OVARY

From Big Medical Encyclopedia

YaYChNIK. Contents:

Comparative anatomy...... 504

Embryology. *............. 504

Anatomy............. 504

Histology............ 505

Physiology............ 506

Pathological anatomy..... 507

Methods of inspection....... 508

Pathology............ 509

Operations............. 518

Ovary [ovarium (PNA, JNA, BNA)] — a pair female gonad (gonad) located in a small basin on both sides of a uterus; is body where ova are formed and ripen and sex hormones are produced.

A comparative anatomy

At invertebrates (sponges, the lowest coelenterates and beskishechny, ciliary worms) ovaries represent only temporary accumulation of sex cells, at more advanced animals they become the isolated bodies. At the lowest worms, erinaceouses, arthropods, mollusks, acranial ovaries meshkoobrazny, eggs are formed in an internal epithelial vystilka of body, in process of maturing they get into a cavity of an ovary and are removed outside on its spew ways. At all vertebrata the ripened eggs get through break of a wall of an ovary to the general (secondary) perigastrium from where then are removed through oviducts. At the highest animals ovaries are also the endocrine glands excreting sex hormones in blood.

Follicles contain an oyna in ovaries of vertebrata the large ovum surrounded with small follicular cells, to-rye serve for food of an ovum and participate in formation of an egg cover. At the lowest vertebrata the new growth of ova occurs during all life, at the highest — only in the embryonal period or at first after the birth.

At mammals in ovaries in a follicle the cavity containing serous liquid is formed. During the maturing of an ovum the wall of a follicle is broken off, and the ovum gets to a perigastrium. On site such follicle the hormone-producing structure — a so-called yellow body forms.

The embryology

Laying of an ovary at a germ of the person in the form of the sexual roller occurs on ventromedialny side of primary kidney (mesonephros). Sexual rollers are distinguishable already at embryos on 31 — the 32nd day of development. Are a part of a bookmark: a coelomic epithelium, from to-rogo further are formed a cover and follicular epithelium of an ovary; a mesenchyma, from a cut connective tissue, intersticial and muscular elements of an ovary form; primary sex cells (oogonium) — future ova. In recent years in a number of works it is claimed that in formation of intersticial and follicular elements the leading role belongs to the cells migrating in an ovary from its network (a rudiment of primary kidney). Oogonium, irrespective of future floor, are distinguishable already at a three-layered germ of the person (see the Germ). The extra gonadal origin an oogonium is proved (the most part is concentrated in an entoderm — the limited area of a vitellicle which is located near an allantois). On 3 — 4th week of development of a germ the oogonium actively proliferates and then migrate to the area of sexual rollers.

The ovary gets morphological features of a sexual differentiation from a germ of 6 weeks of development: growing

into a mesenchyma an oogonium are located with islands among cells of a mesenchyma and epithelial cells of the developing bast layer on all its thickness. An oogonium actively breed, the number them reaches several million. Entered professional azu I of meiosis an oogonium — oocytes are surrounded with follicular cells, at the same time primordialny follicles form. The introduction an oogonium in professional azu happens asynchronously therefore at different stages of embryonic development of an ovary there are certain ratios actively breeding an oogonium and oocytes in different stages professional elements of meiosis. Under the influence of hormones of mother and hormones of a placenta in an ovary of a fruit in the second half of pregnancy the follicles which are at the subsequent stages of development are found. Intersticial gormonpro-dutsiruyushchy cells appear on the 28th week of fetation.

The connective tissue basis of an ovary develops from a mesenchyma: the connective tissue tyazh directed from the center of an ovary, from area of Contact of a mesenchyma with a mesonephros (i.e. areas of future gate of an ovary) towards a superficial epithelium form. By 7th week of embryonic development the ovary separates from a mesonephrosis, is stuck out by gradually going deep furrows in a perigastrium and gate of an ovary begin to form. Through the last circulatory and absorbent vessels, further — nerve fibrils get into an ovary. The cranial part of the canal of primary kidney and the related tubules of a mesonephrosis form network of an ovary. By the end of the II trimester of pregnancy (26 — 27 weeks) elements connective tissue tyazhy completely burgeon in a bast layer and the white of an ovary begins to form.

Anatomy

Ovaries are located in a cavity of a small pelvis at its side walls, between the terminal and nizhnelonny parallel planes. The size and the sizes of an ovary considerably change depending on age and functional activity of tissue of ovary. Average sizes of an ovary of the woman of mature age: length

is 3 — 4 cm, width is 2 — 2,5 cm, thickness is 1 — 1,5 cm. Consistence of an ovary plotnovaty, weight of its 6 — 8 g. The right ovary usually happens slightly more left. The surface of an ovary depending on a functional condition and age of the woman can be smooth or rough. Color of an ovary whitish-pink, opaque. Distinguish uterine and pipe poles (ends) of an ovary. The inner surface of an ovary is turned to the centerline of a basin, the outer (lateral) surface adjoins to a sidewall of a basin, being located in the deepening which is available here. The inner free edge of an ovary is turned into an abdominal cavity (tsvetn. tab., Art. 464, fig. 18); the pipe end is raised up and turned to a funnel of a uterine (fallopian) tube; the mesenteric edge by means of a mesentery of an ovary is fixed to a back leaf of a uterine sheaf. In mesenteric edge of an ovary there pass arteries, veins, limf, vessels, nerves (see below).

The ovary on the one hand is movably connected to a uterus own sheaf (lig. ovarii proprium) which is consisting of fibrous bunches and smooth muscle cells and passing from an uterine fundus of a kzada and conjunctions of a uterine tube with a uterus are lower. On the other hand the ovary is attached to a sidewall of a basin by means of the voronkotazovy (suspending) sheaf (lig. suspensorium ovarii), edges are represented by a part of a wide uterine sheaf. Trubnoyaichnikovy sheaves (ligg. tuboova-rica) — the folds of a peritoneum which are a part of a wide uterine sheaf; they last from a belly opening of the right and left uterine tubes to a pipe pole of the corresponding ovary. On pipe and ovarian sheaves big ovarian fimbrias lie. The ovary prilezhit to a wide uterine sheaf not closely; it is located in deepening of a peritoneum (fossa about varica), freely and is movably strengthened by sheaves. The ovary suspended thus can move forward and back (the movements are connected with excursions of a uterus) both to a certain extent up and down. Its sizes and distensibility of own sheaf, and also pressure from other bodies of a small pelvis (a uterus, intestines) exert impact on position of an ovary.

Blood supply and lymph drainage. The ovary krovosnabzha-tsya from an ovarian artery (a. ova-rica), edges departs from a belly part of an aorta and goes down on a voronkotazovy sheaf, and about varicus, edges is a branch of a uterine artery (a. uterina) and departs in the lateral direction on the upper edge of a wide ligament of uterus. Arteries accompany the veins of the same name: right ovarian vein (v. ovarica dext.) the left ovarian vein falls into the lower vena cava (v. ovarica sin.) — in the left renal vein. The lymph from ovaries is taken away in lumbar and sacral limf, nodes (see fig. 3 to St. Uterus, t. 13, Art. 478). The intraorganic circulatory and lymphatic bed of an ovary is characterized by a difficult interlacing of the vessels anastomosing both within the layer and between cortical and brain layers that provides a possibility of adequate local change of blood supply. In process of fading of function of gonads a part limf, vessels is reduced, and the number of capillaries at the same time decreases. Zapuste-vaniye of capillaries and absorbent vessels occurs in a bast layer in the beginning.

Inner in and tsi I. The main sources of a sensitive innervation of an ovary are the spinal ThI3c — Lin nodes of segments, and in the main ways, on the Crimea afferent fibers go to an ovary, the corresponding spinal nerves, lumbar department of a sympathetic trunk, big celiac nerves and celiac textures serve. Sensitive conductors, reach an ovary of hl. obr. as a part of an ovarian texture (plexus ovaricus). The main sources of a sympathetic adrenergic innervation of ovaries are nodes of a celiac texture and lumbosacral department of a sympathetic trunk. From lower mesenteric and hypogastric textures to an ovary sympathetic fibers also depart, but their number is limited. Parasympathetic cholinergic nerve fibrils go to an ovary from nodes of hypogastric textures. Participate in formation of intraorganic parasympathetic neuroplex of an ovary ovarian a microganglion and a vagus nerve. The innervation of the developing follicles, active in the functional relation of atretic follicles and area of an internal cover of follicles is more difficult and plentiful. The nervous device of an ovary completely forms by the period of puberty.

Age changes. Ovaries of the newborn have the extended and flattened form, weight from 150 to 500 mg. Surface of ovaries smooth. Anatomic asymmetry is inherent in them (as a rule, a prevalence of the sizes of the right ovary over left). The quantity of sex cells varies from 100 thousand to 400 thousand, the vast majority them is imprisoned in primordialny follicles. There can be also follicles of the subsequent stages of development that is explained by effect of hormones of mother. During puberty ovaries increase in sizes; their consistence becomes more dense, weight reaches 5 — 6 g; in a bast layer follicles at various stages of development appear. At reproductive age during a menstrual cycle there is a maturing of several follicles, but the stage of a big mature follicle is only reached more often by one, the others are exposed to atretic changes.

With age gradually the absolute quantity of sex cells decreases (by 36 — 40 years to 30 — 40 thousand); part of gormonpro-dutsiruyushchy structures of an ovary disappears that is followed by the progressing fibrosis of a stroma of an ovary.

Histology

Ovaries are covered with a superficial epithelium, under the Crimea there is a white consisting of dense connecting fabric. In the bast layer located under it there are numerous primordialny follicles, follicles of the subsequent stages of development, follicles in stages of an atresia, yellow bodies at different stages of development. They are surrounded by a stroma, in a cut intersticial gormonpro-dutsiruyushchy fabric is located. The medulla of an ovary consists of friable connecting fabric with numerous vessels. It passes into gate of an ovary where there is a network of an ovary formed by the epithelial tyazha presented by light polygonal cells, a chyle-nye, sometimes nervous cells (tsvetn. the tab., Art. 464, fig. 19),

the Follicle of an ovary represents the ovum (oocyte) surrounded with a follicular epithelium. On degree of a maturity distinguish primordialny, primary, secondary (bubbly, graafova) and preovulya-even follicles. In a primordialny follicle the oocyte is surrounded by the flat follicular cells lying on a basal membrane. The oocyte is in prolonged is wild-tiotene the first meiotic division (see Meiosis), edges is actively supported by the inhibiting influence of follicular cells on maturing of an oocyte. Follicular cells increase in sizes, get a cubic form, in them the numerous mitoses caused by effect of follicle-stimulating hormone (FSG) are found. Gradually follicular epithelium becomes multilayer, and primary follicle is formed. In primary follicles the oocyte sharply increases in sizes. In the following stage of development multiple layers of a follicular epithelium increase and the secondary follicle is formed (tsvetn. tab., Art. 464, fig. 20). Around an ovum there is a transparent zone (zona pellucida) representing a layer of glikozaminoglikan (see Mucopolysaccharides). Shoots of follicular cells and microoutgrowths of cytoplasm of an oocyte get into a transparent zone. Follicular cells produce liquid, at merge of separate drops the cut is formed a cavity of a follicle. In process of increase in amount of liquid in a cavity of a follicle it takes a form of puzyrkovidny structure, in a cut the oocyte surrounded with follicular cells in the form of a radiate crown (corona radiata) gradually holds eccentric position and it is shifted to one edge of a follicle — the oviparous hillock is formed. Follicular cells of other part of a follicle create a granulosa (granular) layer, or to a gran I climb (zona granulosa). Oocytes in secondary follicles increase in volume to a lesser extent. In a preovulyatorny follicle the cavity reaches large volume, in a layer of a follicular epithelium two types of cells — dark and more numerous light differ. Around the growing follicle and especially around a preovulyatorny follicle connective tissue covers clearly are visible: theca int., richly vaskulyarizovanny, containing a large number of gormonprodu-tsiruyushchy cells, and theca ext., presented by fibrous connecting fabric. Diameter of the created preovulyatorny follicle averages 10 — 18 mm. Follicles, reaching the maximum size, form protrusions on the surface of an ovary. In process of approach of an ovulation (see) cells of an oviparous hillock are loosened (tsvetn. the tab.,

Art. 464, fig. 22) also oodit passes into metaphase of meiosis (see Meiosis). At top of a preovulyatorny follicle the small avascular area — a stigma forms. Two mechanisms of an ovulation are noted: a rapid current (1 — 2 sec.) with rapid, single-step release of follicular liquid together with blood and an ovum from a cavity of a follicle; slow release of follicular liquid with the subsequent slowed-down exit of an ovum (several minutes later and even ten minutes). The ovum gets on a fimbria of a uterine tube, its fertilization and further development happens in uterine tubes (see) and a uterus (see).

