Own ligament of the ovary. Location and structure of the ovary Own ligament of the ovary

Anatomy of the ovaries:

Most of the ovary is not covered by the peritoneum. In the region of the mesenteric edge of the ovary there is a recess through which the vessels and nerves pass - the gates of the ovary. One end of the ovary (tubal) approaches the funnel of the fallopian tube, the other (uterine) is connected to the uterus by its own ligament of the ovary.
Next to the ovary, between the sheets of the broad ligament of the uterus, there are rudimentary formations - the epididymis of the ovary (epoophoron) and the periovary (paroophoron).

Blood in the ovaries comes from the ovarian arteries (branches of the abdominal aorta) and the ovarian branches of the uterine arteries. Venous blood flows through the veins of the same name, the right ovarian vein flows into the inferior vena cava, the left into the left renal vein. Lymph drainage is carried out in the lumbar and sacral lymph nodes. The ovary is innervated from the spinal nodes of the lower thoracic and lumbar segments, the abdominal aortic and lower hypogastric plexuses.

Histology of the ovaries:

Above it is the cortical substance, which occupies 2/3 of the volume of the ovary. It is surrounded by a connective tissue albuginea and integumentary epithelium of coelomic origin. The stroma of the cortical substance is formed by connective tissue elements and interstitial cells that secrete androgens. It contains follicles (of varying degrees of maturity and atretic), yellow and whitish bodies.

In accordance with the stage of development, primordial, preantral (primary), antral (secondary) and preovulatory (tertiary) follicles are distinguished. Primordial follicles have a diameter of 50 μm and consist of an oocyte of the first order - an egg cell that has entered prophase I of meiotic division - and a layer of granulosa cells surrounding it. In preantral follicles with a diameter of 150-200 μm, the oocyte of the first order is surrounded by 2-4 layers of granulosa cells located on the basement membrane, around which there are single theca cells.

Antral (secondary, large maturing) follicles with a diameter of 500 microns have a cavity containing follicular fluid, into which the egg-bearing tubercle protrudes - an oocyte of the first order and the granulosa cells surrounding it.
The number of layers of granulosa cells in the antral follicles is greater than in the preantral ones; there are several layers of theca cells around the basement membrane.

In preovulatory follicles (graafian), the average diameter of which is 20 mm, the ovipositous tubercle is located eccentrically, the granulosa cells are hypertrophied, contain lipid inclusions, the layer of theca cells is vascularized. The amount of follicular fluid in the preovulatory follicle is 100 times greater than in the antrum. In the wall of the preovulatory follicle, an avascular protrusion (the so-called stigma) is formed, which breaks, and the egg is released into the abdominal cavity - ovulation.

During ovulation, the first meiotic division of the egg ends - a second-order oocyte is formed. The maturation of the egg is completed after the end of the II meiotic division at the time of fertilization. If fertilization does not occur, the egg dies without completing division.

During one menstrual cycle, only one follicle completes development, it is called dominant.
Follicles that have not reached the preovulatory stage undergo regression (atresia). In place of the ovulated follicle, a corpus luteum is formed, the color of which is due to the luteinization of granulosa cells - the accumulation of lipid inclusions in them. If fertilization does not occur, the corpus luteum is replaced by connective tissue, resulting in a whitish body. Scars form on the tunica albuginea at the site of the rupture of the follicle.

Ontogeny and physiology:

Oogonia reproduce intensively by mitosis. Processes take place in their nuclei that prepare the reduction of genetic material, resulting in the formation of oocytes of the first order. From the 12th week around the oocytes of the first order, primary granulosa cells are formed from the mesenchyme - primordial follicles are formed.

In the future, single primordial follicles develop to antral ones. The number of primordial follicles reaches a maximum in the fetus at 28 weeks. In subsequent periods of ontogenesis (up to the 5th year of postmenopause), 98-99% of the follicles undergo atresia. By the 20th week intrauterine development, the ovarian membrane is formed, by the 25th week. the formation of the morphological structures of Ya is basically ending.

The ovaries of a newborn girl are spindle-shaped, weighing 0.3-0.5 g, 1.5 cm long, 0.5 cm wide and 0.1 cm thick, and their surface is smooth. The cortical layer contains 700 thousand - 1 million primordial follicles. Single follicles reach the antral and even preovulatory stage. The process of maturation of follicles is chaotic.

By the 8-10th year of life, the mass of the ovary reaches 2 g, the number of primordial follicles decreases to 300-400 thousand. A significant number of follicles reaches the antral and preovulatory stages, but ovulation does not occur. From the age of 12-14, cyclic processes of growth, maturation of follicles, ovulation, and the formation of a corpus luteum begin, repeating after 21-32 days, more often after 28 days. The frequency of ovulatory menstrual cycles in the first year after menarche reaches 60-75%, by 16-18 - 92-98%. By the end of puberty, the mass of the ovaries increases to 5-8 g due to the maturation of follicles, the number of primordial follicles decreases to 150-100 thousand.

In the reproductive period of life (16-45 years), the processes of growth, maturation of follicles and the formation of the corpus luteum have a clear cyclical nature. Ovulation occurs in the middle of the menstrual cycle - in most cases on the 13-14th day from the start of the development of the dominant follicle. Capillaries grow into the cavity of the burst follicle, fibroblasts penetrate, granulosa cells undergo luteinization. The corpus luteum reaches its peak 7 days after ovulation, in the next 7 days it is replaced by connective tissue. From the age of 40, the frequency of menstrual cycles without ovulation, cycles with the formation of an inferior corpus luteum, luteinization of granulosa cells of a non-ovulated follicle increases.

