Modern gynecology: diagnostic methods. Methods for examining gynecological patients

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Diagnosis of gynecological diseases

To diagnose diseases of the female reproductive system, the SM-Clinic uses all the possibilities provided by modern medicine.

Every woman should take care of her health and regularly visit a gynecologist. If you are worried about pain in the lower abdomen, itching and burning in the genitals, the menstrual cycle has gone wrong, or other unpleasant symptoms have appeared, the doctor at our clinic will conduct a comprehensive examination and identify the cause of the disease.

It should be borne in mind that many diseases of the reproductive system can develop asymptomatically up to a certain point. Therefore, SM-Clinic doctors recommend that women undergo preventive examinations with a gynecologist once every six months. This is necessary in order to preserve women’s health and promptly detect possible diseases before they cause serious complications.

Gynecological examination

The first stage of the diagnostic examination: conversation with a gynecologist and examination. The doctor will listen carefully to your complaints, collect anamnesis and fill out a chart. A gynecological examination, which is carried out during an appointment on a special chair, allows the doctor to visually assess general state a woman, the condition of her genital organs, the presence of symptoms of inflammatory processes or pathologies.

Depending on the results of the initial examination, the doctor may recommend an extended gynecological examination or additional examinations.

Hardware and instrumental diagnostics in gynecology

• Colposcopy– examination of the vagina and cervix with a digital video colposcope. An image enlarged approximately 40 times is displayed on the monitor, in which pathologically changed areas are clearly visible.
• Hysteroscopy – effective technique necessary for examining the uterine cavity. The gynecologist inserts an optical probe through the cervix, allowing all manipulations to be carried out. The procedure is absolutely safe and does not cause discomfort, as it is performed under general or local anesthesia. Directly during hysteroscopy, the doctor has the opportunity to separate adhesions or even remove small polyps.
• Hysterosalpingography is prescribed if the doctor suspects obstruction of the fallopian tubes. The procedure is also recommended for patients who have uterine malformations, polyps or endometrial growth. A contrast agent is injected into the uterine cavity, allowing high-quality x-rays. Hysterosalpingography is completely painless.
• Ultrasound of the pelvic organs- the most common diagnostic method used to detect pathologies of the ovaries, fallopian tubes and the uterus itself. Ultrasound is also prescribed during pregnancy to monitor the development of the baby.

In addition, the doctor may order x-rays, magnetic resonance imaging, or computed tomography for additional information and clarification of the diagnosis.

Laboratory tests (tests) in gynecology

In gynecology, in addition to general laboratory research There are specific tests to diagnose various diseases And pathological changes.

Among them, the most popular methods are:

• Express diagnosis of infections using PCR. Very often, various sexually transmitted infections provoke inflammatory diseases of the pelvic organs. The main task of the doctor is to identify the pathogen, after which special drug therapy is prescribed.
• Tests for sex hormones. If a patient has menstrual irregularities, mastopathy or endometriosis is detected, the doctor must check the level of the most important sex hormones: progesterone, prolactin, testosterone, estrogen, FSH and LH. In addition, hormonal imbalances can cause infertility.
• Gynecological smears. A popular diagnostic method for complaints of burning, itching and discharge.
• Cultures and sensitivity testing. To prescribe treatment, the doctor must find out what the causative agent of the disease is and how sensitive it is to certain medications.
• Biopsy with further cytological examination. The gynecologist takes cells to determine the presence or absence of cancer cells.
• Oncocytology and tests for tumor markers. They are prescribed in combination to eliminate the risk of developing a malignant process.
• Definition of pregnancy. Already from the first weeks of pregnancy, when specific symptoms are still absent, the amount of hCG in the woman’s blood increases, which is also called the pregnancy hormone.

Gynecological diagnostics at the European level

Modern European medicine gives great importance regular health monitoring and prevention. This helps prevent disease and improve quality of life at any age.

Gynecological diagnostics should normally be carried out not only in the presence of symptoms of any disorders, but also regularly, twice a year, in a check-up format. This approach to women's health helps to prolong youth and avoid many serious problems, because often dangerous gynecological diseases are asymptomatic.

And of course, it is especially important to immediately contact the Clinic for a gynecological examination if symptoms such as:

• discomfort or pain in the lower abdomen and genital area;
• discharge that is unusual in quantity, color or consistency;
• any menstrual irregularities;
• itching, burning, the appearance of erosions, cracks, spots on the mucous membrane;
• unpleasant sensations and discomfort during or after sexual intercourse.

The role of gynecological diagnostics is wider than is commonly believed

Diagnostics in gynecology certainly plays a role important role. A timely diagnosed disease is easier to cure and does not entail serious consequences. This is especially important because the health of the female reproductive system actually affects all major aspects of a woman’s life: it directly affects appearance, self-confidence, and determines the ability to conceive and successfully bear a healthy child.

However, the role of gynecological diagnostics is not limited to this. Modern diagnostics in gynecology, among other things, it allows to identify or exclude possible contraindications to a whole range of cosmetological, aesthetic and medical procedures, which increases their effectiveness and safety, and helps to avoid risks. In particular, at GMTCLINIC, gynecological diagnostics can be prescribed by a doctor before undergoing a course of figure correction procedures. In addition, diagnostics in the field of gynecology and endocrinology help to identify some of the factors that influence aging and determine how their impact can be reduced.

Diagnostics in gynecology at GMTCLINIC. A full range of. High quality.

The Clinic of German Medical Technologies offers consultation and expert diagnostics from experienced specialists in the field of gynecology and endocrinology, as well as access to the most modern diagnostic methods using the best diagnostic equipment and laboratory diagnostic capabilities.

One of the main methods of gynecological diagnostics is informative and safe ultrasound examinations. Ultrasound diagnostics in gynecology, including during pregnancy, are carried out at the Clinic of German Medical Technologies using high-precision ultrasound machines of the latest generation PHILIPS brand. Thanks to the high sensitivity of the device and the qualifications of ultrasound specialists, the information content of this type of study in GMTCLINIC is maximum!

As part of instrumental diagnostics in gynecology, GMTCLINIC performs simple colposcopy and extended video colposcopy - a painless examination of the vagina, cervix, and cervical canal using a special video colposcope device. Among other things, this technique allows us to exclude oncological diseases, which are especially dangerous due to late diagnosis, since they are asymptomatic.

Laboratory diagnostics in gynecology are also carried out at the Clinic of German Medical Technologies wide range. The clinic cooperates with reputable laboratories in Moscow and guarantees utmost accuracy and efficiency. At the Clinic you can take all the tests necessary for diagnostics in gynecology - from a smear for flora and oncocytology, to the Schiller test and cervical biopsy. Express diagnostics and treatment of sexually transmitted diseases are also carried out.

Professional, accurate and prompt diagnosis in gynecology requires modern equipment and experienced specialists. The Clinic of German Medical Technologies is at your service highest level diagnostics that meet strict European standards. Make an appointment with a gynecologist at GMTCLINIC for diagnosis if you have any symptoms that concern you or undergo regular preventive examination. We guarantee accuracy, efficiency, comfort and anonymity of any research. With us you can be sure: your health is in reliable and professional hands.

Price list

Today, a number of methods are used to diagnose gynecological ailments, each of which has its own characteristics and advantages. The choice of the optimal diagnostic option depends on the recommendations of the attending physician, as well as on the specific situation in which a particular patient finds himself. Today we will talk about the most popular diagnostic methods, identify their nuances, as well as strengths and weaknesses.