About 1 of 100 developing follicles reaches full development, the others are exposed to an atresia (involution). On their place richly vaskulyarizirovanny gormonpro-dutsiruyushchy fabric, coming from theca int expands., actively functioning atretic body is also formed (tsvetn. the tab., Art. 464, fig. 21), a cut then is exposed to involution.

Gormonprodutsiruyushchy elements in ovaries are the yellow body, intersticial fabric, to-rye produce progesterone and estrogen.

The yellow bodies developing in an ovary from follicular cells of a granular layer on site of the become torn follicle pass several stages of development (in detail cm. Yellow body). Intersticial fabric includes the intersticial cells which are freely lying in a stroma in close proximity to capillaries, a cell of theca int., located in several layers and oriented around a follicle, and hormone - the producing cells atretiche-skykh bodies. The quantity of the listed cells varies depending on age of the woman and a phase of a menstrual cycle.

Physiology

Distinguish two closely interconnected main functions of ovaries: sekryotsyt steroid hormones, including estrogen (see) and progesterone (eta.), ova, causing emergence and formation of the secondary sexual characteristics, approach of a meystruation, and also development capable to fertilization, providing reproductive function. According to V. B. Rosen, in the course of ontogenesis normal functioning of ovaries depends on completeness of a differentiation of ovaries, and after the birth of the child — on the integrating activity of endocrine system in general.

Ovaries of a fruit have functional activity from first weeks of pre-natal development. So, in ovaries 10 — a 12 weeks fruit estrogen is found in extremely trace amounts; on 8 — the 13th week pre-natal razvitiya signs of functional activity gipotalamo - pituitary and ovarian system of a fruit are defined, edges in the course of further pre-natal development undergoes changes according to gestational age of a fruit. Thus, by the time of the birth the fruit has system, potentially capable to coordinate activity, a hypothalamus — a hypophysis — ovaries, edges functions at other qualitative and quantitative levels in comparison with other age periods of life of the woman at this time.

The ovaries of the newborn girl coming influence of maternal estrogen contain a large number of primordialny follicles, their number in the subsequent progressively decreases; at girls of 8 — 9 years in ovaries primary follicles prevail, in to-rykh a small amount of estrogen is formed. In cells of a granular layer of these follicles there are receptors of follicle-stimulating hormone — FSG and there are no receptors of luteinizing hormone — L G (see Receptors, cellular receptors).

At girls up to 8 — 9 years correlation between products of FSG, growth of follicles in ovaries and concentration of estrogen in blood is revealed. With age gradual increase in the functional activity of ovaries which is followed by increase in secretion of estrogen, however fiziol is noted. signs of an estrogenization at girls of prepuber-tatny age are expressed poorly. According to Forrest (M. of G. Forest, 1979), it is connected with underdevelopment of receptors to estrogen in target organs (a uterus, a vagina, mammary glands). By 8 — 9 years secretion increases it rileasing-gormo-is new (RG), gonadotrophins (GT), sensitivity of a hypophysis to RG, and ovaries — to GT increases. At the age of 11 — 12 years increase in secretion of FSGG under influence is observed to-rogo growth of follicles to a stage bubbly, cosecreting estrogen in the quantity sufficient for development of a uterus and secondary sexual characteristics, and also formations of a body on female type accelerates. Secretion of estrogen by 12 years increases by 10 — 15 times, and if at girls of 8 — 10 years the level of estrone in blood serum exceeds the level of oestradiol, then by 12 years the content of oestradiol begins to prevail over the content of estrone. With approach of the first periods the FSG level decreases, and the nature of secretion of this hormone approaches that at adults. Secretion of LG increases a bit later and by 15 — 16 years approaches the level of its secretion at adults. The first 1 — 2 years after approach of periods prevail anovulatory cycles (see. Anovulatory cycle), to-rye gradually are replaced by ovulatory cycles (see the Ovulation). Final formation of system a hypothalamus — a hypophysis — ovaries comes to the end by 17 — 18 years, and the main characteristic occurring in an ovary at women of reproductive age of processes are cyclic changes — development of a follicle, maturing of an ovum, an ovulation and formation of a yellow body that provides reproductive function.

In a premenopauza secretion of progesterone, and then and estrogen gradually decreases; the ovulatory cycles which are followed by increase in the FSG level at the invariable maintenance of L G are replaced anovulatory with essential decrease in secretion of estrogen. Periods become irregular. The periods of a delay of periods with low release of estrogen are replaced by the periods of recovery of cyclic activity of an ovary, but the ovulatory peak of estrogen at the same time is expressed to a lesser extent.

In the first two years of a postmenopause against the background of reduced secretion of estrogen short-term rises in their level are periodically noted that is explained by functioning in ovaries of single follicles. To 3 — to the 5th year of a postmenopause the expressed decrease in level of estrogen is observed, to-ry further remains steadily low. As well as before approach of periods in the period of puberty estrone becomes the main oestrogenic hormone which is formed in ovaries in the period of a postmenopause. According to Judd (H. L. Judd) and sotr. (1982), the main amount of estrone in a postmenopause is formed due to ekstraglandulyarny peripheral transformation of androstendion into estrone. Secretion of progesterone with the termination of an ovulation significantly decreases: to 3 — to the 5th year of a postmenopause level is twice lower than it, than at young women in an early follikulinovy phase of a menstrual cycle, and the main source of progesterone during this period are adrenal glands. In a postmenopause ovaries cosecrete generally androgens (testosterone and andr ostendion).

In a crust, time are saved up numerous experimental and a wedge, the functions of ovaries given about regulation, physiology and pathologies of growth and maturing of follicles, an ovulation and formation of a yellow body (see. Gonadotropic hormones, Yellow body, Ovulation). The leading role in stimulation and start of all complex system of regulation of function of ovaries is allocated for sex hormones, especially estrogen. The hypothalamus and a hypophysis contain receptors to sex hormones. Preferential localization of receptors to estrogen in preoptichesky and arkuatny areas of a hypothalamus is experimentally established that confirms direct participation of estro-gene-receptor system in regulation of secretion of gonadotrophins with a hypophysis. Lack of receptors in tissue of target organs excludes a possibility of implementation of biological effect of the corresponding hormones (at the fabric level) that is observed at nek-ry endocrine diseases.

In the growing follicles of ovaries under the influence of FSG and oestradiol ability of cells of a granular layer of follicles to connect gonadotrophins due to increase in number of receptors at first to FSG, then to Lgiprolaktin increases. It is confirmed at detection of gonadotrophins in follicular liquid, and concentration of FSG increases in a late follikulinovy phase, and concentration of LG and prolactin — in a lyuteinovy phase of a menstrual cycle (see. Menstrual cycle). The number of receptors to gonadotrophins in covers of a follicle defines so-called dominant follicles for an ovulation. Thus, secretion of hormones of ovaries is under control of gipotalamo-pituitary system (see Neyrogu-moraljnaya regulation), under influence a cut there are cyclic changes both in ovaries, and in target organs (a uterus, a vagina, mammary glands). Sex hormones have difficult biological effect on an organism in general, participating in maintenance of a homeostasis (see). Androgens and estrogen take part in regulation of protein metabolism (anabolic action), bone formation; progesterone reduces a tone of a uterus, promotes secretory transformation of an endometria, development (together with estrogen) mammary glands.

Pathological anatomy

of Change of lipidic, protein, carbohydrate and mineral metabolism in ovaries often are not dystrophic, and gistofizio logical that is connected with their hormonal and reproductive functions. These changes reflect strukturnofunktsionalny features of an ovary during the different age periods, and also at periods and pregnancy. Along with cyclically repeating processes of maturing of follicles in ovaries processes of a cystous and obliteratsi-onny atresia of follicles are observed. As a result fiziol. a regional iterative atresia of follicles (atretic bodies) and involution of a yellow body in ovaries (a white body) there comes the hyalinosis (see). Fiziol. the sclerosis of blood vessels (ovulyatsion-ny and postnatal) with a hyalinosis of their walls appears at young women; it is especially sharply expressed in large vessels of a medulla of ovaries. With age sclerous changes of vascular walls progress. In a climacteric preferential in a medulla of ovaries find closely located vessels with the hyalinized walls and the obliterated gleams. At senile age of a wall of the obliterated vessels of ovaries can be exposed to calcification. In the course of a cystous atresia of follicles ova (with the subsequent their death) and a granular layer are exposed to dystrophic changes. With a syndrome of Matte — Leventalya (see Matte — Leventalya a syndrome) processes of hyaline dystrophy in ovaries are more widespread among patients.

The centers of calcification and psammoz-ny little bodies (see) sometimes meet in ovaries at an adnexitis and superficial inklyuzionny cysts, in superficial papilloma, a papillary cystoma and papillary ovarian cancer (see below the section of the Tumour). The amyloidosis of ovaries is observed at a generalized amyloidosis (see).

Arterial plethora of theca int. and a yellow body it can be noted at an adnexitis and pelvic peritonitis, at acute inf. diseases (sepsis, flu, belly and a typhus, scarlet fever, diphtheria, epidemic parotitis, cholera), poisonings with phosphorus, corrosive sublimate and endointoxications (burns), at a leukosis, a scurvy. The venous plethora of ovaries can be caused by cardiovascular insufficiency with a congestive plethora of bodies of a small pelvis, a prelum of veins of an ovary a big tumor of bodies of a small pelvis, twisting of sheaves or legs of a tumor of an ovary.

Hemorrhage in tissue of an ovary is possible during an ovulation, at arterial or its venous plethora, owing to a rupture of walls of sharply expanded capillaries of theca int. (see the Apoplexy of an ovary).

Massive hypostasis of an ovary meets seldom (in the world literature it is described apprx. 20 cases), arises at girls or young women, in some cases is followed by signs of the Virilism (see Virilescence). The origins of massive hypostasis of a yaichiik are completely not studied, in the majority of observations edematization is caused by partial torsion a mezovariya with obstruction venous and limf, vessels. Diffusion hypostasis of a stroma covers brain and cortical layers is more often than one or both ovaries. Limf, vessels and veins of a medulla are expanded, in tissue of an ovary hemorrhages and deposits of hemosiderin meet.

Inflammatory process in ovaries arises for the second time owing to distribution of contagiums from bodies and fabrics, adjacent to ovaries more often (hl. obr. at a salpingitis and pelvic peritonitis, more rare in the hematogenous way). At an acute inflammation (an acute oophoritis) macroscopically note hypostasis and a plethora of an ovary, on its surface the thin coat of fibrin (an acute fibrinous perioophoritis) is found. Microscopically in rare instances reveal leukocytic infiltration of tissue of ovary.

At hron. an inflammation ovaries are surrounded with friable or dense commissures, to-rye sometimes richly in a vasku-lyarizshchrovana; on a section in the thickness of commissures hemorrhages can be found. Inflammatory infiltrates in tissue of an ovary at the same time are absent therefore the widespread term «chronic salpingo-oophoritis» in most cases means a combination hron. a salpingitis with ц^риоофоритом. Sclerous changes in tissue of an ovary as result hron. it is difficult to distinguish inflammations from the sclerosis (see) which is a consequence of atrophic process.

Abscess of an ovary can be created tsrts acute and chronic vospalenishch, r also due to implementation of microorganisms in the follicle which burst» about time of an ovulation or in a yellow telr. Merge of multiple abscesses of an ovary leads to full fusion of its fabric — to a pyoovarium (see the Adnexitis).

Tuberculosis of an ovary meets considerably reshche tuberculosis of uterine tubes and an endometria. At a tubercular salpingitis there is a vtorishchy infection of ovaries. Preferential bast layer is surprised, in Krom find tuberkuleany Ougorki (see Tuberculosis extra pulmonary), is more rare —

extensive sites of a caseous necrosis.

Syphilis of an ovary is observed in the tertiary period of a disease. In a stroma of an ovary at the same time reveal typical gummas (see Syphilis).

The echinococcus which got on the surface of an ovary from echinococcal bubbles of an abdominal cavity or brought in the hematogenous or lymphogenous way from the remote bodies is sacculated, forming a cyst (see the Echinococcosis). The cyst usually has affiliated bubbles, around it dense inflammatory unions with a peritoneum and bodies of a small pelvis develop.

The schistosomatosis of ovaries is caused more often by Schistosoma haematobium that is caused by existence of rich network of a venous anastomosis between a bladder and generative organs. The ovary is increased in a size, small white small knots — shistosom-ny granulomas are defined on its surfaces (see Shistosomato-za).

