Presentation on the topic of endometriosis modern methods of treatment. Endometriosis academician of the Russian Academy of Sciences, professor, doctor of medical sciences ozolinya lyudmila anatolyevna presentation plan

Academician of the Russian Academy of Natural Sciences, professor, doctor medical sciences
Ozolinya Ludmila Anatolyevna

Presentation plan

Definition and classification
Risk factors
Etiology
Pathogenesis
Clinical manifestations
Diagnostics
Treatment

Endometriosis -

Dyshormonal immune-dependent disease, characterized by a benign growth of tissue similar to the endometrium, but located outside the uterine cavity.

Classification of endometriosis:

extragenital
Genital

Internal: body of the uterus (adenomyosis), isthmus of the uterus, interstitial sections of the fallopian tubes
Outer:
Intraperitoneal:
ovaries
The fallopian tubes
Peritoneum of small pelvis

Extraperitoneal:

external genitalia
Vagina
Vaginal part of the cervix
Retrocervical region

I degree- germination of the mucous membrane into the myometrium to the depth of one field of view at low magnification of the microscope
II degree- defeat up to ½ of the thickness of the uterine wall
III degree- the entire muscle layer is involved in the process

Histological classification of adenomyosis:

Glandular
Stromal

Risk factors for endometriosis:

Diagnosis of endometriosis

Clinical picture (complaints, anamnesis)
Gynecological examination

Examination of the external genitalia, abdomen, examination of the cervix and vaginal walls in the mirrors
Bimanual vaginal-abdominal examination
Rectal, recto-abdominal, recto-vaginal examination

Additional examination methods

Oncocytology from the cervix, from the uterine cavity
Colposcopy
WFD
ultrasound
Hysteroscopy
Laparoscopy
X-ray methods
Sigmoidoscopy, colonoscopy
CT
Consultations of related specialists

I stage

Endoscopic diagnostics (colposcopy, hysteroscopy, laparoscopy)
Biopsy
Surgical intervention (maximum removal of endometriosis foci)

Complex therapy with an emphasis on hormone therapy

Repeat endoscopy to monitor the effectiveness of treatment

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general characteristics endometriosis. Description of endometriosis in the uterus and external genitalia. Consideration of the stages of the pathological process in the mucous membrane of the body of the uterus. risk factors for this disease. Symptoms, differential diagnosis, treatment.



However, one must immediately warn about the danger of turning endometriosis into a "trash can" of a hasty and careless diagnostic search.



= A hormone-dependent disease that develops against the background of a violation of immune homeostasis and is characterized by the growth of tissue identical in structure and function to the endometrium beyond the boundaries of the normal location of the uterine mucosa = Characterized by the appearance of endometrioid heterotopias in the myometrium Endometriosis

Classification of endometriosis Genital - localized in the internal and external genital organs External - vagina, vaginal part of the cervix, retrocervical region, fallopian tubes, ovaries Internal - body of the uterus, isthmus of the uterus, interstitial sections of the tubes (70-90% of all endometriosis of the genital organs) Extragenital – endometrioid implantation in other organs and systems

Genital endometriosis One of the most common diseases of reproductive age On the 3rd place after fibroids and inflammatory diseases

7-50% of women of childbearing period depends on: - age, - race, - geographical area, - social economic situation, — state of the hypothalamus-ovarian-uterus system, — 28% after laparotomy More often after 38 years, B recent times an increase in the number of diseases between the ages of 14 and 24 Genital endometriosis

Often erroneously operated on for: - appendicitis, - adhesive disease, - intestinal obstruction, - ectopic pregnancy, - ovarian apoplexy Reverses to menopause Genital endometriosis

Genital endometriosis By localization more often in: 1. uterus 2. ovaries 3. retrocervical space 4. combined forms 5. retrovaginal space 6. cervix

Genital endometriosis By form: 1. diffuse 2. focal 3. nodular Adenomyosis = focal and nodular form of internal endometriosis By degree of prevalence: 1, 2, 3, degrees