In premenopause (at the age of 45-50 years), anovulatory menstrual cycles and cycles with the persistence of a non-ovulated follicle predominate; the processes of atresia of the follicles increase, the number of primordial follicles decreases to several thousand. In postmenopause, the size of the I. decreases, its weight is about 3 g, the albuginea shrinks, the cortical substance becomes thinner, the interstitial cells are replaced by connective tissue. Within 5 years after a menopause in I. single primordial and atreziruyuschie follicles are still found.

In the first 8 weeks pregnancy, the corpus luteum increases due to vascularization, hypertrophy and luteinization of granulosa cells, at the 8th week. during pregnancy, it is 3 times larger than the corpus luteum formed during the menstrual cycle. After 8 weeks of pregnancy, a slow regression of the corpus luteum begins, by the time of delivery it is 3 times smaller than the corpus luteum in the flowering stage. The maturation of the follicles stops at the beginning of the first trimester of pregnancy, they undergo atresia at the stage of the antral follicle, while the granulosa cells become luteinized.

The main hormones of the ovary are estrogens, progesterone and androgens. All of them are synthesized from cholesterol under the influence of certain enzymes. The site of androgen synthesis in the ovaries is theca cells; a small amount of these hormones is formed in the interstitial cells of the stroma of the ovarian cortex. In a mature ovary, androgens are an intermediate product in the synthesis of estrogens. Estrogens (estradiol and estrone, respectively) are formed from androgens (testosterone and androstenedione) in the granulosa cells of the dominant follicle. Progesterone is produced in the luteinized granulosa cells of the corpus luteum.

Estrogens have a wide range of biological effects: they promote the growth and development of the external and internal genital organs, stimulate the growth of the mammary glands, the growth and maturation of bones in the pubertal period, ensure the formation of the skeleton and the redistribution of adipose tissue according to the female type. Androgens contribute to the growth and maturation of bones, hair growth of the pubis and armpits.

Estrogens and progesterone cause cyclic changes in the mucous membrane of the uterus and vagina, the epithelium of the mammary glands. Progesterone plays a decisive role in preparing the uterus and mammary glands for pregnancy, childbirth and lactation. Sex hormones are involved in water and electrolyte metabolism. Estrogens and progesterone have a pronounced immunosuppressive property.

The hormonal function of the ovary changes during different periods of ontogenesis and is determined by the degree of morphological maturity of the ovary and the system that regulates its hormonal function. In the ovary of the fetus, an insignificant amount of estrogens and androgens is produced. After birth, before the onset of puberty (8-10 years), the production of these hormones is very low, their content in blood plasma corresponds to the sensitivity threshold of the radioimmunological method. In the pubertal period, when cyclic processes of growth and maturation of follicles begin, the synthesis of estrogens and androgens increases. With the onset of ovulation and the formation of the corpus luteum, progesterone is secreted in the ovary.

In the reproductive period, the hormonal function of the ovary reaches its peak, the synthesis of sex hormones has a clearly pronounced cyclical nature and depends on the phase of the menstrual cycle.

In premenopause, the formation of estrogens and progesterone decreases, because. the majority of follicles do not reach the preovulatory stage, the number of anovulatory menstrual cycles and cycles with an inferior corpus luteum increases. In postmenopausal women, estrogens (mainly estrone) are synthesized in a small amount outside the ovary - in adipose tissue, their content in the blood plasma is below the basal level) of women of reproductive age. The concentration of progesterone in the blood plasma in postmenopausal women is consistently low, it is synthesized in the adrenal cortex.

Secretion of estrogens and progesterone in the first 6-8 weeks. pregnancy in the ovary increases sharply, then decreases, and the hormonal "support" of pregnancy from 12-14 weeks. carried out by the placenta.

In addition to sex hormones, inhibin is formed in the ovary - a protein hormone that inhibits the release of follitropin from the anterior pituitary gland, and relaxin - a biologically active substance that relaxes the myometrium. In the cells of the corpus luteum, oxytocin was found, which has a luteolytic effect and promotes the involution of the corpus luteum. Prostaglandins are also formed in the ovary, which are involved in ovulation, providing a rupture of the follicle wall.

The regulation of the hormonal function of the ovary is carried out by a complex multicomponent neuroendocrine system, including neurotransmitters - transmitters of nerve impulses from the higher parts of the central nervous system. (endogenous opiates, dopamine, norepinephrine, serotonin); releasing hormones or gonadoliberins (luliberin-releasing hormone lutropin, folliberin - releasing hormone follitropin), secreted by nerve cells of the hypothalamus and stimulating the release of gonadotropic hormones from the anterior pituitary gland: gonadotropic hormones (lutropin and follitropin) and prolactin, ovarian hormones, primarily estradiol, depending on the amount of which stimulates or inhibits the release of gonadoliberins from the hypothalamus and gonadotropic hormones from the anterior pituitary gland by a feedback mechanism, receptors for sex and gonadotropic hormones in the cells and tissues of the reproductive system (including lutropin receptors on the membrane of the theca cells and follitropin receptors on the membrane of granulosa cells); steroid-binding globulins are special plasma proteins that control the access of hormones to their receptors (receptors interact only with hormones that are not associated with specific globulins).