Atrophy of an ovary as fiziol. the phenomenon is observed at senile age. As patol. the phenomenon an atrophy of ovaries can arise at reproductive age at long feeding of the child (a lactic atrophy), long starvation and the related exhaustion, at a thyrotoxicosis, a diabetes mellitus, heavy hron. inflammatory processes, especially purulent, at chronic intoxication (e.g., phosphorus, arsenic, lead), hron. alcoholism, and also as a result of radiation therapy. The vicarious hypertrophy of an ovary develops after a unilateral ovari-ektomiya.

Among hyperplastic processes of an ovary distinguish a stromal hyperplasia (including its option — a thecomatosis), a hyper thecosis, a nodulyarny tekalyuteinovy hyperplasia of ovaries, a hilusno-cellular hyperplasia. The stromal hyperplasia of an ovary (stromal proliferation, a thecosis) most often meets aged from 40 up to 70 years. The pathogeny is completely not found out. Assume that it develops owing to pituitary stimulation what the increased level of excretion of gonadotropic hormones of an adenohypophysis testifies to. Preferential bast layer of an ovary is surprised. Macroscopically the ovary at the same time is not increased, on a section fabric has it uneven yellow coloring. Microscopically reveal the sites rich with spindle-shaped cells with poorly distinguishable cytoplasm, edges in places contains small drops of lipids and it is characterized by high activity of oxidizing enzymes. The same histochemical features come to light in cells of an epithelioid look at a thecomatosis, to-ry unlike a tecoma (see) quite often happens bilateral. In some cases at a stromal gipertslaziya and a thecomatosis of ovaries the phenomena of a giperestrogeniya and as a result a hyperplasia and endometrial cancer can - be observed.

The hyper thecosis of an ovary meets seldom, preferential at reproductive age. At the same time the sizes of ovaries are not changed or slightly increased (one of ovaries is almost always increased). On a section tissue of ovaries has uneven yellow or yellow-orange coloring. Microscopically reveal a focal hyperplasia and a luteinization of a stroma preferential in the central departments of an ovary. The luteinized cells — large, with the light cytoplasm containing lipids. At a hyper thecosis disturbances of a menstrual cycle, a hirsutism are noted (see) or the virilism is more often. The obesity, arterial hypertension, disturbance of tolerance to glucose which are found at a hyper thecosis allow to assume involvement in process of adrenal glands. The hyper thecosis can be combined with a hyperplasia of a mesh zone of bark of adrenal glands.

The Nodulyarny tekalyuteinovy hyperplasia of ovaries arises in the last trimester of pregnancy, it is found most often accidentally during Cesarean section. In the international histologic classification of tumors of ovaries (1973) for designation of this pathology the term «luteoma of pregnancy» is accepted, edges it is carried to tumorous processes. More than 110 cases of luteomas of pregnancy described in literature do not reflect their true frequency since during pregnancy the luteoma can be not found, and after the delivery it, as a rule, is exposed to regressive changes. In most cases the luteoma of pregnancy is hormonal not active, but sometimes is followed by a virilism, gradually disappearing in a puerperal period. Judgments of an origin of a luteoma of pregnancy are contradictory. In a crust, time its relation to a yellow body, to a granular layer ripening and cystous atreziruyushchikhsya follicles is completely rejected. There is an opinion that the luteoma of pregnancy arises from cells of theca int. ripening and atreziruyu-shchikhsya follicles, from a focal thecomatosis, from tekalyuteinovy cysts. Apparently, the most probable source of development of a luteoma of pregnancy is intersticial gland of an ovary. Almost in half of observations the luteoma of pregnancy is found in both ovaries. At the same time ovaries are increased in sizes, sometimes to 15 — 20 cm. On a section nodular formations of a soft or friable consistence, yellow or orange-yellow color, sometimes with the centers of hemorrhages and a necrosis are visible. Microscopically the luteoma of pregnancy consists of the large cells of a polygonal form which are located in the form of tyazhy or small knots, in to-rykh it is occasionally possible to find the small pseudo-cavities caused, apparently, by killing. Cytoplasm of cells eosinophilic, contains very trace amount of lipids. Kernels of cells large, with clearly the acting kernels. On certain sites numerous mitoses are found. The stroma is scanty, it is rich with capillaries.

Hilusno-kletochnaya the hyperplasia meets seldom. It usually arises in gate of an ovary where and normal hilusny cells contain (histologically and functionally they are equivalent to cells of Leydiga of a small egg). Macroscopically, as a rule, in both ovaries the small henna-red small knots which are not squeezing the fabric surrounding them are visible. Hilusno-kletochnaya the hyperplasia of an ovary is one of the main sources of development of a tumor of cells of Leydiga (see below the section of the Tumour).

Methods of inspection

the Research of a condition of ovaries and their function includes collecting the anamnesis, survey, gynecologic, kolpotsitologichesky, hormonal, functional (including functional trials) researches, radiological and ultrasonic methods, a laparoscopy (in particular, a kuldoskopiya), and also methods of a morphological research.

An indirect idea of hormonal function of ovaries is given by data (the general and gynecologic) the anamnesis, survey (outward, expressiveness of secondary sexual characteristics, indicators of physical development and a constitution), gynecologic survey (feature of a structure of outside and internal generative organs).

At gynecologic (vulval or rectoabdominal) a research (see. A gynecologic research) not changed (normal) ovaries decide in the form of small oblong educations, a softish consistence on a smooth surface, sensitive at a palpation, enough mobile more often, located on the right and to the left of a uterus. Ovaries are more clearly palpated during the period closer to the middle of a menstrual cycle when the bubble, and also in the second half of a menstrual cycle and in early durations of gestation (the functioning yellow body) ripens graaf. Sometimes ovaries are not palpated. Idea of size, a form and features of a surface of ovaries can be received also at X-ray inspection (see Peljvig a raffia) and an ekhografichesky research (see. Ultrasonic diagnosis, in obstetrics and gynecology), and also at a laparoscopy and a kuldoskopiya (see Peritoneoskopiya, in gynecology). At a laparoscopy it is also possible to make aspiration of peritoneal liquid for a cytologic research and a biopsy of an ovary at suspicion of a tumor. However by means of a laparoscopy it is not always possible to establish a stage of ovarian cancer since at the same time the hidden metastasises do not come to light.

Histologic methods of a research (see) are applied to diagnosis various patol. conditions of ovaries after a biopsy or their removal, and also for definition of a condition of an endometria depending on function of ovaries. For the characteristic of hormonal function of ovaries use kolpotsito-logical methods (see. A cytologic research, in obstetrics and gynecology; The Menstrual cycle), and also determine the content in blood or urine of gonadotrophins and sex hormones (see Androgens, Gonadotropic hormones, Hormonal regulation, Progesterone, Estrogen).

During the studying of a functional condition of ovaries determine basal temperature, reveal phenomena of a pupil and a fern, carry out gistol. a research of scraping of an endometria (see. A menstrual cycle), and also a cytologic research of vulval smears

{ see the Vagina, methods of a research).

For diagnosis of tumors of ovaries, along with the methods described above, the tendency to wider use of methods of ultrasonic diagnosis was outlined in recent years. Due to a possibility of a research of internal structure of a tumor the method is recommended for identification of early stages of ovarian cancer. Actual data on use for diagnosis of tumors of ovaries, including cancer, a computer tomography (see the Tomography computer) and nuclear magnetic resonance collect (see). The computer tomography is a valuable method of early recognition of ascites and metastasises, including in limf, nodes. It can be applied to scoping the remained ambassador of operation of tumoral fabric and identification of a recurrence. However the method does not allow to carry out differential diagnosis of malignant tumors of an ovary with high-quality therefore it cannot be used for early diagnosis of cancer. The first attempts by definition of diagnostic opportunities of a method of nuclear magnetic resonance show that with its help it is possible to reveal a recurrence of cancer of ovary and extent of growth of tumoral fabric that cannot be received by means of other methods of scanning.

Determination of level of a seralbumin, S-reactive protein, a ^-acid glycoprotein and fosfogeksozizomeraza can be a possible biochemical marker of progressing of malignant tumors of an ovary. However by means of these methods to reveal a tumor of the small sizes it is usually impossible. P-microglobulin can matter a marker only at limited number of patients, at to-rykh development of cancer is followed by increase in its level.

Pathology

All types of pathology of ovaries subdivide into malformations, damages, disturbances of hormonal function, inflammatory diseases, parasitic diseases, cysts and tumors.

Malformations. A dysgenesis of gonads, additional yapchnik, otshnurovany parts of an ovary, the doubled ovaries concern to them.

The dysgenesis of gonads — inborn defect of development of gonads, meets rather seldom and the wedge, manifestations has quite wide range. Distinguish the typical, pure and mixed forms of a dysgenesis of gonads. At a typiform of a dysgenesis of gonads (Shereshevsky's syndrome — Turner) low-tallness, shortening of a neck with alate folds of skin on it, a barrel-shaped thorax and other symptoms are observed (in detail a pathogeny, clinic, treatment and the forecast of patients with this syndrome — see Turner a syndrome). High growth and eunuchoid constitution are characteristic of women with a pure form of a dysgenesis of gonads, external genitals are developed on female type. The disease is diagnosed at pubertal age (15 — 16 years) when patients address the gynecologist due to the lack or a delay of sexual development. Increase in the FSG and LG levels in blood is characteristic of this form. Treatment (especially with a high growth of the patient) should be begun with high doses of estrogen for closing of regions of growth of bones and acceleration of their ossification. Therapy should be carried out under constant observation of the gynecologist since nek-ry researchers express fears in connection with possible development at the same time of gy-perplastichesky processes in hormonedependent bodies — a uterus y mammary glands. At discrepancy of a phenotype to a karyotype there is a danger of a malignancy of disgenetichesky gonads, in such cases of the patient with a pure form of a dysgenesis of gonads the ovariektomiya with the subsequent replacement hormonal therapy which is carried out is shown as well as at Shereshevsky's syndrome — Turner. Replaceable hormonal therapy at typical and pure forms of a dysgenesis of gonads is applied during the entire period of puberty since in these terms the maximum feminizing effect is reached. Further the issue of expediency of treatment is resolved strictly individually taking into account reaction of target organs and neuro and mental and that the status of the patient. The forecast for life of patients with typical and pure forms of a dysgenesis of gonads favorable, the forecast concerning recovery of menstrual and genital functions adverse.

At the mixed form of a dysgenesis of gonads in an organism elements of an ovary and a small egg are combined. These elements (seed tubules and follicles) can be presented in one gonad (ovotestis) or there are at the same time heterosexual gonads.

True hermaphrodites usually have a uterus, uterine tubes, a vagina. Secondary sexual characteristics have elements of both floors (the mixed type of a figure, mammary glands, pilosis on men's type, a low timbre of a voice are in a varying degree developed). In detail a pathogeny, a clinical picture, treatment of this pathology — see the Hermaphroditism.

Additional ovaries (ovarium the expert-cessorium), as a rule, are located near normal, have the general with them blood supply and similar functions. The kind of additional ovaries, apparently, should be considered also otshnurovany from poles of normal ovaries of small sites

of an ovary of 1 in size — 2 cm. The doubled ovary (ovarium disjunctium) — anomaly of development, at a cut an ovary is divided into two parts, connected among themselves thick tyazhy (crossing point). Additional ovaries and the doubled ovary clinically can not be shown and treatments do not demand.

Damages. The isolated injuries of ovaries meet extremely seldom. Usually injuries of ovaries are combined with damages of a basin (see).

Disturbances of hormonal function. Dysfunction of ovaries is connected preferential with disturbances in gipotalamo - pituitary and ovarian

system. The main forms of dysfunction are a hypoestrogenism (at insufficiency of a follicular phase of an ovarian cycle _

see the Amenorrhea, Infertility, the Hypogonadism, Infantility), a hyperestrogenism (at excessive products of estrogen in a follicular phase of a cycle — see. Dysfunctional uterine bleedings), a gipolyutei-nizm (at insufficiency of a yellow body, its premature maturing and early withering — cm. A yellow body, Progesterone), a giperlyu-theism (at a persistention of a yellow body — cm. A yellow body, Prolactin) i, a giperandrogeniya (at sclerocystic ovaries — see Matte — Leventalya a syndrome), anovulation (see. Anovulatory cycle). Dysfunction of ovaries is observed at nek-ry hormonal and active tumors of an ovary (granulocellular, tekoma, arrhenoblastomas, tumors from an interstitium of ovaries, whether - poidno - cellular tumors), pathologies of other bodies of incretion (see Hemadens), and also at formation and fading of function of ovaries (see the Climacteric, the Menopausal syndrome). Operational switching off of function of ovaries (castration) leads to considerable hormonal changes in an organism (see the Postkastratsionny syndrome).

