Nmts that for diagnosis. Opsomenorrhea

This material reproduces one of the lectures given by the author of this resource at advanced training courses for nursing staff.

Menstrual cycle- These are regular cyclic changes that occur in the reproductive system of a woman and indirectly cause cyclic changes throughout the body. The essence of these changes is to prepare the body for pregnancy. In the absence of fertilization, the menstrual cycle ends with bleeding, called "menstruation" - the crying of the uterus with bloody tears for a failed pregnancy.

The menstrual cycle continues from the first day of the last menstruation to the first day of the next. In most women, the cycle lasts 28 days, however, a cycle of 28 +\- 7 days with a blood loss of 80 ml can be considered normal.

Violation of the menstrual cycle is a symptom of various gynecological and endocrine diseases, sometimes leading to the loss of a woman's reproductive function or the development of precancerous and cancerous processes in the female genital organs.

The menstrual cycle may be irregular for up to 2 years after the first period and up to 3 years before menopause. If it is irregular during the rest of the reproductive period, this is a pathology and requires appropriate examination and treatment.

At present, the issues of etiology and pathogenesis of NMC have not been studied enough, and therefore their rational classification is impossible. Numerous NMC classifications have been proposed, however, most of them are not based on the etiological and pathogenetic principle, but take into account only the clinical symptoms of a cycle disorder (amenorrhea or bleeding, preservation of a two-phase cycle or its absence, pathology of the development of the follicle or corpus luteum, disorders of the hypothalamic-pituitary system, etc.). .d.)

Factors leading to disorders of menstrual function are:

1. strong emotional upheaval
2. mental or nervous diseases (organic or functional);
3. malnutrition (quantitative and qualitative),
4. beriberi,
5. obesity of various etiologies;
6. occupational hazards (exposure to certain chemicals, physical factors, radiation);
7. infectious and septic diseases;
8. chronic diseases of organs and systems
9. transferred gynecological operations;
10. injuries of the genitourinary organs;
11. inflammatory diseases and tumors of the female genital organs
12. brain tumors;
13. chromosomal disorders;
14. congenital underdevelopment of the genital organs;
15. involutional restructuring of the hypothalamic centers in the menopause.

Considering that there are 5 levels of regulation of the menstrual cycle in the reproductive system, the listed factors may affect one of them. Depending on the level of damage to neurohumoral regulation, groups of these disorders are distinguished, classifying them according to the mechanism of pathogenesis:

1. cortical-hypothalamic
2. hypothalamic-pituitary
3. pituitary
4. ovarian
5. uterine
6. NMC in extragenital diseases (thyroid gland, adrenal glands, metabolism)
7. Genetic disorders

Classification by the nature of violations

1. NMC against the background of organic disorders
2. Functional NMC

Classification according to the content of gonadotropins

1. hypogonadotropic
2. normogonadotropic
3. hypergonadotropic

Classification by clinical manifestations

1. amenorrhea - absence of menstruation
2. hypomenorrhea - scanty menstruation that comes on time
3. hypermenorrhea or menorrhagia - heavy menstruation that comes on time
4. metrorrhagia - intermenstrual bleeding
5. polymenorrhea - prolonged menstruation for more than 6 - 7 days
6. oligomenorrhea - short (1-2 days), cyclical menstruation
7. proyomenorrhea, tachymenorrhea - shortening of the duration of the menstrual cycle (less than 21 days)
8. opsomenorrhea - infrequent menstruation, at intervals of 35 days to 3 months
9. algomenorrhea - painful menstruation
10. hypomenstrual syndrome - a combination of rare scanty menstruation with a shortening of their duration

Since we begin the appointment with the clarification of the patient's complaints, it is rational to start the analysis based on the classification according to clinical manifestations. Thus, the classification can be narrowed down to three groups:

1. Amenorrhea
2. Dysfunctional uterine bleeding

Amenorrhea is the absence of menstruation between the ages of 16 and 45 for 6 months or more without taking hormonal drugs.

Distinguish:

1. False amenorrhea - a condition in which cyclic processes in the hypothalamus-pituitary-ovaries-uterus system are normal, there is no external discharge of menstrual blood, most often it is atresia (infection) of the vagina, cervical canal or hymen - surgical treatment
2. True amenorrhea, in which there are no cyclic changes in the hypothalamus - pituitary gland - ovaries - uterus, and menstruation is clinically absent. True amenorrhea can be physiological and pathological, as well as primary and secondary.

Physiological amenorrhea is observed in girls before puberty, during pregnancy, lactation, and in the postmenopausal period. Pathological primary amenorrhea - when menstruation has never been, and secondary - when, after a sufficiently long period of a regular or irregular menstrual cycle, menstruation has stopped. As a result of taking drugs (gonadotropin-releasing hormone agonists (zoladex, buserelin, triptorelin), antiestrogen (tamoxifen), gestrinone, 17-ethynyltestosterone derivatives (danazol, danol, danovan), pharmacological amenorrhea is observed.

