ENDOMETRIOSIS

From Big Medical Encyclopedia

ENDOMETRIOSIS (endometriosis; Greek endon inside + metra a uterus + - osis; synonym: an endometrioid heterotopy, an adenomyosis, an endometrio-ma) — the disease which is characterized by growth in various bodies of the fabric similar on the structure and function to an endometria.

An ectopic arrangement of an endometria for the first time described Müller (N. Muller, 1854) and K. Rokitansky (I860). Distribution of process comes at the retrograde expiration of blood from a uterus through uterine tubes, by hematogenous or lymphogenous innidiation, and also during operation (especially on generative organs) or as a result of a rupture of endometrioid cysts. Despite looking alike tumoral diseases, AA. consider as a dishormonal hyperplasia ectopically of the located endometria.

Distinguish genital endometriosis (meets in 92 — 94% of cases) and extragenital endometriosis (meets in 6 — 8% of cases). Genital E. can be internal and outside. Internal genital E. it is characterized by damage of a uterus and uterine tubes. At outside genital E. ovaries, retrocervical space, a neck of uterus, a vagina, sacrouterine and round ligaments of a uterus, external genitals, a pelvic peritoneum are surprised.

At extragenital E. process is more often localized in the bodies located in a cavity of a small pelvis and in close proximity to it — in a straight line, sigmoid, a caecum and a worm-shaped shoot, ureters, a bladder, is much more rare in a small bowel. Damage of kidneys, lungs, pleurae, diaphragms, top and bottom extremities and other bodies is possible. E is often observed. postoperative hems and navel.

Among ginekol. diseases E. on frequency concedes only to inflammatory diseases of generative organs and a hysteromyoma. Increase of cases E. it is connected first of all with improvement of diagnosis of a disease thanks to wide use of tool methods of a research.

Etiology and pathogeny. Etiology E. it is not established. There is a number of theories. According to the embryonal theory of R. Freund and T. Recklinghausen (1893 — 1896) endometriosis develops from ferruterous elements of myullerovy channels and volfovy bodies. The implantation theory which is put forward by J. A. Sampson in 1921 — 1922 explains development E. engraftment on bodies of a small pelvis and abdominal cavity of the elements of an endometria which are contained in the menstrual blood thrown retrogradno on uterine tubes that is confirmed by frequent developing of a disease at women with a malformation of internal generative organs. The metaplastic theory connects emergence E. with transformation of a mesothelium of a peritoneum. Results of the pilot studies conducted on doe-rabbits formed a basis of the induction theory, at to-rykh endometrio-zopodobny transformation of a mesenchyma at change of fragments of the endometria which is in a condition of an ischemic necrosis by it was observed. The reason of this phenomenon consider diffusion of the chemical substances which are formed at disintegration of elements of an endometria. Assume that similar substances are available in menstrual blood of women and can induce emergence of endometrial fabric from an undifferentiated mesenchyma at retrograde intake of menstrual blood in an abdominal cavity.

The great value in development of a disease is attached to the disturbances of synthesis of sex hormones which are usually observed at patients E. and caused by changes of regulation in system a hypothalamus — a hypophysis — ovaries. More often the giperestrogeniya (absolute or relative) with dominance of estrone and an estradnol, depression of function of a yellow body and hypofunction of bark of adrenal glands comes to light. In some cases at patients the two-phase menstrual cycle remains. Secretion of gonadotrophins has acyclic character. Substantial increase of level of follicle-stimulating hormone (see) and decrease in level of luteinizing hormone is noted (see). Character of excretion of sex hormones changes depending on localization of process. So, at patients with retrocervical endometriosis change of level and a rhythm of production of follicle-stimulating hormone (FSG) is observed and I luteinize-ztsego hormone (LG) at various oestrogenic saturation.

Importance in development E. have immune disturbances; the certificate of it is the deficit of T lymphocytes (see. And to a mm incompetent cells) various degree of manifestation found in women with endometriosis. Owing to immunological insufficiency the migrating endometrial cells do not eliminirutsya, and create the center of endometriosis. An imbalance of sex hormones at E., in turn, leads to disturbance of cellular and humoral immunity. To formation of the centers E. steady stress nonspecific for - shchitno - adaptation reaction of an organism, followed by increase in production of glucocorticoid, gonadotropic and sex hormones against the background of the broken immune balance can promote.

