What is dangerous endometriosis of the abdominal cavity. Treatment of endometriosis of the peritoneum of the small pelvis Endometriosis of the abdominal organs

Endometriosis of the abdominal cavity is a pathological proliferation of endometrial cells outside the uterus, their ingrowth into the soft tissues of neighboring internal organs located in the small pelvis. The process of cell germination in the abdominal cavity is benign, but without timely treatment, in the presence of concomitant diseases, the possibility of degeneration of endometriosis foci into a malignant tumor is not excluded.

Why endometrial cells grow into the abdominal cavity - scientists still have not been able to find out. However, there are a number of factors that can significantly increase the risk of endometriosis in the peritoneum:

• depressed immune system - weak immunity is observed in women who have had severe infectious or viral diseases, which is why the body cannot cope with the growing cells of the endometrium;
• failure of the menstrual cycle, leading to incorrect and untimely maturation and an increase in the thickness of the epithelial uterine layer;
• injuries of the cervix and the organ itself - cases of medical termination of pregnancy, the passage of a curettage procedure for therapeutic or diagnostic purposes, other types of surgical interventions;

• chronic inflammation of the pelvic organs;
• lack of hemoglobin - this pathological condition is observed in diseases of the circulatory system, anemia, malnutrition;
• excess weight, obesity;
• liver disease;
• poor environmental situation in the region of residence;
• hormonal imbalance is a common cause of the development of the disease;
• heredity.

If a woman among blood relatives had cases of peritoneal endometriosis, the risks of the onset of the disease increase significantly, especially in the presence of provoking factors. The probability of pathological proliferation of epithelial cells increases in girls with an early onset of menstruation. This refers to situations when a teenager's period began earlier than 14-15 years.

The etiology of the disease is due to the fact that during menstruation, for unknown reasons, the cells of the uterine layer of the endometrium do not penetrate into the cervical canal, but seep into the peritoneum through the passages of the fallopian tubes. In a normal state of health, the immune system itself copes with pathogenic cells, producing antibodies to them - macrophages. But with weak immunity, this process is too slow, or absent altogether. Then peritoneal endometriosis begins to develop. Endometriosis of the pelvic peritoneum is more often diagnosed in women aged 35 to 40 years.

Symptoms

Endometriosis of the pelvic peritoneum in the early stages of development may not have a pronounced symptomatic picture. The symptoms of the disease appear gradually. Their nature and intensity depend on the tissue of which particular organ the endometrial cells germinate.

Common signs of pathology include:

• severe pain in the lower abdomen;
• increased pain during menstruation, heavy periods;
• constant feeling of discomfort in the abdomen, bloating;
• discomfort in the groin during sexual intercourse;
• bleeding not associated with menstruation.

If the tissues of the bladder, cervical canal, endometriosis of the anterior abdominal wall (see photo) or rectum are damaged, the woman has a violation of the stool, frequent constipation is replaced by prolonged diarrhea, blood clots are present in the feces and urine. Over time, endometrial cells affect more and more tissues, which leads to blockage of the fallopian tubes and the inability to conceive a child.

The disease negatively affects the emotional background. Knowing that every sexual intercourse will cause abdominal pain, a woman deliberately refuses to have sex. Each arrival of menstruation causes a feeling of panic, abundant discharge, which occurs in the middle of the cycle, depresses a woman, and interferes with an active life.

Diagnostics

Soft tissue damage from endometriosis is a serious disease that, if left untreated, can lead to serious consequences. The specificity of endometriosis lies in the fact that it very quickly passes into the chronic stage, and even the surgical treatment performed will not guarantee a complete recovery.

A woman should immediately consult a doctor as soon as she discovered that, in addition to menstruation, she had discharge, and bleeding during menstruation became profuse, her stomach often began to hurt. The diagnosis of abdominal endometriosis is made after the doctor conducts a gynecological examination of a woman on a chair, makes a thorough history, and analyzes complaints.

To clarify the primary diagnosis, determine the degree of development of the disease and the presence of complications, a medical examination is carried out, including the following methods:

1. Ultrasound of the pelvic organs- performed transvaginally. The introduction of a special sensor into the vagina makes it possible to obtain an accurate image of the state of the cervix and uterine cavity.
2. Hysteroscopy- is carried out to analyze the state of the uterine fundus, the degree of patency of the fallopian tubes is analyzed.
3. Laparoscopy Minimally invasive surgery is performed for both therapeutic and diagnostic purposes. This method of examination is used for suspected complications from the pelvic organs.

To assess the general health of a woman, a general and detailed blood test is done. If there are blood clots in the urine or feces, they are tested in the laboratory. Based on the data obtained during the medical examination, the doctor selects a treatment method.

Treatment of abdominal endometriosis

In the early stages of the development of the pathological process, when pathogenic cells have not yet had time to fully grow into the soft tissues of the abdominal organs, conservative treatment is prescribed. It consists in taking medications aimed at normalizing the hormonal background of the reproductive system, stopping the signs of endometriosis and stopping the further spread of the pathological process.

In a severe stage, when the disease has become chronic and provoked a number of complications, there is no point in drug therapy. A positive result can be achieved only through surgical intervention.

Medical treatment

To stop the process of pathological proliferation of endometrial cells, hormonal drugs are prescribed. As a rule, women are prescribed oral contraceptives, the long-term use of which contributes to the normalization of hormonal levels and inhibition of the production of a large amount of the female hormone estrogen.

What does it give? When the concentration of estrogen decreases, there is no ovulation. The organs of the reproductive system stop preparing every month for the possible fertilization of the egg, the endometrium stops growing. Hormone therapy includes the use of certain drug groups to alleviate the general condition of a woman:

1. Antigestagens- drugs quickly reduce the pain symptoms of the disease. The drugs of this group trigger the process of atrophy of the uterine layer of the endometrium, preventing further growth of pathogenic cells. Despite the effectiveness of this therapy, it is resorted to only if the woman has contraindications for surgery, and the disease is developing rapidly. The disadvantage of this treatment is that hormonal agents from the antigestagen group often cause side symptoms - weight gain, hot flashes, acne.
2. Agonists- drugs of this group slow down the process of producing hormones of the female reproductive system. These drugs should be taken in a short course, as long-term use creates an artificial menopause. Not recommended for patients planning pregnancy.
3. Preparations of the estrogen-gestagen group- are prescribed for an intense symptomatic picture, when the endometrial cells have grown deep into the tissues of the pelvic organs, the woman has severe pain in the pelvic region.
4. Progestogens cause atrophy of the endometrium. Effective for symptomatic therapy. Medicines relieve severe pain in a short time. The disadvantage of treatment is the high risk of complications such as rapid weight gain, extensive swelling of soft tissues. Hormonal preparations from the progestogen group are taken for a long course of 6 to 12 months.

In addition to hormonal treatment, symptomatic therapy is carried out. Painkillers and non-steroidal anti-inflammatory drugs are prescribed to relieve attacks of abdominal pain.

To restore the protective functions of the immune system, immunomodulators are prescribed. It is allowed to use traditional medicine methods - taking decoctions from medicinal herbs (chamomile, St. John's wort, celandine). Decoctions are also used for douching. The alternative method of treatment helps to normalize the functioning of the organs of the reproductive system and reduce the intensity of pain.

Doctors take 6 months for conservative treatment, ultrasound is periodically performed to monitor the condition of the endometrium. If after six months there is no positive dynamics, an operation is prescribed.

Surgery

The operation for the treatment of endometriosis is carried out in two ways - laparoscopy and classical surgery. Depending on the severity of the clinical case, during the operation, the uterus and appendages are either partially or completely removed.

Preference is given laparoscopy. This method of operation is characterized by minimal traumatism, the rehabilitation period is short. Complications after laparoscopy are rare. Due to the absence of a cavity incision, a woman does not need to stay in the hospital for a long time. Discharge from the hospital is carried out the next day.

During laparoscopy, the doctor makes several punctures in the abdominal cavity, through which surgical instruments and an endoscope are inserted, through which the doctor receives an image from the peritoneum on the screen.

