Surgery to remove endometriosis of the uterus. Curettage for endometriosis

Content

Surgery for endometriosis is the leading method of combating this chronic disease. Depending on the type of pathology, they may be different. Thus, with adenomyosis, access to the uterus is carried out using a hysteroscope and removal of lesions through curettage, laser destruction, and current. Endometriosis of the ovaries, tubes and pelvis is a reason for laparoscopy or laparotomy.

General approaches to removing endometriosis lesions

Endometriosis of the uterus is a hormone-dependent disease that has no clear origin. Endometrial cells begin to grow outside the uterine cavity. The reasons for such pathological changes have not yet been fully explored by scientists. The most likely factor in the development of endometriosis is the presence hormonal disorder immune homeostasis.

Laparoscopy is the leading method surgical intervention in gynecology. Operations performed by laparoscopy differ minimal risk complications both during and after the intervention. In addition, the rehabilitation period after laparoscopy is easier, which is especially important for patients.

Quite often, laparoscopy as a treatment method is used for endometriosis. Endometriosis develops when endometrial cells located in the inner lining of the uterus are thrown and grow into tissues that are unusual for them. This pathological condition typical for women in the fertile phase.

To relieve signs of the disease, conservative and surgical treatment is carried out. The choice of treatment tactics depends on the specific clinical case.

There are lesions with endometriotic growths inner surface uterus and cervix - adenomyosis and endometriosis, when lesions are observed in the tubes, ovaries, and in the pelvic cavity. , endometrioid ovarian cysts, lesion fallopian tubes and adhesions due to endometriosis are considered reasons for intervention through the abdominal cavity through a laparoscope or a traditional incision.

Adenomyosis or internal endometriosis can be removed by curettage. If lesions are detected during hysteroscopy, they are removed and small areas are cauterized.

After surgery to remove endometriotic lesions Hormonal medications must be prescribed to prevent relapse of the disease.

Conservative tactics involve the use of drugs from the following groups:

• hormonal;
• anti-inflammatory;
• antibacterial;
• immunostimulating;
• anti-adhesion.

Surgery for endometriosis usually involves laparoscopy and subsequent cauterization of the lesions. Drug therapy must be prescribed before surgical treatment, and also after it.

Indications for surgery
Indications for surgery for endometriosis are a common localization of endometrioid heterotopias. Generalized causes excruciating pain and does not respond conservative technique treatment. It is advisable to perform surgery for limited lesions of the pelvic organs by endometriosis.

Before deciding to perform surgery for endometriosis, the gynecologist takes into account its feasibility, the volume of lesions, the patient’s age and the risk of damage to neighboring reproductive organs. Sometimes during surgery the rectum and sigmoid colon, ureter and bladder.

The main reason for surgery for endometriosis- this is the ineffectiveness of conservative and drug treatment.

You can select the following readings for surgery:

• constant or periodic intense pain in the lower abdomen;
• adhesive process;
• pain during defecation;
• infertility;
• uterine bleeding.

Before deciding whether to undergo surgery for endometriosis, doctors consider the following important factors:

• patient's age;
• the total volume of areas affected by endometriotic lesions;
• the likelihood of damage to the rectum and sigmoid colon, ureter and bladder.

Rules for the operation

Surgery for endometriosis is performed three days before the onset of menstruation.

A common form of endometriosis, in which the ovaries and pelvic peritoneum are affected, conglomerate tumors and chocolate cysts are diagnosed, requires immediate removal. In this case, doctors can completely remove the uterus and ovaries. Conservative surgery, during which the unaffected ovary is preserved, is indicated for girls who want to give birth to a child. In this case it is shown complete removal all endometrioid neoplasms.

During complex diagnostics and examination, the doctor checks the uterus and peritoneum for the presence of lesions. If patients are found to have widespread pathological formations, then surgery for endometriosis has its own difficulties. With this course of the disease, tissue that is very close to the bladder, ureter and rectum is affected. Due to the high likelihood of injury, doctors limit themselves to removing not all endometrioid heterotopias that are inside abdominal cavity. Even with such an operation, development stops pathological processes further. Surgical treatment in women of menopausal age is carried out with radical removal uterus and appendages.

Removal of foci of adenomyosis in menopausal women is carried out with ablation - excision of the basal layer to prevent further growth of the endometrium. Young women undergo less invasive surgery. Curettage, cauterization of lesions and hormonal treatment, introduction to medicated menopause for 6-9 months.

Laparoscopic surgery

The essence of laparoscopic surgery for endometriosis lies in several points.

1. Preliminary inspection. The gynecologist assesses the degree of localization and size of pathological neoplasms.
2. Delete. Surgeons remove pathological lesions using one of the methods: coagulation or cauterization.
3. Taking samples of excised tissue for histological examination.

There are several sequential stages when performing laparoscopy.

1. The doctor makes several small holes in the abdominal wall necessary for inserting manipulators.
2. The peritoneal area is pumped with inert gas to improve vision internal organs and separation of the walls from adjacent tissues.
3. The surgeon examines and then identifies the affected areas, after which they are excised or cauterized.