Colposcopy is the optimal and effective option for gynecological diagnosis

Among the variety of methods available today for diagnosing “female” ailments, colposcopy rightfully occupies a leading position, allowing timely and highly accurate diagnosis of various diseases in the uterine area, as well as selecting the most effective treatment options for the problem. In addition, the use of colposcopy allows for constant monitoring of the condition of the epithelium of the vagina and cervix.

The study is carried out using a special device - a colposcope, which is an improved variation of a conventional microscope and allows you to examine pathological changes at a variety of magnifications. In addition, the colposcope is equipped with a device for storing the obtained photo and video material, which allows you not only to evaluate the results in the dynamics of the examination, but also to consult with other doctors, without the need for a repeat examination. The results of the examination are presented in the form of a verbal description and a series of color photographs of the problem organ.

There are the following types of colposcopy:

1. Simple – which does not involve taking medications;
2. Extended - involves examination of epithelial tissues, taking into account their reaction to pre-treatment with drugs.

Examination by a doctor: forced measure or necessity

A preventive examination by a doctor is a necessary procedure that allows not only to prevent the development of a number of gynecological diseases, but also to identify them at an early stage, significantly facilitating treatment and reducing the harm caused to the human body. It usually includes a general assessment of the patient’s condition, as well as a thorough examination of the reproductive system. Its implementation is mandatory, and the frequency of visits should be at least 2 times a year.

Experts advise that before visiting a gynecologist, carry out appropriate preparation, which will increase the information content of the examination performed. It involves emptying Bladder and intestines. You should also take care of maintaining hygiene in the area of ​​the external genitalia.

First of all, the doctor conducts the most detailed survey of the patient, clarifies whether she has any complaints and possible chronic diseases. It is also mandatory to clarify gynecological history indicators - the period when sexual activity began, the number of births, and possibly abortions, duration, frequency and progression of the menstrual cycle. And no matter how insignificant and insignificant these factors may seem to an outside observer, in fact it is very, very problematic to overestimate their importance and necessity.

If necessary, it is also carried out general research– the patient’s weight and height are measured, the thyroid and mammary glands are examined.

The final stage of a visit to a gynecologist includes an examination directly on the gynecological chair, consisting of several procedures. First of all, an examination of the external genitalia is performed to identify possible pathologies, inflammatory processes or condylomas. Next, using a mirror, the doctor examines the cervix and vaginal walls, which makes it possible to diagnose tumors, the presence of erosion or inflammatory processes. A smear is also taken here for further examinations.

Based on the results of the examination, the doctor fills out the patient’s card, indicating in detail all the information received, and, if necessary, prescribes a course of appropriate treatment.

Taking an anamnesis: information you can’t do without

Anamnesis is a collection of information and data that the doctor receives during the process of interviewing the patient and uses in the future to make a diagnosis, choose the optimal direction of treatment and predict the development of the existing disease. Provided that the patient is in serious or unconscious, anamnesis is collected based on interviews with surrounding people or relatives. And only after it is completely collected do they proceed to conduct an objective examination. Following this particular order is not only desirable, but also expedient, since it allows you to establish contact with the person, which is extremely important for further diagnosis and treatment, as well as determining an effective plan for all subsequent actions.

Despite the large selection of laboratory and instrumental diagnostic techniques, it is the collection of anamnesis that is so important and useful, especially with regard to identifying the initial stages of the disease. In the vast majority of cases, the medical history should include the following data and indicators:

• Age of the admitted patient;
• Complaints and pronounced symptoms;
• Diseases that were suffered previously, including in childhood, existing injuries and surgical interventions;
• Heredity factors - information about the diseases that the parents had, as well as the health status of the spouse or sexual partner;
• Lifestyle, features of work and life.

Ultrasound – painless diagnosis of female diseases

Ultrasound examination (ultrasound) is the latest non-invasive diagnostic technique in which the examination is carried out using ultrasound waves. The essence of this method lies in the unique ability of an ultrasonic wave to “reflect” from internal human tissues and organs that have very different densities. As the signal is reflected, it enters a special amplifier and repeater, which convert the information into a graphic image.

Today, ultrasound is generally accepted diagnostic procedure, which allows you to identify all existing diseases with a high degree of efficiency. Among the main advantages of this technique, it is worth highlighting its information content, safety for the patient and painlessness, breadth of use and accessibility.

The use of ultrasound is relevant in the following situations:

• For preventive purposes;
• If there is pain or discomfort;
• During the control examination;
• As prescribed by the attending physician or before an appointment with him.
• Using this method allows you to diagnose a number of different ailments with a high degree of accuracy, including:
• Various neoplasms in the liver area;
• Pre-tumor formations and formed tumors in the pancreas area;
• A number of problems with the genitourinary system, including tumors on different stages development;
• Various pathologies that form in lymphatic system;
• Problems with the adrenal glands and thyroid gland.

MRI is a technique that combines all the delights of modern diagnostics

Magnetic resonance imaging is in extremely high demand today, allowing you to obtain the maximum full information about the pathology that forms in any organ of the human body and about its anatomy.

MRI is carried out using a tomograph, the operating principle of which is based on the interaction of a magnetic field and radio waves emanating from it, which interact with carbon particles present in the human body. As a result, this makes it possible to obtain high-quality images of body parts taken in a variety of planes. The use of MRI occurs without X-ray radiation and penetration into the body, which makes the procedure completely harmless and safe for humans. The only thing that can cause some discomfort is the need to remain motionless for some time, as well as the excessive noise and clicks of the scanner that accompany the procedure.
Diagnosis using MRI allows you to detect, among other things, the following ailments:

• Formations in the spinal cord and brain;
• Hemorrhages and strokes;
• Various processes atrophic and inflammatory in nature;
• Damage to the body of a toxic type;
• Pathologies various organs, joints, vessels of the head and neck;
• Problems with the development of the body and anomalies in it;
• Injuries of a very different nature;
• Hernias in intervertebral discs and osteochondrosis.

Laparoscopy is a diagnostic that has no equal

Considering the variety of options presented today for diagnosing gynecological ailments, it is worth mentioning separately about one of them, such as laparoscopy. This technique successfully combines not only a diagnostic examination, but also surgical intervention performed on the internal organs of a person. The bottom line is this: in the area of ​​the abdominal cavity, the doctor makes several miniature punctures through which everything is introduced inside necessary equipment and devices, including a laparoscope. This is a special device equipped with a video camera, the image from which is sent to the monitor. According to statistics, about 95% of all carried out today surgical interventions performed by laparoscopy.

There are the following types of laparoscopy:

1. Diagnostic – used exclusively for visual inspection internal organs included in the reproductive system. As a rule, for most patients with problems with reproductive function, diagnostic laparoscopy is not just desirable, but a necessary procedure;
2. Surgical – used for the prompt and effective elimination of problems discovered as a result of the examination (adhesions, adhesions, endometriosis, cysts and neoplasms, myomatous nodes).

Among the main advantages of laparoscopy, the following are especially worth highlighting:

• Maximum precise setting diagnosis;
• Carrying out the intervention with minimal blood loss;
• Clear visualization of problem organs during surgery;
• Short time conducting an intervention;
• Minor cosmetic defects;
• Painless and short lasting recovery period(up to 10 days with the most unfavorable outcome).

Hysteroscopy is a highly effective technology for detecting ectopic pathologies

Today, hysteroscopy is one of the most popular methods of gynecological diagnosis, in which the examination of the uterine cavity is carried out using a special optical system. Usage this method allows you to identify with a high degree of efficiency various pathologies ectopic nature, causes of infertility and bleeding in the uterine area, carry out topical diagnosis, and, if necessary, targeted biopsy or surgical intervention.

During the examination, a special telescopic instrument is used - a hysteroscope, equipped with backlight. Using fiber optic technology, the hysteroscope transmits the resulting image to a large monitor, allowing the doctor to carry out the procedure with the greatest possible accuracy and efficiency.

