Abnormal uterine bleeding in girls. What to do?

Introduction

Abnormal uterine bleeding (AUB) during puberty, which is often called juvenile, is one of the most common forms of menstrual dysfunction in girls and is the leading reason for adolescents to visit a gynecologist.
The duration of the period of maturation of relationships in the “hypothalamus-pituitary-ovary” system and the formation of the reproductive system depends on the age of menarche, and the individual duration of the menstrual cycle is established on average 6 years from the first menstruation [1]. During the first years after menarche, 80% of menstrual cycles are anovulatory with regular menstruation. Every 4-5th girl (20-25%) during the first 2 years may periodically experience delayed menstruation, after which spotting appears lasting more than 7 days. If these discharges are not abundant and do not lead to anemia, they should be considered as a normal variant that does not require drug correction. At the age of 14–16 years, the majority (95%) of girls have a regular menstrual cycle, but only by the age of 17–18 years does a regular ovulatory peak occur with the formation of a full luteal phase [2]. Despite the variety of clinical manifestations, there is no unified international classification of AUB of puberty. Juvenile bleeding can be both ovulatory and anovulatory, in the form of menorrhagia (bleeding with a preserved rhythm, but with blood loss of more than 80 ml and lasting more than 7 days), polymenorrhea (bleeding occurring against the background of a regular menstrual cycle lasting less than 21 days), menometrorrhagia (bleeding without cyclicity, with alternating episodes of oligomenorrhea and increased bleeding). Anovulatory cyclic bleeding is most often observed against the background of follicular atresia, much less often - against the background of persistence. These patients usually have profuse bleeding, leading to hypovolemic disorders and the development of iron deficiency anemia (IDA).

In accordance with modern recommendations, the criteria for diagnosing AUB during puberty include a duration of bleeding of more than 7 days, blood loss of more than 80 ml or more pronounced compared to normal menstruation [3]. The problem is that the doctor is not always able to collect a complete medical history from a teenage patient, and this makes it difficult to verify the diagnosis. Therefore, the first step of a doctor in such a situation is to determine the level of hemoglobin (Hb). This will allow not only to make a correct diagnosis, but also to estimate the amount of blood loss, which is fundamentally important when choosing a hemostasis method.

It is the hemoglobin level that forms the basis for assessing the severity of AUB in adolescents, according to Emans et al. (2005). There is a mild degree (menorrhagia or polymenorrhea, lasting 2 months or more, but without anemia - Hb more than 120 g/l), moderate (menorrhagia or polymenorrhea causing mild anemia - Hb more than 100 g/l) and severe (menorrhagia, which causes a significant decrease in Hb - less than 100 g/l and can lead to unstable hemodynamics). The Russian National Guidelines for Gynecology (2009) also recommend focusing on Hb indicators when choosing tactics for managing girls with juvenile bleeding [3].

The high prevalence of anemia in the population should be taken into account. According to a number of authors, in certain population groups the incidence of iron deficiency states reaches 50 and even 70–80% [4–5]. The incidence of anemia over the past 10 years has increased more than 6 times, and anemia is more common among women of childbearing age, pregnant women and children aged 12–17 years [6]. Thus, girls with AUB during puberty are at risk.

Girls hygiene

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Silenko Oksana Nikolaevna

Pediatric gynecologist, candidate of medical sciences

20.01.2020

Dear parents! Today I will try to cover the topic “hygiene of girls aged 0 to 7 years” in my article. It would seem that what is so difficult about washing a child? However, there are certain rules, following which, you will not encounter problems in pediatric gynecology and you will not have to urgently look for a pediatric gynecologist!

Proper hygiene is that hygiene that does not harm the skin of a girl’s vulva and does not cause gynecological diseases. So what is it?

The first rule and the most important:

You need to wash the girl from front to back, and not vice versa! In no case should this be done 5-10 times a day, but rather 2 times a day under running water (morning and evening). Why? In order not to wash off the skin (lipid) lubricant, smegma and not to dry out the delicate, thin and often sensitive skin of the baby’s vulva with water.

