Adenomyosis scientific articles. Modern problems of science and education

Uterine adenomyosis has become one of the commercial diagnoses. Almost every second woman is diagnosed with it, especially one ultrasound. The worst thing is that treatment is prescribed “from the end,” that is, either surgery or the use of gonadotropin-releasing hormone agonists, which cause artificial menopause. For young women planning a pregnancy, this approach is simply not acceptable.

Adenomyosis was previously considered a manifestation of endometriosis, which develops inside the walls of the uterus. However, in 1991, after a thorough analysis of numerous data, a new classification of damage to the walls of the uterus by endometrioid tissue was proposed. In most cases, uterine adenomyosis is not diagnosed, so the frequency of uterine lesions is most often judged after examining surgically removed uteruses for various reasons. According to some data, adenomyosis was found in 9-30% of such cases, according to others, up to 70% of women who had their uterus removed had adenomyosis. The average age of women who develop adenomyosis is 30 years or older, and they are usually women who have given birth. Most often, foci of adenomyosis are found along the posterior wall of the uterus (this wall has a rich blood supply).

The main signs of adenomyosis are painful, heavy menstruation, and sometimes chronic pain in the pelvis. Often such heavy periods cannot be treated with hormonal therapy or removal of the endometrium by curettage. Evidence that adenomyosis may be a cause of infertility is very controversial, but endometrial maturation and detachment may be impaired, which in turn may prevent proper implantation of the fertilized egg.

Adenomyosis can be diagnosed using a vaginal ultrasound, or MRI. Hysterosalpingography and transabdominal ultrasound are often not informative in making this diagnosis. The uterus may be slightly enlarged, but its contours will not change. However, it is practically impossible to differentiate foci of adenomyosis from small fibromatous foci using ultrasound. Enlarged endometrial glands, especially before menstruation, are also mistakenly mistaken for foci of adenomyosis by many doctors.

Until recently, the only treatment for adenomyosis was removal of the uterus, which was associated with increased mortality in such patients.
Modern medicine makes it possible to treat adenomyosis with synthetic estrogens, gonadotropin-releasing hormone agonists and a number of other drugs. Uterine artery embolization is a new type of surgical treatment that allows you to preserve the uterus and reduce the amount of blood lost during menstruation.

The topic of endometriosis-adenomyosis will be discussed in more detail in the book “Encyclopedia of Women's Health.”

Taking into account the increasing incidence of the disease, genital endometriosis is becoming one of the leading causes of infertility M.M. Damirov, 2004. Adenomyosis is detected in 40-45% of women with unexplained primary and in 50-58% with secondary infertility. V.P. Baskakov et al., 2002.

The purpose of our work was the use of Roncoleukin (BIOTECH LLC, St. Petersburg) in the complex therapy of patients with adenomyosis suffering from infertility.

88 patients with adenomyosis of reproductive age were examined and treated. The diagnosis was established through a comprehensive clinical and laboratory examination, using additional methods (hysteroscopy, separate uterine curettage, ultrasound examination using the transvaginal technique in the dynamics of the menstrual cycle).

All patients were divided into two groups: group I (44 patients) – patients with adenomyosis who received traditional complex hormonal therapy,

II (main) group (44 patients) – patients with adenomyosis who received Roncoleukin in addition to traditional treatment.

All patients received hormonal therapy with nemestran (5 mg weekly, twice a week) continuously for 6 months. Additionally, patients of group II after hysteroscopy with separate curettage of the uterus on days 2, 3, 6, 9 and 11 were prescribed Roncoleukin according to the following method: 0.25 mg of Roncoleukin was diluted in 2 ml of 0.9% NaCL solution, the volume was adjusted to 50 ml with the addition of 0. .5 ml of a 10% solution of human albumin and, through a polypropylene catheter inserted into the uterine cavity to the level of the fundus, irrigated it for 6 hours with free flow of fluid through the cervical canal. At the same time, 0.5 mg of Roncoleukin, dissolved in 2 ml of water for injection, was injected subcutaneously, 0.5 ml at four points. Dynamic monitoring of patients with ultrasound guidance was carried out during the course of therapy and 12 months after its completion.

A month after the end of the course of hormonal therapy - after the restoration of menstrual function, 16 patients of group I and 18 patients of group II who suffered from infertility planned pregnancy; the remaining women used a barrier method of contraception throughout the entire observation period.

In the first 3 months after the end of the main course of treatment, pregnancy occurred in 10 women in group II and only in 2 in group I; over the next three months, pregnancy occurred in 7 patients in group II and 4 in group I. Over the next 6 months of observation, pregnancy never occurred in the one remaining patient in group II, while in group I pregnancy occurred in 2 women. As a result, by the end of the year of observation after the end of treatment, 8 patients of the first group and 1 patient of the second had complaints of infertility. As a result, 17 patients from 18 (94.4%) of the main (second) group realized their desire to become pregnant, and only 8 patients from 16 (50%) (p0.01) who received traditional therapy.