Gonadoliberins secreted from the median region of the hypothalamus in a circoral (hourly) rhythm, through the processes of nerve cells, enter the portal veins of the pituitary gland and reach its anterior lobe with blood. Under the influence of gonadoliberins, gonadotropic hormones (lutropin and follitropin) are secreted from the pituitary gland in a certain rhythm with a maximum (ovulatory peak) at the time of the highest content of estradiol in the preovulatory follicle.

Gonadoliberins also contribute to an increase in the production of inhibin in the follicles, which inhibits the release of follitropin; the formation of progesterone and a decrease in the synthesis of estradiol in the granulosa cells of the ovulated follicle, which again stimulates the release of gonadotropic hormones.

Methods for examining the ovaries:

To determine the functional state of the ovary, the content of lutropin, follitropin, prolactin, estrogens, progesterone, androgens in the blood plasma is determined using a radioimmunological method; the amount of estrogen, androgen destruction products (17-ketosteroids) and progesterone (pregnandiol) in daily urine; conduct tests of functional diagnostics; study of basal (rectal) temperature, determination of the karyopyknotic index, extensibility of the cervical mucus thread, pupil symptom, etc. In some cases, the concentration of hormones in the blood is examined before and after the administration of pharmacological drugs that stimulate or suppress the function of the hypothalamus, pituitary gland, ovaries.

To determine the size, structure and position of the ovary allows the research method - ultrasound scanning. This method also makes it possible to follow the dynamics of the growth of the dominant follicle and indirectly judge the ovulation that has occurred by the disappearance of the image of the follicle and the appearance of a fluid level (echo-negative strip) in the retrouterine space.

With laparoscopy, you can visually assess the state of I. and make a biopsy. X-ray examination under conditions of pneumoperitoneum, which allows to clarify the size of the I. and the uterus and determine their ratio, is currently rarely used due to the introduction of a highly informative and non-invasive ultrasound method into clinical practice.

Pathologies of the ovaries:

Distinguish malformations, dysfunction of the ovary, tumors and tumor-like processes of the ovaries. Ovarian apoplexy is also observed.

Malformations:

A pure form of gonadal dysgenesis occurs with a 46XX or 46XY karyotype. Sex glands are fibrous strands with stroma elements. The physique of patients is intersex, there are no secondary sexual characteristics, growth is normal. There are no malformations characteristic of a typical form of gonadal dysgenesis. The external and internal genital organs are underdeveloped.

An erased form of gonadal dysgenesis is observed in the 45X/46XX karyotype. The gonads are sharply underdeveloped ovariesb. (usually no more than 1.5 cm in length and 1 cm in width), consisting of connective tissue, stroma elements, single primordial and preantral follicles. The growth of patients is within the normal range, the physique is intersex, the mammary glands are hypoplastic, the pilosis of the pubis and armpits is very poor. External genitalia, vagina and uterus are underdeveloped.

A mixed form of gonadal dysgenesis occurs with a 45X/46XY karyotype. On the one hand, the gonads are represented by a fibrous cord, similar to that found in patients with a typical form of gonadal dysgenesis, on the other hand, by underdeveloped elements of the testis. The physique of patients is often intersex. Often there are malformations characteristic of a typical form of gonadal dysgenesis. The external and internal genital organs are underdeveloped, the clitoris is enlarged, the pubic and axillary hair is scanty.

To confirm the diagnosis of gonadal dysgenesis and clarify its form, genetic testing, ultrasound scanning of the pelvic organs, laparoscopy and biopsy of the gonads are carried out.

In pure and mixed forms of gonadal dysgenesis, due to the high risk of developing a malignant tumor, removal of the gonads is indicated. With a substitution purpose, as well as to prevent metabolic and trophic disorders in pure, erased and mixed forms of gonadal dysgenesis, cyclic hormone therapy is performed, incl. and after the operation, according to the same principles as in Shereshevsky-Turner syndrome.

Ovarian dysfunction:

Anovulation is the most common. It occurs as a result of a disorder in any of the links in the system that regulates ovarian function: the cerebral cortex, hypothalamus, pituitary gland, etc. Anovulation may be associated with such disorders of growth and maturation of the follicle as atresia of follicles that have not reached the preovulatory stage; follicle persistence - continued growth of a non-ovulated follicle up to 30-40 mm in diameter with the accumulation of follicular fluid; cystic atresia of the follicles with the formation of polycystic ovaries, luteinization of the unovulated follicle.

With atresia (including cystic) and persistence of the follicle, the synthesis of progesterone sharply decreases in it. The formation of estrogen during atresia of the follicles decreases, with the persistence of the follicles, it increases as the follicle grows. With cystic atresia of the follicles in polycystic ovaries, androgen synthesis increases.

Clinically, anovulation is manifested by infertility and menstrual disorders - amenorrhea, acyclic uterine bleeding. With cystic atresia of the follicles, along with menstrual irregularities and infertility, hirsutism and obesity often develop. To confirm anovulation, functional diagnostic tests, ultrasound examination of the ovary, and laparoscopy are performed.

Ovarian exhaustion syndrome (premature menopause) is characterized by intense mass atresia of the follicles in women under the age of 35-38 years. It occurs when exposed to various adverse factors (infection, intoxication, starvation, stress), possibly against the background of congenital inferiority of the follicular apparatus of the ego. The size of the ovary decreases, the albuginea shrinks, and single primordial follicles remain in the cortical substance.

Clinically, ovarian wasting syndrome is manifested by secondary amenorrhea, infertility, as well as sweating, hot flashes to the head and upper half of the body, palpitations and other signs characteristic of menopausal syndrome.

