Blood loss and spotting: causes, dangers and remedies

What you need to know about spotting

The content of the article

Any blood loss that occurs outside of the normal menstrual cycle should be assessed by a gynecologist, whether it is mild (spotting) or heavy bleeding.

However, note that, according to numerous scientific sources, one of the most common causes of intermenstrual bleeding is stress, so this symptom should not lead to premature alarms and concerns about malignancy.

Bleeding often occurs as a single symptom, but it can also be accompanied by other symptoms associated with the underlying pathology:

• pain in the abdomen or pelvis;
• vaginal discharge;
• asthenia and general malaise;
• nausea and vomiting;
• fatigue and feeling tired;
• pallor and tachycardia.

Tachycardia
Diagnosis of such conditions is based on recognition of the symptom and associated signs. It is also important to immediately perform instrumental tests, for example, transvaginal ultrasound, which is necessary to identify organic pathologies.

Therapy depends on the cause of the bleeding, as well as on the woman’s age and her desire to have offspring; the choice of method lies with the gynecologist.

White highlight

During puberty, white discharge may be a sign of inflammatory processes in the intestines, bladder or internal genital organs. Often the discharge is accompanied by pain when urinating and discomfort in the lower abdomen and lumbar region. With severe inflammation, the temperature may rise. In this case, a blood test and other diagnostic methods are necessary.

The structure of the discharge changes after the girl begins to be sexually active. To her microflora is added the microflora of her partner, which has a different composition. For some people adaptation occurs faster, for others it happens more slowly, but in the end this does not harm health. When you change partners, the nature of the discharge also changes. But if a woman’s discharge deviates from the norm for a long time, this may indicate the presence of a sexually transmitted infection.

Copious white discharge with a sour odor is a sign of thrush (candidiasis). Sometimes they gather in lumps or flakes. The bacteria that cause candidiasis are present in the body of every person. The immune system successfully suppresses them throughout life, so if discharge does appear, this indicates problems with the immune system. Often these problems are associated with sexually transmitted infections. Treatment should be aimed at eliminating the true cause of the inflammatory process.

The main causes of vaginal pathological bleeding

There are many causes of vaginal bleeding, but they can generally be grouped into 5 broad categories:

Complications during pregnancy (sometimes undiagnosed, that is, which the woman does not yet know about) include:

• abortion (miscarriage);
• ectopic pregnancy;
• gestational trophoblastic disease.

Dysfunctional reasons:

• anovulatory cycles;
• polycystic ovary syndrome;
• less often metrorrhagia.

Benign organic pathologies:

• uterine fibroids;
• uterine polyps;
• adenomyosis;
• endometriosis;
• genital infections.

Malignant organic pathologies:

• endometrial cancer;
• cervical cancer;
• vaginal cancer;
• sarcomas.

Common systemic causes:

• blood clotting pathologies;
• leukemia;
• hypothyroidism;
• liver and kidney failure.

Spotting may occur during the first cycles of taking hormonal contraceptives (birth control pills) and after using the hormonal IUD.

Bloody discharge during pregnancy

Light spotting is common in the early weeks of pregnancy, but heavy bleeding can occur in the third trimester of pregnancy and poses a serious risk to both mother and fetus.

The severity of bleeding is assessed by:

• volume - small drops or real bleeding;
• duration;
• blood characteristics;
• accompanying symptoms.

There are many reasons for bleeding during pregnancy, including:

• urinary tract infections or hemorrhoidal disease (bleeding in which is misunderstood as blood loss of genital origin);
• polyps in the cervix;
• cervical carcinoma;
• placenta previa (abnormality of the placenta);
• placental abruption before childbirth;
• abortion (miscarriage);
• ectopic pregnancy (the embryo, instead of implanting in the uterus, implants in other areas, especially often in the fallopian tubes);
• gestational trophoblastic disease.

Polyps in the cervix
Both in the presence of bloody discharge and in case of more significant blood loss, the patient is always recommended to consult a doctor. If spotting in the first trimester is physiological in nature, when the bleeding was especially heavy, hospitalization would become mandatory.

Almost always in the third trimester of pregnancy, therapeutic treatment includes:

• If the presentation is mild, close monitoring of symptoms is necessary until vaginal delivery eventually occurs;
• If the clinical picture is severe, emergency treatment with continuous cardiotocography (for fetal monitoring) and immediate cesarean section should be performed.

