Endometriosis represents gormonalnozavisimy pathological growths of ferruterous tissue of uterus (endometrium) beyond its limits: in ovaries, in uterine tubes, in the thickness of a uterus, in a bladder, on a peritoneum, in a rectum and other, more remote bodies. Fragments of endometrium (geterotopiya), expanding in other bodies, undergo the same cyclic changes, as well as endometrium in a uterus, according to phases of a menstrual cycle. These changes of endometrium are shown by pain, increase in the struck body in volume, monthly bloody allocations from geterotopiya, violation of menstrual function, allocations from mammary glands, infertility.
Endometriosis – pathological good-quality growth of fabric, morphologically and functionally similar to endometrium (a mucous membrane of a uterus). It is observed both in various departments of a reproductive system, and out of it (on a belly wall, mucous a bladder, intestines, a peritoneum of a small pelvis, lungs, kidneys, etc. bodies). Clinical manifestations depend on process localization. The general symptoms - pains, increase in endometrioidny knots, bloody allocations from external sites before periods and during it. Genital endometriosis can become the reason of formation of cysts of ovaries, violations of a menstrual cycle, infertility.
Endometriosis is the third on occurrence frequency a gynecologic disease, after inflammatory processes and myoma of a uterus. Endometriosis in most cases arises at women in the reproductive period, i.e. at the age of 25-40 years (about 27%), occurs at 10% of girls during formation of menstrual function and in 2-5% at women at climacteric age. Difficulties of diagnostics, and in some cases and the asymptomatic course of endometriosis allow to assume that the disease much meets more often.
General information and classification of endometriosis
Displays of endometriosis depend on an arrangement of its centers. In this regard endometriosis is classified according to localization. On localization allocate genital and ekstragenitelny forms of endometriosis. At a genital form of endometriosis of a geterotopiya are localized on tissues of genitals, at ekstragenitalny – out of reproductive system.
In a genital form of endometriosis distinguish:
- peritonealny endometriosis - at damage of ovaries, a pelvic peritoneum, uterine tubes
- the ekstraperitonealny endometriosis which is localized in the lower departments of a reproductive system - genitalia, in a vagina, a vaginal segment of a neck of a uterus, a rektovaginalny partition etc.
- the internal endometriosis () developing in a muscular layer of a uterus. At an adenomioza the uterus becomes the spherical shape increased in sizes up to 5-6 week of pregnancy.
Localization of endometriosis can be mixed, it meets, as a rule, at neglect of a disease. At an ekstragenitalny form of endometriosis the centers of geterotopiya arise in intestines, a navel, lungs, kidneys, postoperative hems. Depending on depth and distribution of focal growths of endometrium distinguish 4 degrees of endometriosis:
- The I degree — the endometriosis centers superficial and single;
- The II degree — the endometriosis centers deeper and in bigger quantity;
- The III degree — the deep multiple centers of endometriosis, endometrioidny cysts on one or both ovaries, separate solderings on a peritoneum;
- The IV degree — the multiple and deep centers of an endomerioz, bilateral big endometrioidny cysts on ovaries, dense solderings, germination of endometrium in walls of a vagina and rectum. The IV degree of endometriosis is characterized by prevalence and expressiveness of defeat, will difficult respond to treatment.
Also there is the standard classification of an adenomioz of a uterus (internal endometriosis) in which development allocate four stages on extent of defeat of a muscular layer (miometriya):
- The I stage – initial germination a miometriya;
- The II stage – distribution of the centers of endometriosis on a half of depth of a muscular layer of a uterus;
- The III stage – germination of all thickness a miometriya up to a serous cover of a uterus;
- The IV stage – germination of walls of a uterus and distribution of the centers of endometriosis on a peritoneum.
The Endometrioidny centers can differ by the sizes and a form: from roundish educations by size in several millimeters before shapeless growths several centimeters in the diameter. Usually they have dark cherry color and are separated from surrounding fabrics by soyedinitelnotkanny whitish hems. The centers of endometriosis become more noticeable on the eve of periods thanks to the cyclic maturing. Extending to internals and a peritoneum, sites of endometriosis can deeply sprout in fabric or settle down superficially. Endometriosis of ovaries is expressed in emergence of cystous growths with dark red contents. Geterotopiya usually settle down groups. Degree of endometriosis is estimated in points taking into account diameter, by depths of germination and localization of the centers. Endometriosis quite often is the reason of the adhesive processes in a small basin limiting mobility of ovaries, uterine tubes and a uterus leads to violations in a menstrual cycle and to infertility.
Among experts there is no consensus about the reasons of development of endometriosis. Most of them inclines to the theory of retrograde periods (or the implantation theory). According to this theory, a part of women has a hit of menstrual blood to parts of endometrium in an abdominal cavity and uterine tubes – so-called, retrograde periods. Under certain conditions there endometrium is attached to fabrics of various bodies and continues to function cyclically. In the absence of pregnancy endometrium from a uterus is torn away during periods whereas in other bodies there is a microhemorrhage causing inflammatory process.