The diagnosis is confirmed by the results of a hormonal study (a significant increase in the content of gonadotropic hormones in the blood), laparoscopy and biopsy (follicles in the ovarian biopsy are usually absent). Replacement cyclic therapy is carried out with ovarian hormone preparations, however, modern means cannot restore the hormonal and generative function of the ovary.

Refractory ovarian syndrome - a condition in which the ovary is insensitive to the effects of gonadotropic hormones - is rare in women in their third decade of life. The pathogenesis is not well understood. The most common autoimmune theory is that gonadotropic hormone receptors in the ovary are blocked by specific autoantibodies.

Patients have secondary amenorrhea, infertility, rare hot flashes. The diagnosis presents considerable difficulties. It is confirmed by the data of laparoscopy and histological examination of the ovarian biopsy. (macro- and microscopically, the ovaries are not changed, the biopsy reveals mainly primordial and preantral follicles, there are no preovulatory follicles and corpus luteum), a slight increase in the level of gonadotropic hormones in the blood.

Treatment with drugs that stimulate ovarian function is usually not effective. Cyclic hormone replacement therapy is carried out. In some cases, it is possible to restore the menstrual cycle.

Iatrogenic disorders of ovarian function include ovarian hyperstimulation and hyperinhibition syndromes. Ovarian hyperstimulation syndrome occurs due to an overdose of drugs that stimulate ovulation (gonadotropic drugs, clomiphene citrate) in the first 2-3 days after withdrawal or against the background of their use. The ovaries increase 3-5 times. In their tissue, multiple follicular cysts and cysts of the corpus luteum with hemorrhagic contents are formed, there is a sharp edema of the ovarian stroma with foci of necrosis and hemorrhages, tears and ruptures of the ovarian albuginea are possible.

Clinically, ovarian hyperstimulation syndrome is manifested by a symptom complex of an acute abdomen: nausea, vomiting, pain in the lower abdomen, weakness, tachycardia, etc. In severe cases, fluid accumulates in the abdominal, pleural cavities and even in the pericardial cavity, anuria is observed.

Patients are subject to urgent hospitalization. In stationary conditions, agents that retain fluid in the bloodstream (plasma, protein, albumin), low molecular weight dextrans, gemodez are administered intravenously. Assign glucocorticoid and antihistamines, with an increase in blood viscosity - anticoagulants. The appearance of symptoms of intra-abdominal bleeding due to rupture of the ovary or its cyst is an indication for surgery - resection of the ovary with maximum preservation of its tissue. The prognosis for timely adequate treatment is favorable - ovarian function is restored.

Prevention of ovarian hyperstimulation syndrome includes careful selection of patients to be treated with gonadotropic drugs and clomiphene citrate; individual selection of doses; dynamic monitoring during treatment of the size of the dominant follicle using ultrasound (the diameter of the follicle should not exceed 21 mm); periodic monitoring of the content of lutropin in the blood (should not be higher than the ovulatory peak), as well as the concentration of estradiol in the blood and estrogen in the urine (it is permissible to exceed the corresponding indicators of the ovular peak by no more than 11/2-2 times).

Ovarian hyperinhibition syndrome is characterized by suppression of folliculogenesis and ovulation during long-term use of estrogen-progestin drugs with antigonadotropic properties for contraceptive or therapeutic purposes. The ovaries are somewhat reduced, their albuginea slightly thickens, mature follicles and corpus luteum are not detected in the cortical substance.

Menstruation stops, sometimes galactorrhea occurs. The diagnosis is confirmed by the data of a hormonal study, a decrease in the level of gonodotropic hormones, an increase in the content of prolactin and a sharp decrease in the level of progesterone in the blood.

With the development of ovarian hyperinhibition syndrome, estrogen-progestin preparations are canceled. As a rule, within 2-3 months. after the end of their intake, ovarian function spontaneously recovers. If amenorrhea persists for a longer time, drugs that enhance the secretion of gonadotropic hormones (clomiphene citrate) or gonadotropic drugs (pergonal, human chorionic gonadotropin) that stimulate folliculogenesis and ovulation are prescribed.

With galactorrhea caused by hyperprolactinemia, after excluding prolactinoma (pituitary tumor), it is recommended to take bromocriptine (Parlodel), which suppresses the release of prolactin. The prognosis is favorable. Hormonal and generative functions of the ovaries are restored in more than half of women.

Prevention of ovarian hyperinhibition syndrome consists in careful selection of drugs for hormonal contraception. It is preferable to use estrogen-progestin contraceptives containing no more than 0.03-0.035 mg of estrogens, as well as two- and three-phase drugs.

Tumors of the ovary:

Histological classification of ovarian tumors:

Most ovarian tumors are epithelial. Of the other tumors, germ cell and sex cord stromal tumors with hormonal activity are more common. Often metastatic tumors develop in the ovary.

Epithelial tumors:

Smooth-walled serous cystoma:

Papillary serous cystoma:

Mucinous cystoma:

Brenner tumor:

Clinical manifestations of benign epithelial tumors of the ovary depend mainly on the size and location of the tumor. Tumors of even small size cause a feeling of heaviness and pain in the lower abdomen. When the bladder and intestines are compressed, urination and defecation are disturbed. Some tumors are characterized by ascites.