Thus, combined systemic and local (intrauterine) administration of the highly active immunotropic drug recombinant IL-2 - Roncoleukin - opens up new prospects in the complex therapy of adenomyosis and makes it possible to improve treatment results, one of the indicators of which is restoration of reproductive function.

Adamyan L.V.

Endometriosis remains an unresolved scientific and clinical problem, the main controversial issues of which include the following: is endometriosis always a disease; development mechanisms and classification; genetic and immunological aspects of endometriosis; external, internal endometriosis and adenomyosis; retrocervical endometriosis; endometriosis and pelvic pain; endometriosis and adhesions; endometriosis and infertility; diagnostic criteria; traditional and non-traditional approaches to diagnosis and treatment. Examination, treatment and monitoring of more than 1,300 patients with endometriosis made it possible to determine the authors’ own positions regarding the morphofunctional, endocrinological, immunological, biochemical, and genetic aspects of endometriosis and to develop alternative treatment programs.

Concepts of etiopathogenesis

The definition of endometriosis as a process in which benign growth of tissue occurs outside the uterine cavity, similar in morphological and functional properties to the endometrium, has remained unchanged over the last century. The following basic theories of the occurrence of endometriosis remain priority:

implantation theory, based on the possibility of transfer of the endometrium from the uterine cavity through the fallopian tubes into the abdominal cavity, described in 1921 by J.A. Sampson. There is also a possibility of endometrial translocation during surgical interventions on the uterus and dissemination of endometrial cells by hematogenous or lymphogenous routes. It is the hematogenous path of “metastasis” that leads to the development of rare forms of endometriosis with damage to the lungs, skin, and muscles;

metaplastic theory, which explains the appearance of endometrium-like tissue by metaplasia of the mesothelium of the peritoneum and pleura, endothelium of lymphatic vessels, epithelium of renal tubules and a number of other tissues;

dysontogenetic theory, based on the possibility of disruption of embryogenesis and the development of endometrioid tissue from abnormally located rudiments of the Müllerian canal. According to the observations of the authors of the article, endometriotic lesions are often combined with congenital anomalies of the genital organs (bicornuate uterus, accessory uterine horn, which impede the normal outflow of menstrual blood).

The key point in the development of endometriosis - the occurrence of endometrioid heterotopia - has not yet been explained by any of the theories. There is no doubt that this requires that endometrial cells have an increased ability to implant, and the body's defenses are insufficient to ensure clearance of ectopic endometrial cells. The implementation of these conditions is possible under the influence of one or several factors: hormonal imbalance; unfavorable ecology; genetic predisposition; immunity disorders; inflammation; mechanical injury; disturbances in the systems of proteolysis, angiogenesis and iron metabolism.

Endometriosis as a genetically determined pathology is one of the newest concepts, which is based on the presence of familial forms of the disease, the frequent combination of endometriosis with malformations of the urogenital tract and other organs, as well as the characteristics of the course of endometriosis (early onset, severe course, relapses, resistance to treatment) in hereditary forms of the disease. The authors of the article describe cases of endometriosis in a mother and eight daughters (endometriosis of various localizations), in a mother and two daughters (endometrioid ovarian cysts), and endometriosis in twin sisters. Based on cytogenetic studies, the relationship of the HLA antigen (Human leucocyte antigen) with endometriosis, quantitative and structural changes in chromosomes in endometrial cells (increased heterozygosity of chromosome 17, aneuploidy) have been established; it has been suggested that bilateral endometrioid cysts can arise and develop independently from different clones. The discovery of specific genetic markers in the future will make it possible to identify genetic predisposition, carry out prevention and diagnose preclinical stages of the disease.

The immunological aspects of endometriosis have been intensively studied since 1978. Of interest are data on the presence of changes in general and local immunity in patients with endometriosis, which play a certain role in the development and progression of the disease. Some researchers believe that endometrioid cells have such a powerful aggressive potential that they cause damage to the immune system.

The intravital phase interference images of cells in the peritoneal fluid and peripheral blood of patients with deep infiltrative endometriosis obtained by the authors of the article convincingly indicate the active participation of the immune system in the pathogenesis of this disease. Most modern studies are devoted to the role of peritoneal macrophages, cytokines, integrins, growth factors, angiogenesis and proteolysis, which favor the implantation of endometrial cells and cause pro-inflammatory changes in the peritoneal environment. Recently, assumptions have been made about the influence of an unfavorable environmental situation, including environmental pollution with harmful industrial products production (in particular, dioxins), on the occurrence of endometriosis.