Thus, the women having such feature as retrograde periods are predisposed to development of endometriosis, however not in all cases. Such factors as features in a structure of uterine tubes, an immunosuppression, heredity increase probability of endometriosis. The role of hereditary predisposition to development of endometriosis and transfer it from mother to the daughter is very high. Knowing about the heredity, the woman has to observe necessary measures of prevention. Development of endometriosis is promoted by surgeries on a uterus: surgical termination of pregnancy, cauterization of erosion, Cesarean section, etc. Therefore after any uterus operations medical observation is necessary for timely identification of deviations in reproductive system.
Other theories of development of endometriosis which do not have wide circulation consider as its reasons gene mutations, deviations as cellular enzymes and reaction of receptors to hormones.
The course of endometriosis can be various, at the beginning of emergence – asymptomatic, and in time it is possible to reveal its existence only at regular professional surveys. However, there are reliable symptoms indicating existence of endometriosis.
- Pelvic pain.
Accompanies endometriosis at 16-24% of patients. Pain can have accurate localization or poured character on all basin, to arise or amplify just before periods or to be present constantly. Often pelvic pain is caused by the inflammation developing in the bodies affected with endometriosis.
- Dismenorey – painful periods.
It is observed at 40-60% of patients. It is as much as possible shown in the first three days of periods. At endometriosis it is often connected with bleeding in a cavity of a cyst and increase in it in pressure, with irritation of a peritoneum hemorrhages from the endometriosis centers, a uterus angiospasm.
- Painful sexual intercourse (dispareuniya).
- Pains at defecation or an urination.
- Discomfort and pain during the sexual intercourse it is especially expressed at localization of the centers of endometriosis in a vagina, a wall of a rektovaginalny partition, in sacral and uterine ligaments, uterine space.
- Menorragiya – plentiful and long periods.
It is observed at 2-16% of patients with endometriosis. Often accompanies and associated diseases: uterus myoma, ovaries, etc.
- Development of post-hemorrhagic anemia
Occurs owing to considerable chronic blood loss at periods. It is characterized by the increasing weakness, pallor or yellowness of skin and mucous, drowsiness, fatigue, dizziness.
At patients with endometriosis makes 25-40%. So far the gynecology cannot precisely answer a question of the mechanism of development of infertility at a disease of endometriosis. Among the most probable causes of infertility call changes in ovaries and pipes owing to endometriosis, violation of the general and local immunity, the accompanying violation of an ovulation. At endometriosis it is necessary to talk not about absolute impossibility of approach of pregnancy, and about its low probability. Endometriosis sharply reduces chances to take out the child and can provoke a spontaneous abortion therefore conducting pregnancy at endometriosis has to be carried out with constant medical control. The probability of approach of pregnancy after treatment of endometriosis fluctuates from 15 to 56% in the first 6-14 months.
Hemorrhages and cicatricial changes at endometriosis cause development of adhesive processes in a small basin and abdominal organs. As other frequent complication of endometriosis serves formationendometrioidny cysts of ovaries
, filled with old menstrual blood ("chocolate" cysts). Both of these complications can cause infertility. Sdavleniye of nervous trunks can lead to various neurologic violations. Considerable blood losses during periods cause an anemization, weakness, irritability and tearfulness. In some cases malignant regeneration of the centers of endometriosis meets.
Diagnosis of endometriosis
At diagnosis of endometriosis it is necessary to exclude other diseases of the genitals proceeding with similar symptomatology. At suspicion of endometriosis collecting complaints and the anamnesis at which pains, information on the postponed diseases of genitals, operations, presence of gynecologic pathology at relatives are indicative is necessary. Further inspection of the woman at suspicion of endometriosis can include:
- gynecologic research (vaginal, rektovaginalny, in mirrors) most informatively on the eve of periods;
- kolposkopiya and gisterosalpingoskopiya for specification of the place and a form of defeat, receiving a biopsy of fabrics;
- ultrasonic examination of bodies of a small pelvis, abdominal cavity for specification of localization and a dynamic picture at treatment of endometriosis;
- spiral computer tomography or magnetic resonance for the purpose of specification of character, localization of endometriosis, its interrelation with other bodies etc. Accuracy of results of these methods at endometriosis makes 96%;
- the laparoscopy allowing to examine visually the endometriosis centers, to estimate their quantity, maturity degree, activity;
- gisterosalpingografiya (x-ray pictures of uterine tubes and uterus) and hysteroscopy (endoscopic survey of a cavity of a uterus), allowing to diagnose with an accuracy of 83%;
- research of tumoral markers SA-125, REA and SA 19-9 and the RO-test which indicators in blood at endometriosis increase several times.
Treatment of endometriosis
At the choice of a method of treatment of endometriosis are guided by such indicators as age of the patient, the number of pregnancy and childbirth, prevalence of process, its localization, expressiveness of manifestations, existence of the accompanying pathologies, need of emergence of pregnancy. Methods of treatment of endometriosis share on medicamentous, surgical (laparoscopic with removal of the centers of endometriosis and preservation of body or radical – removal of a uterus and an ooforektomiya) and combined.