To emergence E. promote it is long the proceeding inflammatory diseases of generative organs, traumatizing a uterus during the operative measures which are followed by opening of her cavity, a scraping, manual department of a placenta, diathermocoagulation and a diatermoekstsiziya of a neck of uterus, etc.

Assume that in development of a disease a part is played a constitutional hereditary factor (especially at inborn E. and a disease of persons of young age), disorders of function of a liver, as a result to-rykh metabolism of sex hormones, and also impact of ionizing radiation, chemical substances, etc. is broken.

Pathological anatomy. At E. the struck bodies and fabrics find the centers of endometrioid fabric which are characterized by ability to infiltrative growth and distribution on surrounding fabrics and bodies. In a uterus process can be diffusion or focal. Diffusion endometriosis of a uterus is characterized by its increase, a thickening of a wall up to 4 — 5 cm (in the period of a menopause the uterus is increased slightly). At focal endometriosis in a uterus find the large and small nodes which do not have a clear boundary.

At internal endometriosis of a uterus fabric in the center of defeat has a cellular structure, pale or light pink coloring. Sometimes in myometriums find endometrioid cysts with hemorrhagic contents (fig. 1). Microscopically in the thickness of a wall of a uterus define the centers of endometrioid fabric formed by glands of various form and size, sometimes sharply expanded surrounded with a cytogenic stroma (fig. 2). Glands and cysts are covered by a single-row cylindrical epithelium of endometrial type.

On depth of distribution of endometrioid fabric to myometriums at diffusion process distinguish three degrees internal E. uterus. At internal endometriosis of a uterus

of the I degree inner layers of a myometrium are surprised on depth corresponding to the size of a field of vision at small increase in a microscope. Internal endometriosis of a uterus of the II degree is characterized rasprostra-


by Fig. 1. Macrodrug of a uterus at diffusion internal endometriosis (a sagittal section): shooters specified the endometrioid cysts of various size filled with hemorrhagic contents.

a neniye of endometrioid fabric to the middle of a muscular coat of a uterus. At internal endometriosis of the III degree all wall of a uterus to its serous cover is surprised. At patients with internal endometriosis of the I degree and at a number of patients with internal endometriosis of the II extent of the expressed increase in a uterus it is not noted. At most of patients with internal endometriosis of the II degree and at all patients with internal endometriosis of the III degree, and also at focal E. in the reproductive period and in a premenopauza the adenomyosis — a hyperplasia of the muscular tissue surrounding the centers of endometrioid fabric comes to light. Secretory reaction in endometrioid fabric in a lyuteinovy phase of a menstrual cycle is observed seldom. More often endometrioid fabric reacts to estrogen to what existence of proliferation and a hyperplasia of an epithelium in the centers of endometriosis testifies.


Fig. 2. Microdrug of a wall of a uterus at internal endometriosis: the center of endometrioid fabric formed by glands of various form and size (1) and growths of a cytogenic stroma (2) is visible; coloring hematoxylin-eosine; x 80.

AA. uterine tubes usually is followed by development of process in a uterus and ovaries. Defeat E. all uterine tube, and also focal E. ampullar and istmiko-ampulyar-nogo departments of a uterine tube meet seldom. E is more often observed. a uterine tube in the field of an isthmus, to-ry macroscopically has an appearance of small and large small knots or it is shown by the sharp thickening of a uterine tube in this area caused by a focal hyperplasia of muscular tissue. Endometrioid fabric can be localized in a gleam of a uterine tube and completely replace her mucous membrane. Endometrioid fabric should be distinguished from the small fragments of an endometria located between folds of a mucous membrane which got there retrogradno during periods.

At E. necks of uterus the centers happen various size (from microscopic to 1,5 cm, is sometimes larger). The centers of a rounded or polygonal shape have an appearance of strips and points, eyes, mulberry berry and (or) a nabo-tovy cyst. Most ^етко E. necks of uterus comes to light in a lyuteino-vy phase of a menstrual cycle that is caused by increase in the centers and change of their coloring, edges becomes blue-crimson. The endometrioid centers acting to the canal of a neck of uterus have an appearance of polyps. Histologically under a cover epithelium (sometimes otsloyenny or stratified owing to hemorrhages) in fabric like a cytogenic stroma of an endometria in various quantity glands covered by an endometrial epithelium meet.