Theories of origin 1. Embryonic develops - from the remains of wolf bodies or displaced sections of the embryonic tissue, from which the genital organs develop, in particular the endometrium is confirmed by the detection of active endometriosis cells at 11-12 years old and a combination of "E" with anomalies of the genital organs, MVS, gastrointestinal tract

Theories of origin 2. Endometrial - from the elements of the endometrium, displaced into the thickness of the myometrium, ovaries, tubes and outside the genital apparatus in case of: - hormonal imbalance, - surgical interventions (abortions, diagnostic curettage, cesarean section, enucleation of fibroids) - mechanically or by current blood and lymph

Theories of origin 3. Metaplastic - as a result of: - metaplasia of the embryonic peritoneum or coelomic epithelium, - transformation into endometrioid-like tissue: endothelium of lymph nodes, pleura mesothelium, epithelium of skin tubules and other tissues

Features of endometriosis Ability to infiltrating growth with penetration into surrounding tissues and their destruction: - into the wall of the intestine, - bladder, - ureter, - peritoneum, - bone tissue

Features of endometriosis Possibility of metastasis by lympho- or hematogenous way - foci "E" in the lymph nodes, - on the face, - in the eyes, - scars on the skin, - mammary glands, - subcutaneous fat, - chest, lungs



Concepts of the biological essence of endometriosis True neoplasm Borderline disease (between hyperplasia and tumor) Tumor-like dyshormonal proliferate capable of malignancy

Differences between endometriosis and a true tumor There is no pronounced cellular atypia There is no ability for autonomous non-stop growth Depends on menstrual function

Clinic of endometriosis Enlargement of the size of the uterus Pain of varying intensity during menstruation (the nature of the pain depends on the location of the "E" foci) Bleeding Perimenstrual scanty discharge Infertility Frequent combination with fibroids



Ultrasound technique Informativeness 40-86% TAUS - 45-56% TVUS - informativeness - 83% Dopplerography is informative: - for myomas - 90%, - sarcomas - 100%, - adenomyosis - 9%, Vmax> 23 cm / s - x- on and for myomas, R I > 0.43, different from malignancy - R I< 0, 43 (пороговое значения)

Technique of ultrasonography of CDC - sensitivity 100%, specificity - 83%, accuracy 96% Grade 1 - 20% Grade 2 - 68% Grade 3 - 88% Nodular - 41-77%

The reliability of ultrasound diagnostics depends on: Mandatory use of TVUS in the 2nd phase of the cycle from days 18 to 25 (a few days before the start of the cycle) Dynamic observation in various phases of the cycle in the presence of clinical symptoms and the absence of ultrasound signs Assessment of the basal layer of the endometrium

Typical ultrasound symptoms of internal endometriosis (diffuse form) Enlargement of the uterus (> anterior-posterior size) Asymmetric thickness of the walls of the uterus Appearance in the myometrium of areas - cellular inclusions of increased echogenicity Presence of small (2-6 mm) rounded anechoic inclusions Transverse striation of the myometrium Jagged or corroded contours basal layer

Internal endometriosis Four stages (degrees) according to the depth of myometrial lesion I. Myometrial lesion to a depth of 2-3mm II. Involvement in the process up to half of the wall thickness III. The defeat of the entire thickness of the wall to the serous membrane IV. Involvement of the parietal peritoneum and adjacent organs

Internal endometriosis - I Thickness of the uterus 4.6 ± 0.6 cm; Wall thickness difference 0.3 ± 0.2 cm; Hypoechoic zone around the endometrium; Hypo- and anechoic structures 1-2 mm in the basal layer; Uneven thickness of the basal layer; !! Serration or irregularity of the basal layer; In the myometrium, the basal layer may have hyperechoic areas up to 0.3 cm



Internal endometriosis - II Thickness of the uterus 5.1 ± 0.7 cm; Wall thickness difference 0.8 ± 0.3 cm; In the myometrium, near the basal layer, there is a zone of increased echogenicity of varying thickness; The presence in the zone of increased echogenicity of anechoic inclusions 0.2-1.1 cm, sometimes containing a suspension Serration, indistinctness of the basal layer