Thus, the main etiopathogenetic factors of endometriosis should be considered retrograde menstruation, coelomic metaplasia, activation of embryonic remains, hematogenous and lymphogenous metastasis, genetic predisposition, iatrogenic dissemination, and disorders of the proteolysis system. Risk factors for the development of endometriosis include hyperestrogenism, early menarche, heavy and prolonged menstruation, disturbances in the outflow of menstrual blood, unfavorable environment, obesity, smoking, and stress.

Terminology and classifications

Endometriosis is traditionally divided into genital and extragenital, and genital, in turn, into internal (endometriosis of the uterine body) and external (endometriosis of the cervix, vagina, perineum, retrocervical region, ovaries, fallopian tubes, peritoneum, rectouterine cavity). “Internal endometriosis” in recent years has increasingly been considered as a completely special disease and is designated by the term “adenomyosis.” A comparative analysis of the morphofunctional features of internal and external endometriosis has allowed a number of researchers to suggest that retrocervical endometriosis is an “external” variant of adenomyosis (adenomyosis externa). There are more than 20 histological variants of external endometriosis, including: intraperitoneal or subperitoneal (vesicular - cystic or polypoid), as well as muscular fibrous, proliferative, cystic (endometrioid cysts).

Over the past 50 years, more than 10 classifications of endometriosis have been developed, none of which are recognized as universal. One of the most widely used in world practice was the classification proposed in 1979 by the American Fertility Society (since 1995 - American Society for Reproductive Medicine) and revised in 1996, based on calculating the total area and depth of endometrioid heterotopias, expressed in points : Stage I - minimal endometriosis (1–5 points), stage II - mild endometriosis (6–15 points), stage III - moderate endometriosis (16–40 points), stage IV - severe endometriosis (more than 40 points). The classification is not without drawbacks, the main of which is the frequent discrepancy between the stage of spread, determined by scoring, and the true severity of the disease. The authors of the article use their own clinical classifications of endometriosis of the uterine body, endometrioid ovarian cysts and retrocervical endometriosis, which provide for the identification of four stages of spread of endometrioid heterotopias. There is no doubt that the true severity of the disease is determined by the clinical picture that characterizes the course of a particular variant of the disease.

Malignancy of endometriosis

Malignant degeneration of endometriosis was first reported by J.A. Sampson in 1925, defining the pathological criteria for a malignant process in an endometrioid lesion: the presence of cancerous and benign endometrioid tissue in the same organ; the occurrence of a tumor in endometrioid tissue; complete surrounding of tumor cells by endometrioid cells.

The clinical course of malignant endometriosis is characterized by rapid growth of the tumor, its large size, and a sharp increase in the levels of tumor markers. The prognosis is unfavorable; survival rate for non-disseminated forms is 65%, for disseminated forms - 10%. The most common type of malignant tumors in endometrioid heterotopias is endometrioid carcinoma (about 70%). With widespread endometriosis, even after removal of the uterus and appendages, the risk of hyperplasia of endometrioid tissue and malignancy of extraovarian endometriosis remains, which can be facilitated by the administration of estrogen replacement therapy.

Extragenital endometriosis

Rare forms of endometriosis that require a special approach are extragenital lesions, which can exist as an independent disease or be components of a combined lesion. In 1989, Markham and Rock proposed a classification of extragenital endometriosis: class I - intestinal; class U - urinary; class L - bronchopulmonary; class O - endometriosis of other organs. Each group includes variants of the disease with or without the presence of a defect (with or without obliteration) of the affected organ, which is fundamentally important when determining treatment tactics.

Diagnostics

F. Koninx in 1994 proposed to designate only the anatomical substrate with the term “endometriosis”; and a disease associated with this substrate and manifested by certain symptoms is called “endometrioid disease.” Adenomyosis is detected in histological specimens in 30% of women who have undergone total hysterectomy. The incidence of external endometriosis is estimated to be 7–10% in the general population, reaching 50% in women with infertility and 80% in women with pelvic pain. Endometriosis most often occurs in women of reproductive age (25–40 years), often combined with uterine fibroids, hyperplastic processes in the endometrium, and obstructive malformations of the genital organs.

The final diagnosis of external endometriosis is possible only with direct visualization of the lesions, confirmed by histological examination, which reveals at least two of the following features: endometrial epithelium; endometrial glands; endometrial stroma; hemosiderin-containing macrophages. It should be remembered that in 25% of cases, endometrial glands and stroma are not found in the lesions, and, on the contrary, in 25% of cases, morphological signs of endometriosis are found in samples of visually unchanged peritoneum. The final diagnosis of adenomyosis is also established by pathomorphological examination of the material when the following signs are detected: the presence endometrial glands and stroma at a distance of more than 2.5 mm from the basal layer of the endometrium; myometrial reaction in the form of hyperplasia and hypertrophy of muscle fibers; enlargement of glands and stroma surrounding hyperplastic smooth muscle fibers of the uterus; the presence of proliferative and absence of secretory changes.