It is forbidden to eat or drink liquids 9 hours before surgery. Such precautions will help to avoid vomiting or nausea after surgery, or the reflux of food into the airways during anesthesia.

Laparoscopy is performed exclusively under general anesthesia.

Surgery for endometriosis begins with filling the abdominal cavity with a special gas. This manipulation helps improve visibility during surgery. The abdominal wall is slightly raised, and doctors can clearly see all the walls and control their actions.

Small holes are made on the patient’s stomach, the size of which is no more than two centimeters. A laparoscope and other instruments for manipulation are inserted into them. The tube with the video camera displays the image on the monitor screen. Only tissue affected by endometriosis can be removed. They are cauterized by electric current, liquid nitrogen or laser beams. The latter are the most effective and safe today.

During the operation they are carefully cauterized. blood vessels, therefore, the likelihood of bleeding is completely excluded.

The duration of the operation is on average about 30 minutes (up to an hour), but with severe forms endometriosis it takes longer.

At the last stage, the doctor removes all the instruments and applies sutures. After laparoscopic surgery, patients are left with virtually no scars.

Complications after surgery have a probability of only 1%. TO possible complications relate:

• infection in the abdominal cavity;
• heavy bleeding;
• the presence of adhesions;
• damage to the urethra, bladder or intestines.

One of the indications for laparoscopy is endometrioid ovarian cyst. This pathology occurs when endometriosis spreads to the ovarian area.

An endometrioid ovarian cyst can reach significant sizes and be asymptomatic. As a rule, ovarian formation is detected in the process gynecological examination and then confirmed by ultrasound.

An endometrioid ovarian cyst can cause organ dysfunction and contribute to infertility. In addition, there is an opinion that this form of endometriosis has a risk of degeneration into a malignant tumor.

Many doctors strongly recommend removing endometrioid ovarian cysts using laparoscopy. In the absence of infertility, significant size and signs of oncological suspicion, observational tactics and conservative treatment in women of reproductive age are recommended. This is due to the fact that after laparoscopy, healthy ovarian tissue is affected and the ovarian reserve is often reduced.

Recovery period

IN rehabilitation period After laparoscopy, a woman is advised to take antibacterial, immunostimulating, anti-inflammatory drugs. Appointment is required hormone therapy long-term, which helps to avoid relapses of endometriosis. Among the most popular hormonal drugs distinguish Janine, Vizanne, Buserelin. , as well as other hormones, is used for 6 to 9 months.

During the first two months after surgery, you must avoid physical activity and sexual intercourse. It is important to comply the following recommendations specialist:

• balanced diet;
• fiber should be present in the daily diet;
• refusal bad habits, alcoholic drinks and narcotic substances;
• playing sports;
• walks in the open air;
• maintaining intimate hygiene;
• stop using intrauterine devices.

If after surgery women had no relapses during the first five years and there were no painful sensations, then remission is considered stable.

Scraping

During curettage of the uterine cavity, doctors remove only the top layer of the endometrium. After surgery, it is quickly restored due to the base layer. There are two ways.

1. Separated. During the procedure, the gynecologist cleans the cervix and only then the cavity. The resulting material is sent for histological examination.
2. Traditional. All pathological formations from the body of the uterus are removed blindly. This method often leads to serious complications or damage.

Thanks to hysteroscopy You can fully control the curettage and evaluate the results obtained after the operation.

The procedure is carried out a few days before the onset of menstruation. This promotes rapid restoration of endometrial tissue.

The following indications for curettage accompanying adenomyosis can be identified:

• the presence of abnormalities in the structure of the endometrium, which are clearly visible during ultrasound examination;
• significant thickening of the endometrium, exceeding normal values;
• polyps in the uterine cavity;
• violation menstrual cycle;
• suspicion of a malignant tumor;
• after spontaneous abortion;
• the presence of adhesions in the uterine cavity after labor.

Curettage has virtually no contraindications or serious complications.

When a woman reaches menopause, ablation is possible, when during the operation not only the functional layer of the endometrium is removed, but also several millimeters of the layer located deeper. After such an operation, the woman becomes completely infertile, but the endometrium does not have the opportunity to grow.

Laparoscopy for endometriosis of the uterus, curettage is used if ineffective conservative method, infertility. After the operation, the chances of receiving healthy pregnancy are rising. However, it should be noted that uterine endometriosis is a chronic disease. It is possible to completely get rid of this pathology only by removing the uterus.

Thanks to timely childbirth (before 30 years of age) and treatment, a woman with this disease can become a mother, while after 30 years of age, aggressive hormonal treatment of endometriosis and surgery significantly reduce the likelihood of pregnancy, even with the help of IVF.

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Most experts believe that treatment for endometriosis should always begin with surgery.

