Background processes of the cervix. Background and precancerous diseases of the female genital organs
Precancerous diseases include diseases characterized by a long-term (chronic) course of the degenerative process, and benign neoplasms that tend to malignize. Morphological precancerous processes include focal proliferation (without invasion), atypical epithelial growths, and cell atypia. Not every precancerous process necessarily turns into cancer. Precancerous diseases can exist for a very long time, and the cells do not undergo cancerous degeneration. In other cases, such a transformation occurs relatively quickly. Against the background of some diseases, for example papillary cysts, cancer occurs relatively often, against the background of others (kraurosis and vulvar leukoplakia) - much less often. The identification of precancerous diseases is also justified from the point of view that timely and radical treatment of these forms of diseases is the most effective prevention of cancer. Depending on the location of the pathological process, it is customary to distinguish between precancerous diseases of the external genital organs, cervix, uterine body and ovaries.
Precancerous diseases of the female genital organs. These include hyperkeratoses (leukoplakia and kraurosis) and limited pigmented formations with a tendency to growth and ulceration.
Leukoplakia of the vulva usually occurs during menopause or menopause. The occurrence of this pathology is associated with neuroendocrine disorders. The disease is characterized by the appearance of dry white plaques of varying sizes on the skin of the external genitalia, which can spread significantly. Phenomena of increased keratinization (hyperkeratosis and parakeratosis) are observed, followed by the development of a sclerotic process and tissue wrinkling. The main clinical symptom of leukoplakia is persistent skin itching in the external genital area. Itching is caused by scratching, abrasions and small wounds. The skin of the external genitalia is dry.
To treat this disease, ointments or globules containing estrogen drugs are used. In case of pronounced changes and severe itching, it is permissible to use small doses of estrogen orally or by injection. Along with the use of estrogens, diet (light plant foods, reduced consumption of table salt and spices) is of great importance. Hydrotherapy (warm sitz baths before bedtime) and medications that affect the central nervous system have a calming effect.
Kraurosis of the vulva is a dystrophic process that leads to wrinkling of the skin of the external genitalia, the disappearance of fatty tissue of the labia majora, subsequent atrophy of the skin, sebaceous and sweat glands. Due to the wrinkling of the tissues of the vulva, the entrance to the vagina sharply narrows, the skin becomes very dry and easily wounded. The disease is usually accompanied by itching, which leads to scratching and secondary inflammatory tissue changes. Kraurosis is observed more often during menopause or menopause, but sometimes occurs at a young age. With kraurosis, the death of elastic fibers, hyalinization of connective tissue, sclerosis of the connective tissue papillae of the skin with thinning of the epithelium covering them, and changes in nerve endings occur.
The ethnology of vulvar kraurosis has not been sufficiently studied. It is assumed that the occurrence of kraurosis is associated with a violation of tissue chemistry, the release of histamine and histamine-like substances. As a result of the effect of these substances on nerve receptors, itching and pain appear. Of great importance is dysfunction of the ovaries and adrenal cortex, as well as changes in the metabolism of vitamins (especially vitamin A). There is a neurotrophic theory of the occurrence of vulvar kraurosis.
For treatment, it is recommended to use estrogen hormones in combination with vitamin A. Some menopausal patients experience good results when using estrogens and androgens. To normalize the trophic function of the nervous system, a novocaine solution is injected into the subcutaneous tissue of the vulva using the tight creeping infiltrate method, a presacral novocaine blockade is performed, and the vulva is denervated by dissecting the pudendal nerve. In especially severe cases of the disease, if all described methods of therapy are unsuccessful, they resort to extirpation of the vulva. As a symptomatic remedy to reduce itching, you can use 0.5% prednisolone ointment or ointment with anesthesin. If areas suspicious for cancer are detected, a biopsy is indicated.
PRE-CANCER DISEASES OF THE CERVIX. Dyskeratoses are characterized by a more or less pronounced process of proliferation of stratified squamous epithelium, compaction and keratinization (keratinization) of the surface layers of the epithelium. In relation to malignancy, leukoplakia with a pronounced proliferation process and beginning cell atypia are dangerous. With leukoplakia, the mucous membrane is usually thickened, separate whitish areas are formed on its surface, which sometimes, without clear boundaries, pass into the unchanged mucous membrane. Leukoplakia sometimes looks like whitish plaques protruding on the surface of the mucous membrane. These areas and plaques are tightly fused to the underlying tissues. Leukoplakia of the cervix is very often asymptomatic and is discovered accidentally during a routine examination. In some women, the disease may be accompanied by increased secretion (leucorrhoea). In cases of infection, the discharge from the genital tract becomes purulent in nature.
Erythroplakia is characterized by atrophy of the superficial layers of the epithelium of the vaginal part of the cervix. The affected areas usually have a dark red color due to the fact that the vascular network located in the subepithelial layer is visible through the thinned (atrophied) layers of the epithelium. These changes can be observed especially well when examined using a colposcope.
Cervical polyps rarely develop into cancer. Oncological alertness should be caused by recurrent cervical polyps or their ulceration. Cervical polyps are removed and subjected to histological examination. For recurrent polyps, diagnostic curettage of the mucous membrane of the cervical canal is recommended.
Cervical erosions (glandular-muscular hyperplasia) can be classified as precancerous processes with a long course, relapses, increased proliferation processes, and the presence of atypical cells. An eroded ectropion can also create conditions for the development of cancer. Ectropion occurs as a result of damage to the cervix during childbirth (less commonly, abortion and other interventions) and its deformation due to scarring. With ectropion, the inverted mucous membrane of the cervical canal comes into contact with the acidic contents of the vagina, and pathogenic microbes penetrate into its glands. The resulting inflammatory process can exist for a long time, spreading beyond the external pharynx and contributing to the appearance of erosion. Treatment of erosive ectropion is carried out according to the rules for the treatment of erosions. Treatment of the concomitant inflammatory process is carried out, colposcopy, and, if indicated, a targeted biopsy with histological examination of the removed tissue. In case of erosion, diathermocoagulation and electropuncture are performed in the first circle of the gaping pharynx. After the scab is rejected and the wound surface heals, a narrowing of the gaping pharynx and the disappearance of erosion are often observed. If after diathermocoagulation the cervical deformity does not disappear, plastic surgery can be performed. In the absence of a lasting effect and recurrence of erosion, indications for surgical intervention arise (cousoid electrical excision, amputation of the cervix).