Second rule:

Every time we wash, we do not use mother’s favorite soap or gel for the girl’s hygiene. For a girl under 3 years old, it doesn’t matter what product you use to wash her – expensive, cheap, cherry-flavored or strawberry-scented. The choice of child hygiene products falls entirely on the shoulders of the parents. And here it is important that the product has a neutral pH, without fragrances, flavorings and a mild surfactant. In order not to “rack your brains” over the choice of gel for washing, it is better to buy these products in a pharmacy or online with a pharmaceutical direction, especially if your mother, father or immediate family have or had a history of allergic dermatitis (no matter what kind of dermatitis - to pollen , dust, food, etc.). Hygienic gel is used to wash the vulva 1-2 times a week, not more often! If a girl has manifestations of atopic dermatitis, then once a week is enough. At the same time, we wash the folds of the vulva without fanaticism, we wash away those secretions that can accumulate over the course of a week and are easily washed off (I’ll write more about physiological secretions below).

This rule is used taking into account a clean bottom, in cases where the girl has “been a little” or the mother changes the diaper (and the mother should change the diaper every 2-3 hours!) Up to 3 months of the child’s life, frequent diaper changes and air baths half an hour to an hour are acceptable and recommended by pediatricians and pediatric gynecologists. But from 3 months of age to 1 year, the interval of air baths should increase, and the number of diapers should be reduced to 3-4 pieces per day! We use diapers for walks and choose some part of the night's sleep - the first or second half of the night, when the girl can be in diapers. From 1 year of birth to 2.5 years, diapers should only be used for walks.

Diapers are a “sore” topic for many mothers; not everyone agrees with the hygiene rules that I wrote about above and which our mothers, grandmothers, etc. adhered to for years. Here, parents always have their own choice - either the mother makes it comfortable for herself and uncomfortable for the child, or vice versa. So, in the case when the mother does not get enough sleep and puts the health of her child first, the girl has significantly fewer problems with the vulva, or there are none at all.

Third rule:

If the girl “has gone big”, it is necessary to rinse the anal folds well with hygiene gel and make sure that there are no fecal residues left in the vulva area. If there is even the slightest contamination, we wash the vulva with water and gel!

Fourth rule:

Wet wipes. We use napkins of any manufacture (Japanese, Russian, French, etc.) and even those purchased at a pharmacy with the inscription “for infants” or “for the smallest” in exceptional cases - when it is not possible to wash the child with running water. That is, napkins are an exception to good rules!

The fifth rule concerns physiological secretions (smegma)

: Smegma is a white coating, up to 1 year of a child’s life - a dense coating; from 1 year and older - small, crumbly. This rule has small subtleties taking into account the anatomy and physiology of the girl. After birth, in the first month (up to a maximum of 3-4 months), white plaque is produced by the gonads every day and, accordingly, every day in a certain amount, parents can see it in the folds of the labia minora. The volume of discharge depends to a large extent on the estrogen background of both mother and girl. From 3 months of life (and for some, from 1-2 months), the estrogen level begins to fall and the discharge becomes less and less. Therefore, there is no clear age indicator, but there is individual care for each child. The mother should focus on the amount of discharge the girl has. In the first month of the child’s life, after washing with water, the discharge in the girl’s labia minora is removed daily with a cotton swab or a cotton swab dipped in Vaseline oil (it is more neutral and calm than peach or apricot oil). There is no need to try to thoroughly wash off the “plaque” with water; it is difficult to wash off due to the large amount of lipids in its composition. After 2-3 months from birth, when the discharge becomes less and less, this procedure can be performed every other day. In the future, closer to 1 year and up to 6 years, it is recommended to remove smegma once a week. There is no need to injure the girl’s skin every time with your actions, or make the vulva defenseless against external and internal environmental factors. Smegma is a protective physiological secretion and an indicator of a girl’s health! There is no smegma - therefore there is a risk of skin trauma, there is a risk of synechia of the labia minora, there is a risk of inflammation due to the activation of its opportunistic or pathogenic flora, which feels good where there is no protective smegma.