Surgical treatment of endometriosis

• If there are contraindications to hormonal therapy ( chronic diseases gastrointestinal tract, blood diseases, cardiovascular diseases) or drug intolerance.
• In the absence of the expected or inadequate effect from drug therapy for 6 months, when it is not possible to stop the process and stop the main symptoms of the disease (menometrorrhagia, algodismenorrhea and anemia).
• In the presence of foci of endometriosis with a diameter of more than 2 cm.
• Endometrioid ovarian cysts.
• In complex and severe forms of endometriosis, when there is anatomical deformation pelvic organs with dysfunction of the intestines, bladder, ureters, kidneys.
• In the presence of adhesions.
• For some forms of endometriosis in which hormonal drugs are ineffective, for example, with retrocervical endometriosis.

There are 2 types of surgical treatment for endometriosis:

1. Conservative surgical treatment
2. Radical surgical treatment

1. Conservative surgical treatment (Organ-preserving operations).

It involves removing foci of endometriosis while preserving the ovaries and uterus.

Indicated in the following cases:

• For moderate and severe forms of endometriosis, external endometriosis. The goal of conservative surgery is to remove foci of endometriosis in various organs, endometrioid cysts, dissection of adhesions and restoration normal anatomy pelvic organs as much as possible.
• During a planned pregnancy. To solve the problem of infertility associated with endometriosis, surgical treatment is more effective than hormonal therapy. In women in reproductive age endometriotic implants are excised as much as possible to relieve pain, limit the progression of the process and restore or preserve reproductive function.
• Endometrioma on the ovaries larger than 2 cm, which can cause sharp pains and progress until the cyst ruptures and internal bleeding. In this case, the endometrioid cyst is removed while preserving the ovaries without damaging normal tissue.

The operation can be performed laparoscopically or, more difficult cases, using traditional abdominal surgery, excising the endometriotic implants as much as possible.

Laparoscopy It is considered a minimally invasive operation because The surgeon makes very small incisions (0.5 cm) near the navel and in the lower abdomen. Laparoscope(thin optical instrument) is inserted into an incision near the navel, which allows the doctor to examine the pelvic and abdominal organs. Small instruments are inserted through other incisions to remove endometriosis tissue and adhesions. Since the incisions are very small, only small scars remain on the skin after the procedure, and women recover faster after surgery and have more low risk formation of adhesions.

Laparoscopic access is used to treat infertility in minor forms of endometriosis, ovarian endometrioma, and endometrioid infiltration of the uterosacral ligaments and rectovaginal septum.

If the disease is extensive or there are anatomical deformities, a classic laparotomy is performed (access to the abdominal organs through a large incision).

2. Radical surgical treatment- an operation with removal (extirpation) of only the uterus or together with the appendages (ovaries and fallopian tubes).

Indicated in the following cases:

• Severe forms of endometriosis in women over 40 years of age with ineffective conservative treatment surgery and rapid progression of the disease.
• Retrocervical form of endometriosis.
• Adenomyosis, in which hormonal therapy failed to relieve the main symptoms of the disease (menometrorrhagia, algodismenorrhea and anemia). In this case, the uterus is removed - hysterectomy.

Operations are performed laparoscopically or laparotomically.

In the postoperative period, to prevent relapse of the disease, hormonal therapy is prescribed for 3-6 months.

The effectiveness of surgical treatment of endometriosis.

Only surgical removal of endometriosis foci can be considered a relative guarantee of recovery. But this guarantee is only relative, because endometriosis is prone to recurrence. Indeed, even after surgery, the cyclical process that causes the development of endometriosis does not stop. Removing only the uterus is also not effective, because the ovaries continue to produce estrogen and stimulate remaining endometriotic tissue. Therefore, in some cases there is a need for repeated operations.

The recurrence rate after conservative surgery is approximately 20% after 2 years and 40% after 5 years. After radical operations Due to endometriosis, the disease does not recur.

For endometriosis in young women, the main task surgical intervention is the restoration and preservation of reproductive function. Most doctors believe that surgical treatment for infertility associated with endometriosis is more effective than hormonal treatment. In this case positive result The operation is considered to be a subsequent pregnancy.

Many experts recommend the so-called three-phase treatment: first, laparoscopic removal of endometriosis lesions, then the administration of gonadotropin-releasing hormone analogues (GnRH-a) for 6 months, and, finally, repeat laparoscopy with removal of remaining lesions.

The criteria for cure for endometriosis are wellness(no pain or bleeding), and no relapses for 5 years.

Endometriosis Endometriosis- one of the most common and misunderstood gynecological diseases. This diagnosis is made by gynecologists quite often, but women, as a rule, remain in the dark - what exactly was discovered in them, why it should be treated and how dangerous this condition is.

Let's find out!

In order to understand what endometriosis is, you need to understand how menstruation occurs and what the endometrium is.

The inside of the uterine cavity is lined with a mucous membrane called the endometrium (let me decipher the name: meter - uterus (Greek); endo - inside). This mucous membrane has a complex structure. It consists of two layers - the first is basal, the second is functional. I explain: the functional layer is the layer of the mucous membrane that is shed every month during menstruation (if pregnancy occurs, then it is into this layer that the fertilized egg is implanted). The basal layer is the layer from which a new functional layer grows every month.

This process can be compared to a lawn - you cut the grown grass, and after a while the grass grows back - the lawn is the basal layer; the grown grass is functional.