At retrocervical E. the centers of 0,5 — 6 cm are localized on a back wall of the channel of a neck of uterus and an isthmus of a uterus at the level of an attachment of sacrouterine sheaves. The centers of defeat dense since substantially consist of connecting fabric. Feature retrocervical E. infiltrative growth in the direction of a rectum, a back vault of the vagina is and vulval pryamokishechnoy partitions. Microscopically it does not differ from other forms of endometriosis.

Primary E. vaginas at macro and microscopic researches endometriosis of a neck of uterus is characterized by the same signs, as well as.

AA. ovaries at a long current it is characterized by existence en-to metrioidny cysts of 0,6 in size — 10 cm. Small endometrioid cysts (single and multiple) and endometrioid fabric without cysts, edge sometimes has a typical appearance of a mucous membrane of a body of the womb, hl come to light. obr. not on a surface of body, and on a section of an ovary, a thicket in cortical substance; they are usually not connected with a white and a cover epithelium of an ovary. Endometrioid cysts are covered by a cylindrical and (or) cubic epithelium, as a rule, covered with the capsule from 0,2 to 1,5 cm thick, quite often have numerous preferential dense commissures on an outer surface and hemorrhagic contents of chocolate color (so-called chocolate cysts). Under an epithelium find a cytogenic stroma, in a cut plasmocytes and lymphocytes in a small amount, hemorrhages of various prescription, pseudo-ksantomnye cells, hemosiderin, macrophages come to light. Pigmentsoderzhashchy macrophages are especially numerous in walls of large endometrioid oothecomas. With endometrioid cysts of ovaries on a serous cover and in a subserous layer of uterine tubes and a uterus occurs at patients endometrioid implants. At widespread process the centers E. are observed on a peritoneum of rectouterine deepening, a vesicouterine fold, a serous cover of a rectum, round ligaments of a uterus both other bodies and fabrics. They have the same morphological features, as described above.

In the fabrics surrounding the centers E., find hypostasis, hemorrhages; commissures and cicatricial changes. During pregnancy in the centers internal and outside E. perhaps decidual transformation of a stroma (emergence in it of the cells reminding decidual).

At outside genital E. allocate small and initial forms. Small forms are characterized by development small (to 0,5 cm) the centers of endometrioid fabric located, as a rule, in superficial departments of bodies and on a peritoneum of a small pelvis (is more often in ovaries and sacrouterine ligaments), sometimes and in deeper departments of bodies. A kind of small forms are initial forms at which there is no infiltrative growth of implants of an endometria.

Quite often in the centers internal and outside genital E. dystrophic changes of a ferruterous epithelium, and also the epithelium covering endometrioid cysts (are noted especially at treatment an estro-gene-gestagennymi and gestagenny drugs). As a result of hormonal therapy the cytogenic stroma of the endometrioid centers is exposed to fibrosis, growth of fibrous connecting fabric in the centers of old hemorrhages, a sklerozirovaniye of walls of large arteries is noted. The endometrioid cyst as a result of dystrophy and a necrobiosis of an epithelium is quite often deprived it on a considerable extent. However anatomic changes in the course of hormonal therapy in the centers E. in a uterus and endometrioid oothecomas does not occur. In the period of a postmenopause endometrioid fabric is exposed to more expressed dystrophic and regressive changes therefore at internal genital E. the uterus is increased slightly, and the epithelium covering endometrioid cysts on a considerable extent is absent. At the expressed reaction of an organism to estrogen in endometrioid fabric not only the intensive proliferation of a ferruterous epithelium which is followed by high mitotic activity, increase in content of RNA and falloff of quantity of a glycogen but also restructuring of an epithelial component as the unsharp and expressed atipichesky hyperplasia and a planocellular metaplasia is observed.

In some cases genital E. is exposed to a malignancy. Develop an adenocarcinoma and adenoakanto ma ovaries, an adenocarcinoma of a uterus more often, it is exclusively rare against the background of internal E. there are endometrial stromal sarcoma and a carcinosarcoma. As criterion of an endometrial origin of a malignant tumor serves existence of its elements in sites of endometrioid fabric at preservation in it high-quality epithelial structures. The existing term «endometrioid adenocarcinoma» does not mean that a source of its development surely are the centers of endometriosis.