A common complication is torsion of the peduncle of an ovarian tumor. The pedicle of the tumor is formed by stretched ligaments (the ligament that suspends the ovary, the proper ligament of the ovary, part of the posterior leaf of the broad ligament of the uterus), in which the ovarian artery and branches connecting it with the uterine artery, lymphatic vessels and nerves pass, often the stretched uterine pipe.

Torsion of the pedicle of an ovarian tumor occurs with sudden movements, changes in body position, physical exertion, often during pregnancy, in the postpartum period. Torsion may be complete or partial. With complete torsion, blood circulation in the tumor is sharply disturbed, hemorrhages and necrosis occur, which is accompanied by the appearance of symptoms of an acute abdomen: sudden sharp pain in the abdomen, nausea, vomiting, muscle tension in the anterior abdominal wall, fever, pallor, cold sweat, tachycardia.

The tumor increases in size, its rupture, infection with the development of peritonitis are possible. Partial torsion of the tumor stem proceeds with less pronounced symptoms, the intensity of which depends on the degree of changes occurring in the tumor as a result of impaired blood supply. Perifocal inflammation can lead to fusion of the tumor with surrounding organs and tissues.

Rupture of the ovarian tumor capsule is less common, sometimes it occurs as a result of trauma, a rough gynecological examination. Symptoms of rupture of the tumor capsule I. are sudden pain in the abdomen, shock caused by intra-abdominal bleeding. Serous papillary cystomas are most often malignant. less often mucinous papillary.

The diagnosis of an ovarian tumor is established on the basis of data from gynecological, ultrasound and histological studies. In a gynecological examination, an enlarged ovary is determined. Of great help in diagnosis, especially with small tumors of the ovary, is ultrasound, which allows you to accurately determine the size of the tumor, the thickness of the capsule, the presence of chambers and papillary growths. The final benign nature of the tumor is confirmed by the results of the biopsy. In diagnostic centers, special studies are used for the purpose of preoperative differential diagnosis of benign and malignant ovarian tumors.

Treatment of benign epithelial tumors of the ovary is surgical, because. regardless of the size of the tumor, there is a risk of malignancy. During the operation, an urgent histological examination of the tumor tissue is performed. With a serous smooth-walled cystoma, the volume of the operation depends on the age of the patient: in young women, it is permissible to exfoliate the tumor, leaving healthy ovarian tissue; in postmenopause, panhysterectomy is necessary - removal of the uterus and its appendages. With serous papillary cystomas, mucinous cystomas and Brenner's tumor, the affected ovary in women of reproductive age is removed, in postmenopausal women the uterus and its appendages are removed. When the pedicle of the ovarian tumor is twisted or the tumor capsule is ruptured, the operation is performed on an emergency basis.

The prognosis is determined after a histological examination of the tumor, with timely surgery it is favorable. Women who have undergone surgery for serous papillary ovarian cysts should be observed by a gynecologist.

Malignant epithelial tumors (cancer):

The pathogenesis of ovarian cancer is not fully understood, but the results of numerous experimental, epidemiological, clinical and endocrinological studies have formed the basis for the hypothesis of the hormonal dependence of this tumor. In patients with ovarian cancer, elevated levels of gonadotropic hormones and estrogen in the blood, progesterone deficiency are detected.

In ovarian cystadenocarcinomas, especially in highly differentiated endometrioid tumors, cytoplasmic estradiol and progesterone receptors are often determined, the number of which determines the sensitivity of tumors to therapy with synthetic progestins and antiestrogen. Ovarian cancer can be combined with carcinomas of the endometrium, breast and right half of the colon (primary multiple cancer). In families of patients with cancer of the ovaries, endometrium, breast and colon, a hereditary predisposition to these tumors is noted.

The risk of developing ovarian cancer is high in women with menstrual irregularities, infertility, postmenopausal uterine bleeding, long-term ovarian cysts, uterine fibroids, chronic inflammatory diseases of the uterine appendages, as well as in pre- or postmenopausal women operated on for benign tumors of the internal genital organs leaving one or both ovaries.

The histotype of malignant epithelial ovarian tumors can be different. More than 90% of all malignant tumors of Ya. are serous, mucinous and endometrioid tumors. Ovarian cancer is characterized by aggressiveness, rapid growth and the universal nature of metastasis. The implantation pathway of tumor spread predominates - metastasis to the parietal and visceral peritoneum, to the recto-uterine cavity, greater omentum and pleura with the development of carcinomatous ascites and hydrothorax.

Lymphogenic metastases (mainly in the lymph nodes located around the abdominal aorta and in the iliac lymph nodes) are detected in 30-35% of primary patients. Hematogenous metastases in the lungs and liver are determined relatively rarely, only against the background of extensive implantation and lymphogenous dissemination.

To assess the degree of spread of ovarian cancer, the classification by stages proposed by the International Federation of Gynecologists and Obstetricians (FIGO) and the classification according to the TNM system are used.

Classification of ovarian cancer proposed by the International Federation of Gynecologists and Obstetricians:

Ovarian cancer may be asymptomatic for some time. Possible weakness, pain in the hypogastric region. As the tumor process progresses, signs of ascites (abdominal enlargement), hydrothorax (shortness of breath) appear, intestinal function is disturbed, diuresis decreases, and the general condition worsens. Gynecological examination in the early stages of tumor development may reveal a slight increase in one or both ovaries. In the later stages, in the area of ​​the uterine appendages (in 70% of cases, the lesion is bilateral), tumor masses of heterogeneous consistency, dense, painless, are determined: the mobility of the uterine appendages is limited due to fixation and adhesions, and the tumor is palpated in the recto-uterine cavity.