Intense bleeding in the first weeks after childbirth or after an abortion can occur when the uterus has not yet restored its physiological size, or in case of imperfect (insufficient) cleaning of the internal walls.

Bloody discharge is normal

Bloody discharge before menstruation can be a sign of a shift in the menstrual cycle towards shortening due to various reasons. This is a completely acceptable phenomenon, as is spotting after menstruation, especially against the background of stress or a radical change in environment.

Also, occasionally, discharge may occur during ovulation, bloody, spotting or brownish. If they are short-term and painless, they are not dangerous. Sometimes, in the presence of cervical erosion, there may be discharge after sex due to contact bleeding from injured vessels.

Dysfunctional reasons

Anovulatory cycles are those cycles during which normal ovulation does not occur. The basis may be hormonal changes in FSH and LH, estrogen and progesterone. The imbalance causes excessive growth of the endometrium, which sloughs off irregularly at the end of the cycle, causing bleeding even outside the normal menstrual cycle, often long and heavy.

Polycystic ovary syndrome is a disease that affects young women between the ages of 20 and 40. It is characterized by anovulation (in the absence of a normal menstrual cycle and infertility), hirsutism, acne, insulin resistance with an increased risk of developing type 2 diabetes.

By menorrhagia we mean a pathological increase in the amount and duration of menstrual flow, which, however, in this case usually occurs at the end of the cycle.

Stress and eating disorders (anorexia nervosa, bulimia, etc.) can lead to intermenstrual losses and abnormal cycles, as well as metabolic diseases (metabolic syndrome) and hormonal dysfunctions, such as thyroid disease.

By metrorrhagia we mean heavy vaginal bleeding that occurs outside of the normal menstrual cycle.

Literature:

1. L.E. Radetskaya Mechanisms of uterine bleeding in normal and pathological conditions. Clinical lectures. // Protection of motherhood and childhood. - 2007. - No. 1 (9) pp. 54-59.
2. Kuznetsova I.V. Menstrual cycle in the late reproductive period // Effective pharmacotherapy. Obstetrics and gynecology. No. 2, 18/2013, pp. 32-40.
3. A color-coded guide to vaginal discharge .// MedicalNewsToday / January 10, 2021 / https://www.medicalnewstoday.com/articles/322232
4. Carolyn Kay, MD Ovulation bleeding: What to know // MedicalNewsToday / July 24, 2021 / https://www.medicalnewstoday.com/articles/325847
5. What does the color of period blood mean // MedicalNewsToday / April 1, 2021 / https://www.medicalnewstoday.com/articles/324848
6. The differences between spotting and periods // MedicalNewsToday / January 30, 2021 / https://www.medicalnewstoday.com/articles/317595
7. Aslih, Nardin & Walfisch, Asnat. (2011). Clinical Approach to Pregnancy-Related Bleeding. 10.1007/978-1-4419-9810-1_1.
8. Gynecology. National leadership. Brief edition / ed. G. M. Savelyeva, G. T. Sukhikh, I. B. Manukhina. - M.: GEOTAR-Media, 2013. - 704 p.
9. Ledina A.V. Vaginal discharge: causes, patient management algorithm and modern approaches to treatment and prevention // Obstetrics and gynecology: opinion news, training. 2021. Vol. 7, No. 3. pp. 107–111. doi: 10.24411/2303-9698-2019-13016.
10. I.A. Apolikhina, E.A. Gorbunova Clinical and morphological aspects of vulvovaginal atrophy / Medical Council No. 9 2014, pp. 110-117
11. Kachalina O.V., Korenkova A.A. Cervical endometriosis - possibilities for solving the problem. Medical advice. 2018; 21: 174-177. DOI: https://doi.org/10.21518/2079-701X-2018-21-174-177.
12. Smetnik V.P. All about menstruation. - Yaroslavl, Litera publishing house, 2005. - 56 p.
13. Solovyova A.N. Inflammation. Fundamentals of pathology // Velikoluksky Medical College - 2021: 13 p.
14. Atrophy // Great Medical Encyclopedia (BME), edited by Petrovsky B.V., 3rd edition (access date 08/25/2021) - https://xn--90aw5c.xn--c1avg/index.php/%D0 %90%D0%A2%D0%A0%D0%9E%D0%A4%D0%98%D0%AF
15. Cytological examination of the cervix based on the Papanicolaou staining technique, screening for cervical cancer. Preanalytical stage V1.3 – 04/02/2019 / https://www.papanicolaou.ru/site_files/publikacii/rukovodstvo-po-preanaliticheskomu-etapu-pap-testa.pdf
16. Cervical intraepithelial neoplasia, erosion and ectropion of the cervix // Clinical recommendations - 2021.

