UTERUS

From Big Medical Encyclopedia

UTERUS [uterus (PNA, JNA, BNA)] — the genital muscular hollow body located in a cavity of a small pelvis of the woman.

EMBRYOLOGY

Fig. 1 — 3. Microdrugs of a uterus of a fruit at different stages of development (cross section): fig. 1. Second month: laying of a uterus (1) from paramezonefralny channels; mezonefralny channels (2) — material of future kidneys; they are surrounded by a mesenchyma (3); fig. 2. End of the third month: formation of an epithelial vystilka of a uterus (1) and a differentiation of a surrounding mesenchyma (2) in connecting fabric and muscular elements; fig. 3. Eighth month: the mucous membrane is expressed (1), all layers of a muscular coat are created (2); the arrow specified a gleam of a uterus. Coloring hematoxylin-eosine. Fig. 4. Microdrug of a uterus of the newborn (cross section): 1 — a mucous membrane; 2 — a muscular coat; 3 — a serous cover; the arrow specified a gleam of a uterus. Coloring hematoxylin-eosine. Fig. 5. Microdrug of a uterine tube is normal: a habit view of various departments of a pipe (1) on cross section (at various levels); in a gleam of a pipe branchy folds (2) of a mucous membrane are visible. Coloring hematoxylin-eosine

Emergence of rudiments of generative organs is preceded by development of the urinary bodies exerting the directing impact on differentiation of a reproductive system. At a germ pronephrouses (pronephros) which are completely disappearing within a week, primary kidneys (mesonephros), or volfova of a body which are also exposed to a reduction consistently develop, but a part of their structures is transformed to compound components of a reproductive system, constant, or final, kidneys (metanephros). From these three embryonal educations primary kidneys reaching the maximum development by the end of the 2nd month have a direct bearing on rudiments of generative organs. Primary kidneys are located on both sides of a backbone in the form of large formations of oblong shape. Gyrose tubules of primary kidney open to the canal of a mesonephros (volf the channel; mezonefralny channel, T.), which falls into a foul place. From primary kidney in the sexual device of the adult woman rudimentary educations remain: an appendage of an ovary (epoophoron), an okololichnik (paroophoron), the gartnerovsky course — a rudiment of the channel of a mesonephros.

The first laying of gonads occurs at a germ 5 — 6 mm long in the form of pectineal thickenings (rollers) on an inner surface of primary kidney. They consist of a coelomic epithelium and a mesenchyma, then primary sex cells (gonocytes) which get from an extraembryonic entoderm here are added. Clear differences between male and female gonads appear at a germ 17 mm long.

In parallel with laying of gonads the so-called paramezonefralny (myullerova) channels originally inherent to both floors are put. Paramezonefralny channels reach full development in germs of a female, at men's germs they are exposed to involution, remaining in the form of rudiments. From paramezonefralny channels at female embryos uterine tubes, a uterus develop (tsvetn. tab. of fig. 1) and upper third of a vagina.

Formation of paramezonefralny channels happens at germs 8 — 9 mm long. Rudiments of these channels appear at invagination of a coelomic epithelium in a mesenchyma of cranial department of primary kidney at the height of I chest vertebra. In the form of continuous epithelial tyazhy channels pass near channels of primary kidney and grow in the caudal direction, going down to a basin along mezonefralny channels, and are located together with them in the general urinogenital fold (see. Urinogenital system ).

At germs of 6 weeks the coelomic epithelium of paramezonefralny channels is replaced with lozhnomnogoryadny. Paramezonefralny channels in the course of further growth at the level of the lower ends of primary kidneys pass to the centerline, being located horizontally knutr from kidneys. Paramezonefralny channels of the opposite sides adjoin and densely adjoin to each other, without merging; at the same time they accept the vertical direction. On the 8th week of a partition between paramezonefralny channels resolve, and they merge. At first merge happens in the field of the middle of a sexual tyazh (area of future neck of M.), and then in its ends, in the field of future bottom of M. and a vagina. Final merge of paramezonefralny channels is observed on the 9th week (a germ 35 — 50 mm long); their caudal ends, having reached an urinogenital sine, stick out a dorsal wall of a sine and on 12 — 16th week break through it. Cranial departments of paramezonefralny channels remain separate, they form future uterine tubes. Before merge in paramezonefralny channels the gleam is formed, they turn into tubes (the uterovaginal channel). To the 14th week in the uterovaginal channel it is possible to distinguish an upper part (future body of M.), average (M.'s neck) and lower (vagina). Final isolation (division) into M., pipes and vagina happens to 20 — 24th week of life of a fruit. The border between a body and M.'s neck is designated by an excess of the channel; the neck is implanted into an upper piece of a vagina, forming a vulval part of a neck

of M. V the embryonal period M.'s cavity is covered with a low cylindrical epithelium (tsvetn. the tab. of fig. 2) which in process of fetation becomes high, especially in a neck of M. Glands in the form of tubules are for the first time differentiated in a neck (a fruit of 18 weeks). To the 28th week initial signs of secretion of an epithelium of glands of an endometria and an endotserviks appear.

Muscular elements M. develop from a surrounding mesenchyma during 12 — 16 weeks of embryonal life; the layer of a myometrium forms to the 28th week of pre-natal development. In the beginning it is preferential tsirkulyarno the located cells. Formation of layers of a muscular coat comes to the end to the 32nd week of the embryonal period (tsvetn. fig. 3).

ANATOMY

Fig. 1. Uterus, uterine tubes, ovaries. Back view. The right half of a uterus, uterine tube and ovary are opened: 1 — a neck of uterus; 2 — a round ligament of a uterus; 3 — an ovary; 4 — a funnel of a uterine tube; 5 — an ampoule of a uterine tube; 6 — an isthmus of a uterine tube; 7 — an uterine fundus; 8 — a perimetrium; 9 — a myometrium; 10 — an endometria; 11 — a cavity of the uterus; 12 — an isthmus of a uterus; 13 — the channel of a neck of uterus; 14 — an ostium of the uterus; 15 — a vagina; 16 — a wide ligament of a uterus; 17 — own ligament of an ovary; 18 — a uterine artery.

The m has the pear-shaped form flattened in the perednezadny direction, it is turned by the narrow end into an upper part of a vagina. In M. distinguish vesical and intestinal surfaces, right and left - side edges (margines uteri dext, et sin.), from which wide uterine sheaves depart. In these sheaves there pass uterine tubes and ovaries lie (tsvetn. fig. 1). Anatomically in M. distinguish a bottom (fundus uteri), a body (corpus uteri), a neck (cervix uteri) and a cavity (cavum uteri).

A bottom is called upper part M. (dome), places of an otkhozhdeniye are higher uterine tubes (see). The body has triangular shape, being narrowed to an isthmus. Uterine tubes depart from M.'s edges in an upper part, also kpered from them — round teams of M. are lower (ligg. teretes uteri) and at the same height of a kzada — own ligaments of ovaries (ligg. ovarii propria).

The neck is continuation of a body of M. and makes its bottom; it has two departments: a vulval part (portio vaginalis cervicis) which is going down in a cavity of a vagina (makes apprx. 1/3 necks), and a supravaginal part (portio supravaginalis cervicis) lying above the place of an attachment of the vulval arches. Distinguish still a middle part of a neck (pars media) — between the place of an attachment of front and back vaults of the vagina. The place of transition of a cavity of M. to the channel of a neck of M. is narrowed and carries the name of an isthmus M. (isthmus uteri). The isthmus represents an upper part of a neck, but the microscopic structure of his mucous membrane reminds a structure of a mucous membrane of a body of M.

Fig. 1. Diagrammatic representation of a vulval part of a neck of uterus: at not giving birth woman (at the left) the ostium of the uterus has the cross and oval form and smooth edges; at the giving birth woman (on the right) — a form of a cross crack and the begun to live anguishes at the edges.

M.'s neck at girls and girls has conical shape, at the adult woman, especially at giving birth — a cylindrical form. In the lower end of a neck there is M.'s (ostium uteri) opening opening in a vagina. At M.'s opening which were not giving birth to women has the cross and oval form, at giving birth — a form of a cross crack, as a rule, with the begun to live anguishes at the edges (fig. 1). M.'s opening is limited to front, shorter lip, and back, thinner and long.

Fig. 2. The diagrammatic representation of a frontal section of a uterus of the giving birth woman: a cavity of the uterus of triangular shape, uterine openings of pipes (1), below — the channel of a neck of uterus are above visible (2).

The channel of a neck of M. (canalis cervicis uteri) is expanded in a middle part; above it passes into a little narrowed course — an isthmus M. through which the neck is reported with a cavity of M. The isthmus M. is located at the level of noticeable outside of narrowing between a neck and bodied M. Polost M. of the giving birth woman on a frontal section has triangular shape (fig. 2). In upper corners of this triangle there is about one opening opening in uterine tubes (ostium uterinum tubae) in a bottom corner — the isthmus M. conducting in a cavity of the channel of a neck of M.

The sizes M. at the puberal woman are various. M.'s length at not giving birth women of 7 — 8 cm, at giving birth — 8 — 9,5 cm, width (in the field of a bottom, at the level of an otkhozhdeniye of uterine tubes) 4 — 5,5 cm. M.'s body is occupied on average by 2/3 total lengths of M., a neck — 1/3. The greatest thickness of walls is 1 — 2,5 cm. Nonpregnant M.'s weight fluctuates within 30 — 100 g. Out of pregnancy length of a cavity of M. (at measurement by the probe) from a bottom to M.'s opening at not giving birth women makes 7 cm, at giving birth — 8 cm from which 2,5 cm are the share of a neck. The volume of a uterine cavity at not giving birth women of 1 — 3 cm3, at giving birth — 3 — 5 cm3; the cavity contains a small amount of the secret allocated by glands of a mucous membrane of M.

The suspending device M. — sacrouterine, wide uterine and round ligaments, a rectouterine muscle. Kresttsovomatochny sheaves, or retractors (ligg. uterosacralia) — the steam rooms covered with a peritoneum of education, beginning from a back surface of a neck at the place of its transition to M.'s body and going to a rectum and a sacrum. Sheaves clearly act in the thickness of the pryamokishechnomatochny folds containing also rectouterine muscle, edges consists of dense connecting fabric and a large number of bunches of unstriated muscles. Attracting M.'s neck back and holding it in a back half ring of a basin, retractors promote an inclination of a body of M. forward, raising it up a little. At artificial procrastination of M. from top to bottom sheaves strain, showing a nek-swarm resistance. At a tension of sheaves a vulval part of a neck of M. is taken away kzad, a bottom — kpered. At the time of delivery retractors hold M. on site, slowing down reduction of its muscle fibers at the end of the period of disclosure.

Wide uterine sheaves (ligg. lata uteri) — two leaves of a peritoneum (dublikatur) which are located on M.'s parties go in transverse direction from its edges to a sidewall of a basin (tsvetn. fig. 1). A part of wide sheaves, adjacent to M.'s parties, is called M.'s (mesometrium) mesentery. In the basis of wide sheaves fascial thickenings in the form of accumulation of powerful connective tissue, preferential elastic fibers and a small amount of bunches of unstriated muscles are put. This part of sheaves is called cardinal sheaves (ligg. cardinalia). In wide sheaves among cellulose there pass vessels, nerves, uterine tubes, appendages of ovaries lie. At the emptied bladder wide sheaves hold almost horizontal position, and their front surface is directed down, back — up. For M.'s fixing in typical situation cardinal sheaves have a certain value. However because of the small amount of cells of unstriated muscles which is their part they easily stretch and cannot resist a long time, e.g., to action of the increased intra belly pressure.

Round sheaves — pair flat educations 10 — 12 cm long — depart from M.'s corners of a kpereda from uterine tubes, go forward, lateralno and up to an internal opening of the inguinal channel. Passing this channel, they pass through its outside opening, being lost in cellulose of a pubis and big vulvar lips. Take place in round sheaves an artery of a round team of M. (and. lig. teretis uteri), a vein and limf, the vessels collecting a lymph from M.'s bottom and also nerves (of genitalis — a branch of n. genitofemoralis). Except connective tissue fibers, vessels and nerves, round sheaves contain the bunches of unstriated muscles which are continuation of an outside muscular layer of M. Round sheaves at childbirth at the end of the period of disclosure of a neck brake retraction of muscle fibers M.

The fixing, fixing device represents system of the so-called zones of consolidation making a basis (skeleton) of sheaves and being in close connection with fastion of a basin and adventitious vaginas of pelvic bodies. Are a part of the fixing device: the forefront of a fibromuscular plate representing a skeleton of vesicouterine sheaves (ligg. vesicouterina), and dense tyazh as a part of lonnopuzyrny sheaves (ligg. pubovesicalia); median zone (pars media) — the most powerful part of a zone of consolidation which is a basis of cardinal sheaves; a connective tissue skeleton of sacrouterine sheaves — the tail (pars post.) the fixing device M. The zones of consolidation tense like a hammock in the field of an isthmus M. cover in front a bladder, in the center — M. and behind — a rectum. They represent anatomic education, a cut along with the supporting device fixes normal typical situation M.

The supporting, basic device M. plays the main role in maintenance of situation M. and other bodies of small basin (see). Muscles of a pelvic bottom, front abdominal wall and diaphragm function jointly, causing increase in intra belly pressure, napr, at defecation, attempts. A certain impact on normal situation M. is exerted by M.'s tone, a condition of abdominal organs. So, the form and situation M. can change normal, and then revert to the original state at overflow of a bladder and rectum, at changes of intra belly pressure, during pregnancy, and also depending on position of a body.

Blood supply. Veins M. form extensive vascular network, edges clearly comes to light by method of arteriography.

M.'s blood supply comes generally from two sources: from a uterine artery (a. uterina) and an ovarian artery (a. ovarica); in addition to these main vessels, M.'s bottom is fed by the arteries of round sheaves which are branches of the lower epigastriß artery (a. epigastrica inf.). The uterine artery departs from an internal ileal artery (a. iliaca interna). Going down in retroperitoneal cellulose on a sidewall of a basin, quite often following together with an ureter (is deeper than it), a uterine artery here, having changed the direction to horizontal, goes in the basis of a wide linking of M. At distance of 1 — 3 cm from M.'s neck it forms decussation with an ureter, being located on its front surface. At the level of an isthmus M. the uterine artery branches on the descending branches of the first order sharing then on a branch of the second and third order; all branches are distributed in the thickness of a neck of M. After a branching on the descending branches the main trunk of a uterine artery proceeds in the ascending direction (along M.'s edge); here horizontal branches in vesical and intestinal walls of M depart from a uterine artery.

In the field of the corner formed by a pipe and M.'s edge, the ascending branch of a uterine artery (ramus ascendes) is divided into two, sometimes three branches from which one goes to M.'s bottom, another — in a mesentery of an ovary. The ascending branch of a uterine artery at the giving birth women shtoporoobrazno of an izvit, at not giving birth — has an appearance of the arc-shaped line.

Long parametralny arteries depart from the ascending department of a uterine artery (aa. parametrales), and also an artery in wide sheaves. These vessels form krupnopetlisty networks that matters for collateral circulation of M. and appendages.

With age development of a muscular coat of M. the number of vessels in it increases, especially during pregnancy, by an old age — gradually decreases.

The ovarian artery (a. ovarica) originates from a ventral aorta (more often a. ovarica dext.) or from a renal artery (a. ovarica sin is more often.). Ovarian arteries go along an inner edge of a big lumbar muscle down (t. psoas major), crossing on the way with ureters (in front). Having gone down in a small pelvis, ovarian arteries reach top of a wide team of M. and proceed in the thickness of a voronko-pelvic sheaf (lig. infundibulopel vicum) in the direction M. where anastomose with trailer branchings of uterine arteries. At the person the anastomosis between uterine and ovarian arteries in most cases is located in the basis of gate of an ovary.

A venous blood from M. is taken away on veins which near its edges form the powerful texture surrounding a uterine artery and its branches — a venous uterine texture (plexus venosus uterinus). From here outflow of a venous blood goes in three directions: from M.'s bottom on an ovarian vein (v. ovarica); from the lower half of a body of M. and an upper part of a neck on a uterine vein (v. uterina) joining an internal ileal vein (v. iliaca int.); from the bottom of a neck and a vagina — on veins which connect to a uterine vein and partly fall independently into an internal ileal vein. The venous uterine texture anastomoses with veins of a bladder and a pryamokishechny veniplex (plexus venosus rectalis), being as if the center combining all veniplexes of a small pelvis.

Fig. 3. The diagrammatic representation of absorbent vessels and nodes of internal generative organs of the woman (a part of a rectum is removed, the uterus with uterine tubes and ovaries is turned away forward and down): 1,2 — lumbar lymph nodes; 3 — the general ileal lymph nodes; 4 — sacral lymph nodes; 5 — outside and internal ileal lymph nodes; 6 — a deep pakhovy lymph node.

Lymph drainage. Limf, M.'s vessels form rich network. Conditionally everything limf, M.'s vessels, uterine tubes and ovaries it is possible to divide on inside - and Extra organ. Intraorganic limf, vessels pass into system extra organ and, collecting a lymph from various departments of M., uterine tubes and ovaries, go to regional limf, nodes (fig. 3).

imf, the vessels which are taking away a lymph from M.'s neck and also from two upper thirds of a vagina, go in the basis of wide sheaves, joining in internal and the general ileal limf, nodes (nodi lymphatici iliaci int. et iliaci communes), partly in a back pryamokishechnye limf, nodes (nodi lymphatici anorectales). Limf, vessels of a body of M., uterine tubes and ovaries go in an upper part of wide sheaves, taking away a lymph in lumbar and sacral nodes (nodi lymphatici lumbales et sacrales); the lymph from M.'s bottom is taken away on the course of round sheaves in inguinal nodes (nodi lymphatici inguinales). Outflow of a lymph comes from M.'s wall separately: from limf, vessels of an endometria, myometrium and from limf, vessels of a perimetrium.

Innervation. M. is innervated by sympathetic and parasympathetic parts of century of N of page. Sympathetic nerves go to M. from the lower hypogastric (pelvic) texture — plexus hypogastricus inf. (plexus pelvicus) and from a celiac (solar) texture — plexus celiacus (solaris). There is an anatomic communication between celiac and pelvic neuroplexes therefore irradiation of irritations, coming from generative organs, passes through a celiac texture. At patol, processes it can cause a so-called solar syndrome (see. Solar plexitis ).

