Hysterosalpingography. Diagnostic hysterosalpingography in infertility, indications, contraindications. What does the term "adenomyosis" mean? Hysterosalpingography technique

The diagnosis of adenomyosis (internal endometriosis of the body of the uterus) is established on the basis of characteristic clinical signs: an increase and soreness of the uterus in the premenstrual period. The uterus, as a rule, has a spherical shape and is rejected backwards, often fixed in the posterior fornix. The introduction of ultrasound diagnostics into practical medicine, the use of vaginal sensors has played important role in the diagnosis of adenomyosis; the method has taken a leading place in the diagnosis of internal endometriosis and should be considered as a screening when examining women with complaints of algomenorrhea, menorrhagia or intermenstrual bleeding.

The echoscopic picture of the diffuse form of adenomyosis is characterized by: a cellular structure of the myometrium, in which dotted or small cystic structures are found; the border of the mucous membrane and the muscular layer of the uterus is not smooth, but tortuous; the thickness of the back wall is greater than the front. The echoscopic picture of the nodular form of adenomyosis is characterized, along with the cellular structure of the myometrium, by the presence of nodes of a heterogeneous structure in it, around which, unlike myomas, there is no capsule.

A common method for diagnosing adenomyosis is hysterosalpingography, which allows you to establish the correct diagnosis in 80% of cases. Hysterosalpingography is performed no later than the 5-7th day of the menstrual cycle, so that the thin mucous membrane of the beginning of the proliferation stage does not interfere with the penetration contrast medium in endometrioid foci that communicate with the uterine cavity. At internal endometriosis the body of the uterus, the contrast agent is located outside the contour of the uterine cavity, and the shadows of heterotopias look like tubules, lacunae, diverticula. On radiographs with a common process, an increase in the size of the uterus is visible; unevenness of the contour indicates a combination of endometriosis with uterine fibroids or a nodular form of the disease. Hysterosalpingography allows you to identify the degree of spread of internal endometriosis of the uterine body.

Hysteroscopy is a fairly informative method for diagnosing a diffuse form of adenomyosis. Hysteroscopy is also performed on the 5-7th day of the menstrual cycle, and in case of its violations, on any day before and after diagnostic curettage. Control hysteroscopy is especially indicated for hyperplasia of the uterine mucosa, which prevents the detection of endometrioid heterotopias. Properly performed hysteroscopy allows you to see in detail inner surface uterus, mouth fallopian tubes and endometrioid passages that open into the uterine cavity and have the appearance of dark red pinholes against a pale pink mucous membrane.

Endometrioid heterotopias that have developed on the serous cover of the fallopian tube are detected during laparoscopy.

V.P. Smetnik L.G. Tymilovich

Inflammatory diseases of women genitals,

Hysterosalpingography is an X-ray method uterus and fallopian tubes using a contrast agent. A contrast agent introduced into the uterine cavity makes it possible to detect anatomical changes in the internal outlines of the uterus on the radiograph, which is interpreted by a specialist as a particular disease. Using the same method, this study determines the patency of the fallopian tubes and various pathological processes that are localized in the pelvic area.


Interesting Facts

• Hysterosalpingography is the main method in the diagnosis of infertility in women.
• About two hundred thousand hysterosalpingography procedures are performed annually in Russia.
• Hysterosalpingography is translated from Greek as "hystera" - uterus, "salpinx" - pipe, and the term "grapho" is translated as a graphic representation of something.
• During hysterosalpingography, the average radiation dose can reach up to six milligrays. Such exposure will not affect general health woman and her future offspring. Maximum safe dose irradiation is one hundred milligray.

Anatomy of the uterus

The uterus has three parts:

• body;
• isthmus;
• neck.

The body of the uterus

Isthmus of the uterus

The walls of the uterus are made up of:

• inner layer - endometrium;
• middle layer - myometrium;
• outer layer - perimetry.

endometrium

The mucous membrane consists of two layers:

• basal - germinal ( participates in the restoration of the surface layer);
• superficial - functional ( during the menstrual cycle, this layer undergoes constant changes).

Myometrium

Myometrium is formed by smooth muscle fibers and consists of the following layers:

• internal longitudinal;
• medium circular;
• outer longitudinal.

Perimetry

Cervix

In the cervix, there are:

• the upper part is supravaginal;
• lower part- vaginal.

In the cervix is ​​the cervical canal, which is from one to one and a half centimeters long. Top part cervical canal ends with the internal os, and its lower part borders on the external os, which opens in the vaginal part of the cervix.

In the vaginal part of the cervix there is an opening, which in nulliparous women has a rounded shape, and in those who have given birth it is slit-like. In the cervical canal due to the accumulation of glands internal secretion a kind of mucous plug is formed, which protects the uterus from various pathological microorganisms coming from the vagina.

Fallopian tube anatomy

The walls of the fallopian tubes consist of the following layers:

• internal - mucous;
• medium - muscular;
• external - serous.

• interstitial ( entrance part);
• isthmic ( middle part, the narrowest);
• ampoule ( the most extended part, which ends with a funnel).

Anatomy of the ovaries

Follicles are located in the cortex at different stages of their development. The final process of development leads to the fact that the mature follicle becomes dominant, and all other follicles stop their maturation. Suppression of other follicles contributes to the normal maturation of the egg in dominant follicle, which ultimately leads to its rupture and the release of the egg into the abdominal cavity.
The medulla of the ovary is represented by connective tissue, in which there are nerves and numerous vessels pass through.

Physiological functions of the uterus, fallopian tubes and ovaries

The essence of hysterosalpingography

After the woman has taken the necessary position, using a disinfectant solution ( 10% alcohol solution of iodine) is the treatment of the external genitalia, vagina and cervix. Then a special tube is inserted into the cervical canal ( cannula) through which, with the help of a syringe and a catheter, a radiopaque substance is injected ( ten to twenty milligrams).

Contrast agents have the property of absorbing x-ray radiation, due to which the contours of internal organs are visualized.

X-ray preparations can be divided into three groups:

• water soluble;
• fat-soluble;
• insoluble.

Water soluble preparations

Often, hysterosalpingography uses water-soluble drugs, such as:

• urographine;
• urotrast;
• verografin;
• triombrast and others.

Note. Unlike fat-soluble substances, the dose of water-soluble drugs should be larger.

Fat-soluble drugs

Insoluble drugs

After the introduction of a contrast agent into the uterine cavity, radiography is performed.

The following equipment is used for radiography:

• X-ray tube ( a device that uses electricity to produce x-rays);
• monitor ( broadcasts the received graphic information);
• fluoroscope ( converter x-ray radiation to video image);
• image intensifier ( used to increase the brightness on the monitor).

Guided by the image on the monitor, the doctor observes how the contrast agent fills the uterine cavity. In this case, the injected contrast agent is presented on the radiograph in a bright white color, while the cavities of the studied organs have dark shades.

If you suspect any anatomical change in the contours on the radiograph, the necessary pattern is registered. If the procedure is performed without video surveillance, then a slightly lower dose of contrast agent is injected into the uterine cavity ( five to ten milliliters) and take an x-ray. After that, another fifteen milliliters of a contrast agent is injected and a control image is taken, which should capture the filling of the uterine cavity.

After the study, the doctor removes the syringe, catheter and cannula from the patient's vagina and sends the woman to the ward. Hysterosalpingography on average takes up to thirty minutes.

Hysterosalpingography has the following advantages:

• for the procedure, a woman does not require hospitalization;
• relatively quick and almost painless procedure;
• is a safe research method.

Preparing the patient for hysterosalpingography

• Vaginal smear. The discharge is taken from three places, the urethra, cervix and vagina. Then the taken material is applied to a glass slide for microscopic examination in order to determine the degree of vaginal flora. There are four degrees of microflora, the first and second mean that the woman is healthy, and the third and fourth characterize the presence of an infectious-inflammatory process. It should be noted that the third and fourth degrees of vaginal flora are a contraindication to hysterosalpingography.
• Pap smear from the cervix for cytology. The analysis is aimed at identifying atypical cells in the cervix. The discharge is taken from the vaginal part of the cervix and then sent to cytology, where the cell structure is examined. This analysis helps to timely detect benign and malignant diseases of the cervix.
• Blood test for HIV, syphilis and hepatitis B, C. These studies can detect the presence of antibodies ( protective factor of the body) to the causative agents of HIV infection ( AIDS virus), syphilis ( pale treponema ) and hepatitis B, C.
• General blood analysis. A complete blood count is performed to diagnose the main blood components ( erythrocytes, platelets and leukocytes), also examines the level of hemoglobin and ESR, that is, the erythrocyte sedimentation rate ( an elevated level of ESR indicates the presence of an inflammatory process in the body).
• General urine analysis. A general urinalysis is performed macroscopically ( visual assessment) and microscopically ( examination under a microscope) to detect various kidney diseases.
• Blood chemistry ( by appointment). Informative research providing information about the work of internal organs ( e.g. pancreas, kidneys, liver) and body systems ( e.g. excretory, digestive). Conducting a biochemical blood test is necessary because the contrast agents used in hysterosalpingography can adversely affect the liver. Therefore, if a woman has any diseases associated with this organ, this may increase the risk of negative effects of the substances administered during the study.

