Endometriosis: a clinic and treatment

This section of the website is intended for obstetrician-gynecologists, surgeons, oncologists, neurologists and other specialists.
In recent years significantly increased the interest in endometriosis not only of obstetricians and gynecologists, and surgeons, oncologists, urologists, radiologists, physicians, TB specialists, pediatricians and other specialists. However, with the diagnosis of the disease situation is unfavourable. Proof of this can serve multiple observations of advanced cases of the disease, when the process is spreading from sex on the adjacent organs and causes a violation of their functions until the development of stenosis of the lumen of the intestine and urinary tract. Still a high incidence of surgical interventions for endometriosis to 25-30 % on materials of the Central medical-sanitary unit № 122 of the USSR Ministry of health and the clinic of military medical Academy. S. M. Kirov. One reason for this is the late diagnosis of the disease, when conservative treatment may not cause regression of endometriosis and eliminate the associated functional disorders and anatomical changes.
Significant difficulties arise diagnosis of the disease at a young age and menopause, as well as with a combination of genital endometriosis with TB, fibroids, syndrome Allen-masters [Allen M, W. Masters, 1955], nephroptosis, and other diseases.
Also important differential diagnosis of endometriosis with some oncological diseases and their combination. Often the symptoms of both diseases are very similar, such as endometriosis and carcinoma of the intestine, endometriosis and lung cancer, endometriosis and cervical cancer, etc.
On the other hand, observations are known, when the metastasis of Shnitzler been mistaken for pozavcherashny endometriosis, a disease of Zollinger-Ellison - for endometriosis stump of the stomach or duodenum. Certain difficulties may cause differentiation of malignant cystadenoma ovary with cystic forms of ovarian endometriosis.
One should not disregard the fact that endometriosis may be the cause of acute abdomen (with the defeat of the ovaries, uterus, fallopian tubes, intestines, scars and the navel).
At present the task is not only to timely diagnosis of endometriosis, but in the clarification of its location, shape (core, diffuse, cystic), involvement of adjacent organs. You must also install the severity of the disease, taking into account the duration of reduction or loss of working capacity during periods of exacerbation of endometriosis. A very important finding of concomitant somatic pathology and allergological anamnesis. These provisions determine the choice of method of treatment and solution of the issue about the extent of the procedure, if there is evidence to this method of treatment.
The management of pregnancy, childbirth, postpartum and postabortion periods with endometriosis has a number of essential features.
In the treatment of patients with endometriosis there is some success but the treatment is far from being resolved. In addition, there are new challenges associated with susceptibility of patients to allergic reactions, by presence of concomitant somatic pathology, impeding the use of hormonal drugs.
Long disease of endometriosis can cause damage to the nervous system that increases the suffering of the sick or continues to cause pain even after the suppression of the activity of endometriosis, hormonal therapy, radiation therapy or after radical surgical treatment.
Changes occurred in radiation therapy of the disease. Remote ovarian irradiation from disabling their function was not successful. More successful was directly radiation by method of close-focus irradiation on foci of endometriosis, for example when pozavchera endometriosis and some other locations. At that the maximum exposure to ionizing radiation is focused directly at the center of endometriosis, and not on the ovaries.
This monograph aims to familiarize physicians with the peculiarities of clinic, diagnostics and treatment of patients with endometriosis. In addition, there will be examined questions of pregnancy, childbirth, postpartum, postoperative and post-abortion periods in women with endometriosis.
Material for this monograph was 40-years experience of the author, the data of domestic and foreign literature on various aspects of the problem of endometriosis.