Precancerous diseases of the uterine body. Glandular hyperplasia of the endometrium is characterized by the proliferation of glands and stroma. Not all glandular hyperplasia of the mucous membrane of the uterine body is a precancerous condition; The greatest danger in this regard is the recurrent form of glandular hyperplasia, especially in elderly women.
Adenomatous polyps are characterized by a large accumulation of glandular tissue. In this case, the glandular epithelium may be in a state of hyperplasia. Precancerous diseases of the endometrium are expressed in lengthening and intensification of menstruation, as well as the occurrence of acyclic bleeding or spotting. The appearance of a suspicious symptom should be considered! bleeding during menopause. The detection of endometrial hyperplasia or adenomatous polyps in a patient during this period should always be considered as a precancerous process. In younger women, endometrial hyperplasia and adenomatous polyps can be considered a precancerous condition only in cases where these diseases recur after curettage of the uterine mucosa and subsequent correct conservative therapy.
A special place among precancerous diseases of the uterus is occupied by hydatidiform mole, which often precedes the development of chorionepithelioma. Based on clinical and morphological features, it is customary to distinguish the following three groups of hydatidiform mole: “benign”, “potentially malignant” and “apparently malignant”. In accordance with this classification, only the last two forms of hydatidiform mole should be classified as a precancerous condition. All women whose pregnancy ended with a hydatidiform mole should be monitored for a long time. In such patients, an immunological or biological reaction should be periodically performed with whole and diluted urine, which allows timely fasting! make a diagnosis of chorionepithelioma.
Precancerous diseases of the ovaries. These include some types of ovarian cysts. Most often, cilioepithelial (papillary) cystomas undergo malignant transformation, and pseudomucinous ones are much less common. It should be remembered that ovarian cancer most often develops precisely because of these types of cysts.
21) precancerous diseases of the female genital organs see question 20.
Damage to the genital organs
In the practice of obstetrics and gynecology, injuries to the genital organs outside the birth act are observed quite rarely. They are classified as follows:
ruptures during sexual intercourse;
damage caused by foreign bodies in the genital tract;
injury to the external genitalia and vagina of a domestic or industrial nature caused by any sharp object;
genital bruises, crush marks;
stab, cut and gunshot wounds of the genitals; damage due to medical activities.
Regardless of the cause of the damage, determining its volume requires a thorough examination in a hospital setting, which includes, along with the initial examination, special methods (rectoscopy, cystoscopy, radiography, ultrasonography and nuclear magnetic resonance imaging, etc.).
The varied nature of injuries and complaints, many variants of the course of the disease depending on age, constitution and other factors require individual medical tactics. Knowledge of generally accepted tactical decisions allows the emergency physician to begin emergency measures at the prehospital stage, which will then be continued in the hospital.
Damage to the female genital organs associated with sexual intercourse. The main diagnostic sign of injury to the external genitalia and vagina is bleeding, which is especially dangerous when the cavernous bodies of the clitoris (corpus cavernosus clitoridis) are damaged. Rarely, the cause of bleeding requiring surgical hemostasis can be a rupture of the fleshy vaginal septum. Usually one or more sutures are placed on the vessels, injected with novocaine and adrenaline hydrochloride. Sometimes short-term pressure on the vessel is enough.
With hypoplasia of the external genitalia, their atrophy in older women, as well as in the presence of scars after injuries and ulcers of inflammatory origin, the rupture of the vaginal mucosa can extend deeper into the external genitalia, urethra and perineum. In these cases, a surgical suture will be required to achieve hemostasis.
Vaginal ruptures can occur due to an abnormal position of the woman’s body during sexual intercourse, violent sexual intercourse, especially in a state of intoxication, as well as when foreign objects are used in violence, etc. A typical injury in such circumstances is a rupture of the vaginal vaults.
Doctors often observe extensive damage to the external genitalia and adjacent organs. Forensic practice abounds in such observations, especially when examining minors who have been raped. Characterized by extensive ruptures of the vagina, rectum, vaginal vaults, up to penetration into the abdominal cavity and intestinal prolapse. In some cases, the bladder is damaged. Delayed diagnosis of vaginal ruptures can lead to anemia, peritonitis and sepsis.
Injuries to the pelvic organs are diagnosed only in a specialized institution, therefore, at the slightest suspicion of injury, patients are hospitalized in a hospital.
Damage due to penetration of foreign bodies into the genital tract. Foreign bodies introduced into the genital tract can cause serious problems. From the genital tract, foreign bodies of various shapes can penetrate into adjacent organs, pelvic tissue and the abdominal cavity. Depending on the circumstances and purpose for which foreign bodies were introduced into the genital tract, the nature of the damage may vary. There are 2 groups of damaging objects:
introduced for medicinal purposes;
introduced for the purpose of producing a medical or criminal abortion.
The list of circumstances and causes of damage to the genital tract at the everyday level can be significantly expanded: from small objects, often of plant origin (beans, peas, sunflower seeds, pumpkins, etc.), which children hide during games, and modern vibrators for masturbation to random large objects used for the purposes of violence and hooliganism.
If it is known that the damaging object did not have sharp ends or cutting edges, and manipulations are stopped immediately, then you can limit yourself to observing the patient.
The leading symptoms of genital trauma: pain, bleeding, shock, fever, leakage of urine and intestinal contents from the genital tract. If the damage occurred in an out-of-hospital setting, then of the two decisions - to operate or not to operate - the first is chosen, since this will save the patient from fatal complications.