Before the procedure, a woman must tell the doctor:

• about the presence of infectious and inflammatory diseases of the genital organs;
• about availability allergic reactions on medicines and iodine-containing substances;
• about the presence of diseases that increase the risk of bleeding ( e.g. liver diseases, blood diseases);
• about taking certain drugs that can affect the study process and lead to the development of complications ( e.g. aspirin, warfarin, metroformin);
• about the presence of diabetes mellitus;
• whether there is pregnancy or suspicion of it ( X-ray exposure can adversely affect the development of the fetus).

The procedure, as a rule, is carried out in the middle of the menstrual cycle before ovulation, if the woman knows the day of its onset, if not, then the day is selected from the tenth to the fourteenth from the start of menstruation.

This study is carried out in the middle of the cycle for the reason that before ovulation, the cervical canal opens slightly and the placement of the intrauterine catheter is less painful. It should also be noted that during this period slime layer uterus after menstruation is still thin, which allows the contrast agent to freely penetrate into the mouth of the fallopian ( uterine) pipes.

Before conducting a study, a woman should follow these recommendations:

• it is necessary to protect yourself with a condom, starting from the first day of the menstrual cycle in which this procedure is carried out;
• two days before the study, it is necessary to exclude sexual intercourse;
• five to seven days before the procedure, douching and use of hygiene products, since these factors increase the risk of violation of the microflora of the vagina;
• five to seven days before the study, it is necessary to cancel the treatment that is applied vaginally ( for example, vaginal suppositories, cream), unless it is used as prescribed by the attending physician.

In a medical institution, a woman is assigned:

• performing a cleansing enema to empty the bowels;
• the introduction of antispasmodic and sedative drugs to relieve muscle spasm, as well as anxiety and anxiety before the procedure.

After the procedure, the nurse takes the woman to the ward and puts her on the bed, where it is recommended to stay until the pain disappears. As a rule, this period is from twenty minutes to several hours.

In order to prevent the development of infectious and inflammatory processes after hysterosalpingography, the doctor may prescribe antibacterial drug and vaginal suppositories.

A woman needs to see a doctor urgently in the following cases:

• if there is abundant bloody discharge from the vagina;
• if you are concerned about severe pain in the lower abdomen;
• if there is an increase in body temperature.

Note. After X-ray hysterosalpingography, a woman should refrain from planning a pregnancy for three months.

There are the following contraindications for hysterosalpingography:

• acute infectious and inflammatory diseases of the genital organs ( e.g. vulvovaginitis, cervicitis, endometritis, salpingitis);
• infectious diseases in the acute period e.g. flu, sore throat);
• period of menstruation;
• pregnancy;
• lactation period;
• widespread malignant tumor of the cervix;
• hyperthyroidism ( hyperthyroidism);
• allergy to iodine-containing drugs;
• kidney failure or liver failure;

Indications for diagnostic hysterosalpingography

• pathological conditions of the uterus and fallopian tubes, which can cause infertility;
• reasons for miscarriage.

Hysteroscopy is indicated for the following diseases:

• submucosal uterine fibroids;
• endometrial hyperplasia;
• adhesions in the uterine cavity;
• abnormal structure of the uterus;
• adhesions in the fallopian tubes;
• isthmic-cervical insufficiency.

Interpretation of hysterosalpingography results

• the shape of the uterus is a kind of triangle, directed upwards;
• the edges of the uterine wall are even and smooth;
• the bottom of the uterus - oval or depressed ( saddle) forms;
• the corners of the uterus are sharp;
• the borders of the cervix are even and smooth;
• fallopian tubes - thin, long and winding.

The following features of the changes are distinguished:

• direct symptoms of changes are characterized by a violation of filling and contour deformations of the organ under study;
• indirect symptoms of changes are characterized by curvature, expansion or reduction of the cavity of the organ under study.

• submucosal uterine fibroids;
• uterine polyps;
• endometriosis;
• adenomyosis;
• anomalies in the development of the uterus;
• adhesions in the uterus;
• endometrial cancer;
• isthmic-cervical insufficiency;
• obstruction of the fallopian tubes;
• hydrosalpinx.

