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Endometriosis: clinic and treatment

This section of the site is intended for obstetrician-gynecologists, surgeons, oncologists, neuropathologists and other specialists.

In recent years, not only obstetrician-gynecologists have significantly increased interest in endometriosis, but also surgeons, oncologists, urologists, radiologists, general practitioners, TB specialists, pediatricians and other specialists. Nevertheless, the diagnosis of the disease situation is unfavorable. This is confirmed by numerous observations of advanced forms of the disease, when the process spreads from the genital to adjacent organs and causes impairment of their function up to the development of stenosis of the intestinal lumen and ureters. The percentage of surgical interventions for endometriosis of up to 25–30% according to the materials of the Central Medical Sanitary Unit No. 122 of the USSR Ministry of Health and the Moscow Military Medical Academy clinic is still high. S.M. Kirov. One of the reasons for this is the late diagnosis of the disease, when conservative treatment cannot cause regression of endometriosis and eliminate the functional impairments and anatomical changes caused by it.

Considerable difficulties are caused by the diagnosis of the disease at a young age and menopausal period , as well as with the combination of genital endometriosis with tuberculosis, uterine fibroids, Allen-Masters syndrome [Allen M., Masters W., 1955], nephroptosis and other diseases.

Equally important are the differential diagnosis of endometriosis with certain oncological diseases and their combination. Often the symptoms of both diseases are very similar, such as endometriosis and intestinal carcinoma, endometriosis and lung cancer , endometriosis and cervical cancer, etc.

On the other hand, there are observations when the Schneitzler metastasis was mistaken for post-uterine endometriosis, Zollinger-Ellison's disease for endometriosis of the gastric or duodenal stump. Certain difficulties may be caused by the differentiation of malignant ovarian cystadenomas with cystic forms of ovarian endometriosis.

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It is impossible not to reckon with the fact that endometriosis can be the cause of the development of an acute abdomen (with damage to the ovaries, uterus, fallopian tubes , intestines, postoperative scars and navel ).

Currently, the task is not only to timely diagnose endometriosis, but also to clarify its localization, form (nodular, diffuse, cystic), involvement of adjacent organs in the process. It is also necessary to establish the severity of the disease, taking into account the duration of reduction or loss of efficiency during periods of exacerbation of endometriosis. It is very important to clarify the concomitant somatic pathology and allergic history. These provisions determine the choice of treatment method and the question of the volume of the operation, if there are indications for this method of treatment.

Conducting pregnancy , childbirth, the postpartum and post-abortion periods with endometriosis has a number of significant features.

There are certain successes in the treatment of patients with endometriosis, but still the issues of treatment are far from being resolved. In addition, new difficulties have arisen related to the tendency of patients to allergic reactions, the presence of concomitant somatic pathology in them, which makes it difficult to use hormonal drugs.

A long-term illness of endometriosis can lead to damage to the nervous system, which increases the suffering of patients or continues to cause pain even after suppression of the activity of endometriosis by hormonal drugs, radiation therapy or after radical surgical treatment.

There have been changes in radiation therapy of the disease. Remote irradiation of the ovaries in order to turn off their function was not repaid. Direct radiation exposure by the method of close-focus irradiation on the foci of endometriosis, for example, in case of endometriosis and some other localizations, turned out to be more effective. In this case, the maximum effect of ionizing radiation is focused directly on the site of endometriosis, and not on the ovaries.

This monograph aims to acquaint doctors with the features of the clinic, diagnosis and treatment of patients with endometriosis. In addition, issues of pregnancy, childbirth, the postpartum, postoperative and post-abortion periods in women with endometriosis will be considered.

The material for this monograph served as the 40-year experience of the author, the data of domestic and foreign literature on various aspects of the problem of endometriosis.

Features of endometriosis and its importance in the pathology of the female body

Features of endometriosis . Endometriosis is a hormone-dependent disease that develops against a background of impaired immune homeostasis, the essence of which is the proliferation of tissue similar in structure and function to endometrium, but outside the limits of the normal location of the uterine mucosa.