Generally The causes of amenorrhea can be divided into two groups:

1. amenorrhea due to dysfunction of the gonads
   1. Gonadal dysgenesis - due to genetic defects, which result in malformations of the gonads. There are 4 clinical forms of gonadal dysgenesis: typical or classic (Shereshevsky-Turner syndrome, karyotype 45X0), erased (the karyotype has a mosaic character 45XO / 46XX), pure (karyotype 46XX or 46XY (Swyer's syndrome)) and mixed (karyotype 45XO / 46XY ). Gonads have a mixed structure. Diagnosis: genetic study (karyotype and sex chromatin). Treatment: in the presence of Y - surgical removal of the gonads (malignancy is possible), in other cases, HRT
   2. Testicular feminization syndrome (Morris syndrome, false male hermaphroditism) - karyotype 46XY, complete (NPO female, blind vagina, inguinal hernia) and incomplete (NPO male) forms. Treatment - operative + HRT
   3. Premature ovarian failure (syndrome of "resistant ovaries", exhausted ovary syndrome) - underdevelopment of the ovarian follicular apparatus and a decrease in their sensitivity to the action of gonadotropins. Diagnosis - determination of gonadotropins and sex steroids, laparoscopy and biopsy of the gonads. Treatment - HRT.
   4. Polycystic ovary syndrome (primary polycystic ovaries-Stein-Leventhal syndrome) - a violation of steroidogenesis in the ovaries due to a lack of enzyme systems, excessive testosterone synthesis
   5. Amenorrhea associated with androgen-producing ovarian tumors (ovarian androblastoma), excess testosterone.
   6. Amenorrhea due to damage to the ovaries by ionizing radiation or removal of the ovaries (post-castration syndrome).
2. amenorrhea due to extragonadal causes
   1. congenital adrenogenital syndrome (congenital hyperplasia of the adrenal cortex) - increased production of androgens. The karyotype is female, but NPO virilization is noted. At birth, a girl is mistaken for a boy. Diagnosis - ACTH, hormones of the adrenal cortex, test with glucocorticoids. CT scan of the adrenal glands. Treatment with glucocorticoids, NPO plastic surgery and the formation of the entrance to the vagina
   2. hypothyroidism. Diagnosis - TSH and thyroid hormones. Treatment - thyroid medications
   3. destruction of the endometrium and removal of the uterus - the uterine form of amenorrhea. Causes - tuberculosis, damage to the endometrium due to rough curettage and removal of the basal layer, damage to the endometrium due to chemical, thermal burns or cryodestruction, Asherman's syndrome (intrauterine synechia)
   4. damage to the central nervous system and hypothalamic-pituitary region (central forms of amenorrhea) - wartime amenorrhea, psychogenic amenorrhea (false pregnancy), anorexia nervosa, amenorrhea in mental illness (treatment by a psychiatrist), trauma, tumor, infectious lesions (meningoencephalitis, arachnoiditis), amenorrhea in combination with galactorrhea (Del-Castillo-Forbes-Albright syndrome - amenorrhea due to mental trauma or a tumor of the hypothalamic-pituitary region in nulliparous women, and Chiari-Frommel syndrome - amenorrhea and galactorrhea that occur as a complication of the postpartum period. Amenorrhea due to Morgagni's syndrome -Stuart-Morel (frontal hyperostosis).A hereditary disease of an autosomal dominant type is accompanied by a lesion of the hypothalamic-pituitary region as a result of calcification of the diaphragm of the Turkish saddle.
   5. pituitary secondary true amenorrhea develops as a result of an organic lesion of the adenohypophysis by a tumor or a violation of blood circulation in it with the development of necrotic changes: Sheehan's syndrome (postpartum hypopituitarism) - the disease develops due to necrosis of the anterior pituitary gland against the background of spasm of arterial vessels as a reaction to massive blood loss during childbirth or bacterial shock, Simmonds syndrome - an infectious lesion or injury, circulatory disorders or pituitary tumors. Itsenko-Cushing's disease - pituitary adenoma producing ACTH, acromegaly and gigantism - a tumor producing growth hormone.

Thus, amenorrhea is not a disease, it is a symptom of many diseases, the correct diagnosis of which depends on the effectiveness of treatment.

Therefore, detailed complaints, anamnesis, general and special examination are in the first place. Based on the totality of these data, the direction of additional research methods is determined. And only after laboratory and instrumental confirmation of the presumptive diagnosis, treatment is prescribed.

Dysfunctional uterine bleeding (DUB) is a violation of the menstrual cycle, which is based on a violation of the rhythmic secretion of sex hormones.