Diagnosis of patients with uterine myoma and adenomyosis

Today, for the diagnosis of myometrial pathology, the doctor has all modern diagnostic methods in his arsenal. In addition to collecting an anamnesis and examining the local status among the methods instrumental diagnostics pathology of the myometrium (uterine fibroids, adenomyosis), ultrasound scanning with color Doppler mapping, hysteroscopy, X-ray television hysterosalpingography, computed tomography, multispiral computed tomography, magnetic resonance imaging and laparoscopy are widely used. Diagnosis of uterine fibroids The most informative method for diagnosing uterine fibroids is ultrasound diagnostics. The pathognomonic acoustic criteria for uterine fibroids are: an increase in its size (84.5%), deformation of the contours (66.7%) and the appearance in the walls of the uterus (or in its cavity) of rounded or ovoid structures with a lower wave resistance than that of the myometrium ( 100%). Transvaginal ultrasound diagnosis of uterine fibroids subperitoneal localization presents no significant difficulty. However, it must be differentiated from an adnexal tumor. The tumor is identified as a mass round shape With increased level sound conductivity, tightly soldered to the uterus. The subperitoneal nodes of uterine fibroids on a broad basis are characterized by the following echographic features: acoustic reflection from the surface of the tumor facing the abdominal cavity is characterized by increased sound absorption and, therefore, is less clearly visualized compared to the uterine surface of the myomatous node. In addition, subperitoneal uterine fibroids complicate the scanning of structures located behind it (ovaries, intestinal loops, altered fallopian tubes). When scanning the subperitoneal nodes of fibroids, the use of a high-frequency transvaginal echo emitter with a beam focusing area within 70-80 mm allows you to accurately trace the decrease in the “visibility” of the image on the screen of an ultrasound device from the uterine surface of the tumor to the abdominal one. Distinctive features of the subperitoneal nodes of fibroids on a thin base (“pedicle”) are the absence of the effect of “ingrowth” of the tumor into the myometrium, which is recorded with tumors on a wide base, as well as the mobility of the tumor in relation to the uterus. Color dopplerography The diagnostic value of color Doppler mapping (CDM) cannot be overestimated. The essence of this method is the ability to visualize all moving body fluids in real time and analyze their movement. The study of blood flow in the vessels of neoplasms, which have their own characteristics, allows us to consider this method important in the differential diagnosis of benign and malignant tumors of the uterus. Color Doppler allows you to evaluate three parameters of blood flow simultaneously: direction, speed and character (homogeneity and turbulence). Due to the high resolution of the currently used equipment, it is possible to visualize and identify the smallest vessels up to the microcirculatory system, which are invisible when scanning in B-mode. The system of tumor vascularization, as a rule, is represented by many small, very thin, abnormal in shape and location vessels, randomly scattered within the tumor tissues. The blood flow in these vessels is characterized by extremely low vascular resistance, high speed and diverse direction. The image of the blood flow in this case is characterized by a pronounced brightness of the color signal, and the "color" of tumor tissues can be dominated by both primary colors and the "mosaic" form of mapping. These features of the blood flow are due to the presence of a large number of arteriovenous anastomoses among the newly formed vessels, which provide a high kinetic energy of the blood flow and explain the wide variability of its direction. The color flow method has high sensitivity, specificity and accuracy in early diagnosis neoplastic diseases internal genital organs and their differentiation according to the degree of malignancy. The level of vascularization assessed with the help of color doppler allows us to predict the rate of growth of the identified formation. Ultrasound diagnostics submucosal or intermuscular uterine fibroids with centripetal growth is based on the detection of a deformed or displaced M-echo. For submucosal nodes of fibroids, the appearance inside the expanded uterine cavity of a round or ovoid shape of formations with even contours and medium echogenicity is characteristic. Unlike endometrial polyps, fibroids have more high level sound conductivity. Ultrasound diagnostics intermuscular uterine fibroids with centripetal growth is based on the visualization of the deformed uterine cavity in the form of a crescent with smooth contours. At the same time, near the concave surface of the uterine echo, a formation with a lower acoustic impedance is determined than in the unchanged myometrium. In contrast to submucosal uterine fibroids, with centripetal tumor growth, M-echo deformation is observed, and a pathological formation is identified over a significant extent of the muscular layer of the uterus. With uterine myoma, changes in microcirculation in the blood and lymphatic vessels, edema, etc. are often observed. On echograms, these processes are reflected by the appearance in the tumor localization zone of numerous "cystic" structures separated by echopositive septa. Also observed: the appearance inside the tumor of a zone with increased echogenicity and without clear boundaries, visualization of an anechoic formation surrounded by a border with an increased level of sound conduction, detection of an acoustic amplification phenomenon along the periphery of the tumor. At proliferating uterine fibroids on the echograms, formations of a rounded shape with a dense capsule and a heterogeneous internal structure are visualized: in the projection of fragments of medium echogenicity, acoustic zones with diametrically opposite sound conductivity are recorded (echo-negative areas alternate with elements of dense tissue). Analysis of echograms shows that the ratio of the cystic and dense components of these tumors varies depending on the severity of proliferative processes. With color Doppler mapping of uterine myomas with “true growth”, a loose type of blood supply is recorded along the vascular bundle of the uterus, intense, high-speed blood flow in the myometrium and myomatous nodes. The image of the intratumoral blood flow is characterized by a multitude of signals from the vessels along the periphery and in the center of the myomatous node, the chaotic direction of the vessels and the pronounced brightness of the color signal, and the presence of a “mosaic” form of mapping. Many veins with VV max = 14 cm/sec have been registered. in various parts of the myomatous node. The minimum indices of resistance in the myometrium - 0.50+0.11, in myomatous nodes - 0.34+0.06. Comparison of ultrasound scan results and results morphological study remote preparations revealed high information content (96.5%) of this method. In 95.7% of cases, ultrasound scanning contributed to the detection of submucosal and intermuscular uterine fibroids with centripetal growth, in 92.2% of fibroids with subperitoneal localization. Hysterosalpingography In the last decade, in order to clarify the nature intrauterine pathology widely used method of hysteroscopy. Most authors point to the high diagnostic value of this method for the detection of submucosal myoma nodes and nodes with centripetal growth. In addition, with therapeutic purpose with the help of hysteroresectoscopy, it is possible to remove these formations. Hysterosalpingography is most often performed in patients with suspected uterine myoma with centripetal growth and with myoma nodes of submucosal localization. With fibroids with submucosal localization, characteristic, clear pictures are obtained. The cavity appears to be large, deformed, with distinct but irregular contours. Inside the uterine cavity, in the center or along the edge, one or more lacunar patterns are noted, rounded, with clear contours, of different sizes. With interstitial or subserous fibroids X-ray pictures are less convincing. CT scan Computed tomography is used for the differential diagnosis of subserous nodules of fibroids with ovarian tumors, or for the evaluation of large fibroids. Kom-p-u-ter-but-to-mo-graphic-fiches-kai-kar-ti-na myo-we mat-ki can be different-but-about-different and for-wee-sit from such secondary iz-me-not-nies, like gia-li-no-vaya de-ge-ne-ra-tion, cal-ci-fi-ka-tion and nek-roses of knots. The most frequent symptom of uterine fibroids on the computer is the deformity of the con-tur-ditch of the uterus. A specific sign of myo-we is cal-qi-fi-ka-tion, you-being-lying-scha-sya on a computer-p-u-ter-noy that-mo-gram-me in vi - de point plots with a density of up to +800 - +1000 U.N. For op-re-de-le-niya internal-ren-ney ar-hi-tech-then-no-ki about-ra-zo-va-niya os-shche-st-in-is in-building gis -to-gram. Gis-to-gram-ma from-ra-zha-et dense-but-st-ha-rak-te-ri-sti-ku study-follow-my fabric. Basic pa-ra-meters, according to some-eye ana-li-zi-ru-yut-sya gis-to-gram-we - this is shi-ri-na os-no-va- niya gra-fi-ka, as well as the number of liches-t-in and you-with-that pi-kov. The more similar the fabric, the more basic the gis-to-gram-we are narrower and higher than the single peak. If the internal structure-tu-ra is not-one-but-kind-naya, then the os-but-va-nie gis-to-gram-we for-no-ma-et almost all the city - zone-tal-axis graph-fi-ka and has from 2 to 4 not-you-so-peaks. The myo-ma of the mother usually has a one-native structure, the density of a swarm of fluctuating years is from +40 to +60 U.N. With from-day-st-via on-ru-she-niya pi-ta-nia in knot-le, gis-to-gram-ma ha-rak-te-ri-zu-et-sya very narrow-kim “ os-no-va-ni-em ”and you-so-kim“ peep ”with a density of about 45 U.N. Multislice computed tomography Multislice computed tomography is one of the methods that allows you to study the vascular system of the whole organism or a separate organ in real time, followed by the construction of a three-dimensional computer model of the organ under study. Continuous Rotation Data Acquisition System (3rd Generation) is most suitable for vascular examination. Thanks to the real-time operation, there is a continuous formation of an image that is displayed on the computer screen. The program evaluates the flow of a contrast agent in order to automatically start scanning with optimal contrast filling of the organ under study (in the case of examining the pelvic organs, the standard of optimal contrast filling is taken abdominal region aorta). In the study of the vascular bed of the pelvic organs by this method, several stages are distinguished:

Tomogram. Native study without contrast. Contrast study with intravenous administration (bolus) of Omnipaque 350 at an injection rate of 3 ml/sec. 100 ml. using an automatic injector. There is a reconstruction of the arterial phase in 3-dimensional projections. The portal phase (in this study it would be more accurate to call it parenchymal), which is carried out 1-1.5 minutes after the main study and reflects the flow of a contrast agent into the parenchyma of other organs of the small pelvis (myometrium) and into the system portal vein and liver.

1. Ogies of remote non-invasive tissue ablation with focused ultrasound under the control of magnetic resonance imaging (fuz-MRI ablation) in the treatment of uterine fibroids

   abstract

   The manual outlines the issues of using the technology of remote non-invasive tissue ablation with focused ultrasound under the control of magnetic resonance imaging (FUZ-MRI ablation) in the treatment of uterine fibroids.

2. Complex endosurgical treatment of patients with submucosal uterine myoma 14.00.27 Surgery 14.00.01 Obstetrics and gynecology

   Dissertation abstract

   The defense will take place on November 20, 2008 at 10 a.m. at the meeting dissertation council D.208.071.05 at the Russian Medical Academy of Postgraduate Education, Roszdrav

3. Features of cancer and hyperplastic processes of the endometrium in combination with uterine myoma 14. 00. 14 oncology

   abstract

   The defense of the dissertation will take place in 2007 at the meeting of the dissertation council D.001.32.01 at the Research Institute of Oncology of the Tomsk Scientific Center of the Siberian Branch of the Russian Academy of Medical Sciences, at the address: 634001, St.

4. Gusaeva khanum zamrutdinovna modern aspects of pathogenesis, diagnosis and treatment of combined benign diseases of the uterus

   abstract

   The work was performed in the Department of Operative Gynecology of the Federal State Institution " Science Center obstetrics, gynecology and perinatology named after academician V.I. Kulakov of the Federal Agency for High-Tech Medical Care"

5. Course of lectures in the specialty "Ultrasound diagnostics" Minsk Belmapo

   Lecture course

   The study of the principles of ultrasound diagnostics involves knowledge of elementary theoretical foundations acoustics. The conjecture that the reason for the unmistakable flight of bats in the dark are sound inaudible to the human ear

Hysterosalpingography (HSG)- a method of X-ray diagnostics of diseases of the uterus and its tubes, based on the introduction of contrast agents into them.

INDICATIONS FOR HYSTEROSALPINGOGRAPHY

Indications for hysterosalpingography are suspicion of tubal infertility, tuberculosis of the uterine cavity and tubes, intrauterine pathology (submucosal uterine fibroids, endometrial polyps and hyperplasia, internal endometriosis), abnormal development of the uterus, intrauterine adhesions, infantilism, isthmicocervical insufficiency. Depending on the purpose of the study and the proposed diagnosis, hysterosalpingography is performed on different days of the menstrual cycle: to detect patency of the fallopian tubes, isthmicocervical insufficiency - in the second phase of the cycle, if internal endometriosis is suspected - on the 7-8th day of the cycle, if submucosal MM is suspected - in any phase of the cycle in the absence of abundant bloody uterine discharge.