Result: Every month, under the influence of ovarian hormones, the endometrium grows in the uterus; if pregnancy does not occur, the endometrium is rejected, accompanied by bloody discharge - this is menstruation.

What is discharge during menstruation?- This is a mixture of blood and fragments of the rejected endometrium.

In almost all women, menstrual flow not only comes out (through the vagina), but some of it also enters the abdominal cavity through the tubes. Normally, menstrual fluid that enters the abdominal cavity is quickly destroyed by special protective cells of the abdominal cavity.

However, menstrual flow is not always completely cleared from the abdominal cavity. Pieces of rejected endometrium have the ability to attach to various tissues, implant into them and take root. Again, I’ll give you the example of a lawn. Imagine that you took a shovel and began to dig up areas of the lawn and scatter them on the soil. Most of Such scattered fragments will take root and grow in the form of separate bushes of grass.

Thus, endometriosis- this is a disease when the mucous membrane of the uterine cavity (endometrium) in the form of separate foci is located outside the uterine cavity, and in different places body - most often on the peritoneum (what the abdominal cavity is lined with from the inside, and what the intestines are covered with). These fragments of the endometrium (they are also called endometrioid explants) can be located on the ovaries, tubes, uterine ligaments, intestines, and can also take root in other places outside the abdominal cavity, but more on that later.

After these fragments of the endometrium take root, they begin to exist in the same way as they did while in the uterine cavity - that is, under the influence of ovarian hormones, the explants (foci) increase in size, and then part of them is rejected during menstruation. That is, a woman with endometriosis experiences not only regular menstruation, but also many miniature menstruation in the foci of endometriosis.

Since these miniature menstruation occurs in the abdominal cavity on the peritoneum, which is very well innervated, pain occurs during this process. This is why the leading symptom of endometriosis is abdominal pain.

The theory of the origin of endometriosis that I described is called “implantation theory.” This is one of the oldest and most obvious theories. In addition to this theory, there are also others. These theories suggest that endometriosis lesions may form as a result of the transformation of peritoneal cells into endometrial cells or that these lesions form as a result of genetic predisposition, immunological disorders or as a result of hormonal influences.

There is still no consensus on the problem of endometriosis, but the implantation theory is considered the most obvious.

What can contribute to the development of this disease?

Anything that will contribute to more frequent entry of menstrual fluid into the abdominal cavity.

In particular:

• Early onset of menstruation late onset menopause
iosis, the risk of developing endometriosis in women increases greatly

Foci of endometriosis can be found not only on the peritoneum, but also in a variety of organs and tissues of the body (this happens very rarely). It is believed that this is due to the fact that fragments of endometrial tissue can be carried throughout the body by lymphatic or circulatory system, and also get into wounds during surgery. For example, there is endometriosis of the kidneys, ureters, bladder, lungs, and intestines. Endometriosis was found in the navel, in the suture after caesarean section, as well as on the skin of the perineum in the scar after cutting the skin during childbirth.

What do endometriosis lesions look like?

There are foci of endometriosis different shapes, size and color. Most often these are small seals of white, red, black, brown, yellow and other colors that are scattered throughout the peritoneum. Sometimes these lesions merge and infiltrate the tissue, especially often behind the uterus on its ligaments. Quite large masses of endometrioid tissue can form in this area (a condition called retrocervical endometriosis).

If endometrial tissue enters the ovary, endometrioid cysts can form in it, also called “chocolate cysts.” This benign cysts ovary. Their contents accumulate during the “miniature menstruation” of those foci of endometriosis that line the walls of the cyst.

Clinical manifestations

The most common manifestation of endometriosis is pain syndrome. Pain syndrome is characterized by a gradual increase in pain that occurs immediately before or during menstruation, pain during sexual intercourse and painful bowel movements. In some cases, the pain syndrome may not be designated as an acquired phenomenon, but simply the woman notes that she has I've always had painful periods, although most patients indicate increased pain during menstruation.

Pain most often it is bilateral and the intensity ranges from slight to extremely pronounced; the pain is often associated with a feeling of pressure in the rectal area and can radiate to the back and leg.

Permanent " discomfort“throughout the entire menstrual cycle, worsening before menstruation or during coitus, may be the only complaint presented by a patient with endometriosis.

The cause of the pain has not been fully established; it is assumed that it may be associated with the phenomenon of “miniature menstruation” of endometriotic explants, which leads to irritation of the nerve endings. The disappearance of pain when menstruation stops in patients with endometriosis, that is, the elimination of cyclic hormonal effects on endometriotic explants, actually proves the mechanism of the pain syndrome.

To other manifestations endometriosis relate spotting brownish bloody issues before menstruation or long period after her. Painful sensations above the womb, painful urination, the appearance of blood in the urine (must be distinguished from cystitis - the latter most often occurs acutely and quickly resolves with proper treatment).

A separate manifestation endometriosis is infertility. It is believed that endometriosis can lead to infertility through two mechanisms: adhesions, which disrupt the patency of the fallopian tubes and due to dysfunction of the egg and sperm.