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

Features of endometriosis. Endometriosis - hormone-dependent disease, developing at the background of violations of the immune homeostasis, the essence of which is the growth of tissue, similar in its structure and functions with the endometrium, but outside the normal boundaries of location of the mucous membrane of the uterus.
Under the influence of ovarian function and regulating the work of the centers of the hypothalamus-pituitary system in the foci of endometriosis occurs cyclic transformations, similar to the changes in the mucous membrane of the uterus. During pregnancy in the foci of endometriosis develops decidual reaction. Decidophobia transformations in the stroma of endometriosis can be observed when treating patients with drugs yellow body.
If the body is sick multiple foci of endometriosis (internal and external genital and extragenital) the severity of them cyclic transformations is not always the same. The results of mapping macroscopic and histological data obtained during operations.
R. Schroder (1959), M. Antoine (1960) explained unequal intensity cyclic transformations in the foci of endometriosis different by their origin, namely, the centers of internal endometriosis cancer, developing from the basal layer of the endometrium, less prone to cyclical changes in comparison with external genital and extra genital endometriosis, developing functional layer of the endometrium.
Remains outstanding reason of unequal reaction of endometriosis various sites on the impact of hormonal drugs. Why, for example, endometriosis light for early start of treatment well-being regression, cyclic hemoptysis cease, and the vast majority of patients coming permanent cure, while ectocervical endometriosis in the cervix, postoperative scars and the navel poorly long and intense hormonal therapy. All these foci of endometriosis come from the functional layer of the endometrium.
  • The etiology and pathogenesis of endometriosis
  • Main features of diagnosis of endometriosis
  • Clinical picture and diagnosis of genital endometriosis

  • Endometriosis (adenomyosis) of the uterus
  • Endometriosis, ovarian
  • Pozavcherashny, or cervical, endometriosis
  • Endometriosis vagina and perineum
  • Endometriosis cervix
  • Genital endometriosis and syndrome Allen-masters
  • Reserves to improve the diagnosis of endometriosis
  • Endometriosis and infertility
  • The impact of endometriosis on pregnancy and childbirth
  • Clinic and diagnostic extra genital endometriosis

    Recognition extra genital endometriosis based on the dependence of clinical symptoms and data of objective inspection from the menstrual cycle. In terms of diagnosis of extragenital forms of the disease is important differentiation number of localizations (intestines, lungs, bladder) with tumor process.
  • Endometriosis bowel
  • Endometriosis of the urinary system

  • Endometriosis bladder
  • Endometriosis ureters
  • Endometriosis kidney
  • Endometriosis urethra
  • Endometriosis post-operative scars
  • Endometriosis navel
  • Thoracic endometriosis

    Endometriosis lungs, pleura and aperture refers to the rare locations extragenital disease. This fact is emphasized by many authors [Stuart L., Bednoff M, 1965; Kovarik J., Toll G., 1966; Leh So, 1967; Labay G. et al., 1971; Magre J. et al., 1971; Rebaund E. et al., 1972; Gradberg I. et al.,1977, and others]. However, the number of publications about the observations of thoracic endometriosis is increasing every year. Apparently, attracting attention of different specialists to this peculiar form of the disease improves its recognition.

    Endometriosis (from the Greek. endon - inside and metra - uterus; synonym: adenomyosis, endometrioma, endometrioid heterotopias) - granulomas inclusion and growth of endometrial tissue in different organs and tissues. Before puberty and menopause endometriosis is not developing. With the cessation of menstrual function woman E. reverses its development. These observations have reason to link the development of Economics with hormonal factors.
    According to generally accepted classification endometriosis is divided by sex and extragenital. Sex in turn are divided into internal (lesions of the uterus and tubes) and external (ovaries, pozavcherashny region, vagina, vulva, vaginal portion of the cervix, the peritoneum posudomoechnaja space and fiber pelvis). To extragenital E. include lesions localized in the intestinal loops, the mesentery, the peritoneum in the navel and other organs. The most frequent localization E. - pelvic area. E. may metastasize to the lungs, kidneys and other organs, as well as developed in the postoperative scar.
    Most authors think that in the foci of endometriosis occurs cyclical changes, similar to menstrual cycle. However, in the areas of Economics are only observed phenomenon of proliferation and very rarely observed phase of secretion. Bleeding in these areas depend mainly on the pathological changes of blood vessels affected areas (E. N. Petrova, 3. P. Graschenkova and others). Cyclic changes of external Economics that develops outside the uterus, more pronounced.
    Different severity of cyclical changes in the centers of internal and external endometriosis is the result of a different mechanism of their origin. In external endometriosis, developing functional layer of the endometrium, reactions to estrogens and hormone yellow body are expressed well. Internal endometriosis come from the basal layer cells of the mucous membrane of the uterus, not giving a response to the hormone yellow body. Centers around the E., especially outside as a rule, there are signs of inflammation.
    According to domestic and foreign authors, among patients with endometriosis infertility occurs in 40-80% of cases (B. N. Baskakov). Surveillance B. N. Baskakov confirmed by the studies of other authors about the presence of proteolytic enzymes in the foci of endometriosis regardless of their location.

    internal endometriosis cancer
    Internal endometriosis, uterine: 1 - cystic stretched iron; 2 - titahena stroma.