The foci of endometriosis themselves are removed by cauterization. The following methods are used for this:

• cryodestruction - the destruction of pathogenic cells with liquid nitrogen;
• electrocoagulation - exposure to high-frequency current;
• laser vaporization - a method of evaporating pathogenic tissues with a laser;
• radiocoagulation - exposure to foci with radio waves.

During laparoscopy, the removed tissues of endometriosis foci are sent to the laboratory for histological examination, which determines the nature of the formations. Such an examination is carried out for the reason that there is a risk of degeneration of foci into malignant neoplasms.

After the operation, a woman needs to undergo a course of hormonal therapy in order to restore the functioning of the organs of the reproductive system, normalize the menstrual cycle, and prevent the re-growth of endometrial cells.

Possible Complications

Ascites is dropsy in the abdominal cavity that occurs due to inflammation of tissues damaged by endometriosis cells.

Ascites is manifested by an increase in the volume of the abdomen, severe pain, signs of intoxication of the body. The disease is treated only by surgical intervention. If the operation is not carried out in a timely manner, the dropsy filled with fluid will burst, which will lead to peritonitis.

Despite the fact that during the surgical treatment of abdominal endometriosis, the foci of the disease are removed, there is still a risk of a recurrence of the disease. The recurrence of lesions occurs if the cause of endometriosis has not been cured.

Another complication after surgery is endometriosis of the postoperative scar. The pathology develops gradually, it can manifest itself in a few years. With the development of this disease, endometrial cells begin to grow rapidly outside the uterine cavity and grow into the postoperative scar. Symptoms and treatment are identical to the general clinic of endometriosis.

A woman experiences severe pain in the abdomen, the cycle of menstruation is disturbed. The therapy is conservative, if the disease was diagnosed in the early stages, or an operation is prescribed when medications do not help, the pathology is running and there are complications.

Pregnancy and pathology

It is possible to become pregnant with abdominal endometriosis in the early stages of the development of the pathological process, when there are still no extensive adhesions that block the passages of the fallopian tubes. If a laparoscopy was performed, it is recommended to become pregnant immediately after the completion of restorative hormonal therapy. Under the influence of a natural change in the hormonal background, there is a possibility that the pathological process will stop.

The development of endometriosis of the abdominal cavity in a person is said if the endometrium of the uterus begins to spread into the peritoneum of the small pelvis. Endometriosis cells are constantly exposed to female hormones, causing them to bleed. And if there is no outflow of blood, then it forms numerous cysts, pathological plaques, nodes, and so on.

• The disease develops as a result of some medical manipulations, injuries.
• Endometriosis is characterized by damage to the abdominal cavity.
• Perhaps a latent course of the lesion of the abdominal disease.
• It is detected during laparoscopic diagnostics.
• The best treatment for abdominal endometriosis is surgery.
• Conservative treatment lasts more than six months.
• Some women may develop relapses of the pathology.

What is peritoneal endometriosis

Endometriosis is a disease characterized by the appearance of endometrial tissue outside the uterine mucosa. The endometrium is the inner lining of the uterus. Consists of functional and basal layer. The functional layer is shed monthly during menstruation, and then it is restored from the basal layer. Discharge during menstruation contains blood and remnants of the endometrium. These secretions are mainly excreted externally, and only a small part of them spreads through the fallopian tubes into the abdominal cavity. If a woman is healthy, all cells are destroyed by leukocytes.

Sometimes some fragments of the endometrium are able to implant into tissues and organs. Here they grow, after which foci of endometriosis appear. Most often this process is observed in the peritoneum. Due to the activity of female hormones, pathological foci gradually increase.

Distinguish:

• endometriosis of the abdominal pelvic organs;
• damage to the ligaments of the uterus, ovarian tubes, extrauterine space;
• internal endometrial lesion of the body of the uterus;
• endometriosis lesions of the bladder, lungs and other organs.

All foci of the disease are small seals of different colors, dispersed throughout the abdominal cavity. With the confluence of pathological foci, tissue infiltration develops.

Causes of the growth of the uterine epithelium

The causes of pathological growth of the endometrium include:

• reflux of menstrual blood along with endometriosis cells into the abdominal cavity;
• degeneration of peritoneal cells;
• adverse effects of female sex hormones on embryocytes;
• surgical interventions;
• transition of endometrial cells with blood and lymph flow;
• disorders of the immune system.

Symptoms of endometriosis of the pelvic peritoneum

Peritoneal endometriosis can occur in the following forms:

• damage exclusively to the peritoneum in the pelvic area;
• disease of the uterus, ovaries, intestines and other organs.

The small form of the disease does not manifest itself clinically and is detected during clinical diagnosis. If the focus affects the deep layers of the abdominal cavity, then before and after menstruation, the following signs are found:

• severe pulling pain in the lower abdomen;
• discomfort in the abdomen after intimate contact and during physical exertion;
• urination disorders;
• adhesive process in the peritoneum and, as a result, damage to the uterus;
• ovulation disorders;
• infertility.

Diagnostics

Endometriosis is detected during laparoscopy. The doctor observes:

• whitish vesicles;
• cysts with black content;
• endometriosis foci of different colors;
• spots and tubercles, painted in brown.

Treatment of abdominal endometriosis

For the treatment of abdominal endometriosis, surgical therapy, drug treatment and the experience of traditional medicine are used.

Medical treatment

It is assigned for the purpose of:

• relapse prevention;
• prevention of the formation of adhesions;
• elimination of pain;
• anemia treatment;
• relief of mental disorders.

Duration of drug therapy - from 2 months. up to six months or more. Patients are prescribed such drugs.

1. Estrogen-gestagenic - Microgynon, Ovidon, Diana, Rigevidon. The main side effect of this treatment is a high risk of blood clots.
2. Pain-relieving progestins. The most common drug is Duphaston. May increase weight and cause edema.
3. Gonadotropin-releasing hormone agonists. Cause the cessation of menstruation.
4. Androgens - Testosterone and Sustanon.
5. Anabolics
6. Antiestrogens - Toremifene and Tamoxifen.
7. Immunomodulatory drugs - Thymogen and Cycloferon.
8. Non-steroidal anti-inflammatory drugs.
9. Antispasmodics.
10. Tranquilizers - to eliminate neurological disorders.

With the development of anemia, iron preparations are used - Ferroplex or Fenyuls.

Surgery

It is the most efficient. Advantages of the operation:

• low trauma;
• preservation of reproductive function;
• the doctor can accurately assess the condition of the internal organs;
• the patient can leave the inpatient department the next day;
• scars from surgery heal quickly.

It is possible to carry out coagulation with a laser, removal of the affected areas of the body with the help of an electric knife, ultrasound.

The experience of traditional medicine

Upland uterus is often used to treat endometriosis of the abdominal cavity. The broth is prepared as follows: 1 tbsp. herbs are poured with 2 cups of boiling water, placed in a water bath for 15 minutes. For one day you need to prepare 0.5 liters of infusion. You need to drink in small portions 1 hour before meals.

Together with the upland uterus, you need to use a decoction of the cinquefoil. It should be taken half an hour after a meal.

Possible Complications

The main complication of endometriosis lesions of the abdominal cavity is infertility. Up to half of the patients have some difficulty in conceiving a child.

Patients with this pathology are much more likely to develop ovarian cancer. The incidence of ovarian cancer is insignificant.

Pregnancy and pathology

Abdominal disease can damage the ovary and sperm. But even in these cases, doctors recommend patients not to postpone the birth of a child. The chances of a successful pregnancy with endometriosis decrease every year.

Prevention

To prevent the development of the disease, it is necessary:

• choose the best ways to prevent pregnancy;
• normalize hormonal levels;
• refuse sexual activity during menstruation;
• fight overweight;
• regularly perform diagnostic laparoscopy.

ENDOMETRIOSIS

Endometriosis? dishormonal immune-dependent and genetically determined disease, characterized by the presence of ectopic endometrium with indicators of cellular activity and its growth. Part of endometriosis in gynecological pathology in women of reproductive age is increasing. The high price and insufficient effectiveness of treatment, high morbidity among women of reproductive age, severe physical and psycho-emotional suffering determine the urgency of the trouble. endometriosis .