I will briefly summarize and duplicate the golden rules of hygiene for girls, developed by the head of the gynecological department of children and adolescents, Doctor of Medical Sciences, professor, Honored Scientist and Corresponding Member of the Russian Academy of Sciences, E.V. Uvarova (2010):

1. The skin of the perineum and external genitalia should always be clean. There should be no residues of feces, urine or other secretions on them;
2. You should take a shower 2 times a day and as needed;
3. You need to wash with warm water and clean hands. If desired and according to indications, you should use liquid soap for intimate hygiene, which is best purchased at a pharmacy;
4. The anal area and external genitalia should be washed with different hands, previously washed with soap;
5. To care for the genitals, it is better not to use washcloths, and the moisture after washing should be blotted rather than wiped, so as not to scratch the delicate mucous membrane of the genitals;
6. The towel must be clean, soft and strictly individual - this is a prevention of the provoking factor in relation to infection, including the genital tract.

The material was prepared by a pediatric and adolescent gynecologist, Ph.D. Silenko O.N.

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Own results

The purpose of our study was to study the features of the clinical manifestation of AUB in puberty, the degree of anemia and the effectiveness of various types of hemostasis.

The study was non-randomized observational in nature. An analysis was conducted of 40 pubertal girls with AUB who received treatment in the gynecological department of the State Healthcare Institution “KB SMP No. 7” in Volgograd during 2021. All girls were admitted urgently. The age of the patients ranged from 10 to 17 years and averaged 14 years ± 6 months. Half of the admitted girls were residents of Volgograd, half lived in rural areas.

The scope of the examination upon admission included clarification of complaints, collection of medical history from the girl and those accompanying her, often her mother, general examination with assessment of height, weight and hemodynamic parameters, rectal examination, ultrasound examination of the pelvis with assessment of the endometrial level. All girls urgently underwent a general blood test, which, along with pulse and blood pressure data, made it possible to estimate the amount of blood loss.

Depending on the data obtained during the initial examination, the method of hemostasis was determined.

Upon admission, all patients complained of bloody discharge from the genital tract, in most cases (90%) of the menometrorrhagic type, and only every 10th (10%) noted prolonged and heavy menstruation.

When collecting anamnesis, 45% of girls with juvenile bleeding were identified with problems of a social nature (difficulties in learning, excessive workload in sports clubs, climate change, moving from another city, conflicts in the family, with relatives, with friends). Every 5th (20%) had a history of a recent illness (ARVI, severe influenza that required treatment in an infectious diseases hospital, surgical treatment for appendicitis, umbilical hernia, intestinal dyskinesia with treatment in a surgical hospital for 2–3 months. before going to the gynecological hospital). It is noteworthy that every 10th girl with AUB was found to have severe obesity and a body mass index of more than 35. In addition, quite often (10%) small ovarian cysts (up to 5–6 cm) were diagnosed for the first time upon admission during a rectal examination. ), confirmed later by ultrasound. In addition, the level of the endometrium (M-Echo) was determined during ultrasound in all admitted girls. The results indicate that in 7 patients (17.5%) the endometrial level was 15±5 mm, which was regarded as endometrial hyperplasia. In 10 patients (25%) the endometrial level was low - 4±2 mm. In the majority (23 patients - 57.5%) - 8±2 mm.

In 10 patients (25%) anemia was not detected upon admission; the Hb level was 130±10 g/l, which did not require drug correction. In 25 patients (62.5%), Hb levels were in the range of 100–120 g/l, which is typical for mild anemia. This condition does not threaten the patient’s life and does not lead to hemodynamic disturbances, but requires correction with iron supplements. In 2 patients (5%) upon admission, Hb was 75±5 g/l, which indicated significant blood loss.

The greatest concern was caused by 3 (7.5%) girls with heavy ongoing bleeding and severe anemia. The Hb level upon admission to the hospital was 60±10 g/l. At the same time, hemodynamic parameters were also changed: pulse within 90±10 beats/min, blood pressure 75/50±10 mmHg. Art., which corresponds to compensated hemorrhagic shock and requires urgent medical care. These patients, given the severity of their condition on the first day of admission to the hospital, were in the intensive care unit, where they underwent blood transfusion and plasma transfusion to replenish the volume of circulating red blood cells and coagulation factors.

Depending on the examination results, a different method of hemostasis was chosen for each girl.