The most important clinical symptoms of endometriosis that determine indications for treatment are pelvic pain, disruption of normal menstrual bleeding, infertility, and dysfunction of the pelvic organs. The severity and set of manifestations of the disease vary individually. A characteristic symptom of adenomyosis is menometrorrhagia and perimenstrual spotting-type bleeding, which is caused by both cyclic transformations of the ectopic endometrium and a violation of the contractile function of the uterus. Pelvic pain, usually intensifying on the eve of and during menstruation, is typical for both external endometriosis and adenomyosis.

Complaints of dyspareunia are made by 26–70% of patients suffering from endometriosis with predominant damage to the retrocervical region and uterosacral ligaments. This symptom is due to both obliteration of the retrouterine space by adhesions, immobilization of the lower intestine, and direct damage to nerve fibers by endometriosis. A fairly common occurrence is the absence of pain with endometrioid cysts of significant size. At the same time, intense pelvic pain often accompanies mild to moderate endometriosis of the pelvic peritoneum and is presumably caused by changes in the secretion of prostaglandins and other proinflammatory changes in the peritoneal environment. When assessing the severity of pain, they rely on the patient’s subjective assessment, which largely depends on her personal characteristics (psycho-emotional, socio-demographic).

Another symptom characteristic of endometriosis (in the absence of other visible causes) is infertility, which accompanies this pathology in 46–50%. The cause-and-effect relationship between these two conditions is not always clear. For certain types of endometriosis, it has been proven that infertility is a direct consequence of such anatomical damage as adhesive deformation of fimbriae, complete isolation of the ovaries by periovarial adhesions, and damage to ovarian tissue by endometrioid cysts. The role of factors supposedly involved in the development of endometriosis or being its consequence is more controversial: disturbances in the ratio of hormone levels leading to defective ovulation and/or functional inferiority of the corpus luteum and endometrium; disorders of local (increased levels of pro-inflammatory cytokines, increased suppressor/cytotoxic population of T-lymphocytes, growth factors, activity of the proteolysis system) and general (decrease in the number of T-helpers/inducers and activated T-lymphocytes, increased activity of natural killer cells, increased content of T-suppressors /cytotoxic cells) immunity.

One of the most important methods for diagnosing endometriosis, despite the widespread introduction of ultrasound and laparoscopy into practice, remains a bimanual gynecological examination, which makes it possible to detect, depending on the form of the disease, tumor formation in the area of ​​the uterine appendages, enlargement of the uterus and limitation of its mobility, compaction in the retrocervical area , pain on palpation of the walls of the pelvis and uterosacral ligaments. With endometriosis of the vaginal part of the cervix and vagina, endometrioid formations are visible upon examination.

Comparative studies of the effectiveness of various methods made it possible to determine a diagnostic complex that establishes the clinical and anatomical variant of endometriosis with the greatest degree of accuracy. Ultrasound is considered the optimal and generally available screening method in the algorithm for examining patients with various forms of endometriosis (endometrioid ovarian cysts, retrocervical endometriosis, adenomyosis), although it does not allow identifying superficial implants. As the quality of diagnosis of adenomyosis using ultrasound, magnetic resonance imaging (MRI) and spiral computed tomography (SCT) improves, the use of hysterosalpingography is becoming less relevant, especially since the diagnostic value of this method is limited. MRI and SCT have the greatest diagnostic significance for endometrioid infiltrates of the retrocervical zone and parametrium, making it possible to determine the nature of the pathological process, its localization, relationship with neighboring organs, and also to clarify the anatomical state of the entire pelvic cavity. Colposcopy and hysterocervicoscopy are valuable methods for diagnosing cervical endometriosis.

The most accurate method for diagnosing external endometriosis is currently laparoscopy. More than 20 types of superficial endometriotic lesions on the pelvic peritoneum are described in the literature: red lesions, fire-like lesions, hemorrhagic vesicles, vascularized polypoid or papillary lesions, classic black lesions, white lesions, scar tissue with or without some pigmentation, atypical lesions, etc. The presence of Allen-Masters syndrome indirectly confirms the diagnosis of endometriosis (histologically - in 60–80% of cases).