The only correct solution would be hospitalization. Moreover, due to the unclear nature and extent of the injury, even in the presence of severe pain, anesthesia is contraindicated.
Many difficulties associated with the provision of ambulance and emergency medical care for trauma, blood loss and shock can be successfully overcome if, in the interests of continuity at the stages of medical evacuation, the ambulance team, when deciding to transport the patient, transmits information about this to the hospital where the patient will be delivered.
Injury to the external genitalia and vagina of a domestic or industrial nature caused by any sharp object. Damage of this nature is caused by various reasons, for example, falling on a sharp object, attack by cattle, etc. There is a known case when, while skiing from a mountain, a girl ran into a stump with sharp branches. In addition to the fracture of the ischial bones, she had multiple injuries to the pelvic organs.
A wounding object can penetrate the genitals directly through the vagina, perineum, rectum, abdominal wall, damaging the genitals and adjacent organs (intestines, bladder and urethra, large vessels). The variety of injuries corresponds to their multisymptoms. It is significant that under the same conditions, some victims develop pain, bleeding and shock, while others do not even experience dizziness, and they get to the hospital on their own.
The main danger is injury to internal organs, blood vessels and contamination of the wound. This can be detected already during the initial examination, noting the leakage of urine, intestinal contents and blood from the wound. However, despite the large volume of damage and involvement of the arteries, in some cases the bleeding may be insignificant, apparently due to crushing of the tissue.
If, during a prehospital examination, an object that caused injury is found in the genital tract, it should not be removed, as this may increase bleeding.
Bruises of the genital organs, crushing. These injuries can occur, for example, in traffic accidents. Large hemorrhages, even open wounds, can form
to be in tissues compressed by two moving hard objects (for example, in the soft tissues of the vulva relative to the underlying pubic bone under the influence of a hard object).
A feature of bruised wounds is the large depth of damage with a relatively small size. The threat is posed by damage to the cavernous bodies of the clitoris - a source of severe bleeding, which is difficult to undergo surgical hemostasis due to additional blood loss from the places where clamps are applied, needle pricks and even ligatures.
Long-term pressing of the injury site to the underlying bone may not give the expected results, but it is still used during transportation to the hospital.
Bleeding may also be accompanied by an attempt to achieve hemostasis by injecting a bleeding wound with a solution of novocaine and adrenaline hydrochloride. It should be borne in mind that damage to the external genitalia due to blunt force trauma is more often observed in pregnant women, which is probably due to increased blood supply and varicose veins under the influence of sex hormones.
Under the influence of trauma with a blunt object, subcutaneous hematomas can occur, and if the venous plexus of the vagina is damaged, hematomas are formed that spread in the direction of the ischiorectal recess (fossa ischiorectalis) and the perineum (on one or both sides).
Vast cellular spaces can accommodate a significant volume of flowing blood. In this case, blood loss is indicated by hemodynamic disorders up to shock.
Damage to the external genitalia may be accompanied by injury to adjacent organs (polytrauma), in particular fractures of the pelvic bones. In this case, very complex combined injuries can occur, for example, rupture of the urethra, separation of the vaginal tube from the vestibule (vestibulum vulvae), often with damage to the internal genital organs (separation of the uterus from the vaginal vault, formation of hematomas, etc.).
In case of polytrauma, it is rarely possible to avoid transection and limit oneself to conservative measures. The multiple nature of the injuries is an indication for emergency hospitalization in the surgical department of a multidisciplinary hospital.
Stab, cut and bullet wounds of the genitals are described in violent acts against a person on sexual grounds. These are usually simple wounds with cut edges. They can be superficial or deep (the internal genital and adjacent organs are damaged). The topography of the internal genital organs is such that it provides them with fairly reliable protection. Only during pregnancy, the genital organs, extending beyond the pelvis, lose this protection and can be damaged along with other abdominal organs.
There are almost no comprehensive statistical data regarding the frequency of bullet injuries to the internal genital organs, but in modern conditions women can become victims of violence. Therefore, this type of injury is not completely excluded in the practice of an emergency physician.
The experience of military conflicts has shown that the majority of wounded women with damage to the pelvic organs die in the prehospital stage from bleeding and shock. Bullet wounds are not always assessed adequately. The task is easier with a through wound. If there are entrance and exit openings of the wound canal, it is not difficult to imagine its direction and the likely extent of damage to the internal genital organs. The situation is completely different when there is a blind bullet wound.
When making a decision, the emergency physician must proceed from the assumption that the injury caused multiple injuries to internal organs until the contrary is proven. In this regard, it is most appropriate to hospitalize the wounded woman in a multidisciplinary hospital with urgent surgical and gynecological departments.
Bullet wounds are especially dangerous during pregnancy. Injuries to the uterus usually cause significant blood loss. An injured pregnant woman must be hospitalized in the obstetric department of a multidisciplinary hospital.
23) preparing the patient for gynecological surgery, planned and emergency
Surgical treatment has become widespread in gynecology. The success of the operation depends on various factors.
First among them is the presence of precise indications for surgical intervention. In the event that the disease threatens the life and health of the patient and this danger can only be eliminated through surgical intervention, the operation will be indicated and its implementation will be justified.
It is necessary to take into account not only the indications, but also contraindications for surgery, which may be associated with pathology of other organs. Contraindications to surgery are considered both when surgical treatment is planned and when there is an emergency need for surgery. General contraindications to operations are acute infectious diseases, such as tonsillitis, pneumonia, however, in the case of an ectopic pregnancy or bleeding, surgical intervention will have to be resorted to. Elective surgeries in case of acute infectious process will be postponed.
In order for the outcome to be favorable, it is necessary to carry out a whole range of therapeutic and preventive measures before the operation, during it and in the postoperative period.
In preparation for surgery, an examination is carried out, concomitant diseases are identified, and the diagnosis is clarified. Then, during these activities, the method of pain relief, the extent of surgical intervention are selected, and the patient is prepared for surgery. Preparation consists of psychoprophylaxis and the right emotional mood. Also, in some cases, it is necessary to carry out preventive treatment of concomitant diseases.