In cases of new-onset AUB in puberty that does not lead to anemia, preference was given to symptomatic hemostasis. In addition, in girls with mild anemia, without significant somatic pathology, and with low or normal levels of the endometrium, according to ultrasound data, hemostasis was also performed without the use of hormonal and surgical methods. The basis of symptomatic therapy was hemostatic (tranexamic acid) and uterotonic (oxytocin) therapy aimed at reducing bleeding. These drugs are included in the Standards of primary health care and specialized medical care for minors with uterine bleeding during puberty [7]. Due to the lack of effect of the therapy within 3–4 days, 9 patients were additionally prescribed hormonal hemostasis. In addition, in 5 patients from the study group after symptomatic treatment for 6 months. AUB relapsed and upon re-hospitalization they were prescribed hormonal hemostasis.

For moderate anemia or recurrent AUB of puberty, hormonal hemostasis was performed, since it, influencing the pathogenesis of this condition, has a therapeutic effect much faster compared to symptomatic methods of stopping bleeding. Ethinyl estradiol in combined oral contraceptives provides a hemostatic effect, and progestogens provide stabilization of the stroma and basal layer of the endometrium. The most commonly used low-dose monophasic contraceptive containing desogestrel 0.15 mg and ethinyl estradiol 0.03 mg. In the study group, this contraceptive for the purpose of hemostasis was prescribed upon admission to 10 patients: 5 of them due to severe and moderate anemia, and 5 due to relapse of AUB. After discharge from the hospital, all these patients were recommended to continue hormonal and antianemic treatment for 3 months.

In order to treat IDA, all patients were prescribed a drug in which iron is in the form of a stable complex compound of iron (III) polymaltose hydroxide, similar in structure to the natural iron compound - ferritin. Iron, which is part of the drug, quickly compensates for the lack of this element in the body and restores hemoglobin levels. According to the instructions for use of oral forms (syrup or chewable tablets) of this drug, it is recommended for the treatment of latent iron deficiency, IDA, and the form for intramuscular administration is recommended for use in the treatment of all forms of iron deficiency conditions that require rapid replenishment of iron stores, including severe iron deficiency due to blood loss and impaired absorption of iron in the intestines, as well as in conditions when taking the drug per os

ineffective or impossible. This drug has a good safety profile and is well tolerated, which makes its use in patients with adolescent bleeding a priority.

Patients with mild to moderate IDA received this drug, 1 tablet 2 times a day from the moment anemia was detected. All girls with juvenile bleeding showed a significant positive effect from antianemic therapy with this drug. During the hospital stay, when taking the drug for 10±3 days, the hemoglobin level increased by 15±5 units. When hemoglobin levels were less than 85 g/l, but more than 70 g/l, anemia was treated by administering the drug intramuscularly. In this case, doses were selected individually depending on the iron deficiency and body weight of the girl in accordance with the instructions for the drug. The advantage of parenteral administration of this drug is the rapid onset of effect.

In our observations, there were no refusals to take the drug due to an allergic reaction or poor tolerance.

The surgical method of stopping bleeding during puberty is used extremely rarely. In this sample, surgical hemostasis was performed in one patient (2.5%) in the absence of effect from conservative therapy and ineffectiveness of hormonal hemostasis.

Discharge from the genital tract in a 12 year old girl

Puberty takes from 8 to 15 years.

Inflammation of the vulva and vagina is rare. The course of the infection is mild. Girls have no complaints other than bad-smelling leucorrhoea. This indicates the beginning of hormonal changes in girls’ bodies and the maturation of the immune system.

But during this period, thrush is more common. From the beginning of puberty, leucorrhoea may appear due to inflammation of the uterus, fallopian tubes and ovaries.

Discharge in teenage girls can be caused by vegetative-vascular dystonia. They develop due to sudden hormonal fluctuations. In addition to leucorrhoea, girls usually complain of increased fatigue, irritability, poor appetite and sleep.

White discharge in girls

The appearance of white discharge in girls indicates the beginning of puberty. Such leucorrhoea is not profuse, may have a yellow tint, and is odorless.

They contain:

• vaginal epithelium;
• mucus of the cervical canal and uterus;
• secretion of the vestibular and paraurethral glands;
• fluid from the abdominal cavity;
• lymph;
• leukocytes;
• microorganisms and their metabolic products.