The parasympathetic innervation in pelvic area is carried out by splanchnic pelvic nerves (nn. splanchnici pelvini). In the place of crossing of the splanchnic pelvic nerves getting through sacral openings almost in the horizontal direction with the lower hypogastric texture going in the vertical direction the lower hypogastric texture, or the pelvic texture which is the main source of an innervation of generative organs is formed. It is located on the parties from M. in cellulose of wide sheaves, in parametralny, paravaginal and a pararectal fat, reaching vaults of the vagina. The pelvic texture is subdivided into the following textures: uterine vulval (plexus utero vaginalis), vesical (plexus vesicales) and pryamokishechny (plexus rectales). Through a pelvic texture there pass fibers of a sexual nerve (n. pudendus) which are traced towards M. V formation of a pelvic texture nerve fibrils of nodes of a sympathetic trunk (sacral department) take part.

Age changes

Fig. 4. Diagrammatic representation of a frontal section of a uterus: 1 — the newborn; 2 — the adult woman.

By the time of M.'s birth has length apprx. 4 cm, at the same time her body is twice shorter than a massive neck (fig. 4,1). Soon after the birth, apparently due to the lack of hormones of a placenta, in M. there is a bystry involution and length it at chest age makes 2,5 cm. The strengthened M.'s growth, especially her bodies, begins aged after 7 — 8 years. With approach of puberty M.'s body is extended, its walls are thickened, outlines are rounded, and the body gradually gets a form and the sizes M. of the adult woman (fig. 4,2).

In a climacteric and in a menopause there are involute changes of M. which essence comes down to processes of an atrophy and development of connecting fabric. As a result of these changes of M. decreases in the volume and weight, there comes the atrophy of her mucous membrane — glands are shortened, their gleam is narrowed, the ferruterous epithelium sharply is flattened, atrophies. Senile involution of a mucous membrane of M. is followed by wrinkling of a stroma and a sclerosis of walls of blood vessels.

Topography

Fig. 2. Sagittal section of a female basin: 1 — an urethra; 2 — a vagina; 3 — a pubic symphysis; 4 — a bladder; 5 — vesicouterine deepening; 6 — a uterine tube; 7 — an ovary; 8 — a uterus; 9 — rectouterine deepening; 10 — a rectum; 11 — an anus; 12 — an entrance of the vagina.

M it is located as if in the geometrical center of a basin, is slightly closer to a lobby, than to back, its wall, between a bladder and a rectum, it is fixed in a neck to vaults of the vagina below an isthmus M. (tsvetn. fig. 2). With a bladder the vesical surface of M. (facies vesicalis), borders on a rectum — an intestinal surface (facies intestinalis). A vulval part of a neck of M. and M.'s opening (an outside pharynx) are located at height of the spinal plane (a narrow part of a pelvic cavity), the isthmus M. — is slightly lower than the plane of a wide part of a cavity of a small pelvis. M.'s body is located between two planes — the plane, the corresponding wide part of a pelvic cavity, and the plane of an entrance to a basin, without reaching at the same time the level of an ambit (linea terminalis). In relation to a sacrum M.'s bottom is usually not higher than IV sacral vertebras. At this level M. is kept by generally suspending device (sheaf) fixing or fixing, the device (retinaculum uteri), and also the basic and supporting device.

At an empty bladder M.'s bottom is directed forward, and its vesical surface is turned forward and down; such inclination of M. is called «anteversio». M.'s body is at an angle in relation to a neck. If the corner is open kpered, then situation M. is called «anteflexio» if the corner is turned kzad — «retroflexio». The m has mobility: during the filling of a bladder it can deviate kzad, at a palpation it is possible to displace it kpered, to a pubic symphysis, kzad — to a sacrum, in the parties — almost to sidewalls of a basin, up — 4 — 5 cm higher than a pubis, from top to bottom (at pulling up by means of the tool) — on 2,5 cm, at giving birth M. women can be displaced even more.

Fig. 5. A sagittal cut of a basin of the woman, the course of a peritoneum in a small basin: the peritoneum (it is allocated with the fat line) covers a front abdominal wall (1), goes down in a small pelvis where it covers a bladder (2) behind; at the level of an isthmus of a uterus passes to a uterus, forming vesicouterine deepening (3), covers a bottom and a back surface of a body of the womb, an upper part of a neck, a back vault of the vagina and passes to a rectum, forming rectouterine deepening — duglas a pocket (4).

The peritoneum covers a front abdominal wall, goes down in a small pelvis (fig. 5), covers a top of a bladder and its back surface. From a bladder the peritoneum passes to M. at the level of its isthmus, forming small vesicouterine deepening (excavatio vesicouterina) limited lateralno to slightly noticeable folds (plicae vesicouterinae). The peritoneum is attached to a vesical surface of M. in a lower part rykhlo, in upper — is more dense. It is especially closely connected to a muscular coat in the field of M. Mesto's bottom of a dense attachment of a peritoneum to a vesical wall of M. it is considered the upper bound of an isthmus M. Bryushina covers an intestinal body surface of M., an upper part of a neck (1 — 2 cm), a back vault of the vagina, then passes to a rectum, forming deep direct enterouterine deepening — duglas a pocket (excavatio rectouterina), limited from sides to the arc-shaped rectouterine folds (plicae rectouterinae) in the thickness of which bunches of unstriated muscles are located (mm. rectouterini) — rectouterine muscles. The bottom of rectouterine deepening is below these folds on 3 — 4 cm. Under normal conditions loops of guts can get to rectouterine deepening.

The peritoneum covering M. performs barrier function, contains much limf, vessels and nerve terminations.

The HISTOLOGY

M.'s Wall consists of three layers: mucous membrane (endometria), muscular coat (myometrium), serous cover (perimetrium).

Mucous membrane (endometrium s. tunica mucosa) covers M. Tolshchina's cavity it to 1 mm (varies depending on a phase of a menstrual cycle). The mucous membrane smooth, has no folds and a submucosa, directly connects to a muscular coat. It consists of a cover single-layer cylindrical epithelium and a stroma of an endometria with glands put in it. The cover epithelium of a mucous membrane of M. contains secretory and ciliary cells; the number of that and others varies depending on a phase of a menstrual cycle: in a secretory phase and during pregnancy the quantity of ciliary cells sharply decreases or they disappear absolutely.

The stroma of an endometria consists of network of connective tissue fibers among which are round with a big kernel and a small rim of cytoplasm of a cell, the reminding lymphoid. Except them, depending on a phase of a menstrual cycle, in a stroma of an endometria cells at different stages of turning into light, so-called decidual cells meet. Glands of a mucous membrane of a body of M. — simple tubular, branching depending on a phase of a menstrual cycle. They allocate a small amount of a liquid secret with alkali reaction. The mucous membrane of M. periodically, according to phases of a menstrual cycle, changes a structure and outward. Cyclic changes happen hl. obr. in funkts, the layer which is tearing away in the period of menstrual bleeding. The basal layer of a mucous membrane which is directly contacting to a myometrium remains and is a source of regeneration of an endometria in a new menstrual cycle.

The mucous membrane of an isthmus on a structure is similar to a mucous membrane of a body of M.: it is rich with connective tissue cells, contains a small amount of straight lines, not branching glands. The mucous membrane of an isthmus undergoes unsharply expressed cyclic changes during a menstrual cycle with education funkts, the layer which is tearing away during periods.

In M.'s neck a mucous membrane more massivn, than in M.'s cavity, its thickness apprx. 2 — 3 mm. On front and back walls of a neck it has palmlike folds (plicae palmatae); all complex of folds carries the name of «a tree of life» (arbor vitae). Cyclic changes, similar to a mucous membrane of M., this cover does not undergo.

The epithelium of a mucous membrane of a neck of M. is presented by high cylindrical cells with basally the located kernels; on stained preparations in cells cilia clearly are visible. The stroma of a mucous membrane of a neck of M. more rough, than in M.'s body, contains more elastic fibers giving it plasticity and elasticity. Glands of a mucous membrane of a neck of M. gyrose, allocate a secret in the form of the dense, viscous vitreous slime possessing alkali reaction. This secret fills the channel of a neck of M. and forms a so-called stopper of Kristeller, edge as mechanically, and thanks to the bactericidal properties, interferes with penetration into M.'s neck of microbes.

A muscular coat (tunica muscularis, s. myometrium) — the average, most powerful layer of a uterine wall formed by a texture of bunches of unstriated muscles and vessels.

M.'s muscles according to the course of muscle bundles and development of vessels are subdivided into three layers: outside subserous (stratum subserosum), preferential longitudinal, average — circular or vascular (stratum vasculosum) and internal submucosal (stratum suimucosum), consisting of longitudinal and circular bunches of muscles. Bunches of a muscular coat of uterine tubes and muscle bundles of sheaves by M. V to a neck M. are interwoven into a periblast of a myometrium the muscular coat is less developed, contains more connective tissue elements, elastic fibers. About M.'s opening and an isthmus, and also in the field of uterine openings of pipes muscle cells are located tsirkulyarno and form similarity of sphincters.

Between layers of a myometrium there are anatomic transitions, thanking the Crimea all muscular layers of M. are reduced as a uniform muscle.

On a submicroscopic structure muscle cells of a myometrium are divided into two types. One of them — the dark cells rich with organellas and pinotsitozny bubbles; such structure is inherent to the cells which are in a condition of active reduction. Others — light cells, are poorer in organellas and pinotsitozny bubbles probably are at rest. During the preimplantation period the sizes of muscle cells increase, the quantity of mitochondrions, myofilaments and other organellas increases in them.

The serous cover of M. consists of a thin coat of connecting fabric and covering it mesothelium (see).

The thinnest branches of a uterine artery go on the course of muscle bundles and pass into system of capillaries. The numerous vessels which are distributed in the peritoneum covering M depart from a surface layer of a muscular coat. From deep layers arterial vessels go to a mucous membrane of M., breaking up here to networks of capillaries.

The Limfokapillyarny network of a mucous membrane of M. consists of the single-layer superficial network lying under subepithelial network of circulatory capillaries and venules and deep limf, the capillary network located between groups of uterine glands. The form and the sizes of loops limf, capillaries depend from funkts, conditions of a mucous membrane

of M. Set limf, capillaries of a muscular coat is located between muscle bundles, surrounds blood vessels; the network limf, capillaries of a serous cover is located in deep layers of a connective tissue basis of a perimetrium.

Nervous cells of nodes of a pelvic texture directly adjoin a muscular coat of a neck of M., they can be found also in surface layers of a myometrium. Nerve fibrils of a pelvic texture get into thickness of a muscular coat of M., reaching a mucous membrane. In this texture adrenergic and cholinergic neurons, funkts which activity changes during a menstrual cycle accurately are defined. In M.'s wall nerve fibrils form so-called secondary textures which represent network of the nervous stipitates lying both on a body surface of M. and in the thickness of its wall.

PHYSIOLOGY

the Main functions M. are menstrual and genital. Menstrual function arises usually in 11 — 16 years and continues up to 45 — 50 years (see. Menstrual cycle ), being replaced menopause (see). Genital function M. is inherent to reproductive age of the woman and is characterized by growth and fetation during 40 weeks with the subsequent its birth (see. Childbirth ). Though M. is not a hemaden, it represents a target organ for hormonal influences and body which through effector nerve pathways participates in implementation of influence of hormones on activity of all organism of the woman. The cyclic processes which are made in M. and an organism of the woman are caused by natural fluctuations of level of sex hormones and changes of the humoral environment of an organism. M.'s receptors — an initial link of its afferentation: the impulses going from M.'s receptors can influence a condition of the highest nerve centers. Funkts, dynamics of receptors of M. of a labiln, frequency of their changes is synchronous to changes in an ovary. Rhythms of cyclic changes in M. are regulated by interaction of c. N of page, pituitary and hypothalamic system and hormones of ovaries.

Menstrual function is provided with cyclic changes of a mucous membrane of M. that is a necessary condition of preparation of M. for perception and development of an oospore. If fertilization of the ripened ovum did not happen, there are bloody allocations from a genital tract of the woman as a result of rejection of an endometria. In case of fertilization the ovum makes a way through a uterine tube, comes to M.'s cavity where as a result of previous fiziol, changes of a mucous membrane there are favorable conditions for implantation and further development of an ovum (see. Pregnancy ).

Generative (genital) function M. is provided anatomo-fiziol. the shifts happening in an organism of the woman in general and in M. in particular under influence as the oospore, and as a result funkts, changes in activity of c. N of page and peripheral nervous, endocrine systems and blood circulatory system.

Generative function M. develops of four main components: M.'s preparation for perception and implantation of fetal egg; creations of optimal conditions for its growth and development after implantation; protection of fetal egg against premature sokratitelny activity of M.; the births of a fruit and elements of fetal egg upon termination of fiziol, duration of gestation.

The mucous membrane of M. turns at pregnancy into a thick and juicy deciduous cover (see. Decidua ). Cells of a tight coat of a deciduous cover are rich with a glycogen and have phagocytal properties; at the first stages of pregnancy they provide food of a germ.

Of a deciduous cover it is formed placenta (see), two-piece — uterine and fetal. Since the 12th week of pregnancy the placenta provides a metabolism of the developing fruit.

The m as powerful muscular body resides in a condition of a tone. At a low general tone before there is a reduction, M.'s walls shall come to a condition of tension; at the raised M.'s tone the slightest irritation causes reduction of her muscles, and reduction of a body of M. is followed by disclosure of her neck.

Sokratitelny activity of M. is observed at pregnancy, sexual intercourse, and also in the presence of submucosal nodes of myoma, polyps of an endometria, etc. In development of pregnancy in process of M.'s stretching some fluctuations of its tone which usually are not followed by considerable reductions of muscles of M. Schitayetsya normal gradual increase in a tone are possible, a cut becomes considerable only shortly before childbirth.

Mechanisms of motor function of a uterus are finally not studied. Complex researches of ultrastructure of a myometrium during pregnancy and childbirth, and also them gistofiziol., gistokhy, and biochemical, features show that ability to synchronous reductions is property of a myometrium, a cut it is closely connected with intensity of fabric exchange in myometriums, the level of contents in it of a glycogen and makroergichesky phosphates, with activity of myofibrils, etc.

Sokratitelnuyu function M. provide proteins of myofibrils, at the same time the main sokratitelny substance is compound of actin and a myosin — actomyosin (see. Muscular tissue, biochemistry ; Muscular contraction ). Myofibrils contain readily soluble proteins (fraction T), the Crimea tonic function is inherent. Proteins of a sarcoplasm of muscle cells have enzymatic properties and provide metabolism of a myometrium. Squirrels of a stroma (generally collagen) provide tensile strength and do not take active part in sokratitelny function M.

Reduction in unstriated muscles of the lower segment M. happens thanks to twisting of spirals of sokratitelny substrate; sokratitelny protein participates also in lengthening of myofibrils, a cut occurs thanks to expansion of peptide chains. Reduction of a myometrium is caused by activation of muscular sokratitelny proteins and carrying out excitement on system of cellular membranes. The most important property of smooth muscle cells of M. is their ability to spontaneous sokratitelny activity and to automatic development of impulses for periodic reductions that is connected with relationship acetylcholine (see), catecholamines (see) and other endogenous biologically active agents.

Ability of a separate cell of a myometrium to generation of spontaneous excitation waves, according to R. S. Orlov (1971), allows to consider that rhythmic automatic reductions of M. — a consequence of simultaneous excitement of many cells. Synchronization of electric activity of separate cellular elements is connected with features of a structure of a myometrium and carrying out excitement in it. The membrane potential created due to different ion concentrations of sodium, potassium and chlorine on both sides of a cellular membrane — the most important regulatory mechanism of electric and mechanical activity of cells of a myometrium. An electric flow, extending on muscle fiber, releases energy of ATP, edges a part — on recovery of a charge of a cellular membrane and start-up potassium sodium pompe is generally spent for reduction of muscle fiber, and. Process of recovery of membrane potential matches relaxation of a muscle. Along with sodium potential in myometriums generation of calcic action potential is possible. It is considered that the leading role in the course of excitement in smooth muscle cells belongs to calcium ions. The size of membrane potential is changeable and depends on a phase of a menstrual cycle or duration of gestation, hormonal influences, balance of ions, activity of mediators, etc.

The electric phenomena arising in a smooth muscle cell serve as the mechanism of start of its sokratitelny system. This mechanism is put in a cell membrane and depends on its membrane potential. Owing to instability of membrane potential and its periodic vibrations there are spontaneous automatic reductions of cells of a myometrium. Rhythmical automatic reductions of all M. are result of simultaneous excitement of many cellular units on condition of carrying out this excitement through all thickness of a muscle. All cells of a myometrium are capable to generate action potentials. Group of cells, in a cut under certain conditions there are local prepotentsiala, is considered to be a source of spontaneous automatic impulses — a pacemaker. According to most of researchers, the primary source of excitement (pacemaker) is the group of cells of ring muscles of a bottom of M. located near places of an attachment of uterine tubes, most often on the right. From here impulses extend consistently to all departments of M.

Conditions of rest and M.'s excitement are connected with activity of its interoceptive system (thermo - baro-, chemo - and mechanioreceptors). The important part is assigned at the same time to M.'s chemoceptors, especially to through what work such biol, stimulators as acetylcholine, catecholamines, serotonin and a histamine.

Elektrobiol. processes in myometriums are regulated by c. N of page, sex and other hormones. In preservation of muscular rest of M. at pregnancy the condition of neurodynamic ratios between various departments of c is of great importance. N of page.

According to a number of authors, excitability of a cerebral cortex usually decreases to 12 — 16 weeks of pregnancy and especially in 10 — 12 days prior to childbirth. It is established what at a hyperexcitability of a brain, edges is combined with the lowered excitability of a spinal cord, relative rest of the neuromuscular device M. and its relative inertness are observed; at the same time sokratitelny ability of M. is difficult excitable. At the lowered excitability of a brain (cortical braking) increase in reflex irritability of a spinal cord, including reflex irritability of M., its neuromuscular device is observed; there is a readiness for sokratitelny activity of M.