DMK, like amenorrhea, is a polyetiological disease, its causes are certain adverse effects that have a pathogenic effect on the reproductive system at various stages of the formation, formation and development of the female body.

The occurrence of DMC is facilitated by: unfavorable course of the perinatal period; emotional and mental stress; mental and physical stress; traumatic brain injury; hypovitaminosis and nutritional factors; abortions; transferred inflammatory diseases of the genitals; diseases of the endocrine glands and neuro-endocrine diseases (postpartum obesity, Itsenko-Cushing's disease); taking neuroleptic drugs; various intoxications; professional hazards; solar radiation; adverse environmental factors.

Depending on age, DMC are divided into:

1. Juvenile uterine bleeding (JUB).
2. DMC of reproductive age.
3. DMK premenopausal, postmenopausal (climacteric) period.

The diagnosis of dysfunctional uterine bleeding is made when all other causes of bleeding (blood diseases, etc.) are excluded. The word "bleeding" must be understood as follows: even spotting spotting is also bleeding, which will only be treated differently (for example, profuse bleeding - immediately curettage to stop), spotting requires examination according to functional diagnostic tests and planned diagnostic curettage .

So, DMK is a violation of the system of regulation of the menstrual cycle. In each case, it is important to determine the point at which the violation occurred: the hypothalamic-pituitary system, the ovary, or extragenital diseases.

Full regulation of the menstrual cycle can only be achieved when the feedback between the pituitary and ovary is well preserved and the normal amount of hormones switches the production of FSH and LH. It is also necessary to remember in the event of DMC that all endocrine organs are very interconnected and a violation of any endocrine organ in the first place can lead to a violation of the production of gonadotropic hormones of the pituitary gland.

In the anterior lobe - the adenohypophysis, gonadotropic hormones - FSH and LH are produced, these are the most delicate structures of the pituitary gland. Moreover, a violation of the production of any other tropic hormone leads to a decrease in the production of follicle-stimulating and luteinizing hormone. For example, ACTH, if there is an increased production of ACTH, then adrenal hyperplasia occurs, hyperplastic adrenal glands produce an increased amount of androgens. And the very high content of ACTH in the pituitary gland inhibits the production of FSH and LH, and the increased amount of androgens coming from the adrenal glands also inhibit ovarian function. As a result, we have menstrual dysfunction in the form of opsomenorrhea (rare menstruation), in some cases - amenorrhea (complete absence of menstruation).

Or take somatotropic hormone - the same situation. Beautiful high growth, athletic physique and at the same time genital infantilism. If these women become pregnant, then their pregnancy may be accompanied by miscarriage, early termination of pregnancy, miscarriage, they may also suffer from infertility, because. somatotropic hormone depresses FSH and LH since childhood, and normal gonadotropic function is not formed. Even if they menstruate regularly, they still have a defective cycle.

The same is true for thyroid diseases. Women with thyroid disease suffer from both NMC and infertility. Pancreas - diabetes mellitus, women suffer from NMC, DMC, rare menstruation, with severe diabetes - amenorrhea. Therefore, when a woman has DMC, especially if these bleedings are cyclical, it is necessary not only to work in the pituitary-ovary-uterus system, but also to work on the entire endocrine system, because if we missed the thyroid gland, then we will not do this woman well. let's fly, i.e. there will be no etiopathogenetic treatment, and we will carry out only symptomatic treatment, which will give a temporary effect, only for the time of taking hormonal drugs, and as soon as we remove hormonal therapy, the situation will repeat itself.

Diseases that must be excluded when making a diagnosis of dysfunctional uterine bleeding (differential diagnosis in reproductive age):

1. disturbed uterine pregnancy of early terms
2. ectopic pregnancy
3. placental polyp
4. hydatidiform mole
5. chorionepithelioma
   differential diagnosis will depend on whether this bleeding first occurred or whether it is repeated. If a woman has bleeding for the first time against the background of a delay in menstruation, a differential diagnosis should be made with a disturbed uterine pregnancy or ectopic pregnancy. But if there are repeated violations of the menstrual cycle, for example, for half a year, menstruation comes with a delay of two weeks, passes more abundantly than usual, then naturally this is not a disturbed pregnancy.
6. inflammatory diseases of the uterus and appendages - endometritis, can give intermenstrual spotting for a long time with a clear release of menstruation. There is no pain syndrome and the woman feels practically healthy. Then think, first of all, about endometrial cancer, a hyperplastic process - polyposis, an inflammatory disease - endometritis. Then anti-inflammatory treatment, diagnostic curettage, there are no pathological processes in the uterus, the state of the endometrium corresponds to the phase of the menstrual cycle and leukocyte infiltration of the remaining stroma, which indicates the presence of endometritis.