CONTRAINDICATIONS OF HYSTEROSALPINGOGRAPHY

Contraindications to hysterosalpingography are general infectious processes in the body (flu, tonsillitis, rhinitis, thrombophlebitis, furunculosis), severe diseases of parenchymal organs (liver, kidneys), insufficiency of the cardiovascular system, hyperthyroidism, acute and subacute inflammatory processes of the uterus and appendages, colpitis, bartholinitis, cervicitis. Hysterosalpingography is not performed in the presence of changes in the clinical picture of blood (increased ESR, an increase in the number of leukocytes) and urine. Absolute contraindication for hysterosalpingography hypersensitivity to iodine.

HYSTEROSALPINGOGRAPHY TECHNIQUE

For hysterosalpingography, water-soluble contrast agents are most often used: 50, 70% cardiotrast solutions, 60, 76% triombrast solutions, 60, 70% urotrast solutions, 76% verografin solution, etc.

Hysterosalpingography is performed on a radiolucent urological chair with a digital x-ray machine, which makes it possible to reduce radiation exposure to the patient. She is placed on the edge of the table in a position for vaginal operations. After treatment of the external genital organs with a disinfectant solution, a two-handed gynecological examination is performed. Spoon-shaped mirrors are inserted into the vagina. Its walls are first wiped with a dry cotton ball, and then treated with a ball moistened with alcohol. The anterior lip of the cervix is ​​grasped with bullet forceps without piercing the mucous membrane of the cervical canal rich in receptors.

For hysterosalpingography, a Schulz-type cannula is used (Fig. 7–1), which consists of a tube 30–35 cm long. Its inner diameter is 1.5–2.0 mm. One end of the tube is connected to a 10 or 20 gram syringe. At the other end, a rubber cone-shaped tip is strengthened, which is inserted into the cervical canal to tightly close the external pharynx. The tube has a movable "rider" with a screw, on which the jaws of bullet forceps are fixed so that the latter tightly hold the tip in the cervix. The cannula is filled with a contrast agent heated to body temperature. After making sure that the closure of the external os is tight by introducing a small amount of a contrast agent into the uterine cavity, the vaginal mirrors are removed, and the woman is placed on the table so that the central x-ray passed through the upper edge of the womb. To protect the doctor from x-ray radiation, along with a special apron mounted on an x-ray machine for urological studies, a movable lead screen is used to protect the doctor's torso and legs.

Rice. 7-1. Schultz cannula.

For the first image, 2-3 ml of contrast fluid is injected to obtain a relief image of the uterine cavity. After processing and viewing the first image, another 3–4 ml of contrast agent is additionally injected and a second image is taken. In this case, a tighter filling of the uterine cavity is obtained, and the contrast fluid usually enters the tubes and into the abdominal cavity. After viewing the second picture, if necessary, take a third. Usually, 10 to 20 ml of contrast fluid is used for the entire procedure.

When conducting hysterosalpingography on X-ray machines with an elector-optical converter, the television screen shows the gradual filling of the uterine cavity and tubes, the movement of the contrast agent into the abdominal cavity, the images are taken as the uterine cavity and tubes are filled.

Hysterosalpingography is performed for inpatients and outpatients. Before being sent for research, a woman is warned that from the moment the menstruation ends, it is impossible to live a sexual life. A week before the procedure, blood, urine and discharge from the vagina and cervical canal are prescribed, a blood test for the Wasserman reaction and AIDS, hepatitis. On the day of the procedure, it is necessary to shave the hair on the external genitalia and, if not
chair, make cleansing enema. Before the procedure, you must empty your bladder. After the procedure, outpatients rest on the couch for 40–60 minutes.

INTERPRETATION OF THE RESULTS OF HYSTEROSALPINGOGRAPHY

On radiographs in the norm (Fig. 7-2), the cavity of the body of the uterus has the shape of an isosceles triangle, located with the apex down. The base of the triangle (equal to 4 cm) corresponds to the bottom of the uterine cavity, and at the top there is an anatomical internal uterine os. AT lower section the body cavity of the uterus passes into the isthmus of the uterus. The isthmus is 0.8–1.0 cm long, followed by the cervical canal. Its shape can be conical, cylindrical, fusiform and depends on the phase of the cycle. Tubes appear on radiographs as thin, sometimes rather sinuous, ribbon-like shadows. Radiographically, three anatomical parts of the tube can be identified: interstitial, isthmic, and ampullar. The interstitial section is in the form of a short cone, passing after some narrowing into a rather long isthmic section. The transition of the isthmic region to a wider ampullar region is not always distinct on radiographs. Sometimes the longitudinal folding of the mucous membrane of the tube is clearly visible.

The contrast fluid from the ampoule of the tube flows out in the form of a strip and then, to a greater or lesser extent, is smeared over the abdominal cavity in the form of smoke from a burning cigarette. An indicator of good patency of the tubes is the spreading of the contrast agent along the peritoneum to places remote from the ampoule.

Rice. 7-2. Hysterosalpingography with permeable uterine tubes.

Of the causes of tubal infertility, inflammatory processes are in the first place. More often, obstruction of the tubes in the interstitial section is found, and less often, some expansion of this section. This is characteristic of tuberculosis. The obstruction of the tubes in the ampulla gives different pictures depending on the cause and duration of the inflammatory process. The abdominal opening of the tube is often glued with adhesions, and the exudate stretches the ampullary part of the tube to various sizes(Fig. 7-3). The contrast agent mixes easily with serous exudate and gives a distinct picture of the flask-shaped ampullar part of the tube. Sometimes, after previous treatment, resorption of the contents of the sactosalpinx occurs, its walls collapse. When conducting a vaginal examination before hysterosalpingography, large deviations from the norm are not detected, and a picture of significant sactosalpinxes is revealed on radiographs.

Rice. 7-3. Sactosalpinx.

If, as a result of the inflammatory process, incomplete gluing of the ampullar section of the tube occurs, radiographs reveal that the contrast solution partially penetrates the abdominal cavity through the stenotic opening, and the flask-like expanded ampullar section of the tube is preserved, forming a "ventilated" sactosalpinx. During the adhesive process in the abdominal cavity, the contrast agent penetrates into the encysted cavities, revealing them in the form of contrast formations of various sizes and shapes. Hysterosalpingography in infertility helps to recognize the often asymptomatic tuberculosis of the female genital organs.

The tuberculous process affects the ampullar and isthmic sections of the tubes. There is an obliteration of the lumen of the ampoule. Isthmic sections as a result of damage to the muscle layer become rigid, often expanded and end with bulbous thickenings at the end. Radiologically, the shadows resemble a smoking pipe in shape. With tuberculous endometritis, in advanced cases, deformation of the uterine cavity occurs, its partial or complete obliteration. On the radiograph, a sharply deformed, small-sized uterine cavity is determined (Fig. 7-4).

Rice. 7-4. Tuberculous endometritis and salpingitis.

Hysterosalpingography is of great importance for the detection of malformations of the uterus. With an incomplete septum of the uterus, a septum extending from the bottom, wide in the upper part, at the base is revealed radiographically. With its top, it almost reaches the isthmus, dividing the uterine cavity into two halves. In this case, the angle formed between the two sections of the uterine cavity is acute. Almost the same picture is observed with a bicornuate uterus, but the angle between the two sections of the uterine cavity will be obtuse (Fig. 7–5).

Rice. 7-5. Developmental defects. Intrauterine septum (a) and bicornuate uterus (b).

With an infantile uterus, its cavity on radiographs is reduced, and the neck is elongated so that the ratio of the length of the cervix and the uterine cavity is 3:2 or 1:1. Of the other malformations, a saddle, unicornuate, double uterus is distinguished.

Hysterosalpingography is widely used to diagnose various intrauterine pathologies. With endometrial hyperplasia and polyposis, radiographs show uneven contours of the cavity, uneven intensity of the shadow associated with incomplete distribution of the contrast fluid in it, filling defects ranging in size from 0.5 to 0.7 cm.

The shape of the defects is round, oval, sometimes linear. They are located more often in the bottom and at the pipe corners. With large endometrial polyps, the size of filling defects ranges from 1x1.5 to 2x4.5 cm. More often they are single (Fig. 7-6).

Rice. 7-6. Endometrial polyp.

Large polyps are difficult to radiologically distinguish from small submucosal fibroids. In patients with submucosal uterine myoma (MM), the main symptoms appear on x-rays- an increase in the uterine cavity, its deformation and a large filling defect (Fig. 7–7).