Treatment of endometriosis pursues the aim not only elimination of active displays of a disease, but also its consequences (adhesive and cystous educations, psychoneurological manifestations etc.). Indications to conservative treatment of endometriosis are its asymptomatic current, young age of the patient, a premenopauz, need of preservation or restoration of genital function. In drug treatment of endometriosis hormonal therapy the following groups of medicines is leading:
- the medicines combined estrogen-gestagennye.
These medicines containing small doses of gestagen suppress production of estrogen and an ovulation. Are shown at the initial stage of endometriosis since are not effective at prevalence of endometrioidny process, cysts of ovaries. Side effect is expressed by nausea, vomiting, intermenstrual bloody allocations, morbidity of mammary glands.
- gestagenam (, progesterone, , ).
Are shown at any stage of endometriosis, it is continuous – from 6 to 8 months. Reception of gestagen can be followed by an intermenstrual krovomazaniye, a depression, morbidity of mammary glands.
- antigonadotropny medicines (, etc.)
Suppress development of gonadotrophins in system a hypothalamus hypophysis. Are applied by a continuous course within 6-8 months. Are contraindicated at a giperandrogeniye at women (excess of androgenic hormones). As side effect serve perspiration, inflows, changes in weight, voice coarsening, increase in fat content of skin strengthening of intensity of growth of hair.
- agonists of gonadotropny releasing-hormones (, , etc.)
Advantage of medicines of this group in treatment of endometriosis is the possibility of use of medicines once a month and lack of serious side effects. Agonists of releasing-hormones cause the suppression of process of an ovulation and content of estrogen leading to suppression of distribution of the centers of endometriosis. Except hormonal medicines in treatment of endometriosis immunostimulators, symptomatic therapy are applied: spazmolitik, analgetics, resolvents.
Organ-preserving surgical treatment with removal of geterotopiya is shown at average and heavy stages of a course of endometriosis. Treatment is directed to removal of the centers of endometriosis in various bodies, endometrioidny cysts, a section of solderings. It is carried out in the absence of the expected effect of medicamentous therapy, existence of contraindications or intolerance of medicines, existence of the centers of defeat with a diameter more than 3 cm, violation of functions of intestines, bladder, mochetochnik, kidneys. In practice it is often combined with drug treatment of endometriosis. It is carried out laparoscopic or laparotomichesky by accesses.
Radical surgical treatment of endometriosis (hysterectomy and adneksektomiya) is carried out to patients aged after 40 years at active progressing of a disease and inefficiency of conservative and surgical actions. Unfortunately, radical measures at treatment of endometriosis are required for 12% of patients. Operations are made laparoscopic or laparotomichesky in the ways.
Endometriosis has tendency to a retsidivirovaniye of processes, in some cases forcing to resort to repeated surgery. A recurrence of endometriosis occurs at 15-40% of patients and its weights, localization, radicalism of carrying out the first operation depend on prevalence of process in an organism.
Endometriosis is a terrible disease for a female body, and only its identification in early terms and persistent treatment leads to full disposal of an illness. As criteria of an izlechennost of endometriosis serve the satisfactory health, absence of pains and other subjective complaints, lack of a recurrence within 5 years after passing of a full course of treatment.
In childbearing age success of treatment of endometriosis is defined by restoration or preservation of genital function. At the modern level of surgical gynecology, wide use of the sparing laparoscopic techniques such results are achieved at 60% of patients with endometriosis aged from 20 up to 36 years. At patients with endometriosis after radical operations the disease does not renew.
Prevention of endometriosis
The earlier at emergence of the first symptoms of endometriosis the woman comes to consultation of the gynecologist, the full treatment and lack of need of surgery are more probable. Attempts of independent treatment or waiting tactics in case of endometriosis are not justified at all: with each subsequent periods in bodies there are new centers of endometriosis, cysts are formed, cicatricial and adhesive processes progress, there is a decrease in passability of uterine tubes.
The main actions directed to prevention of endometriosis are:
- specific inspection of teenage girls and women with complaints to painful periods () for the purpose of an endometriosis exception;
- observation of the patients who transferred abortion and other surgical interventions on a uterus for elimination of possible consequences;
- timely and full treatment of sharp and chronic pathology of genitals;
- reception of oral hormonal contraceptives.
The risk of development of endometriosis is higher at the following groups of women:
- noting shortening of a menstrual cycle;
- the exchange processes suffering from violations, obesity, excessive weight;
- using intrauterine contraceptives;
- aged after 30-35 years;
- having the increased level of estrogen;
- suffering from an immunosuppression;
- having hereditary predisposition;
- undergone uterus operations;
- the smoking women.
Concerning endometriosis, as well as many other gynecologic diseases, the strict rule is applicable: the best treatment of a disease is its active prevention. Attention to the health, the regularity of medical examinations, timely therapy of gynecologic pathology allow to find endometriosis in the most initial stage or at all to avoid its emergence.