In general, hysteroscopy is classified as follows:

1. Diagnostic – used to diagnose various problems associated with the uterus, as well as to confirm the results obtained using other methods;
2. Operative – used to cure those pathologies that were identified during the diagnostic process.

Hysteroscopy is relevant in the following cases:

• Uterine pathologies;
• Problems with the menstrual cycle;
• Bleeding in the uterus;
• Suspicion of fibroids or uterine perforation;
• Problems with intrauterine synechia and endometrial pathologies.

Gynecology- teaching, science about women (from the Greek gyne - woman, logos - teaching), which studies the anatomical and physiological characteristics of the female reproductive system and its diseases, diagnostic methods, treatment and prevention.

Examination of gynecological patients consists of a survey and an objective examination. Diagnosis and treatment of gynecological diseases is impossible without a thorough collection and assessment of anamnesis data, which is divided into general and special gynecological. Objective examination also includes general and special methods of gynecological examination.

The collection of anamnesis begins with clarifying passport data (particular attention is paid to the patient’s age), the patient’s complaints, and identifying the possibility of hereditary diseases in close relatives. The patient's age is important due to the fact that various gynecological diseases are characteristic of a certain age.

The following age periodization is currently accepted:

• 1. Newborn period (1-10 days).
• 2. Childhood period (up to 8 years)
• 3. Puberty (8-18 years), which is divided into stages:
  • · prepubertal (7-9 years)
  • Puberty (10-18 years)
• 4. Reproductive period (18-45 years)
• 5. Perimenopausal (menopausal) period (45-55 years)
• Premenopause (from 45 years to the last menstruation)
• Menopause (1 year after last menstruation)
• 6. Postmenopause (after menopause until the end of life)

Rational anamnesis chart presented like this:

• 1. Passport data (full name, gender, age, place of residence, place of work, position).
• 2. Living conditions.
• 3. Related complaints.
• 4. Past diseases: childhood diseases, somatic, infectious (including Botkin's disease) operations, injuries, heredity, allergic history, blood transfusions, husband's diseases.
• 5. Lifestyle, nutrition, bad habits, working and living conditions.
• 6. Special obstetric and gynecological history:
• 1) the nature of menstrual, sexual, reproductive, secretory functions;
• 2) previous gynecological diseases and genital surgeries;
• 3) previous urogenital and venereal diseases,
• 7. History of the present illness.

Gynecological examination- a set of methods for studying the female reproductive system, which is divided into the main ones used in the examination of all patients in mandatory, and additional, i.e. according to indications and depending on the presumptive diagnosis.

Basic methods

• 1. Examination of the external genitalia is performed after emptying the bladder and, preferably, the intestines, in the position of the patient on the gynecological chair on her back with her knees bent and hip joints feet. The study is carried out using disposable rubber gloves. Attention is drawn to the nature and degree of hair growth, the size of the labia minora and majora, the presence of pathological processes - ulcers, swelling, hypertrophies, fistulas, scars, varicose veins, etc. By spreading the labia with the thumb and index finger of the left hand, the vestibule of the vagina, the external opening of the urethra, the paraurethral passages, the hymen and the excretory ducts of the large vestibular glands, and discharge are examined. The clitoris is examined, its shape and size are determined.
• 2. Inspection using mirrors precedes a vaginal examination and is accompanied by taking smears for bacterioscopic and cytological examination. Vaginal specula can be cylindrical, folded or spoon-shaped. Having exposed the cervix, they examine its shape, the presence of scars, ulcers, polyps, fistulas, the condition of the vaginal walls, etc.
• 3. Internal study- divided into vaginal (one-handed), bimanual (vaginal-abdominal or two-handed), rectal and rectovaginal. Vaginal examination is performed with the second and third fingers of the right hand. First you need to spread the labia majora and minora with your left hand, then pull the posterior commissure of the vagina downwards with the third finger of your right hand and then carefully insert the second finger. In this case, the thumb is directed to the symphysis (without touching the clitoris), ring finger and the little finger are pressed against the palm, and the back of their main phalanges rests against the perineum. The condition of the vagina, volume, folding, distensibility, the presence of pathological processes, vaginal vaults, the area of ​​the large vestibular glands, the urethra, and part of the cervix are assessed.

During a vaginal-abdominal or bimanual (two-handed) examination, the condition of the uterus, appendages, ligaments, pelvic peritoneum and tissue, as well as neighboring organs, is determined. When palpating the uterus, its position, size, shape, consistency, and mobility are determined. To inspect the appendages, move the fingers of the inner hand to the left lateral fornix, while simultaneously moving the outer hand to the left inguinal-aerial region, and the right appendages are examined in the same way. Normally, the tubes and ovaries are usually not palpable.

Rectal and rectovaginal examination is used in girls, women with vaginal stenosis or atresia, or to obtain additional information. This study helps to palpate the posterior surface of the uterus, tumors and infiltrates in the retrouterine space.

TO additional research methods relate:

Bacterioscopic examination allows you to establish a type of microbial factor in the vagina, cervical canal and urethra. Pathological secretion - leucorrhoea can be a manifestation of disease in different parts of the genital organs. There are tubal leucorrhoea, uterine or corporal (endometritis, initial stage of endometrial cancer), cervical (endocervicitis, erosion, polyps, etc.).

Cytological examination is one of the most important diagnostic methods(oncocytology), which allows identifying pathological changes in cells. The material is obtained from the surface of the cervix, cervical canal, from the uterine cavity, pleural and abdominal cavities using a spatula, cervical cytobrush, by aspiration of the contents of the uterine cavity or tumor, abdominal cavity, and also by the method of fingerprint smears.

Instrumental research methods

Probing of the uterus carried out to determine the patency of the cervical canal, the length of the uterus, deformation of the uterine cavity and developmental anomalies, the presence of a tumor. It is used before curettage of the uterine cavity or amputation of the cervix.

Separate diagnostic curettage mucous membrane of the uterine body and cervical canal is widely used for suspected malignant tumor, endometrial polyposis, uterine bleeding of unknown etiology.

Methodology: under aseptic conditions, a spoon-shaped speculum is inserted into the vagina and bullet forceps are applied to the anterior lip of the cervix. First, the mucous membrane of the cervical canal is scraped out with a small curette without expansion and the scraping is placed in a 10% formaldehyde solution. Then the uterine cavity is probed, the length of the uterus and its position are determined. Using Hegar dilators, the cervical canal is widened and the uterine mucosa is scraped out with a curette from the fundus to the cervical canal, the uterine angles are carefully scraped out. The scraping is also placed in a 10% formaldehyde solution, and both scrapings are sent to the laboratory for histological examination.

Biopsy used for pathological processes of the cervix, vagina or external genitalia. It is performed after a colposcopic examination of the cervix.

Methodology: under aseptic conditions, the cervix is ​​exposed, bullet forceps are applied to both sides of the area to be removed, and the pathological area is excised between them with a scalpel. The biopsy can be taken with a conchotome, or with diathermoexcision, or with the help of a CO 2 laser, or a radioknife. The resulting material in a 10% formaldehyde solution is sent for histological examination.

Endoscopic methods

Colposcopy- examination of the cervix and vaginal walls with a magnification of 10-30 times or more. This allows us to identify early forms precancerous conditions, select the area most suitable for biopsy. If you have a photo attachment, it is possible to document detected changes. Stands out simple colposcopy, those. examination of the cervix with determination of the relief of the mucous membrane, the border of the squamous epithelium covering the cervix, and the columnar epithelium of the cervical canal.