Adenomyosis - internal endometriosis - II

Internal endometriosis-III (adenomyosis) Thickness of the uterus 6.0 ± 1.2 cm; Wall thickness difference 2.0 ± 1.2 cm; In the myometrium, the hyperechoic zone is more than half the wall thickness; The presence in the hyperechoic zone of anechoic inclusions 0.2-0.6 cm, sometimes containing a suspension; Sign of vertical stripes = transverse striation of the myometrium Decreased sound conduction Irregularity, fuzziness of the basal layer





Internal endometriosis-IV L.V. Adamyan recommends distinguishing the IVth stage of internal endometriosis, which consists in involvement in the pathological process, in addition to the uterus, the parietal peritoneum of the small pelvis and neighboring organs. Sonographically, this can manifest itself in the form of non-specific signs:



Internal endometriosis (nodular form) (In 60-70% combined with fibroids) Hyperechoic zone 1.5-5.4 cm rounded or oval with even and clear contours; The presence in it of anechoic inclusions 0.2-3.0 cm, sometimes containing a suspension; Reduced sound conduction in the node Sign of vertical stripes Uneven and fuzzy contours of the endometrium



Internal endometriosis (focal form) (50% combined with fibroids) Hyperechoic irregular zone with indistinct, blurred and uneven contours; The presence in it of anechoic inclusions 0.2-3.0 cm, sometimes containing a suspension



Stromal type The main manifestations are changes in the contour of the walls of the uterine cavity: - pitting - asymmetry - deformity These changes persist throughout the cycle and do not change In patients with a long course of the disease Deformation of the contours of the cavity corresponds to the stromal and fibrous forms of the histological picture in ADENOMIOZE



Glandular type The main manifestations The appearance of endometrioid cysts and passages deep into the myometrium The dynamics of changes depending on the phase of the cycle: - the appearance in the II phase of the cycle - the disappearance in the I phase of the cycle Cysts and endometrioid passages correspond to the histological picture of the glandular form of ADENOMYOSIS



Monitoring of conservative treatment In the early stages, conservative treatment is possible in order to preserve reproductive function Hormonal therapy with drugs that depress the system of regulation of reproductive function from the hypothalamus to target organs Drug treatment is reflected in the ECHO - a picture of the cavity: with a positive effect, endometrioid cysts and passages disappear, - appears corroded contours of the cavity with ineffective treatment - the appearance of cysts and passages in patients with irregularities in the contours of the uterus



Indications for surgical treatment Adenomyosis accompanied by endometrial hyperplasia Internal endometriosis in combination with ovarian hyperplastic processes and endometrial precancer No positive effect from conservative therapy for 3 months. The presence of contraindications to hormonal therapy The combination of endometriosis with other diseases of the internal genital organs requiring surgical interventions

Endometriosis of the cervix Optimal time diagnostics - luteal phase The echostructure of heterotopias is non-specific, Echogenic "suspension" is often visible in the cysts. The sizes of heterotopias vary from 0.3 to 2 cm



Endometriosis of the cervix … In rare cases, reaching a sufficiently large size Heterotopias decrease or even disappear in the follicular phase

Retrocervical endometriosis (10-14%) Visualization behind the neck or isthmus of a formation ranging in size from 0.7 to 4.5 cm (average 1.7 ± 0.7 cm); The contour of education is usually uneven; The boundaries of education are usually indistinct; Echogenicity is often reduced (63%), less often medium (20%), or increased (17%);

Retrocervical endometriosis (10-14%) Internal echostructure is heterogeneous; Often there is pain when pressing the sensor on the area of ​​interest; The appearance in the wall of the rectum of an echo-negative zone up to 2 cm thick Non-displacement of the intestine when pressed by the sensor

Retrocervical endometriosis The pathological process involves the vaginal wall, sacro-uterine ligaments, isthmic and posterior wall of the uterus, sigmoid and rectum, bladder, ureters. the presence of ovulatory cycles Immediately after menstruation in patients with retrograde reflux of menstrual blood during anovulatory cycles