Rice. 7-7. Submucosal uterine fibroids.

The uterine cavity sometimes takes on bizarre shapes: saucer-shaped, tulip-shaped, rounded, crescent-shaped, etc. Filling defects are partially or completely covered thin layer contrast fluid.

With cancer of the body of the uterus, depending on the prevalence of the process, the x-ray picture is not the same.
When the process is localized in one area, radiographs will show a filling defect with uneven corroded outlines in the region of one of the tubal corners or the lateral contour of the uterine cavity. In the diffuse form, when almost the entire endometrium is affected, the uterine cavity will be deformed without clear boundaries with uneven fringed edges and multiple bizarre filling defects with an uneven radiological shadow.

Hysterosalpingography is a valuable diagnostic method for detecting uterine endometriosis. In patients with this pathology, single or multiple contour shadows in the form of spikes, gaps, pockets are visible. The sizes of these contour shadows are from 2–4 mm to 1–2 cm. More often they are determined on the bottom of the isthmicocervical part of the uterus, less often on the lateral contours of the cavity. Sometimes radiographically it is possible to detect endometriosis of the tubes, in which many peretubular passages in the form of short strokes or dots depart from the visible lumen of the isthmic section of the tube - a picture resembling a Christmas tree branch (Fig. 7–8).

Rice. 7-8. Endometriosis in the isthmic section of the left fallopian tube.

With the help of hysterosalpingography, intrauterine adhesions are also well recognized. At the same time, radiographs in the uterine cavity often show single filling defects of various shapes with clear, even contours, which, unlike endometrial polyps, are not filled with a contrast agent even with tight filling of the uterine cavity (Fig. 7–9).

Rice. 7-9. Intrauterine adhesions

Hysterosalpingography is widely used in patients with habitual miscarriages outside of pregnancy in order to detect isthmicocervical insufficiency. Normally, in the second phase of the cycle, the isthmic-cervical section is significantly narrowed (isthmus is not more than 0.4 cm), with isthmic-cervical insufficiency, its significant expansion is noted (up to 1.5 cm or more).

Thus, hysterosalpingography is a valuable additional instrumental method for diagnosing a number of diseases of the uterus and tubes.

FACTORS AFFECTING THE RESULT OF HYSTEROSALPINGOGRAPHY

For the diagnosis of adenomyosis, hysterosalpingography is informative after separate diagnostic curettage on the 2nd day; when diagnosing patency of the fallopian tubes, it is performed in the first phase of the menstrual cycle.

Complications of HSG:

1. Early Complications GHA: vascular reflux (penetration of a contrast agent into the capillary and venous network of the uterus); lymphatic reflux (ingress of a contrast agent into the utero-tubal lymphatic vessels or into the wide ligament of the uterus); perforation of the uterine wall; rupture of a pipe under very strong pressure; allergic reactions.
2. Late Complications GHA: development of inflammatory processes due to infection during the procedure or exacerbation of existing ones.

What is endometriosis?

Endometriosis is a pathological process in which a benign growth of tissue occurs outside the uterine cavity, similar in morphological and functional properties to the endometrium.

Foci of endometriosis can be from microscopic to massive tumor-like endometrioid cysts, leading to severe anatomical disorders of the fallopian tubes and ovaries, as well as the formation of an extensive adhesive process, often affecting the intestines, bladder and ureters.

One of the features of endometriosis should include its ability to infiltrative growth with penetration into the surrounding tissues and their destruction. That is why endometriosis can "grow" into any tissue or organ - into the wall of the intestine, bladder, ureter, peritoneum, bone tissue.

What is the place of endometriosis in the structure of gynecological morbidity?

In structure gynecological pathology endometriosis ranks third among diseases of the female genital organs (after inflammation and uterine fibroids). The frequency of endometriosis ranges from 7 to 59% in women of reproductive age. According to V.P. Baskakova et al. (1998), it occurs in 17% of patients young age suffering from algodysmenorrhea, and reaches 30% of those in need of gynecological operations.

What population of women has endometriosis?

Endometriosis is a disease of women of reproductive age, but can occur in girls with established menstrual function and in postmenopausal women receiving hormone replacement therapy. Endometriosis is observed in 7-10% of the total female population, in 25-40% of women suffering from infertility and in 70% of patients with complaints of pelvic pain.

What are the current classifications of endometriosis? What classification is the most used in world practice?

Widely used in world practice is the one proposed in 1979 and revised in 1985 and 1986. American Fertility Society (R-AFS) classification. It is based on counting the number of heterotopias, expressed in points:

Stage I (minimal changes) - 1-5 points;

Stage II (minor changes) - 6-15 points;

Stage III (pronounced changes) - 6-40 points;

Stage IV (very pronounced changes) - more than 40 points.

Table 7.1.American Fertility Society classification of endometriosis

Note:* - if the fimbrial section of the tube is completely sealed, then 16 points are set.

The presence of 1-5 foci is attributed to mild form; 6-5 - to moderate; 16-30 - to severe; more than 30 foci of endometriosis indicate widespread endometriosis. This classification was actually compiled in such a way as to predict the restoration of fertility after one or another treatment based on the sum of points. Although classifications are currently being developed that include parameters of disease activity, the American Fertility Society's revised classification is the only internationally accepted standard for evaluating spontaneous evolution and comparing therapeutic outcomes.

In 1984, K. Semm, using the results of diagnostic laparoscopy, proposed to isolate the so-called small forms of endometriosis. The advantage is that this variant of the spread of endometriosis is easy to identify "at a glance" at the time of laparoscopy. The concept of "small forms" of external endometriosis includes endometrioid heterotopias that do not exceed 0.5 cm in diameter and are usually not accompanied by severe clinical manifestations, with the exception of infertility.

According to L.V. Adamyan and V.I. Kulakov (1998), the main drawback of the classification of the American Fertility Society (R-AFS) is its limitation to only a visual assessment of anatomical lesions without taking into account infiltrative forms in lesions of the rectovaginal tissue and parameters, functional changes, clinical picture, etc.

What classification of endometriosis depending on localization is used in clinical practice?

Depending on the localization of endometrioid heterotopias, endometriosis is divided into genital and extragenital. Genital endometriosis can be localized in the myometrium (adenomyosis) and on the peritoneum, ovaries, recto-uterine cavity, rectovaginal septum, cervix, vagina and perineum.

Extragenital endometriosis is topographically not associated with the tissues and organs of the reproductive system and includes the organs of the abdominal cavity (appendix, rectum, sigmoid and colon, small intestine, hernial sacs), lungs and pleural cavity, skin (episiotomy and other postoperative scars), groin, limbs, navel, lymph nodes, nerves and brain (Fig. 7.1).

Rice. 7.1.Localization of foci of endometriosis.

What is internal genital endometriosis?

Internal genital endometriosis (adenomyosis) is the growth of endometrioid heterotopias in the muscular layer of the uterus.

In everyday work, clinical classifications of internal endometriosis (adenomyosis) of the uterine body, endometrioid ovarian cysts and retrocervical endometriosis (retrovaginal septum) are widely used, while 4 stages of the distribution of endometrioid heterotopias of the above localizations are distinguished.

According to the degree of spread of the pathological process, 4 degrees of the diffuse form of adenomyosis are distinguished:

I degree - germination of endometrioid heterotopias by 2-4 mm into the thickness of the myometrium;

II degree - up to the middle of the thickness of the myometrium;

III degree - 2/3 of the muscle layer;

IV degree - germination of endometrioid heterotopias to the serous membrane.

Adenomyosis is usually divided into diffuse and focal.

What is external genital endometriosis?

External genital endometriosis is classified in relation to the peritoneum:

Intraperitoneal (peritoneal): ovaries, fallopian tubes, peritoneum;

Extraperitoneal: vulva, vagina, vaginal part of the cervix, retrocervical region.

With external endometriosis, the most informative classification proposed by A. Acosta (1973), dividing endometriosis into "small" and severe forms.

What are "small" forms?

The "small" forms include:

Single heterotopies on the pelvic peritoneum;

Single heterotopies on the ovaries without the presence of adhesions and cicatricial processes.

What are severe forms?

To severe forms relate:

Endometriosis of one or both ovaries with the formation of cysts with a diameter of more than 2 cm;

The defeat of the ovaries with a pronounced periovarian and / or peritubar process;

Damage to the fallopian tubes with deformation - scarring, impaired patency;

Damage to the pelvic peritoneum with obliteration of the rectal space;

Damage to the sacro-uterine ligaments and peritoneum of the recto-uterine space with its obliteration;

Involvement in the process of the urinary tract and / or intestines.