Adhesions in endometriosis are formed due to the fact that at the site of foci of endometriosis on the peritoneum, an inflammatory process actually constantly occurs, which stimulates the formation of adhesions. Adhesions disrupt the patency of the fallopian tubes, which leads to infertility.

Impaired sperm and egg function is due to the fact that in the presence of endometriosis in the abdominal cavity, the activity of the local immune system changes. It doesn't work correctly - it's too active. In addition, the presence of endometriosis lesions on the ovary can disrupt the process of egg maturation, the process of its release (ovulation), and it is also assumed that endometriosis lesions can change the quality of eggs, which leads to the disruption of fertilization and implantation of the fertilized egg.

Diagnosis of endometriosis.

The gold standard for diagnosing endometriosis is laparoscopy. In fact, only with the help of this method can we see foci of endometriosis and take a biopsy from them to confirm the diagnosis. Endometriotic cysts are visible on ultrasound; fairly precise characteristics have been formulated for them; however, in some cases, such cysts may be similar to other ovarian formations, for example, “on corpus luteum».

With endometriosis, the level of a special marker CA125 in the blood increases. This marker is also used to diagnose ovarian formations (it is often prescribed when there are suspicious (regarding malignancy) ovarian cysts). This marker is not very specific as it does not reflect the severity of endometriosis. In general, its diagnostic value remains only for assessing the regression of endometriosis during treatment, although this is not performed so often.

Other techniques have also been developed, but they have not yet received wide application.

Thus, without laparoscopy, the diagnosis of endometriosis can only be assumed (with the exception of endometriotic cysts, which are visible on ultrasound). Ultrasound cannot detect the presence of foci of endometriosis in the peritoneum. This method can only detect the accumulation of endometriotic tissue in the retrouterine space in a condition such as retrocervical endometriosis.

The presence of endometriosis can be assumed based on the clinical picture and gynecological examination. The doctor most often pays attention to pain and its connection with menstruation and sex life. During the examination, the doctor may palpate in posterior fornix uterus (this is deep behind the cervix) painful seals in the form of “spikes” - these, as a rule, are foci of endometriosis. Patients with such seals often complain of pain during sexual activity, especially during deep penetration by a partner or in a certain position.

Endometriosis can be assumed as one of the reasons infertility paired with. This question still remains open. There are proven facts indicating that after laparoscopic destruction of endometriosis foci, pregnancies occur that had not occurred before. There are facts of detection of endometriosis in women who became pregnant on their own.

There are many opinions and tactics - in one clinic they may tell you that laparoscopy to exclude or confirm endometriosis with its subsequent treatment is necessary for almost all patients with infertility, in another - the opinion may differ radically - they will leave laparoscopy for later and will search for and treat other causes infertility. What is paradoxical is that both will have good results in the treatment of infertility. This is such a mysterious disease - endometriosis.

What should I do? I also cannot answer this question unambiguously. I believe that each specific situation must be examined separately. If a couple has other reasons that can lead to infertility besides endometriosis, they need to correct them and try to get results. If it is not there, perform laparoscopy (if there were no other indications for it before). If you have passed all the examinations and everything is normal, you can rule out the role of endometriosis. So logical, In my opinion. After all, if a woman has impaired ovulatory function, has problems with the endometrium and a bad spermogram in her husband, she must first correct these disorders and try to get pregnant.

Classification of endometriosis

The most common and worldwide accepted classification of endometriosis is the classification proposed by American Society Fertility (AFS). It is based on determining the type, size, and depth of endometriosis foci on the peritoneum and ovary; the presence, prevalence and type of adhesions and the degree of sealing of the retrouterine space.

This classification is based on determining the prevalence of endometriosis and does not take into account parameters such as pain syndrome and degree of fertility. According to this classification, there are 4 degrees of severity of endometriosis, which are determined by the sum of points assessing various manifestations diseases.

Treatment of endometriosis

First I want to note that endometriosis is completely disappears only after menopause(unless the woman is receiving hormone replacement therapy, during which endometriosis can persist). Until it's using therapeutic methods we can achieve stable remission, but it is impossible to guarantee complete relief from endometriosis as long as menstruation continues and there is sufficient hormonal activity of the ovaries or other hormone-producing tissues (subcutaneous fatty tissue).

Exist 2 ways treatment of endometriosis: removal of foci of endometriosis or temporary shutdown of menstrual function so that foci of endometriosis atrophy. Often these two methods are combined.

Drug treatment

To completely turn off menstrual function, drugs from the group “ GnRH agonists"(buserelin-depot, zoladex, lucrine-depot, diferelin, etc.). Such drugs are usually prescribed for a course of 3 to 6 months (the drugs are administered intramuscularly, 1 injection once every 28 days). Against their background, a woman’s menstruation disappears and a condition similar to menopause occurs (with all characteristic symptoms– hot flashes, mood lability, etc.), but this condition is reversible, that is, after the last injection of the drug, after 1-2 months, menstruation is restored and the “menopause” condition passes. During this time, foci of endometriosis, deprived of hormonal stimuli, undergo atrophy.

It's sad, but after such treatment it can be quite many relapses. Apparently, after the restoration of menstruation, the mechanism of formation of endometriosis foci starts again and a relapse of the disease occurs.