At the heart of emergence and development of patrimonial activity reflex activity of receptors of M lies. In the course of childbirth there is an irritation of all receptors of M. and in process of involvement in process of new receptor zones force and frequency of uterine reductions changes.

During childbirth strengthening of reflex vegetative reactions and emergence of qualitatively new reflexes is noted. Character and degree of manifestation of reflex reactions in many respects depend on impact on a nervous system of various hormonal factors, and also on a tone sympathetic (adrenergic) and parasympathetic (cholinergic) parts of century of N of page. Noradrenalin (see) and adrenaline (see) can cause depolarization of cells of a myometrium, increase of categories of action potentials and M.'s reduction and, on the contrary, to relax M., oppressing her activity and hyper polarizing membranes of cells. A Nek-ry role in transfer of adrenergic impulses is played by the predecessor of noradrenaline dopamine. Effects of catecholamines are explained by their action on α-and β-adrenoceptors;;;;;;;;;; at excitement of α-adrenoceptors M.'s reduction is observed, at excitement of β-adrenoceptors — — braking of reductions of M.

The means influencing adrenergic processes are subdivided into adrenomimetik, adrenolytic drugs, adrenoblockers and the blocking syntheses of an adrenergic mediator or its allocation. A. P. Nikolaev (1939 — 1951) researches,

L. S. Persianinova (1948 — 1952), etc. is shown a big role acetylcholine (see), and consequently, and holinoretseptor in regulation of sokratitelny activity of M.

At physiologically proceeding childbirth influence of acetylcholine causes reductions of uterine muscles, and destruction of acetylcholine cholinesterase is followed by gradual falling of a wave of reduction; the following reduction of M. arises under the influence of a new portion of acetylcholine. At disturbance of the mechanism of timely rhythmic destruction of acetylcholine the effect of excitement of the neuromuscular device is replaced by a depressor effect — M.'s reductions weaken or stop. Disturbance of synthesis and emission of acetylcholine in a synaptic gap, and also high activity of cholinesterase can lead to decrease in sokratitelny activity

M. Atsetilkholin interacts with other humoral substances strengthening his exciting action on motor function M. and creating a background of its readiness for childbirth. Action of acetylcholine and noradrenaline exerting tonotropny impact on M. is summed up. Both of these mediators, as well as nervous structures in which there is their synthesis in funkts, the relation are uniform and define a condition of motor function M.

In emergence and development of patrimonial activity high sensitivity of M. to various humoral substances is of great importance. In myometriums, in addition to alpha and beta adrenoceptors, serotonino-, m-holino-and gistaminoretseptor, the mediator and hormonal receptors interacting with estrogen are revealed. Sensitivity of receptors of M. depends on a hormonal background, generally on a ratio estrogen (see) and progesterone (see). Estrogen plays an undoubted role in increase in excitability of M. and so-called maturing of her neck by the beginning of childbirth. They cause strengthening in M. of synthesis of actomyosin, accumulation of a glycogen and phosphoric connections, and also proteins of fermental fraction, influence the cellular potential (reducing rest potential), increase accumulation of calcium ions, stimulate α-adrenoceptors.......... Estrogen increases ATF-aznuyu activity of actomyosin and its sensitivity to calcium ions, oppresses effect of the enzymes destroying oxytocin and serotonin which possess specific tonomotorny action on a myometrium. It is established that oestradiol provides maturing of a neck of M. by the beginning of childbirth and increases its sensitivity to oxytocin.

Progesterone suppresses action potentials of cells of a myometrium. In emergence of patrimonial activity the large role is played by a ratio of estrogen and progesterone: the progesterone - an estrogenic index is lower, the readiness of an organism of the woman for childbirth is higher.

In regulation of motor function M. along with hormones a certain role belongs to serotonin (see), to kinina (see), to enzymes, intermediary substances through which system hormones influence bioelectric and plastic processes in myometriums. The important central neurohumoral regulator of sokratitelny activity of M. is oxytocin (see), action to-rogo depends on a hormonal background, first of all on the level of estrogen and progesterone, and also from funkts, M.'s conditions, including also existence of spontaneous activity. Oxytocin — synergist of acetylcholine. These substances, mutually strengthening sokratitelny effect, play an important role in the course of a childbed. Action of oxytocin stimulating reduction of all departments of M. is most expressed in process of the developed childbirth and it is important for their end and prevention of puerperal bleedings.

The great value in development of patrimonial activity is attached to prostaglandins of the E and F group. Prostaglandins (see) find at the time of delivery in a blood plasma, a deciduous cover and an amniotic fluid. So, F2α prostaglandin causes the stimulating effect at full simultaneous blocking alfa-adreno-, m-holino-and M. Pokazano's gistaminoretseptor that synthesis of F2α prostaglandin happens generally in a uterine part of a placenta; strengthening of its synthesis is caused by increase in concentration of estrogen. It is characteristic that E and F prostaglandins stimulate reductions of a myometrium in upper parts of M., and the myometrium of the lower segment remains rather insensitive to them.

In approach of a childbed and regulation of sokratitelny activity of M. the great value is attached fiziol, system a fruit — a placenta. Hormones of a fruit and placenta come to current of maternal blood, exerting a great influence on sokratitelny activity of M. Produktom of system a fruit — the placenta is estriol (see), synthesis to-rogo is carried out in a placenta from a degidroepiandrosteron, a 16-oksidegidroepiandrosteron arriving from adrenal glands of a fruit. Estriol is of great importance in the course of so-called maturing of a neck of M. and preparation of soft patrimonial ways to childbirth.

The complex of the neuroendocrinal changes happening in an organism of pregnant women by the time of childbirth carries the name of a patrimonial dominant. The act of childbirth proceeds in the presence of the created patrimonial dominant. In formation of a patrimonial dominant interaction of sex hormones and various formations of the central and peripheral nervous systems is of great importance. The important role for emergence of patrimonial activity and its correct regulation is played by preparation of an organism of the woman for childbirth, readiness of a neck of M. and its lower segment, and also sensitivity for influence of kontraktilny substances.

See also Menstrual cycle , Childbirth .

METHODS of the RESEARCH

Depending on a research objective and M.'s condition apply an obstetric or gynecologic research. In addition to the anamnesis and the general a wedge, methods of a research (blood, urine, etc.), in obstetric practice special methods apply: outside and internal and vulval researches, definition of a form, the sizes of a basin, size of a fruit, etc. (see. Obstetric research ). According to special indications in some cases apply rentgenol, methods of a research by which it is possible to define the provision of a fruit, feature of a structure of a basin, existence of polycarpous pregnancy.

At various diseases and anatomofunkts. deviations apply gynecologic research (see), a cut includes the anamnesis, an objective research, at indications — uterine probing (see), a scraping of a mucous membrane of M. (see. Scraping ), aspiration of contents of a cavity of M., biopsy (see), kolposkopiya (see), Kuldoskopiya (see. Peritoneoskopiya ), cytologic research (see). For definition funkts, conditions of a uterus and ovaries use tests funkts, diagnoses (see. Menstrual cycle ).

Rentgenol, a research M. widely apply to determination of her size, a form, situation, existence of malformations and tumors, a foreign body, concrements. Are for this purpose offered pelvigrafiya (see), a gisterografiya, a gisterosalpingografiya (see. Metrosalpingografiya ), ginekografiya (see), urography (see). According to indications use limfografiya (see), intrauterine flebografiya, the selection angiography. Apply ultrasound to differential diagnosis of various tumors of M. (see. Ultrasonic diagnosis ).

The radio isotope research by means of radionuclide of phosphorus-32 sometimes is applied to diagnosis of tumors of M. In 2, 24, 48 hours after administration of radionuclide conduct a research the band SMB-13 counter which is brought to M.'s neck, enter into the canal of a neck and into a cavity of M. Increase in extent of accumulation of radionuclide more than for 100 — 150% in comparison with norm can demonstrate tumoral process. Diagnosis of metastasises of tumors of M. in inguinal, pelvic and lumbar limf, nodes can be carried out by means of an indirect radio isotope limfografiya with the subsequent scanning (see) and takhografiya (see). On accumulation of radionuclide and speed of its advance draw the conclusion about changes in limf, nodes (see. Radio isotope diagnosis ).

The PATHOLOGICAL ANATOMY

Proteinaceous, carbohydrate, fatty and mineral dystrophy of M. not always happens display of pathology. These types of dystrophy can reflect structural funkts. features of an endometria and a myometrium, a vulval part and a mucous membrane of the channel of a neck of M. in the different age periods, throughout a menstrual cycle, during pregnancy, childbirth, the puerperal and lactic periods. The deviations defined histochemical in exchange of RNA, proteins, carbohydrates and lipids reveal at disturbance of sokratitelny activity of M., napr, at an atony.

Hyaline dystrophy of an endometria and myometrium develops sometimes owing to a metroendometritis.

Disturbances krovo-and M.'s lymphokineses arise at periods, an endometritis, tumors, the wrong situation and M.'s loss, and also at dekompensirovanny heart diseases. At the same time owing to plentiful blood supply of M. necrotic changes in it develop seldom. During the bandaging of uterine arteries usually there comes the atrophy and a sclerosis endo-and a myometrium. Focal fusion of walls of M., up to perforation, can arise at a putrefactive metroendometritis, as a result of, e.g., criminal abortion. At the same time the distribution of inflammatory process from a placenta in depth of a myometrium which is followed by thrombosis and a thromboangitis of vessels is histologically observed. The extensive centers of a necrosis find out at morfol, a research of the large, especially quickly growing nodes of myoma of M. that, apparently, it is connected with their insufficient blood supply. Extensive hemorrhages in an endometria and a gematometr arise at premature department and presentation of an afterbirth, and also at a number of diseases (e.g., flu, dysentery, a leukosis) and poisonings (e.g., phosphorus, arsenic, etc.).

M.'s twisting, and also stenoses and atresia of an isthmus M can lead to formation of a gematometra.

The pyometra (accumulation in M.'s cavity suppurating) develops at a delay of allocations, napr, at endometrial cancer, myoma of a neck of M., etc. In these cases of M. can have an appearance of the thin-walled bag filled with purulent exudate in number of 200 — 400 ml and more. Microscopically at the same time the endometria is usually completely replaced with the granulyatsionny fabric rich with leukocytes, in the thickness of a myometrium perivascular infiltration is noted, muscle fibers are exposed to an atrophy.

Owing to a rupture of walls, and also at disintegration of tumors of M. there are cervical and vulval, belly and uterine and other fistulas. Microscopically walls of such fistulas are formed by fibrous fabric, and an inner surface — the granulyatsionny fabric rich with leukocytes, plasmatic and lymphoid cells, sometimes with impurity of colossal cells of foreign bodys.

The inflammatory process limited to a mucous membrane of a body of M. is called an endometritis. Upon transition of an inflammation to a myometrium as it sometimes happens, e.g., at a puerperal endometritis, arises metroendometritis (see). Microscopically at a purulent endometritis find a fibrinoid necrosis and leukocytic infiltration of a mucous membrane and the remains of placental fabric from which in the subsequent forms placental polyp (see). The endometritis which is not connected with the puerperal and postabortion periods arises owing to a disease of gonorrhea more often.

Fig. 6. Microdrug of a mucous membrane of a uterus at a chronic endometritis: accumulations lymphoid and plasmocytes (1) and iron of an endometria are visible (2).

By means of microscopic examination at hron, an endometritis observe focal and diffusion infiltration of an endometria preferential lymphoid and plasmocytes (fig. 6), and also focal sclerous changes of its stroma.

The inflammation of a mucous membrane of the channel of a neck M. (endocervicitis) can also be acute and chronic. At the same time the epidermization of a cover epithelium and glands of a neck of M. resulting from an indirect metaplasia of proliferating basal cells is quite often observed. Distribution hron, inflammations from an endotserviks on ektotserviks (see. Cervicitis ) conducts to desquamation of a multilayer flat epithelium and education erosion of a neck of uterus (see).

Fig. 7. Microdrug of a mucous membrane of the channel of a neck of uterus at a tubercular endocervicitis: the tubercular granuloma (1), huge multinucleate cells of Langkhans (2) and gland of an endotserviks are visible (3).

M.'s tuberculosis is usually combined with tubercular damage of uterine tubes, is more rare than ovaries and bodies of an urinary system. Tubercular granulomas at the same time find preferential in an endometria, also myometriums are more rare in an endotserviks (fig. 7). Microscopically tubercular hillocks most often correspond to a productive form of an inflammation, are constructed preferential of epithelial cells with impurity of the colossal cells of Langkhans limiting a zone of a caseous necrosis. The mucous membrane of M. at a tubercular endometritis looks atrofichny, as a rule without signs cyclic funkts, changes.

Primary syphilis of a neck of M. is shown in the form of the ulcer defect having signs of primary affect (see. Affect primary ). At morfol, a research M. in the tertiary period of syphilis gummas of a neck of M. and an endometria can be found.

At M.'s actinomycosis in it at gistol, a research find the centers of granulyatsionny fabric, sometimes with availability of druses of actinomycetes and abscesses with formation of fistulas.

At morfol, a research of an echinococcosis of M. are defined various size of a cyst which walls have a chitinous cover and are surrounded with the infiltrates containing eosinophilic granulocytes and colossal cells of foreign bodys (see. Echinococcosis ).

The trichomoniasis in morfol, the relation is shown by nonspecific changes, is more often in the form of a cervicitis.

By means of microscopic examination at a schistosomatosis in an endometria, endo-and an ektotserviksa find eggs of parasites Schistosoma haematobium, s. Mansorii. In the beginning around eggs note leukocytic infiltration, to-ruyu in the subsequent productive inflammatory reaction with formation of a shistosomatozny granuloma replaces.

Fiziol, the hypertrophy and a hyperplasia of an endometria and myometrium arise at pregnancy, M.'s atrophy — in time lactations (see) and during the period menopauses (see), owing to an inflammation, hron, poisonings, castration and other factors. At an atrophy of an endometria there is no differentiation on funkts, and basal layers, its thinning and collagenization is found. At anovulatory cycles, after long hormonal therapy and the postponed endometritis the mucous membrane of a body of M. on certain sites can become thinner owing to what becomes uneven, in places in it fibrous structures begin to prevail; such mucous membrane is called dysplastic.

Among hyperplastic processes of an endometria distinguish polyps, ferruterous, ferruterous and cystous, basal and atipichesky a hyperplasia. Rare option of a ferruterous and ferruterous and cystous hyperplasia is the stromal hyperplasia of an endometria, for a cut large, quite often polymorphic kernels of stromal cells are characteristic. At a basal hyperplasia there is a thickening of a basal layer of an endometria due to proliferation of glands located in a compact layer.

Atipichesky hyperplasia (synonym: diffusion adenomatosis, an adenomatous hyperplasia) funkts, and basal layers differs from other types of a hyperplasia of an endometria in restructuring and more intensive proliferation of glands. The unsharp form of an atipichesky hyperplasia of an endometria is characterized by availability of small and larger glands which unlike other types of giperplaziya on various sites are separated from each other by rather thin layers of a stroma. A cylindrical epithelium quite often multirow, with a tendency to increase in volume of a cell and formation of the papillopodobny outgrowths sent to gleams of glands. At the expressed form of an atipichesky hyperplasia the multirow ferruterous epithelium differs a nek-eye in polymorphism. Gleams of glands narrow and seldom happen kistozno expanded. Glands are sometimes located so closely to each other that the stroma between them is practically absent. In large kernels of a ferruterous epithelium quite often find small kernels. As a result of intensive proliferation, and also a close arrangement of small glands the epithelium gains sometimes as if multilayer character that can cause suspicion on a malignancy.

Polyps of an endometria arise more often from a giperplazirovanny basal layer of a mucous membrane. At women of childbearing age polyps of an endometria usually have a ferruterous structure. Glands in them can sometimes be unevenly or are kistozno expanded with the flattened epithelium that reminds a picture of a ferruterous and cystous hyperplasia. Idiosyncrasy of a structure of polyps are the sclerosed blood vessels which are located in the form of balls preferential at the basis and in a leg of a polyp. At intensive proliferation of glands and their epithelium polyps of an endometria call adenomatous. Sometimes the glandular polyp is covered with a functional layer which participates in cyclic changes, reflecting all phases of a menstrual cycle and being torn away during periods. In glandular polyps disturbances of blood circulation, hemorrhage, necrotic and inflammatory changes can be observed. Some polyps differ markedly the expressed vascularization (telangiectatic polyps). At advanced age fibrous polyps which usually represent a regressive form of a glandular polyp can meet occasionally. The stroma of a fibrous polyp is collagenized, glands in it are not enough or they are absent.

In a mucous membrane of isthmic part M. there can be a polyp having the mixed endocervical and endometrial type of a structure.

Glandular polyps of a mucous membrane of the channel of a neck of M. have the different size and the form, a soft consistence; in them quite often observe the inflammatory phenomena and an epidermization, and during pregnancy — decidual reaction. The polyp rich with ferruterous fabric with a proliferating epithelium, meets seldom; exclusively seldom also the single fibrous polyps (deprived of glands) on a vulval part of a neck of M meet.

Fig. 8. Microdrug of a mucous membrane of a uterus at an atipichesky hyperplasia of an endometria: shooters specified planocellular small knots.

Focal proliferata of ferruterous fabric (focal adenomatosis) observe in an endometria at a ferruterous, zhelezistokistozny, basal hyperplasia and in polyps of an endometria. At an atipichesky hyperplasia, in an adenomatous polyp and at focal adenomatosis so-called planocellular small knots (fig. 8) arising from the basal cells located under an epithelium, and in some observations — accumulations in a stroma of large cells can meet the light cytoplasm containing lipids.

The hyperplasia of a mucous membrane of the channel of a neck of M. is shown by its thickening, sometimes with availability of the expanded glands which are closely located kistozno more often covered by the flattened and cubic epithelium. In a mucous membrane of the channel of a neck of M. also change-types of a so-called microferruterous hyperplasia meet, edges it is characterized by availability of the small glands covered by the flattened or cubic epithelium, sometimes with signs of a moderate atipizm. These glands contain slime, in cells of a ferruterous epithelium find subnuclear vacuoles. The microferruterous hyperplasia of an endotserviks arises usually at reception of steroid hormones.