In connection with the above, preparation for surgery can take from a few minutes in an emergency to several days or weeks in elective operations. It should be noted that part of the examination or treatment can be carried out on an outpatient basis, before the patient is admitted to the hospital.
There is a standard set of studies that every patient must undergo before surgery. It includes a medical history, general and special objective examinations, as well as laboratory and additional tests: general urine and blood tests, determination of platelet count, blood clotting time and bleeding duration, prothrombin index, biochemical studies (for residual nitrogen, sugar, bilirubin, total protein), it is necessary to determine the blood type and Rh affiliation.
An X-ray of the chest organs, an electrocardiogram, and a determination of the Wasserman reaction are also required. In addition, smears from the vagina are examined for flora, as well as from the cervical canal for atypical cells. HIV testing is mandatory.
Practical gynecology
Guide for doctors
Medical news agency
UDC 618.1 BBK 57.1 L65
Reviewers:
G.K Stepankovskaya, Corresponding Member of the National Academy of Sciences and the Academy of Medical Sciences of Ukraine, Doctor of Medical Sciences, Professor, Department of Obstetrics and Gynecology No. 1 of the National Medical University. AA. Bogomolets;
AND I. Senchuk, Doctor of Medical Sciences, Professor, Head. Department of Obstetrics and Gynecology of the Medical Institute of the Ukrainian Association of Traditional Medicine;
B. F. Mazorchuk, Doctor of Medical Sciences, Professor, Head. Department of Obstetrics and Gynecology No. 1 Vinnitsa National Medical University named after. M.I. Pirogov.
Likhachev VC.
L65 Practical gynecology: A guide for doctors / V.K. Likha-
chev. - M.: Medical Information Agency LLC, 2007. - 664 p.: ill.
ISBN 5-89481-526-6
The practical guide provides modern ideas about the etiology and pathogenesis of the most common gynecological diseases, algorithms for their diagnosis and treatment, based on the principles of evidence-based medicine. The issues of inflammatory diseases of the female genital organs with characteristics of sexually transmitted infections are presented in detail; the problem of infertility and the use of modern reproductive technologies; all aspects of menstrual cycle disorders, menopause and postmenopause; background conditions, precancerous diseases and tumors of the female genital area; problems of endometriosis and trophoblastic disease; family planning methods; clinic, diagnosis and treatment tactics in cases of “acute abdomen”. The appendices provide information about modern pharmacological drugs, methods of herbal medicine, gynecological massage and therapeutic exercises.
For practicing doctors - obstetricians-gynecologists, family doctors, senior students, interns.
UDC 618.1 BBK 57.1
ISBN 5-89481-526-6 © Likhachev V.K., 2007
© Design. Medical Information Agency LLC, 2007
List of abbreviations................................................... .......................................... 12
Chapter 1. Methods of examination of gynecological patients.......................... 16
1.1. Anamnesis................................................. ........................................ 17
1.2. Objective examination......................................................... ..... 17
1.3. Special laboratory research methods........ 22
1.3.1. Cytological diagnosis.................................................... 22
1.3.2. Tests for functional diagnostics of ovarian activity 22
1.3.3. Hormonal studies................................................... 25
1.3.4. Genetic studies......................................................... 27
1.4. Instrumental research methods......................... 30
1.4.1. Probing the uterus......................................................... ....... thirty
1.4.2. Diagnostic fractional curettage of the cervical canal and uterine cavity 30
1.4.3. Abdominal puncture through the posterior
vaginal vault......................................................... ................ 31
1.4.4. Aspiration biopsy......................................................... 31
1.4.5. Endoscopic research methods................................... 32
1.4.6. Ultrasound examination.................................................... 35
1.4.7. X-ray research methods......................... 37
1.5. Peculiarities of examination of girls and adolescents........... 39
Chapter 2. Inflammatory diseases of the female genital organs............... 43
2.1. Mechanisms of development of inflammatory diseases
female genital organs........................................................ ........ 43
2.1.1. Factors in the occurrence of inflammatory diseases of the female genital organs 43
2.1.2. Mechanisms of biological protection of the female reproductive system from infection 44
2.1.3. Conditions that violate the barrier mechanisms of protection of the female reproductive system 45
2.1.4. The main links in the pathogenesis of inflammatory diseases of the female reproductive system 46
2.2. Characteristics of infections transmitted
sexually ........................................................... ........................... 48
2.2.1. Trichomoniasis................................................... .................... 48
2.2.2. Gonorrhea................................................. ............................ 50
2.2.3. Urogenital candidiasis.................................................... 54
2.2.4. Chlamydia......................................................... ....................... 56
2.2.5. Mycoplasmosis and ureaplasmosis.................................................... 60
2.2.6. Bacterial vaginosis................................................... 63
2.2.7.Infections caused by the herpesvirus family 66
2.2.8. Human papillomavirus infection................................... 73
2.3. Clinic, diagnosis and treatment of individual forms
inflammatory diseases
female genital organs........................................................ ...... 76
2.3.1. Vulvitis........................................................ ........................... 76
2.3.2. Bartholinitis........................................................ .................... 80
2.3.3. Colpitis......................................................... ............................ 83
2.3.4. Cervicitis......................................................... ........................... 95
2.3.5. Endometritis......................................................... .................... 98
2.3.6. Salpingo-oophoritis......................................................... ......... 102
2.3.7. Parametritis................................................. .................... 118
2.3.8. Pelvioperitonitis......................................................... ........ 119
Chapter 3. Menstrual irregularities.................................................. 123
3.1. Neurohumoral regulation of reproductive
functions of a woman................................................... ................... 123
3.1.1. Physiology of the female reproductive system.. 123
3.1.2. Neurohumoral regulation
menstrual cycle................................................... .. 135
3.1.3. The role of prostaglandins in the regulation of the female reproductive system 136
3.1.4. Anatomical and physiological features of the functioning of the female genital organs
at different age periods................................... 137
3.2. Hypomenstrual syndrome and amenorrhea............................................ 141
3.2.1. General principles of examination and treatment of patients
with hypomenstrual syndrome and amenorrhea.... 145
3.2.2. General principles of patient treatment
with hypomenstrual syndrome and amenorrhea.... 146
3.2.3. Features of clinical manifestations, diagnosis and treatment of primary amenorrhea 151
