Atipichesky giperplaziya of endometrium
Atipichesky giperplaziya of endometrium – pathological growth of an inside layer of a uterus with the advent of atipichesky cages. It is provoked by excess of estrogen and a lack of progesterone. Is considered as a precancer disease. Can develop at any age, however comes to light after 45 years more often. Is followed by violations of a menstrual cycle and uterine bleedings (menorragiya, metrorragiya). The diagnosis is established on the basis of complaints, the anamnesis and these additional researches. Treatment – hormonal therapy, a scraping or an ablyation of a mucous membrane.
Atipichesky giperplaziya of endometrium
Atipichesky giperplaziya of endometrium – the strengthened endometrium proliferation which is followed by change of morphology of cages. Data on prevalence are absent. Pathology comes to light at women at the age of 45-55 years more often. The long repeating giperplaziya in the period of a climax and a menopause is considered as a precancer disease. The probability of malignant regeneration depending on a form of a disease fluctuates from 8 to 29%. The Atipichesky giperplaziya of endometrium is quite often combined with other diseases of reproductive system. Tactics of treatment is defined depending on age of the patient, her desire to have children, existence or absence of the accompanying genital and ekstragenitalny pathology. Treatment is performed by experts in the field of gynecology and oncology.
Development of this disease is caused by increase in level of estrogen, reduction of level of progesterone and existence or lack of an ovulation. Estrogen and progesterone participate in regulation of cyclic changes of endometrium. In the first phase of a menstrual cycle estrogen provides proliferation of cages. In the second phase progesterone suppresses proliferation and stimulates secretion. In the absence of an ovulation, a relative or absolute giperestrogenemiya the phase of secretion either does not come, or is shown insufficiently brightly. Cages of a functional layer of endometrium continue to expand, there is a giperplaziya.
The contributing factors of development of an atipichesky giperplaziya of endometrium are the age changes of level of sex hormones, the early beginning of periods, the late beginnings of a climax, a disease and a state which are followed by an anovulyation and dysfunction of ovaries (a syndrome of polycystous ovaries, gormonprodutsiruyushchy tumors of ovaries, obesity, a hypertension, diabetes and other diseases of endocrine system), inflammatory diseases and congenital anomalies of reproductive system, multiple abortions and diagnostic a scraping, hereditary predisposition, reception of estrogensoderzhashchy medicines and tamoxifen.
The Atipichesky giperplaziya of endometrium is characterized by pathological growth of a functional layer of a mucous membrane of a uterus, at the same time ferruterous fabric of an epithelium is exposed to more expressed changes in comparison with stroma elements. In the course of the histologic research increase in amount of glands and hypostasis of a stroma comes to light. Glands settle down closely to each other. Vessels are located unevenly. Epithelium cages with hyperchromic kernels. Numerous pathological mitoses are defined.
Depending on features of an arrangement of ferruterous cages distinguish two forms of an atipichesky giperplaziya of endometrium: simple and adenomatozny. At a simple form increase in quantity and excess growth of cages without change of structure of a mucous membrane is observed. At an adenomatozny form the special structures which are absent in endometrium of a healthy uterus are formed of ferruterous cages. These structures can be located throughout endometrium (a diffusion form) or to form the separate centers (a focal form). Besides, sites of an adenomatozny giperplaziya can be found in the field of uterus polyps.
The main symptom of this disease are uterine bleedings. At most of patients such bleedings arise against the background of a periods delay for a period of 1-3 months. Less often (as a rule, in the absence of obesity and obvious endocrine pathology) regular cycles lasting menorragiya more than 7 days are observed. Approximately at a quarter of patients with an atipichesky giperplaziya of endometrium anovulyatorny uterine bleedings come to light. In 5-10% of cases metrorragiya are diagnosed. Poor bloody allocations in the middle of a menstrual cycle or in the absence of periods are possible.
More than obesity is diagnosed for a half of patients. In 70-75% of cases excess weight is combined with virilization symptoms: pilosis on men's type, a voice posterization, increase in a clitoris etc. At normal body weight signs of a virilization are observed at 30% of patients. All categories of patients with an atipichesky giperplaziya of endometrium often have chronic inflammatory diseases of reproductive system, pregnancy not incubation, secondary infertility, endometriosis, adenomiozy and mastopathy, however at patients without obesity the listed pathological states come to light twice more often.