Extended colposcopy, when the examination is carried out after treating the cervix with a 3% solution of acetic acid, which causes short-term swelling of the epithelium, swelling of the cells of the spinous layer and a decrease in blood supply. The action of acetic acid lasts 4 minutes. After examining the cervix with a colposcope, a Schiller test is performed - the cervix is ​​lubricated with 3% Lugol's solution. Iodine contained in the solution stains glycogen in the cells of healthy, unchanged squamous epithelium of the cervix in dark brown color, and pathologically altered cells are poor in glycogen and are not stained.

Colpomicroscopy- intravital histological examination of the vaginal part of the cervix. Before examination, the cervix is ​​stained with a 0.1% hematoxylin solution, and the tube of a contrast fluorescent colposcope is brought directly to the cervix. In the unchanged neck, squamous epithelial cells have a polygonal shape, clear boundaries, cell nuclei are colored violet, the cytoplasm is blue, subepithelial vessels are uniform, straight, their bed is not expanded.

Hysteroscopy- examination of the walls of the uterine cavity using optical systems. Currently, hysteroscopy in combination with histological examination is the gold standard in diagnosing endometrial conditions.

Types of provocations

• 1. Chemical provocation - lubricating the urethra to a depth of 1-2 cm with a 1-2% solution of silver nitrate, the lower rectum to a depth of 4 cm with a 1% Lugol's solution in glycerin.
• 2. Drug provocation - intramuscular injection gonovaccine containing 500 million microbial bodies (mt), or gonovaccine simultaneously with pyrogenal (200 µg).
• 3. Thermal provocation - diathermy is carried out daily for 3 days consecutively for 30,40,50 minutes. Or iductothermy for 3 days for 15-20 minutes.
• 4. Biological methods provocations - these include the physiological menstrual cycle in women. The analysis is scheduled for 4-5 days of the cycle.

Method of taking a smear

gynecological biopsy colposcopy uterus

When taking material, the nurse should remember the need to follow the rules of asepsis and antisepsis. To take smears, only sterile instruments are used (the same instrument cannot be used to take smears from different places). Smears are taken before a gynecological examination of the patient, as well as before vaginal medical procedures.

A smear is taken from a woman in a lying position on a gynecological chair. First of all, swabs are taken from the urethra; for this, a finger inserted into the vagina is gently massaged. The first portion of discharge from the urethra should be removed with a cotton ball, and then inserted into the urethra (to a depth of no more than 1.5-2 cm) the tip of the tweezers or a special spoon (Volkmann). The material from the urethra is obtained by lightly scraping and applied in the form of a circle on two glass slides with a U mark.

STATE EDUCATIONAL INSTITUTION OF HIGHER PROFESSIONAL EDUCATION

OMSK STATE MEDICAL ACADEMY

FEDERAL AGENCY FOR HEALTH AND SOCIAL DEVELOPMENT

METHODOLOGICAL DEVELOPMENT

TO practical lesson with students on a cycle "obstetrics and gynecology"

SUBJECT: « METHODS OF EXAMINATION IN GYNECOLOGY. DEONTOLOGY IN MEDICINE"

1. LESSON TOPIC: Examination methods in gynecology. Deontology in medicine

2. FORM OF ORGANIZATION OF THE EDUCATIONAL PROCESS:

Practical lesson.

3. SIGNIFICANCE OF THE TOPIC:

It is necessary to teach students how to collect anamnesis from gynecological patients, how to conduct gynecological examination. To become familiar with modern examination methods in gynecology such as laparoscopy, hysteroresectoscopy, extended colposcopy and other methods used both in outpatient and inpatient settings.

4. LEARNING OBJECTIVE:

Introduce students to examination methods in gynecology

5. PLACE OF THE CLASS:

Training room, ORiPM, gynecological department

6. CLASS EQUIPMENT

1. slides, film

2. Phantom.

3. Outpatient cards gynecological patients

4. Tables.

7. Issues studied in related disciplines

Department of Medical Biology with Basics of Genetics

8. DURATION OF THE CLASS

Organizational part - 10 minutes.
Control of the initial level of knowledge - 25 minutes.

Theoretical understanding of the problem - 100 minutes.
Assignments to master the topic of the lesson - 25 minutes.
Conclusion - 20 minutes.

Questions for preparation:

1. Anamnesis collection

2.Objective research:

A) general examination

b) examination of internal organs

3.Special gynecological examination:

a) inspection in the mirrors

b) bimanual examination

4. Methods for examining gynecological patients on an outpatient basis

5.Modern research methods in gynecology

a) laparoscopy

b) diagnostic hysteroscopy, hysteroresectoscopy

c) echo - GSSG

d) extended colposcopy

History and examination of gynecological patients

Scheme for collecting anamnesis of gynecological patients:
chief complaints;
additional complaints;
past illnesses;
menstrual and reproductive functions, contraception;
gynecological diseases and genital surgeries;
family history;
lifestyle, nutrition, bad habits, working and living conditions;
history of present illness.

Upon examination, the body type is determined:
female;
male ( high growth, broad shoulders, long body, narrow pelvis);
eunuchoid (tall, narrow shoulders, narrow pelvis, long legs, short torso).
Significant deviations in body type give an idea of ​​the characteristics of puberty. Thus, with hyperandrogenism in the puberty period, a male or virile body type is formed, and with insufficiency of the hormonal function of the ovaries, the body type acquires eunuchoid features.
Phenotypic features: dysplasia and dysmorphia (micro- and retrognathia, arched palate, wide flat nose bridge, low ears, short stature, short neck with skin folds, barrel-shaped chest, etc.), characteristic of various clinical forms of disorders of the development of the gonads.
Hair growth and condition skin : excessive hair growth, skin condition (increased greasiness, acne, folliculitis, increased porosity), stretch marks, their color, number and location.
Condition of the mammary glands: size, hypoplasia, hypertrophy, symmetry, changes in the skin. With the patient in a standing and lying position, sequential palpation of the outer and inner quadrants of the gland is carried out. It is necessary to note the absence or presence of discharge from the nipples, its color, consistency and character. Brown discharge from the nipples or an admixture of blood indicates a possible malignant process or papillary growths in the ducts of the mammary gland; liquid transparent or greenish discharge is characteristic of cystic changes in the gland. The appearance of milk or colostrum when pressing on the areola in combination with amenorrhea or oligomenorrhea allows us to establish the diagnosis of galactorrhea-amenorrhea - one of the forms of hypothalamic disorders of reproductive function. In this situation, it is also necessary to exclude a prolactin-secreting pituitary adenoma.

Nodes in the mammary glands, determined by palpation, serve as an indication for ultrasound of the mammary glands and mammography.

Determination of body length and weight necessary to calculate body mass index (BMI) - the ratio of body weight to the square of body length:

BMI = Body weight (kg) / Body length² (m)

The normal BMI of a woman of reproductive age is 20-26. A BMI over 40 (corresponds to stage IV obesity) indicates a high likelihood of metabolic disorders.
At overweight body, it is necessary to find out when obesity began: from childhood, at puberty, after the onset of sexual activity, after abortion or childbirth.

Abdominal examination carried out with the patient lying on her back. During palpation, the size of individual organs is determined, ascites, flatulence, volumetric formations. Palpation begins by determining the position, consistency and shape of the edge of the liver. The size of the liver is determined by percussion. Then the remaining abdominal organs are palpated clockwise. After this, auscultation of the abdomen is performed. Intestinal peristalsis is noted.
By palpation, the condition of the abdominal wall is determined (tone, muscle protection, diastasis of the rectus abdominis muscles), painful areas, the presence of tumors and infiltrates in the abdominal cavity.
Abdominal examination can provide very valuable information. Thus, if a patient with a pelvic mass is found to have a mass in the epigastric or umbilical region, ovarian cancer with metastases to the greater omentum should be excluded.