Under the influence of ovarian function and the centers of the hypothalamic-pituitary system regulating their activity, cyclic transformations occur in the foci of endometriosis, which are similar to changes in the mucous membrane of the uterus. During pregnancy, a decidual reaction develops in the foci of endometriosis. Decidopodobnye transformations in the stroma of endometriosis can be observed in the treatment of patients with preparations of the corpus luteum.

If a patient has several foci of endometriosis (internal and external genital, as well as extragenital), the degree of cyclic transformations in them is not always the same. This is evidenced by the results of the comparison of macroscopic and histological data obtained during operations.

R. Schroder (1959), M. Antoine (1960) explained the unequal severity of cyclic transformations in the foci of endometriosis by their different origins, namely, foci of internal endometriosis of the uterus, developing from the basal layer of the endometrium, are less susceptible to cyclic changes compared to external genital and extragenital endometriosis developing from the functional layer of the endometrium.

It remains unclear the cause of the unequal response of endometriosis of different localization to the effects of hormonal drugs. Why, for example, endometriosis of the lungs with a timely start of treatment is well subjected to regression, cyclic hemoptysis stops, and in the overwhelming majority of patients there is a steady recovery, while ectocervical endometriosis in the cervix, in the postoperative scars and navel is poorly amenable to long-term and intensive hormonal therapy. All of these foci of endometriosis originate from the functional layer of the endometrium.

Clinic and diagnosis of genital endometriosis

Clinic and diagnosis of extragenital endometriosis

Recognition of extragenital endometriosis is based on the dependence of clinical manifestations and objective examination data on the menstrual cycle. In terms of diagnosis of extragenital forms of the disease, the differentiation of a number of localizations (intestines, lungs, bladder) with the tumor process is important.

Endometriosis of the urinary system

Thoracic endometriosis

Endometriosis of the lungs, pleura and diaphragm belongs to the rare localization of the extragenital form of the disease. This circumstance is emphasized by many authors [Stuart L., Bednoff M., 1965; Kovarik J., Toll G., 1966; Leh T., 1967; Labay G. et al., 1971; Magre J. et al., 1971; Rebaund E. et al., 1972; Gradberg I. et al., 1977, et al.]. Nevertheless, the number of publications on the observations of thoracic endometriosis is increasing every year. Apparently, attracting the attention of various specialists to this peculiar form of the disease helps to improve its recognition.

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Endometriosis (from the Greek. Endon - inside and metra - the uterus; synonym: adenomyosis, endometrioma, endometrioid heterotopia) - tumor-like inclusion and growth of endometrioid tissue in various organs and tissues. Before puberty, as well as during menopause, endometriosis does not develop. With the termination of the menstrual function of a woman E. undergoes reverse development. These observations gave grounds to associate the development of E. with hormonal factors.

According to the standard classification, endometriosis is divided into genital and extragenital. Genital in turn is divided into internal (lesions of the uterus and tubes) and external (ovaries, posterior region, vagina, external genitalia, vaginal part of the cervix, peritoneum of the adrenal space and tissue of the pelvis). Extragenital E. include lesions localized in the loops of the intestine, mesentery, peritoneum in the navel and other organs. The most frequent localization of E. - the pelvic area. E. can metastasize to the lungs, kidneys and other organs, as well as develop in the postoperative scar.

Most authors believe that cyclic changes similar to the menstrual cycle occur in the foci of endometriosis. However, in areas E. only proliferation phenomena are observed and the secretion phase is very rarely observed. Hemorrhages in these areas depend mainly on pathological changes in the vessel walls of the endometrial sites (E. N. Petrova, 3. P. Grashchenkova, and others). Cyclic changes of external E., developing outside of a uterus, are more expressed.

The unequal severity of cyclical changes in the foci of internal and external endometriosis is the result of a different mechanism of their origin. In external endometriosis, developing from the functional layer of the endometrium, reactions to estrogen and the hormone of the corpus luteum are well expressed. Internal endometriosis comes from the cells of the basal layer of the mucous membrane of the uterus, which do not respond to the hormone of the yellow body. Around E. foci, especially external, as a rule, there are signs of inflammation.