Fig. 9. Microdrug of an epithelium of a neck of uterus at the expressed dysplasia: over a proliferating epithelium (1) with signs of a cellular atipizm the layer of the low-changed epithelium is visible (2); shooters specified figures of division of epithelial cells.

In some cases at gistol, a research in a cover epithelium of an ektotserviks, in sites of a planocellular metaplasia of an erosion and an endotserviks, in a leukoplakia observe the so-called dysplasia which is characterized by various extent of proliferation of epithelial cells. Depending on distribution of proliferation on a smaller or deep water of epithelial layer and degree of an atipizm of cells (at the same time over a giperplazirovanny layer of the changed cells there is almost always a layer of the low-changed epithelium) distinguish unsharp (easy) and expressed (heavy) forms of a dysplasia. At an unsharp form of a dysplasia the proliferating epithelium of cells basal and parabasal type occupies about a half of thickness of epithelial layer. Existence patol, changes (a proliferating epithelium with signs of an atipizm) in the most part of thickness of epithelial layer indicates the expressed form of a dysplasia (fig. 9), to a cut it is accepted to refer also changes only of a deep layer of an epithelium with its sharp polymorphism and a large number patol, mitoses.

Pathological anatomy of tumors of M. — see the section «Tumours».

See also Myoma , Cancer , Sarcoma .

PATHOLOGY

Malformations

Distinguish anatomic defects of M. and an arrest of development of correctly created M. K to anatomic defects refer total absence of M. or existence of its rudiments, M. Pochti's doubling all malformations of M. and a vagina are caused by disturbance of merge of paramezonefralny channels. Depending on on what site there was no merge of the right and left channel, there is this or that malformation.

Developing of malformations of M., according to most of authors, can be connected with disturbance of its embryogenesis as a result of the unfavorable conditions influencing a fruit, and also an organism of the girl during puberty.

At it is long the current toxicosis of pregnancy, cardiovascular pathology at mother, immunoconflict pregnancy, infectious and toxic diseases, use pharmakol, means during pregnancy disturbance of the course of ontogenesis is possible, and as a result of it there can be malformations of M. of a fruit. The great value in their emergence is attached to alcoholism of parents. One of the important reasons of an underdevelopment of M. — the decrease in level of estrogen in blood of mother and a fruit caused by hormonal disturbances in system a hypothalamus — a hypophysis — ovaries that is quite often observed at somatic and obstetric pathology at mother. Results of a large number of researches indicate dependence of a number of malformations, disturbances of a sexual differentiation and delay of sexual development from chromosomal and genovariations.

Fig. 10. The diagrammatic representation of a vagina, uterus and appendages of a uterus at some anatomic malformations of a uterus (a frontal section), the cavity of the uterus and vaginas is shown by black color: 1 — a normal uterus; 2 — a saddle uterus; 3 — a two-horned uterus; 4 — a two-horned uterus with two necks; 5 — a two-horned uterus with unequally developed horns; 6 — doubling of a uterus and vagina; 7 — a two-horned uterus with an atrezirovanny right horn, with preservation of his cavity; 8 — a two-horned uterus with an atrezirovanny left horn; 9 — a full atresia of a uterus and vagina.

Malformations of M. are various (fig. 10). Total absence of M. (aplasia uteri) arises under the influence of the reasons influencing during early pre-natal development when paramezonefralny channels are only put. M.'s aplasia usually during puberty due to the lack of periods comes to light. At M.'s aplasia at the adult woman at a vaginal and rectal research M. is not defined or on site M. is palpated a small cylindrical form tyazh.

M.'s doubling arises at not merge of normally developed paramezonefralny channels. At the same time two isolated M. are formed, each of which, as a rule, unites to the corresponding part of the doubled vagina (uterus didelphys). At the same malformation of M. and a vagina (uterus duplex, vagina duplex) both vaginas and M.'s necks can be spliced. This pathology can have options: one of vaginas can be closed and in it menstrual blood (hematocolpos) accumulates; one of M. can not have messages with a vagina and in it menstrual blood (gematometra) accumulates. Additional malformations of the doubled M. can be observed: asymmetric development of M., total or partial absence of a cavity in one or two M., and also an inborn atresia of the channel of a neck of M. (see. Gynatresia ).

In a rudimentary horn of M. with a cavity in the period of puberty menstrual blood can collect, in rare instances in it there comes implantation of an oospore. At M.'s doubling it can represent two rudimentary the cavities divided or merged horns, not having. Two-horned M. can have one neck (uterus bicornis unicollis) and if paramezonefralny channels did not merge in the field of future M. and a neck, then two-horned M. with a double neck (uterus bicornis bicollis) is formed. M.'s half can be asymmetrical; at merge of horns of M. at its bottom saddle M. (uterus introrsum arcuatus simplex) is formed, M. can also have an appearance of an anvil (uterus incudiformis).

If paramezonefralny channels merged only partially, then in two M. the general cavity is formed, at this M. it is externally not changed, but her cavity is divided entirely or partially by a partition (uterus septus duplex). The partition can remain in M.'s (uterus subseptus) body or in M.'s (uterus biforis) neck. At satisfactory development of one horn of M. and sharply expressed rudimentary condition of another the M is formed odnorogy.

In the presence of two correctly developed M. in each of them cyclic changes can be made, in everyone there can occur the pregnancy which is coming to the end with normal childbirth. However at M.'s doubling the myometrium is usually developed insufficiently, childbirth can be complicated by weakness of patrimonial activity, in an afterbirth and puerperal period there can be bleedings; childbirth quite often comes to an end with an operative measure; misbirths and premature births are often observed.

At implantation of an oospore in a rudimentary horn there can come its gap, especially if existence of pregnancy is timely not established.

The arrest of development of correctly created uterus and the changes connected with it arising in the post-natal period usually have character of a hypoplasia. Disturbances of the regulating function of a hypothalamus or sharply expressed decrease in hormonal function of ovaries can be its cause at hyper gonadotropic activity of a hypophysis. M.'s hypoplasia is often connected with the general underdevelopment, however sexual infantility can be shown separately. Depending on length of a cavity of M. distinguish three degrees of its underdevelopment: germinal M. — length is up to 3 cm, infantile M. — length is 3 — 5,5 cm, M. of the teenager — length 5,5 — i of cm (see. Infantility ).

At funkts, insufficiency of ovaries post-natal development of M. does not happen or is made by incompleteness, M. remains at children's M.'s stage with an excessive bend of a kpereda (an excessive antefleksiya) and a conic neck. The wrong provisions of hypoplastic M. (small M., but the correct form) arise because of weakness of its copular device. M.'s underdevelopment quite often is followed by existence of long gyrose uterine tubes and is often combined with frustration of a menstrual cycle on type of a hypomenstrual molimina that usually leads to infertility. Weak resistance to contagiums, injuries is noted; at approach of pregnancy often there are misbirths and premature births. With approach of puberty and under the influence of treatment in some cases perhaps dorazvity hypoplastic M.

At malformations of M. spontaneous ruptures of a rudimentary horn of a uterus with intra belly bleeding can be observed. Blood at a gematosalpingsa quite often happens infected therefore at its gap there is a danger of development peritonitis (see). At establishment of the diagnosis of a malformation of M. it is necessary to consider also a possibility of malformations of an urinary system.

M.'s infantility is diagnosed in the period of puberty in the presence funkts, disturbances (delay monthly, pains in sacral area, morbidity at the sexual intercourses, infertility, etc.).

Rentgenol, a picture at malformations of M., as a rule, allows to make the correct diagnosis. The incomplete partition at a malformation of M. is visible on the roentgenogram in M.'s cavity as the wide crest in the field of a bottom which is narrowed at an isthmus and dividing M.'s cavity into two parts equal to a thicket by the size. The full partition of a cavity of M. reaches M.'s opening, at the same time on the roentgenograms of a basin made in the conditions of a pneumoperitoneum, M. has the form of a sphere. Two-horned M.'s shadow on the roentgenogram of a basin in the conditions of a pneumoperitoneum consists as if of two closely adjoining parts. The shadow of a cavity of odnorogy M. has the form of a horn with one uterine tube departing from it. Double M. in the x-ray image has two odnorogy M.' appearance close to the uterine tubes departing from them. M.'s aplasia is diagnosed at a pnevmopelvigrafiya; on the roentgenogram only shadows of ovaries are visible, sometimes under ovaries from one or both parties it is possible to see shadows of rudiments of M. in the form of rollers.

Some malformations of M. are distinguished at a peritoneoskopiya and hysteroscopy.

Treatment of malformations of M. generally operational. The main indications to operation are inefficiency of hormonal treatment, the misbirth repeating not less than 2 — 3 times, disturbance of a menstrual cycle (dysmenorrhea), infertility. Optimum postoperative results receive at uniform doubling of M., at Krom in the operational way it is possible to connect both M., having opened their cavities or excising the partition dividing them. Operational treatment yields good results at the following defects: two-horned M. with a uniform neck, two-horned M. with one neck and an incomplete partition. At patients from the double and reported M. (in the form of a letter «H»), and also with two-horned M. and two necks recovery of a cavity of M. is complicated. In similar cases the combined intervention is required: in the vulval way recover one channel of a neck of M. and intraperitoneally — a cavity of M.

Apply physiotherapeutic methods, hormonal therapy to treatment of infantility of M., combining them with good nutrition, to lay down. gymnastics, M.'s massage (see. Massage, in gynecology ).

Anomalies of position of a uterus

Patol, M.'s removals can occur up, down, in the horizontal plane. At M.'s removal up (elevatio uteri) M.'s bottom or all she acts from a cavity of a small pelvis, the vagina is extended and M.'s neck at a bimanual research is not defined or defined hardly. Tumors of a vagina, a hematocolpos, a pozadimatochny hematoma, napr, as a result of an extrauterine pregnancy, and also a tumor of an ovary, commissure between M. and a front abdominal wall, etc. can be the cause of these shifts.

M.'s removals down the direction to a vagina are called omission or loss (prolapse) — see. Prolapse of the uterus, vaginas .

M.'s removal in the horizontal plane (bodies and M.'s necks) can occur kpered (antepozition), kzad (retroposition), to the right (dextroposition) and to the left (sinistropozition). M.'s tumors, appendages, a bladder or a rectum, cicatricial and commissural processes in a small basin can be the reasons of this or that position M. As a result of inflammatory diseases of M. it can be displaced towards the most expressed cicatricial and commissural process. Similar changes can arise at formation of hems after operations on bodies of a small pelvis. Observed funkts, frustration at the wrong provisions M. depend usually not on M.'s removal, and on the basic disease which caused this anomaly of situation. Therefore many removals of M. independent a wedge, do not matter.

At a pathological inclination M.'s body is displaced in one party, and a neck — in another. Distinguish an inclination of a body of M. of a kpereda (anteversiya), kzad (retroversion) and side (dekstro-and sinistroversion). Dekstro-and sinistroversion are most often caused by a unilateral inflammation of cellulose of a wide sheaf and okolosheechny cellulose. At this M. can be mobile or fixed. Treatment of a mobile anteversiya is carried out by means of introduction of uterine rings, and at the fixed anteversiya and especially the retroversion, and also dekstro-and sinistroversions apply antiinflammatory therapy, ginekol, massage, mud tampons.

At a giperantefleksiya, edges it is often observed at M.'s underdevelopment, between a body and M.'s neck the acute angle is formed, vulval part M. usually has conical shape, M.'s body is reduced in sizes, M.'s opening round, narrowed. Giperantefleksiya can be inborn, and also arises owing to inflammatory process in sacrouterine ligaments. At a giperantefleksiya menstrual bleeding happens sometimes scanty, is more rare plentiful that is connected with M.'s underdevelopment and insufficient function of ovaries. At women with a giperantefleksiya the dysmenorrhea and infertility are quite often observed. In the presence of hems and unions it is necessary physiotherapeutic and a dignity. - hens. treatment, apply therapy by sex hormones.

At a retroflexion (an excess of a body of M. of a kzada, at Krom the corner between a body and a neck is open kzad) M. can be mobile and fixed. The retroflexion is often combined with the retroversion; such situation M. is called retrodeviation. At retrodeviation in case of M.'s mobility often there are complaints to pains in sacral area, bleach, plentiful menstrual bleedings, heavy feeling in a stomach, the dysuric phenomena, hron, locks, etc.; however the specified symptoms can be absent. In most cases the retro of deviation on 12 — 16th week of pregnancy of M. adopts the normal provision. In rare instances at pregnancy the provision of retrodeviation remains that can lead to M.'s infringement, a prelum of a rectum and neck of a bladder.

The diagnosis of retrodeviation of M. is established at ginekol, a research after bladder emptying and a rectum: vulval part M. is located below usual level, M.'s neck is turned not kzad, but kpered, towards a pubic symphysis, M.'s body is in the provision of a retro of deviation, but not from a bosom. At M.'s deviation fixed by a retro badly it konturirutsya, it seems as if increased, the research is painful.

At retrodeviation in case of M.'s mobility of special treatment usually it is not required. At M.'s infringement in a small basin that is observed extremely seldom, resort to its reposition. Before manipulation it is necessary to empty a bladder and a rectum. In position of the woman on ginekol, a chair enter index and average fingers of one hand into a vagina and aim to push aside kzad vulval part M. or enter fingers into a back vault of the vagina, removing M.'s body as it is possible above and kpered. At the same time other hand through an abdominal wall take M.'s bottom and bring it into the normal provision of an anteversiya. M.'s reposition can be made also by means of bullet nippers, to-rymi take a front lip of a neck and as much as possible reduce it to an entrance of the vagina, and the fingers entered into a back vault of the vagina raise M.'s body up. If the specified receptions were unsuccessful, sometimes it is possible to bring pregnant M. out of the provision of retrodeviation at the phenomena of infringement it in a small basin, having put the woman on a couch in genucubital position; at impossibility to empty a bladder by means of a catheter resort to its puncture through an abdominal wall. After M.'s removal from the provision of retrodeviation the woman shall lie on beds, the lower end the cut is raised. At the fixed retrodeviation of M. connected with inflammatory processes apply antiinflammatory therapy, ginekol. massage, mud tampons, and if necessary resort to operational treatment.

M.'s ectropion is possible as a complication of childbirth or at the tumor born from her cavity (see. Ectropion of a uterus ). The turn M. (rotatio uteri) around a longitudinal axis arises at the inflammatory processes in a small basin leading to shortening of sacrouterine sheaves. Treatment operational. M.'s (torsio uteri) twisting is observed seldom and expressed in turn of her body in the field of the lower segment to the right or to the left on 180 ° more while the neck keeps initial situation. The reason — torsion of an oothecoma or subserous myoma on a leg. The diagnosis is difficult, is specified, as a rule, at a trial laparotomy. At disturbance of food of M. (e.g., as a result of an ectropion) its extirpation is shown.

Damages

M.'s Bruises can arise at injuries, thus pregnant M.'s injury is more often observed (falling, a bruise, a raising of weight, etc.) that can lead to an abortion or premature births (see. Premature births , Misbirth ).

Ruptures of a neck of M. (laceratio cervicis uteri) are generally connected with the act of childbirth. The size of a rupture of a neck of M. fluctuates from insignificant side anguishes before broad splitting with deformation of an opening of M. In some cases the gap passes to M.'s body and to the vulval arches. Ruptures of a neck of M. arise at the unbent presentations of a head of a fruit, presentation of an afterbirth, bystry childbirth, hl. obr. at insufficient disclosure of a neck of M., at extraction of a fruit the pelvic end, and also in connection with rigidity of a neck of M. owing to the inflammatory processes postponed in the past.

Fig. 11. The diagrammatic representation of a vulval part of a neck of uterus at its gaps: 1 — unilateral: 2 — bilateral; 3 — star-shaped.

Ruptures of a neck of M. (fig. 11) occur more often on each side than a neck and in lengthwise direction; the gap can be unilateral and bilateral; often there are many small gaps (see. Birth trauma ). Deep gaps lead to an ectropion of a mucous membrane of the channel of a neck M. (ectropion) and to development of an erosion of a neck of uterus (see).

The traumatic necrosis of a neck of M. can arise at a rigid neck of M. and at its long prelum, napr, at long childbirth. Most often the front lip is exposed to infringement between a head of a fruit and pelvic bones, but also circular necroses of all vulval part of a neck of M. meet (see. Birth trauma).

Cervical and vulval fistulas — one of types of fistulas of generative organs. They result from a rupture of a neck of M. in a middle part of its channel, at the same time edges of an opening of M. are not damaged, and fistula is formed between the channel of a neck and the vulval arch. Such fistulas can be formed after abortion, births in time, most often in the field of a back vault of the vagina.

Diagnosis of injuries of a neck of uterus is based on its careful survey. M.'s necks examine by means of big mirrors and the elevator directly after the delivery as soon as the afterbirth was born. The indication to obligatory suture on a gap is bleeding from area of a gap. In case of detection of a gap on M.'s neck impose nippers to Myuza by means of which she is brought up from top to bottom and aside, opposite to a gap. Imposing of catgut seams is begun with a corner of a gap. Cervical and vulval fistula is usually sewn up after excision of its edges by a special technique, it is frequent using alloplastichesky materials. At a necrosis of a neck of M. operational treatment is not shown, after sloughing of fabric heal second intention.

Fig. 12. The diagrammatic representation of a sagittal section of a basin at belly and uterine fistula (it is specified by shooters): 1 — a uterus; 2 — a vagina; 3 — a bladder.

Belly and uterine fistula can be formed after Cesarean section and other operations with opening of a cavity of M., at a wound repair by second intention. The inflammatory process in the field of a wound of an abdominal cavity which is followed by an union of an abdominal wall with M is the cornerstone of its emergence. The subsequent purulent fusion of unions leads to developing of fistula between M.'s cavity and an abdominal wall (fig. 12). Treatment of belly and uterine fistulas operational.

Apply plastic surgeries with a cicatrectomy and recovery of a shape of a neck of M to treatment of the hems arising sometimes in the field of gaps.