    Pathological anatomy. In the diffuse internal endometriosis, uterine wall her thickened (4-5 cm), with focal lesions are large and small sites, not having precise borders with an environmental tissue of the uterus; on the cut fabric mesh structure. In the thick of it are glandular education (figure), surrounded by tithenai the stroma (heterotopic endometrium). Cancer of various shapes and sizes, sometimes dramatically expanded. Rarely in the myometrium observed cysts. Gland cyst is lined single row cylindrical epithelium, sometimes flattened. Depending on the depth of penetration of heterotopic endometrium in myometrium distinguish endometriosis, uterine I degree - penetration glands and stroma of the basal layer of the endometrium is not more than one field of view, II degree - to 1/2 the thickness of the wall of the uterus and III extent to serous cover. In II and III degree endometriosis, uterine notes and hyperplasia of the muscle fibers (hence the name adenomyosis). Histopathologically reaction in heterotopic endometrium in the luteal phase of the cycle is rarely observed. Most often heterotopic endometrium respond to estrogen. E. cervical cancer is less common.
    Sarcomatosis the transformation of the stroma in the foci of endometriosis cancer is rare.
    Endometriosis serosal surface of the cervix can occur when endometrioid ovarian cysts during extensive adhesive process. The latter is one of the features of endometrioid ovarian cysts. The contents of hemorrhagic cysts, chocolate color. A thick skin endometritei ovarian cyst lined single row cylindrical epithelium, sometimes flattened; podperevalny connective tissue cysts rich stromal cells, are pseudoxanthoma cells, cellular elements of inflammatory infiltrate, blood vessels, old and fresh hemorrhage. In endometriosis, ovarian they contain pockets of heterotopic endometrium, which often characterized histopathologically reaction in the luteal phase of the cycle. In rare cases there is a malignancy of endometriosis, ovarian adenocarcinoma, adenocarcinoma. When pregnancy in the centers of heterotopic endometrium may be decidual metamorphosis stroma.
    E. vaginal and peritoneal red pocket appears as a small tight door with a small cysts filled with hemorrhagic content.
    Clinical course, symptoms and treatment of endometriosis depend on the localization (internal or external).
    Endometriosis cancer occurs most often. Cardinal symptom is a violation of the menstrual cycle - cyclical bleeding type menorrhagia (Hyper - and polimenoreya), rarely observed metrorragiya. These bleeding depend on ovarian dysfunction (giperestrogenia, the lack of yellow body and others), hyperplastic endometrium, insufficient contractility of the uterus, pathological changes of blood vessels, frequent combination of endometriosis, fibroids, inflammatory processes and other
    The second most common symptom of endometriosis of the uterus are a pain localized in the lower abdomen and lower back, which begin before the menstrual period, worse with the onset of menses, and then gradually decrease. These pain depends on the irritation of the nerves and receptors numerous blood vessels in the result of the compression of them periodically swelling of the tissues of lesions and of peritoneal irritation (with third degree of lesions).
    Diagnosis of endometriosis cancer is very difficult, especially if it is combined with fibroids. However, when studying historical data, data gynaecological examination and dynamic observation of the patient the diagnosis can be made.
    Bleeding in endometriosis are persistent in nature, can not be conservative methods of treatment and even repeated curettage of the uterine mucosa is not effective in the opposite of metropolii. The uterus when E. more normal size (as in 5-, 8-weeks of pregnancy), its surface is uneven (with focal lesions) or smooth (with diffuse lesion), form usually asymmetric, consistency uneven: in places of dense, locally softer (health station). During follow-up may be noted the increase in the uterus before and during menstruation, and with the termination of her womb taking its original dimensions.
    For the diagnosis of E. use petrografii after injection of a contrast agent.
    Diagnostic curettage of the uterine cavity with endometriosis do not provide a basis for establishing the correct diagnosis, as in the endometrium of the uterus there is specific for E. changes. Curettage is produced only for the differential diagnosis (submucosal site fibroids, cancer of the womb and others).