N80 Endometriosis.
N80.0 Endometriosis of uterus.
N80.1 Endometriosis of ovaries
N80.2 Fallopian tube endometriosis
N80.3 Endometriosis of pelvic peritoneum.
N80.4 Endometriosis of the rectovaginal septum and vagina.
N80.5 Intestinal endometriosis.
N80.6 Endometriosis of skin scar.
N80.8 Other endometriosis
N80.9 Endometriosis, unspecified

EPIDEMIOLOGY OF ENDOMETRIOSIS

Endometriosis is seen at any age. endometriosis up to 10% of women suffer. In the structure of persistent pelvic pain syndrome, endometriosis occupies one of the first places (80% of patients), among patients with infertility endometriosis seen in 30%. Genital endometriosis is noticed much more often, in 6–8% of patients extragenital forms of endometriosis. Laparoscopic data in multiparous patients undergoing DHS at will suggest no or at least very low incidence of external endometriosis in this group of women.

PREVENTION OF ENDOMETRIOSIS

Prevention measures for endometriosis have not been established at all. The role of realized reproductive function, prevention and timely treatment of menstrual disorders in adolescents are discussed, but there are few data taken by evidence-based medicine. The risk of endometriosis decreases after the completion of tubal transection for the purpose of DHS, probably due to the absence of menstrual blood reflux. Lowering the frequency of uterine endometriosis can be achieved by preventing instrumental abortions, reducing the frequency of diagnostic curettage, HSG and other invasive intrauterine manipulations.

SCREENING

Screening not created. Some authors believe that all women who have been treated for a long time and in vain for OVZPM, suffering from persistent pelvic pain syndrome, infertility, recurrent ovarian cysts, and dysmenorrhea should be subjected to an in-depth examination. It is possible to study the level of tumor markers, especially CA125, but its increase is nonspecific.

CLASSIFICATION OF ENDOMETRIOSIS

Traditionally, genital endometriosis is divided into external, located outside the uterus, and in the uterus - internal.

Endometriosis of the ovaries, fallopian tube, pelvic peritoneum, rectovaginal septum and vagina is classified as external, and endometriosis of the uterus (adenomyosis)? to the inner. Extragenital endometriosis is topographically not associated with the genitals and can affect every organ and tissue, but the validity of some descriptions of extragenital endometriosis is currently disputed. The introduction of endosurgical methods of diagnosis and treatment made it possible to recognize the so-called small forms of external genital endometriosis, at a time when the diameter of the focus does not exceed 5 mm, but cicatricial transformations of the peritoneum can take place. Correlations of the severity of the process with the clinical picture are not noted.

Depending on the localization of endometrioid heterotopias, there are:

• genital endometriosis;
• extragenital endometriosis.

Currently, the following classification of adenomyosis (internal endometriosis) of the diffuse form is used (V.I. Kulakov, L.V. Adamyan, 1998):

• stage I? the pathological process is limited to the mucous membrane of the body of the uterus;
• stage II? the transition of the pathological process to the muscle layers;
• stage III? the spread of the pathological process throughout the entire thickness of the muscular wall of the uterus to its serous cover;
• stage IV? involvement in the pathological process, except for the uterus, the parietal peritoneum of the small pelvis and neighboring organs.

It is fundamentally important to isolate the nodular form of adenomyosis, at a time when endometrioid tissue grows in the uterus in the form of a node resembling MM.

Classification of endometrioid ovarian cysts:

• stage I? small point endometrioid formations on the surface of the ovaries, the peritoneum of the rectal space without the formation of cystic cavities;
• stage II? endometrioid cyst of one of the ovaries no larger than 5–6 cm in size with small endometrioid inclusions on the pelvic peritoneum. Insignificant adhesive process in the area of ​​the uterine appendages without the involvement of the intestine;
• stage III? endometrioid cysts of both ovaries. Endometrioid heterotopias of small sizes on the serous cover of the uterus, fallopian tubes and on the parietal peritoneum of the small pelvis. Pronounced adhesive process in the area of ​​the uterine appendages with partial involvement of the intestine;
• stage IV? bilateral endometrioid ovarian cysts of enormous size (more than 6 cm) with the transition of the pathological process to neighboring organs: the bladder, rectum and sigmoid colon. Widespread adhesive process.

In most cases, endometrioid cysts of enormous size are not accompanied by adhesions.

Classification of endometriosis of retrocervical localization:

• stage I? placement of endometrioid lesions within the rectovaginal tissue;
• stage II? germination of endometrioid tissue in the cervix and vaginal wall with the formation of small cysts;
• stage III? the spread of the pathological process to the sacro-uterine ligaments and the serous cover of the rectum;
• stage IV? involvement in the pathological process of the mucous membrane of the rectum, the spread of the process to the peritoneum of the rectal space with the formation of an adhesive process in the area of ​​the uterine appendages.

American Fertility Society Classification

The assessment of damage to the peritoneum, ovaries, obliteration of the retrouterine space, adhesions in the ovarian region is performed in points, which are then summarized (Table 24-5).

Table 24-5. Assessment of endometriosis lesions of the pelvic organs

• I stage? 1–5 points;
• II stage? 6–15 points;
• III stage? 16–40 points;
• IV stage? over 40 points.

ETIOLOGY (CIRCUMSTANCES) OF ENDOMETRIOSIS

The etiology has not been established at all and remains a matter of debate.

• unrealized reproductive function, delayed first pregnancy;
• menstrual dysfunction in adolescents;
• genetic and domestic factors.

PATHOGENESIS OF ENDOMETRIOSIS

In the classical medical literature, the following theories of the origin of endometriosis are discussed:

• embryonic, interpreting the development of endometriosis from heterotopias of the paramesonephric ducts that appeared embryonic;
• implantation, involving reflux of menstrual blood and endometrial particles in the trunk;
• metaplastic, allowing metaplasia of the peritoneal mesothelium;
• dishormonal;
• immune imbalance.

It is believed that the mechanisms of entry of the endometrium into the body are not important, because the reflux of menstrual blood appears, according to various sources, in 15–20% of healthy women. The presence of immunosuppression due to the inhibition of the activity of natural killer cells and a sharp increase in the concentration of vascular endothelial growth factor and metalloproteinases that destroy the extracellular matrix in endometrioid heterotopias have been proven. In the foci of endometriosis, apoptosis is inhibited, and an increased concentration of aromatase is noted, which increases the conversion of precursors to estradiol. Perhaps all these mechanisms are realized against the background of a genetic predisposition.

The circumstance of infertility in endometriosis may be the syndrome of luteinization of the unovulated follicle, phagocytosis of sperm by peritoneal macrophages, luteolysis. Absolutely the circumstance of infertility in endometriosis has not been established.

CLINICAL PICTURE (SYMPTOMS) OF ENDOMETRIOSIS

The clinical picture has fundamental differences in various forms of endometriosis. In patients with endometriosis of the pelvic peritoneum, ovaries, fallopian tubes, rectovaginal septum, the leading symptom is constant pelvic pain, while they do not change under the influence of quite often unreasonably carried out anti-inflammatory and bactericidal therapy, they increase during intercourse and during menstruation, quite often making the lady incapacitated. Pain during sexual intercourse usually causes the patient to avoid sexual activity. Some patients may develop dysuric phenomena, but during laparoscopy, endometriosis of the peritoneum of the pelvis, but not the bladder, is detected.

Radical excision of endometriosis foci leads to healing. Endometriosis of the rectovaginal septum may invade the posterior vaginal wall and is visualized on speculum examination as cyanotic lesions requiring a differential diagnosis from choriocarcinoma.

Infertility is considered a typical symptom of endometriosis. It is fundamentally important that in small forms there may not be any other indicators or clinical signs. Endometriosis of the uterus for the most part manifests itself as a violation of the menstrual cycle, usually leading, due to hyperpolymenorrhea, to severe anemia of the patient. In 40%, hyperplastic processes of the endometrium are detected. Possible intermenstrual bleeding. Contact bleeding is characteristic of endometriosis of the cervix.

Extragenital forms can be manifested by hemoptysis, adhesive disease of the abdominal cavity, blood discharge from the navel, bladder and rectum, especially during the perimenstrual period.