Laparoscopic signs of a typical endometrioid cyst are: an ovarian cyst with a diameter of no more than 12 cm; adhesions with the lateral surface of the pelvis and/or with the posterior leaf of the broad ligament; thick chocolate-colored contents. The accuracy of diagnosing endometrioid cysts during laparoscopy reaches 98–100%. Retrocervical endometriosis is characterized by complete or partial obliteration of the retrouterine space with immobilization by adhesions and/or involvement in the infiltrative process of the walls of the rectum or sigmoid colon, infiltration of the rectovaginal septum, distal ureters, isthmus region, uterosacral ligaments, and parametrium.

Adenomyosis, which diffusely affects the entire thickness of the uterine wall with the involvement of the serous membrane, causes a characteristic “marble” pattern and pallor of the serous cover, a uniform increase in the size of the uterus or, in focal and nodular forms, a sharp thickening of the anterior or posterior wall of the uterus, deformation of the wall by an adenomyosis node, hyperplasia myometrium. The effectiveness of diagnosing internal endometriosis using hysteroscopy is controversial, since visual criteria are extremely subjective, and the pathognomonic sign - gaping endometriotic ducts with hemorrhagic discharge coming from them - is extremely rare.

Some authors suggest performing a myometrial biopsy during hysteroscopy followed by histological examination of the biopsy. The detection of various tumor markers in the blood is becoming increasingly important in the diagnosis of endometriosis and the differential diagnosis of it and a malignant tumor. The most accessible methods at present are the detection of oncoantigens CA 19-9, CEA and CA 125. The authors of the article have developed a method for their comprehensive determination in order to monitor the course of endometriosis.

Alternative methods for managing patients with endometriosis

Treatment of endometriosis has become the most widely debated aspect of this problem in recent years. The situation that is indisputable today is the impossibility of eliminating the anatomical substrate of endometriosis by any of the influences other than surgery, while other treatment methods provide, in a limited number of patients, a reduction in the severity of symptoms of the disease and restoration of the functions of various parts of the reproductive system. However, surgical treatment is not always appropriate or acceptable for the patient.

As an alternative, one can consider a trial (without verification of the diagnosis) drug treatment of minimal and moderate endometriosis, or more precisely, the symptoms presumably caused by this disease. Such therapy can only be undertaken by a doctor with extensive experience in treating endometriosis, subject to the exclusion of space-occupying formations in the abdominal cavity, the absence of other (non-gynecological) possible causes of symptoms, and only after a thorough examination of the patient. The authors of the article consider drug treatment of endometrioid ovarian cysts, which although it leads to a reduction in the size of the formation and the thickness of its capsule, it contradicts the principles of oncological vigilance.

Despite data from a number of authors about the fairly high effectiveness of hormonal therapy in relation to pain symptoms, the advantages of its positive effect on fertility over surgical destruction of lesions have not been proven (the reported pregnancy rate is 30–60% and 37–70%, respectively), preventive value in regarding further progression of the disease is doubtful, and the cost of the course of treatment is comparable to that of laparoscopy. On the other hand, in the absence of clear statistical data in favor of surgical or drug treatment of minimal-moderate endometriosis, the right of choice remains with the patient.

The authors of the article prefer surgical removal of lesions, the adequacy of which depends on the experience and erudition of the surgeon. If endometriosis is accidentally detected during laparoscopy, it is necessary to remove the lesions without injuring the reproductive organs. The visually determined boundaries of the endometriotic lesion do not always correspond to the true extent of the spread, which makes it necessary to critically evaluate the usefulness of the intervention performed. Infiltrative retrocervical endometriosis, the authors of the article remove laparoscopic or combined laparoscopic - vaginal access using their own method, according to indications - with simultaneous resection of the affected area of ​​the rectal wall or in in a single block with the uterus.

With endometrioid cysts, it is fundamentally important to completely remove the cyst capsule, both for reasons of oncological vigilance and to prevent relapses, the frequency of which after using alternative methods (puncture, drainage of the cyst, destruction of the capsule through various influences) reaches 20%. In case of nodular or focal cystic form of adenomyosis, it is possible to perform reconstructive plastic surgery on young patients to the extent of resection of the myometrium affected by adenomyosis, with mandatory restoration of the defect, warning the patient about the high risk of recurrence due to the lack of clear boundaries between the adenomyotic node and the myometrium. Only total hysterectomy can be considered a radical treatment for adenomyosis.

Dynamic observation or non-aggressive symptomatic treatment of patients with adenomyosis, as well as deep infiltrative endometriosis, is acceptable after clarification of the diagnosis using biopsy and histological examination. Drug therapy can become a component of treatment, the main burden of which falls on the insufficient effectiveness of surgical treatment or refusal of it. A special role is given to non-steroidal anti-inflammatory drugs (inhibitors of prostaglandin synthetases), as well as hormonal or antihormonal drugs, the therapeutic effect of which is based on the suppression of steroidogenesis in the ovaries, the creation of a hypoestrogenic state or anovulation.