Gynecological examination carried out on a gynecological chair. The patient's legs lie on supports, buttocks on the edge of the chair. In this position, you can examine the vulva and easily insert a speculum into the vagina.
Examination of the external genitalia: condition and size of the labia minora and labia majora; condition of the mucous membranes (juiciness, color, condition of cervical mucus); size of the clitoris; development hairline; condition of the perineum; the presence of pathological processes (inflammation, tumors, ulcerations, condylomas, fistulas, scars). Hypoplasia of the labia minora and majora, pallor and dryness of the vaginal mucosa indicate hypoestrogenism. Juiciness and cyanosis of the vulvar mucosa, abundant transparent secretion are signs of hyperestrogenism. Hypoplasia of the labia minora, enlargement of the clitoral head, increase in the distance between the base of the clitoris and the external opening urethra(more than 2 cm) in combination with hypertrichosis indicate congenital adrenogenital syndrome. Pay attention also to the gaping of the genital slit; Having asked the woman to push, they determine whether there is prolapse or prolapse of the walls of the vagina and uterus.
Examination of the vagina and cervix in speculums carried out for women who are sexually active. Timely recognition of cervical cancer, erosions, polyps and other diseases related to precancerous conditions is possible only with the help of mirrors. Particular attention is paid to the vaginal vaults, since space-occupying formations and genital warts are often located there. During the examination in the speculum, smears are taken for flora, cytological examination, and a biopsy of space-occupying formations of the cervix and vagina is possible.
Bimanual the study is carried out after removing the mirrors. Index and middle fingers one gloved hand (usually the right) is inserted into the vagina. The other hand (usually the left) is placed on the front abdominal wall. Right hand palpate the walls of the vagina, its fornix and the cervix, note any space-occupying formations and anatomical changes. Then, carefully inserting your fingers into the posterior vaginal fornix, move the uterus forward and upward and palpate it with the second hand through the anterior abdominal wall. The position, size, shape, mobility, consistency and mobility of the uterus are noted, and attention is paid to space-occupying formations.
Rectovaginal examination mandatory in postmenopause, as well as in all cases when it is necessary to clarify the condition of the uterine appendages. Some authors suggest performing it on all women over 40 years of age to exclude concomitant diseases rectum. A rectal examination determines the tone of the anal sphincters and the condition of the muscles. pelvic floor, exclude space-occupying formations: internal hemorrhoids, tumor.

Special methods for studying gynecological patients

Functional diagnostic tests

Functional diagnostic tests, used to determine the functional state of the reproductive system, have still not lost their value.
"Pupil" symptom allows us to judge the production of estrogen by the ovaries. With a two-phase menstrual cycle, the external opening of the cervical canal begins to expand from the 5th day of the cycle, reaching a maximum at the time of ovulation. In the second phase of the cycle, the external uterine os begins to gradually close, and there is no mucus in its lumen.
Sprain symptom cervical mucus also allows us to judge the production of estrogen by the ovaries. The maximum stretch of the mucous thread from the cervical canal occurs at the time of ovulation and reaches 10-12 cm.
Karyopyknotic index (KPI)- the ratio of keratinizing and intermediate cells during microscopic examination of a smear from posterior arch vagina. During the ovulatory menstrual cycle, the CPI is: in the first phase 25-30%, during ovulation - 60-80%, in the middle of the second phase - 25-30%.
Basal temperature(temperature in the rectum) depends on the phase of the menstrual cycle. During an ovulatory cycle with a full first and second phase, the basal temperature rises by 0.5 °C immediately after ovulation and remains at this level for 12-14 days. The rise in temperature is due to the influence of progesterone on the thermoregulation center (Fig. 1.3). If the second phase of the cycle is insufficient, the hyperthermic phase lasts less than 8-10 days, rises stepwise or periodically falls below 37 ° C. During anovulation, the temperature curve remains monophasic (Fig. 1.4).

Rice. 1.3

Rice. 1.4

Histological examination of endometrial scraping remains an accurate method for assessing ovarian function. Secretory endometrium, removed during curettage of the uterus 2-3 days before the onset of menstruation, indicates with an accuracy of 90% that ovulation has occurred.

Tissue biopsy and cytological examination

Biopsy- intravital removal of a small volume of tissue for microscopic examination for diagnostic purposes. In gynecology, excisional (excision of a piece of tissue), targeted (under visual control using a colposcope or hysteroscope) and puncture biopsy are used.
A biopsy is most often performed if a malignant tumor of the cervix, external genitalia, vagina, etc. is suspected. Cytological diagnosis. Cells obtained from cervical smears, punctate (pelvic mass formations, fluid from the retrouterine space) or aspirate from the uterine cavity are subjected to cytological examination. The pathological process is diagnosed by the morphological characteristics of cells, the quantitative ratio of individual cell groups, and the location of cellular elements in the preparation.
Cytological studies are a screening method for mass preventive examinations female population, primarily in high-risk groups.

