resection of the endometrium
    • Transcervical resection of the endometrium (TCRE) has been considered the criterion standard cure for menorrhagia for many years.
    • This procedure requires the use of a resectoscope (ie, hysteroscope with a heated wire loop), and it requires time and skill but achieves an 84% satisfaction or success rate.
    • The primary risk is uterine perforation.
  • Roller-ball endometrial ablation
    • Roller-ball endometrial ablation essentially is the same as TCRE, except that a heated roller ball is used to destroy the endometrium (instead of the wire loop).
    • It has the same requirements, risks, and outcome success as TCRE.
    • Satisfaction rates are equal to those of TCRE.
  • Endometrial laser ablation
    • Endometrial laser ablation requires Nd:YAG equipment and optical fiber delivery system.
    • The laser is inserted into the uterus through the hysteroscope while transmitting energy through the distending media to warm and eventually coagulate the endometrial tissue.
    • Disadvantages include the expense of the equipment (high), the time required for the procedure (long), and the risk of excessive fluid uptake from the distending media infusion and irrigating fluid.
    • Of patients, 50% have amenorrhea and another 30% have hypomenorrhea, resulting in an overall success rate of nearly 80%.
  • Endometrial ablation or resection preparation
    • A trial of medical therapy should have failed in patients considered for this therapy.
    • The endometrium should be properly sampled and evaluated before surgery.
    • Patients should be pretreated with danazol or a GnRH analogue for 4-12 weeks before surgery to atrophy the endometrium, reducing surgical difficulty and time.
    • Success rates are similar to laser ablation techniques.
  • Uterine balloon therapy
    • A balloon catheter filled with isotonic sodium chloride solution is inserted into the endometrial cavity, inflated, and heated to 87°C for 8 minutes.
    • Uterine balloon therapy cannot be used in irregular uterine cavities because the balloon will not conform to the cavity.
    • Studies report a 90% satisfaction rate and a 25% amenorrhea rate. This success rate is slightly higher than the other techniques described above, but the rate is based on short-term studies. Long-term studies are in place but have not been completed because this technique has not been available for as long as the others.
  • Hysterectomy
    • Hysterectomy provides definitive cure for menorrhagia.
    • This procedure is more expensive and results in greater morbidity than ablative procedures.
    • The mortality rate ranges from 0.1-1.1 cases per 1000 procedures.
    • The morbidity rate usually is 40%.
    • Risks include those usually associated with major surgery.
  • Microwave endometrial ablation alternative
    • Microwave endometrial ablation (MEA) uses high-frequency microwave energy to cause rapid but shallow heating of the endometrium.
    • Microwaves are selected so that they do not destroy beyond 6 mm in depth.
    • MEA requires 3 minutes of time and only local anesthetic. It is proving to be as effective as TCRE.
    • This procedure was developed and has been used in Europe since 1996.
  • HydroThermAblator
    • HydroThermAblator (HTA) is an office procedure in which normal saline is infused into the uterus via the hysteroscope.
    • The solution is heated to 194°F/90°C for 10 minutes under direct visualization.
    • This procedure requires only local anesthesia and reportedly has an 87% satisfaction rate.
    • HTA may be used in patients with irregularly shaped endometrial cavities and/or with fibroids.
    • Vaginal and skin burns are the most reported complications.






Acute menorrhagia requires prompt medical intervention. This is bleeding that will compromise an untreated patient.

Successful treatment of chronic menorrhagia is highly dependent on a thorough understanding of the exact etiology. For instance, acute bleeding postpartum does not respond to progesterone therapy, while anovulatory bleeding worsens with high-dose estrogen.

Drug Category: Nonsteroidal anti-inflammatory drugs -- Block formation of prostacyclin, an antagonist of thromboxane, which is a substance that accelerates platelet aggregation and initiates coagulation. Prostacyclin is produced in increased amounts in menorrhagic endometrium. Because NSAIDs inhibit blood prostacyclin formation, they might effectively decrease uterine blood flow.

Drug Name

Naproxen (Anaprox, Naprelan, Naprosyn) -- Used for relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which is responsible for prostaglandin synthesis.

Adult Dose

250-500 mg PO bid; give at last 2 d and first 3 d of cycle, for a total of 5 d

Pediatric Dose

Not established

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency

Interactions

Probenecid may increase toxicity of NSAIDs; coadministration with ibuprofen might decrease effects of loop diuretics; coadministration with anticoagulants might prolong PT (watch for signs of bleeding); might increase serum lithium levels and risk of methotrexate toxicity (eg, stomatitis, bone marrow suppression, nephrotoxicity)

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis might occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and might require discontinuation

 

Drug Name

Diclofenac (Cataflam) -- Inhibits PG synthesis by decreasing activity of enzyme cyclooxygenase, which in turn decreases formation of PG precursors.

Adult Dose

Initial: 100 mg PO once, then 50 mg PO tid

Pediatric Dose

Not established

Contraindications

Use in persons with allergic reaction to aspirin/NSAIDs, such as swelling, asthma, hives, urticaria, or any forms of angioedema; active GI bleed; active ulcer

Interactions

Reports suggest that NSAIDs may diminish the antihypertensive effect of ACE inhibitors, concomitantly with ACE inhibitors; concomitant administration of low-dose aspirin may result in increased rate of GI ulceration or other complications compared to use of NSAIDs alone; clinical studies and postmarketing observations show that NSAIDs can reduce the natriuretic effect of furosemide and thiazides in some patients, and this response has been attributed to inhibition of renal prostaglandin synthesis; NSAIDs have produced an elevation of plasma lithium levels and a reduction in renal lithium clearance

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

GI bleeding; anaphylaxis; renal or liver injury; pregnancy category D if given at third trimester

Drug Category: Combination oral contraceptives -- OCPs containing estrogen and progestin used to treat acute hemorrhagic uterine bleeding.