These are hormonal contraceptives, progestogens (medroxyprogesterone), androgen derivatives (gestrinone), antigonadotropins (danazol), gonadotropin-releasing hormone (GnRH) agonists (triptorelin, buserelin); Trials of GnRH antagonists and new generation progestogens are currently underway. The drug must be selected strictly individually, taking into account side effects, if possible, starting with the least aggressive one. In particular, GnRH agonists should be prescribed with caution to patients with disorders of the functional state of the central nervous system and autonomic regulation, which may be aggravated while taking drugs of this group, while danazol, although quite effective, in high daily doses (400–800 mg) it has adverse effects on the gastrointestinal tract, and also has androgenizing and teratogenic potential.

The preoperative prescription of GnRH agonists is debated, the proponents of which justify its feasibility by reducing the size of endometriosis foci, vascularization and the infiltrative component. From the point of view of the authors of the article, this is unjustified, since as a result of such an effect, radical removal of heterotopias due to masking of small foci, identification of the true boundaries of the lesion in infiltrative forms, and enucleation of the sclerotic capsule of the endometrioid cyst are difficult. Therapy with GnRH agonists is indicated as the first step in the treatment of symptoms of endometriosis of non-reproductive organs in the absence of obliteration. If there is obliteration (partial or complete), the method of choice is surgery with the involvement of related specialists, followed by hormonal therapy.

Postoperative treatment with GnRH agonists is advisable for widespread endometriosis in women of childbearing age in whom radical removal of endometriosis foci was not performed in the interests of preserving reproductive potential or due to the risk of injury to vital organs, as well as in patients at high risk of relapse or persistence of the disease. In case of widespread endometriosis, postoperative hormonal therapy should be combined with anti-inflammatory and spa treatment, which helps to prolong the remission of pain and reduce the risk of repeated operations. The principles of add-back therapy to reduce bone density loss and hypoestrogenic effects during GnRH agonist therapy include: progestogens; progestogens + bisphosphonates; progestogens in low doses + estrogens.

A special place among hormonal treatment options is occupied by hormone replacement therapy after radical operations performed for endometriosis (hysterectomy with or without removal of appendages). Persistence of endometriosis foci with recurrence of symptoms after radical surgical treatment has been described. Taking into account the danger of both possible relapse and malignancy of residual lesions, estrogens are recommended to be used in combination with progestogens.

Recurrence or persistence of endometriosis after treatment is one of the most controversial problems in modern gynecology, due to the unpredictability of the course of the disease. Most authors agree that in the absence of a method that provides an accurate assessment of the adequacy of the intervention performed, removal of all endometrioid substrate cannot be guaranteed by any surgical technique, and especially by drug therapy. On the other hand, recognizing the role of systemic disorders in the pathogenesis of endometriosis, the possibility of de novo endometriosis cannot be denied.

The recurrence rate of endometriosis varies, according to different authors, from 2% to 47%. The highest recurrence rate (19–45%) is retrocervical endometriosis, which is associated both with the difficulty of determining the true boundaries of the lesion in infiltrative forms of endometriosis, and with the conscious refusal of an aggressive approach to removing lesions located near vital organs.

Thus, endometriosis is characterized by paradoxical aspects of etiopathogenesis and clinical contrasts in its course, which have not yet been explained. In fact, with the benign nature of the disease, an aggressive course with local invasion, wide spread and dissemination of foci is possible; minimal endometriosis is often accompanied by severe pelvic pain, and large endometrioid cysts are asymptomatic; cyclical exposure to hormones causes the development of endometriosis, while their continuous use suppresses the disease. These mysteries stimulate further deepening and expansion of both fundamental and clinical research in all areas of the problem of endometriosis.

Please help, my husband really needs a boy. I have an eldest daughter from a previous marriage, then we had a daughter together. Now the husband is directly demanding a boy. I’m even ready for IVF with implantation of an embryo of the desired sex. But my gynecologist told me that IVF is definitely not for me, hormonal preparation will have a very bad effect on my blood vessels and blood pressure. Up to a stroke. I also told my husband about this. He is going to take me to the border because in our clinics (we were in two) they said gender transfer can only be done for health reasons, and my health may not be able to tolerate IVF. My sister says that we need to try traditional methods. And I'm scared. If the first ultrasound doesn’t show the gender, then I don’t know what will happen at the second one if it’s a girl again. What if the husband will be so against the girl that... Or will he then send for a fourth? Help! There are some ways to count days, I once read about the desired day of conception! For the desired floor. If anyone has used this method and if it worked for you, please tell me!