Determination of hormones and their metabolites

In gynecological practice, protein (lutropin - LH, follitropin - FSH, prolactin - Prl, etc.) and steroid hormones (estradiol, progesterone, testosterone, cortisol, etc.) are determined in blood plasma. Metabolites of androgens (17-ketosteroids - 17-KS) and pregnanediol, a metabolite of the corpus luteum hormone progesterone, are determined in the urine.
In recent years, when examining women with manifestations of hyperandrogenism and conducting hormonal tests, instead of determining 17-CS in urine, the content of dehydroepiandrosterone (DEA) and its sulfate (DEA-S) and 17-hydroxyprogesterone (17-OPN) - precursors of testosterone and cortisol, respectively, and testosterone itself. The determination of pregnanediol has also given way to the study of progesterone in the blood.
Functional tests. A single determination of hormones and their metabolites in the blood and urine is not very informative; these studies are combined with functional tests, which makes it possible to clarify the functional state of various parts of the reproductive system and determine the reserve capabilities of the hypothalamus, pituitary gland, adrenal glands, ovaries and endometrium.
Test with gestagens determines the degree of estrogen and progesterone deficiency in diseases accompanied by amenorrhea. Intramuscularly inject 1 ml of 1% (10 mg) oil solution of progesterone daily for 6-8 days or 1 ml of 2.5% (25 mg) oil solution of progesterone every other day (3 injections in total) or 2 ml of 12.5% ​​(250 mg) oil solution of 17-hydroxyprogesterone capronate (17-OPK) simultaneously. The appearance of a menstrual-like reaction 2-4 days after discontinuation of progesterone or 10-14 days after administration of 17-OPK indicates a moderate deficiency of estrogen and a significant deficiency of gestagens. A negative test may mean profound estrogen deficiency or organic changes in the endometrium ( intrauterine synechiae).
Test with estrogens and gestagens carried out to exclude (confirm) disease or damage to the endometrium (uterine form of amenorrhea) and to determine the degree of estrogen deficiency. 1 ml of 0.1% (10 thousand units) folliculin oil solution is injected intramuscularly daily for 7 days. Injections can be replaced by oral ethinyl estradiol (microfolline) at a dose of 0.1 mg (2 tablets) daily for 7 days. Then progesterone is administered in the doses indicated for the test with gestagens. 2-4 or 10-14 days after the administration of progesterone or 17-OPK, respectively, a menstrual-like reaction should begin. The absence of such a reaction indicates profound organic changes in the endometrium (damage, disease). A positive result indicates a pronounced deficiency of endogenous estrogens, and not endometrial pathology.
Test with dexamethasone carried out to establish the cause of hyperandrogenism in women with signs of virilization, primarily to exclude an ovarian tumor.
The test is based on the ability of dexamethasone (like all glucocorticosteroids) to suppress the release of ACTH by the anterior pituitary gland, as a result of which the formation and release of androgens by the adrenal glands is inhibited.
Small dexamethasone test: dexamethasone 0.5 mg every 6 hours (2 mg/day) for 3 days, total dose 6 mg. 2 days before taking the drug and the next day after its discontinuation, the content of testosterone, 17-OPN and DHEA in the blood plasma is determined. If this is not possible, the content of 17-KS in daily urine is determined. When these indicators decrease by more than 50-75% compared to the initial ones, the test is considered positive, which indicates the adrenal origin of androgens; a decrease of less than 30-25% means the ovarian origin of androgens.
If the test is negative, a large dexamethasone test is performed, taking dexamethasone 2 mg (4 tablets of 0.05 mg) every 6 hours for 3 days. (total dose 24 mg). The study is monitored in the same way as with a small dexamethasone test. A negative test result - the absence of a decrease in the level of androgens in the blood or urine - indicates a virilizing tumor of the adrenal glands.
Functional tests to determine the level of dysfunction of the hypothalamic-pituitary system. Tests are carried out at normal or reduced levels of gonadotropins in the blood.
Test with clomiphene carried out for diseases with chronic anovulation against the background of oligomenorrhea or amenorrhea. The test begins after a menstrual-like reaction caused by taking estrogen and progesterone. From the 5th to the 9th day from the onset of a menstrual-like reaction, clomiphene is prescribed at a dose of 100 mg per day (2 tablets of 50 mg). The test result is monitored either by determining gonadotropins and estradiol in the blood plasma before the start of the study and on the 5-6th day after the end of taking the drug, or by basal temperature and the appearance or absence of a menstrual-like reaction 25-30 days after taking clomiphene.
A positive test (increased levels of gonadotropins and estradiol, biphasic basal temperature) indicates preserved functional activity of the hypothalamus, pituitary gland and ovaries.
A negative test (no increase in the concentration of estradiol, gonadotropins in the blood plasma, monophasic basal temperature) indicates a violation of the functional sensitivity of the pituitary zone of the hypothalamus to the release of luliberin and the pituitary gland to the release of gonadotropins.
Test with luliberin carried out with a negative test with clomiphene. 100 mcg of a synthetic analogue of luliberin is administered intravenously. Before the start of drug administration and 15, 30, 60 and 120 minutes after administration, blood is taken from the ulnar vein through a permanent catheter to determine the LH content. With a positive test, by the 60th minute the LH content increases to levels corresponding to ovulation, which indicates preserved function of the anterior lobe of the pituitary gland and dysfunction of the hypothalamic structures.

Instrumental methods for studying gynecological patients

Endoscopic methods

Colposcopy- detailed examination of the vaginal part of the cervix, vaginal walls and vulva through an optical lens system with a magnification of 6-28 times. During colposcopy, the shape, size of the neck and external pharynx, color, relief of the mucous membrane, the border of the squamous epithelium covering the neck and the columnar epithelium of the cervical canal are determined.
During extended colposcopy, before examination, the cervix is ​​treated with a 3% solution of acetic acid, which causes short-term swelling of the epithelium, swelling of the cells of the styloid layer, contraction of subepithelial vessels and a decrease in blood supply. After a detailed examination, a Schiller test is performed - the neck is lubricated with 3% Lugol's solution. Iodine stains the cells of healthy squamous epithelium of the cervix dark brown; thinned (atrophic) and pathologically changed cells with dysplasia of the cervical epithelium are not stained. In this way, areas of pathologically altered epithelium are identified and areas for cervical biopsy are designated.
Colpomicroscopy- intravital histological examination of the vaginal part of the cervix. Produced with a contrast fluorescent colpomicroscope or a Hamou colpomicroscope (a type of hysteroscope).

Hysteroscopy- examination using optical systems of the inner surface of the uterus. Hysteroscopy can be diagnostic or surgical. Diagnostic hysteroscopy is currently the method of choice for diagnosing all types of intrauterine pathology.
Indications for diagnostic hysteroscopy:
menstrual cycle disorders during different periods of a woman’s life (juvenile, reproductive, perimenopausal);
postmenopausal bleeding;
suspicion of uterine fibroids,
adenomyosis,
endometrial cancer,
abnormalities of the uterus,
intrauterine synechiae,
retained remains of the fertilized egg,
foreign body in the uterine cavity,
perforation of the uterine wall;
location clarification intrauterine contraceptive device or its fragments;
infertility;
miscarriage;
control examination of the uterine cavity after operations on the uterus, hydatidiform mole, chorionepithelioma;
assessing the effectiveness of hormone therapy and monitoring its implementation;
complicated course of the postpartum period.
Contraindications for hysteroscopy the same as for any intrauterine intervention: general infectious diseases (influenza, tonsillitis, pneumonia, acute thrombophlebitis, pyelonephritis, etc.); acute inflammatory diseases of the genital organs; III-IV degree of vaginal cleanliness; serious condition of the patient with diseases of cardio-vascular system and parenchymal organs (liver, kidneys); pregnancy (wanted); cervical stenosis; advanced cervical cancer; profuse uterine bleeding.
After visually determining the nature of the intrauterine pathology, diagnostic hysteroscopy can proceed to surgery either immediately or delayed if preliminary preparation is necessary.
According to complexity, hysteroscopic operations are divided into simple and complex.
Simple Operations: removal of small polyps, separation of thin synechiae, removal of an IUD freely located in the uterine cavity, small submucous myomatous nodes on a stalk, thin intrauterine septum, tubal sterilization, removal of hyperplastic uterine mucosa, remnants of placental tissue and fertilized egg.
Complex operations: removal of large parietal fibrous polyps of the endometrium, dissection of dense fibrous and fibromuscular synechiae, dissection of the wide intrauterine septum, myomectomy, resection (ablation) of the endometrium, removal of foreign bodies embedded in the uterine wall, falloposcopy.
Possible complications diagnostic and operative hysteroscopy:
anesthesiological;
complications caused by the environment for expansion of the uterine cavity (fluid overload of the vascular bed, cardiac arrhythmia due to metabolic acidosis, gas embolism);
air embolism;
surgical (uterine perforation, bleeding).
Complications of hysteroscopy can be minimized by following all the rules for working with equipment and apparatus, manipulation techniques and operations.

Laparoscopy- examination of the abdominal organs using an endoscope inserted through the anterior abdominal wall. Laparoscopy in gynecology is used both for diagnostic purposes and for surgical intervention.
Indications for elective laparoscopy:
infertility (tubal-peritoneal);
polycystic ovary syndrome;
tumors and tumor-like formations of the ovaries;
uterine fibroids;
genital endometriosis;
malformations of the internal genital organs;
pain in the lower abdomen of unknown etiology;
prolapse and prolapse of the uterus and vagina;
stress urinary incontinence;
sterilization.
Indications for emergency laparoscopy:
ectopic pregnancy;
ovarian apoplexy;
acute inflammatory diseases of the uterine appendages;
suspicion of torsion of the leg or rupture of a tumor-like formation or ovarian tumor, as well as torsion of subserous myoma;
differential diagnosis of acute surgical and gynecological pathology.
Absolute contraindications to laparoscopy:
hemorrhagic shock;
diseases of the cardiovascular and respiratory systems in the stage of decompensation;
uncorrectable coagulopathy;
diseases in which the Trendelenburg position is unacceptable (consequences of brain injury, cerebral vascular damage, sliding hernia hiatus diaphragm, etc.);
acute and chronic hepatic-renal failure;
ovarian and fallopian tube cancer (with the exception of laparoscopic monitoring during chemotherapy or radiation therapy).
Relative contraindications to laparoscopy:
polyvalent allergy;
diffuse peritonitis;
pronounced adhesive process after operations on the abdominal and pelvic organs;
late pregnancy (more than 16-18 weeks);
large uterine fibroids (more than 16 weeks of pregnancy);
large size of a true ovarian tumor (diameter more than 14 cm);
suspicion of malignant neoplasms uterine appendages.

