Precancerous diseases and cancer of the external genital organs. Factors in the development of background and precancerous diseases of the cervix. cervical dysplasia

- a group of congenital and acquired pathological conditions that precede the development of oncological lesions, but not always transforming into a malignant tumor. May be optional or obligatory. The group of precancers includes a large number of diseases of an inflammatory, non-inflammatory and dystrophic nature, malformations, age-related changes and benign neoplasia. It is diagnosed on the basis of clinical, laboratory and instrumental studies. Treatment tactics and malignancy prevention measures are determined by the type and localization of the pathological process.

Precancer - changes in organs and tissues, accompanied by an increased likelihood of developing malignant neoplasms. Their presence does not mean mandatory transformation into cancer, malignancy is observed in only 0.5-1% of patients suffering from various forms of precancer. The study of this group of diseases began in 1896, when the dermatologist Dubreuil proposed to consider keratoses as pathological conditions preceding skin cancer. Subsequently, the theory of precancers became the subject of research by doctors of various specialties, which led to the formation of an integral concept that takes into account the clinical, genetic and morphological aspects of the formation of cancerous tumors.

The modern version of this concept is based on the idea that malignant neoplasia almost never occurs in healthy tissue. Each type of cancer has its own precancer. In the process of transformation from healthy tissue to a malignant tumor, cells go through certain intermediate stages, and these stages can be distinguished by studying the morphological structure of the affected area. Scientists have been able to identify precancers for many cancers of various localizations. At the same time, the precursors of other groups of oncological lesions remain unidentified in most cases. Treatment of precancerous processes is carried out by specialists in the field of oncology, dermatology, gastroenterology, pulmonology, gynecology, mammology and other fields of medicine.

Classification of precancers

There are two types of precancers: facultative (with a low probability of malignancy) and obligate (degenerate into cancer in the absence of treatment). Experts consider these pathological processes as two initial stages of cancer morphogenesis. The third stage is non-invasive cancer (carcinoma in situ), the fourth stage is early invasive cancer. The third and fourth stages are considered as the initial stages of the development of a malignant neoplasm and are not included in the group of precancers.

Taking into account localizations, the following types of precancers are distinguished:

• Skin precancers: Paget's disease, Bowen's dyskeratosis, xeroderma pigmentosa, cutaneous horn, senile keratosis, radiation dermatitis, long-term fistulas, post-traumatic and trophic ulcers, post-burn scars, skin lesions in SLE, syphilis and tuberculosis, congenital malformations and acquired skin diseases.
• Precancers of the red border of the lips: dyskeratosis, papillomas.
• Precancers of the oral mucosa: fissures, ulcers, leukokeratosis.
• Precancers of the nasopharynx and larynx Key words: papillomas, dyskeratosis, basal fibroid, chondroma, adenoma, contact fibroma.
• Precancers of the mammary gland: nodular and diffuse dishormonal hyperplasia.
• Precancers of the female genital organs: hyperkeratosis, erosion and polyps of the cervix, endometrial hyperplasia, endometrial polyps, adenomatosis, cystic mole, some ovarian cystomas.
• Precancers of the gastrointestinal tract: post-burn scars of the esophagus, leukoplakia of the esophagus, gastritis, gastric ulcer, adenomatous polyps of the esophagus, stomach and intestines, ulcerative colitis, fistulas and fissures of the anus, scars of various localization.
• Precancers of the liver and biliary tract: cirrhosis, cholelithiasis, hepatoma.
• Precancers of the urinary tract, testicles and prostate: leukoplakia of the bladder mucosa, papillomas, adenomas, cryptorchidism, prostatic hyperplasia, teratoid testicular tumors, specific lesions of the epididymis in gonorrhea and tuberculosis.

Facultative precancers are chronic diseases and conditions with a relatively low risk of malignancy. Such pathological processes are accompanied by tissue dystrophy and atrophy, as well as disruption of cell regeneration processes with the formation of areas of cell hyperplasia and metaplasia, which can subsequently become a source of a malignant tumor. The group of facultative precancers includes chronic nonspecific and specific inflammatory processes, including esophagitis, atrophic gastritis, gastric ulcer, ulcerative colitis, cervical erosion and many other diseases. In addition, this group includes some developmental anomalies, age-related changes and benign neoplasia.