Extragenital E. on morfol. to signs does not differ from genital endometriosis.

The clinical picture is defined by localization of process and a functional condition of system a hypothalamus-hypophyses-ovaries. Main manifestation genital E. painful periods — aljgodismenoreya are (see). Also pains at sexual intercourse are observed, plentiful periods, not incubation of pregnancy (see). In some cases the disease is shown by infertility.

At the endometriosis of a uterus which is found most often along with plentiful bleedings during periods (menorrhagia) irregular uterine bleedings (metrorrhagia) can be observed. Bleedings at E. have persistent character and will not respond to treatment (a scraping of an endometria also not effectively).

AA. uterine tubes it is usually shown by infertility or development of pipe pregnancy.

At E. a vulval part of a neck of uterus bloody allocations before and after periods are observed.

AA. retrocervical space it is characterized by the most severe persistent pains in a small pelvis irradiating in a rectum and a vagina, especially at distribution of process on these bodies.

Wedge, picture E. vaginas depends on depth of defeat of its walls and involvement in process of adjacent bodies. Superficial E. vaginas it is shown pre-and post-exchanges-strualnymi by bloody allocations. At germination endometrioid fabric of a wall of a vagina the main symptom are colpodynias and in a bottom of a stomach during periods, often pains at the sexual intercourse. Intensity of pains increases at defeat of pelvic bones, a crotch and an outside sphincter of a rectum. At distribution of process on a front wall of a vagina also the urodynia is observed speeded up. On the eve of and during periods in a zone of growth of endometrioid fabric painful nodes or melkokistozny educations are probed, to-rye at survey have crimson sinyushny or brown color.

Wedge, picture E. ovaries reminds a chronic recurrent adnexitis. During periods, but not at each menstrual cycle, there can be strong pristupoobrazny abdominal pains which are followed by nausea, vomiting and a faint. At spontaneous perforation of one of endometrioid cysts of ovaries the picture of an acute abdomen reminding an extrauterine pregnancy develops. AA. ovaries it is often shown by primary infertility.

Symptomatology E. intestines depends on localization of defeat of a gut and depth of growing of endometrioid fabric into its wall. Patients are disturbed by the stupid aching abdominal pains which are followed by nausea and strengthening of a vermicular movement matching periods. At germination of all thickness of a wall of a gut from an anus slime and blood are emitted. In process of progressing of process of pain become constants, the phenomena of a stenozirovaniye of a gleam of a gut (strong colicy pains, difficulty of a passage of flatus and a delay of a chair, abdominal distention, sometimes nausea and vomiting) join, the picture of intestinal impassability develops.

At E. a bladder during periods it is noted speeded up, an urodynia, at distribution of process to a gleam of a bladder — a hamaturia. At E. ureters their expansion and a hydronephrosis can develop (see).

AA. lungs it is characterized by the recurrent pneumorrhagia arising during periods. At E. pleurae and diaphragms pheumothorax (see), at a number of patients — pheumothorax and a hemothorax develops (see), only the hemothorax is more rare.

AA. postoperative hems and a navel it is shown by pain and bloody allocations from them during periods, and also formation of painful nodes, skin over to-rymi gets crimson and cyanotic or brown coloring.

For E. are characteristic nevrol. disturbances — a pelvic plexitis (see), neuritis of a femoral and sciatic nerve (see Neuritis), a polyganglioneuritis (see the Ganglionitis), a coccyalgia (see), sometimes a solar plexitis (see), caused by defeat of peripheral nerves and neuroplexes. Their feature are the remittiruyu-shchy current and aggravations during the periods of periods. At a long current E. neurosis-like states develop. Patients complain of irritability, tearfulness, bad mood, perspiration, decrease in working capacity. The most often neurosis-like states are shown asthenic, asthenohypochondriac and astenovegetativ-ny by syndromes.

In the period of a climax and a menopause the centers of endometrioid fabric in most cases are exposed to regress, however a number of patients during this period can have an activation of the process which is before in a stage of clinical stabilization.