According to domestic and foreign authors, among patients with endometriosis, infertility is observed in 40-80% of cases (V. P. Baskakov). The observations of V. P. Baskakov confirm the studies of other authors about the presence of proteolytic enzymes in the foci of endometriosis, regardless of their location.

internal uterine endometriosis
Internal endometriosis of the uterus: 1 - cystic distended gland; 2 - cytogenic stroma.

Pathological anatomy . With diffuse internal endometriosis of the uterus, its wall is thickened (up to 4-5 cm), with focal lesions, large and small nodes that do not have clear boundaries with the surrounding tissue of the uterus wall are found; on a section fabric of a cellular structure. In its thickness there are glandular formations (Fig.), Surrounded by a cytogenic stroma (heterotopic endometrium). Glands of various shapes and sizes, sometimes dramatically expanded. Rarely in the myometrium observed cysts. Glands and cysts are lined with a single row cylindrical epithelium, sometimes flattened. Depending on the depth of penetration of the heterotopic endometrium into the myometrium, endometriosis of the uterus of the I degree is distinguished - penetration of the glands and stroma from the basal layer of the endometrium to no more than one field of view, II degree - up to 1/2 the wall thickness of the uterus and III degree - to the serous cover. In grade II and III endometriosis of the uterus, hyperplasia of the muscle fibers is also noted (hence the name adenomyosis). The histophysiological reaction in the heterotopic endometrium in the luteal phase of the cycle is rarely observed. Most often heterotopic endometrium responds to estrogens. E. cervix is ​​less common.

Sarcomatous transformation of the stroma in the foci of endometriosis of the uterus is rarely observed.

Endometriosis of the uterus serous cover can be observed with endometrioid ovarian cysts with extensive adhesions. The latter is one of the features of endometrioid ovarian cysts. The contents of hemorrhagic cysts, chocolate color. The thick sheath of an endometrial cyst of the ovary is lined with a single row cylindrical epithelium, sometimes flattened; the subepithelial connective tissue of cysts is rich in stromal cells, pseudoxantomy cells, cellular elements of inflammatory infiltrate, blood vessels, old and fresh hemorrhages are found. In case of endometriosis of the ovaries, foci of heterotopic endometrium are found in them, which often has a histophysiological reaction in the luteal phase of the cycle. In rare cases, there is a malignancy of endometriosis of the ovary - adenocarcinoma, adenoacanthoma. In pregnancy, decidual metamorphosis of the stroma can be observed in foci of heterotopic endometria.

E. vagina and peritoneum Douglas pocket manifests itself in the form of small, dense nodules with small cysts filled with hemorrhagic contents.

The clinical course, symptoms and treatment of endometriosis depend on the location (internal or external).

Endometriosis of the uterus is most common. Its cardinal symptom is menstrual dysfunction - cyclical bleeding such as menorrhagia (hyper- and polymenorrhea), metrorrhagia is less common. These bleedings depend on ovarian dysfunction (hyperestrogenism, insufficiency of the corpus luteum, etc.), endometrial hyperplastic processes, insufficient contractility of the uterus, pathological changes in the vascular walls, frequent combination of endometriosis with myoma, inflammatory processes, etc.

The second most common symptom of endometriosis of the uterus is pain, localized in the lower abdomen and in the lower back, which begin on the eve of menstruation, increase with the onset of menstruation, and then gradually decrease. These pains depend on irritation of the nerves and receptors of numerous blood vessels as a result of their compression by periodically swelling tissues of lesions and irritation of the peritoneum (with a third degree of damage).

The diagnosis of endometriosis of the uterus is very difficult, especially if it is combined with myoma. However, in the study of anamnestic data, gynecological examination data and dynamic observations of the patient, this diagnosis can be made.

Bleeding in endometriosis is persistent, not amenable to conservative methods of treatment and even repeated curettage of the uterine mucosa is not effective in contrast to metropathy. The uterus with E. is larger than usual size (as with 5-, 8-week pregnancy), its surface is uneven (with focal lesions) or smooth (with diffuse lesion), the form is often asymmetric, the consistency is uneven: in some places dense, in some places softer (healthy plot). When dynamic observation can be noted an increase in the uterus on the eve and during menstruation, and with the termination of its uterus acquires the original size.