   Inflammatory processes of the appendages often give violations of an acyclic nature according to the type of metrorrhagia (i.e., there is a delay, and then copious spotting), then we carry out a differential diagnosis with an ectopic pregnancy, because there is pain, delayed menstruation and prolonged spotting.

7. submucosal uterine fibroids (very small, it practically does not affect the size of the uterus, the uterus may be slightly larger, but of normal consistency with a smooth surface), because mixed or subserous uterine fibroids, we expose immediately during the initial examination. We differentiate when a woman has cyclic disorders, heavy and prolonged menstruation, but the cycle is preserved, comes regularly and has a characteristic pain syndrome in the form of cramping pains during menstruation.
8. endometriosis of the uterus - we differentiate with repeated menstruation, profuse, prolonged, and there are spotting spotting and pain before and after menstruation.

   With DMC, there is no pain, sometimes organic diseases proceed without pain, for example, endometriosis of the uterine body.

9. hyperplastic process of the endometrium (endometrial polyposis, atypical glandular hyperplasia - endometrial adenomatosis). The group of hyperplastic processes of the endometrium also includes glandular and glandular-cystic hyperplasia, but we will say that these hyperplasia can be a manifestation of DMC, i.e. ovarian dysfunction that leads to these changes and we will expect this histological result and take this result as confirmation of DUB.
10. Cancer of the body of the uterus and cervix. We will immediately see the cervix, we reject it during colposcopy. Remember the old rule that any bleeding should be considered bleeding due to cancer, as long as we do not rule out its presence in any age period.
11. Ovarian sclerocystosis is differentiated if there is a violation of the menstrual cycle according to the type of opsomenorrhea (rare menstruation), although sclerocystosis can occur without a delay in menstruation according to the type of DMC, which can occur before the period of menstruation at first, and then, as the disease develops, opsomenorrhea is formed, which smoothly turns into amenorrhea if the woman is not treated.
12. Blood diseases

Ovarian dysfunction (primary, secondary due to dysfunction of the pituitary gland, but all forms of ovarian dysfunction are the same, regardless of the level of damage). In the course of the examination of these women, we will conduct a differential diagnosis and at the same time identify the level of the lesion. Now this is done simply: a study of the level of hormones of the thyroid gland, adrenal glands and pituitary gland, (prolactin - in high doses inhibits the level of FSH and LH, therefore, in women with infertility and menstrual irregularities, it is the first to examine prolactin). Regardless of the level of damage in the primary ovary or in the pituitary gland, the forms of the disorder will be the same.

Forms of infringement.

1. Slow development of the next follicle. Clinic: menstruation turns into DMC and spotting occurs up to 14 days. Or menstruation has passed for 3-5 days, ended and a day later spotting began again, continues for several days and stops on its own.
2. Persistence (prolonged existence) of an immature follicle - a delay in menstruation or menstruation on time. Bleeding is not profuse and not too long. The main manifestation is a delay in menstruation and complaints of infertility.
3. The persistence of a mature follicle is the only one of all DMC, accompanied by profuse bleeding, anemic for the patient, occurs after a delay or during menstruation. Often they end up in a hospital for curettage in order to stop bleeding.
4. Follicle atresia (reverse development) - a long delay (up to 2 - 3 months), sometimes on or before the period of menstruation. Bleeding is moderate, closer to meager
5. Intermenstrual spotting (a drop in hormone levels after ovulation) - spotting in the middle of the cycle, stops on its own. In abundance, they can resemble menstruation, then the woman will say that she had three menstruation in one month.
6. Persistence of an immature corpus luteum - bleeding before the onset of menstruation, at term, or after a delay at a reduced progestogen level (low progesterone in the second phase)
7. Persistence of the mature corpus luteum - bleeding on time or after a delay, not abundant, but prolonged. The reason is a stressful situation transferred in the second phase of the cycle. Very difficult to treat. If a woman does not immediately apply, then bleeding in duration with each cycle will increase all the time (2 weeks, a month, a month and a half and up to 2 months). At the same time, the woman will feel the early signs of pregnancy, and if she comes with a temperature chart, we will make the only diagnosis - a disturbed early pregnancy. This is due to the high level of gestagens. Treatment is less effective - only taking COCs
8. Syndrome of luteinization of the unovulated follicle - the follicle without ovulation turns into a corpus luteum. The reason is unknown. Complaints about infertility. Menstruation on time, of normal duration and intensity, a two-phase cycle according to rectal temperature. Diagnosis only by ultrasound: after ovulation, the follicle should disappear, and with this pathology we will see the follicle (liquid formation), which begins to decrease in size (it is delayed by the corpus luteum). Then laparoscopy in the second phase, after a rise in temperature: we should see the stigma of ovulation (a rounded hole with inverted edges), and we will see a yellowish formation - this will be an unovulated follicle undergoing luteinization. Treatment: ovulation stimulation
9. Atresia of the corpus luteum - bleeding before the period of menstruation, on time or after the delay of menstruation. The onset depends on the time of death of the corpus luteum: abrupt death - before the deadline, slow death - the temperature decreases gradually and menstruation on time, if it dies even more slowly, the temperature goes beyond 37 ° C, it stays like this for some time and only then against the background of a delay bleeding starts. Normally, the temperature decreases one day before menstruation, if it decreases more days before the onset of menstruation, then the corpus luteum is atreziruetsya