What is the macroscopic characteristic of endometriosis?

Endometriosis can be in the form of nodes, infiltrates without clear contours, or cystic formations filled with hemorrhagic or thick brown fluid.

What are the characteristics of endometriosis?

Endometriosis is characterized by:

The absence of a connective tissue capsule around it;

Its ability to infiltrative, penetrating growth into the surrounding organs and tissues with the destruction of the latter, which

can be explained by the enzymatic activity of endometriosis, the ability to secrete lipolytic enzymes;

The ability of endometriosis to metastasize, its spread by hematogenous and lymphogenous routes.

What is the difference between endometriosis and malignant tumor?

Endometriosis differs from a malignant tumor in the absence of cellular atypia, the ability for autonomous non-stop growth. There is a difference in the relationship with pregnancy, the latter contributes to a decrease in clinical activity and regression of endometriosis, while in patients with malignant diseases, pregnancy contributes to the progression of the tumor process.

What changes are endometriosis foci exposed to?

Changes in endometriosis foci:

Suppuration;

Malignant transformation, and stromal endometriosis is more prone to malignancy;

Around the foci of endometriosis, an inflammatory reaction always develops.

What is known about the etiology of endometriosis?

Currently, there are several main theories of the occurrence of endometriosis.

1. Translocation (implantation) theory - the transfer of the endometrium from the uterine cavity through the fallopian fallopian tubes to the peritoneum.

2. The dysontogenetic theory is a violation of embryogenesis with abnormal remnants of the Mullerian (paramesonephric) duct (in the peritoneum, etc.). This theory was developed as early as the end of the 19th century, but it is recognized by modern authors who believe that endometrioid tissue can develop from abnormally located embryonic primordia, in particular the Müllerian canal.

3. Metaplastic theory - under the influence of hormonal disorders, inflammation, mechanical trauma or other influences, the mesothelium of the peritoneum and pleura, the endothelium of the lymphatic vessels, the epithelium of the tubules of the kidneys and a number of other tissues can turn into endometrioid-like tissue.

What is the pathogenesis of endometriosis?

In the development of endometriosis, the constitutional hereditary factor, nervous and immune factors, ionizing radiation are important (Fig. 7.2).

Rice. 7.2.Scheme of the pathogenesis of endometriosis

What is the clinic of adenomyosis?

Endometriosis of the uterus (adenomyosis - internal endometriosis) is one of the most common types of genital endometriosis. The leading symptom is algomenorrhea. There are nodular and diffuse forms of adenomyosis. The pain syndrome depends on the form of adenomyosis, the depth of ingrowth into the myometrium, the involvement of the peritoneum in the process, and the proximity of the location of endometriosis to the sacro-uterine ligaments. The pain is more pronounced with the nodular form. If we talk about the depth of ingrowth into the myometrium, then the pain is most pronounced if the lesion is superficial or very deep, that is, characteristic of internal endometriosis of stages I and IV.

Stage I - the pathological process is limited to the submucosa of the body of the uterus.

Stage II - the pathological process passes to the muscle layer.

Stage II - the pathological process extends to the entire thickness of the muscular wall of the uterus to its serous cover.

Stage IV - involved in the pathological process, in addition to the uterus, the parietal peritoneum of the small pelvis and neighboring organs.

Particularly severe pain occurs when the isthmus of the uterus, sacro-uterine ligaments are affected. The pains are radiating. With the defeat of the corners of the uterus, pain radiates to the corresponding inguinal region, with endometriosis of the posterior part of the isthmus of the uterus - to the rectum.

The next most important symptom of adenomyosis is abundant and prolonged menstruation of the nature of menorrhagia, but metrorrhagia may also occur. Uterine bleeding is more pronounced with diffuse adenomyosis. It is especially important to note the frequent combination of adenomyosis with uterine myoma. According to many authors, the percentage of the combination ranges from 60 to 80%, while symptoms of both diseases are detected. With a combination of fibroids and adenomyosis, pain, hyperpolymenorrhea and secondary anemia are often expressed.

What are the clinical symptoms of ovarian endometriosis?

Ovarian endometriosis ranks first in the group of external genital endometriosis. It should be noted that not only the frequency of this disease is important, but also the role of ovarian endometriosis in the generalization of the process. Almost always damage to the intestines, diaphragm with perforation to the side pleural cavity, the development of posterior cervical endometriosis, damage to the ureters begins with the ovaries. According to the direction of development, several types of ovarian endometriosis are distinguished: growing (proliferating), stable (fibrous), regressive (dystrophic) and malignant.

Endometriosis of the ovaries can be asymptomatic until a certain time, until the microperforation of the chambers and the involvement of the peritoneum of the pelvis or adjacent organs in the process begin. During menstruation, the pain intensifies. In 60-70% of patients, algomenorrhea is observed. At perforation of a cyst the picture of an acute abdomen takes place.

Any form of ovarian endometriosis very often causes anovular cycles, infertility.

What are the stages of the spread of endometrioid heterotopias in ovarian lesions?

Stage I - small point endometrioid formations on the surface of the ovaries, the peritoneum of the rectal-muscular space without the formation of cystic cavities.

Stage II - an endometrioid cyst of one ovary no larger than 5-6 cm in size with the presence of small endometrioid inclusions on the peritoneum of the small pelvis. A slight adhesive process in the area of ​​​​the uterine appendages without involving the ovary.

Stage III - endometrioid cysts of both ovaries of various sizes. Endometrioid heterotopias of small sizes on the serous cover of the uterus, fallopian tubes and on the parietal peritoneum of the small pelvis. Pronounced adhesive process in the area of ​​the uterine appendages with partial involvement of the intestine.

Stage IV - large bilateral endometrioid ovarian cysts with the transition of the pathological process to neighboring organs - the bladder, rectum and sigmoid colon. Widespread adhesive process.

What are the clinical symptoms of an endometrioid ovarian cyst?

An endometrioid ovarian cyst can be unilateral or bilateral, of various sizes - from 0.5 to 10 cm in diameter. Endometrioid cysts are characterized by adhesions with surrounding tissues, a dense capsule, hemorrhagic contents that have the color of chocolate (“chocolate” cysts), constant pain that intensifies the day before and during menstruation with irradiation to the lower back, sacrum, and rectum. Microperforation of the cyst wall is possible, which entails a sharp exacerbation of the pain syndrome and the subsequent formation of dense adhesions with surrounding organs. A bimanual examination in the area of ​​the uterine appendages is determined by a painful, inactive or immobile tumor formation, which has a taut-elastic consistency. When fused with surrounding organs, the size and consistency of the cyst become insufficiently distinct.

What are the clinical symptoms of retrocervical endometriosis?

Retrocervical endometriosis (endometriosis of the rectovaginal septum) may occur primarily, especially often after diathermocoagulation or in cases of transition of the process to this area with adenomyosis, endometriosis of the ovaries and tubes. With this localization, foci of endometrioid heterotopia extend to the sacro-uterine ligaments, rectum, parametrium, posterior fornix.

vagina, ureters. The pain syndrome is intense, especially during menstruation. There are pain during intercourse, dysuric phenomena, bloating, constipation, irradiation of pain in the lower back, coccyx, anus.

What are the stages

distribution of endometrioid heterotopias in retrocervical endometriosis?

Stage I - endometrioid lesions are located within the rectovaginal tissue.

Stage II - germination of endometrioid tissue in the cervix and vaginal wall with the formation of small cysts.

Stage III - the spread of the pathological process to the sacro-uterine ligaments and the serous cover of the rectum.

Stage IV - involvement in the pathological process of the mucous membrane of the rectum, the spread of the process to the peritoneum of the rectal-uterine space with the formation of an adhesive process in the area of ​​the uterine appendages.

for endometriosis of the fallopian tubes and vagina?

Endometriosis of the tubes and vagina is extremely rare. Most often, endometriosis of the tubes is detected during surgery. Diagnosis is difficult. With endometriosis of the vagina, visually and palpation determine the germination of the vaginal wall by a painful tumor with fuzzy contours and characteristic cyanotic areas - “eyes”.

The main complaint with endometriosis of the vagina is pain in the vagina and depth of the pelvis - from moderate to very strong and painful. Pain is cyclical. They are aggravated during sexual activity, a week before and after menstruation. Pain in the vagina may be accompanied by local itching, bloody and brown discharge from the vagina is possible. These secretions appear a week before and after menstruation.

What are the clinical symptoms

for endometriosis of the vaginal part of the cervix?