3.2.4. Features of clinical manifestations, diagnosis and treatment of secondary amenorrhea 160
3.3. Dysfunctional uterine bleeding................................ 173
3.3.1. Clinical and pathophysiological characteristics of dysfunctional uterine bleeding 175
3.3.2. General principles of examination of patients with DUB. 178
3.3.3. General principles of treatment of patients with DUB.............................. 179
3.3.4. Features of DMK in different age periods.... 181
3.4. Algodismenorrhea......................................................... .................... 194
Chapter 4. Menopause and postmenopause.......................................................... 199
4.1. Physiology and pathophysiology of perimenopausal
and postmenopausal periods.................................................... 202
4.2. Pathology of the peri- and postmenopausal periods...... 206
4.2.1. Psychoemotional and neurovegetative disorders 207
4.2.2. Urogenital disorders and trophic changes in the skin 211
4.2.3. Cardiovascular disorders
and osteoporosis................................................... .................... 213
4.3. Diagnosis of menopausal syndrome.................................... 217
4.4. Drug therapy for peri-
and postmenopausal periods.................................................... 221
4.4.1. Hormone replacement therapy................................... 224
4.4.2. Selective estrogen receptor
modulators........................................................ .................... 231
4.4.3. Tissue-selective regulator of estrogenic activity - STEAR 232
4.4.4. Phytoestrogens and phytohormones.................................... 233
4.4.5. Androgens........................................................ ....................... 234
4.4.6. Systemic and local HRT for urogenital disorders 234
4.4.7. Prevention and treatment of osteoporosis...................... 235
4.5. Physiotherapy of peri-pathology
and postmenopausal periods.................................................... 238
4.6. Herbal medicine for pathology of peri-
and postmenopausal periods.................................................... 240
Chapter 5. Polycystic ovaries................................................................... 243
5.1. Characteristics of various forms
polycystic ovaries................................................................ ....... 243
5.1.1. Polycystic ovary disease.................................... 243
5.1.2. Polycystic ovary syndrome.................................... 245
5.2. Diagnosis of PCOS................................................... .................... 248
5.3 Treatment of PCOS.................................................... ........................... 252
5.3.1. Conservative methods of treatment................................... 252
5.3.2. Surgical methods of treatment................................... 256
5.3.3. Physiotherapy................................................. ................. 258
Chapter 6. Infertility............................................................................................. 260
6.1. Features of clinical manifestations,
diagnosis and treatment of various forms of infertility............ 262
6.1.1. Endocrine infertility................................................... 262
6.1.2. Tubal and tubo-peritoneal infertility..... 276
6.1.3. Uterine and cervical forms of infertility.................................. 282
6.1.4. Immunological infertility................................................... 283
6.1.5. Psychogenic infertility................................................... 285
6.2. Algorithm for diagnosing infertility.................................................... 285
6.3. Algorithm for the treatment of various forms of infertility................................. 287
6.4. Modern reproductive technologies................................... 290
6.4.1. In vitro fertilization.................................... 291
6.4.2. Other reproductive technologies........................ 294
6.4.3. Ovarian hyperstimulation syndrome.................................... 296
Chapter 7. Background and precancerous diseases of women
genitals................................................................................. 300
7.1. Background and precancerous diseases of the cervix
uterus........................................................ ........................................... 300
7.1.1. Etiopathogenesis of cervical diseases................................. 301
7.1.2. Classification of cervical diseases.............. 303
7.1.3. Clinic of cervical diseases.................................... 305
7.1.4. Diagnosis of background and precancerous diseases of the cervix 316
7.1.5. Treatment of background and precancerous
diseases of the cervix......................................................... 321
7.1.6. Clinical tactics of patient management
with various forms of background and precancerous
diseases of the cervix......................................................... 328
7.2. Hyperplastic processes of the endometrium (HPE).......... 331
7.2.1. Etiopathogenesis of HPE................................................................. ....... 331
7.2.2. Classification of GGE................................................... ...... 333
7.2.3. GPE Clinic......................................................... ................... 339
7.2.4. Diagnosis of GPE................................................... .......... 340
7.2.5. Treatment of GPE................................................... .................... 344
7.3. Hyperplastic and dysplastic processes
mammary gland (mastopathy)................................................... 359
Chapter 8. Benign tumors of the uterus and ovaries............................ 375
8.1. Uterine fibroids (UF)................................................... .......... 375
8.1.1. Etiology and pathogenesis of FM.................................................... 375
8.1.2. Classification of FM................................................... ....... 379
8.1.3. FM Clinic........................................................ .................... 381
8.1.4. Diagnostics of FM................................................... ............ 386
8.1.5. Treatment of FM.......................................................... .................... 391
8.2. Benign ovarian tumors................................... 399
8.2.1. Epithelial benign
ovarian tumors........................................................ .......... 404
8.2.2. Sex cord stromal tumors (hormonally active) 409
8.2.3. Germ cell tumors........................................................ 411
8.2.4. Secondary (metastatic) tumors................................. 414
8.2.5. Tumor-like processes................................................... 415
Chapter 9. Endometriosis......................................................................................... 418
9.1. Etiopathogenesis of endometriosis.................................................... 418
9.2. Morphological characteristics
endometriosis........................................................ ........................... 422
9.3. Classification of endometriosis................................................... 422
9.4. Clinic of genital endometriosis.................................... 425
9.5. Diagnosis of endometriosis................................................... ... 431
9.6. Treatment of endometriosis................................................... ............ 438
9.6.1. Conservative treatment............................................. 438
9.6.2. Surgery................................................ 445
9.6.3. Combination treatment......................................................... 447
9.6.4. Algorithms for the management of patients with various forms of endometriosis 449
9.7. Prevention of endometriosis................................................... 452
Chapter 10. Emergency conditions in gynecology........................................... 453