Syndrome of hyper stimulation of ovaries — excessive strengthening of function of ovaries owing to hormonal influences; it is more often observed at treatment by gonadotrophins and clomifene. It is morphologically shown by acceleration of maturing of follicles and yellow bodies, a giperlyuteini-zation, education in an ovary of lyuteinovy cysts with the subsequent their possible gap and bleeding in an abdominal cavity. Clinically bystry increase in the sizes of ovaries (preferential at the expense of a giperlyuteiniza-tion), inflows, abdominal pains, a meteorism, a menorrhagia is defined. At emergence of these symptoms it is necessary to cancel drug. At ruptures of lyuteinovy cysts the symptoms of internal bleeding demanding an operative measure are quite often observed (see the Apoplexy of an ovary).

Syndrome of exhaustion of ovaries — the state, a cut was described under the name of «an early climax» earlier. At the same time the FSG and L levels G in blood are increased, but ovaries do not answer gonadotropic stimulation since the follicular device ran low (I eat. Climacteric). Disturbance of a rhythm and duration of a menstrual cycle, and in the subsequent lengthening of an interval between periods are characteristic. Less often changes of menstrual function are followed by emergence of irregular, plentiful and long menstrualnopodobny bleedings. At emergence of this state to age of a natural menopause (about 45 years) replacement hormonal therapy by microdoses combined estrogen - gestagenny drugs is shown. This treatment is carried out for the purpose of prevention of a senilism of an organism, emergence of vegetative reactions and cardiovascular diseases, but not for recovery of menstrual function. The forecast for life favorable, for recovery of menstrual and generative functions — adverse.

A syndrome of refractory (resistant) ovaries — a disease, at Krom in ovaries there are no receptors to gonadotrophins or dysfunctions of these receptors are observed. Causes of illness to a crust, are not known to time. Level of gonadotrophins is increased. Also the nek-eye an underdevelopment of secondary sexual characteristics is clinically shown by primary or secondary amenorrhea. Internal generative organs are developed on female type, a sex chromatin women's, a karyotype 46, XX. Macroscopically and microscopically ovaries are, as a rule, not changed. Because the etiology of a disease is not clear yet, there is no standard scheme of treatment. A number of gynecologists recommend to carry out hormonal treatment in the cyclic mode or treatment by gonadotrophins according to the standard scheme. The forecast for life favorable, for recovery of menstrual and generative function — rather favorable. Exceptional cases of approach of pregnancy at these patients after the carried-out treatment are described.

Inflammatory diseases of ovaries (oophorites) can be nonspecific (are caused by stafilokokka, streptococci, etc.) and specific. The last meet seldom, are observed at tuberculosis (see Tuberculosis vnelegoch-ny) and syphilis (see). Inflammatory diseases of ovaries usually develop for the second time and are connected with inflammatory processes in uterine tubes therefore most often use the term «inflammation of appendages of an uterus», or an adnexitis (see). Much less often pathogenic microorganisms are brought in ovaries by a blood flow and a lymph. In detail a pathogeny, clinic and treatment of an oophoritis — see the Adnexitis.

Parasitic diseases of ovaries meet seldom, defeat at the same time, as a rule, is secondary (see Shistosomatoza, the Echinococcus).

Cysts of ovaries represent retentsionny educations. Distinguish endometrioid cysts (see Endometriosis), follicular cysts, cysts of a yellow body, tekalyutei-new and inklyuzionny cysts.

Follicular cysts and occurs most often at women of reproductive age and in a premenopauza. At girls up to 15 years follicular cysts make not less than 1/3 all cysts and tumors of the ovaries which are found in this age group. Follicular cysts can be found in ovaries of a fruit and the newborn. Macroscopically follicular cyst represents thin-walled and single-chamber education band, as a rule. The cyst is located in one of ovaries, its size from 2 to 7 hardly in the diameter more often, is rare — more.

Wedge, a picture of follicular cysts in many respects is defined by degree of their hormonal activity and existence accompanying ginekol. diseases (hysteromyoma, endometriosis, inflammatory processes). When the follicular cyst shows hormonal activity, the hyperplasia of an endometria, uterine bleedings are observed, at girls premature puberty is noted. At cysts of the big sizes patients can complain of pains in a bottom of a stomach.

The most frequent complication of follicular cysts of ovaries, especially at children, torsion of a leg of a cyst is, to-ry can cause a rupture of its wall, is followed by suppuration of contents of a cyst and development of peritonitis. Sharply, more often after an exercise stress or at a sharp postural change of a body, poyavlyuteya the sharp pains in a bottom of a stomach irradiating in a crotch, a hip, lumbar area are quite often noted nausea, vomiting. Body temperature during the first hours usually remains normal. Sometimes pains quickly abate, and the made torsion of a leg of a cyst is not reflected in the general condition of the patient. The differential diagnosis of torsion of a leg of a cyst with other morbid conditions and diseases causing a symptom complex of an acute abdomen (see. Acute abdomen, table). Also so-called asymptomatic follicular cysts meet, to-rye can be found at routine maintenances.

At identification at a sick follicular cyst of the small sizes dynamic observation within 2 — 3 months and performing conservative treatment, in particular an electrophoresis with potassium iodide or a gestagenama is shown. At increase in the sizes of a cyst, its excessive mobility, inefficiency of treatment or emergence of complications an operative measure is shown.

Cystsand a yellow body meets considerably less than follicular. It is observed, as a rule, at women of reproductive age and can arise both in

a menstrual yellow body, and in a yellow body of pregnancy. Believe that formation of a cyst of a yellow body is connected with defects of lymphatic and circulatory system of a yellow body therefore liquid in its central part can collect. The sizes of a cyst of a yellow body vary from 2 to 7 cm in the diameter. Ate a cyst of less than 3 in the diameter sometimes call a cystous yellow body. The inner surface of such cyst quite often happens yellow color, contents — light, and at hemorrhages — hemorrhagic. P*ri long existence of a cystous yellow body at the patient notes menometrorrhagias, and in some cases the symptoms allowing to suspect pipe pregnancy. Cysts of a yellow body of the big size are hormonal not active. At a rupture of a cyst there can come profuse bleeding with symptoms of an acute abdomen (see). In a stage of regression of a cyst its contents resolve, walls of a cavity are fallen down and on site a layer of granulezolyuteinovy cells the white body is formed; in rare instances the cavity of a cyst remains — a cyst of a white body.

Tekalyuteinovy cysts (tsvetn. the tab., Art. 464, fig. 23) more often happen bilateral and multiple. Size their various, in some cases tekalyuteinovy cysts have the big sizes — to 15 — 20 cm in the diameter. Their gleam contains light or pale yellow color liquid. The inner surface of cysts of yellow color, is covered by a layer of tekalyuteinovy cells, over to-rymi the granuleza without signs of a luteinization quite often is located. Developing of tekalyuteinovy cysts is connected with action of a chorionic gonadotrophin (see), contents to-rogo sharply increases at a vesical drift (see), a horionepitelioma and some other the diseases combined by the name a trophoblastic disease (see). Less often tekalyuteinovy cysts are observed at the polycarpous pregnancy proceeding against the background of a diabetes mellitus at a preeclampsia, an eclampsia and an eritroblastoza. At the same time clinical manifestations can be absent, signs of a virilism, gradually disappearing in a puerperal period are only sometimes noted. Unilateral, single and single-chamber tekalyuteinovy cysts can arise also out of pregnancy, in particular at use of clomifene, a chorionic gonadotrophin and other medicines for the purpose of induction of an ovulation. In these cases bystry increase in the size of an ovary, an abdominal pain, a meteorism, a menorrhagia is observed. At a rupture of a cyst symptoms of internal bleeding are observed. Tekalyuteinovy cysts can be found also in ovaries of a fruit and the newborn. At newborns they sometimes reach 8 — 12 cm in the diameter and lead to development of intestinal impassability.

Tekalyuteinovy cysts of special treatment do not demand since the tendency to spontaneous regression and turning into fibrous bodies is inherent to them. Occasionally regression can occur owing to a spontaneous or traumatic gap.

Superficial inklyu-zionny oothecomas (superficial epithelial cysts, germinal cysts) happen both multiple, and single, They represent the small closed cavities, usually microscopic size covered by a cubic or cylindrical epithelium. Inklyuzionny cysts can be predecessors of nek-ry cystous epithelial tumors.

Diagnosis. As cysts of ovaries quite often develop asymptomatically or malosimptomno, inspection needs to be begun with careful collecting the anamnesis. At the same time it is possible to reveal nek-ry symptoms: pains in lower parts of a stomach of various degree of manifestation and character, these or those disorders of menstrual function (bleeding, amenorrhea), disturbance of reproductive function (infertility, abortions). Crucial importance in diagnosis of cysts of yavichnik has a bimanual gynecologic research, at Krom it is possible to determine the amount of education, its mobility, character of a surface, a consistence, an arrangement in relation to bodies of a small pelvis. Specification of the diagnosis is promoted by the results received by means of additional methods of a research (see above).

Treatment of cysts of ovaries preferential operational (see below Operations). At single cysts at women of reproductive age make organ-preserving operative measures, napr, a resection of an affected area.

Tumors of ovaries. There are various classifications of tumors of ovaries. Their variety is defined by the principles, to-rykh originators adhered: division

of tumors on high-quality and malignant, the macroscopic characteristic (cystous and solid), etc. In one classifications all tumors of ovaries divide on epithelial, connective tissue and teratoid. Other classifications, e.g. offered

by M. F. Glazunov (1961), were made by the onkonozologichesky principle, i.e. its morphology and a histogenesis were considered as feature of clinic and a pathogeny of a certain form of a tumor, and. There are also classifications which basis it is or the formal and morphological principle without functional features of tumors, or, on the contrary, their functional features (biochemical data and a wedge, manifestations) without taking into account morfol. data. Also the attempt of creation of classification of tumors of ovaries based on their histochemical features is known. Despite existence of numerous classifications of tumors of ovaries, any of them does not satisfy completely requests of practical doctors of various profile and other specialists.

Creation of classification of tumors of ovaries full in every respect in many respects depends on a solution of the problem of their histogenesis and a pathogeny. The histogenesis of tumors is among the difficult and not completely studied problems, than and the existing disagreements in opinions on a source of an origin of this or that tumor speak.

Attempts of creation of classification of tumors of ovaries were made on a symposium of the International federation of gynecologists and obstetricians in Stockholm (1961) and on the congress of WHO in Leningrad (1967). In 1973 the International histologic classification of tumors of ovaries of «Histological typing of ovarian tumors» based on the microscopic characteristic of new growths was published. It was created with the assistance of the International help center (Leningrad) and 12 centers of various countries cooperating with it. However and this classification is not comprehensive and in connection with accumulation of new data demands introduction of a number of specifications.

In clinical practice distinguish epithelial tumors (cystomas, or cystadenomas), tumors of a stroma of a sexual tyazh (or hormone - the producing tumors) c ger-minogenny tumors. Besides, all epithelial tumors of ovaries divide into high-quality, proliferating, malignant and metastatic (secondary).

One of basic groups of new growths of ovaries is made by epithelial tumors, among to-rykh allocate serous (tsilioepiteli-alny), mucinous, endometrioid and clear cell tumors, Brenner's tumor (see Brenner a tumor), the mixed epithelial tumors (various combinations of compound components of the previous tumors), an undifferentiated carcinoma, not classified epithelial tumors.

Distinguish a serous cystoma (a tsi-lioepitelialny cystadenoma) and a papillary cystoma (a papillary cystadenoma), superficial papilloma from benign and proliferating tumors of an ovary, adenofibry and cysts-adenofibromu (kistadenofibry). Among malignant tumors distinguish an adenocarcinoma, a papillary adenocarcinoma, a papillary cystadenocarcinoma, a superficial papillary carcinoma, malignant adenofibry and a cyst to denofibry.

Proliferating tumors of an ovary take the intermediate place between high-quality and malignant new growths. In explanatory notes to the international histologic classification it is specified that to proliferating the tumors having only nek-ry morfol belong. symptoms of a malignant tumor (stratification of epithelial cells, mitotic activity, changes in kernels, etc.) and not having infiltrative growth. At proliferating tumors implants on a peritoneum can be observed, to-rye sometimes differ in infiltrative growth, the remote metastasises occasionally meet. However the forecast at these tumors more favorable, than at malignant, even in the presence of implants on a peritoneum. Nek-ry researchers call proliferating tumors «potentially malignant» or «boundary». However according to

N. A. Krayevsky, A. V. Smoljyanni-kov, D. S. Sarkisov (1982) and some other researchers, these terms make extremely uncertain sense.