In addition to a gap as a complication of childbirth, the rupture of a body of M. as a dangerous effect of operation is possible Cesarean section (see). It can occur at the subsequent pregnancy and childbirth on a hem; frequency of such gaps depends on a method of operation. According to a number of authors, M.'s ruptures on a hem approximately in 85% of cases arise at the women who transferred korporalny and to 15% of cases — istmiko-korporalny Cesarean section.

The main reason of a gap — insolvency of a hem, edge, in turn, depends on a number of factors; the postponed postoperative inflammatory process, the equipment of stitching on a wall M., an arrangement of a placenta in the field of a seam with growing of elements of chorion into a hem, etc. As there is always potentiality of a rupture of M. on a hem, especially after korporalny Cesarean section, an interval between operational delivery and the subsequent pregnancy, according to L. S. Persianinov, shall make not less than two years. Apply a metrografiya to clarification of character of a uterine hem, to-ruyu make not earlier than in 6 months after operation. Rentgenol, a research gives the chance to reveal changes of contours of a cavity of M. according to the location of a hem.

For the purpose of the prevention of a rupture of M. on a hem at repeated pregnancy it is necessary to consider the following a wedge, data. 1. The signs indicating a possibility of formation of a defective hem of a wall of M.: temperature increase in the postoperative period, healing of a postoperative wound of an abdominal wall second intention, abdominal pains during pregnancy, and also these metrografiya. 2. The factors indicating a possibility of a rupture of M. on a hem: in addition to above-mentioned signs of a defective hem, an arrangement of a placenta on a front wall of M., an interval between operation and the real pregnancy less than 2 years, anatomically or clinically narrow basin, the wrong insertion of a head, the cross provision of a fruit. 3. Signs of the menacing gap: abdominal pains, in the field of a hem during pregnancy (in its last trimester), at the beginning of childbirth — the pains out of a fight amplifying during the fight, the painful and dicoordinated patrimonial activity, morbidity of a hem and its thinning defined at a palpation, lack of advance of a fruit at full opening of a neck of M., especially in combination with painful contractions.

Bloody allocations from patrimonial ways, nausea, vomiting (even single), dizziness, feeling of weight and pain in epigastriß area, change of heartbeat of a fruit are signs of beginning M.'s rupture on a hem. It is necessary to consider that in some cases the listed symptomatology can be expressed softly.

Emergence of signs of menacing or beginning M.'s rupture on a hem is the indication to repeated Cesarean section, in time to-rogo quite often there is a question of sterilization since danger of a rupture of M. on a hem at the following pregnancy increases.

Pregnant women who were exposed operational delivery earlier), shall be under dispensary observation. At the uncomplicated course of pregnancy they are hospitalized for 2 weeks before childbirth, and at suspicion on a defective hem — for 4 — 5 weeks.

The perforation (perforation) of M. can sometimes occur at criminal abortion, and also in some cases at artificial abortion and disturbance of the equipment of a scraping of a cavity of M. In some cases the perforation can arise at a scraping owing to considerable morfol, changes of a wall of M., napr, at cancer, a horionepitelioma.

M.'s perforation, as a rule, is followed by the pain syndrome and symptoms characteristic of intra belly bleeding (increase of pulse, pallor of skin, falling of the ABP, at percussion is defined accumulation of blood in sloping places of an abdominal cavity). Further development of limited or diffuse peritonitis is possible (see).

For treatment the laparotomy with sewing up of a perforated opening, sometimes amputation and even an extirpation of M is shown. The forecast depends on the amount of damage of M. and the next bodies, timeliness of establishment of the diagnosis and volume of a surgery. At the isolated M.'s damage and its timely treatment the forecast, as a rule, favorable. The forecast is serious at simultaneous damage of the next bodies (a bladder, a rectum) and at development of peritonitis.

Chemical and thermal damages of M. are observed seldom; they can arise at careless use with to lay down. the purpose of solutions of high temperature, and also various chemical agents (zinc chloride, nitric to - that, a form of l in, caustic silver, etc.). Chemical damages of M. can be also observed at criminal abortions when enter various chemical substances into M.'s cavity that, as a rule, is followed by infection of a cavity of M. with development of a septic state. In the acute period of chemical and thermal damages of M. into the forefront symptoms act metroendometritis (see) and the general intoxication (temperature increase, pains in the bottom of a stomach, sometimes a metrorrhagia owing to necrotic changes of a mucous membrane of M.), and in case of infection — symptoms of peritonitis and sepsis.

Treatment is usually conservative, it includes the disintoxication, antiinflammatory therapy, actions directed to normalization of a water and salt metabolism, etc. At extensive necrotic changes of M. with the phenomena of peritonitis operational treatment — M.'s extirpation with drainage of an abdominal cavity is shown. Healing after chemical and thermal damages of M. can proceed with formation of the hems leading to a stenosis, or an atresia of a neck of M. and intrauterine synechias that is followed by disturbance of menstrual function (a uterine form of an amenorrhea, a hypomenorrhea), infertility (see. Ashermana syndrome ). Treatment usually operational (see. Gynatresia ), it is sometimes supplemented with hormonal therapy.

Diseases

Disorders of function M. are shown by various disturbances of a menstrual cycle (see), connected with it infertility (see), misbirths (see), not incubation of pregnancy (see).

Disturbances of blood circulation in M. arise at its wrong situation, during the twisting and loss. At the same time menstrual and genital functions are usually broken, inflammatory processes often develop.

At M.'s twisting symptoms are possible acute abdomen (see), at M.'s loss erozirovanny sites — decubituses are formed. Narrowings and fusions of an isthmus M. and the channel of a neck of M. can be during the healing of the multiple cracks which arose in connection with disturbance of the technology of expansion of the channel of a neck of M. and at excessively deep scraping of a mucous membrane. The atresia of the channel of a neck of M. leads to accumulation of menstrual blood and a so-called traumatic amenorrhea. At the same time there are pains in the bottom of a stomach and in the field of a sacrum, especially in days of the expected periods. The diagnosis is established by sounding of the channel of a neck of M. Treatment is operational, it is made not earlier than in 3 months after emergence of a traumatic amenorrhea.

In M. quite often observe so-called internal endometriosis (see), characterized by a heterotopy in a myometrium of fabric of an endometria. At the same time the geterotopirovanny endometria keeps ability to be exposed to cyclic changes. A wedge, symptoms of endometriosis of M. most often are: a dysmenorrhea (the strengthened or extended periods, intervals between them are shortened); the pains developing some days before periods; the increased dense M., and it sharply increases before periods and decreases after it. Characteristic rentgenol. the feature of internal endometriosis revealed at a metrosalpingografiya — so-called zakonturny shadows, i.e. availability of contrast medium out of contours of a cavity of M. Form of these shadows depends on localization of the center of endometriosis (as a rule, they linear, from 2 to 4 mm long), are most often observed in the field of an isthmus and a bottom of M.

Inflammatory processes can be localized within an endometria — an endometritis, in a mucous membrane of the channel of a neck of M. — cervicitis (see). The term «metritis» designates an inflammation of a myometrium of M., but as the metritis is usually preceded by an endometritis, it is more correct to designate an inflammation of a body of M. as a metroendometritis (see). If inflammatory process passes to a perimetrium and a parametrium, develops parametritis (see). At penetration of contagiums into depth of fabrics M. formation of abscess is possible, at Krom there can be a necrosis and sequestration of sites of a myometrium, gangrene of M in certain cases can develop. At a metroendometritis the vein thrombosis of M. is possible (see. Metrotromboflebit ).

The greatest role in emergence and development of inflammatory processes of M. is played by streptococci and staphylococcus, gonokokk, colibacillus and some anaerobic bacteria are more rare. Violation of the rules of an asepsis and antiseptics during the conducting childbirth, abortion, performance of diagnostic and to lay down. intrauterine manipulations happens the reason of entering of contagiums in M. Microorganisms can be brought in M. and from a vagina or the channel of a neck of M., napr, at hron, a gonorrheal cervicitis. M.'s inflammation can be observed at a row acute inf. diseases (flu, quinsy, scarlet fever, measles, typhus, etc.). Transition to M. of an inflammation, including hron, specific processes, from a worm-shaped shoot and intestines, uterine tubes is possible. From hron, specific inflammatory processes in M. tuberculosis, syphilis, an actinomycosis are more often observed. Parasites, mechanical (a bruise, wound), thermal and chemical damages can be the cause of an inflammation of M.

Inf. processes in M. can be complicated by development of a pyometra with accumulation of purulent exudate in M. Klinicheski's cavity the pyometra can proceed asymptomatically, but body temperature usually increases, there are strong, sometimes colicy pains, from the channel of a neck of M. a large amount of purulent exudate then there occurs improvement of a state is allocated. In the subsequent resuming of these symptoms is possible. Treatment: expansion of the channel of a neck of M., washing of a cavity of M. solutions of desinfectants, antibacterial therapy.

Penetration into M. of the mycobacteria of tuberculosis causing a tubercular endometritis happens in the lymphogenous way at tuberculosis of uterine tubes or hematogenous. In some cases tubercular defeat of a vulval part of a neck of M. is noted, at Krom patol, process is localized usually on a back lip or around M. Izredk's neck the ulcer form of tuberculosis of a neck of M. meets; at primary survey it is difficult to distinguish it from cancer of a neck of M. Diagnosis of a tubercular endometritis is based by hl. obr. on gistol, a research of scraping of an endometria, in a stroma to-rogo find tubercular granulomas, and the piece of fabric taken at a biopsy (see. Tuberculosis of urinogenital bodies ).

Fig. 1. The vulval part of a neck of uterus at primary syphilis bared by mirrors (the arrow specified a hard ulcer).

Primary syphilis (see) more often strikes area of a vulval part of a neck of M. where primary affect is localized (tsvetn fig. 1). Displays of secondary syphilis (syphilitic papules) on M.'s neck happen seldom. In the tertiary period of syphilis gummas of M can be formed. The diagnosis is made on the basis of a careful ginekol, inspection, results serol, reactions, detection of treponemas in separated, napr, at disintegration of gummas.

Fig. 2. The vulval part of a neck of uterus at an actinomycosis bared by a mirror: around an ostium of the uterus the diffusion infiltrate which is partially covered with the pus which is emitted from the fistular courses (it is specified by shooters).

M.'s actinomycosis meets seldom and has usually secondary character (primary center can be, e.g., in a caecum.) Primary actinomycosis of M. is possible sometimes at its loss. Formation of diffusion dense infiltrates and multiple abscesses with development of the fistular courses is observed (tsvetn. fig. 2). The diagnosis is established at microscopic examination purulent separated, in Krom find druses of actinomycetes (see. Actinomycosis ).

Parasitic diseases of M. are observed seldom. M.'s echinococcosis meets in the form of so-called endogenous (when the echinococcus develops from the very beginning in M.) and exogenous (the echinococcus develops in fabrics, adjacent to it, is more often in cellulose of a basin) forms. Initially the echinococcus can get to M. via veins (intestines — a portal vein — a liver — the lower vena cava — lungs — a big circle of blood circulation). The possibility of penetration of a parasite through a wall of a rectum in a mesentery is allowed, then in cellulose of a basin and in M. Chashche M.'s Echinococcosis happens a secondary origin — after a rupture of an echinococcal cyst of a liver or a spleen.

Klien, a picture at M.'s echinococcosis reminds displays of myoma of M. The echinococcal cyst of usually tugoelastichesky consistence, is slow-moving, painless, grows slowly, but can reach the big sizes — to dia, to 25 — 30 cm. Apply a row to diagnosis a lab. methods (see. Echinococcosis ), the trial laparotomy is in certain cases shown. Treatment operational.

The basic a wedge, manifestation of a schistosomatosis — bleeding. Treatment of this disease — intravenous administration of emetine of a hydrochloride.

Nek-roye a wedge, matter. other helminths which are not so often found in M. (pinworms, round worms, joints of tapeworms). Yeast-like fungi can cause inflammatory process.

Concrements, or uterine stones, can be formed at adjournment of salts of calcium around a foreign body or at penetration into M.'s cavity, napr, through uterovesical fistula, an urinary stone. In rare instances in M. there is a dead a fruit which is exposed to calcification (see. Lithopedion ). Uterine concrements can be a long time in M. asymptomatically, but can cause pains, M.'s infection, uterine bleeding, sometimes damage of a wall of M. Apply a gisterosalpingografiya, an ultrasonic method and hysteroscopy to diagnosis.

Foreign bodys are a hl. obr. various objects which remained in a cavity M. entered, e.g., for the purpose of abortion, masturbation (see. Foreign bodys, vaginas and uterus ).

Occupational diseases of M. meet rather seldom, hl. obr. in connection with violation of the rules of safety by industrial production of different types of synthetic rubbers, pharm, drugs, etc., in cases of exceeding of maximum allowable concentration of chemical agents. The mechanism of the damaging action of these factors, as a rule, the hypophysis mediated as a result of the general changes in an organism, generally through system — a hypothalamus — ovaries. To M.'s diseases carry its also wrong provisions (omission and losses) connected with heavy lifting, vibration, etc. to the prof. Especially adverse can be an influence of such factors on M. during pregnancy that causes sometimes its premature interruption.

Tumors

divide M.'s Tumours on high-quality and malignant. In addition, allocate so-called opukholepodobny changes, to the Crimea carry polyps of M. Polyps of a body of M. arise in a basal layer of an endometria in the form of the node which is located more often in the field of a bottom and M.'s corners and taking further the finger-shaped or pear-shaped form. Polyps usually at mature and advanced age in the form of single or multiple educations meet. The wedge, a picture at the same time is characterized by the symptoms of a menorrhagia amplifying at the so-called born polyp. As a result of gradual increase in a polyp M.'s reductions begin, there is a disclosure of its opening, and the polyp is as if pushed out in a vagina. The leg of the born polyp is extended, the prelum of the vessels located in it causes disturbance of blood circulation and secondary necrotic changes in a polyp.

For the purpose of diagnosis of a polyp carry out sounding and a scraping of a cavity of M. with the subsequent gistol. research, and also rentgenol. research and hysteroscopy.

Benign tumors

From benign tumors M.'s myoma developing from elements of smooth muscular tissue of body meets more often. In myoma connecting fabric soon begins to develop that gives to a tumor more dense consistence. Depending on dominance of muscular or connecting tissue the tumor can be carried to myoma or a fibromyoma. In a wedge, practice these terms consider as identical, however in literature both of them are applied.

Myomas meet widely developed network of blood vessels — so-called angiofibromioma. Around blood vessels and between muscle bundles cracks are located limf; outflow of a lymph happens through an anastomosis in limf, vessels of the capsule of myoma. At disturbance of outflow there comes the lymphostasis, at Krom the tumor increases in sizes, becomes soft, and limf, cracks turn into cystous cavities — so-called myoma lymphangieetaticum is formed.

Fig. 13. Scheme of stages of development of a hysteromyoma: 1 — subserous; 2 — submucosal; 3 — intersticial.
Fig. 1 — 3. Macrodrugs of a uterus at myoma: fig. 1 — the cavity of the uterus is opened, nodes of myoma (are specified by shooters) are located intramuralno and subserozno; fig. 2 — on a slit of a body of the womb is visible the node of intramural myoma which is characterized by the fibrous drawing; fig. 3 — the cavity of the uterus is opened, expanded, the submucosal polipovidny node of myoma is attached in the field of an uterine fundus.

M.'s myomas are observed preferential at the age of St. 30 — 35 years. Find multiple nodes of various size more often. There are descriptions of myomas the weight of St. 50 kg. Localization of myoma is various (tsvetn. fig. 1 — 3). As it arises in the thickness of a myometrium, at the beginning of the development always happens intersticial. Further, if growth of a node happens towards a perimetrium, it turns into subserous (fig. 13,7); if growth goes in the direction of M.'s cavity — to submucosal (fig. 13, 2); more often the node of myoma keeps intersticial localization (fig. 13,3).

Changes of a mucous membrane of M. at myomas are various — from a ferruterous and cystous hyperplasia of an endometria and formation of polypostural growths to an atrophy.

In the period of a menopause myoma usually decreases in sizes that is explained with decrease in secretion of estrogen. In the anamnesis the early beginning of the periods which are often proceeding on type is noted anovulatory cycle (see), and infertility.

Development of infertility depends on many reasons (deformation of a cavity of M., excesses and closing of a gleam of uterine tubes, a hyperplasia, polypostural growths of an endometria, anovulatory cycles of periods).

On a wedge, to manifestations distinguish simptomny and asymptomatic myomas. Slowly growing myoma in many cases proceeds asymptomatically. In most cases patients see a doctor concerning bleedings: menorrhagias, are more rare than acyclic bleedings — metrorrhagias. At a number of patients menstrual bleedings are extended and the amount of the lost blood increases, at others periods are followed profuse by bleeding with development of heavy anemia. Bleedings happen at submucosal myoma much more often, is more rare at intersticial and are even more rare at subserous an arrangement of a myomatous node. In developing of bleedings increase in a surface of an endometria owing to stretching of a cavity of M. tumoral nodes, disturbance of sokratitelny function of a myometrium, and also change of a mucous membrane (a hyperplasia, polypostural educations, an atrophy, in some cases sites of a necrosis) matters.

Pains at myoma are observed rather seldom. Usually they appear at disturbance of blood circulation and a necrosis of a node, twisting of a leg of subserous myoma. In the presence of submucosal nodes of pain are observed sometimes during periods. Strong colicy pains arise at the birth of submucosal nodes. Pains can be connected also with pressure of nodes of myoma upon a bladder, ureters, a rectum. At the same time there can be dysuric phenomena — increase or difficulty of an urination, incomplete bladder emptying, etc. At subserous myoma, the growing knaruzha towards a perimetrium, a part of a tumor acts over M.'s surface, remaining connected to it on the bigger or smaller site; the leg of various length can be formed, edges it is sometimes overwound that causes a necrosis of a node and a wedge, a picture of an acute abdomen. At several subserous nodes M. it is sharply deformed; the arrangement of subserous nodes of side departments of M. between leaves of wide sheaves (so-called intraligamentarny myoma) is possible.

At submucosal myoma of M. it is also deformed. In process of growth of a submucosal tumor there are skhvatkoobrazny reductions of M. as a result of which the node as if is born in a cavity of M. Further the tumor can move ahead to the canal of a neck of M. and in a vagina, remaining the connected leg with a body of M. After the birth of a node M.'s neck is sometimes reduced, squeezing a leg therefore there comes the necrosis of a tumor.