Drug Name

Ethinyl estradiol and a progestin derivative (Ovral, Ortho-Novum, Ovcon, Genora) -- Reduce secretion of LH and FSH from the pituitary by decreasing amount of GnRH. Reduce pituitary production of gonadotropins and result in reduced LH and FSH with no ovulation.

Adult Dose

1 tab PO qd for 3 wk; followed by a week of inactive pills, during which a withdrawal bleed generally occurs; repeat monthly

Pediatric Dose

Not established

Contraindications

Documented hypersensitivity; pregnancy; active or inactive thrombophlebitis or thromboembolic disorders, cerebral vascular disease, myocardial infarction, coronary artery disease, or a past history of these disorders; known or suspected breast cancer; known or suspected genital cancer; history of cholestatic jaundice in pregnancy or jaundice with prior pill use; past or present liver tumors

Interactions

Hepatotoxicity might occur with concurrent administration of cyclosporine; concomitant use of rifampin, barbiturates, phenylbutazone, phenytoin sodium, and, possibly, griseofulvin, ampicillin, and tetracyclines might influence efficacy of oral contraceptives and increase amount of breakthrough bleeding and menstrual irregularity

Pregnancy

X - Contraindicated in pregnancy

Precautions

Complete physical examination, documentation of recent Pap smear test, and family history recommended; pay special attention to blood pressure, breasts, abdomen, and pelvic organs; repeat physical examination annually as long as patient is on hormonal therapy
Oral contraceptives can cause fluid retention (address any condition aggravated by this factor)
Monitor patients with epilepsy, migraine, asthma, or renal or cardiac dysfunction
History of psychic depression might be aggravated (observe patient closely)
Progestin compounds might elevate LDL levels, making control of hyperlipidemia more difficult (observe closely); certain forms of congenital hypertriglyceridemia might be aggravated by oral contraceptives, with resultant pancreatitis
Discontinue if jaundice develops
Contact lens wearers with visual changes should be examined by ophthalmologist
Patients might develop hypertension secondary to increase in angiotensinogen production (reevaluate blood pressure approximately 3 mo after initiating therapy in all patients)

Drug Category: Progestins -- Occasional anovulatory bleeding that is not profuse or prolonged can be treated with progestins, antiestrogens given in pharmacologic doses. Inhibit estrogen-receptor replenishment and activate 17-hydroxysteroid dehydrogenase in endometrial cells, converting estradiol to the less-active estrone.

Drug Name

Medroxyprogesterone (Provera)/megestrol acetate/19-nortestosterone derivative -- Provera: Short-acting synthetic progestin. Works as an antiestrogen by minimizing estrogen effects on target cells. Endometrium is maintained in an atrophic state. Effective against hyperplasia and has modest effects on serum lipids (ie, lowering HDL)
Megestrol acetate: May be substituted for Provera. Is active against hyperplasia without significantly altering serum lipid levels.
Derivatives of 19-nortestosterone: Potent progestins used in oral contraceptives. Have partial androgenic properties and lower HDL cholesterol levels.

Adult Dose

Provera: 10 mg/d PO for 10 d monthly
Provera for atypical hyperplasia: 10 mg/d PO for 12 d once
Megestrol acetate: 40-80 mg PO for 10 d monthly
Megestrol acetate for atypical hyperplasia: 40-80 mg PO for 12 d once
Derivatives of 19-nortestosterone: Used in oral combination birth control pills; doses vary from 0.075-0.35 mg/pill depending on derivative
Derivatives of 19-nortestosterone for atypical hyperplasia: 5 mg/d for 12 d once

Pediatric Dose

Not established

Contraindications

Documented hypersensitivity; cerebral apoplexy; undiagnosed vaginal bleeding; thrombophlebitis; liver dysfunction; missed abortion; known or suspected malignancy of breast or genital tract; active or past history of thrombophlebitis, thromboembolic disorders, or cerebral apoplexy (based on past experience with combination oral contraceptive medications; little data suggest that progestin therapy used without estrogen is associated with an increased risk of thrombotic events)

Interactions

Decreases aminoglutethimide efficacy

Pregnancy

X - Contraindicated in pregnancy

Precautions

Caution in asthma, depression, renal or cardiac dysfunction, or thromboembolic disorders; perform complete physical examination, document recent Papanicolaou smear, and take family history before therapy; give special attention to blood pressure, breasts, abdomen, and pelvic organs; repeat physical examination annually; progestins can cause fluid retention (address any condition aggravated by this factor); monitor patients with epilepsy, migraine, asthma, renal or cardiac dysfunction, and history of psychic depression

Drug Category: Gonadotropin-releasing hormone agonists -- Work by reducing concentration of GnRH receptors in the pituitary via receptor down-regulation and induction of postreceptor effects, which suppress gonadotropin release. After an initial gonadotropin release associated with rising estradiol levels, gonadotropin levels fall to castrate levels, with resultant hypogonadism. This form of medical castration is very effective in inducing amenorrhea, thus breaking the ongoing cycle of abnormal bleeding in many anovulatory patients.

Drug Name

Leuprolide (Lupron) -- Suppresses ovarian and testicular steroidogenesis by decreasing LH and FSH levels.

Adult Dose

3.5-7.5 mg IM monthly for 3-6 mo

Pediatric Dose

Not established

Contraindications

Documented hypersensitivity; undiagnosed vaginal bleeding and spinal cord compression

Interactions

None reported

Pregnancy

X - Contraindicated in pregnancy

Precautions

Urinary tract obstruction, tumor flare, and bone pain may occur; monitor patients for weakness and paresthesias; may cause menopauselike symptoms; may cause bone demineralization and/or reduction in HDL cholesterol if given for >6 mo

Drug Category: Androgens -- Certain androgenic preparations have been used historically to treat mild-to-moderate bleeding, particularly in ovulatory patients with abnormal uterine bleeding. Use might stimulate erythropoiesis and clotting efficiency. Alters endometrial tissue so that it becomes inactive and atrophic.