10.1 Acute bleeding from the internal genitalia
organs........................................................ ................................... 454
10.1.1. Ectopic pregnancy......................................... 454
10.1.2. Ovarian apoplexy................................................... 469
10.2. Acute circulatory disorders in tumors
and tumor-like formations of internal
genital organs........................................................ ............... 472
10.2.1. Torsion of the pedicle of the ovarian tumor.................................... 472
10.2.2. Eating disorder
fibromatous node......................................................... 474
10.3. Acute purulent diseases of internal
genital organs........................................................ .................... 476
10.3.1. Pyosalpinx and piovar, tubo-ovarian purulent tumor 476
10.3.2. Pelvioperitonitis......................................................... .. 486
10.3.3. Generalized peritonitis................................... 486
Chapter 11. Anomalies in the position of the internal genital organs................... 490
11.1. Anatomical and physiological features
position of the internal genital organs......................... 490
11.2. Anomalies in the position of the internal genitalia
organs........................................................ ................................... 491
11.3. Descent and prolapse of internal
genital organs........................................................ ............... 495
Chapter 12. Modern methods of contraception............................................. 504
12.1. Methods of natural family planning................... 505
12.2. Barrier methods of contraception.................................................... 509
12.3. Spermicides........................................................ ........................... 512
12.4. Hormonal contraception................................................... 513
12.4.1.Principles of prescribing oral hormonal contraceptives 514
12.4.2. Combined oral contraceptives. 519
12.4.3. “Pure” gestagens.................................................... ......... 525
12.4.4. Injectable contraceptives................................... 527
12.4.5. Implantation methods................................... 530
12.5. Intrauterine contraceptives.................................................... 530
12.6. Voluntary surgical contraception (sterilization) 533
12.7. Emergency contraception................................................................. 536
12.8. Principles for choosing a contraceptive method.................................... 538
Chapter 13. Gestational trophoblastic disease.................................... 543
13.1. Etiopathogenesis of gestational trophoblastic disease 544
13.2. Nosological forms of gestational trophoblastic disease 546
13.2.1. Bubble skid................................................... ....... 546
13.2.2. Chorionepithelioma (chorionic carcinoma)........... 553
13.2.3. Other forms of trophoblastic
illnesses........................................................ ........................... 560
13.3.................................................. ........................................................ Prevention of relapses of gestational
trophoblastic disease................................................... 561
Annex 1. Antibacterial agents................................................... ... 562
1.1. Classification and brief description
antibacterial drugs.................................................. 562
1.2. Antimicrobial agents effective against certain microorganisms 572
1.3. Doses and methods of administration of some antibiotics. 578
1.4. Combination of antimicrobial drugs........................ 583
1.5. Use of antibacterial drugs
during pregnancy and lactation................................... 584
Appendix 2. Direct acting antivirals.................................... 589
Appendix 3. Immunoactive agents......................................................... ........ 592
Appendix 4. Herbal medicine in complex treatment
gynecological diseases......................................................... ... 598
4.1. Menstrual irregularities.................................................... 598
4.2. Pathological menopause.................................... 606
4.3. Inflammatory diseases of female genitalia
organs........................................................ ..................................... 608
4.4. Fees that improve blood circulation in the small
pelvis and having antiseptic
and desensitizing properties................................... 613
4.5. Kraurosis of the vulva................................................... ........................ 615
Appendix 5. Gynecological massage................................................... ........ 616
5.1. Mechanism of action of GM......................................................... .......... 616
5.2. Indications, contraindications and conditions
GM. General GM methodology................................................... ........ 618
5.3. Features of GM technical methods depending on
from readings........................................................ ........................... 624
Appendix 6. Therapeutic gymnastics for gynecological
diseases........................................................ ................................... 637
6.1. Therapeutic exercises for unfixed retroflexion of the uterus 637
6.2. Therapeutic gymnastics for prolapse of the genital organs. 640
6.3. Therapeutic exercises for chronic inflammatory diseases of the female genital organs 641
6.4. Therapeutic exercises for dysmenorrhea.................................... 644
6.5. Therapeutic exercises for functional urinary incontinence 645
6.6. Therapeutic exercises in the preoperative period.... 646
6.7. Therapeutic exercises for pathological menopause........648
Appendix 7. Normal vaginal microflora.................................................... 650
Literature................................................. ........................................................ .... 655
A group of diseases that contribute to the emergence and development of malignant neoplasms in women are precancerous diseases of the female genital organs. Some of them respond quite well to treatment, but there are also those that cause a woman a lot of trouble.
Leukoplakia
Leukoplakia is a dystrophic disease of the mucous membrane, which is accompanied by keratinization of epithelial cells. As a rule, such a disease affects the external genital area and is characterized by the appearance of dry, light-colored plaques, which subsequently lead to sclerosis and tissue wrinkling. Leukoplakia can also be localized on the vaginal side of the cervix or in the vagina itself.
There are two types of the disease: thin leukoplakia and scaly leukoplakia, which rises significantly above the surface of the uterine cervix. Often the disease indicates the occurrence of disturbances in the functioning of the ovaries, although it can also be the result of papilloma viruses or herpes simplex. As a rule, leukoplakia is asymptomatic, only in some cases itching may occur. Treatment of the disease mainly comes down to cauterization with a surgical laser, which in most cases gives a positive effect.
Erythroplakia
The disease is characterized by damage to the mucous membrane of the cervix from the vagina and leads to atrophy of the upper layers of the epithelium. Erythroplakia is an area of epithelium that is translucent through. There are often no symptoms of the disease, but in some cases contact bleeding and leucorrhoea may occur. Erythroplakia is often accompanied by diseases such as cervicitis and colpitis with corresponding symptoms.
This problem of the female genital organs is treated with laser therapy or surgical electrocautery; in some cases, cryosurgery can be used. With timely detection and treatment, the prognosis is usually quite favorable.