The necrosis of a myomatous node quite often is followed characteristic a wedge, a picture (pains, vomiting, temperature increase, a leukocytosis). In a further nekrotizirovanny sites of a tumor can be exposed to calcification. At full calcification of myoma its transformation into a uterine stone is possible.

From complications of myoma the rupture of blood vessels with a hemoperitoneum, M.'s twisting, twisting of a leg of a subserous tumoral node about a wedge, a picture of an acute abdomen is observed. Treats rare complications ectropion of a uterus (see) at the birth of big submucosal nodes, especially coming from

in large part of cases leads areas of a bottom of M. Miom M. to infertility. However subserous myomas usually do not interfere with approach and development of pregnancy. At intersticial myoma abortions in early terms are often observed. Cervical myomas in some cases interfere with delivery. At interstitsialno the located nodes of myoma primary weakness of patrimonial activity, and after the delivery hypotonic bleeding is possible. Approach of pregnancy at M.'s myoma, as a rule, is not the indication to its interruption. At a combination of myoma and pregnancy an operative measure can be required if myoma of the big sizes and interferes with wearing out of pregnancy if nodes are located low and interfere with a childbed if in a tumor there were changes — a necrosis, hemorrhage, there is a suspicion on a malignancy. At low located tumors interfering delivery, and the isolated nodes with disturbance of blood circulation savings operations — enucleation of tumoral nodes with preservation of pregnancy are possible. The malignancy of myomas of M. is observed seldom and makes, on a nek-eye to data, no more than 1 — 1,5% of cases. Thus there comes the malignancy of submucosal myoma more often.

Recognition of myoma in most cases does not cause difficulties. At a bimanual research reveal such characteristic diagnostic characters as tuberosity of body, density of nodes and painlessness at their palpation. Difficulties can arise at intersticial myoma in combination with pregnancy because of a softening of a tumor and an ambiguity of its borders. The m in these cases of the big sizes, than follows at this duration of gestation. At an ambiguity of the diagnosis apply biol, reactions to identification of pregnancy, ultrasonography, repeated surveys. Difficulties arise also at the differential diagnosis between myoma, a cyst and a tumor of an ovary, especially if the myomatous node on a leg proceeds from a sidewall of M. or is located in a wide sheaf (intraligamentarno).

About a cyst or a tumor of an ovary it is possible to judge only by an elastic consistence of the palpated education; quite often at the same time in a small basin there is small accumulation of ascitic liquid that can be established by means of a puncture through a back vault of the vagina.

From rentgenol, methods of a research especially valuable information is given by a gisterografiya at a submucosal arrangement of nodes of myoma. At the same time the main rentgenol, symptoms are increase in a cavity of M. (M.'s length on the roentgenogram can sometimes reach 12 — 15 cm), its deformation, a serious defect of filling and, perhaps, expansion of an isthmus M. Depending on size and an arrangement of a node of myoma the shape of a cavity of M. happens the most various. The size of defects of filling is also various, but edges their usually equal and accurate. In many cases defects of filling are filled partially in with a thin coat of a contrast agent. Rentgenol. the picture of submucosal myoma of M. should be differentiated with rentgenol. picture of polyps of an endometria, knotty form of internal endometriosis. In some cases along with a gisterografiya make hysteroscopy for specification of the diagnosis.

For diagnosis of a subserous arrangement of nodes of myoma use a pnevmopelvigrafiya and an intrauterine flebografiya. At the same time against the background of gas in an abdominal cavity the shadow of the increased M. with polycyclic contours is well visible. In the presence of a subserous node on a leg M.'s shadow and the shadow of a node of myoma which is imposed on it is visible. The intrauterine flebografiya allows to distinguish existence of the nodes of myoma which are especially located interstitsialno on a characteristic picture of so-called avascular zones. These zones arise because vessels are usually more developed on the periphery of myoma.

M.'s neck at myoma needs to be inspected carefully by means of a kolposkop, to take smears for tsitol, researches from a surface of a vulval part and the channel of a neck of M. At acyclic bleedings the separate diagnostic scraping and gistol, a research of a mucous membrane of M. and its channel is shown. The wedge, the diagnosis of a malignancy of myoma can be made most often presumably on the basis of signs of rapid growth of a tumor, uterine bleeding in the presence of myoma in the period of a menopause, an otkhozhdeniye with bloody allocations of pieces of a tumor or emergence of the recurrent polyps acting from the channel of a neck of M.

Indications to an operative measure are: the submucous myomas which are followed by bleedings and secondary anemia (at unsuccessfulness of conservative treatment), the born submucosal myomas, the twisting of a leg of subserous nodes, pains caused by a prelum of nerves dense fibromyomas, disturbances of defecation and an urination, a fast-growing tumor, especially in the period of a menopause, suspicion on a malignancy of myoma, and also a combination of myoma to tumors of an endometria and appendages of M.

The choice of a method of operation depends on the general condition and age of the patient, localization, the sizes and number of tumoral nodes, associated diseases. Radical M.'s myoma operations are supravaginal amputation and an extirpation of M. If nodes of myoma are located in M.'s body, supravaginal amputation is the most frequent type of an operative measure, at Krom the topography of a bladder and rectum, a very techtonic dance of a vagina almost remains, the risk of omission and loss of its walls decreases. There are data that at preservation of a neck of M. less often vegetative and neurotic disturbances come better humidity of a vagina thanks to existence mucous separated from a neck remains; it is specified also preservation of hormonal activity of the not changed ovaries which remained at simultaneous preservation of a neck of M. and uterine tubes. At supravaginal amputation of M. make transplantation of a rag of an endometria to the canal of a neck of M. that promotes preservation of normal interoceptive relationship between generative organs and the regulating centers of a brain.

M.'s extirpation is shown at cervical myomas, gangrenous disintegration of a tumor and in the presence patol, changes of a neck of M.

Conservative plastic surgery (myomectomy) is shown, e.g., to young women when it is established that nodes of a tumor interfere with approach of pregnancy; it consists in enucleation of one or several nodes of a tumor, a defundation or high amputation of M. with preservation of its bottom and a mucous membrane. Conservative plastic surgery by Alexandrov's method is more reliable in sense of the prevention of a recurrence, at a cut delete nodes of a tumor and excise the capsule and a part of hypertrophied fabrics of a uterine wall.

Broad application for treatment of myomas is found by methods of medicinal therapy. Hormonal drugs possess effective action: androgens, drugs of a yellow body (gestagena). Apply to conservative treatment also Methylandrostendiolum (see), growth-retarding myomas and normalizing disturbance of a menstrual cycle.

Malignant tumors

In M. are observed cancer (see), sarcoma (see), a horionepitelioma (see. Trophoblastic disease ).

Epidemiology

the Frequency of diseases of M.'s cancer in various countries, in the certain districts of the USSR is very variable. The statistical materials published over the certain countries, as a rule, have no the generalized data on epidemiology of cancer of M. V to the table incidence of malignant new growths of M. in some countries of Europe for 1977, according to WHO data is presented.

Table. INCIDENCE of MALIGNANT NEW GROWTHS of the UTERUS IN SOME COUNTRIES of EUROPE for 1977


In the USSR inching of cancer cases of a neck of M. is noted, a cut it is reached by improvement of obstetric aid (careful conducting childbirth, careful treatment of ruptures of a neck of M.), routine maintenances and timely treatment of precancerous diseases of a neck of M., improvement of sanitary living conditions of life of the population. The summed-up data onkol, institutions of the USSR show that the number of patients with cancer of a neck of M. considered onkol, institutions with for the first time the established diagnosis in the standardized indicators on 100 Ltd companies of female population in 1970 made 21,4, in 1974 — 19,4, and in 1975 — 18,7.

In structure of mortality of the population of the USSR from malignant tumors in 1970 mortality from cancer of a neck of M. made 3,9%; in 1974 — 3,6%. The number of the dead from malignant tumors of a neck of M. on 100 000 female population is distributed on age as follows (1971 — 1972): up to 20 years — 0; 20 — 29 years — 0,3; 30 — 39 years — 2,6; 40 — 49 years — 11,9; 50 — 59 years — 29,9; 60 years are also more senior — 29,2.

Depending on an arrangement of a tumor, features the wedge, pictures, ways of innidiation, methods of treatment and the forecast distinguish cancer of a neck and cancer of a body of M.

Cancer of a neck of uterus

Cancer of a neck of uterus is observed most often at the age of 40 — 50 years. Low incidence is noted at the women who were not leading sex life. Many authors give an essential role to a birth trauma of a neck of M. with the subsequent its cicatricial changes, development of ectropion and an erosion.

At patients with it is long the existing ulcers and hems of a neck of M. there can be precancerous diseases. The following wedges, signs are characteristic of them: long hron, a current, constancy of symptoms, firmness concerning conservative methods of treatment, a recurrence after treatment. Carry to precancerous diseases of a neck of M. leukoplakia (see), eritroplakiya (see), an erosion, it is long the existing erozirovanny ectropion.

At a leukoplakia the mucous membrane of a neck of M. is thickened, is sometimes edematous, on its surface whitish spots and white plaques with sharply outlined borders are formed. Patients quite often note emergence of vulval allocations of milky-white color; at development of a colpitis of allocation can be yellowish and even dark green, putreform, and at an erozirovaniye of a mucous membrane to allocations blood can be added.

Eritroplakiya of M.'s neck meets less often. Affected areas of dark red color act against the background of the mucous membrane having usual coloring. In a wedge, a picture note existence of sticky allocations of yellowish color.

Erosion and ectropion are, as a rule, observed at deformation and inflammatory processes of a neck by M. Papillyarna call such erosion, edges is characterized by formation of the papillary outgrowths covered with a cylindrical epithelium; follicular — an erosion with growth in M.'s neck of erosive glands. Carry to a precancer also the erosion recuring after diathermocoagulation. Such erosion easily bleed and can serve as the reason of contact bleedings. It is necessary to distinguish an erosion of a vulval part of a neck of M. from ectropion. Ectropion of a neck of M. is diagnosed rather easily. In the anamnesis at the same time, as a rule, there are instructions on childbirth, late abortions, ruptures of a neck of M. Specification of the diagnosis is helped by reception of the data of the broken-off front and back lips of a neck of M. at ginekol, a research; disappearance of a red surface testifies to ectropion.

Precancerous disease consider the erozirovanny ectropion developing further as a result of infection of the channel of a neck M. Harakter of allocations at the same time it is various: mucous, mucopurulent, mucosanguineous.

The aim biopsy is shown to patients with precancerous diseases of a neck of M. after a kolposkopiya. At a recurrence make deep diathermocoagulation or a diatermoekstsiziya of a neck M.

Diatermokoagulyation M.'s necks carry out both in stationary, and in out-patient conditions, usually appoint it in the second phase of a menstrual cycle because of danger of developing of endometriosis. On the operating table the patient is stacked in situation, usual for vulval operations. The mucous membrane of a vagina, and also M.'s neck and its channel is processed alcohol and dried up a tampon. An active electrode (spherical, lanceolated or flat) coagulate the changed tissue of a neck of M. before formation of a uniform scab, and then grease 5 — 10% with solution of potassium permanganate. Further the scab is processed the same solution in 1 — 3 day before its full rejection. Lech. the effect is estimated after rejection of a scab and end of full epithelization.

For a diatermoekstsiziya of a neck M. (diatermokonization), to-ruyu carry out usually in the conditions of a hospital, apply the special electroknife used as the active electrode for excision of the struck part of a neck to M. Sheyk M. at the same time is delimited a special rubber cuff, to-ruyu brought to a vagina for protection of its walls from accidental burns. Enter a core of an electroknife into M.'s opening and include current. The knife crashes into tissue of a neck of M. on necessary depth, and then it is rotated around before completion of amputation of the interior of a neck of M. Sleduyet to aim at that the section was carried out on border of the healthy and changed part of a neck of M. After removal of the interior of a neck of M. the wound surface is greased by 5 — 10% with solution of potassium permanganate and delete a rubber cuff. In the postoperative period the koagulirovanny surface of a neck of M. is processed several times solution of potassium permanganate. It is necessary to write out the patient from a hospital after rejection of a scab since at the same time approximately on 9 — the 10th day can arise considerable bleeding.

At an erozirovaniye of ectropion resort to operational amputation of a neck. In some cases apply to treatment of displaziya of a neck of M. cryosurgery (see). Use of beams of the carbonic laser for treatment of displaziya of a neck of M. is offered; at the same time process of radiation is not followed by pain, the scab is not formed and there is no bleeding from the irradiated site; epithelization comes to the end during 2 — 3 weeks.

Fig. 3. Macrodrug of a uterus at exophytic cancer of a neck: the cavity of the uterus is opened, in a neck the tumoral node of a polipovidny form is visible (it is specified by an arrow).

Cancer of a neck of M. on gistol, to a structure most often is planocellular and only in some cases ferruterous. Distinguish cancer of a vulval part of a neck of M. and cancer of the channel of a neck of M. though it is not always possible to define the initial place of developing of a tumor precisely. At an exophytic form growth is directed to a gleam of a vagina and by the form she, as a rule, reminds a cauliflower or has an appearance of a polyp (tsvetn. fig. 3). At the endophytic nature of growth of a tumor M.'s neck increases in sizes and becomes dense. Irrespective of the nature of growth the tumor is exposed to a necrosis, there is its disintegration and an ulceration.

Classification of cancer of neck of uterus (on the TNM, 1966 system): T — primary tumor; TIS — preinvazivny cancer (carcinoma in situ); T1 — cancer limited to a neck of uterus; T1a — invasive cancer which can be distinguished only histologically; T1b — the invasive cancer revealed clinically; T2 — the cancer extending out of limits of a neck of uterus, but not reaching walls of a basin or cancer involving in patol, process of a wall of a vagina without distribution on its lower third, or cancer passing to a body of the womb; T2a — cancer, infiltriruyushchy only a vagina or a body of the womb (without infiltration of a parametrium); T2b — cancer, an infiltriruyushchy parametrium with involvement of a vagina or a body of the womb; T3 — cancer, infiltriruyushchy the lower third of a vagina or a parametrium to walls of a basin (there is no free space between a tumor and a wall of a basin); T4 — cancer which is going beyond a small pelvis or infiltriruyushchiya a mucous membrane of a bladder or a rectum.

N — regional (pelvic) limf, nodes; Nx — to estimate a condition regional limf, nodes are impossible; in the subsequent addition of data gistol, researches of remote limf.uzl is allowed (Nx_ — lack of metastasises; Nx + — metastasises are found); N0 — at a limfografiya is not revealed changes in regional limf, nodes; N1 — at a limfografiya are revealed metastasises in regional limf, nodes; N2 — is palpated the fixed consolidation on a wall of a basin in the presence of the free space between consolidation and primary tumor.

M — the remote metastasises; There is no M0 — signs of the remote metastasises; M1 — the remote metastasises, including defeat lumbar and inguinal limf, nodes are available.

In everyone specific a wedge, observation symbols T, N, M are grouped and there correspond a wedge, classifications of cancer of neck of uterus by stages: a stage 0 — TISN0M0; a stage of Ia — T1aN0M0; a stage of Ib — T1bNxM0; a stage of IIA — T2aNxM0; a stage of IIB — T2bNxM0; a stage of III — T3NXM0, T1N2M0, T2aN2M0, T2bN2M0; a stage of IV — T4 (or) M1.

B a wedge, a picture of cancer of neck of M. usually describe a classical triad of symptoms: bleach, bleedings, pains. In initial stages of a disease these symptoms are absent more often and appear when disintegration of a tumor begins. Emergence is more white is caused by damage limf, vessels at rejection of nekrotizirovanny sites of a tumor. Impurity of blood to allocations quite often gives them a characteristic type of meat slops. Bleedings are observed often or in the form of small bloody allocations, or in the form of plentiful bleedings, or are connected with frustration of a menstrual cycle. The joining infection promotes emergence of a fetid smell of allocations.

The contact bleedings developing owing to a slight injury of a tumor, napr at an internal research are characteristic of cancer of a neck of M., at the sexual intercourses. Cancer of a neck of M. can extend on continuation, sprouting walls of a vagina, a bladder and a rectum, can be followed by formation of fistulas (see. Urinogenital fistulas ). Spread of a tumor on M.'s body and appendages is observed seldom. In late a wedge, stages of a disease metastasises of cancer of neck of M. in a vagina, a parametric fat, limf, vessels of a basin, in the next and remote bodies are observed. In some cases there are metastasises of cancer of neck of M. in a backbone.

For diagnosis of cancer of neck of M, use tsitol, a method: its reliability increases aim capture of smears from the surface of a neck of M. or the channel of a neck of M. Primenyayut also a kolposkopiya and a kolpomikroskopiya. In most cases it is necessary to use a biopsy with the subsequent gistol, a research. The choice of the site for a biopsy is facilitated by Schiller's test (coloring of a surface of a neck of M. solution of Lugol): recommend to take for a research a piece of fabric from the iodnegative site.

At cancer of a neck of M. apply limfografiya to the solution of a question of prevalence of tumoral process). For the purpose of diagnosis of metastasises in inguinal, pelvic and lumbar limf, nodes apply radio isotope indirect a limfografiya) with radioactive colloid gold (198Au). Radionuclide is entered subcutaneously into the first interdigital interval of both feet on 200 mkyur. In 24 hours make scanning and a takhografiya. On accumulation of isotope and speed of its movement do the conclusion about changes in limf, nodes.

Apply radiation therapy to cancer therapy of a neck of M. The issue of operational treatment is resolved depending on special indications. In some cases the most effectively combined treatment. If according to the corresponding indications choose operational treatment, then the expanded extirpation of M. — Vertgeym's operation shall be carried out (see. Hysterectomy ).

According to A. I. Serebrov, cases of cancer of neck of uterus at women aged up to 30 years when the disease proceeds especially zlokachestvenno are subject to operational treatment with the subsequent radiation therapy; patients with forms of cancer, insensitive to action of ionizing radiation, patients with a recurrence of cancer of neck of uterus after radiation therapy if operation is feasible; patients, the Crimea in connection with an atrophy, a stenosis, an atresia of a vagina it is impossible to apply beam tera-went; suffering from cancer necks of M. in combination with a tumor of a body of M. and its appendages, especially at pregnancy.