Benign organic pathologies

Uterine fibroids and endometrial polyps are among the most common causes of vaginal bleeding during the fertile phase. The former are nothing more than abnormal growths of muscle tissue, and the latter - the endometrial mucosa. They can increase in size and often, in combination with hormonal changes, cause bleeding in the form of menorrhagia and metrorrhagia. In this category, it is also important for us to consider ovarian cysts.

Endometriosis means the abnormal presence of endometrium in organs other than the uterus, such as the ovary, fallopian tube, peritoneum, vagina, intestines, lungs. These ectopic lesions may also bleed during the normal menstrual cycle.

Occasional light-colored spotting, possibly worsening with sexual intercourse, may be caused by the presence of an ectropion (an "ulcer" on the cervix).

Genital infections can cause various types of vaginal discharge, but only rarely do they cause bleeding. The most common are those that are sexually transmitted - chlamydia and gonorrhea.

Brown discharge

The color of the discharge can indicate the cause and appearance. Bacterial infections may appear as a light brown discharge - pay attention to the smell and whether it is itchy. Dark brown discharge indicates the presence of coagulated blood in it, which appears due to damage to the uterus and appendages, erosion, and endometriosis.

When is brown discharge normal?

Brown discharge does not always indicate a disease. Mucusy brown discharge can cause:

• conception and first days of pregnancy
• sexual intercourse
• taking medications
• ovulation
• postpartum period
• starting to take birth control pills
• menopause
• preparing the pelvic organs for menstruation
• endometrial release after menstruation

Normally, this discharge does not cause discomfort, is odorless, low-intensity, and spotting in nature. During the postpartum period, such discharge may be copious.

Brown discharge mid-cycle

During this period, brown discharge may be normal. Mucous leucorrhoea from the vagina may acquire a brown tint due to the ingress of coagulated blood from a ruptured follicle. In this case, the discharge does not have an unpleasant odor, is not accompanied by pain, lasts no more than a couple of days and is spotty in nature. If the discharge is heavy, does not stop between periods, or your health worsens, consult a doctor immediately.

Brown secretion before menstruation

Normally, one or two days before your period, you may experience brown mucus discharge. Their volume is small. This secretion indicates the initial processes of menstruation. If the discharge continues during the week before your period, it is probably caused by the following reasons:

• psycho-emotional stress
• poor nutrition
• excess weight
• bad habits
• lack of sleep
• excessive physical activity
• hormone deficiency

And, nevertheless, if you encounter such a phenomenon, we recommend that you consult a gynecologist. It is important to exclude the possibility of developing pathology.

Discharge after menstruation

Spotting brown discharge after menstruation in the absence of other complaints may be normal. They are due to the fact that the endometrium, which is shed during menstruation, comes out gradually and thus its remains are released. This kind of daub lasts no more than 2-3 days. Longer discharge can indicate the presence of infection, hormone deficiency, inflammation and other pathologies. In any case, it would be a good idea to contact a specialist.

Discharge at conception

When a fertilized egg enters the uterus, a small part of the blood vessels may be damaged. This is what causes scanty brown or pink discharge about a week after ovulation. They can last several hours or several days. However, brown discharge does not always indicate pregnancy. In order to be sure of your health and the causes of discharge, consult a gynecologist.

When brown discharge is a sign of pathology

Typically, in the presence of pathologies, women are concerned about the following symptoms:

• Brown discharge is abundant, thick or, on the contrary, watery
• blood impurities appear in mucus regularly
• pain during intercourse
• elevated body temperature
• unpleasant odor in the intimate area
• discomfort in the perineum
• cycle failure

Even if it seems to you that there are objective reasons for brown discharge (stress, diet, etc.), you should consult a gynecologist to rule out pathologies.