DIAGNOSIS OF ENDOMETRIOSIS

ANAMNESIS

When studying a home history in patients with ovarian tumors, special attention should be paid to the presence of endometriosis in relatives. In the patient herself, it is especially scrupulous to go to collect a sexual history. Particular attention is paid to the long fruitless treatment of inflammation.

LABORATORY Studies

Specific laboratory diagnostics has not been established.

INSTRUMENTAL Studies

RADIOLOGICAL METHODS

The method of hysterography has not lost its significance in the diagnosis of adenomyosis. The study is performed on the 5-7th day of the menstrual cycle with a water-soluble contrast. The X-ray picture is characterized by the presence of contour shadows.

CT provides certain data in determining the boundaries of the lesion. According to modern concepts, MRI in endometriosis can be of great help in the diagnosis.

Ultrasound is widely used for diagnosis. Established clear criteria for endometrioid ovarian cysts. They are characterized by a dense capsule, up to 10-12 cm in size, hyperechoic contents in the form of a fine suspension. With uterine endometriosis, areas of increased echogenicity in the myometrium, irregularity and serration of the boundaries of the myo and endometrium, rounded anechoic inclusions up to 5 mm in diameter are detected, with nodular forms? liquid cavities up to 30 mm in diameter.

ENDOSCOPIC METHODS

Colposcopy allows you to accurately diagnose endometriosis of the cervix.

Through hysteroscopy, endometrioid passages, the unhewn relief of the walls in the form of ridges and crypts are accurately identified.

Along with this, it is advisable to apply the hysteroscopic classification of the prevalence of endometriosis, proposed by V.G. Breusenko et al. (1997):

• Stage I: the relief of the walls is not changed, endometrioid passages are determined in the form of dark blue eyes or open bleeding. The wall of the uterus when scraping a simple density.
• Stage II: the relief of the walls of the uterus is uneven, has the form of longitudinal or transverse ridges or flaky muscle tissue, endometrioid passages are visible. The walls of the uterus are rigid, the uterine cavity is not well extensible. When scraping, the walls of the uterus are denser than in most cases.
• Stage III: on the inner surface of the uterus, bulges of various sizes are determined without clear contours. On the surface of these bulges, open or closed endometriotic passages are sometimes visible. When scraping, the uneven surface of the wall, ribbing are felt. The walls of the uterus are dense, a characteristic creak is heard.

Laparoscopy in many ways from a diagnostic method in the distant past has turned into a surgical approach, but usually the final diagnosis of peritoneal endometriosis can only be established during the operation, determining tactics.

The final diagnosis of external endometriosis is established during laparoscopy, which, in most cases, is both diagnostic and therapeutic, i.e. gets the temperament of timely access.

With endometriosis of the gastrointestinal tract, it is difficult to overestimate the importance of gastro and colonoscopy.

DIFFERENTIAL DIAGNOSIS OF ENDOMETRIOSIS

The differential diagnosis is performed in patients with endometrioid cysts with ovarian tumors. The basis for establishing the diagnosis is the anamnesis, ultrasound data. But in patients with ovarian endometriosis, a persistent pain syndrome may be absent, and with ovarian tumors, abdominal pain without a clear localization is likely.

The CA125 level may be elevated not only in ovarian tumors, but also in endometriosis. As a result, elevated, especially borderline (35–100 U/ml) levels of this marker cannot testify in favor of one or another diagnosis. The rest of the markers are also non-specific. The diagnosis is made during the operation. Rectovaginal endometriosis may require a differential diagnosis of choriocarcinoma metastases in the posterior vaginal fornix, which will also have a bluish color. The diagnosis is assisted by the history data, the determination of the level of hCG, causing great doubt and possible indicators of pregnancy.

Tuboovarian inflammatory formation (abscess) is usually difficult to differentiate, because the characteristic clinical picture of inflammation may be erased, for example, with chlamydial etiology of inflammation, and the size and consistency of the formation can resemble that of benign tumors and endometrioid cysts.

We must not forget that ovarian formations that do not regress within 6–8 weeks are considered an irrelevant indication for timely treatment, and morphologists usually make the final diagnosis.

With endometriosis of the uterus, a differential diagnosis with MM and hyperplastic processes of the endometrium is needed.

The presence of bleeding is considered an indication for hysteroscopy, allowing the diagnosis to be established. Rectovaginal lesions and endometriosis of the sacro-uterine ligaments in the form of spikes require the obligatory exclusion of malignant tumors of the gastrointestinal tract, therefore, the rule about its mandatory examination before surgery is correct both for these forms of endometriosis and for ovarian tumors.

INDICATIONS FOR CONSULTATIONS WITH OTHER EXPERTS IN ENDOMETRIOSIS

Consultation of other experts is needed for the germination of adjacent organs.

EXAMPLE FORMULATION OF THE DIAGNOSIS FOR ENDOMETRIOSIS

Endometriosis of the uterus. Menometrorrhagia.

TREATMENT OF ENDOMETRIOSIS

GOALS OF TREATMENT

In the reproductive period, the goal of treatment is the restoration of reproductive function, in pre- and postmenopause, the radical removal of pathological tissue, increasing the quality of life.

INDICATIONS FOR HOSPITALIZATION

Endometriosis of the pelvic peritoneum, ovaries, tubes, rectovaginal. Infertility. Adenomyosis in the presence of menometrorrhagia for hysteroscopy or surgical treatment.

NON-DRUG TREATMENT OF ENDOMETRIOSIS

From the standpoint of evidence-based medicine, non-drug treatment of endometriosis before surgery is not recommended.

MEDICAL TREATMENT OF ENDOMETRIOSIS

From the standpoint of evidence-based medicine, anti-inflammatory, hormonal, enzyme therapy for endometriosis does not exactly affect the results of treatment. Treatment of external endometriosis at the initial stage is only timely with the use of laparoscopic access.

Endometriosis of the uterus 1-2 stages of treatment, in most cases, does not require. Perhaps the appointment of monophasic COCs. It is also possible to use hormone-containing IUDs. With heavy anemic bleeding in stages 3–4, timely treatment has been demonstrated.

Antigonadotropins: danazol and gestrinone are used in the postoperative period in patients with external endometriosis to prevent recurrence for at least 6 months. For the same purpose, GnRH agonists are prescribed. But the absence of postoperative treatment does not worsen reproductive results, therefore, from the standpoint of evidence-based medicine for infertility, such treatment may not be carried out.

All these drugs can also be used as a temporary measure for adenomyosis for the treatment of anemic bleeding. The effect is temporary. At the end of discontinuation of treatment, the symptoms return.

Synthetic progestins and progestogens, according to modern concepts, will be able to stimulate foci of endometriosis, in addition, their promoter effect in terms of the development of breast cancer is being discussed. Their use is futile.

The aromatase inhibitor anastrozole is being studied. When using mifepristone, no convincing results of its effectiveness were obtained. At present, there are few evidence-based studies on the use of GnRH antagonists, and convincing evidence in favor of their use has not yet been obtained.

Drug therapy for endometriosis is presented in Table 24-6.

Table 24-6. Medical therapy for endometriosis

Continuous use for 6–9 months

Hypercoagulation, fluid retention

SURGICAL TREATMENT OF ENDOMETRIOSIS

According to modern concepts, any hormonal, anti-inflammatory, enzymatic treatment of external endometriosis is ineffective. The first stage of treatment should be surgical intervention, allowing to accurately establish the diagnosis, extent of distribution and reproductive possibilities. The purpose of this stage in the reproductive age: a large excision of endometrioid implants and the restoration of reproductive function. In most cases, endometrioid cysts are resected, rectovaginal infiltrate is excised, and the affected peritoneum is excised. to point out that radical excision provides the best long-term results when compared with coagulation, regardless of the type of energy (laser, electric, etc.).

When excising endometrioid cysts in reproductive age, special attention is paid to the very careful handling of the so-called capsule, since in fact it is the cortical layer of the ovary that envelops the endometrioma. The follicular reserve at the end of the operation will also depend on the volume of coagulation of this tissue, therefore it is advised to use the most sparing methods: avoid monopolar coagulation, actively irrigate the tissue with cooled liquid, carry out all excisions only in a sharp way, carefully identifying healthy tissue by increasing when approaching the optics to the area of ​​action. However, IVF experts claim that the functional reserves of the ovary after such operations are reduced. In pre and postmenopause, radical treatment is preferable: panhysterectomy; subtotal hysterectomy for endometriosis of the uterus is not created.