At E. the increased tendency to development of hyperplastic and tumoral processes in various bodies is noted that is caused by hormonal and immune disturbances. As a result of the infiltriruyushchy growth and destruction of bodies and fabrics at E. there can be a perforation of a wall of a gut, diaphragm, a hysterorrhesis during pregnancy and childbirth, destruction of a wall of a blood vessel and internal bleeding. At E. there is an extensive commissural process. Essential value has a possibility of a malignancy of the centers E., especially at advanced age. And fading of function of ovaries in the period of a menopause, and also their removal is not prevented by dangers of a malignancy. The patients suffering E., are inclined to allergic reactions that is caused by hit in a blood stream of products of destruction of fabrics, dysfunction of immune system and disturbances of functions of a liver and other digestive organs.

The diagnosis is made on the basis of the anamnesis, data gynecologic and other methods of a research, results of dynamic overseeing of the patient. A characteristic diagnostic character is communication of symptomatology with a menstrual cycle (see). Confirm the inborn nature of a disease emergence of the first symptoms during the first periods or in the next three years from the beginning of periods, burdened ginekol. the anamnesis on the maternal line, and also existence of malformations of urinogenital system (the additional closed horn of a uterus, an aplasia of a vagina at the functioning uterus, etc.). For diagnosis E. existence of a heavy algodismenorea and the persistent menorrhagias and metrorrhagias which are not giving in to treatment is important a uterus. Ginekol. the research allows to reveal the increase in a uterus which was more expressed before periods and during it and also asymmetry and an uneven consistence of body. Because at E. specific changes of an endometria are not observed, the scraping of a mucous membrane of a body of the womb is applied only for the purpose of differential diagnosis to an exception of other diseases. At retrocervical E. sharply painful infiltrate on a back surface of an isthmus of a uterus is palpated. At localization of process in a vagina at a gynecologic research in the period of periods education in the form of small cysts or small knots of crimson and cyanotic or brown color is defined. For diagnosis E. ovaries along with complaints to an algo-dysmenorrhea matter increase in ovaries (often unilateral) before periods and existence of the expressed commissural process. Importance in diagnosis both genital, and extragenital E. have a peritoneo-skopiya (see), hysteroscopy, a gistero-salpingografiya (see M an etrosalpin-gografiya), a kolonoskopiya (see), excretory and retrograde urography (see), a computer tomography (see the Tomography computer), ultrasonic investigation (see. Ultrasonic diagnosis), etc.

Diff erentsialny diagnosis E. it is carried out with tumors of generative organs, intestines, bodies of uric system, with inflammatory diseases of generative organs. Endometriosis of lungs is differentiated with a pulmonary tuberculosis, eosinophilic infiltrate.

Existence of myoma and cancer of a uterus (see the Uterus, tumors) is confirmed by data of a gisterosalpingogra-fiya and gistol. researches of the material received at a diagnostic scraping.

At tumors of intestines (see Intestines, the Rectum) symptomatology and data rentgenol. researches do not depend on phases of a menstrual cycle, change of a relief of a mucous membrane of a rectum is noted.

Clinical displays of tumors of a bladder and ureters are not connected with a menstrual cycle; the important place in diagnosis is taken by the data obtained at rentgenol. research of bodies of uric system, tsistoskopiya, tsitol. a research of an uric deposit (see the Bladder, the Ureter).

Differential diagnosis with an adnexitis (see) is based on disappearance of symptoms of an inflammation against the background of treatment, and also on data of a peritoneoskopiya.

At a pulmonary tuberculosis (see Tuberculosis of a respiratory organs) the pneumorrhagia is not connected with phases of a menstrual cycle.

Positive takes of a research a calla on eggs of worms, an eosinophilia, lack of elements of an endometria in a phlegm testify to eosinophilic infiltrate (see Lungs).

Treatment appoint only at clinically active E. Treatment clinically inactive E. can promote activation of process. Patients inactive E. need constant dynamic observation. Treatment is preceded by obligatory inspection for the purpose of an exception onkol. diseases. Conservative treatment complex, provides impact on the major pathogenetic factors (dysfunction of a hypothalamus,

the I hypophysis, ovaries, adrenal glands' and immune system), and also on inflammatory reaction around the centers E., neurologic disturbances, etc. At purpose of treatment consider age, the general condition of the patient, localization of process, its distribution on adjacent bodies, disease severity, tendency of the woman to allergic reactions, desire of the patient to have the child, the course of the previous pregnancies and other factors.