Brown discharge in girls

They have this color due to the admixture of blood. They talk about the imminent start of menstruation.

But here the mother should be extremely careful, because brown discharge can occur with inflammatory diseases, injuries to the genital organs, or a foreign body in the vagina.

You should pay attention to the time of appearance and duration of coffee discharge. If they precede menstrual flow or continue for several days after, this is a variant of the norm. If their appearance does not depend on the phase of the cycle, the child should be shown to a specialist.

Green discharge in girls

Yellow-green discharge in a girl indicates an inflammatory process of the vulvar and vaginal mucosa. The green color of the leucorrhoea indicates the presence in the secretions of leukocytes in large numbers, as well as microbes and their metabolic products. There is purulent inflammation in the vagina. Such discharge is typical for gonorrhea, thrush, trichomoniasis, bacterial vaginosis and other bacterial infections.

Clinical observation

Patient S., 11 years 9 months, was admitted to the gynecological hospital with a diagnosis of pubertal AUB. Complaints of prolonged bleeding from the genital tract for 1 month. according to the type of menometrorrhagia.

From the anamnesis

: this is the first menstruation - menarche (the only case in the study group), about 2 months.
I suffered from ARVI back and was treated in an infectious diseases hospital. There is no somatic pathology, there were no operations. Taking into account the ongoing heavy bleeding and the Hb level at admission of 85 g/l, hormonal hemostasis was started (with a low-dose monophasic contraceptive containing desogestrel 0.15 mg and ethinyl estradiol 0.03 mg, according to the regimen), hemostatic therapy (tranexamic acid 750 mg intravenously, tranexamic acid 250 mg 3 times a day per os
), uterotonic therapy (oxytocin 1.0 ml 3 times a day intramuscularly), antianemic therapy (iron (III) hydroxide complex with dextran intramuscularly). Considering the duration of bleeding and the risk of infectious complications, anti-inflammatory therapy was started.

Examination carried out

. Magnetic resonance imaging of the brain: there is no evidence of pathological changes in the brain. Ultrasound of the thyroid gland: no structural changes. Hormonal profile: follicle-stimulating hormone up to 0.1 mIU/ml, human chorionic gonadotropin up to 1.0 mIU/ml, luteinizing hormone up to 0.1 mIU/ml, T4 14.4 pmol/l, thyroid-stimulating hormone 0.686 µIU/ml, cortisol 353 nmol/l, prolactin 223 mIU/l. Echocardiography and electrocardiography: without pathologies. Survey ultrasound of the abdominal cavity: no structural changes. She was examined by a pediatrician (moderate anemia) and a hematologist (no hematological pathology). Ultrasound of the pelvic organs revealed an M-Echo of 23 mm, heterogeneous. Conclusion: endometrial hyperplasia.

Against the background of 2 weeks. Conservative therapy and hormonal hemostasis failed to achieve any effect; a decrease in hemoglobin level to 79 g/l was noted. In this regard, it was decided to use a surgical method of hemostasis using hysteroscopy and vacuum aspiration of the endometrium, which was performed. Histological conclusion: in the preparations there are fragments of the endometrium with glands of different sizes: small hypoplastic type and larger ones, some cystically dilated of the indifferent type, the picture corresponds to endometrial hyperplasia. In the postoperative period, hormonal, antianemic therapy was continued using iron (III) hydroxide complex with dextran intramuscularly, then switching to the tablet form (iron (III) hydroxide polymaltosate). Complete hemostasis was achieved, the condition at discharge was satisfactory, Hb 106 g/l. It is recommended to continue hormonal and antianemic treatment on an outpatient basis for at least 3 months.

Discharge from the genital tract in teenage girls

From 15 to 18 years of age, the reproductive system completes its maturation. The menstrual cycle becomes regular. The egg begins to mature. Normal discharge changes during the menstrual cycle and depends on its phase:

• light transparent scanty in the first 2 weeks after menstruation;
• during ovulation, mucous is more abundant, transparent and stretchy;
• two weeks before menstruation, they are light white or with a yellowish tint, their consistency resembles cream.