Each intraoperative trouble should be corrected in time with the participation of relevant experts. But the operating gynecologist must have the minimum necessary skills to correct emerging troubles. Rectovaginal endometriosis often requires excision of heterotopies from the anterior wall of the rectum, which in most cases the gynecologist does on his own. If you are unsure of your abilities, you need the help of a surgeon who is well versed in the technique of not only laparoscopy, but also various types of endosutures.

APPROXIMATE TERMS OF DISABILITY FOR ENDOMETRIOSIS

At the end of conservative operations by laparoscopic access, the rehabilitation period does not exceed 2 weeks, at the end of radical? 6–8 weeks Sexual activity is likely after surgery on the uterine appendages from the 7th day of the postoperative period, aerobic exercise? from 5–7 days, after the completion of radical operations, sexual and physical activity is allowed 6–8 weeks after the operation.

INFORMATION FOR THE PATIENT WITH ENDOMETRIOSIS

Every woman who has been receiving treatment for inflammation for a long time and unsuccessfully needs a highly qualified consultation to exclude endometriosis. Any information about ovarian elevation requires an immediate consultation with a gynecologist.

PROGNOSIS FOR ENDOMETRIOSIS

The prognosis is generally favorable, but with advanced forms, restoration of fertility can be a problem. Radical surgical treatment in pre and post menopause provides an acceptable level of quality of life.

Creator: Gynecology - National Administration, ed. IN AND. Kulakova, G.M. Savelieva, I.B. Manukhin 2009

The growth of tissue outside the uterus of a benign nature is called. In this case, the endometrium, that is, the lining of the uterus, is attached to other organs and begins to function actively. This disease is in third place in the list of all diseases of the fair sex and more often affects women in reproductive age.

Causes

To date, the root causes of endometriosis in the female half have not been fully determined, but there are common factors that can provoke this disease.

The main reasons for the development of pathology:

• Hormonal failure in the body of a woman;
• Decrease in the protective function of the body, since with immunity normally the body is able to fight cells growing beyond the uterine cavity;
• “Reverse” menstruation, that is, when a woman’s regular discharge does not come out all, but some enters the abdominal cavity, where the endometrium attaches to other organs and begins to actively function there;
• hereditary factor;
• Surgical intervention in the uterine cavity or inflammatory processes;
• Pathologies associated with abnormal structure of the genital organs;
• Obesity;
• Decrease in the level of hemoglobin in the blood;
• Use of an intrauterine device for a long time.

Most often, endometriosis affects the female half up to 40 years old, as well as girls who have early "critical days" and are accompanied by copious discharge for more than seven days.

Symptoms

Most often, the disease passes without obvious manifestations, that is, a woman, as a rule, does not bother anything. But there are a number of symptoms by which pathology can be recognized.

Symptoms of endometriosis:

• Altered vaginal discharge between "critical days" (they may be accompanied by an unpleasant odor, be in the form of pus during inflammation, and also have a brown or red color).
• Pain in the lower abdomen, regardless of the "menstruation".
• Discomfort and intimacy, as well as during sports.
• that have nothing to do with menstruation.
• The presence of blood in the urine or feces during menstruation (this occurs when the disease and the rectum).

At the same time, the manifestations of the disease directly depend on the degree of growth of the endometrium outside the uterus, the larger the area of ​​​​the lesion, the stronger the woman will have various manifestations. Also, endometriosis and infertility are interrelated concepts. 90% of women with the disease have problems conceiving, even when there are no obvious manifestations of the disease.

Forms of the disease

Endometriosis can come in three different forms:

1. Genital (develops inside the genitals).

This form of the disease occurs most often, but it may not have pronounced symptoms. In this case, the endometrium affects the ovaries, fallopian tubes, cervix and cervical canal.

1. (endometrium grows outside the internal genital organs).

Here, not only the organs of the peritoneum are affected, but also the pulmonary region and the genitourinary system. If there are internal scars on some organ after surgical operations, then the endometrium is actively attached to them. In rare cases, the disease can affect the organs of vision. In this case, blood may come out of the eyes.

1. Mixed (development of the disease both inside and outside the internal genital organs).

Also, endometriosis has several stages. At the 1st and 2nd stages, there may not be manifestations, but if left untreated, then the disease acquires. First, small areas are affected, and then the foci of the disease begin to grow. It is also a seemingly benign and harmless disease, if left untreated, of a malignant nature.

Also, foci of endometriosis in the abdominal cavity lead, first of all, to infertility, constant pain in the pelvic region, and also to the adhesive process, if there are scars after a cesarean section or other surgical intervention in this area.

Complications

If treatment is not carried out or the therapy is incorrect, then this can provoke a number of complications. The initial stage of the disease, when only the mucosa is affected, passes into the second, affecting the layers of the myometrium to the middle. Subsequently, the pathology grows to the peritoneal lining of the uterus (3rd form) and affects the entire abdominal cavity (4th stage).

If treatment is not started in a timely manner, then this leads to various consequences.

Possible complications of endometriosis:

• The patency of the fallopian tubes is disrupted, which significantly reduces the reproductive function of a woman;
• The onset of pregnancy, but ectopic;
• Miscarriage;
• Adhesions in the pelvis and abdominal cavity;
• Anemia due to severe and persistent blood loss;
• Education ;
• Malignant neoplasms.

Also, the growth of endometriosis affects other organs, which can lead to neurological disorders. And in the case of anemia, a woman feels constant weakness, she is tormented by migraine, heart palpitations and shortness of breath.

Is it possible to conceive with endometriosis?

In general, - rarely compatible concepts. Since the disease itself entails that a woman simply cannot conceive a baby. And even if pregnancy occurs, which is extremely rare, it can end in a miscarriage. But it also cannot be definitely said that endometriosis and infertility are completely incompatible concepts. Pregnancy can occur, although in rare cases. Along with this, not only endometriosis leads to the inability of a woman to conceive a baby, this problem has other root causes.

So, endometriosis negatively affects ovulation, can lead to obstruction of the fallopian tubes or adhesions, which in turn makes it difficult for the egg to be released. In addition, a woman with a normal and regular menstrual cycle, but with the presence of a disease, may not ovulate at all. And accordingly, such a woman has no chance of becoming pregnant.

Proper treatment of endometriosis in more than 50% of cases leads to pregnancy within six months or 12 months.

If the therapy was on time and pregnancy came after, then it is this condition that will contribute to the fact that a woman can finally recover from endometriosis. This is because during the period of bearing a baby and feeding him with breast milk, menstruation stops, and the hormonal background changes somewhat. The area affected by endometriosis completely heals during this time and after 10-15 months there are no relapses. At the same time, of course, care must be taken to avoid, if possible, those factors that can provoke the disease.

Diagnostics

This disease is not diagnosed by symptoms, as they are similar to other pathologies in the pelvic region of a woman. To do this, a number of surveys are assigned.

The definition of the disease is carried out by the following methods:

• (the vaginal sensor allows you to determine many changes in this area);
• Hysteroscopy (helps to examine the surface of the uterus and determine the patency of the fallopian tubes);
• Hysterosalpingography (especially relevant for infertility, since it is possible to determine the depth and degree of damage to endometriosis foci);
• Laparoscopy (an excellent method of diagnosis, as well as therapy, because during the procedure it is possible to remove foci of pathology and not affect other organs and systems);
• General blood test (with the help of a marker, an ailment is determined).

These laboratory tests are prescribed by a specialist after a visual examination and determination of the location of the disease.

Treatment

Treatment may be in the form of surgery or drug therapy. Both of these methods are often used in combination. If the therapy is conservative, then it is aimed at blocking the pathological process of cell proliferation.

Thus, endometriosis of the pelvic peritoneum is treated with oral contraceptives, during which the hormonal levels are corrected. Anti-inflammatory and analgesic drugs are also prescribed, as well as vitamins and immunomodulators, which increase the protective functions of the whole organism. It is possible to use local preparations in the form. But it should be understood that such therapy is designed for a long period, up to six months. But some women may have allergic manifestations to both tablet preparations and suppositories, so conservative therapy in this case is not possible.