Drug Name

Danazol (Danocrine) -- Synthetic steroid analog with strong antigonadotropic activity (inhibits LH and FSH) and weak androgenic action. Competes with androgen and progesterone at receptor level, resulting in amenorrhea within 3 mo.

Adult Dose

100-400 mg PO qd for 3 mo

Pediatric Dose

Not established

Contraindications

Documented hypersensitivity; breastfeeding; seizure disorders; markedly impaired hepatic function or porphyria

Interactions

Prolongation of PT occurs in patients who are on warfarin; carbamazepine levels might rise with concurrent use; might interfere with laboratory determinations of DHEA, androstenedione, and testosterone

Pregnancy

X - Contraindicated in pregnancy

Precautions

Caution in renal, hepatic (may elevate serum transaminase levels), or cardiac insufficiency and in seizure disorders; androgen effects may cause hirsutism, acne, lowering of voice, or decreased breast size

Drug Category: Arginine vasopressin derivatives -- Indicated in patients with thromboembolic disorders.

Drug Name

Desmopressin (DDAVP) -- Has been used to treat abnormal uterine bleeding in patients with coagulation defects. Transiently elevates factor VIII and von Willebrand factor.

Adult Dose

0.3 mcg/kg in 50 mL NS IV push (15 min)

Pediatric Dose

Not established

Contraindications

Documented hypersensitivity; platelet-type von Willebrand disease

Interactions

Coadministration with demeclocycline and lithium decrease effects; fludrocortisone and chlorpropamide increase effects

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Avoid overhydration in patients using desmopressin to benefit from its hemostatic effects; may cause platelet aggregation in von Willebrand type IIB

Drug Category: Estrogens -- Effective in controlling acute, profuse bleeding. Exerts a vasospastic action on capillary bleeding by affecting the level of fibrinogen, factor IV, and factor X in blood and platelet aggregation and capillary permeability. Estrogen also induces formation of progesterone receptors, making subsequent treatment with progestins more effective.

Drug Name

Conjugated equine estrogen (Premarin) -- Only controls bleeding acutely but does not treat underlying cause. Appropriate long-term therapy can be administered once the acute episode has passed.

Adult Dose

Acute bleeding: 25 mg IV q4h for a maximum of 48 h; 2.5 mg PO q6h for a maximum of 48 h

Pediatric Dose

Not established

Contraindications

Documented hypersensitivity; known or suspected pregnancy; breast cancer, undiagnosed abnormal genital bleeding, active thrombophlebitis, or thromboembolic disorders; history of thrombophlebitis, thrombosis, or thromboembolic disorders associated with previous estrogen use (except when used in treatment of breast or prostatic malignancy)

Interactions

May reduce hypoprothrombinemic effect of anticoagulants; coadministration of barbiturates, rifampin, and other agents that induce hepatic microsomal enzymes may reduce estrogen levels; pharmacologic and toxicologic effects of corticosteroids may occur as a result of estrogen-induced inactivation of hepatic P450 enzyme; loss of seizure control has been noted when administered concurrently with hydantoins

Pregnancy

X - Contraindicated in pregnancy

Precautions

Certain patients may develop undesirable manifestations of excessive estrogenic stimulation (eg, abnormal or excessive uterine bleeding, mastodynia); may cause some degree of fluid retention (exercise caution); prolonged unopposed estrogen therapy may increase risk of endometrial hyperplasia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complications:

  • Treatment must be individualized to treat each patient's specific symptoms. Cost, dosing, and patient compliance can play major roles.
  • If bleeding does not subside within the expected time frame, have the patient keep a menstrual calendar to better assess the resulting bleeding pattern.
  • If a specific treatment fails, investigate all possibilities, including noncompliance, medication dosing, diagnosis, patient age, and comorbid conditions.

Prognosis:

  • With proper workup, diagnosis, treatment, and follow-up care, prognosis is excellent.

Patient Education:

  • Reassure patients that most bleeding stops, but not immediately. Provide literature on the treatment of choice, including expectations and adverse effects.
  • Many patients appreciate reassurance that they do not have cancer and are not alone in their plight.
  • Reassure patients who experience a treatment failure that other options are available.

 

 

 

 

 

 

 

 

PEDIATRIC GYNECOLOGY

ORGANIZATION OF GYNECOLOGICAL AID
TO CHILDREN

The main task of pediatric gynecology is prophylaxy of gynecological diseases in girls, active revealing of diseases of reproductive organs in teenage girls, sanitary-educational work with parents, and with the stuff of children’s establishments, assignment of specialized gynecological help to ill children and their prophylactic medical examination. There are three stages of the management of this help:

l I stage — prophylactic work in kindergartens and schools

l II stage — prophylactic and sanitary-educational medical work of pediatric gynecologists in gynecological rooms of children’s and juvenile policlinics

l III stage — gynecological help in pediatric gynecological departments in pediatric hospital

Pediatric gynecologist performs observation and treatment of girls. A nurse and midwife assigns actively at the every stage of help assignment to children. Namely they teach mothers how to care for newborns and girls of elder age, explain the receptions for sick children, necessity of gynecologist’s consultation and performing of his prescriptions.

Child reconvalescence in the hospital depends greatly on the ability to become close to child, to perform doctor’s prescriptions carefully.

In-time revealing and effective treatment of gynecological diseases in girls is rather a good method of obstetric and gynecological pathology prevention in adult women.

ANATOMIC AND PHYSIOLOGICAL PECULIARITIES

Nowadays pediatric gynecology is a separate part of science and practice. Gynecological aid to girls is realized by pediatric gynecologist both in ambulatory and in the hospital. Anomalies of female genitals, traumas, inflammatory pro­cesses, dysfunctional uterine bleeding in juvenile period happens frequently. There are such periods in girls genesis: a neonatal period — first 28 days of life, mammarial period - till 1 year, early childhood — from 1 to 8 years, prepubertatic period is from 8 years to the first menses, pubertant period lasts from the first menses appearing till 17-18 years.