Retrocervical endometriosis The presence of free fluid in the retrouterine space reveals adhesions and deformities of the contours of the posterior fornix. The recto-uterine space during RE is changed: - the contours of the Douglas space are deformed, - there are retractions, irregularities with the formation of asymmetric cavities



Retrocervical endometriosis The presence of free fluid in the posterior fornix. Parietal endometrioid heterotopia Deformation, fusion of the posterior fornix. Fluid asymmetry relative to the neck

Retrocervical endometriosis With complete fusion of the posterior fornix, the border is not differentiated, the rectum is tightly adjacent to the posterior contour of the uterus in the region of the neck and isthmus. Free fluid is determined around the ovaries and in the lateral fornix.

Endometriosis of the ovaries Localization of cysts on the side and posterior to the uterus (very rarely above the uterus); The wall is thickened to 0.2-0. 5 cm; Double wall contour (in 72%); Contents: - Homogeneous finely dispersed immovable suspension (80%), - with parietal hyperechoic inclusions (4%) - anechoic (10%)

Endometriosis of the ovaries Absence of blood flow along the periphery of the cyst No change in size during dynamic observation Non-displacement, fixation in the small pelvis





Ovarian endometriosis - differential diagnostic series Mucinous cystadenoma Mature teratoma Solid ovarian tumors Hematosalpinx Piovar Yellow body

Prof. A.A. Popov Moscow Regional Research Institute of Obstetrics and Gynecology

slide 2

Endometriosis in numbers

1 in 10 women of reproductive age suffers from endometriosis Rogers et al. Reprod.Sci 2009 16:335-346 1,761,687,000 women aged 15-49 World Bank Population Protection Tables by Country and Group, 2010 176 million women today have endometriosis

slide 3

infertility and endometriosis

The most common cause of infertility Endometriosis as the cause of infertility was registered in 38% of infertile couples There is no correlation between the degree of prevalence of endometriosis and the frequency of impaired fertility The success of treatment does not exceed 45-58%

slide 4

Endometriosis is one of the main causes of female infertility.

After surgical and hormonal treatment, pregnancy occurs in 30-52% of patients. Repeated laparoscopy as a method of restoring fertility is not effective. Koga K et al., Hum Reprod 2006, Ragni G et al., Am J Obstet Gynecol 2005, Kulakov V.A. et al., 2002, Volkov N.I., 1996

slide 5


Surgery for endometriosis-associated infertility: a pragmatic approach P. Vercellini, E. Somigliana, P. Vigano, A. Abbiati, G. Barbara, P. G. Crosignani Human Reproduction, Vol.

The actual pregnancy rate during surgical treatment does not exceed 25% and depends little on the type of lesion. The effectiveness of surgery for peritoneal endometriosis is also low. The result of excision of rectovaginal lesions is questionable and is associated with a higher rate of complications.

slide 6

ESHRE guidelines for the diagnosis and treatment of endometriosis (2005)

www.endometriosis.org/guidelines.html Laparoscopy is the gold standard in the diagnosis and treatment of endometriosis. In minimal endometriosis, ovarian suppression alone is not effective enough to restore eating. fertility. Ablation of heteropopies and dissection of adhesions is more effective in restoring natural fertility compared to a diagnostic procedure. There is insufficient evidence whether surgical ablation for severe endometriosis increases pregnancy rates. IVF is the best treatment for patients suffering from infertility, however, the effectiveness of IVF in these patients is lower than in patients with TPB. The treatment of endometriosis is complex and should be carried out in clinics where there is extensive experience and capabilities in the treatment of this disease.

Slide 7

Ablation or excision of endometrioid heterotopias?

• Slide 8

  Genital endometriosis and infertility

• Slide 9

  Peritoneal endometriosis I-II degree.

  Laparoscopy Expectant management 6 months CIO (3-4 cycles) If there is no effect - IVF

  Slide 10

  Peritoneal endometriosis III-IV degree

  Laparoscopy Waiting for pregnancy 6 months. In the absence of effect - IVF

  slide 11

  Rationale for perioperative use of hormones.