As a rule, surgical treatment is carried out after conservative therapy has not brought positive results for six months. In most cases, it is carried out. This method allows you to save the internal genital organs of a woman. It is performed under general anesthesia for half an hour. The recovery process is fast. But if the degree of endometriosis is high and severe, then the woman is recommended to remove the uterus. This often occurs in more advanced forms.

Regarding traditional medicine, it has proven itself well, that is, treatment with leeches. This herbal medicine leads to the restoration of hormonal balance, blood thinning and restoration of the circulatory system. But it should be understood that all this will not lead to the destruction and elimination of endometrial foci, since so far no folk remedy has been able to cope with them.

Prevention

Prevention is especially relevant for women who have already had this disease, as well as for those who have only heard about it.

Preventive measures are as follows:

1. Avoid sexual intercourse during menstruation;
2. Engage in timely treatment of any gynecological diseases;
3. Watch your weight and stick to proper nutrition;
4. Avoid depression and stress, which can lead to various pathologies in the body;
5. Avoid interventions in the genital organs, including abortion, which can provoke uterine injuries and the development of various diseases;
6. Contraceptives should be selected only after consultation with a specialist.

It should be understood that nulliparous women after 30 years are at risk. Frequent climate change is also dangerous, which has a negative effect on the woman's body and on the hormonal background. Therefore, according to statistics, it is the representatives of the weaker sex, whose activities are associated with mental stress, that are susceptible to this disease. As a rule, such women put motherhood on the back burner, as they are busy building a career, and this accordingly reduces their chances of getting pregnant and bearing a baby normally.

Also at risk are women who change sexual partners too often and their sex life is “too active”.

And if the therapy of endometriosis did not bring positive results, then the woman is recommended in vitro fertilization. But it does not always give a positive result. Therefore, at the first symptoms or suspicions of a disease, it is important to undergo appropriate treatment.

Endometriosis (endometrioid disease) is a disease characterized by the growth of tissue similar to the endometrium outside the normally located mucous membrane of the uterine body.

Endometriosis is capable of infiltrative growth with penetration into surrounding tissues and their destruction; it can grow into any tissue or organ: the wall of the intestine, bladder, ureter, peritoneum, skin; it can metastasize by lymphogenous or hematogenous routes. Foci of endometriosis are found in the lymph nodes, subcutaneous tissue of the anterior abdominal wall or in the area of ​​the postoperative scar, as well as in distant parts of the body - such as the navel and conjunctiva of the eye. Endometriosis differs from a true tumor in the absence of pronounced cellular atypia and the dependence of clinical manifestations on menstrual function.

Classification of endometriosis. Depending on the localization, genital and extragenital endometriosis are distinguished. Genital endometriosis is divided into internal (uterine body, isthmus, interstitial sections of the fallopian tubes) and external (external genitalia, vagina and vaginal part of the cervix, retrocervical region; ovaries, fallopian tubes, peritoneum lining the pelvic organs). With extragenital endometriosis, endometrioid implants are detected in other organs and tissues of the woman's body (lungs, intestines, navel, postoperative wounds, etc.).

Epidemiology. Endometriosis is one of the most common diseases of the reproductive system in women aged 20-40 years, the frequency of its detection decreases sharply in postmenopausal women. Endometriosis is diagnosed in 6-8% of patients in gynecological clinics, and in patients with infertility, its detection increases to 35-44%. The main part is genital endometriosis (92-94%), extragenital endometriosis is much less common (6-8%).

Causes of endometriosis

The translocation theory (implantation) considers the possibility of developing endometrioid heterotopias from endometrial elements transferred retrograde with menstrual secretions into the abdominal cavity and spread to various organs and tissues. Implantation of endometrial cells and its further development can be carried out only under additional conditions: when endometrial cells have an increased ability to adhere and implant, and when there is a violation of the hormonal and immune systems.

The theory of endometrial origin considers the possibility of developing endometrioid heterotopias from endometrial elements displaced into the thickness of the uterine wall. It has been proven that intrauterine medical manipulations (abortions, diagnostic curettage of the uterine mucosa, manual examination of its cavity after childbirth, caesarean section, enucleation of myomatous nodes, etc.) contribute to the direct germination of the endometrium into the uterine wall, leading to the development of internal endometriosis of the uterine body. During gynecological operations, endometrial elements can also spread to other organs and tissues with the blood and lymph flow. Lymphogenous and hematogenous pathways of spread lead to the development of endometriosis of the lungs, skin, muscles.

Embryonic and dysontogenetic theories consider the development of endometriosis from displaced areas of the germinal material, from which the female genital organs and, in particular, the endometrium, are formed during embryogenesis. The detection of clinically active endometriosis at a young age and its frequent combination with anomalies of the genital organs, organs of the urinary system and the gastrointestinal tract confirm the validity of the embryonic or dysontogenetic concept of the origin of endometriosis.

metaplastic concept. According to this hypothesis, endometriosis develops as a result of metaplasia of the embryonic peritoneum or coelomic epithelium. The possibility of transformation into endometrial-like tissue of the endothelium of the lymphatic vessels, the mesothelium of the peritoneum and pleura, the epithelium of the tubules of the kidneys and other tissues is allowed.

Of the many factors contributing to the development and spread of endometriosis, hormonal disorders and dysfunction of the immune system should be distinguished.

Hormonal disorders are not the direct cause of the formation of endometriotic foci, but are only predisposing conditions for the onset of the pathological process. In patients with endometriosis, the presence of non-systematic peaks of FSH and LH, as well as a decrease in the basal level of progesterone secretion, were noted; development of a syndrome of a luteinization of a follicle is noted. However, 40% of patients with endometriosis maintain a normal biphasic menstrual cycle. In these patients, the mechanism of cytoplasmic binding of progesterone is disrupted, which leads to a perversion of the biological action of hormones.

Estrogens stimulate the growth of the endometrium, their excess leads to the growth of foci of endometriosis.

In patients with endometriosis, hyperprolactinemia and a violation of the androgenic function of the adrenal cortex are often detected.

An important role in the pathogenesis of endometriosis belongs to autoimmune reactions. When hormonal status is disturbed, the dysfunction of the immune system is expressed in the suppression of the activity of natural killer cells, as well as in an increase in the concentration of vascular endothelial growth factor, which causes excessive angiogenesis.

Endometriosis of the cervix

The prevalence of endometriosis of this localization is associated with damage to the cervix during gynecological manipulations, diathermoconization of the cervix. Trauma during childbirth, abortion, and various manipulations can contribute to the implantation of the endometrium in damaged cervical tissues. Perhaps the occurrence of endometriosis of the cervix from the elements of the Mullerian tubercle of the primary vaginal plate. In addition, lymphogenous and hematogenous spread of endometriosis to the cervix from other foci is not excluded.

Depending on the depth of the lesion, ectocervical and endocervical endometriosis of the vaginal part of the cervix is ​​distinguished, less often endometrioid heterotopias affect the cervical canal.

Diagnosis of endometriosis of the cervix

With endometriosis of the cervix, there may be complaints about the appearance of spotting blood discharge on the eve of menstruation or during sexual contact. Pain is observed with atresia of the cervical canal or endometriosis of the isthmus of the uterus. Sometimes endometriosis of the cervix is ​​not clinically manifested in any way and is diagnosed in the form of foci of red or dark purple color only when examining the cervix. Endometrioid heterotopias increase significantly on the eve or during menstruation. During this period, individual foci can be opened and emptied. At the end of menstruation, endometrioid heterotopias decrease in size and turn pale. With colposcopy, a differential diagnosis of cysts of the natal glands, ectopia, erythroplakia, polyps of the mucous membrane of the cervical canal, ectropion and endometriosis of the cervix is ​​​​performed. The data of a cytological study of prints from the mucous membrane of the cervix are not very informative for the diagnosis of endometriosis, but they make it possible to judge the state of the stratified squamous epithelium of the cervix and identify cellular atypia.