For the diagnosis of E. used metrography after the introduction of a contrast agent.

Diagnostic curettage of the uterus during endometriosis does not provide a basis for establishing the correct diagnosis, since there are no changes specific for E. in the endometrium of the uterus. Scraping is performed only for a differential diagnosis (submucosal myoma node, cancer of the uterus, etc.).

Treatment in the early stages of endometriosis of the uterus is symptomatic (hemostatic means, means that increase the contractility of the uterus, vasoconstrictor, analgesic; hormone therapy: androgens in the first half of the menstrual cycle, preparations of the corpus luteum in the second half, etc.). In the absence of the effect of conservative treatment, surgical intervention is indicated: supravaginal amputation of the uterus or extirpation. To avoid relapse, semi-radical operations (endometrial preservation) are contraindicated. This is especially important to consider when combined with E. uterine myoma. In some cases, older women are prescribed radiotherapy; it has not received wide application as it is ineffective.

Endometriosis of the ovaries takes the second place among all localizations of endometriosis. Unilateral damage is twice as common as bilateral. Etiology: implantation of endometrial particles as a result of retrograde blood injection through the tubes from the uterus, hematogenous and lymphogenous pathways. Endometriosis foci in the ovary are more pronounced than in the uterus, respond to hormonal cyclical changes.

E. The ovaries are of various sizes - from small nodules to cystic cavities filled with dark liquid blood or tar-like liquid, from which the name "chocolate cysts" came.

As a rule, ovarian endometriosis occurs with a large adhesive process.

The diagnosis of E. ovaries presents great difficulties. One of the characteristic symptoms is persistent pain, aggravated during menstruation. Primary infertility is often observed.

Ovarian endometriosis must be differentiated from inflammatory processes, tuberculosis, true tumors (celioepithelial), cancer, etc.

The study of the patient's history (lack of indications of inflammatory diseases, primary infertility, etc.), lack of effect from conservative treatment, data of dynamic observation make it possible to clarify the nature of the disease.

Surgical treatment - removal of appendages. With bilateral lesions in younger women (30-40 years), it is necessary to conduct sparing operations (partial resection of the ovaries). After such operations, with a diffuse lesion of the ovaries, relapses are possible, since it is very difficult to remove the endometrial sites.

Posterior endometriosis is the third largest among all localizations. With this localization, the sacro-uterine ligaments, the rectovaginal cellulose, the vaginal wall and the rectum are affected.

Etiology - the ingestion of the contents of endometrioid ovarian cysts (this is indicated by the frequent combination of posterior endometriosis with endometriosis of the ovaries), atresia of the cervical canal, abrupt retroflection of the uterus, it is also possible to spread through the lymphatic
and blood pathways. V.P. Baskakov observed the direct germination of E. through the neck of the endometrium.

Clinical course: the main complaint of patients is pain, which can be so intense that it makes the patient disabled.

With the spread of endometriosis on the rectum may be bleeding, coinciding with menstruation. The same "menstruating" fistula may be with the defeat of the vaginal vaults.

The diagnosis is not difficult: during a pelvic exam, posterior vaginal vaginal vaginalis behind the cervix palpable nodules from 0.5 to 3-4 cm (or more) in diameter, often merging with each other, of a dense consistency, immobile and sharply painful.

In cases where there is a proliferation of endometrioid tissue on the vaginal wall and rectum, colposcopy, rectoromanoscopy and biopsy are indicated in order to differentiate endometriosis from the inflammatory process and the malignant neoplasm. With this localization, more frequent malignancy of endometriosis is observed.

Treatment is very difficult, since all types of modern therapy are not always effective. Hormone therapy (progesterone 5–10 mg per day in the second half of the menstrual cycle for 4–6 months, androgens in the first half of the menstrual cycle), potassium iodide electrophoresis, microclysters with 1% potassium iodide solution, belladonna extract candles are recommended. papaverine and ichthyol (V.P. Baskakov).

Radiotherapy is indicated only in old age. Surgical treatment (extirpation of the uterus with tubes and rectovaginal fiber), recommended by many authors, often gives only a short-term effect. Despite the extensiveness of the intervention, relapses are observed.