Obligate precancers are considered as pathological conditions that, if left untreated, sooner or later transform into cancer. The probability of malignancy in such lesions is higher than in facultative precancers. Most obligate precancers are due to hereditary factors. These diseases include adenomatous polyps of the stomach, Bowen's dermatosis, xeroderma pigmentosa, familial polyposis of the large intestine, etc. the level of maturity with a predominance of less specialized forms) and a violation of the architectonics of tissues (a change in the normal structure, the appearance of areas of asymmetry, atypical relative positions of cells, etc.).

Specialists usually distinguish three degrees of dysplasia in precancer: mild, moderate and severe. The main criterion that determines the degree of dysplasia is the level of cell atypia. The progression of dysplasia is accompanied by an increase in cellular polymorphism, an increase in nuclei, the appearance of hyperchromia, and an increase in the number of mitoses. The appearance of areas of dysplasia in precancer does not necessarily result in the formation of a clone of malignant cells. Stabilization of the process, a decrease or increase in the severity of pathological changes are possible. The more pronounced dysplasia, the higher the likelihood of malignancy.

Precancerous conditions (precancerous)

Skin precancers

Precancerous skin diseases are a widespread and well-studied group of precancers. The leading place in the list of factors provoking such pathological conditions is occupied by adverse meteorological effects, primarily excessive insolation. In addition, high humidity, wind and low ambient temperatures matter. Skin precancers can be triggered by prolonged contact with chemical carcinogens, including tar, arsenic, and lubricants. Radiation dermatitis occurs when a high dose of ionizing radiation is received. The cause of trophic ulcers is circulatory disorders. Post-traumatic ulcers can form at the site of extensive purulent wounds. Unfavorable heredity plays an important role in the development of some diseases.

The risk of malignancy of keratoacanthoma is about 18%, skin horn - from 12 to 20%, post-burn skin lesions - 5-6%. The diagnosis of precancer of the skin is made taking into account the data of the anamnesis and external examination. If necessary, take material for cytological examination. Treatment usually consists of excising the affected tissue. Surgical removal, cryodestruction, laser therapy, diathermocoagulation are possible. Some precancers require therapy for the underlying disease, dressings, skin grafting, etc. Prevention consists in minimizing harmful effects, observing safety rules when working with chemical carcinogens, and timely and adequate treatment of traumatic injuries and inflammatory skin diseases. Patients at risk should be regularly examined by a dermatologist.

Precancers of the gastrointestinal tract

Precancers of the gastrointestinal tract include a large number of chronic diseases of the gastrointestinal tract. The most important are atrophic gastritis, tumor-stimulating gastritis (Monetrier's disease), gastric ulcer, adenomatous polyps of the stomach and intestines, Crohn's disease and ulcerative colitis. The reasons for the development of precancers can vary. Important factors are unfavorable heredity, Helicobacter pylori infection, eating disorders (irregular meals, consumption of spicy, fatty, fried foods) and autoimmune disorders.

The probability of malignancy of precancers of the gastrointestinal tract varies significantly. With familial polyposis of the colon, malignancy is observed in 100% of cases, with large adenomatous polyps of the stomach - in 75% of cases, with Monetrier's disease - in 8-40% of cases, with atrophic gastritis - in 13% of cases. In stomach ulcers, the prognosis depends on the size and location of the ulcer. Large ulcers are malignant more often than small ones. With the defeat of the greater curvature (very rare localization of the ulcer), malignant degeneration is observed in 100% of patients.

The leading role in the diagnosis is usually played by endoscopic methods of research. During gastroscopy and colonoscopy, the doctor evaluates the size, location and nature of the precancer and performs an endoscopic biopsy. The tactics of treatment is determined by the type of pathological process. Patients are prescribed a special diet, conservative therapy is carried out. At a high risk of malignancy, surgical excision of precancers is performed. Preventive measures include adherence to a diet, timely treatment of exacerbations, correction of immune disorders, early identification of persons with a hereditary predisposition, regular examinations by a gastroenterologist in combination with instrumental studies.

Precancers of the female reproductive system

In the group of precancerous diseases of the female reproductive system, experts combine precancers of the female genital organs and mammary glands. Among the risk factors for the development of precancers, researchers indicate unfavorable heredity, age-related metabolic and endocrine disorders, early onset of sexual activity, numerous births and abortions, lack of childbirth, sexually transmitted diseases, some viral infections (human papillomavirus, herpesvirus type 2), smoking, use chemical contraceptives and occupational hazards.