Endometriosis of the vagina and perineum

The vagina and perineum are more often affected by endometriosis for the second time during germination from the retrocervical focus, less often as a result of implantation of endometrial particles into the damaged area during childbirth.

Leading in endometriosis of this localization is a complaint of pain in the vagina - from moderate to very strong and painful. Pain appears cyclically, on the eve and during menstruation, aggravated by sexual intercourse. Severe pain is observed when the perineum and external sphincter of the rectum are involved in the process. Defecation during periods of exacerbation is accompanied by severe pain.

Diagnosis is based on complaints related to the menstrual cycle and gynecological examination data, which includes examination of the cervix and vagina with the help of mirrors, two-handed vaginal-abdominal and rectovaginal examination. In the thickness of the vaginal wall or in the rectovaginal cavity, dense painful scars, nodes or thickenings are palpated. On the mucous membrane of the vagina during examination, brown or dark blue foci are determined. On the eve and during menstruation, endometrioid heterotopias increase in size and may bleed.

To determine the prevalence of the process, additional research methods are used: sigmoidoscopy, ultrasound of the pelvic organs, laparoscopy, tissue biopsy and histological examination of the biopsy.

Retrocervical endometriosis

With retrocervical endometriosis, the pathological process is localized in the projection of the posterior surface of the cervix and its isthmus at the level of the sacro-uterine ligaments. The lesions are capable of infiltrative growth, usually in the direction of the rectum, the posterior fornix of the vagina, and the rectovaginal cavity.

Clinical picture of retrocervical endometriosis

Complaints in retrocervical endometriosis are due to the proximity of the rectum and pelvic nerve plexus. Patients complain of aching pain in the depths of the pelvis, lower abdomen and lumbosacral region. On the eve and during menstruation, the pain intensifies, becomes pulsating or twitching, and can radiate to the rectum and vagina. Less commonly, pain radiates to the side wall of the pelvis, to the leg. Patients may complain of constipation, sometimes - the release of mucus and blood from the rectum during menstruation. Severe endometriosis in 83% of cases causes periodic disability and in a significant number of cases mimics diseases of other organs.

Diagnosis of retrocervical endometriosis

Patient complaints and gynecological examination data are taken into account. With retrocervical endometriosis, a dense mass is palpated in the rectovaginal tissue behind the cervix. Sufficiently informative ultrasound data; a heterogeneous echo density formation behind the cervix, smoothness of the isthmus and an indistinct contour of the rectum are determined. To clarify the prevalence of the process, sigmoidoscopy, colonoscopy, excretory urography, cystoscopy, and MRI are necessary.

ovarian endometriosis

Most often, ovarian endometriosis is localized in the cortical layer of the ovaries, widespread endometriosis also affects the medulla. Endometrioid heterotopias are pseudocysts up to 5-10 mm in diameter, filled with a brown mass. The walls of heterotopia consist of layers of connective tissue.

There are several histological varieties of ovarian endometriosis: glandular, cystic, glandular-cystic and stromal. When the foci of endometriosis merge, endometrioid or "chocolate" cysts are formed, the walls of which are lined with a cylindrical or cubic epithelium.

Endometrioid glands are often found in the cytogenic stroma and tissue of the affected ovary. This form of ovarian endometriosis corresponds to the truth of an epithelial tumor - ovarian endometrioma. Glandular and glandular cystic endometriosis has the greatest ability for proliferative growth and malignancy.

clinical picture. Endometriosis of the ovaries may not manifest itself until a certain time. During menstruation, microperforations may occur in endometrioid heterotopias or endometrioid cysts. When endometrioid contents enter the abdominal cavity, the parietal and visceral peritoneum are involved in the pathological process, further spread of endometriosis foci and the formation of an adhesive process occur. There are complaints of dull aching pains in the lower abdomen, aggravated during menstruation. The adhesive process and the spread of foci of endometriosis along the peritoneum increase pain during physical exertion and sexual intercourse. In 70% of patients with ovarian endometriosis, algomenorrhea and dyspareunia are noted.

Diagnosis of ovarian endometriosis

External endometriosis involving the ovaries in the early stages of the disease is indicated by chronic pain syndrome. Small cystic heterotopias of endometriosis do not lead to a noticeable increase in the ovaries and are practically not diagnosed during a gynecological examination. With the formation of the adhesive process, the mobility of the uterus can be limited, often the ovaries are palpated in a single conglomerate with the uterus. Data from a gynecological examination and additional research methods are more informative when endometrioid transudate accumulates and endometrioid cysts form. The volume of endometrial formations varies depending on the phase of the menstrual cycle: their size before menstruation is smaller than after it.

With small endometrioid ovarian heterotopias, the cystic cavity is not formed and, therefore, their ultrasound visualization is difficult. With the formation of endometrioid formation, the information content of ultrasound increases to 87-93%. Endometrioid formations of the ovaries have a rounded shape with a pronounced echo-positive capsule, contain a finely dispersed echo-positive suspension against the background of liquid contents, are more often bilateral, localized posterior to the uterus. The internal relief of the walls can be uneven due to the near-wall settlement. The size of endometrioid cysts can reach 15 cm in diameter. Highly resistant blood flow is recorded in the wall of the endometrioma in CDI. For the differential diagnosis of endometriosis and malignant tumors, the determination of the following oncoantigens is important: CA 19-9, CEA and CA 125, the analysis of which is carried out by ELISA. It has been established that in patients with endometriosis, the concentration of CA 19-9 averages 13.3-29.5 U/ml, oncoantigen CA 125 - an average of 27.2 U/ml and in 95% of cases does not exceed 35 U/ml. The content of cancer-embryonic antigen (CEA) is 4.3 ng/ml. For a more complete and accurate screening, as well as for monitoring the treatment of endometriosis, it is advisable to use testing with three tumor markers.

The greatest diagnostic value for ovarian endometriosis is laparoscopy, in which inclusions in the ovarian stroma of small sizes (2-10 mm) of cyanotic or dark brown color, sometimes with dark blood leakage, are determined. Endometrioid formations have a whitish capsule with a pronounced vascular pattern and a smooth surface. The capsule of endometrial formations is often intimately soldered to the posterior surface of the uterus, fallopian tubes, parietal peritoneum, serous cover of the rectum. The content is tar-like, thick, chocolate-brown in color.

Fallopian tube endometriosis

Its frequency is from 7 to 10%. Endometrial foci affect the mesosalpinx, can be located on the surface of the fallopian tubes. The accompanying adhesive process often contributes to the violation of the functional usefulness of the pipe.

The main method for diagnosing endometriosis of the fallopian tubes is laparoscopy.

Endometriosis of the pelvic peritoneum

There are two main variants of peritoneal endometriosis. In the first case, endometrioid lesions are limited to the pelvic peritoneum; in the second case, endometriosis affects the ovaries, uterus, fallopian tubes, and the pelvic peritoneum in the form of foci.

Small forms of endometriosis do not manifest themselves clinically for a long time. However, the frequency of infertility in isolated small forms of endometriosis can reach 91%.

With the spread and invasion of endometriosis foci into the muscle layer of the rectum, pararectal tissue, pelvic pains, dyspareunia appear, which are more pronounced on the eve of menstruation and after it.

Endometriosis diagnosis

The main diagnostic method is laparoscopy, which allows to detect pathological changes. More than 20 types of superficial endometriotic lesions on the pelvic peritoneum have been described. There are red and flaming lesions, hemorrhagic vesicles, vascularized polypoid or papular lesions, wrinkled black inclusions, pigmented scar tissue or white lesions, as well as other types of heterotopias that can be confirmed histologically. According to morphological and biochemical properties, red lesions represent the most active stage in the development of endometriosis. Petechial and blistering lesions are more commonly diagnosed in adolescents and may resolve spontaneously during reproductive years. In premenopause, red foci are replaced by pigmented and fibrous heterotopias, and in postmenopause, black and white cicatricial foci predominate.

The modern approach to the treatment of patients with endometriosis provides for the following combinations:

Surgical method aimed at the maximum removal of endometriotic lesions;

Hormone modulating therapy;

Immunocorrection in common forms of the disease.