Other drugs that act on foci of endometriosis include derivatives of male sex hormones - danazol, nemestran etc. These drugs are quite effective, they are still used today. While taking them, a condition similar to menopause also develops. The negative point in their use is quite severe side effects(especially from danazol, nemestran is relatively well tolerated). These drugs are also prescribed for a course of 3 to 6 months, relapses also occur frequently.

Hormonal contraceptives.

Hormonal contraceptives have a therapeutic and preventive effect on endometriosis. The mechanism of their action is that against the background hormonal contraception The cyclic effect of hormones on endometriosis lesions is switched off and they lose activity. In addition, some contraceptives (for example, Janine) include a progestogen component, which may have an additional healing effect due to direct impact on foci of endometriosis.

The effect of contraceptives on foci of endometriosis is less pronounced than that of the drugs described above. Contraceptives are effective for small and medium forms of endometriosis; in addition, their use ensures the prevention of this disease.

To contraceptives had the most pronounced effect they must be accepted according to the new, so-called “ prolonged scheme" The essence of this scheme is as follows: contraceptives are taken not for 21 days and then a 7-day break, but for 63 days (that is, 3 packs in a row) and only after that there is a break of 7 days. Thus, a woman has one menstruation every three months. This prolonged regimen not only has a therapeutic and preventive effect against endometriosis, but is also better tolerated in general.

Contraceptives can also be used as second phase after main therapy medications(GnRH agonists). As I noted above, after discontinuation of these drugs, a relapse of the disease often occurs due to the fact that menstrual function is restored. Therefore, if, after completing the main course, you start taking contraceptives according to a prolonged regimen, the likelihood of relapse is sharply reduced and the effect achieved by the main treatment course lasts longer.

Surgery

Used for surgical treatment of endometriosis laparoscopy. During the operation, endometriosis foci are destroyed using various energies. Endometriotic cysts are simply removed from the ovary. If endometriosis has led to the appearance of adhesions (which occurs quite often), the adhesions are destroyed and the patency of the fallopian tubes is immediately checked.

The effect of such an operation is unfortunately doesn't last long. After some time, foci of endometriosis appear again, and adhesions also develop again. In order to the effect of the operation lasted longer Immediately after surgery, patients are prescribed a course of drug therapy (GnRH agonists, nemestran).

If a woman didn't plan pregnancy, after completing the main course, she can start taking contraceptives for further prevention relapses.

If pregnancy was planned– It is necessary to attempt to become pregnant immediately after the operation. It is important to remember that the more time has passed after the operation, the greater the likelihood that the effect achieved by the operation has already worn off - most likely, adhesions have formed again and new foci of endometriosis have appeared.

If disorders caused by endometriosis lead to the development of infertility, then surgical treatment of such conditions is usually has good results. Prescription of medication GnRH agonist therapy, danazol and gestrinone in the postoperative period irrational, since this treatment leads to suppression reproductive function, and the highest frequency of pregnancies after surgical treatment is observed in the first 6-12 months after surgery.

The need for surgical treatment of women suffering from infertility due to mild and moderate forms of endometriosis contradictory. On average, 90% of women with mild to moderate endometriosis get pregnant on their own within 5 years. This is comparable to the pregnancy rate in healthy women in the same time period (93%).

The fact that surgical treatment increases the fertility of women suffering from mild and moderate forms of endometriosis is supported by only some of the authors; the other part refutes these data. And, although it can be assumed that surgical treatment increases the fertility index in the first 6-12 months after surgery, and also helps prevent relapses, on the other hand, unjustified surgical activity in any case increases the likelihood of occurrence and inevitable recurrence of the adhesive process.

Long-term results of surgical treatment of pain associated with endometriosis are largely depends on individual characteristics each specific patient, in particular from her psychological status. Diagnostic laparoscopy only without completely removing all foci of endometriosis (in other words, placebo surgery) can lead to the disappearance of pain in 50% of women. Laparoscopic laser destruction of endometriosis foci with moderate severity of the disease usually leads to the disappearance of pain in 74% of women. At the same time, surgical treatment of mild forms of endometriosis usually does not lead to significant pain relief.

In custody:

• Endometriosis- a fairly common disease that most often manifests itself pain syndrome and infertility
nts of the endometrium (uterine mucosa) to the peritoneum. These fragments begin to exist independently, and “miniature menstruation” occurs in them.

Endometriosis – site

Foci of endometriosis can be removed with two methods:

• Excision
• Coagulation.

Excision

During excision, the endometrioid lesion is excised from the surrounding tissue using scissors, laser beam or a red-hot wire loop. This technique does not destroy the integrity of the endometrioid tissue focus, so the operating doctor can send this area of ​​tissue for examination under a microscope to confirm the diagnosis of endometriosis or exclude a cancerous tumor.

Excision allows the surgeon to separate the lesion from the surrounding tissue, thereby ensuring that the entire lesion of tissue is removed without any residue.