The external genital organs of the newborn girl differ by some typical peculiarities. Various factors of external environment can influence on girls’ ge­nital organs especially during gestation period and embriogenesis when these organs are developing and forming. Alcohol, narcotics and medicines, that pregnant woman may take as well as mother’s extragenital diseases and difficult labor provoke the impairing effect. Labias majora in the newborn girls come more for­ward, labia minora are covered by labia majora in the majority of girls. They have smaller vestibular glandules than adults. Occasionally mother’s estrogens cause the epithelial desquamation in small girls. This affection gradually regresses. Then genitals grow slowly and begin to function only in the puberty period. This is a neutral period. Sexual hormones rate is low in this time and there are no ex­cretions from vagina.

 The prepubertant period begins from the secondary sexual signs develop­ment and results in the first menses (menarche) appearing. Due to pituitary hor­mones and estrogens level increasing secondary sexual signs appear. There appear hair on pubis, breasts enlarge, bones grow and hypodermic fat deposits are in cer­tain places.

The follicles which begin to mature undergo atresia in ovary that is not yet prepared to execution of basic function. Uterus is not ready to perform its basic function because the endometrial glands are not developed. First menses confirms the beginning of puberty period. One of the premordial follicules becomes mature in ovary and ovum goes out from it. Estrogens are excreted while follicules are maturing. Corpus luteum appears just after the ovum outlet and produces pro­gesterone. These hormones effect into endometrial proliferation, secretion, de­squamation and then menses begin. A prepubertant period is over.

First menses can be irregular in 1,5-2 years after. They should become regular then. Juvenile bleeding can be observed in this time. The secondary sexual signs are developed completely and a female organism is formed. A normal ovulatory cycle with corpus luteum formation is fixed till the end of pubertant period.

EXAMINATION OF GIRLS
WITH GYNECOLOGICAL DISEASES

Examination of girls with gynecological diseases differs from the examina­tion of adults including both approach to the ill child and methods of examination. A girl is usually frightened, feels discomfort before a doctor. That’s why friendly meeting, a kind word, and sometimes a few questions which do not concern the di­sease can help a girl trust a doctor and make contact better. Examination of girl, as an adult woman, begins from history taking.

It is better for mother to tell about the disease of a girl sometimes even when a daughter is absent (if she understands the questions essence). It is necessary to determine parents’ age, childbirth course. It is important also to find out the  initiation of child’s diseases with birth to present disease, to know how she feeds, conditions in which she lives. Special attention should be paid to the menstrual function if a girl has menses.

Physical research should begin with painless and neutral methods. Pediatrist consultation is obligatory minding child’s age but doctor-gynecologist has to examine a girl by himself. Examination of girls includes general examination, determination of body constitution, skeleton deformations presence, hypodermic fat development, skin and mucous membranes color and rash presence.

A degree of secondary sexual signs development and their accordance to girl’s age is determined. Morphotype is determined too. Physical research of major organs and systems (cardiac-vascular, respiratory, digestive, etc.) is also performed.

Palpation and percussion of the abdomen is carefully made. Hands should be warm. If abdomen has local tenderness, palpation begins with painless part.

Gynecological examination of girls is rather a complicated stage owing to the bad children reaction to examination and resistance to doctor’s actions. The elder girl is the more fear, shame and discomfort she feels. A doctor has to take all these factors into account. Examination must be performed in mother’s pre­sence, or trained nurse when a child is in a hospital. Before the examination girl has to empty bladder and to evacuate intestines.

Girls up to 3 years age are examined on the swaddling table, the elder ones are examined on the gynecological chair. At first the external genital organs are examined and adequate development of the genitals to the girl’s age. Attention is paid to anomalies, traumatic damages and other changes. Then, holding labia majora with a piece of sterile cotton wool doctor inspects attentively the external urethral orifice, urethral glands, vagina, and external orifice of vestibular glands. It is necessary to stretch labia majora forwards and downwards for careful exa­mination of hymen.

The smear is taken for research of vaginal content after examination of girl’s external genital organs. Various instruments, such as child glass pipettes, capillary tubes, grooved probes are used for this purpose. Sometimes not only bacterio­scopy, but bacteriological research is performed.

One of the main methods of examination in girls, as in adult women, is bimanual examination. It must be done for every patient. As a rule that is a recto-abdo­minal examination. However, it should be done at the end of examination as the most unpleasant thing for a child.

Recto-abdominal examination has some disadvantages. That is why bowels and gallbladder empting is particulary important and abdomen has to be soft and pliable. It is necessary to determine size and direction of the vaginal portion of the cervix through the recto-vaginal wall by intrnal finger, its painfulness and movability. Uterus is palpated with external palm and internal finger which is in rectum. Uterus position, its movability, painfulness and uterine body size are determined. Then ovaries are examined. The tubes and ovaries of children are not palpable. If they are enlarged, it is necessary to specify a degree of their enlar­gement and movability, their shape, consistence, painfulness and adhesions presence. Infiltrates and painfulness may be revealed in the parametriums and recto-vaginal space. The proximate organs and walls of true pelvis should be palpated at the end of examination.

Recto-abdominal examination is performed under anesthesia in some cases, especially when child is exited and if there are no contraindications. This is less harmful then discussing with excited patient that is leading to a psychic trauma and failure of the information taking necessary to make a diagnosis.

This examination is not enough in most cases and it is necessary to perform vaginoscopy. It is performed by optical vaginoscope. With the help of this device one can see the mucous vaginal layer and to reveal foreign body. This manipulation demands some acquired skills, unqualified intervention can cause trauma. Vaginoscopy is necessary only when actually valuable results are expected and there are no contra-indications (acute inflammatory process): one can see at vagi­no­scopy soft pink coloured mucous vaginal layer with a yellow hue; there are slightly expressed folds mostly in the upper part of vagina. One can see form and size of vaginal part of uterine cervix.