In the combined therapy of genital endometriosis, the leading role belongs to surgical treatment. The choice of method and access for surgical intervention depends on the localization and prevalence of the process.

Treatment of endometriosis of the cervix consists in the use of electro-, radiocoagulation or laser vaporization, as well as cryodestruction of ectocervical endometriosis.

For the prevention of recurrence of endometriosis of the cervix and vagina, it is advisable to prescribe low-dose estrogen-progestogen drugs for 3-6 months.

In the retrocervical form of the disease, surgery is performed with excision of foci of endometriosis. In a severe form of the disease, an operation is indicated in the amount of extirpation of the uterus with appendages. If necessary, perform plastic surgery on the rectum, vagina, organs of the urinary system. Hormone therapy with GnRH agonists (a-GnRH) is used as a preoperative preparation to reduce the destruction zone and blood loss for 3-6 months.

With common forms of external endometriosis with the formation of adhesions and infiltration of other organs in the preoperative period, hormonal preparations are used to limit the pathological process and facilitate surgical intervention (α-GnRH and antigestagens). In patients with small forms of endometriosis and external endometriosis, the appointment of hormonal therapy before surgery is impractical, as this may complicate the complete removal of endometrioid heterotopias due to atrophic changes and partial regression. Endometriosis foci during laparoscopy are subjected to electrocoagulation, cryo- or laser exposure, removal with a beam argon coagulator or an ultrasonic scalpel after a preliminary biopsy.

The main principle of hormone therapy is the suppression of ovulation processes, as well as the induction of hypoestrogenism and amenorrhea. In this regard, two main strategies for hormonal treatment of endometriosis can be distinguished. The first is to create an acyclic, low estrogen environment, as low estrogen levels promote endometrial atrophy. The effectiveness of hormone therapy is determined by the degree and duration of inhibition of the hormone-secreting function of the ovary. The second strategy is to transfer the hormonal status to a highly androgenic one, in which there is a decrease in estrogen levels and the occurrence of atrophic processes in the endometrium and endometrioid implants. For hormonal therapy of endometriosis, various groups of drugs are used: progestogens, estrogen-progestin agents, a-GnRH, antigestagens, etc.

Progestogens (synthetic analogs of progesterone) cause hypoestrogenism and hyperprogestinemia, which ultimately leads to endometrial atrophy. For the treatment of patients with endometriosis, the following are used: medroxyprogesterone, dydrogesterone, etc. Treatment is carried out from the 5th to the 26th day of the menstrual cycle or from the 16th to the 25th day for 3-12 months. Progestogens are effective against pain. Therapy with progestogens is well tolerated, but is associated with side effects: weight gain, edema, breast tension, irregular uterine bleeding.

Estrogen-gestagenic drugs (femodene, marvelon, rigevidon, zhanin, lindinet 30, regulon, novinet, etc.) are effective as first-line therapy in women suffering from pelvic pain and menorrhagia. Treatment is carried out for at least 6-9 months. The appointment of low-dose estrogen-progestin preparations in a continuous mode justified itself. Side effects are determined by the estrogen component; the most important of these is the increased risk of thrombosis.

GnRH agonists. Currently, the following drugs are used: goserelin, triptorelin (decapeptyl-depot, diferelin), buserelin. There are several forms of administration - intranasal, subcutaneous and intramuscular. Depot forms are most convenient for long-term use. It is advisable to carry out treatment for a long time, for 6 months.

The effect of these drugs is a temporary blockade of the gonadotropic function of the pituitary gland, which leads to reversible amenorrhea. Against the background of taking GnRH agonists, 60% of patients experience regression of endometriosis, and 85% experience clinical improvement. Relapses of the disease during the year are observed in 15-20% of patients. The widespread use of this group of drugs is limited by the development of estrogen deficiency symptoms in young women (hot flashes, depression, mineral metabolism disorders, etc.).

Antigestagens. Currently, two drugs from this group are used: gestrinone (nemestran) and mifepristone.

Gestrinone (a derivative of ethinylnortestosterone) has antiestrogenic, antiprogesterone and weak androgenic effects. The drug suppresses the secretion of LH and FSH and leads to a decrease in the level of estradiol and progesterone by 50-70%; this causes the development of endometrial atrophy and leads to amenorrhea. Antiprogesterone action is also associated with the binding of progesterone receptors. The androgenic effect is caused by a decrease in the amount of sex hormone-binding protein and an increase in the concentration of free testosterone. The use of gestrinone for 4 months leads to a decrease in clinical manifestations in 75-95% of patients with endometriosis. However, side effects were noted in 30-45% of patients; they are expressed in an increase in body weight, acne, seborrhea, hirsutism, a decrease in the timbre of the voice, depression, hot flashes, a decrease in the level of high-density lipoproteins and an increase in low-density lipoproteins.

Mifepristone is a synthetic steroid drug related to progesterone inhibitors; has a strong antiprogestagenic and antiglucocorticoid effect. In addition, mifepristone has a direct anti-angiogenic effect, which leads to a sharp decrease in the content of vascular endothelial growth factor (VEGF) and the expression of the VEGF RNA molecule in the endometrium. The use of high doses of mifepristone for a long time can lead to the development of endometrial hyperplasia, since there is no antiproliferative effect of progesterone. The use of mifepristone in patients with endometriosis is at the stage of developing doses and duration of treatment. The modern approach in the complex treatment of endometriosis involves the use of drugs that affect its pathogenetic link - aromatase inhibitors, prostaglandin synthesis inhibitors and angiogenesis inducers. This type of therapy has not yet been widely used in the treatment of endometriosis, but it is considered a promising direction in its complex treatment.

Symptomatic therapy. Along with pathogenetic therapy, which significantly reduces pain in endometriosis, it is advisable to carry out symptomatic treatment. In order to relieve pain and as anti-inflammatory therapy, NSAIDs (indomethacin, ketoprofen, naproxen, celecoxib, etc.) are used. It is possible to use antispasmodics and analgesics.

Posthemorrhagic anemia requires the appointment of iron supplements.

The effectiveness of treatment depends on properly selected hormonal therapy and timely surgical treatment.

Prevention of endometriosis. In the surgical treatment of endometriosis, one should be aware of the implantation spread of endometrioid heterotopias and avoid contact of the endometrium and tissues affected by endometriosis with the peritoneum and surgical wound. With laparoscopic access, the removal of endometrioid formations of the ovaries and uterus affected by adenomyosis through the operating channel should be carried out in a container. When conducting organ-preserving treatment for endometriosis in order to prevent relapse, it is advisable to prescribe hormonal therapy in the postoperative period. The use of hormonal contraception in young women prevents the onset and development of endometriosis.

Endometriosis prognosis. Endometriosis is a relapsing disease, the recurrence rate in terms up to 5 years is 40%, and after 5 years it reaches 74%. A more favorable prognosis after hormonal treatment of endometriosis in premenopausal women, since the onset of physiological postmenopause prevents the recurrence of the disease. In patients who have undergone radical surgery for endometriosis, the process does not resume.

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A consultation on treatment with traditional oriental medicine (acupressure, manual therapy, acupuncture, herbal medicine, Taoist psychotherapy and other non-drug methods of treatment) is held at the address: St. Petersburg, st. Lomonosov 14, K.1 (7-10 minutes walk from the metro station "Vladimirskaya / Dostoevskaya"), with 9.00 to 21.00, without lunch and days off.

It has long been known that the best effect in the treatment of diseases is achieved with the combined use of "Western" and "Eastern" approaches. Significantly reduce the duration of treatment, reduces the likelihood of recurrence of the disease. Since the "eastern" approach, in addition to techniques aimed at treating the underlying disease, pays great attention to the "cleansing" of blood, lymph, blood vessels, digestive tract, thoughts, etc. - often this is even a necessary condition.

The consultation is free of charge and does not obligate you to anything. On her highly desirable all the data of your laboratory and instrumental research methods over the last 3-5 years. After spending only 30-40 minutes of your time, you will learn about alternative methods of treatment, learn how to improve the effectiveness of already prescribed therapy and, most importantly, about how you can fight the disease yourself. You may be surprised - how everything will be logically built, and understanding the essence and causes - the first step to successful problem solving!