Uterine fibroids
Precancerous diseases such as uterine fibroids are very common and are benign formations that develop from muscle tissue. Many women are not even aware of their illness, discovering it only during a visit to the gynecologist.
Fibroids can reach significant sizes and consist of nodes that can be felt through the abdominal wall. In advanced cases, such a node can connect to the uterine wall and be accompanied by long, heavy menstruation, which often provokes the development of anemia. Sometimes there is pain or pressure in the pelvic area, which is caused by the significant weight or size of the fibroids. Some women may experience pain in the buttocks, lower back and back, which indicates pressure from the mass on the nerve endings. Fibroids can also lead to problems with the intestines and urethra.
Treatment methods for the disease depend on the size of the tumor and the severity of its symptoms. Possible treatments include:
Drug therapy;
Surgical intervention;
Embolization of the uterine arteries.
Cervical dysplasia
Dysplasia is often the result of another concomitant disease of the female genital organs and, as a rule, does not have its own clinical picture. The reasons for this may be hormonal disorders, prolonged treatment with progestin drugs, or pregnancy. However, dysplasia can also be caused by factors such as:
Bacterial, viral and fungal chronic infections
Vaginal dysbiosis;
Problems with the production of sex hormones;
Abuse of alcohol, smoking and spicy seasonings;
Promiscuous sex life.
As a rule, precancerous diseases such as cervical dysplasia are treated comprehensively; only in severe cases does it require removal of damaged tissue using a laser, radio waves, liquid nitrogen, or surgical excision.
Ovarian cyst
An ovarian cyst is a benign formation that has the shape of a round cavity and contains a clear liquid, jelly-like mass, fat or blood. The disease mainly occurs in young women and can develop into a malignant tumor, so after detection the cyst must be removed.
Types of cysts:
Follicular;
Paraovarian;
Mucinous
Endometrioid
Serous;
Corpus luteum cyst.
Symptoms of the disease include unpleasant nagging pain in the lower abdomen, irregular menstruation and the appearance of random bleeding. Cysts often lead to intestinal dysfunction, frequent urination, abdominal enlargement, infertility and even death.
Corpus luteum cyst and follicular cyst can be treated with medication, but all other types of cysts must be immediately surgically removed, after which the woman can carry and give birth to a healthy child.
Vaginal cyst
This disease is often discovered by chance, as it is small in size. The vaginal cyst is located superficially, has an elastic consistency and contains a serous mass. Such precancerous diseases of the female genital organs are often complicated by suppuration, which leads to inflammatory processes and serious health consequences.
Cervical polyp
This disease is characterized by excessive growth of the mucous membrane and is a benign process. Polyps occur more often in older women, which is explained by endocrine changes and chronic inflammation of the genital organs. The disease is often asymptomatic and is detected only during a gynecological examination. In some cases, a woman may experience heavy vaginal bleeding some time after her period. Rarely does a polyp develop into cancer.
Presented with minor abbreviations
The most common female genital organ affected by cancer is the cervix, followed by the ovaries in second place, and the vagina and external genitalia in third place. The largest percentage of precancerous diseases in women occurs between the ages of 30 and 40 years, when their reproductive system is most susceptible to injury due to abortion and childbirth.
Precancerous disease of the cervix, identified during mass preventive examinations in the city, is 3-5%. In rural areas, where the work of women's preventive institutions is not well organized, up to 10.5% of precancerous diseases, mainly of the cervix, were found among women aged 25 years and older who underwent mass examination. Precancerous diseases of the cervix include all kinds of chronic inflammatory processes, as well as diseases in which the elements of the mucous membrane of the cervix grow (hyperplastic changes).
Cervical erosions occur mainly due to inflammatory processes in the cervical canal and uterine cavity in the presence of discharge. Very often, these secretions are corrosive, have a pungent odor and, when they get on the mucous membrane of the cervical canal, cause persistent, chronic inflammation. The long-term existence of erosion can lead to the formation of an ulcer, which can later turn into cancer.
To treat cervical erosion, irrigation of the vagina and cervix with special, non-irritating douching is used. A beneficial effect is obtained by pricking the erosion at the border with healthy tissue with a 0.25% novocaine solution once every 5-7 days.
Of great importance in the prevention of diseases of the cervical canal is the refusal to use various irritating substances as means of preventing pregnancy. Leukoplakia and polyposis of the mucous membrane of the cervical canal are also available to modern treatment methods. It should be noted that cervical polyps rarely degenerate into cancer, since, accompanied by bleeding at periods unusual for menstruation, they are very quickly diagnosed and undergo radical and timely removal.
As for inversions of the mucous membrane of the birth canal, they arise as a result of incorrect or completely untreated birth trauma to the cervix. It is on these inversions that ulcerations very often appear, which can turn into cancer. Unfortunately, this disease occurs more often than we think, as it mainly depends on the rupture of the cervix during childbirth. The most appropriate preventive measure is suturing cervical ruptures in the postpartum period. Currently, examining postpartum women and suturing existing tears immediately after childbirth is becoming an important measure in the prevention of precancerous diseases.
If the consequences of a birth injury to the cervix are not eliminated in a timely manner, that is, the tears are left unsutured, then most women will be doomed to the fact that sooner or later a precancerous disease may arise from these postpartum injuries to the cervix.
In case of prolonged chronic (minor) bleeding from the uterine cavity or prolonged menstruation, you should consult a doctor and, if necessary, agree to curettage of the uterine cavity for diagnostic purposes. A woman must firmly remember that menstruation must end on time, and long-lasting so-called postmenstrual “spotting” is a painful condition. Any changes in the menstrual cycle, also during menopause, should alert a woman.
Precancerous diseases of the uterine body include the so-called glandular hyperplasia of the mucous membrane, i.e., the proliferation of various glands present in the mucous membrane of the uterus. These growths can later lead to polyposis.