During vaginoscopy one should remember that there may be uterine cervix psevdoerosion which is not a pathology.

In some cases according to the special indications the additional methods for girls are used.

It is necessary to make sounding for revealing of foreign bodies in vagina. For this purpose the method is used mostly in small girls. In some elder girls it can be used when stricture of vagina is suspected. Uterine sounding is performed extra­ordinarily rarely, when diagnostic curettage is necessary or when pyometra and hematometra are suspected.

Diagnostic puncture. Sometimes in gynecologic practice puncture is per­formed especially when there is hymen or vaginal atresia and for determination of vaginal cavity, or when hematokolpos is suspected.

Diagnostic curettage is performed as an exception for vital indications in case of profuse bleeding when conservative therapy is not effective. Sometimes, when there is a suspicion on malignant process, biopsy is needed.

Colpocytological research. This method in pediatric gynecological practice is used frequently to determine ovarian hormonal function.

Gaseous X-ray pelviography. This method can be used for estimation of the internal genital organs and its shape, revealing and determination of tumors in true pelvis.

ANOMALIES OF GENITAL ORGANS
DEVELOPMENT  IN GIRLS

Usually the anomalies of structure of female genital organs are revealed in teenagers when menses are absent and sometimes even later due to sexual act im­possibility or infertility. Although some defects of urinary-genital system are revealed in earlier age.

During examination of external genital organs the structure anomalies that embarrass child sex differentiation can be found.

Hypospadia. This abnormality is shortening or absence of urethra, its ex­ternal orifice or ostium of bladder is localized in vagina or on its anterior wall.

Recognition of hypospadia is not difficult due to visual shortening of urethra or absence of its external orifice.

Epispadia is underdevelopment of upper wall of urinary canal; its splitting and shortening with displacement of its external orifice to clitoris and pubic joint.

In case of mild form of urethral epispadia its structure may be not changed, but only displaced upper, and its external orifice is localized between clitoris and pubic joint. Vulva and vagina can be developed normally in such cases.

The most difficult form is complete epispadia, when the upper urethral wall is totally absent and it looks like a groove which is opened upwards. Defect spreads on sphincters, and sometimes on the lower part of the anterior wall of bladder. Total epispadia, as a rule, is associated with anterior unaccretion of pubic bone, splitting of clitoris and other abnormalies of external genital organs, and especially, pseudohermaphroditism. Total epispadia is combined with bladder ectopy.

 However, epispadia of middle degree can happen more frequently. Urethra is in this case partially split on the anterior wall, shortened and its external orifice is localized near clitoris or even more close to pubic joint, meet more frequently. Atypical localization of clitoris and some other anomalies of genital organs often accompany this disease.

Vulva and hymen atresia

Congenital atresia of vulva and hymen belong to abnormalities of girl’s external genital organs. However, these anomalies are not the result of intrauterine violations. Congenital atresia of vulva appears as a rule as a sequel of intrauterine (intranatal) inflammatory process. Unintimate accretion of labia pudenda, that sometimes interfere with normal urination and discharging, can be separated rather easily with non-acute instrument, and sometimes by fingers.

Hymen atresia is combined with atresia of lower part of vagina and may be diagnosed as the only hymen atresia in the majority of cases.

Aplasia and atresia of vagina and uterus are not the synonyms. Aplasia should be considered as a primary (total or partial) absence of these organs in the result of anomalies of their development from Muller ducts, whereas atresia appears secondary as a result of inflammatory process, that, evidently, can take place during intrauterine life. With the beginning of menses blood is accumulated in vagina causing hematocolpos.

Total aplasia of vagina occurs rarely and can be combined with uterine aplasia or sometimes it can happen at normal uterus and adnexa development. This is manifested clinically when menses begin and hematometra develops. In case of simultaneous vaginal and uterine aplasia clinics is not manifested, and complaints appear only with the beginning of sexual life because its impossibility.

At congenital atresia of vagina with partial or total impassability the clinics is manifested only with beginning of menses. There is menstrual blood inside. There is periodical colic pain in lower abdomen according to menstrual days, nausea, vomiting, general weakness, and sometimes raised temperature. Later pain becomes permanent and extraordinarily strong, with symptoms of dysuria. If uterus is not able to evacuate blood, it is accumulated, and then it can be discharged through the uterine tubes into abdominal cavity and then causes peritoneal irritation symptoms.

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Atresia of hymen and lower third of vagina can rarely cause hematometra and hematosalpings development. Clinical manifestations are typical: there are no menses, periodic pain in days, when menses are expected develops. Prominent hymen, fluctuation and dark blood after its incision is observed. These symptoms give a possibility to make a correct diagnosis. If dark viscous mass is aspirated the punc­ture of hymen proves the diagnosis.

The deeper and thicker the impassable part of vagina is localized, the more complicated diagnostics becomes and more frequently medical mistakes are found. The symptomocomplex, caused by high atresia (paroxysm of pain, nausea, vomiting), and local changes like soft elastic tumor in true pelvis usually can direct a doctor to the thought about inflammatory process in Douglas pouch, cyst torsion or even appendicitis. Only attentive history taking, attentive exa­mination of vagina — a cecal sack is found, absence of uterine cervix, and punc­ture can help to make a correct diagnosis. It is very hard to diagnose hema­to­metra and hematosalpinx before emptying hematocolpos. They can be only suspected. Specifying diagnosis is possible only after the hemato­colpos emptying or during bimanual examination.

Atresia treatment is surgical only. Hymen atresia must be dissected. Girl’s parents should be warned and their written agreement on defloration is necessary. This operation is simple, however, it demands some certain preventive arran­gements to avoid possible complications. If there is a necessity of diagnostic puncture, it should be performed just before dissection. The hymen incision is made in longitudinal and transversal directions to its base. After the outflow of viscous mass vagina is cleaned from all the remainders of hemolised blood by tupfers. It is not recommended to irrigate vagina. After vagina emptying from its contents it is necessary to make bimanual examination for determining uterine and adnexa state. Later several interrupted catgut sutures are put on hymen incision.