D about r about to and h e with t in e N of N y e tumors. Benign epithelial tumors make more than a half of all new growths of ovaries. Serous and mucinous tumors most often occur among them, at the same time serous tumors arise more often than mucinous. The serous cystoma (tsilioepitelialny cystadenoma) and papillary cystoma (papillary cystadenoma) most often occur among serous tumors.

The Tsilioepitelialny cystadenoma more often happens unilateral, single-chamber and, as a rule, smooth-bore. The sizes of its from 2 — 3 to 30 cm in the diameter; this tumor reaches the big sizes only in some cases. Contents of a tumor — usually transparent serous liquid of straw color, in a cut flickering crystals can be found. The epithelium covering a wall of a cystoma single-row, is more often cubic or flattened, cylindrical is more rare. The ciliary epithelium is found only on certain sites. Capsule of a tumor generally plotnovoloknisty.

The papillary cystadenoma, as a rule, has the small sizes and only in rare instances has a diameter of 20 cm and more. Generally these tumors multichamber, with characteristic papillary growths, are more often on an inner surface (tsvetn. tab., Art. 464, fig. 28). These growths can fill the most part of one or many cameras of a tumor, remind by the form a cauliflower; in other observations only the insignificant number of warty growths is found. At adjournment of salts of calcium papillary growths get considerable density. Papillary cystadenomas quite often happen bilateral. Contents of papillary cystadenomas usually liquid, sometimes viscous, yellowish or brown color. Numerous nipples in papillary cystadenomas have a connective tissue basis rather thin, rich with cells and blood vessels, a significant amount of acid glikozaminoglikan contains edges. In a stroma of nipples quite often meet to dogs-moznye of a little body. Epithelial to - the shelter of nipples single-row, differs in especially strong likeness with a pipe epithelium, and under certain conditions in it it is also possible to distinguish 4 main types of cells (see. Uterine tubes), the Crimea the structurally functional changes similar observed in a pipe epithelium in various phases of a menstrual cycle are inherent, during pregnancy and a lactation, and also in a postmenopause.

One of forms of a papillary cystadenoma of an ovary is the grubososochkovy cystoma. Its characteristic feature are the dense papillary educations and plaques found on an inner surface, a massive dense connective tissue basis to-rykh quite often is in a condition of hypostasis or a hyalinosis.

Superficial papilloma meets seldom. Macroscopically it represents the tumor of a papillary structure, usually considerable size located on the surface of an ovary and sometimes completely shrouding it. Damage of ovaries this tumor more often happens bilateral. Histologically superficial papilloma is characterized by the same features of a structure, as a cystadenoma *

Superficial papilloma of an ovary needs to be differentiated with mik-ropapillozy (a papillary hypertrophy of bark of an ovary, a warty ovary), to-ry meets more often at women of advanced age. At a mikropapilloza of an ovary nipples usually very small, indiscernible it is macroscopic, nevetvya-shchiyesya, are located on a surface of body, it is preferential in the form of small focal accumulations. Mikropapilloz of an ovary proceeds without wedge, manifestations.

A serous adenofibrom and cysts-adenofibroma treat rather rare tumors of an ovary. Macroscopically they sometimes look as fibromatozno the changed ovary (the size from 3,5 to 4,5 cm in the diameter), with numerous small cysts on a section (adenofibrom); seldom similar tumors which are located in a bast layer have diameter of 0,1 — 0,3 cm. In separate observations these small tumors are connected to the surface of an ovary a thick leg. However more often the adenofibroma is combined with a cystadenoma (serous tsistadenofib-rum); such tumors also have small size. In rare instances the similar tumor can have 20 cm a diameter. A dense part serous a cyst denofib rums is constructed as fibroma, in a cut ferruterous inclusions meet.

It is possible to distinguish three basic groups from mucinous tumors: mucinous cystadenomas, the vast majority to-rykh arises of a myullerov of an epithelium; mucinous cystadenomas, to-rye are combined with Brenner's tumors; teratomas (see), a source of development to-rykh is the entodermalny epithelium of intestinal type. Most often the simple (setserniruyu-shchy) mucinous cystoma meets. Defeat preferential unilateral (bilateral localization of this tumor is observed approximately in 10% of cases). As a rule, the sizes of a tumor — from 15 to 30 cm in the diameter, but in some cases it can have 50 cm a diameter. Form of a tumor roundish or ovoidny. In most cases this tumor is multichamber education. Contents of its cameras having various size, usually jellylike, but in large cameras and big single-chamber tumors it can be more liquid. Wall of mucinous cystomas and partition of their cameras rather thick. Inner surface of cameras smooth.

Papillary mucinous cystomas more than in half of cases happen bilateral. On an inner surface of cameras of a cystoma the papillary growths sometimes reminding by the form a cauliflower are found. Epithelial cover of nipples of mucinous cystomas single-row. Height and form of cells can vary: along with a high cylindrical epithelium cubic and scyphoid cells come to light, high cells can meet the extended kernels and a narrow rim of cytoplasm also. Disturbances in the course of a slizeobrazovaniye are sometimes noted: nek-ry cells lose ability to produce slime, cytoplasm of other cells is crowded with droplets of mucin. Mitoses are observed seldom.

Treat rare forms of mucinous tumors of an ovary an adenofibroma and a tsistadenofibroma. The mucinous adenofibroma, as well as a serous adenofibroma, consists of two components — fabrics like fibroma and ferruterous inclusions or small cysts. Small cysts are usually covered by a high cylindrical epithelium, from them the large band educations covered by the same epithelium — mucinous a cyst of a denofibroma can develop.

Endometrioid new growths of an ovary — the tumors having similarity in morfol. relation with tumors of an endometria (tsvetn. tab., Art. 464, fig. 25). The term «endometrioid tumour» does not mean that a source of development surely is endometrioid fabric or an endometrioid cyst (see Endometriosis). Only in a small number of cases it is possible to find proofs of an origin of an endometrioid tumor from endometriosis. It is described apprx. 20 observations of true high-quality endometrioid new growths. Microscopically in benign endometrioid tumors reveal single-row low cylindrical or a cubic epithelium of endometrial type, including in the ferruterous inclusions and cysts which are located in connecting fabric of an adenofibroma. The stroma surrounding ferruterous inclusions can have poorly expressed cytogenic character.

Benign clear cell tumors meet exclusively seldom. They can have the form of an adenofibroma and tsistadenofib-rums, to reach the big sizes. Clear cell these tumors are called because the tubules forming them and small cysts are covered by hl. obr. odnoryadny epithelium from the light cells containing a glycogen and (or) the cells reminding a wallpaper nail in a form. The epithelium of papillary structures found sometimes on certain sites of a tumor has a similar structure. In sites of the tumor consisting of numerous small cysts, a stroma scanty unlike a stroma of its other part in a cut it has the nature of fibroma.

A wedge, displays of serous and mucinous tumors of an ovary have much in common. Therefore data about a wedge, it is reasonable to picture of a disease to provide not separately for each of the called categories of a new growth, and together, allocating those a wedge, data, to-rye in smaller or bigger degree are inherent to serous or mucinous tumors or their separate types.

These tumors occur at any age, including at girls and girls. Serous tumors are found in women at the age of 30 — 50 years more often, and mucinous — in 40 — 60 years.

Early stages of a disease proceed asymptomatically. In the course of the slow growth of tumors depending on their size, an arrangement and features of growth the corresponding complaints appear. Most often patients complain of pains in the bottom of a stomach, and also in lumbar area, sometimes in inguinal area. More often dull aches, the aching character. Acute pains develop at torsion of a leg of a tumor what is promoted the considerable length of a leg, the sharp movements and changes of position of a body, physical tension. Quite often torsion of a leg of a tumor comes during pregnancy and in a puerperal period. Full torsion of a leg of a tumor is shown by a picture of an acute abdomen, at the same time blood supply of a tumor is sharply broken that leads to hemorrhages, a necrobiosis and a necrosis of its certain sites. Further at the expense of consecutive infection suppuration and development of limited peritonitis, and in nek-ry cases of diffuse peritonitis is possible (see). At papillary cystadenomas of pain can arise slightly earlier, than at other forms of tumors that, perhaps, is caused by their bilateral localization (in 50 — 75% of cases) and an inter-copular arrangement with a prelum and shift of the next bodies. By Yoyavleniye of pains it is connected partly and with the nature of growth of papillary educations. So, with a growth of papillary educations on an outer surface of a tumor of pain arise more often; quite often at the same time ascites is found (see). Development of papillary growths on an outer surface of a tumor as a result of germination of nipples through its wall can be followed by implantation of nipples on a peritoneum. Ascites and planting of a peritoneum are observed also at typical superficial papilloma of an ovary. Implants of a tumor on the surfaces of a uterus, uterine tubes and an epiploon revealed during an operative measure not always indicate a zlokachestvennost of process. In some cases implants can resolve after removal of the main tumor. The growing tumor of an ovary can cause dysfunction of intestines, frustration of an urination, etc. Serious, though rare, a complication of mucinous tumors of ovaries is the pseudomyxoma (see), one of mechanisms of development a cut — treatment by slime of a wall of a mucinous cystoma with the subsequent its necrosis and a rupture of a cyst. Outpouring in an abdominal cavity of jellylike contents of a cystoma together with tumoral elements is followed by their implantation on a peritoneum.

Klien, picture of benign endometrial and clear cell tumors of an ovary is described insufficiently because of a rarity of these new growths. A wedge, displays of a tumor of Brenner — see Brenner a tumor.

Treatment of benign tumors of an ovary operational (see below). The patient, at a cut is established a tumor of an ovary, shall be subjected to an operative measure irrespective of its age and size of a new growth. Similar tactics is defined not only need to avoid the complications caused by existence of a tumor, but also impossibility to exclude a malignancy of benign epithelial tumors. The forecast at early diagnosis and timely treatment favorable.

Proliferating tumors. Proliferating serous tumors make about 15% of total number of benign and malignant serous tumors of ovaries. Macroscopically proliferating serous tumors of an ovary have the same features, as not proliferating; slightly more often they are bilateral.

The main symptoms of these tumors * are found at gistol. research. The expressed proliferation of an epithelium is noted, edges про^ is a true multilane, education epithelial (deprived of a stroma) nipples, emergence of mitoses. In nek-ry fields of vision it is possible to observe clear isolation of small groups and islands of cells without symptoms of dystrophy, active in the functional relation that is confirmed by means of histochemical and electronic and microscopic researches. In certain sites of a tumor various anomalies of kernels which are not observed in an epithelium of not proliferating tumors obnaru-ruzhivatsya. However the expressed atipizm of cells and the infiltrative growth observed at cancer of an ovary in proliferating tumors are absent.

The listed symptoms of proliferating serous tumors can be found in various combinations, and for establishment morfol. the diagnosis existence of all given signs is not obligatory.,

Proliferating mucinous tumors make 10 — 14% of total number of high-quality and malignant mucinous new growths of ovaries. Macroscopically proliferating mucinous tumors differ from their high-quality options a little. Approximately in half of observations on an inner surface of a cystoma papillary growths come to light. Frequency of a bilateral proliferating mucinous cystoma does not exceed the frequency of bilateral damage of ovaries at localization in them simple mucinous cystomas; in half of observations of proliferating mucinous cystomas in the second ovary the benign mucinous tumor usually is located.

The proliferating mucinous tumor is characterized by intensive proliferation of an epithelium with loss on nek-ry sites of a specific differentiation and function of cells, emergence of a multirow epithelium (no more than 2 — 3 rows), a moderate atipizm, a hyperchromatosis of the increased kernels and single mitoses. Unlike malignant mucinous tumors the expressed atipizm of cells, numerous mitoses and infiltriruyushchy growth at proliferating option of these new growths are absent. Clinically proliferating mucinous tumors proceed usually as well as not proliferating tumors (see above). The forecast for the vast majority of patients with proliferating mucinous tumors favorable therefore at treatment of persons of young age (in case of lack of the accompanying changes in a uterus) at damage of one ovary it is necessary to be limited to a unilateral salpingoovariectomy. With the diagnostic purpose in these cases also wedge-shaped resection of the second low-changed ovary is shown. Long dispensary observation of similar patients is obligatory.

Malignant tumors. Among them ovarian cancer meets more often. On the basis of epidemiological researches the risk factors important in developing of ovarian cancer are described: hormonal, genetic, age, features of menstrual and genital function, menopause, viral infections, chemical онкогены^ ionizing radiation, etc. In particular, D. W. Cramer, etc. (1983) specify that the virus of epidemic parotitis possesses a certain tropnost to tissue of ovaries and, causing reduction of quantity of oocytes, increases risk of developing of cancer. There are data that in a pathogeny of ovarian cancer age increase in products of gonadotrophins can play a role. However these risk factors are not indisputable and demand further studying.

Ovarian cancer can develop at any age, but he meets at the age close to a menopause more often, and in a postmenopause.