Lyubakha

Hello girls.
In general, I began to think about an au pair (I am alone with three children recently). In principle, I manage to do everything, but it costs me nerves and a lot of physical effort... I always look like a cornered horse.... I can’t forget about putting on makeup and styling my hair in the morning.... and so on all day.. .poke point, point point. To make life a little easier, I’m thinking about finding an assistant to do the cleaning at least once a week. My first problem in my head... is that I’m really ashamed to seek help around the house, since I’m physically healthy and, in principle, I can do everything myself (I’m doing it now too). My second problem is in my head....will I be satisfied with the cleaning? After all, a stranger is unlikely to clean as well as at home. I'm not really a neat person, but I never have a mess at home....there are no scattered toys, clothes, or tumbleweeds of dust)). I resisted washing the floor with a mop for a long time, because I thought (and still do) that it was just smearing dirt from corner to corner... but physically I simply won’t be able to wash 100 square meters with my hands... and my children won’t give me that much time. cleaning. On the one hand, I think it would be great to take the kids and go for a walk while the house is getting organized. On the other hand, suddenly you’ll have to rewash everything again... and that’s not a small amount of money.
In general, these are all my cockroaches, I agree. Who has au pairs and similar cockroaches... how did you choose, by what criteria, a cleaning lady? How often did you have to change it, if necessary?

Nata Ser

I just don’t understand how this can be? About a year ago we moved into a new apartment, finally a big one. The renovation was done before us, I can’t say that everything is perfect, but overall it’s fine. And somewhere around August, the neighbors above us began renovations: the buzzing and drilling was terrible, the roaring noise, but everything was strictly during working hours. Now, as I understand it, finishing work is going on there, because although there is noise, it’s different: tapping, etc. But this is not the problem, a month ago, on the same Sunday, a neighbor from below came to us and said that there was a leak from the ceiling in his bathroom. At that time, no one was washing in our bathroom, but they had used it before, maybe half an hour ago... We let him in, he made sure that everything was dry under the bathtub and in the toilet too. But today the doorbell rings again, it’s leaking again. Yes, I was just in the bathroom and today everyone was there alternately. But, I took a bath yesterday and before that on different days, and nothing flowed either. And again everything was dry. She didn’t let her neighbor in because she was in a negligee and was talking to him through the door. He is indignant and demands that we call a plumber. But what do we need it for? Everything is dry here. Could this be due to the renovations being carried out by the neighbors above? And who should call a plumber anyway? It’s not difficult for me, but I don’t understand why?

Sirens

Good Sunday morning!

This Thursday (which was), I was at a consultation with a psychologist in kindergarten. At first I wanted to ask questions, but then I realized that, in principle, I still have a daisy child, with, of course, his quirks, desires and self-indulgence, of course, and hysterics (without this there is nowhere). After this consultation, the mothers who were there approached the teacher and asked how they (the children) behaved in the group. And the teacher said about mine: “Of course she’s a hooligan, what could we do without it. She’s stubborn. But she’s like that girl in the video, if they beat her, she’ll rather lie down and lie down, she likes to feel sorry for children, those who cry.” In principle, I was happy for my daughter. But, there is a small “but”, is this right, they will beat her, but she will lie down. Of course, I wouldn’t want her to hit her and take part in fights, but I also don’t want her to lie down and be beaten. Can this be fixed somehow or is it not worth it, maybe I’m worrying about it in vain? So that she doesn’t give up, but fights back. Now I’m worried, but life is long. Of course, in the future I plan to enroll in some club so that I know the techniques (for every firefighter).

Ultrasound examination and MRI make it possible to diagnose adenomyosis, a disease most typical for women of reproductive age. In most cases, it is not accompanied by specific complaints, complicating the diagnostic process. That is why ultrasound is an effective and affordable method that allows you to quickly and painlessly detect the problem.

A Denomyosis was first described by Carl von Rokitansky in 1860, after the invention of the microscope: he described the presence of endometrial glands in the wall of the uterus. But the terms “endometriosis” and “adenomyosis” themselves were proposed only in 1892 by Blair Bell. Later, in 1896, the Von Recklinghausen classification of endometriosis was proposed.

Adenomyosis is more common in women of reproductive age. It is found in approximately 30% of women from the total female population and in 70% of cases during pathological studies of preparations after hysterectomies. Diagnosis of this disease is possible through ultrasound or magnetic resonance imaging (MRI), in this article we will consider the characteristic ultrasound signs of adenomyosis.

DESIGNATION

Adenomyosis is the presence of ectopic inclusions of endometrial glands in the myometrial stroma. The presence of these inclusions leads to hypertrophy and hyperplasia of the myometrial stroma.