The diagnosis of endometriosis of the vaginal part of the cervix is ​​established by examining the cervix, confirmed by colposcopic

and histological studies. There are superficial (ectocervical) and deep (endocervical) endometriosis of the cervix. Typical complaints are pre- and postmenstrual brown or bloody discharge of a spontaneous or contact nature. Ectocervical endometriosis does not respond well to hormone therapy. The mechanical removal of its foci with the subsequent imposition of thin catgut sutures on larger wound surfaces justifies itself better.

Endometriosis of the vaginal part of the cervix is ​​observed quite often, since diathermo- and cryocoagulation is widely used in gynecological practice, as well as laser treatment of pseudo-erosions, while implantation occurs in the area of ​​the formed wound surface of endometrial particles that are shed during menstruation. Foci of endometriosis on the vaginal part of the cervix are small (2-5 mm in diameter), reddish in color against the background of a pale pink mucous membrane of the cervix. In the luteal phase of the cycle, and especially before menstruation, the foci of endometriosis acquire a blue-purple color, increase and bleed. Endometriosis can take the form of pseudo-erosions with the presence of glands filled with hemorrhagic contents, and chronic endocervicitis. Pain sensations for this localization of endometriosis are uncharacteristic.

What are the clinical symptoms of perineal and vaginal endometriosis?

Endometriosis of the perineum and vagina - endometrioid heterotopias - look like bluish rounded or irregularly shaped foci - "eyes". Before menstruation, the size of these foci increases, and during menstruation, dark blood is released from them.

What are the clinical symptoms of peritoneal endometriosis?

Endometriosis of the peritoneum of the uterine-rectal cavity and ligamentous apparatus can only be recognized with laparoscopy (cyanotic foci are visible - “eyes”). This endometriosis belongs to the "small" forms. The main symptom is infertility, a sharp pain syndrome. There are no menstrual dysfunctions; there are also no disturbances in the content of gonadotropins and sex steroids in the blood.

How does endometriosis of extragenital localization manifest itself?

Extragenital endometriosis most often located in the umbilical region and postoperative scar on the anterior abdominal wall and perineum. It develops more often after gynecological operations. When examining the scar or navel, bluish formations are found. During menstruation, they may bleed.

Extragenital endometriosis may be suspected in the presence of cyclic pain or a palpable tumor outside the genitals, as well as cyclic bleeding (Table 7.2). The most common localization is the colon and rectum. In this case, there are cyclic pains in the abdomen and lower back, constipation, cyclic bleeding from the rectum. With endometriosis of the bladder, the clinical picture is characterized by cyclic pain, dysuria and hematuria.

Table 7.2.Symptoms of endometriosis in various implant locations

Pneumothorax, hemothorax, or hemoptysis coinciding with menses can be attributed to typical manifestations lung endometriosis.

Endometriosis of the navel can be diagnosed in the presence of tumor-like formations in this area, the presence of cyclic pain and bleeding from the navel.

What is the importance of diagnosing endometriosis in young and old?

It is in young and old age with the diagnosis of endometriosis that the situation is especially unfavorable. The importance of diagnosing the disease in these age groups lies in the fact that it allows to reduce the frequency of advanced forms of the disease, improve the results of treatment, which will favorably affect the rehabilitation of working capacity and specific functions of the woman's body, and in older women it will help to differentiate from oncological diseases and avoid unnecessarily radical surgical procedures. interventions.

What is the role of history in diagnosing endometriosis?

In the diagnosis of endometriosis, a purposeful collection of anamnesis plays an important role. Of leading importance are the cyclical manifestations of the disease and the relationship of exacerbations with menstruation. When collecting an anamnesis, it is necessary to pay attention to the family history along the female line (painful and heavy menstruation in the mother, sisters, gynecological diseases and operations they have undergone). Of certain importance are the transferred obstetric and gynecological operations during which the uterine cavity was opened ( C-section, husking of fibromatous nodes), operations for perforation of the uterus, ectopic pregnancy etc.

What is the role of the clinical picture in the diagnosis of endometriosis?

In the diagnosis of endometriosis, the clinical picture of the course of the disease plays an important role (disturbance of well-being, anemia, severity of pain syndrome, prolonged menstruation, decrease in periodicity, violation of cyclicity, specific symptoms of damage to a particular organ), data gynecological examination, special instrumental, laboratory research methods (sonography, computed tomography, magnetic resonance imaging).

To date, the issue of diagnosing endometriosis causes certain difficulties. In the vast majority of patients with

clinically active endometriosis, timely diagnosis of this disease is possible. To do this, it is necessary first of all to remember the existence of endometriosis and the fact that it can give certain clinical manifestations, sometimes pronounced at different ages, starting from the onset of menarche (12-14 years) and up to 50-60 years.

The most important clinical sign of endometriosis is a pain syndrome associated with the menstrual cycle: pulling pains in the lower abdomen and in the lumbar region throughout the month, aggravated on the eve of menstruation, and sharply painful menstruation.

What is the role of ultrasound in the diagnosis of endometriosis?

Ultrasound is one of the most important methods for diagnosing endometriosis. This method helps to clarify the localization, size of endometrioid cysts, their dynamics depending on the menstrual cycle, on the influence of therapy, etc., although it does not allow identifying superficial implants. It should be noted that this method does not detect superficial implants on the peritoneum, however, it provides a reliable diagnosis of adenomyosis, endometrioid cysts, and also allows one to suspect the localization of this pathological process in the rectovaginal septum.

In what phase of the menstrual cycle is an ultrasound examination performed if adenomyosis is suspected?

This study, if internal endometriosis is suspected, should be carried out in the second phase of the menstrual cycle - a few days before the onset of menstruation. At the same time, the greatest attention, especially for the diagnosis initial stages development of endometriosis, it is necessary to pay attention to the state of the basal layer of the endometrium. Preference for echography should be given to transvaginal scanning.

What are the most characteristic ultrasound signs of adenomyosis?

The most characteristic ultrasound signs of internal endometriosis are:

The appearance in the myometrium of individual sections increased echogenicity;

Serration and uneven thickness of the basal layer of the endometrium;

Preferential increase in the anteroposterior size of the uterus and asymmetric thickening of one of its walls;

The presence in the zone of increased echogenicity of rounded anechoic inclusions with a diameter of 2-5 mm, as well as liquid cavities with a diameter of 6-33 mm, containing a fine suspension;

An increase in echogenicity in the area of ​​the anterior front of the formation and a decrease in the area of ​​the far front;

Identification of closely spaced increased and decreased echogenicity bands oriented perpendicular to the scanning cavity.

What is the role of hysterosalpingography in the diagnosis of adenomyosis?

With internal endometriosis, the hysterosalpingography method allows for an accuracy of up to 83%. Hysterosalpinography is carried out with aqueous solutions of contrast agents on the 7th-8th day of the menstrual cycle, since at this time the rejected functional layer of the mucous membrane of the uterine body does not interfere with the penetration of the contrast agent into the endometrioid passages. A characteristic radiological feature of internal endometriosis is the presence of "edge shadows". In order to improve the information content of the hysterosalpingography method in the diagnosis of adenomyosis, a method was proposed at the Department of Obstetrics and Gynecology of the Peoples' Friendship University of Russia, in which a day before the study, the uterine cavity mucosa was scraped. This measure facilitated the penetration of aqueous contrast agent into all courses of endometrioid heterotopias. As a result, the information content of the method increased by 3 times.

What are the main hysteroscopic signs of adenomyosis?

Hysteroscopycarried out on the 8-10th day of the menstrual cycle. In the presence of internal endometriosis in the area of ​​the bottom or side walls of the uterus, endometrioid passages are visible in the form of dark red holes, from which blood is released (“oxytocin test”). With hysteroscopy, it is necessary to differentiate the nodular form of endometriosis with subucous uterine myoma.

What is the purpose of a colposcopy?

Colposcopyfollowed by targeted biopsy is used to clarify the diagnosis of endometriosis of the cervix.

What are the indications for laparoscopy?

Currently, laparoscopy is considered one of the most accurate methods for diagnosing external endometriosis. There are red lesions, fire-like lesions, hemorrhagic vesicles, vascularized polypoid or papular lesions; black spots.

Laparoscopy- examination of the abdominal organs with the help of an optical system. Perform in the II phase of the menstrual cycle, but no later than 3-4 days before the expected menstruation. The procedure may include examination and palpation with a blunt manipulator of the bowel, bladder, uterus, tubes, ovaries, recto-uterine recess, and broad ligament. When diagnosing endometriosis, histological verification of the results of laparoscopy is extremely important not only for barely visible areas, but even for typical foci, since, according to available data, 24% of patients have no signs of endometriosis in the morphological and histological examination of such foci.