Diagnosis of ovarian cancer in the early stages of its development is difficult. Worldwide, 70-75% of newly diagnosed patients are persons with stages III and IV of the disease. Difficulties in diagnosis are associated with an asymptomatic course of ovarian cancer, the absence of pathognomonic signs, and the underestimation of existing symptoms by patients and doctors.

Ascites is often mistakenly regarded as a manifestation of heart or liver failure, hydrothorax - as a result of pleurisy, swelling in the umbilical region (metastases) is mistaken for an umbilical hernia. Gynecologists sometimes observe patients with ovarian cancer for months, mistaking it for inflammation of the uterine appendages or (with fusion of the tumor with the uterus) for subserous uterine myoma. The frequency of erroneous conclusions increases if a rectovaginal examination is not performed.

An ultrasound examination of the pelvic organs is of great help in the early diagnosis of ovarian cancer. If a slight enlargement of the ovary is detected (more than 4 cm in the juvenile period and postmenopause, more than 5 cm in the reproductive age), a thorough examination is indicated, including puncture of the recto-uterine cavity followed by a cytological examination of the punctate, laparoscopy and laparotomy. During laparotomy, an express biopsy is performed to clarify the histotype of the tumor, a thorough revision of the pelvic and abdominal organs, including the greater omentum, liver and diaphragm, to determine the degree of spread of the process.

Specialized research centers also use computed tomography and MRI introscopy to diagnose ovarian cancer. The immunological method proposed in recent years for the early diagnosis of ovarian cancer by determining the CA 125 antigen in the blood is not sufficiently sensitive and specific, and therefore cannot be considered a reliable screening test. However, if a high concentration of the specified antigen was determined before treatment, then a study of its level after surgery or chemotherapy makes it possible to judge the onset of remission or the progression of the disease.

Before surgery, chest X-ray, intravenous urography, echography of the pelvis, liver and kidneys, fibrogastroscopy or fluoroscopy of the stomach, sigmoidoscopy, colonoscopy, X-ray examination of the colon after the introduction of barium sulfate are recommended.

The treatment of ovarian cancer consists in the individualized use of surgical, chemotherapeutic, radiation, and, in recent years, hormonal and immunotherapeutic methods. Treatment of patients with stage I and II ovarian cancer begins with surgery (a longitudinal incision of the anterior abdominal wall and a thorough revision of the pelvic organs and abdominal cavity are required). The optimal operation is the removal of the uterus, its appendages and the greater omentum. After the operation, chemotherapy is indicated. In some clinics, radiation therapy is successfully used - remote irradiation of the pelvis.

In stage III and IV ovarian cancer, complex treatment is considered adequate, including surgery, chemotherapy and (or) remote irradiation of the pelvis and abdominal cavity. In most patients, it is preferable to start treatment with surgery, with ascites and hydrothorax - with polychemotherapy (preferably the introduction of drugs into the abdominal and pleural cavities). When performing the operation, they proceed from the principles of cytoreductive surgery, i.e. strive for the maximum removal of the main tumor masses and metastases in order to create the best conditions for subsequent chemotherapy and radiation therapy. For this purpose, supravaginal amputation or extirpation of the uterus is performed with the removal of its appendages, the greater omentum and individual metastatic nodes.

Monochemotherapy (prescription of cyclophosphamide, thiophosfamide, fluorouracil, methotrexate or other antitumor agent) is effective in 35-65% of patients, it allows to provide remission lasting from 10 to 14 months. The best results are obtained by polychemotherapy, in which combinations of cyclophosphamide, methotrexate and fluorouracil or cyclophosphamide, adriamycin and cisplatin are often used. Polychemotherapy lasts at least 1 year. After that, the issue of a second laparotomy is decided, which allows to objectively confirm remission and interrupt chemotherapy, to perform a second cytoreductive operation: to clarify the further treatment plan.

One of the promising directions in the treatment of advanced ovarian cancer is the irradiation of the pelvis and abdominal cavity after surgery using the "moving bands" technique, as a result of which the 5-year survival rate of patients with stage III ovarian cancer increases to 40%. Techniques are being developed for the use of monoclonal antibodies associated with radionuclides, which make it possible to clarify the localization and extent of the spread of a progressive tumor and, at the same time, to carry out a selective cytotoxic effect.

In recent years, in connection with the discovery of cytoplasmic progesterone and estradiol receptors in ovarian adenocarcinomas, hormonal preparations have begun to be used to treat patients with ovarian cancer. The combination of synthetic progestins (for example, oxyprogesterone capronate) with antiestrogens (tamoxifen) is recognized as the most appropriate. Hormone therapy does not replace traditional methods of treatment, but complements them; it is most effective in patients with highly differentiated endometrioid adenocarcinomas. Cancer immunotherapy is still in the phase of clinical trials, promising areas are the use of LAK-cells (activated killer lymphokines), intra-abdominal administration of interleukin 2 and recombinant a-interferon.

The prognosis for ovarian cancer depends on the biological properties of the tumor (histotype, degree of differentiation, content of estradiol and progesterone receptors), the extent of the process and the adequacy of the treatment. The 5-year survival rate for stage I ovarian cancer is 60-70%; Stage II - 40-50%, Stage III - 10-40%, Stage IV - 2-7%. Despite the improvement of all components of the combined treatment, these indicators do not tend to noticeably increase.