When diagnosing precancer, data from a gynecological examination, colposcopy, hysteroscopy, ultrasound of the pelvic organs, Schiller test, examination of cervical scrapings, mammography, histological examination and other methods are taken into account. Treatment may include diet, physiotherapy, hormonal drugs, antipruritic and antimicrobial agents, etc. Chemical coagulation, diathermocoagulation, radiodestruction, cryosurgery, and traditional surgical techniques are used to remove various types of precancer. Indications for surgery and the scope of intervention are determined individually, taking into account the history of the disease, the risk of malignant transformation, the age of the patient and other factors.

Leukoplakia of the vagina

The disease manifests itself in the form of slightly raised plaques or white spots of various sizes in the area of ​​the labia, clitoris or perineum.

Kraurosis vulva

Vaginal papillomas

Diseases of the cervix

A special risk group are women with pathological processes in the cervical region:

Cervical erosion

Polyp of the cervix

However, the removal of a polyp is not a radical method of cure, since it is known that a focus of tumor growth can arise from externally unchanged areas of the mucous membrane of the cervix, which indicates the appearance in all its areas of common prerequisites for the occurrence of both polyps and malignant tumors. The concomitant chronic inflammation of the cervix complicates the situation and increases the risk of tumor degeneration of polyps.

Leukoplakia of the cervix

Diseases of the body of the uterus

It is necessary to take into account heredity, since it has been established that predisposition to ovulation disorders, obesity, diabetes mellitus and cancer of the uterine body can be inherited.

Predisposing factors include, first of all, a violation of ovulation, which causes primary or secondary infertility and is accompanied by the development of endometrial hyperplastic processes.

Polycystic ovaries (Stein-Leventhal syndrome)

Recurrent glandular hyperplasia of the endometrium

Endometrial polyps

Malignant degeneration of polyps is observed against the background of concomitant metabolic disorders, obesity and diabetes mellitus. Removal of a polyp is not a radical method of cure, since it is known that a focus of tumor growth can arise from externally unchanged areas of the endometrium, which indicates the appearance in all of its areas of the same prerequisites, both for the occurrence of polyps and malignant tumors of the endometrium.

uterine fibroids

The causes of the disease are frequent abortions, pathology of the cardiovascular system, liver disease, hormonal disorders. Oncological alertness is caused by growing fibroids with an increase in myomatous nodes during menopause and during menopause.

Obesity and diabetes are common precursors of uterine cancer. Therefore, the detection and treatment of not only overt, but also latent diabetes mellitus in women with any of these diseases is an important preventive anticancer measure.

Ovarian diseases

Various long-term changes and irregularities in the menstrual cycle are conditions that precede malignant changes in the ovaries.

An increased risk group includes women who have previously taken hormones for a long time in order to suppress the estrogenic function of the ovaries.

Until now, the distinction between ovarian tumors and inflammatory processes of the uterine appendages remains the most difficult. According to various clinics, 3-19% of patients with malignant ovarian tumors are under observation with an erroneous diagnosis of "chronic inflammation of the uterine appendages", and in 36% of cases, chronic inflammatory processes in the appendages are diseases associated with ovarian tumors. In addition, in some cases, these inflammatory processes play the role of a cause that provokes malignant transformations in benign ovarian tumors.

Benign tumors and tumor-like formations of the ovaries are represented by a large number of different forms. Complaints of patients and symptoms of the disease depend on the size and location of the tumor. Most often, patients complain of changes or disruption of the menstrual cycle, pain in the lower abdomen, less often in the lower back and rectum, which is often the cause of erroneous treatment "from sciatica" or "from hemorrhoids." Large tumors are manifested by the presence of palpable formations of the appendages, pain, and an increase in the abdomen. It must be remembered that any benign ovarian tumor can undergo a transition to a malignant one.

A great danger in terms of the occurrence of malignant ovarian tumors is fraught with long-term passive observation of patients with asymptomatic or asymptomatic uterine fibroids.

Finishing the description of precancerous diseases, it should be noted once again that the nature of these diseases does not lie in a local pathological change in some particular area of ​​tissue or organ. The reason for the appearance of precancerous conditions is always hidden more deeply and goes beyond the scope of a single damaged organ.

Pathological formations in organs or tissues can be compared with the tip of the iceberg, when the bulk of painful changes remain hidden, but the most significant. For this reason, surgical treatment that eliminates only visible manifestations of the pathological process is at least incomplete.

At the same time, precancerous changes in organs and tissues do not have to turn into cancer; they are completely reversible with the possibility of partial or complete restoration of the functions of all damaged organs. This is achieved by an integrated approach to the disease that has arisen, involving all organs and systems involved in the pathological process, without dividing a single disease with various organ manifestations into separate parts, which, unfortunately, occurs with traditional treatment by medical specialists.