All these disorders at the first admission are called (put down in the diagnosis) NMC against the background of ... (indicate the clinical manifestation, symptoms) opsomenorrhea, hyperpolymenorrhea, etc. In the future, we examine the woman according to TFD, confirm them with the results of histology and reach a clinical diagnosis: DMC of the reproductive period against the background (indicate the form of the violation), for example, delayed development of the next follicle. In substantiating the diagnosis, we write: on the basis of tests of functional diagnostics (TFD), a decrease in estrogen levels at the beginning of the cycle, a discrepancy between the histological result and the day of the menstrual cycle, this diagnosis was made.

Treatment: complex

1. stopping bleeding - hemostasis (medical or surgical), if operational - a mandatory histological examination of endometrial scrapings. With profuse bleeding - means aimed at increasing blood coagulability and contractility of the uterus + blood and plasma substitutes. If there is no effect, further measures are hormonal hemostasis and preparation for emergency curettage.

   Surgical hemostasis in girls is used for ineffective hormonal hemostasis, as well as in cases of hypovolemic shock and severe anemia (Hb less than 70 g/l and Ht less than 20%).

   At the present stage, surgical hemostasis should be carried out under the control of hysteroscopy to exclude organic causes of bleeding (myomatous node, polyp, etc.).

   An auxiliary method for curettage of the uterine mucosa in the perimenopausal period can be cryodestruction of the endometrium, laser vaporization and electroextraction (ablation) of the endometrium, which give a lasting therapeutic effect. Your textbook says that such manipulations lead to the absence of the need for further hormone therapy. This is not true! It must be remembered that in addition to the endometrium, a woman has other target organs for sex steroids, therefore

2. therapy aimed at maintaining and normalizing menstrual function is required!

   Menstrual function is not menstruation, it is a combination of the ovarian and uterine cycles, and if the uterine cycle (endometrial growth and its rejection) is eliminated, this does not mean that the ovarian cycle will be eliminated. The ovary will also continue to produce hormones that will act on target tissues, including breast tissue. There are no contraindications (except for oncopathology, and then, with some degree, we can say relative ones) to hormone therapy, there is a contraindication to a specific hormone, and it is up to the doctor to find the hormone that suits the woman.

Prevention of recurrent bleeding - depends on the cause of its cause

1. rational nutrition (increase in body weight),
2. general strengthening therapy (adaptogens) and vitamin therapy (E and C)
3. physiotherapy (phototherapy, endonasal galvanization), which enhances the gonadal synthesis of steroids
4. elimination of excessive stress factors
5. identification of etiological (extragenital) causes of DMC and their elimination or correction (diseases of the liver, gastrointestinal tract, metabolic disorders, etc.), sanitation of foci of infection
6. Additional treatment for anemia
7. In women of reproductive age, hormone therapy with COCs before pregnancy is planned (as a prophylaxis and a method of contraception)

Uterine bleeding in postmenopause- an indication for diagnostic curettage. No therapeutic measures before scraping! The appearance of bloody discharge in postmenopause is a symptom of malignant neoplasms (adenocarcinoma or hormonally active ovarian tumor), and there may also be inflammatory changes against the background of endometrial atrophy, senile colpitis. In any case, we first exclude oncopathology.

Of exceptional importance for a woman is the realization of the opportunity to become a mother. Sooner or later, but everyone thinks about the birth of a child. And a necessary condition for conception is the normal functioning of the reproductive system, the main indicator of which is the menstrual cycle. And every woman should monitor her periods, paying attention to any deviations. And if you notice any changes, you should immediately go to the doctor. But you can often find a situation where you first consult with friends or acquaintances. One way or another, the question of what NMC is in gynecology is relevant and requires clarification.

General information

Before considering violations, it should be mentioned what cyclic processes take place in a woman's body and how they are normally characterized. The main changes occur in the pituitary-ovaries-uterus system, but other organs that depend on hormonal substances are also involved. The menstrual cycle is under the influence of the main regulators - follitropin and lutropin, which are produced in the brain and "monitor" the function of the ovaries.