Therefore, the key to the problem of ovarian cancer is the development of new approaches to its early diagnosis. It is important to identify women with risk factors for developing ovarian cancer, who should be under the supervision of a gynecologist (examinations at least once every 6 months) and, if necessary, be examined in a hospital setting. The real way to prevent ovarian cancer is the timely detection and surgical treatment of benign tumors of this organ.

Borderline epithelial ovarian tumors occupy an intermediate position between benign and malignant tumors. Due to the fact that borderline epithelial tumors of I. have signs of malignancy, some authors call them low-grade carcinomas. However, the prognostic evaluation of these tumors has not been fully clarified.

The diagnosis of a borderline epithelial ovarian tumor is established by histological examination of numerous sections of the tumor. Surgical treatment: extirpation of the uterus with appendages and omentectomy. In young women who wish to preserve childbearing function, removal of the ovarian tumor and the greater omentum is acceptable. If germination of the tumor capsule or implantation metastases are determined, several courses of polychemotherapy are performed after surgery.

germ cell tumors:

Clinical manifestations are due to the size of the tumor. Tumor pedicle torsion often occurs, accompanied by symptoms of an acute abdomen. During gynecological examination, dermoid cysts are palpated laterally and anteriorly from the uterus. Surgical treatment - removal of the tumor, leaving healthy ovarian tissue. The prognosis is favorable.

The most common germ cell malignancies of the ovary include dysgerminoma, immature teratoma, and chorionepithelioma.

Dysgerminoma:

Dysgerminoma develops in girls and young women. Clinically, it can be manifested by pain in the lower abdomen, sometimes (for example, with hemorrhage into the tumor) acute. The diagnosis is based on the results of gynecological, ultrasound and histological studies.

In young patients with a small tumor that does not germinate the capsule, removal of the affected ovary and greater omentum is allowed, followed by chemotherapy (6-8 g of cyclophosphamide per course). In the next 3 years, prophylactic chemotherapy is recommended. In other cases, a radical operation is performed (removal of the uterus with appendages) and chemotherapy. The prognosis for adequate treatment is relatively favorable.

Immature teratoma:

Sex cord stromal tumors:

Feminizing ovarian tumors:

Thecacellular tumor is formed from thecacells, does not reach large sizes (usually its diameter is not more than 8 cm), has a dense texture, often repeats the shape of the ovary. On the section in the tumor of the stroma of the sex cord, solid structures of intense yellow color are determined. Granulosa cell tumors are composed of granulosa cells and theca cells.

All three types of feminizing ovarian tumors often develop in postmenopausal women, less often in the first decade of life before the onset of menarche. In reproductive age, these tumors rarely occur. Many patients with feminizing tumors of the uterus have uterine fibroids, ovarian follicular cysts, and various hyperplastic processes in the endometrium (glandular cystic hyperplasia, atypical hyperplasia, adenocarcinoma).

The clinical manifestations of feminizing ovarian tumors depend on the age at which they develop. In girls of the first decade of life, premature sexual development is observed: external and internal genital organs, mammary glands increase: pubic hair appears; menstrual-like acyclic discharge begins.

In women of reproductive age, acyclic uterine bleeding occurs, similar to dysfunctional. In postmenopause, menstrual-like discharge appears due to hyperplastic changes in the endometrium, due to hyperestrogenism, signs of “rejuvenation” are observed: skin turgor increases, mammary glands engorge, atrophic changes in the internal and external genital organs disappear, libido appears.

Most feminizing ovarian tumors (75-80%) are benign. But even in the absence of histological signs of malignancy, metastases can occur on the serous cover of the abdominal organs, parietal peritoneum, omentum, and tumor recurrences 5-30 years after its removal.

The diagnosis of feminizing ovarian tumors in girls in the first decade of life and postmenopausal women is not difficult due to the characteristic clinical symptoms. It is confirmed by the detection of an enlarged ovary (more than 4 cm on an ultrasound scan). Auxiliary diagnostic value is the detection of estrogen levels in the blood and urine that are significantly higher than the age norm, which indicates the autonomous secretion of these hormones.

In reproductive age, a feminizing ovarian tumor must be differentiated from diseases that manifest uterine bleeding, especially acyclic ones: dysfunctional uterine bleeding, uterine myoma, external and internal endometriosis. It is possible to suspect a feminizing tumor of I. in the presence of recurrent hyperplastic processes in the endometrium in women with dysfunctional uterine bleeding, especially in the case of ineffective hormone therapy. Of decisive importance in the diagnosis is ultrasound, which allows to determine the size and structure of the ovary.

Treatment of feminizing ovarian tumors is surgical. In girls and young women, only the affected ovary can be removed; in menopause and postmenopause, panhysterectomy is necessary.

The prognosis is established after a histological examination of the tumor. Given the possibility of relapses and metastases in the long term after surgery, patients should be under the supervision of a gynecologist-oncologist throughout their lives.

Virilizing tumors of the ovary:

A tumor from Sertoli cells and Leydig cells, as a rule, is small (no more than 5-6 cm in diameter), soft in texture, does not have a capsule, and on section resembles immature or cryptorchid testicles. The tumor can be malignant or benign, depending on the degree of its differentiation. Leydig cell tumors are rare. It develops in the region of the gate of the ovary in the form of a delimited, not having a capsule, yellowish in the section of a node with a diameter of not more than 10 cm. In most cases, it is benign.