As the independent method of treatment radiation therapy is applied in the form of intracavitary gamma therapies (see), the tumor directed to primary center, in combination with the tele-irradiation influencing zones of regional innidiation.

Tele-irradiation is carried out with the help gamma devices (see), particle accelerators (see) or X-ray apparatus (see). The intracavitary gamma therapy is carried out by means of sources of cobalt-60, caesium-137, radium-226 by their manual introduction to M.'s cavity and side vaults of the vagina and by their implementation on cores conductors, and also by means of the device with distance steering.

Indications to radiation therapy are tumors of a uterus of I, II and the III wedge, stages (T1N0M0; T2NxM0; T3N0,1,2M0). Radiation therapy of tumors of M. is contraindicated at pregnancy, existence of the sacculated suppurative focuses in a cavity of a small pelvis, acute inflammatory processes of M. and tumors of appendages of M.

Fig. 14. The scheme of a basin and internal generative organs with the indication of points for dosing (And yes In) at radiation therapy of tumors of a uterus.

Planning of beam treatment taking into account the sizes of fields of radiation, size of absorbed doses, quantities and arrangements of sources of ionizing radiation, etc. is of great importance for performing radiation therapy. During the scheduling of radiation therapy calculation of doses is conducted for a point And — the center of primary tumor and a point In — the center of a zone of regional innidiation (fig. 14).

The combined radiation therapy of tumors of a neck of M. is usually begun with tele-irradiation static and mobile with ways. Radiation is carried out, as a rule, daily, the single dose makes 200 is glad. After the total absorbed dose reaches 1000 — 2000 is glad, tele-irradiation is combined with intracavitary.

Training of the patient for an intracavitary gamma therapy: a cleansing enema with the subsequent introduction to a rectum of 30 — 50 ml of a liquid paraffin and anesthesia of 2% solution of Promedolum (1 ml) and 0,1% solution of atropine (1 ml).

In position of the patient on ginekol, a chair broaden the canal of a neck of M. with Hegar's dilator to number 6, then enter sources of ionizing radiation or a metrostata.

At manual (protragirovanny) introduction sources of ionizing radiation (activity of each source makes 10 — 20 mg / ekv radium) enter vnutrimatochno in applicators or on cores conductors into metrostata or kolytostata 3 — 5 pieces; in the vulval arches — on one in front and back. Fixing of metrostat or colpostats with a source of ionizing radiation is carried out by means of a lobby and a back hard tamponade of a vagina, and their arrangement (for timely correction) is controlled by a X-ray analysis. Duration of a session of radiation — 24 — 48 hours, an interval between sessions of 2 — 5 days. For 4 — 6 sessions of radiation the total absorbed dose in a point And makes 6500 — 7500 is glad, in a point In — 1200 — 1800 is glad.

Introduction of sources of ionizing radiation is carried out also on the gamma device AGAT-V charged with seven sources of a superactivity on 100 — 300 mkyur everyone. At the same time fractionation of a dose in a point And is carried out in three options: a single dose 500 I am glad, intervals between radiations of 2 — 3 days, a total absorbed dose 5000 I am glad; a single dose 700 I am glad, intervals between radiations of 5 days, a total absorbed dose 4200 — 4900 I am glad; a single dose of 1000 I am glad, intervals between radiations of 7 days, a total absorbed dose 4000 I am glad. Duration of each session of radiation makes usually 20 — 60 min.

Total absorbed doses in a point And for a course of the combined radiation therapy make from 8000 to 10 000 is glad at manual (protragirovanny) introduction of sources of ionizing radiation and from 6000 to 7500 is glad at radiation by means of the gamma device. In a point In a total absorbed dose at I wedges, makes stages of a tumor 4500 — 5000 I am glad, at II and the III wedge, stages — 6000 is glad. At distribution of tumoral process on the lower third of a vagina (T3a) tele-irradiation from the additional perineal field by the sizes of 6x6 cm in a dose 100 can be shown I am glad to a total absorbed dose of 1000 is glad.

The question of chemotherapy of cancer of neck of M. in a complex with operational and beam methods of treatment and about use of chemotherapy as independent method is studied at late stages of a disease.

The forecast at cancer of a neck of M. depends on a stage of process. A number of authors indicates dependence of an outcome of a disease from gistol, structures of a tumor: the forecast is more favorable at planocellular cancer, is less favorable — at the low-differentiated and ferruterous cancer.

Prevention of cancer of neck of M. is directed to timely diagnosis and treatment of precancerous diseases and cancer of in situ. For this purpose perform routine maintenances of women with tsitol, a research of vaginal swabbings. Women, since 40-year age, are recommended to have routine maintenances at least once a year.

the Hysterocarcinoma

the Hysterocarcinoma meets less than cancer of a neck of M., generally at the age of St. 50 years. Development of cancer of body of M. is quite often preceded by focal and diffusion adenomatous changes of an endometria, its ferruterous and cystous hyperplasia in combination with neuroendocrinal and exchange disturbances, napr, obesity, and also a recurrent hyperplasia of an endometria in the period of a menopause. These precancerous changes of an endometria, as a rule, develop against the background of anovulatory menstrual cycles and a hyperplasia of teka-tissue of ovaries. Often the precancer and cancer of a body of M. are combined with tumors of ovaries and a syndrome of Matte — Leventalya, an abnormal liver function.

The precancer of an endometria can be distinguished with the help tsitol., gistol, and other methods of a research, and also definition of the mitotic mode increased, uneven accumulation in an endometria of radioactive phosphorus and nucleinic to - t.

Clinically hyperplastic processes of an endometria are shown by disturbances of a menstrual cycle or acyclic bleedings, emergence of bloody allocations in a menopause.

Treatment of precancerous diseases of a body of M. depends on degree of manifestation of proliferative changes and age of the patient. In the genital period and a premenopauza it is directed to normalization of function of endocrine system and a menstrual cycle (see. Dysfunctional uterine bleedings ). In a postmenopause appoint gestagenny drugs, napr, pregnenoldione kapronat, or the androgens promoting suppression of function of ovaries. At the same time medicinal treatment shall be directed to regulation of functions of a liver, thyroid gland, etc. Patients shall be under dispensary observation.

In the presence of a syndrome of Matte — Leventalya at women of childbearing age the volume of operation can be limited by a sectoral resection ovaries (see). At detection of hormone-producing nonmalignant tumors of an ovary in childbearing age of the woman make an oncotomy of an ovary. In the period of a menopause carry out supravaginal amputation or M.'s extirpation with appendages. In all cases of not radical operative measure it is necessary to add it with hormonal treatment and to carry out control of a condition of an endometria.

Cancer of a body of M. has various gistol. forms. The adenocarcinoma (high-differentiated and low-differentiated is most often observed); less often mucous cancer comes to light, and it is exclusively rare — planocellular endometrial cancer.

Macroscopically cancer of a body of M. represents preferential ekzo-, an endophytic tumor. Often the tumor has an appearance of a polyp or the papillomatous growths reminding by the form a cauliflower. Involvement in tumoral process of a parametric fat happens later, than at cancer of a neck of M. Endometrial cancer even in late stages seldom burgeons in a neck of M. Innidiation is more often observed in lower lumbar limf, nodes, but innidiation and in limf, nodes of a basin is not excluded, especially at a low arrangement of a tumor; sometimes reveal metastasises in inguinal limf, nodes (innidiation on limf, to vessels of a round sheaf). In far come stages of a disease there are metastasises in a liver, lungs, is rare in a bone.

Depending on clinically defined distribution of tumoral process a hysterocarcinoma divide into the following stages: The I stage — a tumor is limited to limits of an endometria; The II stage (Pas tumor with infiltration of a myometrium, 116 — a hysterocarcinoma with infiltration of a parametrium without transition to a wall of a basin, IIV — a hysterocarcinoma with transition to a neck of uterus); The III stage (IIIA — a hysterocarcinoma with infiltration of a parametrium with one or on both sides, with transition to a wall of a basin, III6 — a hysterocarcinoma with metastasises in regional limf, nodes, appendages, in a vagina; IIIV — a hysterocarcinoma with germination of a peritoneum, but without involvement in process of nearby bodies); The IV stage (IVa — a hysterocarcinoma with transition to a bladder or to a rectum, IVB — a hysterocarcinoma with the remote metastasises).

On the TNM system of a stage of a hysterocarcinoma designate as follows: T — primary tumor; TIS — a preinvazivny carcinoma (carcinoma in situ); T1 — cancer limited to a body of the womb; T1a — the cavity of the uterus is not expanded; T1b — a cavity of the uterus is expanded; T2 — cancer of a body with involvement of a neck of uterus; T3 — cancer which is going beyond a uterus including on a vagina, but within a small pelvis; T4 — the cancer extending out of limits of a small pelvis or affecting a mucous membrane of a bladder or a rectum (existence of violent hypostasis is not enough for reference of a tumor to T4).

N — regional limf. nodes; Nx — to estimate a condition pelvic limf, nodes are impossible; at addition with data gistol, researches use designations: Nx_ — lack of metastasises or Nx + — existence of metastasises; N0 — changes regional limf, nodes at a limfografiya are not found; N1 — at a limfografiya are found changes regional limf, nodes.

M — the remote metastasises; There is no M0 — signs of the remote metastasises; M1 — the remote metastasises, including defeat inguinal limf, nodes are available.

G — division on degree of a cellular differentiation; G1 — a tumor with high degree of a differentiation of cells; G2 — a tumor with average degree of a differentiation of cells; G3 — an anaplastic tumor.

In a wedge, a picture the basic and the most frequent symptom causing suspicion of cancer of a body of M. is bleeding. Bloody allocations can appear, e.g., at defecation or the sexual intercourse; there are acyclic plentiful blood losses less often. Suspicion on development of cancer of body of M. causes emergence of bloody allocations in the period of a menopause. Are sometimes observed bleach in the form of plentiful allocations with impurity of slime. At disintegration of a tumor to allocations blood is added, at a pyometra — purulent exudate. Quite often cancer of a body of M. is followed colpitis (see) which results from impact of the infected allocations on a mucous membrane of a vagina.

The pain syndrome joins usually in far come stages of a disease though still V. F. Snegirev noted that the colicy pains in the bottom of a stomach giving to the lower extremities are observed sometimes and in early stages of a disease; these pains are caused by reductions of uterine muscles as a result of M.'s stretching the growing tumor or accumulation of allocations in it.

In diagnosis of cancer of body of M. data gistol, researches of scraping of a mucous membrane of M are decisive. For specification of localization of a tumor the so-called fractional scraping is recommended (see. Scraping, mucous membrane of a uterus ) and a gisterografiya (see. Metrosalpingografiya ). According to many authors, tsitol, the research of the material received by way of aspiration from M.'s cavity and also by so-called washout, allows to specify the diagnosis of cancer of body of M. in 80 — 100% of cases. For tsitol, researches also the deposit received by centrifuging of flushing liquid is suitable. Also apply an intracavitary radio isotope research to diagnosis of endometrial cancer phosphorus-32.

For definition of prevalence of a tumor the pelvigrafiya, a flebografiya, a ginekografiya, a limfografiya, urography are recommended.

Apply operational treatment and radiation therapy to treatment of patients with cancer of a body of M. According to many authors, it is reasonable to make an expanded extirpation of M. (with removal regional limf, nodes), as at cancer of a neck of M. (see the Hysterectomy). However expediency of use in all cases of an expanded extirpation of M. is disputed by a number of clinical physicians since an expanded operative measure at patients of advanced age is connected with big risk and in these cases quite often it is necessary to be limited to a simple extirpation of M. with appendages. As it is accepted at cancer of a neck of M., usually conduct a course of postoperative radiation therapy. At widespread cancer of a body of M. and contraindications to operation and radiation therapy use hormonal drugs (progesterones, or progesterone, in particular pregnenoldione kapronat).

Radiation therapy is carried out gl.obr. at II6, IIV and the III wedge, stages of tumors of a body of M. (T2bNxM0, T3bNxM0). At the same time intracavitary radiation is alternated with remote, a cut carry out static and mobile in the ways only on parametralny area and limf, nodes of a basin as well as at radiation therapy of tumors of a neck of M.

The intracavitary gamma therapy (see) is carried out by filling of a cavity of M. with a beads of cobalt-60 or linear sources of ionizing radiation by a manual way, or by means of special devices after expansion of the channel of a neck of M. (a dilator to number 10). Duration of a session of radiation makes 45 — 48 hours, the total absorbed dose at an interval between radiations of 5 — 7 days for 3 — 4 fractions in a point And makes 8000 — 9000 is glad. Between sessions of intracavitary applications carry out tele-irradiation to a total absorbed dose in a point In — 6000 I am glad.

For the combined treatment of tumors of a body of M. carry out remote or intracavitary radiation before and after operation, the total absorbed dose usually makes 3000 — 4000 is glad.

The forecast at cancer of a body of M. is more favorable, than at cancer of a neck of M. Life expectancy of St. 5 years after treatment, according to many authors, is noted more than at 60% of patients.

Prevention consists in carrying out dispensary observation at anovulatory uterine bleedings (see. Dysfunctional uterine bleedings ), infertility (see), late approach of a menopause, oestrogenic type of vaginal swabbings in the period of a menopause, etc. At routine maintenances make a research of an endometria by aspiration or a diagnostic scraping.

Sarcoma of a uterus

Sarcoma of a uterus is observed rather seldom and makes, according to various data, from 2 to 8% of all malignant tumors of M. Chashche M.'s sarcoma develops in a climacteric and in a menopause, however cases of sarcoma of M. at children are described.

Fig. 4. Macrodrug of a uterus at sarcoma of a body of the womb: the cavity of the uterus is opened, in myometriums diffusion tumoral growths are visible (are specified by shooters).

Sarcoma is localized preferential in M.'s body, a vulval part of a neck of M. is surprised very seldom. Muscular and connecting tissue M., a stroma of a mucous membrane, M.'s vessels, and in some cases fabric of myoma can be a source of development of sarcoma. Intraparietal sarcoma of M. can have the knotty or diffusion form (tsvetn. fig. 4); it quickly burgeons in a parametric fat. Endometrial sarcoma meets less often than intraparietal; usually has an appearance of the polyps which sometimes are going down in a vagina. M.'s sarcoma developing from deep layers of a mucous membrane of a makroskopicheka can have an appearance of a cauliflower, simulating cancer of a neck

of M. Sarkomatoznaya fabric has an appearance of crude fish meat with a mat surface on a section unlike a brilliant surface of myomatous nodes.

On gistol, to a structure distinguish leiomyosarcoma (see), and also veretenoobraznokletochny, kruglokletochny and polymorphocellular sarcoma (see).

Innidiation most often hematogenous; metastasises find in various bodies, but a thicket in lungs and a liver.

Wedge, a picture of sarcomas of a mucous membrane of M. (endometrial sarcoma), and also the sarcoma growing in a submucosa of a myometrium is characterized by bloody, purulent discharges, pain, temperature reaction. Suspicion of sarcoma arises in cases of rapid growth of myoma, and also at a recurrence of polyps of an endometria. In some cases the diagnosis can be made by a diagnostic scraping of a cavity of M.

Treatment of sarcoma of M. preferential operational — an expanded extirpation of M. with the subsequent radiation therapy.

The forecast at sarcoma of M. developing in a myomatous node is rather favorable. The long-term results of treatment considerably concede to results which are available at cancer of M. According to literary data, long recovery (for 5 and more years) is observed only in 20 — 25% of cases.

A hysteromyoma, questions of a morphogenesis, diagnosis, conservative treatment

(From additional materials).

A hysteromyoma — the benign, hormonal and dependent tumor developing from elements of muscular tissue (see). In recent years on the basis of complex morphological and histochemical researches 3 consecutive stages of emergence of a hysteromyoma are allocated: the 1st stage — formation of the active region of growth in myometriums which is located around a thin-walled vessel and characterized by a high level of a metabolism and increased by vascular and fabric permeability; the 2nd stage — rapid growth of a tumor without signs of its differentiation; the 3rd stage — the expansive growth of a tumor with its differentiation and maturing.

The hysteromyoma, as a rule, happens multiple. However depending on preferential localization of nodes it is accepted to distinguish divide-zistuyu, intermuscular (intersticial) and subperitoneal (subse-rozny) myoma. Each type of myoma has certain morphological, histochemical, clinical features. So, in an iodslizisty node the quantity of muscle cells, a glycogen, ribonucleoproteins, increase in activity of enzymes of a cycle tricarboxylic to - t and glycolytic enzymes is noted bigger in comparison with subperitoneal. Features of structure of a myomatous node and a metabolism in it to a certain extent repeat features of that layer myometriums, in Krom it is formed. Subperitoneal nodes consist preferential of connecting fabric, intermuscular and submucosal nodes are formed generally by growths of smooth muscular tissue. Depending on expressiveness of proliferative processes in smooth muscle fibers distinguish simple and proliferating hysteromyomas.

The main role in emergence and development of a hysteromyoma functional disturbances in system play a hypothalamus — a hypophysis — ovaries — a uterus, to Disorder of functions of and m to cash *) - gi i of a yufiz rno go z veins and this system promote hron.

diseases (adenoid disease, disbolism, endocrine diseases), heavy inf. diseases, etc. Dysfunctions of ovaries can arise as a result of frustration of the highest regulating centers, and also is as a result long the current inflammatory processes, napr, recurrent salpingo-oophorites (see the Adnexitis). Dysfunctions of a uterus can be caused by disorder of functions gipotalamo-gi-pofizarnoy systems, ovaries or the changes in the uterus arising owing to frequent artificial abortions (see Abortion artificial) and is long the current endometritises (see M etroend about a metritis), and also at malformations of a uterus. Thus, if function of one of links of system a hypothalamus — a hypophysis — ovaries — a uterus, in patol is broken. process all links of this system are involved in a varying degree. The most important role is played at the same time by the hormonal shifts happening at early stages of development of a tumor. At patients with a hysteromyoma disturbances of products of follicle-stimulating (FSG) and luteinizing (LG) of hormones are revealed (see. Follicle-stimulating hormone, L yuteiniziruyushchy hormone) and the sexual steroids interfaced to them. Comprehensive examination of women with a hysteromyoma allowed to establish that a number of patients has a two-phase ovulatory cycle (see. A menstrual cycle) that is confirmed by approach of pregnancy. At other patients inferiority of function of a yellow body owing to insufficient products a hypophysis of luteinizing hormone takes place. At many women with a hysteromyoma it is noted and N about in at l I am c iya (with m. And it is new at la that r and y y

a cycle), sometimes there are anovulatory to a disf national uterine bleedings (see) both against the background of a gi-perestrogeniya, and at normal concentration of estrogen (see).