Malignant serous tumors (tsvetn. the tab., Art. 464, fig. 29) meet most often, making about 40% of all primary malignant tumors of ovaries. Cancer of an ovary developing from a serous tumor, more than in 50% of observations happens bilateral. In some cases innidiation from one ovary in another is possible. The tumor is characterized by rapid growth and infiltration in the next bodies. Distinguish an adenocarcinoma, a papillary adenocarcinoma and a papillary cystadenocarcinoma, a superficial papillary carcinoma, and also a malignant adenofibroma from malignant serous tumors and a cyst-denofibromu.

Malignant mucinous tumors meet less often. The malignant tumor which developed from a benign mucinous tumor more often happens unilateral, bilateral localization of process is noted approximately in * / z all observations. The tumor happens multichamber, 50 cm can have a diameter. In one or several cameras sites of a solid structure meet, in nek-ry cases all tumor has a solid appearance.

Malignant endometrioid tumors (endometrioid carcinomas) macroscopically have an appearance of a cystous tumor from 2 to 35 szh in the diameter. Defeat in most cases unilateral. In a tumor small sites of a solid look are found, also zones of a papillary structure meet. The endometrioid carcinoma of an ovary only in 5 — 10% of cases arises from endometrioid fabric therefore it is inexpedient to carry to endometrioid carcinomas only those new growths, the origin to-rykh is connected with endometriosis. Moreover, it is possible that the endometrioid carcinoma of an ovary arises from benign endometrioid tumors more often. The endometrioid carcinoma of an ovary more than in 20% of observations is combined with primary high-differentiated adenocarcinoma of a body of the womb (approximately in 2/3 cases limited by an endometria) and the expressed atipichesky hyperplasia of an endometria.

The malignant endometrioid adenofibroma and a tsistadenofibroma meet in combination with high-quality and (or) proliferating option of the specified tumors more often. Exclusively seldom endometrioid stromal sarcoma and the mixed mesodermal (myullerova) tumors, homologous and heterological are found (see the Uterus).

Malignant clear cell tumors unlike their high-quality option meet rather often (make up to 11% of cases of all primary carcinomas of an ovary). The tumor more often happens unilateral, from 2 to 30 cm in the diameter, in most cases partially cystous. Its solid sites have white, gray, sometimes yellowish color, in a tumor the centers of hemorrhages and a necrosis are quite often noted.

The undifferentiated carcinoma belongs to malignant epithelial tumors without characteristic differentiation (see Cancer) meets in 5 — 15% of all cases of ovarian cancer h. Sometimes an undifferentiated carcinoma at gistol. a research mistakenly take for a granulocellular tumor.

Horionepitelioma (choriocarcinoma) consists of elements of a cyto-trophoblast and a sincytium, meets seldom as a part of more difficult germinogenny tumor (see the Teratoma). Besides, the horionepitelioma of an ovary can arise at an ovariocyesis and as a metastasis from other body (see. Trophoblastic disease).

Gemangioendotelioma of an ovary comes to light seldom — in literature there are only six observations. The tumor possesses the expressed zlokachestvennost.

The leiomyosarcoma and a rhabdomyosarcoma belong to exclusively rare malignant tumors of a negerminogen-ny origin (see Sarcoma). The leiomyosarcoma of an ovary occurs at patients aged 60 years, a rhabdomyosarcoma — at any age are more senior.

The fibrosarcoma of ovaries is observed at women of 45 — 70 years, has looking alike fibroma (see), however in it focal hemorrhages and necrotic changes come to light more often, polymorphism of cells and mitotic activity are more expressed.

Undifferentiated stromal sarcoma of an ovary — the rare, not having a specific differentiation tumor, meets more often at girls up to 20 years and less often at women 30 years are more senior. The tumor usually has the big sizes, a dense or soft consistence, is characterized by different degree of polymorphism and mitotic activity.

Malignant tumors of ovaries do not cause specific a wedge, manifestations, and in an early stage of development these tumors clinically cannot be distinguished from benign tumors. Upon transition patol. process out of limits of the struck body there are complaints not only to weight and constant pains in the bottom of a stomach, but also on pain at the act of defecation, locks and (or) ponosa, deterioration in the general state, increase in a stomach and weight loss. Ascites is rather characteristic, to-ry accrues during the progressing of a disease. However ascites can be observed both at high-quality, and at proliferating tumors, in particular at papillary cystomas and superficial papilloma. During the same period of a disease along with ascites there can be a hydrothorax (see). It is necessary to consider that ascites in combination with a hydrothorax can be observed also at fibroma of an ovary (see Meygs a syndrome).

Degree of manifestation a wedge, manifestations and results of objective inspection of patients depend on prevalence of tumoral process. In a crust, time apply the classification of primary ovarian cancer by the TNM system offered by the International anticarcinogenic union (1966) and the classification of primary ovarian cancer by stages offered by the International federation of gynecologists and obstetricians (1971).

Classification of primary ovarian cancer by the TNM system: T — primary tumor; Tj — the tumor affecting one ovary (mobile); T2 — the tumor involving both ovaries (mobile); T3 — the tumor extending to a uterus and (or) uterine tubes; T4 — the tumor extending to others ok-ruzhashchiye anatomical structures.

N — regional limf, nodes; at addition with data gistol. researches use designations: Nx_ — metastasises in regional limf, nodes are absent; Nx + — are available metastasises in regional limf, nodes; Nx — a state limf, nodes is unknown; N0 — regional limf, nodes on a limfogramma are not changed; Nx — regional limf. nodes on a limfogramma are changed.

M — the remote metastasises; There is no M0 — signs of the remote metastasises; Shg — there are implantation or other metastasises; M1a — metastasises only in a small basin; М^ — metastasises only within an abdominal cavity; M1C — metastasises outside an abdominal cavity and a small pelvis.

G — degree of a differentiation of cells of a tumor: Gx — a tumor of potentially low zlokachestvennost; G2 — a tumor obviously malignant.

Using this classification it is possible to reflect briefly and rather in detail by means of the specified symbols the corresponding stage of tumoral process. E.g., the mobile tumor of one ovary with metastasises in regional limf, nodes and the remote metastasises outside an abdominal cavity and a small pelvis is designated as follows — T1NX+M1C.

Classification of primary ovarian cancer by stages: The I stage — a tumor is limited to ovaries; 1a a stage — the tumor is limited to one ovary, there is no ayetsit (1Y1 — on an outer surface of the capsule there is no tumor, the capsule of an intaktn; 1a2 — the tumor is available on an outer surface of the capsule and (or) the rupture of the capsule is found); 1 *, a stage — the tumor is limited to two ovaries, there is no ascites (1^ — on an outer surface of capsules there is no tumor, capsules of an intaktna; 1 — the tumor is available on an outer surface and (or) the rupture of capsules is found); 1s a stage — a tumor either stages 1a, or stages but with ascites or positive peritoneal washout (at tsitol. a research tumor cells are found ‘); The II stage — one are involved in process or both ovaries with distribution on area of a basin; Pa a stage — metastasises in a uterus and (or) uterine tubes; llj, a stage — distribution on other tissues of a small pelvis; Is a stage — a tumor either stages On, or stages of lib, but with ascites or positive peritoneal washout;

The III stage — in process it is involved one or both ovaries with intraperitoneal and (or) retroperitoneal metastasises, the tumor is limited to a small pelvis with histologically the proved distribution on a small bowel or an epiploon; The IV stage — one are involved in process or both ovaries, are available the remote metastasises, in pleural liquid tumor cells come to light.

In classification of primary ovarian cancer by stages (1971) considersya data not only wedge, inspections of patients and laparotomy, but also results gistol. researches of the material received after operation, and tsitol. researches of ascitic and pleural liquid, and also peritoneal washout.

Already at 1s stages of ovarian cancer at the patient ascites is observed, and at the IV stage — a hydrothorax that is the basis for carrying out a cytologic research of the smears received from ascitic or pleural liquid for the purpose of identification of otsukholevy cells. At

the II stage of distribution of process primary tumor can become slow-moving or motionless that comes to light at vaginal examonation. At the III stage of ovarian cancer the stomach of the patient is quite often increased, blown slightly up, painful at a deep palpation.

Disorders of menstrual function are noted more often at patients with primary endometrioid carcinoma of an ovary that is caused by existence almost at 1/3 such patients of primary adenocarcinoma of an endometria or its expressed atipichesky hyperplasia.

Ovarian cancer in most cases (apprx. 80%) differs in bystry distribution first of all on a peritoneum and in an epiploon (the implantation way of innidiation is more often observed), and also on the next bodies. As a result of lymphogenous and hematogenous innidiation damage of a uterus, uterine tubes, paraortalny, pelvic and others limf, nodes, retroperitoneal cellulose is possible. Very seldom metastasises in a vagina meet. Metastasises in lungs and a liver, and also in other remote bodies for ovarian cancer are not characteristic, and meet generally at sarcomas and malignant germino-gene tumors of ovaries.

Treatment of patients with malignant tumors of ovaries combined: an operative measure with the subsequent radiation therapy (see) and (or) chemotherapy (see Chemotherapy of tumors).

Operative measure at ovarian cancer of I and II stages consists in an extirpation or supravaginal amputation of a uterus with appendages (see the Hysterectomy), removal of available metastasises and a big epiploon. Radical operation should be made in all cases if it is impossible to exclude malignant process; at suspicion of cancer of an ovary it is necessary to resort during operation to an urgent gistol. to a research. The chemotherapy can be begun even during operation by intraperitoneal introduction of antineoplastic means and shall proceed after an operative measure. Use various antineoplastic means (see) — Thiophosphamidum, Cyclophosphanum, ftorura-tsit also some other. At himiorezis-tentny forms of malignant tumors of ovaries the method of treatment by a hyperthermia using bacterial immunostimulators is offered.

Hormonal therapy of malignant tumors, in particular with use of androgenic drugs, can be carried out in combination with other methods of treatment; in some cases hormonal therapy exerts beneficial influence on health of the patient, promotes disappearance of pains. Observations of certain researchers show that in treatment of malignant tumors of ovaries there can be effective gestagena. There are data that the research of receptors of estrogen and progesterone in tumors of ovaries can be used for control of efficiency of hormonal and cytotoxic therapy.

Radiation therapy is applied in various combinations to surgical, medicinal and hormonal methods of treatment. However its use in a crust, time is a little limited in connection with emergence of new antineoplastic drugs. Indications to radiation therapy depend on a stage of a disease and gistol. structures of a tumor. As a component or a stage of complex treatment radiation therapy is preferable at germinogenny and hormonal and dependent forms of tumors, and also in breaks between courses of chemotherapy at ferruterous cancer of an ovary. It is applied in initial stages of a disease after radical operations, at an advanced tumor after not radical operation, and also in cases of a recurrence and metastasises of tumors of ovaries.

Use tele-irradiation on gamma and therapeutic devices (see the Gamma therapy), linear accelerators and betatrons, and also intracavitary radiation by the liquid short-lived radioisotopes (198ai or 90Y) which are seldom closed by linear sources of radiation of cobalt (60so). Remote radiation therapy is carried out taking into account patterns of spread of tumors of ovaries and shall cover all abdominal cavity, including subphrenic departments. For this purpose in a crust, time apply a technique of the displaced fields of a figured form with shielding of a liver. The area of a stomach from a pubic joint to a xiphoidal shoot in front of and from the level XII of a chest vertebra to a sacrococcygeal joint behind is irradiated

with fields of 2 in size — 4 x 20 — 22 cm with daily change of localization of volume of radiation by movement of fields of radiation up and down (a ladder technique). The total, absorbed dose makes 3000 — 4000 is glad (30 — 40 Gr). Consecutive radiation of all abdominal cavity provides, on the one hand, satisfactory effect of radiative effects on a tumor, on the other hand, reduces risk of beam injury of intestines.

One of perspective techniques of radiation therapy at ovarian cancer is use of radioactive gold (Shai) in the form of the colloidal solutions entered into an abdominal cavity. Use of radioactive gold in complex treatment is reasonable as at early stages of a disease for the purpose of prevention of dissimination of a tumor on a peritoneum, and at widespread process for the purpose of delay of accumulation of ascitic liquid.

Radiation therapy is used at single metastasises or a recurrence of tumors of ovaries in a small basin. At the same time with the palliative purpose carry out remote static or mobile radiation. The total absorbed dose makes usually 4000 is glad (40 Gr). At metastasises of a tumor of an ovary the intracavitary gamma therapy by sources of radiation 60so can be carried out to a neck of uterus or a vagina.