Contraindications to planned laparoscopic interventions:
existing or experienced less than 4 weeks ago acute infectious and colds;
subacute inflammation of the uterine appendages;
III-IV degree of vaginal cleanliness;
inadequate examination and treatment of the couple at the time of the proposed endoscopic examination for infertility.
Complications of laparoscopy can be:
1) anesthesiological
2) related to performing manipulations:

Perforation of abdominal organs with a Veress needle;

Emphysema of the omentum, subcutaneous and retroperitoneal tissue;

Gas embolism;

Mediastinal emphysema;

Injury to the great vessels;

Damage to the gastrointestinal tract and urinary system with subsequent development of peritonitis.

The frequency and structure of complications are related to the qualifications of the surgeon and the nature of the interventions performed.
Prevention of complications in laparoscopic gynecology: careful consideration of absolute and relative contraindications; experience of an endoscopist surgeon corresponding to the complexity of the surgical intervention.

Ultrasonography

Ultrasound examination (ultrasound) is a non-invasive instrumental research method used in gynecology to diagnose diseases and tumors of the uterus, appendages, and identify abnormalities in the development of the uterus. The latest models of ultrasound devices allow you to monitor follicle growth, ovulation, record the thickness of the endometrium and detect its hyperplasia and polyps. Using ultrasound, the normal sizes of the uterus and ovaries in women, girls and girls have been established.
In gynecology, ultrasound is performed using abdominal and vaginal sensors. The use of vaginal sensors allows you to obtain more informative data about the state of the endometrium, myometrium, and the structure of the ovaries.

X-ray research methods

Hysterosalpingography used to establish the patency of the fallopian tubes, identify anatomical changes in the uterine cavity, adhesions in the uterus and in the pelvic area. Water-soluble contrast agents are used (Verotrast, Urotrast, Verotrast, etc.). It is advisable to conduct the study on the 5-7th day of the menstrual cycle, which reduces the frequency of false negative results.
X-ray examination skull is widely used in the diagnosis of neuroendocrine diseases. X-ray examination of the shape, size and contours of the sella turcica - the bone bed of the pituitary gland - is used to diagnose a pituitary tumor. Signs of a pituitary tumor: osteoporosis or thinning of the walls of the sella turcica, a symptom of double contours. If a tumor of the pituitary gland is suspected based on X-ray data, a computed tomography scan of the skull is performed.
Computed tomography (CT)- a variant of x-ray examination, which allows obtaining a longitudinal image of the area under study, sections in the sagittal and frontal or in any given plane. CT provides a complete spatial representation of the organ under study, the pathological focus, and quantitative information about the density of a certain layer, thus allowing one to judge the nature of the lesion. The resulting images of structures do not overlap each other, and CT makes it possible to differentiate the image of tissues and organs by density coefficient. The minimum size of the pathological focus determined using CT is 0.5-1 cm.
In gynecology, CT has not received such widespread use as in neuropathology and neurosurgery. CT of the sella region remains the main method for differential diagnosis of functional hyperprolactinemia and prolactin-secreting pituitary adenoma.
Magnetic resonance imaging (MRI)- a more informative diagnostic method in gynecology than CT. Currently used for differential diagnosis of pathological formations in the pelvis with questionable ultrasound data.

Cytogenetic studies

Cytogenetic studies are carried out by geneticists. Indications: various forms of absence and delay of sexual development, abnormal development of the genital organs, primary amenorrhea, recurrent short-term miscarriage, infertility, disruption of the structure of the external genitalia.
Pathological conditions of the reproductive system can be caused by chromosomal abnormalities, gene mutations and hereditary predisposition to the disease.
Markers of chromosomal abnormalities are multiple, often erased, somatic developmental anomalies and dysplasia, as well as changes in the amount of X-chromatin (sex chromatin). Sex chromatin is determined in the nuclei of surface epithelial cells in a scraping of the mucous membrane of the inner surface of the cheek. To detect chromosomal abnormalities, Y-chromatin can also be determined in the cells of the buccal mucosa. With a Y chromosome in the karyotype, Y chromatin is found in almost all cell nuclei. Determination of sex chromatin is used as a screening test. The final diagnosis of chromosomal abnormalities can only be established based on the determination of the karyotype.
Indications for karyotype examination are, first of all, deviations in the amount of sex chromatin, short stature, multiple, often erased somatic developmental anomalies and dysplasia, as well as malformations in a family history, multiple deformities or spontaneous miscarriages in early pregnancy.
Determination of the karyotype is an indispensable part of the examination of patients with gonadal dysgenesis. The detection of a Y chromosome or a section thereof indicates the presence of elements of testicular tissue in a dysgenetic gonad and, therefore, a high risk (up to 30%) of malignant growth.

Abdominal puncture through the posterior vaginal fornix

Puncture of the abdominal cavity through the posterior vaginal fornix (Fig. 1.7) is performed in a hospital in cases where it is necessary to determine the presence or absence of free fluid (blood, serous exudate, pus) in the pelvic cavity.

Aspiration biopsy

An aspiration biopsy is performed to obtain tissue for microscopic examination. Its essence lies in the fact that the contents are sucked out of the uterine cavity using a tip placed on a syringe or a special “Pipel” instrument.