Fibroids and myomas of the uterine body are benign tumors. They should be removed only when there is an increase in them, especially in the first 10 days after the cessation of menstruation.
Precancerous ovarian diseases include ovarian cysts, of which the most dangerous are papillary cysts. All ovarian cysts in women in the early stages of development are usually asymptomatic and are diagnosed only during a gynecological examination. Any recognized cyst should be removed.
The development of vaginal cancer is usually preceded by leukoplakia. In unscrupulous women, corrosive leucorrhoea leads to the fact that leukoplakias turn into ulcers, which in the future can become the basis for cancer. These diseases are usually long-term and chronic. In advanced cases, conservative treatment can be difficult, especially for women who are careless about their health and miss appointments and visits to the clinic.
It should be remembered that vaginal cancer is more dangerous than even cervical cancer, therefore all chronic inflammatory diseases of the vagina should be treated in a hospital setting.
Preventive examination of women and therapeutic measures to eliminate precancerous diseases have led to the fact that currently the number of women with malignant neoplasms has decreased approximately 4-5 times during the post-war years. But at the same time, the percentage of detected precancerous diseases is increasing every year. This is a very good sign that women have realized that the goal of fighting gynecological cancer includes eliminating precancerous lesions. Every woman, whether she is sick or healthy, if she has visited a clinic or outpatient clinic for any reason, must go to the examination room for a medical examination - to check the condition of her genitals.
It should be remembered that a precancerous disease of the female genital organs may not give any symptoms and can be detected only during a preventive (preventive) examination.
Based on an examination of a huge number of women, it was found that the most common precancerous diseases of the female genital area are cervical erosion, cervical polyps, benign uterine tumors, and ovarian cysts. They should be identified promptly and subjected to surgical treatment.
These include:
Leukoplakia
Bowen's disease
Paget's disease
Leukoplakia– it is characterized by proliferation of multilayered squamous epithelium and disruption of its differentiation and maturation – para- and hyperkeratosis, acanthosis without pronounced cellular and nuclear polymorphism, disruption of the basement membrane. Round cell infiltration is noted in the underlying basement membrane.
Macroscopically
Leukoplakia manifests itself in the form of dry plaques of a whitish or yellow color with a pearlescent sheen, slightly rising above the mucous membrane.
Located tumor in a limited area. Most often in the area of the labia minora and around the clitoris. As the tumor progresses, it thickens and ulcerates.
Colposcopic picture
with leukoplakia the following: the keratinized surface is slightly transparent, looks like a simple “white spot” or like a white bumpy surface, devoid of blood vessels, Schiller’s test is negative.
Krauroz
– with it, atrophy of the papillary and reticular layers of the skin, death of elastic fibers and hyalinization of connective tissue are noted. First, the epidermis hypertrophies (with symptoms of acanthosis and inflammatory infiltration of the underlying connective tissue), then the skin of the labia atrophies.
During colposcopy detect pronounced telangiectasia. The skin and mucous membrane of the external genitalia are atrophic, fragile, easily wounded, depigmented, the entrance to the vagina is narrowed. The Schiller test is negative or weakly positive.
A targeted biopsy, cytological examination of scrapings from the affected surface, and taking smears - fingerprints - are performed.
Leukoplakia and kraurosis accompanied by itching and burning, which leads to skin injury, secondary infection and the development of vulvitis.
In 20% of cases, cancer of the external genitalia may develop.
Treatment
consists in prescribing a set of means:
1. Desenbilizing and sedative therapy
2. Compliance with the work and rest regime
3. Gymnastic exercises
4. Elimination of spices and alcoholic beverages
To relieve itching, 10% anesthetic and 2% diphenhydramine ointments, 2% resorcinol lotions, novocaine blockades of the pudendal nerve, or surgical denervation are used locally.
If conservative therapy is successful, vulvectomy or radiation therapy is indicated.
Bowen's disease occurs with symptoms of hyperkeratosis and acanthosis.
Clinically, flat or raised spots with clear edges and infiltration of the underlying tissues are determined.
Paget's disease- peculiar large light cells appear in the epidermis. Clinically, isolated bright red, sharply limited eczema-like spots with a granular surface are identified. The skin around the spots is infiltrated.
Invasive cancer often develops against the background of Bowen and Paget's disease.
Treatment– surgical (vulvectomy).
Condylomas of the vulva
Genital condylomas of the genital area are warty growths covered with stratified squamous epithelium. It is transmitted sexually, manifests itself with itching and pain, and occurs at a young age. Diagnosed upon examination.
Treatment is local (local) and systemic.
Dysplasia (atypical hyperplasia) of the vulva
– atypia of the multilayered epithelium of the vulva without spreading, local and diffuse forms are distinguished; depending on the atypia of epithelial cells, weak, moderate and severe degrees of dysplasia are distinguished.
Malignant tumors of the external genitalia
Cancer of the external genitalia
– in the structure of tumor diseases of the female genital organs, it ranks fourth after cancer of the cervix, uterine body and ovaries, accounting for 3-8%. It is more common in women aged 60-70 years, combined with diabetes mellitus, obesity and other endocrine diseases.
Etiology and pathogenesis Vulvar cancer has not been studied enough. The cause of the development of dysplastic changes in the integumentary epithelium of the vulva is considered to be a local viral infection. 50% of cases of vulvar cancer are preceded by precancerous diseases (atrophic vulvitis, leukoplakia, kraurosis).
In 60% of cases, the tumor is localized in the area of the labia majora and minora and the perineum, in 30% - the clitoris, urethra and ducts of the large glands of the vestibule; may be symmetrical. Mostly there are squamous keratinizing or non-keratinizing forms, less often - poorly differentiated or glandular. There are exophytic, nodular, ulcerative and infiltrative forms of the tumor.
The tumor spreads along its length, often obscuring the site of its primary localization and involving in the process the lower third of the vagina, the tissue of the ischeorectal and obturator zones. The most aggressive course is characterized by tumors localized to the clitoral region, which is due to the abundant blood supply and characteristics of lymphatic drainage.