Coagulation

Coagulation is a method of destroying foci of pathological tissue using cauterization with a special hot loop or laser. When coagulating, care is required so that the doctor is sure that the focus of endometrioid tissue is completely destroyed. This is important in terms of preventing re-growth of the lesion.

In addition, the doctor must be careful not to damage underlying tissues, such as the intestines, bladder, or uterus. Therefore, gynecologists are afraid to perform coagulation of pathological foci (for example, endometriosis) in the area of ​​vital organs, for example in the intestines or in the area of ​​large blood vessels.

Which technique is preferable?

Of the two listed techniques, excision is preferable, as it is more effective, and at the same time more complex and takes longer. This means that this technique is not used by all gynecologists.

Excision efficiency compared to coagulation has been proven in clinical trials, which showed that women who had excision had fewer symptoms at 12 and 18 months than those who had coagulation.

Ovarian endometriosis

Treatment for ovarian endometriosis depends on the size of the lesion and its location. In the ovarian area, endometriosis manifests itself as a cyst. The contents of such a cyst are usually thick and dark brown in color, and doctors often call such a cyst “chocolate”.

Superficially located lesions

Superficially located lesions in the ovarian area are usually removed using coagulation.

Small endometrioid cysts

Small endometriotic cysts less than 3 cm in diameter are usually punctured and drained. Further research inner layer cysts, after which it is destroyed.

Large endometrioid cysts

Large endometrioid cysts with a diameter of more than 3 cm are usually excised or drained and then cauterized using a cautery. When excising a large cyst, some surrounding tissue is also excised to ensure that all abnormal tissue is removed with greater certainty. During drainage and coagulation large cysts the cyst is opened, and the inner layer of the cyst is coagulated.

Doctors believe that cysts with a diameter of more than 3 cm are better to excise than to drain and coagulate. Cysts larger than 6 cm are best operated on in two stages. Complete excision results in significant improvements in pain and fertility. Moreover, much less risk cyst recurrence.

Spikes

Adhesions with endometriosis must be removed. They can be cut with scissors, cauterized with a loop or laser.

When dissecting adhesions, there is always a risk of re-formation of adhesions at the site of their dissection. However, there are certain measures to prevent their formation. Some women have a greater tendency to form adhesions than others. This may lead to the fact that subsequent operations to dissect adhesions will no longer be desirable.

Endometriosis of the rectovaginal space and rectosigmoid region

Surgical treatment for this localization is carried out only if manifestations of endometriosis are noted. If endometriosis is present in the rectovaginal space, it is usually not touched and left under observation, since this form of endometriosis rarely worsens during its course and is manifested by any symptoms. However, if the endometriotic lesion begins to compress the intestines or ureter, then surgical treatment is necessary.

If this form of endometriosis is suspected, then it is necessary to remove all lesions during one operation to avoid subsequent interventions. This operation is quite complicated and can lead to many complications. It is very important to consult with your gynecologist about which surgery you can choose to give your consent.

If you are thinking about surgical treatment, then you should choose a multidisciplinary center that specializes in the treatment of endometriosis. Such centers offer the full range of treatment, as they employ qualified specialists, gynecologists, surgeons, urologists.

Endometriosis of the uterus is quite common female disease. . The disease is diagnosed in women childbearing age. The tissue lining the uterine cavity is called the endometrium; when the disease occurs, the layer grows outside the body. Cervical endometriosis requires treatment, depending on the degree of development and complexity of the disease, with medication or surgical intervention. In 97% of cases, the endometrial layer affecting adjacent tissues is a benign formation. The disease requires special attention, the symptoms cause discomfort, and endometriosis of the uterine body can lead to infertility.

Surgery may be necessary to treat endometriosis

Endometrial tissue has hormone receptors female body. In the endometrial tissue, during the development of the disease, functional changes, which lead to a long and heavy menstrual cycle. Microbleedings lead to inflammatory processes in surrounding, healthy tissues. Endometriosis is classified into two types, depending on the sites of the disease:

• genital (within the uterus, ovaries);
• extragenital (outside the genital organs - intestines, navel area).

Symptoms of gynecological disease

Symptoms of endometriosis of the uterine body may not be clearly expressed. However, thanks to certain features, it is possible to diagnose the disease on early stage development. It is very difficult to deal with the symptoms on your own; you will need the help of a gynecologist. The symptoms inherent in the disease are also characteristic of many other hormone-dependent disorders, all of which can cause disruptions in the menstrual cycle, exacerbation of PMS and sudden change moods.

It is endometriosis that is accurately indicated by bleeding similar to menstruation in the period between cycles.

Exacerbated PMS may be a symptom of endometriosis

Main symptoms internal endometriosis body of the uterus:

• pulling or squeezing pain in the lower abdomen (occurs on the first day of menstruation and goes away with it);
• unpleasant pulling sensations in the perineum;
• dark-colored menstrual blood or clots;
• chronic nagging pain in the back, regardless of the menstrual cycle;
• feeling of discomfort and pain during intimacy;
• spotting between cycles;
• heavy bleeding during menstruation;
• severe pain during menstruation.