Main component of complex therapy E. hormonal treatment is. For this purpose apply synthetic it is oestrogenic - gesta-gene drugs (Bisecurinum, non-ovlon, etc.), gestagena (a mink Loot, orgametrit, Turin l, pregnenoldione kapronat, progesterone). To women 40 years are aged more senior appoint also androgens (metiltes-tosteron, Testosteroni propionas, Testoenatum, suyetanon-250) or anabolic steroids (Methylandrostendiolum, retabolil, Nerobolum).

Duration of courses of hormonal therapy and intervals between them is defined by results of treatment and the general condition of the patient with portability of drugs and indicators of tests of functional diagnosis.

For the purpose of elimination of immune disturbances apply immunomodulators: levamisole (on 18 — 20 mg a day within 3 days, carry out

3 — 4 such bucketed courses for

4 — 5 days; the cycle is repeated every 2 month), mintezol, Thymalinum. At tendency of patients E. to allergic reactions appoint the hyposensibilizing means (Suprastinum, Diazolinum, Dimedrol, etc.). Has good antiinflammatory and antiallergic effect etimizol, exerting the stimulating impact on adrenocorticotropic function of a hypophysis.

For treatment nevrol. disturbances successfully apply reflexotherapy, at neurosis-like states appoint tranquilizers (Rudotelum, Relanium), neuroleptics (Theralenum, neuleptil, Frenolonum, with-nopaks), antidepressants (amitriptyline), the means stimulating a nervous system (piracetam, nootropil).

During the strengthening of pains the symptomatic treatment is shown by spasmolytic and analgesic means. Essential components of complex therapy are the biogenic stimulators and fermental drugs having resorptional effect. Purpose of antibacterial agents patient E. it is not shown. From physiotherapeutic procedures apply an electrophoresis of sodium thiosulphate, to-ry possesses the antiinflammatory and hyposensibilizing action and promotes regress of the mature collagen making a basis of cicatricial fabric.

Use radonic (with concentration of radon to 180 nkyuri/l) bathtubs, vulval irrigations and intestinal microclysters is effective. Radon waters contribute to normalization of hormonal balance, possess good antiinflammatory, antiallergic and analgesic action. Thermal procedures are excluded. After abortions, diatermo surgical intervention, not radical and conservative surgeries patient E. carry out antirecurrent treatment by the listed above means.

In the course of conservative treatment control of a condition of ureters (carry out excretory, infusional or retrograde urography) and intestines (make a kolonoskopiya, an ir-rigoskopiya) for the purpose of timely establishment of the beginning steno-zirovaniye and change of tactics of treatment is necessary.

Great value at E. has operational treatment. An operative measure is shown in the absence of effect of conservative therapy within 6 — 9 months, at endometrioid cysts of ovaries, at E. postoperative hems and a navel, at the proceeding stenozi-rovaniye of a gleam of a gut or ureters, at intolerance of hormonal means or existence of contraindications to their use (e.g., at hyperplastic processes in mammary glands, chronic thrombophlebitis).

Women of young age, according to a number of researchers, should make operation as soon as possible. Late diagnosis or a late operative measure can lead to considerable expansion of its volume in connection with distribution of process on the next bodies. It is necessary to operate patients in 3 — 5 days after the termination of periods.

At operation delete the centers of endometrioid fabric within not changed fabrics. Not radical operations with incomplete removal of the centers E., as a rule, lead to progressing of process. To young women even at distribution of process on the next bodies as an exception, conservative surgeries on a uterus and (or) ovaries for the purpose of preservation of generative function are shown.

The nature of operation depends on localization of process. At a diffusion adenomyosis of a uterus and defeat of an isthmus of a uterus carry out a hysterectomy (see); at endometriosis of ovaries and retrocervical endometriosis — excision of the centers; in case of transition of process at retrocervical E. on a back vault of the vagina make excision of the centers and a resection of a part of a back vault of the vagina. At extragenital E. (intestines, a bladder, a navel, postoperative hems) resect the struck part of body within not changed fabrics. At women 40 years to slow regressing of a disease are more senior (within 1 — 2 years) the bilateral ovariekto-miya promotes, however at a part of patients this operation is not effective that is caused, apparently, by effect of estrogen of an adrenal origin and existence of the broken function of immune system. After operation by the patient appoint gornomat ny and immunomodulators, reflexotherapy, physical therapy.