Normally, the cycle lasts from 21 to 34 days (average 28 days). After the end of menstruation, which lasts no more than a week, a dominant follicle begins to form in the ovary (first phase). This is accompanied by a gradual increase in the concentration of estradiol, which stimulates the proliferation of the endometrium in the uterus. In the middle of the cycle, i.e., approximately on the 14th day, ovulation occurs - the release of the egg from the mature follicle, and a corpus luteum forms in its place (second phase). The latter produces progesterone, under the influence of which the endometrium swells, and the number of glandular cells increases in it. This creates the conditions for implantation of the embryo. But if the pregnancy does not occur, then everything starts again, and the next menstruation comes.

The characteristics of the menstrual cycle are determined by the balance of hormones in the female body.

Causes and mechanisms

Many have probably already guessed that NMC stands for menstrual disorders. But this is not considered an abbreviation generally accepted in medicine, and therefore it is undesirable to use it. This situation is common among many women, but each has its own reasons. They cover both functional and specific organic states - most of them are directly related to the reproductive system. For example, the menstrual cycle may be disrupted due to diseases of the ovaries and uterus:

1. Polycystic.
2. Adnexitis.
3. Fibroids.
4. endometriosis.
5. Anomalies of development.

Changes in reproductive function are also facilitated by injuries and surgical interventions on the uterus, for example, frequent abortions. General diseases are important when the whole organism suffers. Diabetes mellitus, infectious pathology, severe diseases of the kidneys, heart and liver, and oncology can have a similar effect. But, despite this, external factors still occupy a significant share among the causes of menstrual dysfunction:

• Malnutrition, deficiency of vitamins and minerals.
• Overweight and obesity.
• Physical stress.
• Psycho-emotional stress.
• Change of climatic zones.
• Hypothermia and overheating.
• Radiation exposure.
• Taking certain medications (contraceptives, antidepressants, anticoagulants, etc.).

This can also happen for completely physiological reasons, for example, in teenage girls, when menstruation is just beginning to be established, as well as in women 45–50 years old with the approach of menopause. The absence of cyclic discharge is the norm after childbirth and during breastfeeding.

The main mechanism of menstrual dysfunction is considered to be hormonal changes in the body - both sudden and gradual. This disrupts the established relationships in the regulatory system and leads to various clinical manifestations.

The menstrual cycle is disrupted due to various external and internal factors that affect the hormonal background and the ovary-uterus system.

Symptoms

There are various types of menstrual irregularities. There may be a change in the duration of menstruation, their frequency and abundance. The cycle itself, respectively, is reduced or lengthened. Possible clinical forms of menstrual dysfunction include:

• Amenorrhea.
• Algodysmenorrhea. - Painful menstruation with general disturbances.
• hypermenstrual syndrome.
• Hypomenstrual syndrome.
• Uterine bleeding.

The first situation is accompanied by a complete absence of menstruation for six months. They talk about algomenorrhea if a woman's onset of cyclic discharge is accompanied by noticeable pain in the lower abdomen and general disorders: malaise, nausea, dizziness and headache. If we talk about hypomenstrual syndrome, then in its structure it should be noted:

• Polymenorrhea - the duration of menstrual bleeding for more than a week.
• Hypermenorrhea - the volume of secretions exceeds 150 ml.
• Proiomenorrhea - frequent periods, the interval between which is less than 21 days.

This situation is also called menorrhagia. Of course, it leads to chronic blood loss, which affects the general well-being of a woman. Iron deficiency anemia develops, and it, in turn, is accompanied by general weakness, dizziness, increased heart rate, blanching of the skin, brittle hair and nails.

With hypomenstrual syndrome, the opposite situation develops - there are fewer periods than required by physiology. Its structure includes the following violations:

• Oligomenorrhea - the duration of menstruation is only 1-2 days.
• Hypomenorrhea - the volume of secretions is less than 50 ml.
• Opsomenorrhea - monthly rare, and the interval between them is increased to 35 or more days.

There are also single-phase cycles when ovulation does not occur, and the follicle is either atretic (did not have time to mature and became empty) or persists (formed, but does not break). Then there are dysfunctional uterine bleeding. It must be taken into account that any violations of the menstrual cycle can become an obstacle to conception and pregnancy, i.e. often lead to infertility.

Clinically, violations of the female cycle are combined into several options, each of which has its own characteristics.

Additional diagnostics

To confirm menstrual dysfunction, find out its nature and determine the cause, an additional examination is required. Therefore, after a clinical and gynecological examination, the doctor prescribes certain laboratory and instrumental studies:

1. Measurement of basal temperature.
2. General blood and urine tests.
3. Blood biochemistry (hormonal spectrum, glucose, antibodies to infections, tumor markers, etc.).
4. Analysis of vaginal discharge.
5. Pap test (for atypical cells).
6. Colposcopy.
7. Hysterography etc.

It may also be necessary to consult related specialists, most often an endocrinologist. And only a complete picture of changes in a woman's body will be the key to a correct diagnosis. And on its basis, they are already treating menstrual dysfunction, the methods and methods of which are strictly individual - they are determined by the cause and nature of the pathology.