Pelvic pain in acute stage the course of diseases of the uterine body may appear before the onset of the menstrual cycle, or be chronic. The intensity of the pain is explained by the accumulation of fluid in the tissues, which provokes the formation of an adhesive process that affects the body of the organ. As a result pain symptom indicates the accumulation of menstrual blood in the lesions and the development inflammatory process. Signs of the development of endometriosis may include increased and lengthened menstruation. With stage 4 endometriosis, pain may accompany bowel and bladder emptying. In rare cases, symptoms of uterine disease include bloody tears and infertility.

Pelvic pain with endometriosis is a consequence of excessive fluid accumulation in the tissues of the uterus.

Disruption of a woman's menstrual cycle is a common symptom of a malfunction. hormonal levels body. However, gynecologists advise paying attention to the symptoms of disorders. One of additional symptoms illness may be sudden onset of anemia, heavy bleeding provoke a decrease in hemoglobin levels in the blood. Anemia is detected using general analysis blood.

Chronic pain in the lumbar region and pulling in the lower abdomen may also indicate endometriosis of the uterine body.

If symptoms appear, it is better to consult a gynecologist and not engage in dangerous self-medication. Poorly expressed symptoms complicate the overall clinical picture and interfere with diagnosis. If a combination of symptoms is present, the gynecologist will refer the patient for an ultrasound examination to confirm the diagnosis. Detailed and general clinical tests are also prescribed.

Symptomatic therapy

Pain affects the quality of life of patients, therefore symptomatic therapy pay great attention. Prescribed for pain relief NSAID drugs and analgesics. Preparations containing iron are prescribed when anemia is detected. Hemostatic tablets are prescribed in the presence of heavy bleeding during menstruation and when blood clots appear. As a local anesthetic therapy, gynecologists prescribe vaginal suppositories. Suppositories have a therapeutic analgesic and anti-inflammatory effect. Suppositories are also prescribed in the rectum to relieve pain.

Iron supplements are prescribed against anemia in endometriosis

Hormonal therapy for endometriosis

Endometriosis of the uterine body can be treated in different ways, depending on the degree of development. Treatment methods depend on the form of the disease, the complexity of its course and timely diagnosis. The disease cannot be completely cured, but well-chosen drugs can provide long-term remission. Development of modern diagnostic centers made it possible to identify asymptomatic and sluggish forms of the disease.

There is no need to treat endometriosis of the uterine body in the first degree. It is important to monitor development and prevent the influence of unfavorable factors.

The disease can progress after an abortion or a sudden hormonal imbalance. In this case, it is necessary to treat patients with properly selected hormonal therapy. Intrauterine device in case of illness it is contraindicated, therefore the use of medicinal and contraceptive effects is important.

Among hormonal drugs, monophasic, combined and oral contraceptives, With high content progesterone. Treatment methods may vary as the development and progression of the disease is monitored.

IN initial stages endometriosis are limited to regular testing and observation by a doctor

When diagnosing the disease during menopause or in the presence of other pathologies in the female genital area, treatment methods may be wait-and-see. It is not advisable to treat endometriosis in such cases; in practice, cases have been identified in which regression of the diagnosis occurred after menopause.

Drug and hormonal treatment is used by gynecologists in most cases. Contraceptive drugs are prescribed to normalize general hormonal levels and, at the same time, to prevent unwanted pregnancy.

Hormonal drugs, when taken for a long time, contribute to the gradual regression of the disease.

Surgical treatment of uterine endometriosis

If the disease progresses and affects adjacent healthy tissue, surgical intervention is used. As a result of the operation, the foci of the disease are completely removed. Depending on the degree and complications, surgical intervention can be performed in various types:

• resection;
• electrocoagulation;
• laser vaporization;
• laparotomy;
• abdominal surgery.

Sometimes abdominal surgery may be necessary to treat endometriosis

The operation allows you to take biological material for a biopsy study. Conservative treatment after surgery, a long course of taking hormonal hormones is required contraceptives. Tablets are prescribed for a course of 3, 6 and 9 months. Hormone therapy drugs are most often prescribed with a high content of estrogens and gestagens. The tablets act in endometriotic lesions and can prevent cyclic changes.

Before prescribing treatment with hormonal, contraceptive, oral therapy, a detailed examination is carried out functional indicators ovaries.

Treatment of progressive disease

Surgery for endometriosis is prescribed if there are serious indications. Gynecologists classify the need for surgical intervention when:

1. Retrocervical location of endometriosis.
2. The presence of endometriosis on the ovaries.
3. Combination of endometriosis with uterine tumors.
4. Progression of the disease to the third or fourth degree.
5. For the nodular type of endometriosis.
6. Presence of contraindications to hormonal therapy.

The choice of operating method remains with the gynecologist-surgeon. Surgery for internal endometriosis is prescribed after a thorough, multi-stage examination. If there are clinical indications, laparoscopy is performed.

Before the operation, appointments are made hormonal pills, which in this case are aimed at reducing foci of endometriosis and reducing pathological activity.

The purpose of the operation is to eliminate operationally foci of pathology. Regardless of clinical indicators, surgeons strive to preserve the uterus and female reproductive function.