    Treatment in the early stages of the development of endometriosis, uterine symptomatic (hemostatic means, a means of improving the contractility of the uterus, a vasoconstrictor, analgesic; hormone therapy: androgens in the first half of the menstrual cycle, drugs luteum in the second half and others). In the absence of the effect of conservative treatment, surgery is shown: supracervical amputation of uterus or extirpation. In order to avoid relapse polyradicular operations (save endometrium) is contraindicated. This is particularly important E. when combined with uterine myoma. In some cases, older women appointed x-ray treatments; wide application of it has not received as ineffective.
    Endometriosis, ovarian cancer ranks second of all localizations of endometriosis. One-sided defeat twice as likely to be bilateral. Etiology: the implantation of the particles of the endometrium as the result of retrograde throw blood on pipes from the uterus, hematogenous and lymphogenous ways. The foci of endometriosis in the ovary more markedly than in the uterus, respond to hormonal cyclical changes.
    E. the ovaries can be different sizes - from small knots to cystic cavities filled with a dark, liquid blood or tarry liquid, hence the name "chocolate cysts".
    As a rule, endometriosis, ovarian flows with large commissural process.
    Diagnosis E. ovarian presents considerable difficulties. One of the characteristic symptoms are persistent pain, worse during menstruation. Very often observed primary infertility.
    Endometriosis, ovarian must be differentiated with inflammatory processes, tuberculosis, true tumors (reliabillity), cancer, and other
    History of the patient (absence of instructions on inflammatory diseases, primary infertility, and others), the absence of the effect of conservative treatment, data dynamic observations provide an opportunity to clarify the nature of the disease.
    Treatment surgical - removal appendages. When bilateral lesions in younger women (30-40 years) should be sparing surgery (partial resection of the ovaries). After such operations in the diffuse lesion ovarian possible relapse, so as to remove the affected areas is very difficult.
    Pozavcherashny endometriosis ranks third among all localizations. When this localization amazed Sacro-uterine ligaments, premonicion-vaginal tissue, the vaginal wall and rectum.
    Etiology - getting content endometrioid ovarian cysts (as evidenced by the frequent combination POSADSKOGO endometriosis, ovarian endometriosis), atresia cervical canal, sharp retroflexa cancer may also spread through the lymphatic
    and the blood ways. B. N. Baskakov watched direct germination E. through the belly of the isthmus of the endometrium.
    Clinical course: the main complaint of patients - pain can be so intense that make the patient disabled.
    In the propagation of endometriosis on the rectum may be bleeding, coinciding with menstruation. The same "menstruating" fistulas may be with the defeat of the vaginal vault.
    The diagnosis is not difficult: gynecological examination through the rear vaginal vault behind the cervix palpable nodules from 0,5 up to 3-4 cm or more in diameter, often merging with each other, thick consistency, fixed and sharply painful.
    In cases where there is a growth of endometrial tissue in the vaginal wall and rectum shown colposcopy, sigmoidoscopy and biopsy, in order to way of distinguishing endometriosis from the inflammatory process and malignant neoplasms. When this localization is more frequent malignancy of endometriosis.
    The treatment is of great difficulty, because all types of modern therapies not always effective. Recommended hormones (progesterone 5-10 mg / day in the second half of the menstrual cycle within 4-6 months, androgens in the first half of the menstrual cycle), electrophoresis with potassium iodide, microclysters with a 1% solution of potassium iodide, candles with the extract of belladonna, papaverine and Ichthyol (B. N. Baskakov).
    Radiotherapy is shown only in old age. Surgery (hysterectomy with pipes and rectovaginal fiber), recommended by many authors, often gives only short-term effect. Despite the vastness of the intervention, there are relapses.