In a pathogeny of a hysteromyoma the oestrogenic receptors which are in myometriums are of great importance. At myoma increase in their quantity, and also sensitization to oestrogenic influences, especially to oestradiol is revealed. As a result of it the sensitization of a myometrium to effect of estrogen raises, and these to some extent can explain emergence of a hysteromyoma at women with the normal or lowered products of estrogen.

An important role in a pathogeny of a hysteromyoma is played by disturbance of blood supply of ovaries and a uterus. So, in ovaries at a hysteromyoma the thickening of walls of vessels, especially venous is noted. Disturbance of vascularization of follicles as a result of sclerous changes in intersticial tissue of ovaries can be one of causes of infringement of process of an ovulation. Also changes of very tectonics of vascular network of a uterus are observed. At an intermuscular arrangement of mi yum and that evil nodes in many of them there are diffusion disturbances of blood circulation, and at submucosal localization of myoma focal circulatory disturbances are noted. The dystrophic processes caused by disturbances of blood circulation lead to changes of the neyrore-tseptorny device of a uterus and an afferent impulsation.

At patients with a hysteromyoma also change of a homeostasis is observed that is expressed by oppression of a nonspecific immune responsiveness of an organism, the hyperproteinemia expressed by a disimmunoglobu-linemiya, an autoserotherapy to tissues of a uterus, uterine tubes and ovaries, etc. Disturbances of a homeostasis are aggravated with development iron of the scarce anemia (see) which is often observed at a hysteromyoma.

A number of researchers indicate a certain role of heredity in development of a hysteromyoma.

E. M. Vikhlyaeva (1980) conditionally allocates two kliniko-pathogenetic options of a hysteromyoma: primary and secondary myoma. Primary myoma arises against the background of hereditary burdeness, disturbance of hormonal ratios in the pubertal and post-pubertal period, the expressed genital infantility, primary infertility. Secondary myoma develops at women with earlier undisturbed reproductive function. Changes of receptors of a myometrium owing to local patol are the cornerstone of such myoma. the processes caused most often by repeated abortions, chronic inflammatory diseases of generative organs, operative measures on appendages of a uterus, etc.

The diagnosis of a hysteromyoma usually does not represent difficulties. At a two-handled research (see. A gynecologic research) find increased, a dense consistence, a painless uterus. However at obesity, tension of an abdominal wall during the research, and also at an arrangement of nodes near an edge of a uterus it is necessary to conduct additional, quite often comprehensive examination.

The clinic for women defines hematologic indicators, functional activity of ovaries (tests of functional diagnosis, content of estrogen and progesterone in blood and urine), a condition of mammary glands. At difficulties in diagnosis the patient is directed in ginekol. the hospital where make a gisterografiya (see Met-rosaljpingografiya), hysteroscopy (see), is more rare a pnevmopelviografiya (see Peljvigrafiya), ultrasonic investigation (see. Ultrasonic diagnosis, in obstetrics and gynecology), a pelvic flebografiya (see. A pelvic angiography), the size allowing to establish, localization of myoma, to differentiate it with a cyst or a tumor of an ovary and to estimate efficiency of treatment. In some cases carry out a laparoscopy (see Peritoneoskopiya). According to indications carry out an aim biopsy of an endometria, a vulval part of a neck of uterus, a separate diagnostic scraping (see), and also definition of a bioelectric uterine activity. At development of myoma, especially at its rapid growth, the change of a bioelectric uterine activity which is expressed in increase in amplitude and frequency of bioelectric potential (see) is noted. Distinctions in indicators of a bioelectric uterine activity depending on localization of nodes of a tumor are noted. At disturbance of a lipometabolism investigate cholesterol (see), bilirubin (see) and other indicators of lipidic exchange (see the Lipometabolism), sugar in blood and urine. At the expressed gipotalamo-pituitary disturbances carry out EEG (see Elektroentsefalografiya), a kraniografiya (see), determine the level of gonadotropic hormones in a blood plasma.

As a result of the researches conducted in recent years the non-interference position existing for many years up to emergence of indications to operational treatment was replaced by a clear tendency to performing conservative therapy. Corrective actions carry out already at early stages of development of a hysteromyoma, strictly consistently, taking into account a premorbidal background, age of the patient, the nature of hormonal disturbances, features of growth of a tumor, an arrangement of myomatous nodes, etc. At absence a wedge, displays of a disease it is possible to carry out conservative therapy at the sizes of a tumor corresponding to the size of a uterus to 13 — 14 weeks of pregnancy during the reproductive period and to 15 — 16 weeks of pregnancy — to the premenopauzny period.

Surely include treatment of the accompanying gynecologic and extragenital diseases (special attention is paid to chronic colpitises, endometritises, salpingo-oophorites), correction of neuroendocrinal and exchange disturbances, treatment of anemia in a complex of therapeutic actions.

Appoint (especially at disturbances of a lipometabolism) vitamins A, Vkh, B6, B15, C, P, sedative and other symptomatic means, and also physiotherapeutic procedures. The last include electrotreatment (see) — an electrophoresis of Bj vitamin, AKTG, zinc and other pharmaceuticals, electrostimulation of a neck of uterus, balneotherapy (see) — radonic, iodine-bromine, narzan, pine needle baths, ultrasonic therapy (see). The listed methods of treatment allow to reduce considerably further amount of the entered hormones, and at early stages of development of a tumor in a number of patients to avoid their use.

Purpose of gestagen (see Progestins) is shown to patients with the hysteromyoma proceeding without the expressed symptomatology at prescription of a disease up to five years. Treatment is carried out during three menstrual cycles. Hormonal therapy is performed under control of tests of functional diagnosis. The supporting treatment (physical therapy, hormonal therapy) is carried out by two times a year within two-three years.

The positive effect from conservative therapy (the termination of growth and reduction of the sizes of a tumor, normalization of a menstrual cycle, disappearance of pains and other symptoms) is observed more than at two thirds of patients with a hysteromyoma. Bibliography: Vasilevskaya L. N.

Gipotalamo - pituitary and ovarian вза^ an imootnosheniya at the combined dishormonal giperplaziya of a uterus and mammary glands, Akush. and ginek., No. 9, page 10, 1971; it, Complex conservative treatment of patients with a hysteromyoma in the reproductive period, in the same place, No. 1, page 15, 1980; Vikhlyaeva E. M. Topical issues of clinical practice at conservative maintaining patients with a hysteromyoma, in the same place, No. 1, page 8, 1980; Vikhlyaeva E. M and P and l of l and d and G. A * Pathogeny, clinic and treatment of a hysteromyoma, Chisinau, 1982; To l e N and the Central Committee and y Ya. S. Hysteromyoma, Alma-Ata, 1966, bibliogr.; Meypalu V. E. and to Sillast V. A. Comparative histology of myomatous and muscular tissue of a uterus, Vopr. onkol., t. 14, No. 10,

page 41, 1968; The Hysteromyoma, under the editorship of,

JI. N. Vasilevskaya, etc., M., 1979; With ER about in V. V., etc. Morphogenesis of hysteromyomas, Akush. and ginek., No. 1, page 3, 1973; G a v and 1 1 e of I. Beitrage zur Klarung der pathologischen Bedeutung der Ovarial-funktion anhand von Beobachtungen bei gynakologischen Operationen, Z. Geburtsh. Gynak., Bd 168, S. 300, 1968; Hohl M. K. Erhaltung der Funktion bei Uterus Myomatosus, Gynakologie (Berl.), Bd 13, S. 138, 1980;

Matsu-naga E. Shiota K. Estopic pregnancy and myoma uteri, Obstet, gynec., Surv., v. 35, p. 579, 1980; Pietila K. Tahti E. Zur Rontgendiagnose des Uterusmyoms, Fortschr. Rontgenstr., Bd 122, S. 262, 1975. JI. H. Vasilevskaya.


OPERATIONS

At operations on M. which are carried out according to the emergency indications, e.g. concerning bleeding from M.'s neck after a biopsy, diathermocoagulation, an injury, uterine bleeding at submucosal myoma, M.'s rupture, etc. of special preoperative preparation pe carry out. In the course of preparation for planned operative measures appoint bulk analysis of blood and urine, definition of group, a Rhesus factor accessory of blood and a koagulogramma, a bakterioskopichesky research of vulval allocations. In some cases in the preoperative period carry out treatment of associated diseases of a liver, kidneys, cardiovascular system, a diabetes mellitus, anemia, etc.

Before the operations on M. performed by vulval access within 2 — 3 days appoint vulval syringings disinfecting solutions (at the III—IV degree of purity of vulval allocations carry out longer syringings).

On the eve of operation by the patient dine easy, in the evening — sweet tea; in the evening and appoint cleansing enemas in the morning.

Plastic surgeries on M.'s neck can be executed under local anesthesia in combination with an anesthesia nitrous oxide. At a laparotomy method of the choice of anesthesia are inhalation anesthesia (see), peridural, and also local anesthesia (see. Anesthesia local ).

Access at operations to M. can be through an abdominal wall (see. Laparotomy ) and through a vagina. Abdominal section can be longitudinal or cross (see. Pfannenshtilya section ). (On Dederleyna) resort to a slit more often since it provides broad access to an abdominal cavity. E.g., operations for malignant tumors make through an abdominal wall by means of a slit as audit of abdominal organs and a small pelvis is necessary. Cross section (across Pfannenshtil) is more preferable at simple operations, tumors of the small sizes.

At M.'s myomas of operation make in the abdominal way more often; at small tumors or the born submucosal nodes apply a vulval method. At a vulval method the chrevosecheniye is made through the front or back vulval arch; if a vagina narrow, do additional perineovaginal incision.

Conservative plastic surgeries — a myomectomy (enucleation of nodes of myoma) should be made not earlier than 14 weeks duration of gestation; are usually limited to enucleation of the isolated subserous nodes which in size and an arrangement interfere with development of pregnancy. At the same time all manipulations shall be carried out carefully and carefully, without removal of a uterus from an abdominal cavity. Before and after operation it is necessary to carry out prevention of abortion. After opening of an abdominal cavity over a node cut the capsule. The node which seemed in an opening of the dissect capsule is taken nippers to Myuza, a Kocher's forceps or a corkscrew and tightened on M.'s surface, then in the acute or stupid way the node is otseparovyvat and taken. The bed depending on the size of a remote node and depth of a wound is taken in separate knotty catgut seams to 2 — 3 floors (muscular and muscular, muscular and serous, gray and serous). At sewing up of a bed of a remote node of a ligature it is not necessary to carry out through a mucous membrane of M. since it in the subsequent can lead to internal endometriosis.

In a puerperal period in the presence of M.'s myoma plentiful bleeding can be observed, a cut does not stop also after removal of a placenta; in such cases supravaginal amputation or a hysterectomy is shown (see). In a late puerperal period at submucosal myoma of M. bleedings and fetid allocations can be observed that can be the indication for operation: make untwisting of a submucosal tumor, supravaginal amputation or M.

Tekhnik's extirpation of supravaginal amputation of a uterus without appendages. Open with a cross suprapubic section an abdominal cavity. M.'s bottom is taken bullet nippers and tightened to an operational wound. After M.'s removal impose clips on a round linking and the uterine ends of pipes on both sides, cut and tie up a catgut. Between stumps of round sheaves cut a peritoneum. The bladder is taken away in the stupid way from top to bottom. On both sides at the level of an isthmus M., is closer to M.'s neck, press and cross uterine vessels. The ends tie up them a strong catgut or silk. After that M.'s body is cut at the level of an isthmus M., is slightly higher than the tied-up uterine vessels. The stump of a neck of M. is taken clips, grease 10% with spirit solution of iodine and taken in separate catgut seams. Peritonization of a stump of a neck of M. is carried out by rapprochement by a continuous catgut suture of back and front leaves of a serous cover of M.; stumps of appendages immerse between leaves of a wide sheaf purse-string seams. Make a toilet of an abdominal cavity and take in a wound layer-by-layer tightly.

Defundation and high amputation of a uterus. Technology of operation reminds a technique of supravaginal amputation of M. In certain cases the tumor is located only in day, and at excision it is possible to keep M.'s communication with appendages. However more often operation is begun with separation of appendages from M. and imposing of clips on the ascending branches of uterine vessels at the level, above to-rogo it is supposed to excise a bottom of M. After bandaging of vessels make a defundation M. Zatem separate catgut seams close an opening of a cavity of M., over it for the best contact impose the second tier of catgut seams. Peritonization is carried out as well as at supravaginal amputation of M.

Concerning omission and M.'s loss and its wrong situation many operational methods — are offered see. Ventrosuspenziya of a uterus , Prolapse of the uterus, vaginas , Dzhilyama — Doleri operation etc.



Bibliography: Alexandrov M. S. Surgical treatment of fibromyomas of a uterus, M., 1958, bibliogr.; B and to sh e e in H. G. and Orlov R. S. Sokratitelnaya function of a uterus, Kiev, 1976, bibliogr.; B about x - m and Ya. V. Klinik's N and cancer therapy of a neck of uterus, Chisinau, 1976, bibliogr.; it, Metastasises of cancer of uterus, JT., 1976, bibliogr.; Braude I. L. Operational gynecology, M., 1959; Braude I. L., Malinovsky M. S. of A. I iserebr. Not operational gynecology, page 34, etc., M., 1957; In and x - l I am e in an E. M. Principles of maintaining patients with a hysteromyoma, Akush, and ginek., No. 9, page 3, 1971; Volkova O. V. and Baking M. I. Embriogenez and age histology of internals of the person, M., 1976; Golovin D. I. Atlas of tumors of the person, L., 1975; Zheleznov B. I. Precancerous changes of a neck of uterus and endometria, Arkh. patol., t. 34, No. 5, page 3, 1972, bibliogr.; Clinical oncology, under the editorship of H. N. Blochina and B. E. Petersona, t. 2, page 490, M., 1979, bibliogr.; Kozlova A. V. Radiation therapy of malignant tumors, page 148, M., 1976; Lebedeva L. I. and Orlov R. S. A functional condition of the central nervous system during a childbed, Akush, and ginek., No. 4, page 7, 1969, bibliogr.; A hysteromyoma, under the editorship of E. M. Vikhlyaeva, M., 1970; The Multivolume guide to obstetrics and gynecology, under the editorship of L. S. Persianinov, t. 5, page 70, M., 1962; The Multivolume guide to pathological anatomy, under the editorship of A. I. Strukov, t. 7, page 501, M., 1964; Pathology of an endometria, under the editorship of I. M. Gryaznova and G. M. Savelyeva, M., 1977; Persianinov L. S. Operational gynecology, M., 1976; Persianinov L. S., Zheleznov B. I. both Bogoyavlensky N. V. Fiziologiya and pathology of sokratitelny activity of a uterus, M., 1975, bibliogr.; Pokrovsk V. A. Genital tuberculosis, Voronezh, 1947, bibliogr.; Regulation of patrimonial activity, under the editorship of N. S. Baksheev, etc., page 12, Kiev, 1966; The Guide to cytologic diagnosis of tumors of the person, under the editorship of A.S. Petrova and M. P. Ptokhov, page 117, M., 1976; Tymoshenko L. V. and d river. Fibromyoma of a uterus and pregnancy, Chisinau, 1972, bibliogr.; Topchiyeva O. I., Pryanishnikov V. A. and Zhemkova 3. P. Biopsiya of an endometria, M., 1978, bibliogr.; Yakovleva I. A. ikukute B. G. Morphological diagnosis of pretumor processes and tumors of a uterus on biopsies and scrapings, Chisinau, 1979, bibliogr.; Ackerman L. V. a. d e 1 Regat about J. And. Cancer, diagnosis, treatment and prognosis, St Louis, 1970; Biology of the uterus, ed. by R. M. Wynn, N. Y., 1977; Burg-hardt E. Histologisciie Fruhdiagnose des Zervixkrebses, Stuttgart, 1972, Bibliogr.; o h of e, Early histological diagnosis of cervical cancer, Philadelphia, 1973; Dallenbach-Hellweg G. Histo-pathology of the endometrium, V. a. o., 1975; Endocrinology of the pregnancy, ed. by F. Fuchs a. A. Klopper, Hagerstown, 1977; Ferenczy A. Rich a r t R. M. Female reproductive system, N. Y., 1974; F i n n C. A. a. Porter D. G. The uterus, L., 1975; Genetics of human cancer, ed. by J. J. Mulvihill, N. Y., 1977; Gynecological oncology, ed. by H. R. K. Barber a. E. A. Graber, p. 69, Amsterdam, 1970; K aser O. u. I kl e A. Atlas der gynakologischen Operationen, Stuttgart, 1960; Mikulicz-Rade-c k i F. Gynakologischen Operationen, Lpz., 1962; Novak E. R. The endometrium, Clin. Obstet. Gynec., v. 17, p. 31, 1974; Novak E. R. a. Woodruff J. D. Novak’s gynecologic and obstetric pathology with clinical and endocrine relations, Philadelphia a. o., 1974; Oxytocin, ed. by R. Caldeyro-Barcia a. H. Heller, p. 100, N. Y. a. o., 1961; Pathology of the female genital tract, ed. by A. Blaustein, p. 124, N. Y. a. o., 1977; Those Linde R. W. a. Mattingly R. F. Operative gynecology, Philadelphia — Toronto, 1970; The uterus, ed. by H. J. Norris a. o., p. 255, Baltimore, 1973.


L. S. Persianinov, G. M. Savelyeva; O. V. Volkova, M. S. Malinovsky (An., gist.), B. I. Zheleznov (stalemate. An.), V. N. Kiselyova (I am glad.), H. M. Pobedinsky (rents.), A. I. Serebrov (PMC.).

Яндекс.Метрика