Throughout her life, a woman goes a wonderful way from a girl to a woman who can give life to another person. It is the stage when this ability can and should be used is called childbearing. The reproductive age of a woman is estimated differently in different countries and by different specialists. But there is unity in one thing - the opinion that a woman should give birth from 20 to 35 is supported everywhere. It is optimal to give birth to the first child before the age of 25-27, when the body is already fully mature and ready for bearing, but at the same time, not worn out.

It is believed that after 45-50 years, eggs cease to be produced, as a result of which the woman's ability to conceive disappears. However, in the world there are cases of the birth of children by women over 50 years old. Much of this is facilitated by modern technology.

It is believed that early pregnancy is dangerous for both the woman and the baby she carries. Too young mothers have an increased risk of spontaneous miscarriage, bleeding and toxicosis. Babies born to mothers under the age of 20 are often underweight, after birth they gain it poorly, and do not adapt well to new conditions for them. In addition, the girl may not be psychologically ready for motherhood. She does not have all the necessary knowledge to properly care for a child.

In the case of late pregnancy planning, problems with conception and bearing may arise, because by the age of 36 or more, a woman, as a rule, has certain diseases, health abnormalities that do not allow her to conceive or give birth to a baby. In addition, after the age of 40, the probability of having a child with genetic abnormalities is high.

DMC of reproductive age

The question of a woman's reproductive age is often associated with the question (WMC). Women are concerned about whether they are manifestations of menopause. According to statistics, DMC occurs in 4-5 women of reproductive age. They manifest themselves in the form of menstrual irregularities, when menstruation occurs after a significant delay or before the expected date. Most often, the cause of DMK is a malfunction of the ovaries. Other causes may be diseases of the lungs, kidneys or liver. With DMK, ovulation does not occur, the corpus luteum does not form, and progesterone levels are reduced. All this makes it impossible to conceive a child. DMC usually occurs in women who have had an abortion, an ectopic pregnancy, an infectious disease, or a disease of the endocrine system.

NMC in reproductive age

Violation of the menstrual cycle (NMC) during the reproductive period is a common occurrence. NMCs include:

• amenorrhea - absence of menstruation;
• hypomenorrhea - on-time scanty menstruation;
• hypermenorrhea - too heavy menstruation that occurs on time;
• polymenorrhea - too long (6-8 days) menstruation;
• - too short (1-2 days) menstruation;
• tachymenorrhea - a shortened menstrual cycle;
• opsomenorrhea - too rare menstruation (with a cycle of more than 35 days).

Reproductive age of a woman in different countries

In Russia and other European countries, there is an established opinion that a woman of reproductive age should be from 18 to 45 years old. During this period, it is believed that Slavic and European women can conceive and give birth to a child. At the same time, in women of the southern national groups, the reproductive age begins and ends much earlier. Oriental girls mature early and get married, and already being mature women, they age much more rapidly. In Western Europe, the opposite trend is observed - towards a shift at a later date: childbirth far beyond 30 and even 40 years is considered normal, respectively, and menopausal age is delayed, which is facilitated by the widespread use of hormonal drugs.

How to prolong a woman's reproductive age?

To prolong the childbearing age, women need to carefully monitor their health, treat any diseases in time, and monitor their hormonal levels. Prevention of abortion is the key to the duration of the reproductive age.

Nature conceived regular periods: an indicator of a woman's health. Gynecologists believe that by the age of 15, the girl should have a menstrual cycle. This is a complex set of biochemical processes occurring in the body with a certain frequency. Participation in it is taken by the structures of the brain - the cortex and subcortical formations; organs of the endocrine system - adrenal glands, thyroid gland, ovaries.

The well-coordinated work of the body systems provides the "gold standard": a 28-day cycle. Its duration of 26-38 days is considered normal. This includes the interval from the first day of menstruation to the next first day. A delay or shortening of the cycle by five to seven days is considered a variant of the norm.

Types of menstrual disorders (NMC)

Anxiety should be caused by too frequent periods or, on the contrary, rare ones. Their absence for several months is a serious cause for concern. Scarcity of secretions, abundance, short-term (one or two days), prolonged duration - deviations from the norm. The following types of NMC are most often diagnosed in gynecology:

1. Hyperpolymenorrhea: a short menstrual cycle of 14 to 21 days is accompanied by a long period of heavy bleeding - from 7 to 12 days. It is fraught with blood loss, and this is a big burden on the body and subsequently leads to violations of the adaptive mechanism. Such NMC often indicates serious problems of women's health.
2. Oligomenorrhea occurs in 3% of cases. The interval between periods can last 40-180 days, they themselves occur in two to three days. It is diagnosed more often in young women. The disease is accompanied by an increase in body weight, problems with conception.
3. Polymenorrhea is a common disorder. With an undisturbed cycle duration, abundant and prolonged blood loss is observed: more than seven days.
4. Almost half of women under the age of 50 are diagnosed with algomenorrhea. It manifests itself as cramping, pronounced or muffled pain in the lumbar region, headache, nausea, and malaise. Symptoms can go away after a few hours, sometimes after a day.