  Persistent hypoestrogenism. Reducing blood loss during surgery. Reducing the size of formations Treatment of anemia (excluding menstrual loss). Improving the course of the postoperative period. Reducing the frequency of recurrence of endometriosis.

  slide 12
  

  Laureates NP (1977) for the discovery of GnRH R. Guillemin and A. Schally

  slide 13

  Tactics for endometrioid ovarian cysts

  Anamnesis (presence of endometriosis during surgical interventions) Size of the cyst (more or less than 4 cm) Localization (one or two-sided) The age of the woman The state of the ovarian reserve Any ovarian formation - oncological alertness!

  Slide 14

  Impact of endometrioma surgery on ovarian function

  Endometrioma is a true ovarian tumor that requires removal and histological verification Surgery for extensive ovarian endometriosis gives the most favorable balance between the ratio of effectiveness and possible harm (P.Vercellini, 2009) Laparoscopic surgery is the "gold" standard The technique of mechanical removal of the cyst pseudocapsule followed by hemostasis (V. Cela, 2005, N. Volkov, 2004)

  slide 15
  

  PR after IVF (n=104, data from OR MONIAH) 23

  slide 16

  "Sparing" hemostasis after removal of endometrioma

• Slide 17
  

  Unilateral ovarian cysts in women under 38 Newly diagnosed ECO recurrence > 4 cm

  Slide 18
  

  Bilateral ovarian cysts Laparoscopy Maximum respect for ovarian tissue! Urgent IVF

  Slide 19
  

  The results of surgical treatment of infertility in endometriosis PE 1-2 PE 3-4 ECO 1 stage ECO 2 stage 34.3% 14.9% 11.9% 32.0% - % of patients with pregnancy within 1 year (after surgical treatment)

  Slide 20

  Infiltrative endometriosis

  slide 21

  MONIIAG + MC "Moskvorechye" 2004-2010

  Infiltrative endometriosis 123+1 Excision of the infiltrate 63 Segmental resection 8 Circular resection 7+1 Ureterolysis 24 Bladder resection 1 Ureterocystoanastomosis 1+1

  slide 22

  Circular resection

• slide 23

  Is recto-vaginal endometriosis a progressive disease?

  Only 6 out of 88 women (6.8%) noted the progression of the disease at follow-up periods of more than 68 months. Fedele at al, Am. J. Obstet. Gynecology, 2004

  slide 24

  Infiltrative endometriosis

  Does “asymptomatic” infiltrative endometriosis require surgical treatment? Is perioperative hormonal therapy appropriate? Does it cause fertility problems? Does IVF affect results? V.Bianchi (2009) PR (IVF) 40 vs 22

  Slide 25
  

  Fertility in Infiltrative Endometriosis: Spontaneous Pregnancy Rate after Surgery

  Vircellini at al. 2006 15/44 34% 20-50 Landi at al. 2008 11/4425% 13-40 Stepniewska at al.2009 43/133 32% 24-41 Darai at al. 2010 12/3931% 17-48 Cumulative 31% 26-37

  Adequate preoperative diagnostics (MRI, FCC, cystoscopy) Adequate intraoperative diagnostics Adequate surgical intervention As an alternative: diagnostic Ls>expert department

  Slide 29

  The main provisions of the treatment tactics of external-internal endometriosis.

  Hormone therapy with long courses for a long time has no effect and leads to advanced common forms. The appointment of a long course of hormone therapy for initially severe forms of endometriosis without subsequent surgical treatment is ineffective. Surgery is the main treatment for endometriosis.

  slide 30
  

  4. In the absence of a pronounced adhesive process, damage to the intestines and urinary system, surgical intervention by laparoscopic access is preferable.

  Slide 31
  

  5. The basis of prevention - early diagnosis mild and moderate forms of endometriosis and active combined tactics (surgery + drug therapy). Performing reconstructive operations against the background of perioperative use of hormones.

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