Deep atresia of vagina should be operated surgically by deep transversal incision with the vaginal plastic. If cicatricial stenosis occurs after incision that does not prevent menstrual blood outflow, but later can become an obex for sexual life and labor, a surgical renewing of normal passage of vagina should be performed in reproductive age.

Hematometra in such case does not need treatment and uterus is emptying spontaneously after hymen dissection. At cervical atresia or deeply placed vaginal atresia it is not possible to empty the vagina from blood, that’s why hysterectomy must be performed.

Bicornuate uterus and vagina. Unmergering of Muller ducts causes bicor­nuate of uterus and vagina. It can be total and partial, it is localized at any level; development degree of each portion can be different — from normal to rudi­mentary.

There can be found double cervix and double uterus during colposcopy and bimanual examination. Ultrasound research is very informative. Treatment of complications because of bicornuate uterus is necessary in children only if there is a delay of menstrual blood in one of the uterine horns. Reconstructive ope­rations should be performed in reproductive age.

SEXUAL DEVELOPMENT DISORDERS IN GIRLS

Genital glands hormones regulate a process of sexual maturation. Pituitary and ovarian functions become stronger before the first menses. It is considered, that during this period ovarian function is cyclic, but ovulation does not occur even after menarche. Initialization of ovarian function is caused by regulative effect of hypothalamus and hypophysis.

During the period of sexual maturation the level of both sexual hormones and steroids increases. They stimulate function of other endocrine glands, espe­cially adrenal glands. The production of mineralo-, glucocortycoids, and andro­gens by adrenal glands increases. Due to their influence, hair growth on pubis and in armpits, girl’s fast growth is observed. First menses appear in our population at the age of 12-14. Heredity, climatic conditions and other certain factors affect the first menses. The variation of menarche appearance is from 11 till 15 years. Disorders of sexual maturation may be premature development or delayed puberty.

Premature sexual development

Premature sexual maturation (pubertal praеcox) is an anomaly that occurs rather rarely and is characterized by development of secondary sexual signs and menses from 8 to 10. The signs of premature sexual maturation except the secondary sexual signs and menarche beginning include speed-up physical growth during puberty with its following delay, early ossification, that results in low height after the period of puberty, intellectual development delay.

Constitutional, or cryptogenetic, cerebral, ovarian and adrenal forms of premature sexual development are differentiated.

Constitutional form of premature sexual development is accompanied by true menses with ovulation, girl can become pregnant. Unovulatory cycles can be sometimes observed. There are no any organic pathological changes in genital organs, hypophysis, and adrenal glands. These girls delay in mental development sometimes, but later they overtake their playmates. Doctor must explain girl’s disease to parents, teachers and the girl herself. He should persuade that after finishing of puberty period girl’s development will normalize and also warn about the pregnancy possibility.

Cerebral form appears as a result of various diseases, such as cerebral hydrocephalia, encephalitis, meningitis, tumors of gray hump, hypophysis, ventri­cular cyst and others. There are cyclic uterine bleedings without an ovulation.

Ovarian form of premature sexual development is genetically associated with ovarian tumors. It can be caused not only by hormonogenic, but also by ma­li­g­nant ovarian tumors. This form is followed by periodic uterine bleeding, that can be regular, but without ovulation. Sometimes bleeding is extraordinarily severe.

Adrenal form of premature sexual development is caused by tumors of adre­nal glands’ cortex. This form is associated with virilism (hirsutism, hyper­trophy of clitoris, excessive muscles development). Girl’s internal genitals ade­quate her real age or are even hypoplastic, as a rule there are no menses. Ova­rian and adrenal forms often are called false premature puberty.

Diagnosis of premature sexual development is not difficult. It happens in case of adrenal glands diseases, when the symptoms of virilization can simulate premature puberty. Revealing of pubertal praecox reasons demands usually detai­led clinical examination, especially at suspicion on disease of adrenals or cerebrum.

 

 

 

 

Treatment depends on the cause and form of anomaly. When there are ovaries or adrenal glands tumors the best results gives in-time surgical operation. The disease symptoms are reduced after surgical treatment, the evolution of symptoms depends on the duration of the disease, girl’s age and some other factors. Menses cease, and reverse development of the secondary sexual signs stops gradually in 1-2 years. The most resistant for therapy are the cerebral forms, caused by severe brain injuries.

A constitutional form of premature sexual development does not need special treatment. However, such girls should be under careful doctor’s supervision, because functional genesis of this pathology is not confirmed in every case. An organic disease, that causes the abnormality, is found in certain cases and special treatment is necessary.

Sexual development delay

As a rule, this pathology is a sequel of disorders in right links between hypo­thalamus, pituitary, ovaries and uterine that regulate a process of pubertal development.

Such states, when there are no secondary sexual signs or growth delay is found are considered to be a sexual development delay. There are central (hypo­talamo-pituitary) and peripheral (ovarian) genesis of sexual underdevelopment, and also the idiopathic one, caused by serious extragenital diseases.

Hypothalamic sexual underdevelopment manifests itself in two forms — with obesity and without it. The first form of disease manifests itself as adipo­sogenital dystrophy (Frohlich’s syndrome). If the disease develops in girls-teena­gers there is cease of external, internal sexual organs, secondary se­xual signs development and there are no menses. There is hypertrophy of muscles, wide pel­vis, big extremities and no hirsuity. There are fat deposits in excessive amount everywhere, but mostly in the lower part of abdomen, thighs and buttocks. Children complain ordinary on headache and vision disorders. Mental develop­ment is normal. It is necessary to differentiate Frohlich’s syndrome with banal pubertal obesity. For its treatment special regimen, diet and physical training is enough for good effect. At Frohlich’s syndrome prognosis is inauspicious.