Brown discharge instead of menstruation

Sometimes, instead of the usual menstruation, a woman observes scanty brown spotting. In this case, the discharge is accompanied by pain, nausea, weakness, etc. Among the pathologies that caused this phenomenon:

• hormonal imbalance
• malfunction of the pituitary gland
• endometrial damage
• inflammation
• disruption of the endocrine system
• oncology

Diseases that cause brown discharge

• pelvic inflammation
• genitourinary system infections
• ectopic pregnancy
• endometritis
• endometriosis
• cystitis
• benign formations
• polyps
• oncological diseases

All pathological processes are generally accompanied by not one, but a group of symptoms. Listen to your body. But often diseases remain asymptomatic for a long time. Therefore, we advise you to undergo a preventive examination by a gynecologist at least once a year.

At the medical clinic in Moscow, all conditions have been created for the diagnosis and treatment of gynecological diseases. Make an appointment with any of our specialists.

Malignant organic pathologies

They most often occur in the perimenopausal period and consist of malignant tumors of the genital organs. Most common:

• cervical cancer (the most important risk factor is human papillomavirus infection);
• endometrial cancer;
• ovarian cancer;
• cancer of the vagina and vulva.

Ovarian cancer
These are pathologies with a very poor prognosis if they are not recognized in time and treated.

Yellow and green discharge

Yellow and green discharge in women clearly indicates STDs or nonspecific genital inflammation. Sexually transmitted diseases, in addition to unnatural discharge, are accompanied by itching and pain when urinating. If these symptoms appear, you should immediately consult a doctor to have your discharge analyzed. The most common sexually transmitted infections are:

• Gonorrhea. The discharge is light yellow, almost white, and is not large in volume. Their appearance is not “tied” to the cycle. A change in color from gray-white to yellow indicates the transition of the disease to the chronic stage. The infection gradually rises up the body, affecting the uterus, tubes and ovaries.
• Chlamydia. Discharge appears from the cervical canal. They have a pronounced yellow color. In addition, patients experience pain in the lower abdomen and lower back. The most reliable way to diagnose this and other sexually transmitted infections is PCR.
• Trichomoniasis. The discharge is greenish or yellowish in color. In appearance, they are easy to distinguish from the symptoms of other sexually transmitted infections, as they have an abundant foamy character. In case of contact with skin, it causes irritation.

It also happens that the discharge is a consequence of inflammatory processes in the pelvic organs. These include:

• Adnexitis and salpingitis. Inflammation affects the ovaries and fallopian tubes. Discharge is always accompanied by pain in the lower abdomen. The cause of the pathology is sexually transmitted infections or “independent” inflammation of internal organs, not caused by other diseases. Inflammation can be acute or chronic, which affects the nature of the pain. In the first case they are strong and cramping, in the second they are pulling and dull.
• Colpitis. Another name for the pathology is nonspecific vaginitis. When the vagina is inflamed, the discharge is of a different nature and varies depending on the stage of inflammation. At the initial stage they are watery and light, then they become thicker and acquire a green tint. Leukocytes give the discharge a white-yellow tint, green gives the pus, and blood gives the discharge a pinkish color.

In addition, grayish copious discharge appears with bacterial vaginosis. They acquire a yellow-green or orange color when the disease enters the chronic stage. Symptoms are especially severe immediately after sexual intercourse. Itching in the perineum occurs periodically, although it is not as intense as with other diseases.

Common systemic causes

These are systemic pathologies that can affect several systems, which among the symptoms can also produce vaginal bleeding.

For example:

• bleeding disorders such as hemophilia A and B, von Willebrand disease, platelet function disorders;
• leukemia and lymphomas;
• liver failure;
• renal failure;
• severe dysthyroidism.

An important and fundamental classification for tracking the various causes of vaginal bleeding is the classification by age group.

Causes of vaginal bleeding by age group

In girls, bleeding before menarche (the first menstrual cycle) should always be carefully investigated). Possible causes of the pathology:

• vulvovaginitis;
• vaginal neoplasms;
• accidental injury;
• foreign bodies;
• violence;
• premature puberty;
• hormonal tumors;
• accidental use of certain drugs.

Causes of intermenstrual bleeding in adolescence and subsequent years:

• inability to ovulate;
• polycystic ovary syndrome;
• changes in coagulation;
• pregnancy (even unrecognized);
• sexually transmitted diseases;
• violence.

Causes of intermenstrual bleeding during the reproductive period:

The predominant cause is menorrhagia (heavy and prolonged menstrual flow), associated with benign organic pathologies - fibroids, polyps. In this category, bleeding due to problems during pregnancy is also likely.