CLINICAL MANIFESTATIONS

Most patients do not express specific complaints. Symptoms associated with adenomyosis include dysmenorrhea, dyspareunia, chronic pelvic pain, and menometrorrhagia. Adenomyosis most often occurs as a diffuse form, spreading throughout the entire thickness of the myometrium (Fig. 1). A focal form known as adenomyoma also occurs (Figure 2).

Rice. 1. Adenomyosis is a diffuse form.

Rice. 2. Adenomyosis is a focal form.

Adenomyosis may be associated with other conditions such as uterine leiomyoma, endometrial polyp and endometriosis. Establishing a clinical diagnosis of endometriosis is difficult, since there are no characteristic symptoms for this disease. However, a diffusely enlarged (rounded) uterus during bimanual examination indicates adenomyosis.

DIAGNOSTICS

Confirmation of the diagnosis of adenomyosis is carried out by pathological examination of specimens after hysterectomy. The presence of endometrial glands in the myometrial stroma more than 2.5 mm from the basal layer of the endometrium confirms the diagnosis. Ultrasound and MRI can make a diagnosis. The latest meta-analysis of the diagnostic reliability of ultrasound examination showed that this method has a sensitivity of 82.5% (95% credible interval, 77.5-87.9) and a specificity of 84.6% (79.8-89.8) from the likelihood ratio to a positive result – 4.7 (3.1-7.0) and the likelihood ratio to a negative result – 0.26 (0.18-0.39). The sensitivity and specificity of MRI in diagnosing adenomyosis are similar to ultrasound data and are 77.5 and 92.5%. When performing transvaginal ultrasonography, the sensor directly touches the body of the uterus, providing clear visualization of the focus of adenomyosis. In the presence of fibroids, the possibility of ultrasound visualization of adenomyosis is reduced, and leiomyoma is generally associated with adenomyosis in 36-50% of cases.

Ultrasound signs

Ultrasound signs of adenomyosis during transvaginal sonography include the following:

1. Increase in the length of the uterine body - the rounded shape of the uterus, the length of which is generally more than 12 cm, not due to fibroids of the uterine body, is a characteristic feature (Fig. 3).

Rice. 3. The uterus is round in shape; an unclear border between the endometrium and the myometrium is also visualized.

2. Cysts with anechoic contents or lacunae in the myometrial stroma. Cysts with anechoic content within the myometrium come in different sizes and can fill the entire thickness of the myometrium (Fig. 4). Cystic changes outside the myometrium may represent small arcuate veins rather than foci of adenomyosis. To carry out differentiation, color Doppler mapping is used; the presence of blood flow in these lacunae excludes adenomyosis.

Rice. 4. Anegochene cystic lacunae behind the uterine wall (arrow) with a heterogeneous echo pattern.

3. Consolidation of the uterine walls may show asymmetry of the anterior and posterior walls, especially in the focal form of adenomyosis (Fig. 5).

Rice. 5. When measuring the thickness of the posterior wall of the uterus, we observe its thickening compared to the anterior wall (calipers), and a heterogeneous echo is visualized - the structure of the myometrium.

4. Subendometrial linear striations. Invasion of the endometrial glands into the subendometrial space results in a hyperplastic reaction, accounting for the linear striations outside the endometrial layer (Fig. 6).

Rice. 6. Linear striations (arrows) are outside the heterogeneous M-echo structure.

5. Heterogeneous structure of the myometrium. This is an insufficiently homogeneous structure of the myometrium with an obvious violation of the architectonics (Fig. 1 and 4). This finding is more typical of adenomyosis.

6. Fuzzy border of the endometrium and myometrium. Invasion of the myometrium by glands also results in an unclear endometrial-myometrial boundary. (Fig. 2 – 6).

7. Compaction of the transition zone. This is a zone of hypoechoic rim around the endometrial layer; its size more than 12 mm indicates the presence of adenomyosis.

The main criteria for diagnosing adenomyosis are: the presence of a rounded uterus, cystic cavities in the myometrial wall, linear striations in the endometrial zone. To carry out differential diagnosis with uterine leiomyoma, color Doppler scanning is used. When assessing the speed of blood flow in the uterine arteries, in 82% of cases of adenomyosis, the arteries inside or around the formation in the myometrium have a pulsation index of more than 1.17, and in 84% of cases with diagnosed uterine fibroids - less than 1.17.

CONCLUSIONS

Adenomyosis occurs predominantly in women of reproductive age. Most women do not have specific complaints. Symptoms characteristic of adenomyosis are: the presence of chronic pelvic pain and pathological uterine bleeding. Diagnosis of adenomyosis using ultrasound can be compared with the diagnostic capabilities of MRI. This is an effective, safe and inexpensive examination method.

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