For several years, fluctuations in the duration of the cycle, changes in the amount of discharge in women after forty years are observed. These are signals of the extinction of the activity of the ovaries, which leads to a decrease in the efficiency of their work. In this case, the diagnosis of NMC indicates the onset of premenopause. The condition is considered physiological, natural and continues until entering menopause.

Causes of menstrual irregularities

Some women have a long menstrual cycle due to genetics. Very often, psychophysical factors become the cause of violations: overwork, moving to another place of residence with a change in time zone, stress, anxiety before a responsible exam, taking certain medications, and even extreme heat in summer.

Systematic lack of sleep has a powerful negative effect: in the pre-morning hours, a woman's body actively synthesizes hormones that regulate monthly cycles. A completely banal cause of failure can be a urethrogenital infection: mycoplasmas, chlamydia, uroplasmas.

Conscientious anti-inflammatory treatment will get rid of problems. Uncontrolled dieting causes a general distortion of metabolism and entails NMC. The consequences of diabetes mellitus, obesity, thyroid disease, hypertension, anorexia can be NMC.

Diagnostics

Based on the woman's complaint, the doctor prescribes an examination. In this case, the violation of the menstrual cycle is only a symptom. Diagnostic activities typically include:

• study of the hormonal state of the body;
• conducting an ultrasound examination to exclude pathologies in the pelvic organs;
• laboratory analysis of a smear from the vagina.

Treatment of NMC

Adequate measures are chosen by the attending physician, based on the results of the examination. In the arsenal of methods: hormone therapy, physiotherapy, anti-inflammatory drugs, antibacterial. In some cases, surgery is possible. Often, gentle methods, for example, homeopathic remedies, have a corrective effect.

The customer must already determine the NMC in the procurement schedule. If by the time of publication the purchase price is adjusted, changes are made to the schedule.

It is necessary to justify both the price of competitive purchases and purchases from a single supplier. In Art. 22 44-FZ describes several methods for determining NMC:

1. Market analysis method,
2. normative method,
3. tariff method,
4. design estimate method,
5. Cost method.

Let's take a closer look at them.

Market analysis method for calculating NMC

This is the preferred method. The customer must always apply it, unless 44-FZ provides otherwise. The customer compares prices for similar goods or services, and if there are none, then for homogeneous ones. To calculate NMC using the market analysis method, the customer can:

• Use information from the Internet
• Request prices in the EIS,
• From potential suppliers.​

You need to send at least five requests, and for the calculation use at least three price offers to determine the NMC of a similar purchase.

If you enter into a contract with a single supplier, it is not necessary to adhere to the average price level determined by the market analysis method. It is possible to conclude a contract at the lower of the offered prices.

Example of substantiation of the NMC contract for the wholesale supply of petroleum products using the market analysis method

The average price per ton of gasoline is 45,000 rubles, which means that the NMC of the entire purchase is 2 million 998 thousand 450 rubles.

Normative method for determining NMC

There are certain types of goods whose purchases are rationed (for example, stationery, furniture, medical consumables). The customer buys them at marginal prices. Decrees, in which there are cost norms for various products for certain organizations, are posted in the EIS. The standard method can be used together with the market analysis method, but the received NMC should not exceed the price established in the standard.

Tariff method of calculation of NMC

The customer applies it if the price of the goods is regulated by the state or municipal authority. In this case, the NMC is determined according to the tariffs approved in resolutions, orders, etc. In the justification of the NMC, the customer refers to the regulatory document.

Design and estimate method for calculating NMTs

Used to calculate prices for:

• Construction and reconstruction of buildings,
• Major repairs and general repairs of premises,
• Carrying out work on the preservation of cultural heritage objects (monuments of history and culture) of the peoples of the Russian Federation, in addition to scientific and methodological guidance, technical and architectural supervision.

Cost method for determining NMC

When it is necessary to clarify the amount received by one of the listed methods, or other methods are not suitable, customers use the costly method of calculating the NMC. To do this, list and summarize all possible costs for the performance of works or services, for example:

• Production or acquisition costs,
• Sales, transportation, storage,
• Insurance and other expenses.

The customer can take information about ordinary profit for a certain field of activity from contracts posted in the EIS or other sources.

Here is an example of calculating the NMC by the cost method from the purchase for the retraining of medical staff:

You can use other methods, justifying why you can not use the standard one. Recommendations on the justification and application of other methods may be established by the government of the Russian Federation in its regulations.