At hypothalamic sexual underdevelopment without obesity a girl usually delay in growth, and also have other somatic disorders. Sometimes there are the symptoms, typical for brain tumor (hemiplegia, changes on eyegrounds, vision disorders). The amount of gonadotropic hormones, 17-ketosteroids and estrogens is significantly decreased.

Hypothalamic sexual underdevelopment of hereditary genesis is character­ized by considerable delay in growth, diabetes insipidus, obesity and defects of extremities’ development. There are no effective methods of treatment.

Pituitary sexual underdevelopment appears due to isolated deficiency of go­nadotropic hormones. This form of the disease manifests itself by underdevelop­ment of mammary glands, sometimes by complete default of menses. Sexual under­development can be accompanied by acromegalia, gigantism or, on the cont­rary, by nanism (hypophisar nanism). Dwarfism is expressed by hypoplasia of internal organs. Genital infantilism remains in adult age. Each form of sexual development delay of the pituitary origin depend on pituitary gland function insufficiency. Lowering of endocrine function of sexual glands has secondary character.

 

Sexual underdevelopment of ovarian genesis is caused by various forms of genital glands dysgenesis. “Pure” form of genital glands dysgenesia manifests itself by high growth, underdevelopment of external and internal sexual organs and secondary sexual signs. Ovaries are in rudimentary state, sexual chromatin is usually absent. Chromosome defects of sexual differentiation is a base of di­sor­­ders at Turner’s syndrome, аdrenogenital syndrome and masculine pseudo­herma­phroditism.

Treatment begins in pubertant age and has 2 stages. During first the 3-4 months estrogens of prolonged action are prescribed, and the further treatment is cyclic: estrogens during 15 days, then progesterone (or other gestagens) during 6 days. Due to such a treatment secondary sexual signs develop, cyclic uterine bleeding can appear, but infertility is still.

Constitutional (idiopathic) decelerated sexual development is caused by hereditary factors, and by various diseases, having negative effect for an organism. If at the age of 15-16 there are no secondary sexual signs and no other forms of sexual underdevelopment are found, a girl should be treated by chorionic gona­dotropin 500 AU once on 3 days during the “expectative” lutein phase, 4-5 times per course. 2-3 such treatment courses with 2-3 months’ intervals should be taken. Prophylaxis of sexual development delay should be done during pregnancy and it is in treatment of gestosis, anemias, hypovitaminosis, avoiding of harmful factors of production and environment that can play a role in child’s development both during intrauterine period and in future. Rational baby’s nutrition, full value feeding in prepubertant age, prevention of chronic infectious diseases, indispu­tably, affects the normal child development.

INFLAMMATORY DISEASES
OF GIRLS’ GENITAL ORGANS

Inflammatory diseases of girls’ genital sphere occur rather frequently and influence on woman’s health in future and her reproductive function. Vulvovagi­nitis occurs more frequently. It depends on easy injuring of vulvar mucous layer, disability of vagina for self-cleaning (cells of vaginal epithelium are poor on gly­cogen, there are no Doderlain lactobacillus and vaginal discharge pH reaction is alkaline).

As compared with adult women cervical canal is rarely involved. The amount of diseases is less in puberty period because genitals become more mature and are under estrogenes effect. At the same time, the factors, that cause diseases in adult women (sexual life, abortions, labor, etc.) are absent. Causal agents are Staphyllococci and Streptococci, E.coli, Pneumococci, Candidas, Diphtheria and more rarely Tubercular Mycobacteria.

Infectious disease may be caused not only by microorganisms, but also by peculiarities of girl’s organism immunobiological properties. Different endoge­nous factors, such as anemia, diabetes mellitus, exudative diathesis, pyelone­phritis, cystitis, Enterobiosis are also able to be causative factors. Presence of va­ri­ous irritants, i.e. thermal (coldness or heatness), chemical, mechanical (mastur­bation) leads to these diseases development.

Hard hygiene outrages, untidiness, irregular care for genital organs have a great role in infecting. The secondary infection of genital organs from extragenital sources is sometimes observed. Transmission of infection takes place by different ways, such as hematogenic and lymphogenic.

Nonspecific vulvovaginitis. Children complain of burning feeling after urina­tion, itching and pain in the area of genital organs. General state of children almost does not change.

Careful history taking (presence of allergic diseases, exudative diathesis, presence of extragenital focuses) has an important role in diagnostics. Examination of external genital organs gives a possibility to reveal an edema, hyperemia of external genitals, sometimes itching, discharge, that can be various — serous, purulent or serous-purulent. Diagnosis can be made basing on data got from history, during objective examination and from the results of discharge bacterio­scopic research. In some cases cultural diagnostics is performed. Other additional methods of examination, especially vaginoscopy, are used in case when treatment is not effective or disease recurrences. Presence of foreign body in vagina can be suspected in this case.

 

 

 

Treatment of vulvovaginitis. One of the important components of treatment is to keep personal hygiene and rational nutrition.

If vulvovaginitis develops as concomitant disease of extragenital pathology, basic disease must be treated.

Local treatment consists of seating bath with matricary, salvias, and eucalyp­tus infusion. Syringing of vagina by furacillin 1:10000 solution or by herbs infu­sions are held. Procedures should be performed not more than during 5 days. After treatment Bifidumbacterin or Lactobacterin are inserted into vagina.

In chronic cases synechia (accretion of labia minora and majora) can appear. It is necessary to separate them just after diagnosing.

In no case one should leave this procedure to the period of pubescence. Non-keeping to this demand can cause formation of cicatrical changes, urination disorders and impediment of menstrual blood outflow.

Treatment of specific candidiasis and trichomoniasis is per­formed according to the same principles, that in adults, with correction of medicine dose according to the age.