The forecast at malignant tumors of ovaries adverse, depends on a stage of distribution of process, volume the remained ambassador of operation of a tumor at II and III stages, gistol. like a malignant tumor. According to literary data,

5-year survival of patients with malignant tumors of ovaries averages at

the I stage — 69,6%, at the II stage — 45,9%, at the III stage — 20%, at

the IV stage — 3,9%.

Seldom found tumors of ovaries. Tumors of various histogenesis concern to this group, to-rye can be high-quality, proliferating and malignant.

Tumors of a stroma of a sexual tyazh consist of cells, to-rye arose from a sexual tyazh of embryonal gonads — granulosa cells, teka-to a letok, kollagenprodutsiruyushchy

cells, Sertoli's cells and cells of Leydiga, and also cells reminding them embryonal predecessors. Distinguish from tumors of a stroma of a sexual tyazh granu - lezo - stromal and cellular tumors (granulocellular, to a gran lezoteka-cellular, to a tekakletochn yu), androblastomas, ginandroblasty and not classified tumors. New growths of this group generally belong to gormonalnoaktivny.

Granulocellular, granulezo-tekakletochny and tekakletochny tumors (see the Tecoma) belong to feminizing estrogenprodutsi-ruyushchy tumors (tsvetn. tab., Art. 464, fig. 24). The tumors containing Sertoli's cells and cells of Leydiga of various degree of a maturity, and in nek-ry cases — indifferent gonadal cells of an embryonal look, belong to androblastomas, or tumors from Sertoli's cells — Leydiga (see the Arrhenoblastoma). The term «arrhenoblastoma» in relation to this group of tumors is widely used and now, especially by clinical physicians. However apply also the term «androblastoma», to-ry emphasizes structural and gistogenetichesky unity of androblastomas of an ovary and a small egg, specifies that the tumor in its various forms repeats separate phases of development of a men's gonad. Though the majority of the considered tumors also is virilizing, nek-ry of them there are inaktivny, and others — feminizing.

Ginandroblastoma, or a tumor of a stroma of a sexual tyazh, treats tumors of the mixed type. The term «ginandroblastom» is entered

by R. Meyer (1930) who described a case of an androblastoma, certain

sites a cut had looking alike a granulocellular tumor. Ginandroblastoma occurs at women of any age. The tumor more often unilateral, rather small size (1,4 — 6 cm in the diameter), is more often than yellow color, sometimes brown or white. Morphologically among sites of the typical high-differentiated granulocellular tumor the tubes covered by the differentiated Sertoli's cells come to light.

Wedge. manifestations of a ginandrob-lastoma are various. At patients the phenomena of virilescence and (or) defenemination are observed. In nek-ry cases the signs indicating only oestrogenic activity of a tumor, napr, the hyperplastic processes of an endometria which are followed by acyclic uterine bleedings are revealed. In separate observations signs of a virilism at patients from ginandrob-lastomy are combined with a gipe-restrogeniya. At young women is after removal of the ovary affected with a tumor (the tumor in all observations described in literature was high-quality), menstrual function can be recovered. Not classified tumors make apprx. 10% of all tumors of a stroma of a sexual tyazh. In 1970 Scully (R. E. Scully) described benign tumors of a sexual tyazh with ring-shaped tubules. In literature 14 such observations are known. These tumors have a solid structure, a soft or dense consistence, sometimes happen bilateral; size varies them from the microscopic size to 17 cm in the diameter. Histologically the tumor often happens multifocal, is characterized by existence of roundish nests of epithelial cells with the plentiful, often vacuolated cytoplasm containing large drops of fat. In nests of epithelial cells acidophilic hyaline little bodies are found. The tumor is observed often at patients with Peytts's syndrome — Egersa (see Peytts — Egersa a syndrome). In a half of the described observations in a wedge, a picture the symptoms caused by Peytts's syndrome — Egersa dominated, in 4 cases from 14 the signs of oestrogenic activity shown by uterine bleedings and a hyperplasia of an endometria at 2 patients are noted irregular bleedings were observed, but changes from an endometria were not revealed. Only at one patient the signs indicating androgenic activity (a hirsutism and an oligomenorrhea) are noted.

The group of lipidokletochny tumors (see) included the tumors consisting of the cellular elements reminding cells of Leydiga, lyu-teinovy cells and cells of bark of an adrenal gland. This group included also tumorous processes, to the Crimea, in particular, the luteoma of pregnancy belongs (nodulyarny those-kalyuteinovaya a hyperplasia of pregnancy — see above).

Germinogennye tumors make one of the most extensive categories of tumors, including undifferentiated forms. Teratomas (see), a dysgermoinoma (see), a tumor of an endodermal sine, poliembriom and an embryonal carcinoma are among tumors of this group (see. Embryonal cancer), a horionepiteliom (see. Trophoblastic disease).

Gonadoblastoma (a gonotsitoma, a dis-genetic gonad, a tumor of dis-tenetichesky gonads, Scully's tumor) is for the first time described in 1953. The tumor meets seldom — more than 100 of its cases are described. At patients 15 years are more senior they meet twice more often. In 33 — 50% of cases of a tonadoblastom it is combined with a dysgermoinoma. Approximately in 10% of cases the combination of gonado-blastomas to other germinogenny tumors is possible (an embryonal carcinoma, Endo's tumor a derma of a lny sine, teratomas, including mature and unripe solid teratomas, including horionepiteliy). Gonadoblastoma consists of two main types of cells: big germinal, similar to cells of a dysgermoinoma (see) or seminomas (see), and smaller, reminding an unripe granuleza and Sertoli's cells. The stroma may contain the cells reminding lyuteinovy and cells of Leydiga. So far the origin and the nature of a gonadob-lastoma are completely not found out.

The sizes of a gonadoblastoma vary from microscopic up to 10 cm and more in the diameter (tsvetn. the tab., Art. 464, fig. 26, 27), bilateral localization is noted approximately in 1/3 all cases. The tumor usually happens rounded shape, has a smooth surface, plotnoelastichesky, soft or very firm consistence more often (at calcification). On a section fabric of a tumor has characteristic gray-pink color, sometimes with sites of yellowish or orange color. At extensive calcification the cut surface has a granular appearance. Macroscopically petrifikata are found approximately in 45%, and at rentgenol. a research — in 20% of cases. In nek-ry observations of a gonadoblastom it is presented only by small focuses in the tumor having character of a dysgermoinoma. In a gonadobla-ostomy mitoses can be found only in formative cells. The cellular nests having a thick basal membrane are delimited by a stroma, in a cut eosinophial cells like lyuteino-vy or cells of Leydiga can be observed.

Approximately in half of observations of a gonadoblastom arises in gonads, the type to-rykh (an ovary or a seed plant) cannot be determined mostly because of full substitution of gonads by a tumor. At Vz of patients of a gonadoblastom arises in a stroke gonads (the gonad is presented connective tissue tya-zhy), and at the others in unripe, atrophic or diyegenetichesky seed plants.

A wedge, manifestations at a gonadobla-ostomy are defined first of all by disturbances in development of gonads. Symptoms depend in a certain measure on the size of a tumor and existence or lack of hormonal activity. The age of patients with a gonadobla-ostomy varies from 6 to 28 years, the majority by the time of establishment of the diagnosis has age of 16 — 25 years. About 85% of all patients of gonadoblastomy have women's фе^ notip. In the absence of manifestations of a virilism external genitals usually have signs of infantility, mammary glands normally or are poorly developed. At persons 15 years, as a rule, are more senior primary amenorrhea is noted; only at a part of patients the secondary amenorrhea or an oligomenorrhea are observed; Shereshevsky's syndrome — Turner (see Turner a syndrome) is found seldom. In some cases, it is preferential at girls, complaints to pains in the bottom of a stomach are noted. The tumor usually comes to light only during operation. At the same time a uterus, as a rule, infantile, an endometria at-rofichen though uterine tubes quite often have a normal appearance. Bilateral development of a gonadoblastoma is found approximately in V3 of patients. At unilateral localization of a tumor the opposite gonad also represents a stroke gonad. Signs of a virilism are found more than in a half of patients gonadoblastomy with a female phenotype. Age of the vast majority of these patients — 15 and more years. Also primary amenorrhea is observed. Mammary glands are usually developed poorly, the tendency to infantility of external genitals and a hypertrophy of a clitoris is noted. At most of patients the hirsutism of various degree is observed (see the Hirsutism). Complaints to abdominal pains are absent, a uterus almost always infantile. The type of gonads, in to-rykh arises a gonadoblastoma, or is not defined, or gonads are presented a stroke gonads, and also unripe seed plants. In case of hemilesion a tumor the opposite gonad usually also has character a stroke gonad.

Patients with gonadoblastomy and a men's phenotype make apprx. 15% of all patients of gonadoblastomy. According to Fox and Langley (N. of Fox, F. A. Langley, 1976), practically at all patients of this group observe anomalies of external genitals. At most of patients the uterus and uterine tubes are underdeveloped. Type of a gonad, in a cut there was a tumor, either is not defined, or represents a stroke gonad or unripe testicular fabric. The opposite gonad, in a cut is not found a tumor, is an unripe seed plant.

Gonadoblastoma usually is considered as a benign tumor. Sometimes gonadoblastoma are regarded as potentially malignant that is shown in mitotic activity and (or) a local invasion of formative cells. At high-quality character of formative cells effective method of treatment is the oncotomy together with a gonad. When morfol. signs of a malignancy of formative cells are undoubted, but formative cells do not extend out of limits of a tumor, it is possible to be limited gonads-ektomiyey since postoperative radiation therapy happens ineffective. In cases of a dysgenesis the opposite, not struck tumor of a gonad bilateral gonads-ektomiya is the most effective method of treatment. Similar approach to treatment is connected with the fact that in a disgenetichesky gonad the microscopic gonadoblastoma can be localized, edges in the subsequent can become a source of a dysgermoinoma and other malignant ger-minogenny tumors. According to

Shellkhas (H. Schellhas, 1974) (removal not only an opposite gonad, but also a uterus) it is necessary to resort to more radical operative measure in connection with risk of development of endometrial cancer after use for the purpose of replacement therapy of estrogen.

At a combination of a gonadoblastoma to a dysgermoinoma the forecast more favorable, than at a dysgermoinoma for lack of a gonadoblastoma; at a combination of a gonadoblastoma and a dysgermoinoma metastasises appear later less often. At a combination of a gonadoblastoma to an embryonal carcinoma, a tumor of an endodermal sine and other germinogenny tumors the term of life of patients, as a rule, does not exceed 18 months after operation.

Except described above, very seldom in ovaries the tumors arising from elements of muscular tissue, circulatory and limf, vessels, etc. meet.

The leiomyoma of an ovary develops usually in one ovary, has diameter from 1 to 24 cm. Small leiomyomas are localized in gate of an ovary. Assume that steroid contraceptives can be the cause of their rapid growth, however convincing proofs of it are absent. The symptomatology of a disease in these cases is defined by existence of a hysteromyoma.

The hemangioma of an ovary of various size is described more than at 20 patients aged from 4 months up to 63 years; more often one ovary is surprised, at 4 patients bilateral localization of a tumor is described. Approximately in 2/3 described cases the hemangioma was asymptomatic. At 4 patients torsion of a tumor, at

3 — ascites was observed.

The lymphangioma of an ovary meets seldom (it is described less than at 10 patients), has unilateral localization, up to 6 cm, rarely more largely. The neurofibroma, a nev-rilemmoma and a ganglioneuroma of an ovary are also found seldom.

Treatment of the tumors included in this group, operational (see below). The volume of an operative measure and the subsequent tactics of treatment, in particular use of antineoplastic means and methods of radiation therapy, are defined by results morfol. researches.

The forecast depends on degree of a maturity of a tumor.

Clinical prevention of tumors of ovaries is based hl. obr. on early detection and treatment of pretumor diseases. The large role in it is played by annual routine maintenances. Women with burdened a gine-stake. the anamnesis (permanent disturbances of menstrual function, anovulation) make risk group: at suspicion of a cyst or a tumor of an ovary they are subject to dispensary observation.

Metastatic tumors of ovaries. Ovaries quite often are a zone of hematogenous, lymphogenous and implantation metastasises of primary cancer of other bodies. Most often in an ovary metastasises of endometrial cancer meet, a breast cancer and bodies went. - kish. path.

Among metastatic tumors of ovaries the greatest value has F. E. Kru-kenberg's tumor. It is described in 1896 by F. E. Kru-kenberg as peculiar primary tumor of an ovary. In 1910 K. P. Ulezko-Stroganova pointed by one of the first to the metastatic nature of this tumor, though did not exclude a possibility of its primary emergence in an ovary. Most of researchers consider that F. E. Kru-kenberg's tumor represents a metastasis in an ovary of a carcinoma of the stomach, intestines, a mammary gland or other body, in Krom development of mucous cancer is possible. However recently again there was a question of a possibility of primary development in an ovary of a tumor of F. E. Kru-kenberg.