The diagnosis is established on the basis of complaints, yielded the anamnesis and results of tool researches. During the poll the gynecologist finds out age of menarche, establishes the cycle duration, duration and a profuseness of periods, specifies whether there were delays of a cycle and bloody allocations. Then the doctor carries out gynecologic survey and appoints to transvaginal ultrasonography for assessment of a condition of endometrium (its structure, thickness, uniformity) and identifications of pathological changes of ovaries (symptoms of a tumor, cyst or SLEEPING).
Accuracy of diagnostics of hyper plastic processes when performing ultrasonography makes 60-70%, however it is not possible to confirm or disprove an endometrium atipiya by means of ultrasonography usually. The patient is directed to ultrasonography for 5-7 day of a cycle. At long bleedings of ultrasonography appoint regardless of a cycle phase. Normal in childbearing age thickness of a mucous membrane of a uterus makes no more than 7 mm, at a postmenopause lasting less than 5 years – no more than 5 mm, at a postmenopause lasting more than 5 years – no more than 4 mm. Increase in thickness, heterogeneity of structure and existence of ekhogenny inclusions allow to suspect an endometrium giperplaziya.
In some cases after ultrasonography carry out an aspiration biopsy with the subsequent histologic or cytologic research of an aspirat. This procedure belongs to the category screening tests and is carried out in out-patient conditions. However the gold standard of diagnostics of an atipichesky giperplaziya of endometrium is hysteroscopy and a separate diagnostic scraping. Informational content of a research makes more than 90%.
At suspicion on SLEEPING and the metabolic syndrome is appointed by blood tests for determination of level of progesterone, testosterone, an estradiol, LG, FSG, hormones of adrenal glands and a thyroid gland. Carry out mammography. At a frequent recurrence carry out a laparoscopy with a biopsy or a wedge-shaped resection of ovaries and the subsequent histologic research of material. The Atipichesky giperplaziya of endometrium is differentiated with other diseases provoking uterine bleedings: adenomiozy, polipozy, submucous fibroma of a uterus and malignant tumors of a mucous membrane of a uterus (adenocarcinoma, uterus body cancer).
treatment should be carried out only under the supervision of a doctor. Self-treatment is unacceptable!!!
Treatment of this pathology can be both conservative, and quick, to be carried out on an outpatient basis or in the conditions of a hospital. The indication to planned hospitalization at reproductive age are bleedings and bloody allocations, in a postmenopause – bleedings, long watery or purulent allocations. The emergency hospitalization is shown at plentiful bleedings. Tactics of treatment of an atipichesky giperplaziya of endometrium is defined with age of the patient, her desire to have children, existence of somatic diseases and diseases of reproductive system (especially – an adenomioza or myomas), a form of an atipichesky giperplaziya of endometrium and the number of a recurrence.
In the presence of a metrorragiya or a menorragiya at the first stage hold events for a stop of bleeding and completion of blood loss. Carry out an endometrium scraping, appoint oxytocin and cold to a stomach bottom. Apply iron medicines. If necessary transfuse blood and blood substitutes. Perform infusional therapy with use of isotonic solution, glucose solution, or a dextran for restoration of water and electrolytic balance and improvement of rheological properties of blood.
After a bleeding stop carry out by the patient with an atipichesky giperplaziya of endometrium within 3-6 months the hormonal therapy directed to suppression of proliferation of a mucous membrane. In the subsequent appoint hormonal medicines for restoration of a two-phase menstrual cycle or achievement of a resistant menopause. Hormonal therapy is carried out against the background of reception of vitamins, the hyposensibilizing medicines and gepatoprotektor.
As indications to expeditious treatment consider all cases of an atipichesky giperplaziya of endometrium in the post-climacteric period, and also existence of contraindications to hormonal therapy, lack of effect of conservative therapy and a disease recurrence at women of reproductive age. Carry out an endometrium abalyation – low-invasive surgical intervention which purpose is destruction or removal of all thickness of a mucous membrane. Operation is performed by gisteroskopichesk with use of high-frequency currents. Dispensary observation after conservative treatment is carried out within 5 years, after surgical intervention – within 6 months.
The forecast at an atipichesky giperplaziya of endometrium depends on age, tendency of a disease to a retsidivirovaniye, existence of the accompanying genital and ekstragenitalny pathology. Perhaps absolute recovery with preservation of reproductive function, recovery with loss of reproductive function or regeneration in a malignant tumor of endometrium. In the latter case the hysterectomy or a pan-hysterectomy will be required (removal of a uterus together with an adneksektomiya). Predictively combinations of an atipichesky giperplaziya of endometrium to any exchange violations and diseases of endocrine system are considered as adverse, especially – 45 years are aged more senior. The risk of malignant regeneration at a simple form of a disease makes 8%, at adenomatozny – 29%.