TUMORS OF GENITAL ORGANS IN GIRLS

Tumors of any localization, like the tumors of genital organs, can occur at any age. The benign tumors of genital organs in girls occur 3 times more fre­quently, than the malignant ones. As for tumors localization, in children, unlike adult women, more frequent are various kinds and forms of ovarian tumors. Some neoplasms are found in children only (for example, racemose sarcoma of vagina). Among ovarian tumors serous and psevdomucinous cystomas are found more frequently. This formation is unilateral in the majority of cases. Hormono­genic and herminogenic tumors are found more rarely. The so-called retential cyst can be revealed in children of different age. These retential cysts differ from the real cysts by pathogenesis and histological picture, but for clinical manifes­tations they are similar and frequently recognized just after the microscopic re­search.

Clinic. Tumor can be asymptomatic for a long period and is found during examination of girl because of other reason. More often there are complaints on abdominal ache, and on enlarging of abdomen if the size of tumor is significant. Sometimes patients apply for medicare when complications, such as torsion of cystoma pedicle, rupture of cysts wall or malignization appear. In diagnostics of cystomas it is necessary to exclude such diseases as wandering kidney that is in true pelvis, mesenteric cyst, omentum tumor and ovarian inflammatory diseases.

Cystoma pedicle torsion in girls happens more frequently, than in adults. This is conditioned by some topographic-anatomic peculiarities of age (small uterine sizes, relatively high localization of ovaries). Abrupt movements, which children can do assist the torsion. Symptomatic of tumor pedicle torsion is similar to such diseases as acute appendicitis, peritonitis, and acute intestinal obstruction.

 

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Diagnosis of ovarian tumors in girls, especially of young age usually has some difficulties and is based on the objective examination. Estimation of ab­do­minal shape, palpation and percussion, with which the examination should begin allow to except ascite and to define the tumor’s borders. In typical cases an ova­rian cyst is determined as a mobile formation having a round or egg-shaped form, elastic or firm consistence and it is localized in true pelvis, sometimes above uterine adnexa. The ultrasound research gives a big help in diagnostics. It is difficult to differ the retential cyst from cystoma. If tumor is asymptomatic, it can be observed during several weeks for growth and other changes of the tumor. In majority of cases the character of tumor is recognized after its histological examination after the operation.

Treatment of ovarian tumors is their removal. Surgical intervention should be conservative, especially in case of bilateral tumors. A permanent continued supervision after the operated girl is needed.

TRAUMAS OF GENITAL ORGANS IN GIRLS

Traumas of genital organs in children occur rather frequently. More frequent they happen as a supervention of falling on acute objects or because of street traumatism. Mostly labia majora, clitoris and perineum are damaged, more rarely — the hymen and vagina (last ones traumatize in case of raping). Traumas of genitals are followed by pain and external or internal bleeding of different intensivity depending on the trauma localization. Especially severe bleeding happens at trauma of clitoris.

Recognition of trauma does not make difficulties and is based on history taking and external gynecological examination. At suspicion on trauma of vagina it is necessary to perform vaginoscopy, examination of urethra and urinary bladder — their catheterization, cystoscopy, sounding.

Treatment includes stopping of bleeding, putting of pressing bandage. If haematoma increases, it is necessary to open it to perform hemostasis. The infected haematoma should be opened and drained.

THE GIRLS’ HYGIENE

Neonatal period. Taking into account the anatomic-physiological pecu­liarities of external genitals of the newborn, it is necessary to perform hygienic care after them especially carefully.

Skin of external genital organs needs regular washing by boiled water with addition of Potassium permanganate. Washing should be performed with motions from front to back, for not infecting genital organs by microorganisms, that are at the anus region. After washing a skin is drained and processed by one of child creams or by sterile oil. Special attention should be paid to the care after inguinal folds and brich folds. The pediatrist and nurse have to teach a mother how to take care of the newborn girl.

In neutral period, which continues up to 7-8 years, there is no the expressed influence of sexual hormones. But the experience is evident, that just in this age some hygienic habits, that have great importance for sexual development are acquired. Daily washing of external genital organs with warm water and soap cau­tiously without excessive friction is obligatory. It is necessary to keep an eye on regular emptying of urinary bladder and bowels at this age, because chronic constipations and irregular emptying of urinary bladder can cause steady retro deviation of uterus.

In prepubertant period considerable changes of the external and internal genital organs take place and secondary sexual signs appear.

Propagandizing of physical training, mobile plays, rational and nutrition of full value by schools doctors is of particular importance. Hard work is catego­rically forbidden. Sanitary educational work among girl’s parents is of a great importance. They should be acquainted with physiological peculiarities of this period and questions of sexual hygiene.

It is necessary to warn a girl about a possibility of menses appearance. In other words, appearance of blood from genitals in unwarned girl, especially with the unbalanced nervous system, can cause psychic trauma. Various deviations in menstrual function are ordinary associated with this. In pubertant period it is necessary to explain the necessity of keeping hygienic rules during menses 2-3 times a day, regular change of gaskets. Due to the increased secretion of genital canal glands, development of hairity in region of external genital organs, it is necessary to wash them regularly between the menses. General care for skin is also important, because just at this age sec­retion of sebaceous glands increases, sometimes acne vulgaris, that disappear spon­ta­neously after finishing of the period of sexual maturation appear. Daily humid sponging down or shower bath has favourable influence on the entire girl’s organism.

Prepubertant and pubertant periods, the period of enforced organism growth and forming of skeleton belong to school age. So, doctors, working in schools, should keep an eye on the correct school desks height, together with teachers they should pay girl’s attention to correct seat at school desk for preventing spine deformation and incorrect forming of pelvis. At this age girl’s organism becomes more sensitive to infectious diseases, and also to nervous, endocrine, hematopoetic systems disorders. That’s why during this important period of intensive sexual development keeping to all hygienic rules is extremely important and is directed to strengthening of girl’s general phy­sical state.