One of methods of treatment E. radiation therapy is, to-ruyu apply as independently, and after not radical operations. At independent radiation therapy make radiation of the centers E. The radiation therapy which is carried out after not radical operations comes down to radiation of the centers E. and ovaries (at intolerance of hormonal drugs). At E. ovaries, especially at endometrioid cysts, radiation therapy is contraindicated.

The forecast serious in connection with danger of a stenozirovaniye of a gut, ureters, emergence of heavy neurologic disturbances, bystry progressing of a disease, a malignancy, and also development of post-operational inflammatory and septic processes and peritonitis.

Prevention E. it is not developed. For the prevention of a retrograde pelting of menstrual blood in abdominal organs and a small pelvis in days of periods it is necessary to avoid an excessive exercise stress, to especially young women with unsuccessful concerning E. family anamnesis; in case of an atresia of a neck of uterus it is necessary to recover passability of the cervical channel as soon as possible; it is necessary to limit use of diatermokhirurgichesky interventions on a neck of uterus, replacing them with a cryolysis and laser treatment, to avoid abortions, recommending to apply intrauterine contraceptives. Bibliography: Baskakov V. P. Endometrioses, M., 1966, bibliogr.; it sh e, Clinic and treatment of endometriosis, L.,

1979, bibliogr.; Baskakov V. P., both Tsvelev Yu. V. Endometrioz and cancer, Vopr. onkol., t. 28, No. 3, page 45, 1982, bibliogr.; Bo hm and N Ya. V., Baskakov V. P. and Kolosov A. E., Oncological aspects of endometriosis, Akush. and ginek., No. 10, page 47, 1979;

Genital endometriosis, under the editorship of L. F. Shinkareva, Bitter, 1980; D and-vydovs. N, Berdichevskaya A. Ya. and Kovalyova T. B. About endometriosis after diathermocoagulation of pseudo-erosion of a neck of uterus, Owls. medical, No. 1, page 109, 1970; Zheleznov B. I. and the Martin to about in A. N. Genital endometriosis, M., 1985; Suprun L. Ya. Characteristic of the immunological status of patients with endometriosis, Akush. and ginek., No. 2, page 41, 1983; Ulezko-is strict-N about in and To. To a question of endometrioid geterotopiya, Zhurn. akush. and Shen. Bol., t. 36, book 4, page 340, 1925; D i z e-rega G. S., Barber D. L. a. Hodgen G. D. Endometriosis, role of ovarian steroids in initiation, maintenance, and suppression, Fertil. and Steril., v. 33, p. 649,1980; Farinon A. M. a., V a d about r an E. Endometriosis of the colon and rectum, an indication for peroperative coloscopy, Endoscopy, v. 12, p. 136, 1980; Novak E. R. a. W oodruff J. D. Novak’s gynecologic and obstetric pathology with clinical and endocrine relations, Philadelphia, 1979; Ohtsuka N. Study on pathogenesis of adhesions in endometriosis, J. Jap. obstet, gynec. Soc., v. 32, p. 1758, 1980; Parsons L. Sommers S h. C. Gynecology, p. 957, Philadelphia a. o., 1978; Pathology of the female genital tract, ed. by A. Blaustein, p. 464, N. Y. a. o., 1982; Portuondo J. A. a. o. Peritoneal flushing and biopsy in laparoscopically diagnosed endometriosis, Fertil. and Steril., v. 38, p. 538, 1982; Sen ft H. H., Schroder F. A. u. To o r t e W. Behandlung der Endomet-riose, Fortschr. Med., Bd 99, Suppi., S. 475, 1981; Wheeler J. M. a. M a 1 i-n a k L. R. Recurrent endometriosis, incidence, management, and prognosis, Amer. J. Obstet. Gynec., v. 146, p. 247, 1983.

V. P. Baskakov; B. I. Zheleznov (stalemate. An.)

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