Examination of children with gynecological diseases

Examination of children with gynecological diseases differs in many respects from examination of adult women, both in psychological approach and methodology.
Most children, especially those who visit a gynecologist for the first time, experience some anxiety, fear, awkwardness and inconvenience in connection with the upcoming examination. When meeting with the girl and her relatives, even before the examination begins, the doctor must establish psychological contact, reassure, and gain the girl’s favor and trust. It is better to conduct a preliminary conversation with the mother in the absence of the child, to give the mother the opportunity to talk about the development of the disease in her daughter, and then ask additional questions to her, and then to the girl.
A general examination of girls is carried out according to the methodology adopted in pediatrics. The examination begins with clarification of complaints, life history and illness. It is necessary to pay attention to the age, health of the parents, the course of pregnancy and childbirth in the mother of the girl being examined, to carefully determine the diseases suffered by the child during the neonatal period, early childhood and beyond. late age. They ask about the general reaction of the girl’s body to previously suffered diseases (temperature, sleep, appetite, behavior, etc.). This can give some insight into the body's reactivity. They also find out living conditions, nutrition, daily routine, behavior in a team, relationships with peers.
Then it is necessary to dwell in detail on the period of formation menstrual function girls, find out the nature of vaginal discharge not related to menstruation.
An objective examination of a girl with a gynecological disease should begin with determining the main indicators physical development according to age (height, body weight, circumference chest, pelvic dimensions), then a general examination of organs and systems is carried out, the degree of sexual development, skin condition, the nature of hair growth, the development of subcutaneous fatty tissue and mammary glands are noted.
Special examination includes assessment of the development of secondary sexual characteristics; examination, palpation and percussion of the abdomen, if pregnancy is suspected - auscultation of the fetal heartbeat; examination of the external genitalia, hymen and anus; vaginoscopy; rectal-abdominal examination. If a vaginal foreign body is suspected, a rectal-abdominal examination is first performed, and then a vaginoscopy.
Immediately before the examination, the girl must empty her intestines (cleansing enema) and bladder. Girls younger age(up to 3 years) are examined on a changing table, older girls are examined on a children's gynecological chair with a special device that allows you to change its depth. When examining girls in outpatient settings, as well as during the initial examination in hospitals, the mother or one of the closest relatives must be present.
When examining the external genitalia, the nature of hair growth is assessed (by female type- horizontal hairline; By male type- in the form of a triangle with a transition to the linea alba and the inner surfaces of the thighs), the structure of the clitoris, labia majora and minora, hymen, their color, the color of the mucous membrane of the vaginal entrance, discharge from the genital tract. Penis-shaped clitoris combined with male-type hair growth in childhood indicates congenital androgenital syndrome; growth of the clitoris during puberty indicates an incomplete form of testicular feminization or villizing tumor of the gonads. Juicy hymen, swelling of the vulva, labia minora and their pink color at any age (childhood or puberty) indicate hyperestrogenism. With hypoestrogenism, there is underdevelopment of the external genitalia, the mucous membrane of the vulva is thin, pale and dry. With hyperandrogenism during puberty, hyperpigmentation of the labia majora and minora, male-type hair growth, and a slight enlargement of the clitoris are noted.
Vaginoscopy- examination of the vagina and cervix using optical device- combined urethroscope and children's vaginal speculum with lights. Vaginoscopy is performed on girls of any age and makes it possible to determine the condition of the vaginal mucosa, the size and shape of the cervix and external pharynx, the presence and severity of the “pupil” symptom, pathological processes in the area of ​​the cervix and vagina, foreign body, malformations.
Vaginoscopy for girls in the “neutral” period is performed with a combined urethroscope using cylindrical tubes of various diameters with an obturator. During puberty, examination of the vagina and cervix is ​​carried out using children's vaginal speculums with lights. The choice of urethroscope tube and pediatric vaginal speculum depends on the age of the child and the structure of the hymen.
Two-manual rectal-abdominal examination They are given to all girls with gynecological diseases. Bimanual examination of young children should be carried out with the little finger, when examining older girls - with the index or middle finger, which is protected by a fingertip lubricated with Vaseline. The finger is inserted when the patient strains.
During a rectal examination, the condition of the vagina is determined: foreign body, tumors, blood accumulation; during a bimanual examination, the condition of the uterus, appendages, fiber and adjacent organs is determined. When palpating the uterus, its position, mobility, pain, the ratio of the sizes of the cervix and body and the severity of the angle between them are examined.
Thus, with sexual infantilism in girls, the angle between the cervix and the uterus is not expressed, the uterus is located high in the pelvis, the ratio of the sizes of the cervix and the body of the uterus is 1:1. In case of gonadal dysgenesis syndrome instead of the uterus midline a roll-like cord is palpated. Unilateral enlargement of the ovary, especially on the eve of menstruation, requires a mandatory re-examination after the end of menstruation.
A rectal-abdominal examination is carried out under anesthesia in children under 3-4 years of age with genital injuries and in older girls if a tumor in the pelvis is suspected.
When examining girls, asepsis and antisepsis are especially carefully observed due to the high susceptibility of children's genitals to infection. After finishing the external and internal research the external genitalia and vagina are treated with a solution of furatsilin (1:5000). If the skin of the vulva is irritated, lubricate it with streptocidal ointment or sterile petroleum jelly.
Depending on the nature of the disease, the following additional research methods are used.

Functional diagnostic methods and hormonal studies(described above) are indicated for patients with juvenile bleeding, with pathology of puberty and suspected hormonally active ovarian tumors.
Probing of the vagina and uterine cavity used to diagnose developmental defects, foreign body, if hemato- or pyometra is suspected.
Separate diagnostic curettage of the mucous membrane of the uterine body with hysteroscopy indicated both for stopping uterine bleeding and for diagnostic purposes in cases of scanty, prolonged bleeding in patients with a disease duration of more than 2 years and in case of ineffectiveness of symptomatic and hormone therapy. Diagnostic curettage is performed under short-term mask or intravenous anesthesia. The cervix is ​​exposed in children's speculums with a lighting system. Cervical canal dilated to Hegar number 8-9, and the endometrium is scraped out with a small curette No. 2.4. With proper diagnostic curettage, the integrity of the hymen is not damaged.
Endoscopic methods (hysteroscopy, laparoscopy) do not differ from those in adults.
Ultrasound examination (ultrasound) of the internal genital organs. In recent years, pelvic ultrasound has become widely used in practical gynecology in children and adolescents due to its safety, painlessness and the possibility of diagnostic observation. Ultrasound allows you to diagnose genital malformations, ovarian tumors and other gynecological diseases.
In girls, the uterus is normally visualized by ultrasound as a dense formation with multiple linear and dotted echo structures, shaped like an elongated ovoid and located in the center of the small pelvis behind the bladder. The average length of the uterus in children aged 2 to 9 years is 3.1 cm; from 9 to 11 years - 4 cm; from 11 to 14 years - 5.1 cm. In girls over 14 years old, the length of the uterus is on average 6.5 cm.
The ovaries in healthy girls under 8 years of age are located at the border of the entrance to the small pelvis and only at the end of the first phase of puberty they descend deeper into the small pelvis, adjacent to its walls, and are visualized as ellipsoidal formations with a more delicate structure than the uterus. The volume of the ovaries in children aged 2 to 9 years is on average 1.69 cm3, from 9 to 13 years - 3.87 cm3, in girls over 13 years old - 6.46 cm3.

X-ray and radiocontrast research methods
In pediatric gynecology, as well as in adults, it is used X-ray examination skull and extremely rarely (according to strict indications) - hysterosalpingography using a special small children's tip for suspected genital tuberculosis or abnormal development of the genital organs in girls over 14-15 years old.
Of great importance for the diagnosis of gynecological diseases is an X-ray examination of the hands to determine bone age, followed by its comparison with passport data. IN special tables The timing and sequence of appearance of ossification and synostoses between the metaphyses and epiphyses of long tubular bones are indicated, depending on age.
This examination method allows us to identify the pathology of ossification - violations of its rate and sequence, which are influenced by hormonal influences, as well as factors of heredity and nutrition.
In pediatric gynecology, as well as in adults, computed tomography and magnetic resonance imaging are used for differential diagnosis. In children early age and in patients with various mental affects, studies are carried out with mandatory anesthesia (medication-induced sleep after parental administration of drugs).
To carry out hysterosalpingography, hysteroscopy, diagnostic curettage and laparoscopy, CTE and MRI, it is necessary to obtain the consent of the patient’s parents, about which an appropriate entry should be made in the medical history.
In addition to the listed examination methods, cytogenetic research (determination of sex chromatin, and, if indicated, karyotype) is widely used to diagnose a number of gynecological diseases. It is indicated for disorders of somato-sexual development (impaired sexual differentiation, delayed sexual development, etc.).
Bacterioscopic examination discharge from the genital tract is done after examining the genitals. Vaginal discharge is examined in all girls; discharge from adjacent organs (urethra, rectum) is examined depending on the nature of the disease (for example, if gonorrhea or trichomoniasis is suspected). The material is taken with a grooved probe or rubber catheter. Before inserting the instrument, use a cotton ball moistened with a warm isotonic sodium chloride solution to wipe the vaginal opening, the external opening of the urethra and the anal area. Instruments for taking material are inserted into the urethra to a depth of approximately 0.5 cm, into the rectum - to a depth of about 2-3 cm, and into the vagina - if possible to the posterior fornix. The results of the study are assessed taking into account the girl’s age.