Causes of intermenstrual bleeding in perimenopause: in this age group there is a very high risk of developing an organic malignant disease (genital cancer).

Causes of intermenstrual bleeding during menopause: during the postmenopausal period, benign causes predominate, such as endometrial and vaginal atrophy, endometrial polyps and, much less frequently, malignant tumors.

Uterine bleeding - symptoms and treatment

Treatment of uterine bleeding is divided into surgical and medical. Drug treatment can be hormonal and non-hormonal [11][20].

In case of acute uterine bleeding and for women over 35 years of age, surgical treatment is preferable:

• Hysteroscopy with biopsy. Insertion of a hysteroscope into the uterine cavity to visualize it, identify and remove a pathological focus in the uterus. At the same time, it is also a diagnostic research method. The operation is effective for polyps, submucosal uterine fibroids and endometrial hyperplasia.

• Separate diagnostic curettage of the uterine cavity and cervical canal. Recommended for premenopausal, postmenopausal women and for acute bleeding. The disadvantage of this method is the formation of adhesions in the pelvic cavity and Asherman's syndrome, which lead to infertility [11][20].
• Endometrial ablation is the complete destruction of the endometrium. Effective in eliminating uterine bleeding, but leads to amenorrhea, scarring in the uterine cavity (which will complicate biopsy taking) and infertility. Therefore, it is performed only in premenopausal and postmenopausal women [15][17].
• Hysterectomy - removal of the uterus via laparotomy (an incision in the lower abdomen along the hairline). It may be recommended for patients who refuse hormonal therapy and for those who experience symptomatic anemia or a significantly reduced quality of life due to bleeding [11][20].
• Emergency measures are required extremely rarely, only in case of heavy bleeding. Hemodynamics (blood movement through the vessels) is stabilized by intravenous administration of crystalloid solutions, blood products and other measures. If the bleeding does not stop, uterine tamponade is performed - a urinary catheter balloon is inserted into the uterine cavity, expanding it with the introduction of 30-60 ml of water. In this way, the vessels in the uterus are mechanically compressed, and bleeding stops [20].

Non-hormonal drug treatment (for young girls under 35 years old) includes:

• Taking NSAIDs (non-steroidal anti-inflammatory drugs) reduces bleeding by 25-35% and eliminates pain due to a decrease in the production of prostaglandins [5][18].
• Antifibrinolytics - tranexamic acid, which inhibits the production of enzymes that dissolve blood clots. Stop bleeding, reducing blood loss by 40–60%. They also have anti-allergic and anti-inflammatory effects. Take no more than five days. Allowed for pregnant women [2].

Hormone therapy suppresses endometrial growth and reduces menstrual bleeding. Treatment usually lasts six months or more [11][12][20]. Hormone therapy treatments include:

• combined oral contraceptives;
• vaginal rings;
• gestagens;
• progestin-releasing intrauterine systems.

Combined oral contraceptives:

• contains at least 30 mcg ethinyl estradiol;
• contain levonorgestrel 150 mcg or gestodene 75 mcg - as an analogue of progesterone, which is produced by the corpus luteum after ovulation.

Take one tablet every 3-4 hours (up to six tablets per day) until bleeding stops completely. Then the intake should be continued, reducing the number of tablets by one per day. When one tablet per day remains, you should take them until 21 days from the start of treatment. Then take a break of 7 days (bloody menstrual-like discharge will appear). Then continue one tablet a day for 21 days, then break again for 7 days. The course is six months or more.

The ethinyl estradiol and etonogestrel vaginal ring can be used instead of the pill after bleeding has stopped if this method is more convenient than taking the pill every day. The vaginal ring is an elastic ring that conforms to the anatomical shape of the vagina, from which ethinyl estradiol is released daily. It is installed deep in the vagina from the first day of menstruation (or immediately, without a break after taking hormonal pills) on the 21st day (similar to taking combined oral contraceptives). Then it is removed for 7 days (similar to a break when using hormonal pills). It is recommended to use for at least six months [12][14][20].

Progestin drugs:

• dydrogesterone - 30 mg per day;
• micronized progesterone - 300 mg per day;
• norethisterone - 5-10 mg per day.

Taking gestagens continues for at least six months. Approved for use during pregnancy [11][20].