What are the indications for computed tomography?

CT scan allows you to accurately determine the nature of the pathological process, its localization, the relationship with neighboring organs, as well as clarify the anatomical state of the pelvic cavity, in particular with endometrial infiltrates of the retrocervical zone and parametria.

What are the indications for magnetic resonance imaging?

MRIprovides excellent visualization of the pelvic organs, their localization, structure and relationship with neighboring organs, and also allows you to clarify the anatomical state of the pelvic organs.

What are the treatments for endometriosis?

Treatment of endometriosis should be complex, differentiated. It includes:

Conservative methods of treatment: hormonal, anti-inflammatory, desensitizing and symptomatic therapy;

Surgical methods of treatment carried out by laparotomic and laparoscopic ways.

What are the criteria for choosing a treatment for endometriosis?

Should be considered:

The age of the patient and her attitude to reproductive function;

Localization, prevalence and severity of the course of the pathological process;

Combination with inflammatory processes, its consequences (cicatricial adhesive processes), endometrial hyperplastic processes and destructive changes in the ovaries and uterus;

Concomitant extragenital diseases.

What are the goals of endometriosis treatment?

The modern approach to the treatment of patients with endometriosis consists in a combination of a surgical method aimed at the maximum removal of endometrioid lesions and hormone modulating therapy. Hormone therapy is aimed at suppressing the synthesis of estrogens. That is why the various therapeutic effects used in the treatment of endometriosis ultimately pursue the same goal - the suppression of the hypothalamic-pituitary-ovarian system and the development of atrophic changes in the tissue of endometrioid heterotopias.

What is the mechanism of action of estrogen-progestin drugs?

These drugs suppress the release of gonadotropic emissions, inhibit the synthesis of steroids in the ovaries and proliferative processes in the endometrium. Under their influence, cyclic processes in the endometrium and endometrioid heterotopias stop, and with prolonged use, regressive changes develop, leading to sclerosis and obliteration of endometrioid foci.

What estrogen-progestogen drugs are used to treat endometriosis?

These include: combined oral contraceptives (OK); two- and three-phase - triziston, triquilar, trinovum, synphase - are administered orally 1 tablet at night from the 5th to the 25th day of the menstrual cycle; monophasic - silest, marvelon, mersilon, femoden, miniziston, diane-35 - from the 1st to the 21st day.

Treatment is carried out for 6-12 months. The duration of taking hormonal drugs is determined by the prevalence of the process and the effectiveness of therapy.

What "pure" progestins are used to treat endometriosis?

The following progestins are used: norkolut, norethisterone, medroxyprogesterone, 17-hydroxyprogesterone, dufaston. The latter is used 1 tablet (10 mg) 2 times a day from the 11th day for 14 days or from the 16th to the 25th day for 10 days of the menstrual cycle, or 1 tablet 2 times a day from 5 to th to the 25th day of the cycle.

What antigonadotropic drugs are used to treat endometriosis?

Currently, a synthetic derivative of 17-β-ethynyl-testosterone, danazol, which has an antigonadotropic effect, is widely used; blocking the ovulatory release of gonadotropins, blocks estradiol, progesterone and androgen receptors in the ovaries. Danazol is taken at 400-800 mg per day (2800 mg per week) for 6-8 months. Since the 1980s gestrinone is used - a derivative of 19-norsteroids, which has a high antigonadotropic activity, which allows it to be used in small doses - 2.5 mg 2 times a week (5 mg). This drug causes more intense involutive changes in the tissue of endometrioid heterotopias. The drug causes symptoms similar to those climacteric syndrome: hot flashes, sweating, sleep disturbance, but at the end of treatment, these symptoms disappear.

What RG-LH agonists are used to treat endometriosis and what is their mechanism of action?

Gonadotropic releasing hormone agonists block receptors in the "gonadotropic" zones of the anterior pituitary gland, inhibit the secretion of gonadotropins. As a result, the formation of sex hormones in the ovaries decreases, the level of which in the blood drops to postmenopausal levels. Of the drugs of prolonged action (deposited form) are used:

Zoladex (goserelin) - 3.8 mg subcutaneously in the anterior abdominal wall 1 time in 28 days;

Decapeptyl-depot (triptorelin) - 3.75 mg intramuscularly 1 time in 28 days;

Lucrein-depot - 3.75 mg intramuscularly 1 time in 28 days;

Buserelin - endonasal spray, daily dose of 900 mcg for irrigation of the nasal mucosa (2 presses 3 times a day).

The duration of treatment with gonadotropic RG agonists is 3-6 months.

What are the indications for surgical treatment of endometriosis?

Surgical treatment of endometriosis is subject to:

Knotty forms of adenomyosis;

The combination of a diffuse form with uterine myoma, endometrial hyperplastic processes;

Adenomyosis III degree;

Endometrioid ovarian cysts;

Retrocervical endometriosis;

Endometriosis of the perineum, vagina and vaginal portion of the cervix;

With "small" forms of endometriosis.

What surgeries are used for endometriosis?

With adenomyosis - supravaginal amputation of the uterus without appendages with excision of the mucous membrane of the cervical canal. With endometriosis of the cervix, cryo- and laser therapy, radiosurgical methods are recommended. Endometrioid ovarian cysts are removed laparotomically or laparoscopically. In small forms of endometriosis, electrocoagulation or cauterization of endometrioid heterotopias is performed during laparoscopy. With retrocervical endometriosis, the affected tissues are excised and the bed is affected or cryodestruction is performed; with a combination of adenomyosis, retrocervical endometriosis and lesions of the cervix, the uterus is extirpated.

A sine qua non for efficiency surgical treatment is the use of hormone therapy after surgery for at least 3-6 months. to avoid relapses. In addition, physiotherapy is recommended - electrophoresis of iodine and zinc with a sinusoidal modulated current, analgesics and drugs that inhibit the synthesis of prostaglandins (indomethacin, butadion, naprosin), tranquilizers, vitamins, acupuncture, therapeutic ultrasound, hyposensitizing agents.

What diseases should be differentiated from adenomyosis?

Endometriosis of the uterus (adenomyosis) most often has to be differentiated from uterine fibroids(usually with submucous myomatous node). In the presence of submucosal fibroids, menstruation becomes erratic, acyclic, i.e., acquire the character of metrorrhagia. Endometriosis is characterized by menorrhagia. In submucosal fibroids, anemia is usually stable and increases with blood loss. With adenomyosis, anemia after menstruation is relatively quickly eliminated. For the purpose of diagnosis, methods such as hysterosalpinography and hysteroscopy are used.

To differentiate this disease from endometrial cancer, apply a separate diagnostic curettage of the mucous membrane of the cervical canal and the mucous membrane of the uterine cavity, followed by a histological examination.

What diseases should be differentiated from ovarian endometriosis?

Endometriosis of the ovaries must be differentiated from tumor-like formations of an inflammatory nature, benign and malignant tumors, tuberculosis of the uterine appendages.

What diseases should be differentiated from endometriosis of the cervix?

Cervical endometriosis is differentiated from diseases such as cervical erosion, endocervicitis, erythroplakia, cervical cancer.

What diseases should be differentiated from retrocervical endometriosis?

Retrocervical endometriosis is characterized by a slow growth of the endometrioid formation, the absence of a tendency to decay, ulceration and bleeding of the tissue, as well as the presence of "bluish eyes". When making a differential diagnosis of retrocervical endometriosis and cancer of the rectum, vagina, stage III-IV ovarian cancer, it must be remembered that in such patients there are significant changes in the blood count, ascites often occurs, the general condition of the patient and other signs of cancer pathology attract attention.

What is the prevention of endometriosis?

The significant prevalence of endometriosis and the tendency to increase its frequency dictate the need to develop measures to prevent the disease and prevent its recurrence.

Since the leading role in the pathogenesis of endometriosis is the displacement and implantation of endometrial elements outside the uterine cavity with an appropriate hormonal background and a violation of immune homeostasis, then preventive measures should include these circumstances:

Timely and sufficiently vigorous treatment of chronic inflammatory processes of the internal genital organs;

Introduction of modern contraceptives in order to prevent unwanted pregnancy;

A strict medical approach to various diagnostic and therapeutic procedures (diagnostic curettage, hysterosalpingography, probing of the uterus, operations with opening the uterine cavity, caesarean section, etc.);

Targeted treatment of uterine bleeding using hormonal drugs after curettage of the mucous membrane of the uterine cavity;

Prevention of traumatism of the birth canal (careful suturing of ruptures of the cervix, vaginal walls, perineum);