Androblastomas are more common in young women. The clinical picture is due to the ability of tumors to secrete androgens, under the influence of which the defeminization of the female body occurs: menstruation is disturbed and then stopped, the clitoris enlarges, hair growth acquires viril features (male-type hair growth on the face, trunk, limbs), the voice becomes rougher, in older women baldness is often observed. As a rule, the first symptom of the disease in women of reproductive age is oligomenorrhea, then amenorrhea occurs.

Similar symptoms also occur with adrenoblastoma (hypernephroma) - an ovarian tumor from the ectopic tissue of the adrenal cortex that occurs in reproductive age, rarely before the onset of puberty and in postmenopause.

The diagnosis of a virilizing ovarian tumor is confirmed by ultrasound, which reveals an enlarged ovary, as well as an increased level of testosterone in the blood and 17-ketosteroids in the urine, which remains high after the administration of dexamethasone.

The differential diagnosis of virilizing tumors of the ovary with adrenogenital syndrome and virilizing tumors of the adrenal glands is based on the results of tomography of the adrenal glands under conditions of pneumorethroperitoneum, computed tomography and ultrasound.

Treatment of virilizing ovarian tumors is surgical: removal of the affected ovary or (over the age of 50) removal of the uterus and its appendages.

The prognosis is determined after a histological examination of the tumor. After the operation, the symptoms of virilization disappear, in women of reproductive age, the menstrual cycle is restored.

Metastatic tumors:

The primary tumor is located more often in the stomach, less often in another organ of the gastrointestinal tract. In 70-90% of cases, Krukenberg tumor is bilateral. Its clinical manifestations are similar to those of primary ovarian cancer. Amenorrhea is observed in some patients, which is associated with the presence of hormonally active luteinized stromal cells in the tumor. The diagnosis is confirmed by the results of a histological examination of the tumor and the detection of a primary focus in another organ. Treatment and prognosis depend on the underlying disease.

Tumor processes:

Other tumor-like processes of the ovary - strema hyperplasia and hyperthecosis, massive edema, simple cysts, superficial epithelial inclusion cysts and, especially, luteoma of pregnancy - are rare. Multiple luteinized follicular cysts and corpus luteum are iatrogenic diseases resulting from the use of inadequately large doses of drugs that stimulate ovulation.

Follicular ovarian cyst:

Follicular cysts with a diameter of up to 4-6 cm are often not clinically manifested. With hormonally active cysts, hyperestrogenism and menstrual irregularities caused by it are possible: acyclic uterine bleeding in women of reproductive age or premature sexual development in girls in the first decade of life. If the diameter of the follicular cyst is 8 cm or more, torsion of the cyst stem may occur, accompanied by impaired blood circulation and necrosis of the ovarian tissue, and (or) rupture of the cyst. In these cases, a picture of an acute abdomen develops.

The diagnosis of a follicular ovarian cyst is established on the basis of clinical manifestations, gynecological and ultrasound data. During a gynecological examination (vaginal-abdominal, rectal-abdominal) in front and to the side of the uterus, a tumor-like formation of a tight-elastic consistency with a smooth surface is palpated, in most cases mobile, not painful. On the ultrasound scan, the follicular cyst is a single-chamber rounded formation with thin walls and homogeneous contents.

Patients with follicular cysts up to 8 cm in diameter are subject to dynamic observation with repeated ultrasound examination. As a rule, within 11/2-2 months. the cyst regresses. To accelerate it, estrogen-progestin preparations (ovidon, non-ovlon, bisekurin, etc.) are used from the 5th to the 25th day of the menstrual cycle for 2-3 cycles.

With a diameter of a follicular cyst of 8 cm or more, husking of the cyst and suturing its wall or resection of the ovary is indicated. In recent years, these operations are performed during laparoscopy. With torsion of the legs of an ovarian cyst, rupture of the ovary. surgery is carried out on an emergency basis, in case of circulatory disorders in the ovary, it is removed. The prognosis is favorable.

Yellow body cyst:

Complications are torsion of the cyst stem and rupture of the cyst as a result of hemorrhage in its cavity, accompanied by a picture of an acute abdomen. A gynecological examination determines a tumor-like process in the ovary, which on an ultrasound scan has the same structure as a follicular cyst, sometimes a fine suspension (blood) is detected in the yellow body cyst.

Patients with asymptomatic small cysts of the corpus luteum (up to 6-8 cm in diameter) are observed by a gynecologist for 2-3 months. For larger cysts, as well as for rupture of the cyst or torsion of its legs, surgical treatment is performed. Effusion of the cyst and suturing of its wall, resection of the ovary within healthy tissues in recent years is performed during laparoscopy. In the case of necrotic changes in the ovary with torsion of the cyst leg, laparotomy and removal of the ovary are performed.

Hyperplasia of the striae of the ovary:

In a gynecological examination, a slight diffuse increase in one or both ovaries is noted, often the size of the ovary remains normal. On ultrasound scans, the length of the ovary does not exceed 5 cm, the width is 3 cm, the structure of the ovary is homogeneous and hyperechoic.

The diagnosis is established only on the basis of the results of a histological examination of the ovary. Of particular importance in the diagnosis are indications of recurrent endometrial hyperplasia, which is not amenable to hormone therapy. Due to the fact that with hyperplasia of the ovarian stroma there is a high risk of developing endometrial cancer, an operation is recommended - the removal of one or both ovaries. With hyperthecosis and hyperplastic stroma of the ovary, focal accumulations of luteinized cells are formed, with a macroscopic examination of the ovary on the cut, they look like yellowish foci.