Levonorgestrel-releasing intrauterine systems. Under the influence of body temperature, a daily dose of a hormone is released that acts on progesterone and estrogen receptors in the uterus, thereby inhibiting the growth of the endometrium. Intrauterine systems are effective for 97% of patients. They are used for from 6 months to 5 years, providing contraception (hormonal effect on the endometrium and mechanical effect like a spiral) [11][19].

Gonadotropin-releasing hormone agonists (GnRH) - These drugs suppress the production of hormones by the ovaries, leading to amenorrhea. They are used to reduce the size of leiomyomas or before surgical treatment. However, their side effects (eg osteoporosis) limit their use to six months [11][16].

Summarizing:

• for uterine bleeding in juvenile age, hormonal drugs should be used;
• for bleeding in pregnant women, gestagens (dydrogesterone or micronized progesterone) and fibrinolysis inhibitors (tranexamic acid) should be used;
• in perimenopausal and postmenopausal age, surgical methods are used (hysteroscopy and curettage of the uterine cavity).

If, after a histological examination of a biopsy sample from the uterus, malignant changes are detected, then hysterectomy (removal of the uterus) is used with possible removal of the appendages and regional lymph nodes. If there is a question about a woman’s reproductive function, and the ovaries cannot be preserved, cryopreservation of oocytes is recommended.

Symptoms

Along with vaginal bleeding, other symptoms sometimes occur due to the underlying pathology. The most common:

• abdominal or pelvic pain (due to anovulation and other causes);
• vaginal discharge (with genital infection);
• asthenia and general malaise;
• nausea and vomiting;
• feeling tired;
• pallor and tachycardia associated with anemia secondary to bleeding that reduces hemoglobin levels.

4.Diagnostics and treatment

How does a doctor diagnose abnormal vaginal discharge?

First of all, the doctor will ask you about the symptoms of the problem and the nature of the discharge. He can clarify when the discharge started, what color it is, and whether it has a smell. It is worth telling your doctor if you have any itching, pain or burning in or around the vagina.

After the interview, the doctor may take a sample of the discharge or do a cervical smear - a Pap test - to collect cells for further analysis.

Treatment of abnormal vaginal discharge

Treatment for vaginal discharge will depend on its cause. For example, yeast infections are usually treated with antifungal medications in the form of a cream or gel inserted into the vagina. There are also special tablets. Bacterial vaginosis requires treatment with antibiotics in the form of tablets or creams. Trichomoniasis is treated with medications based on metronidazole or tinidazole.

Following simple recommendations will help prevent vaginal infections, and therefore most causes of abnormal vaginal discharge:

• Keep your genitals clean. Wash regularly with warm water and mild soap.
• Do not use scented soaps or other bath and shower products on the genital area.
• After using the toilet, wipe your genitals from front to back to avoid bacteria entering the vagina and causing infection.
• Wear underwear made from natural fabrics and avoid very tight clothing.

Diagnostics

The diagnosis is made based on observation of symptoms and the general clinical picture associated with the use of instrumental studies.

Gynecologist assesses bleeding characteristics:

• duration;
• intensity;
• associated symptoms;
• main pathologies.

If the bleeding is quite cyclical and regular, it is likely due to benign organic lesions or anovulation. If bleeding is irregular, the possibility of malignancy should also be considered.

Blood tests are performed to assess whether the patient has anemia, which in severe cases requires supportive care, including blood transfusion.

Blood tests

From an instrumental point of view, the gold standard for diagnosing vaginal bleeding is transvaginal ultrasound, which can identify both benign and malignant organic lesions, evaluate the characteristics of the endometrial mucosa and any changes in the ovaries.

The ultrasound results may then require other methods such as

• CT scan of the abdomen and pelvis;
• Nuclear magnetic resonance;
• In case of organic lesions - hysteroscopy and endometrial biopsy.

But first of all, the possibility of pregnancy is always excluded using an hCG test.

Treatment and reasons for choosing a therapy method

Treatment depends only on the underlying cause of the bleeding. Once identified, drug therapy (dysfunctional causes) or surgical intervention (malignant formations) may be required.

A woman should always choose the most appropriate treatment, including taking into account her age or her desire to have children. This allows you to increase patient adherence to therapy, as well as achieve maximum success.

ONLINE REGISTRATION at the DIANA clinic

You can sign up by calling the toll-free phone number 8-800-707-15-60 or filling out the contact form. In this case, we will contact you ourselves.