F. E. Kru-kenberg's tumor in 70 — 90% of cases happens bilateral and can reach the big sizes. At the small sizes of these tumors the affected ovaries macroscopically sometimes can remind sclerocystic ovaries (see Matte — Leventalya a syndrome). The surface of a tumor quite often hilly, on a section fabric of a tumor can be similar to fibroma! In a tumor the small cavities filled with preferential mucous contents are quite often observed. Characteristic gistol. feature of a tumor of F. E. Kru-kenberg are cricoid cells, cytoplasm to-rykh contains slime. In nek-ry tumors extensive accumulations of slime are found. The tyazh, tubules constructed of tumor cells are less often observed. Difficulties in gistol. to diagnosis arise in the presence in a tumor only of single cricoid cells, to-rye can remain unnoticed at a research gistol. the cuts painted by hematoxylin and eosine especially as a wedge, displays of primary cancer can be absent. Therefore at suspicion of metastatic cancer use of coloring on slime mucicarmine or alcian blue is necessary.

Metastatic tumors of ovaries like F. E. Kru-kenberg's tumor grow quickly and, as a rule, many times over surpass in size primary center of cancer, to-ry clinically (to gistol. researches of remote tumors of an ovary) sometimes remains not distinguished. Symptoms of metastatic cancer are not typical. Only rapid growth of tumors of an ovary, increase in a stomach in connection with the joined ascites and weight in the bottom of a stomach force the patient to see a doctor. Disturbances of menstrual function most often are absent. Despite existence of big bilateral tumors, in the remained tissue of an ovary can be defined as the ripening follicles, and a yellow body. The disturbances of menstrual function which are observed sometimes at patients with F. E. Kru-kenberg's tumor can be caused by its hormonal activity connected with existence in a tumor of the luteinized stromal cells. Oestrogenic influences are clinically characterized by uterine bleedings, a hyperplasia of an endometria, androgenic — a hirsutism, increase in a clitoris, etc. Klin, manifestations can be caused focal stromal or a chyle - but - a cellular hyperplasia of not struck tissue of ovaries. At young women generative function can be kept. In literature several observations when in the presence of F. E. Kru-kenberg's tumor at pregnant women signs of a giperandrogeniya were noted are described.

At differential diagnosis it is necessary to consider that metastatic tumors of an ovary are more mobile, than primary cancer of this body. For an exception of metastatic nature of a tumor of an ovary before operation conduct examination of bodies, tumors to-rykh a thicket give metastasises in ovaries. For this purpose first of all carry out X-ray inspection of bodies went. - kish. path and mammary gland.

Treatment of patients with metastatic tumors of ovaries represents a difficult task as a radical operative measure on primary tumoral node and metastasises does not provide removal of all elements of a tumor. However in separate observations after radical removal of primary tumor and metastatic tumoral nodes (F. E. Kru-kenberg's tumors) the long-term favorable effect is noted.

Operations

Distinguish radical operations (an ovariektomiya — removal of all ovary) and saving (a resection of an ovary, enucleation of his tumor, an ovariotomy — a section of tissue of ovary). Preoperative preparation same, as well as at any band operation (see. Preoperative period). If

an operative measure is carried out at the pregnant woman, then it is necessary to take measures to preservation of pregnancy: before operation and after

it the patient enter progesterone or its analogs, Methacinum, beta hell of Renault-mimetiki (Partusistenum, Ritodrinum), inhibitors of calcium, vitamin E, sedative drugs. Quick accesses — preferential longitudinal lower midsection (see the Laparotomy) and are more rare cross section (see Pfapnenshtil a section). Vulval access at ovary operations is inexpedient since it does not allow to be guided adequately in an abdominal cavity and to expand if necessary the volume of operation. The last is established after opening of an abdominal cavity, definition of nature of a tumor and its relationship with surrounding bodies. The affected ovary is removed in an operational wound, without breaking integrity of the capsule of a tumor. Sometimes for the purpose of simplification of removal from an abdominal cavity big patol. educations punktirut it previously. After an otgranicheniye napkins from an abdominal cavity (for the prevention of accidental hit of contents in it patol. educations) by means of a trocar, on to-ry the rubber tube for removal of liquid is got, puncture a wall patol. educations also produce liquid before necessary reduction of its sizes. After fall of walls of a cyst or a cystoma on an opening impose a Kocher's forceps or a fenestrated forceps and patol. education is brought out of an abdominal cavity. At suspicion of a malignant tumor of an ovary, commissural process in a small basin or an intraligamentarny arrangement of a tumor it is not necessary to punktirovat it. If practically all ovary is involved in patol. process, make an ovariektomiya. At partial damage of an ovary and confidence in high quality of process enucleation of a tumor or a resection of an ovary is admissible. The overwound leg of a cystoma is not untwisted since in these cases there is a danger of a thromboembolism. Clips impose on a leg of a cystoma below the place of torsion. On a wide leg of a cystoma impose clips and tie up it step by step. Peritonization of a stump of a leg of a tumor is made at the expense of a round ligament of a uterus or leaves of a wide ligament. The remote tumor is opened (out of a surgery field), examine its contents and an inner surface, out urgent gistol. research. When results of the conducted research testify to a zlokachestvennost of process, continue operation — delete a uterus with appendages and an adjacent part of a big epiploon. In the presence of a benign tumor examine appendages of the opposite side and in case of need carry out a biopsy of the second ovary, whenever possible keeping it as the functioning body.

Saving ovary operations aim at the maximum preservation of its fabric. To their number treat enucleation of a benign tumor within healthy fabric without disturbance of the capsule of a tumor and a wedge-shaped resection of an ovary, at a cut also within healthy fabric excise patholologically the changed site of an ovary with recovery of its integrity the resolving suture material (see. Suture material).

Postoperative leaving does not differ from standard after abdominal organs operations (see. Postoperative period).

Change of ovarian fabric is shown at treatment of ovarian insufficiency and a postkastratsionny syndrome in cases of inefficiency of conservative therapy and intolerance of hormonal drugs. Contraindications: in

fektsionny, inflammatory diseases and tumors of any localization. Material for transplantation (see) get from the donor during an operative measure concerning a benign tumor of a uterus, napr, myomas. In these cases ovaries, as a rule, are kistozno changed in this connection their resection within healthy fabric is made, cover pieces and serve as material for free change (without preservation of vascular bonds). Transplantation is made in hypodermic cellulose, a direct muscle of a stomach, preperitoneal cellulose, to-rye rich with blood vessels. This method does not allow to gain long-term clinical effect in connection with graft rejection (see Immunity transplant). For the purpose of suppression of the immune conflict at change of ovarian fabric use immunodepressants (see. Immunodepressive substances). Use of biological semipermeable diffusion chambers is effective, in to-rykh food of a transplant (see) it is carried out due to diffusion of nutrients and metabolites from intercellular lymphs of an organism of the recipient through the semipermeable membrane shrouding donor tissue of an ovary. Immunekompetentny cells (see) the recipient do not get in the diffusion chamber that substantially weakens reaction of graft rejection and increases duration of its functioning. At the same time hormones from a transplant arrive to the recipient. In 1971 — 1972 tissue transfer of an ovary is developed and applied in clinic to treatment of severe forms of ovarian insufficiency, at a cut as the diffusion chamber the amniotiche-ky cover is used.

Bibliogrbabichev V. N. Neurohormonal regulation of an ovarian cycle, M., 1984; Baksheevn. Page and B and to sh it in and A. A. Cancer therapy of ovaries, Kiev, 1969, bibliogr.; Blokhinn. N. Sostoyaniye and perspectives of development of oncology, Vestn. USSR Academy of Medical Sciences, No. 12, page 17, 1982; Bochkov N. P. Genetics of the person, M., 1978; Volkova O. V. Functional morphology of female reproductive system, M., 1983; Glazunov M. F. Tumors of ovaries, L., 1961, bibliogr.; Golovin D. I. Atlas of tumors of the person, L., 1975; Demidkin P. N. and Shnirelmana. I. Radiodiagnosis in obstetrics and gynecology, M., 1980; Diagnosis and medical tactics at early forms of malignant tumors of ovaries, under the editorship of V. I. Chissov, etc., M., 1984; Zheleznov B. I. Controversial and not clear issues of terminology, morphology, diagnosis and treatment of sclerocystic ovaries, Akush. and ginek., No. 2, page 10, 1982; Zheleznov B. I. and Strizhakova. H. Genital endometriosis, M., 1985; Clinical oncology, under the editorship of H. N. Blochina and B. E. Peterson, t. 2, page 490, M., 1979; Kovalyova E. A. Change of tinned tissue of ovary at insufficient function of ovaries, in book: Recovery hir., under the editorship of P. P. Kovalenko, page 237, Rostov N / D., 1967; Krayevskaya. S. Rak of an ovary, M., 1978; The Multivolume guide to pathological anatomy, under the editorship of A. I. Strukov, t. 7, page 462, 574, M., 1964; Nechayeva I. D. Tumors of ovaries, JI., 1966, bibliogr.; it, Treatment of tumors of ovaries, L., 1972,

bibliogr.; Pathoanatomical diagnosis of tumors of the person, under the editorship of N. A. Krayevsky, etc., M., 1982;

Rosen V. B. Fundamentals of endocrinology, M., 1984; The Guide to clinical endocrinology, under the editorship of V. G. Baranov, L., 1977; Savitsky G. A. Surgical treatment of congenital anomalies of sexual development, M., 1975; Seleznyova N. D. izheleznovb. I. Benign tumors of ovaries, M., 1982, bibliogr.; S. F sirs. iskaldir. E. Histologic classification of tumors of ovaries, M., 1977; Travin A. A. and Andreyev I. D. To a question of change of an ovary on an arteriovenous leg, Akush. and ginek., No. 7, page 69, 1971; Fanchenko N. D. Modern ideas of the mechanism of effect of steroid hormones, in the same place, No. 1, page 6, 1978; Endoscopy in gynecology, under the editorship of G. M. Savelyeva, M., 1983; Epidemiology of cancer in the USSR and the USA, under the editorship of H. N. Blochin and M. A. Schneiderman, M., 1979; Anteby S. Lake, Yosef S. M of a. S with h e n k e of J. G. Ovarian cancer, Arch. Gynec., v. 234, p. 137, 1983; Classification and staging of malignant tumors in the female pelvis, Acta obstet, gynec. scand., v. 50, p. 1, 1971; Fox H. Langley F. A. Tumours of the ovary, L., 1976; Gestational trophoblastic diseases, Wld Hlth Org. techn. Rep. Ser. No. 692 1983; Gompel C. Silverberg S. G. Pathology in gynecology and obstetrics, Philadelphia — Toronto, 1977; Gynecologic endocrinology, ed. by J. R. Givens, Chicago — L.#1977; Janovski N. A. a. Paramanandhan T. L. Ovarian tumors, Stuttgart, 1973;

Judd H. L. and. lake of Origin of serum estradiol in postmenopausal women, Obstet, and Gynec., v. 59, p. 680, 1982; K an u p p i 1 an A. o. Clinical significance of estrogen and progestin receptors in ovarian cancer, ibid., v. 61, p. 320, 1983; Novak E. R. a. W o-odruff J. D. Novak’s gynecologic and obstetric pathology with clinical and endocrine relations, Philadelphia, 1979; Ovarian follicular development and function, ed. by A. R. Midgley a. W. A. Sadler, N. Y., 1979; Parsons L. Sommers S. C. Gynecology, Philadelphia a. o., 1978; Pathology of the female genital tract, ed. by A. Biaustein, N. Y. a. o., 1982; Schindler A. E. Endocrine und morphologische Veranderungen wahrend Pubertat und Adole-szenz, Gynakologie, Bd 16, S. 2, 1983; S e i d 1 S. Praktische Karzinom-Fruhdi-agnostik in der Gynakologie, Stuttgart, 1974; WillcocksD. o. Estrogen and progesterone receptors in human ovarian tumors, Gynec. Oncol., v. 16, p. 246, 1983; Yen S. S. a. J a f f e R. B. Reproductive endocrinology, Philadelphia, 1978. See also bibliogr. to St. Infertility, Dysfunctional uterine bleedings, Climacteric, Uterus, Uterine tubes, Menstrual cycle, Ovulation.

K. R. Avetisova (physical.), V. I. Alipov (pathology, methods issl., operations), O. V. Volkova (An., gist., embr.), I. M. Gryaznova, L. V. Balios (change of ovarian fabric), B. I. Zheleznoye (stalemate., An., PMC., the author of color slides), K. N. Kostromina (I am glad.).,

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