It must be remembered that the main factors contributing to the further progression of precancerous changes in tissues include: maintaining a state of chronic inflammation in the altered organs or the pathological focus itself; chronic intoxication against the background of latent or chronic foci of infections, as well as chronic household or professional toxic effects; long-term disorders in the work of the endocrine glands with hormonal imbalance and changes in metabolism; chronic stress, exhausting the nervous and immune systems.

It becomes clear that the treatment of a precancerous disease is not an easy task, but with a correct assessment of all the changes in the patient, it is quite solvable. At the same time, the conscious participation and medical discipline of the patient himself is a necessary condition, since any, even the most effective prescriptions and useful advice from a doctor, cannot cure the patient by themselves. He needs to be actively involved. In the treatment of a precancerous disease, given its potential for transition or, conversely, not progression to cancer, the patient's intelligence often becomes a more important factor than his immunity.

Lecture 11

In the cervix, a vaginal part is distinguished, protruding into the lumen of the vagina, and a supravaginal part, located above the attachment of the walls of the vagina to the uterus, consisting mainly of connective and muscle tissues, in which vessels and nerves are located. The vaginal part of the cervix is ​​covered with stratified squamous epithelium, called exocervix. Muscle tissue is mainly contained in the upper third of the cervix and is represented by circularly arranged muscle fibers with layers of elastic and collagen fibers, the functional activity of which is provided by sympathetic and parasympathetic innervation. Muscle tissue provides the obturator function of the cervix; during pregnancy, during childbirth, it forms the lower segment of the birth canal. The cervical canal has a fusiform shape, its length from the external os to the isthmus is not more than 4 cm and the width is not more than 4 mm, the external os is round or in the form of a transverse slit. C. to. covered with single-row high cylindrical epithelium and is called endocervix. The stratified squamous epithelium of the vaginal part of the uterus is a highly differentiated tissue with a complex structure and certain functional features. The epithelium covering the cervix consists of 4 layers:

1) basal, which is immature epithelial cells located on the basement membrane in one row. These cells have uneven contours and varying sizes. The basement membrane separates the squamous stratified epithelium from the underlying connective tissue;

2) above the basal cells there is a layer of parabasal cells arranged in several rows. The cells of the basal and parabasal layers have mitotic activity;

3) the layer of intermediate cells consists of 6-7 layers of moderately differentiated cells;

4) the surface layer is represented by 2-3 rows of superficial cells, which tend to become keratinized and are easily desquamated depending on the phase of the menstrual cycle.

The main function of the stratified squamous epithelium, like any epithelium located on the border with the external environment, is protective. Lumps of keratin provide the strength of the mucous membrane and thus create a mechanical barrier, the immunological barrier is created by lactic acid, which is formed due to the metabolism of glycogen with the participation of lactobacilli. In the cervix, the border of 2 genetically different types of epithelium is the transition area between the squamous stratified epithelium of the vaginal part and the high cylindrical epithelium of the mucous membrane of the c.c. This area has a complex histoarchitectonics.

In women of reproductive age, in most cases it coincides with the area of ​​​​the external pharynx. However, it can also be located on the vaginal part of the uterus, which is associated with age, as well as hormonal balance in the body.

Diagnosis of pathology of the cervix:

1. examination of the cervix using vaginal mirrors.

3. Cervicoscopy

Cervical erosion- a defect in the epithelium of the uterus with exposure of subepithelial tissue.

Etiology: according to the etiological basis, the following types of erosion of the uterus are distinguished:

1) inflammatory; its development is considered the result of maceration and rejection of stratified squamous epithelium during inflammatory processes

2) specific, the result of specific inflammation (syphilis, tuberculosis)

3) traumatic, may be the result of trauma with gynecological instruments

4) burn; the result of scab rejection after chemical, electrical, laser or cryogenic exposure.

5) trophic; usually accompanies uterine prolapse or is the result of radiation therapy.

6) cancerous, malignant tumor of the uterus.

Pathogenesis:

The impact of various etiological factors leads to focal desquamation or maceration of the stratified epithelium of the vaginal part of the uterus.

clinical picture.

With the development of e. patients sometimes note the appearance of bloody discharge from the genital tract.

Diagnostics.

O.z. - a deep defect in the epithelium in the form of a red spot. With traumatic and, in some cases, with inflammatory erosion, a section of rising squamous epithelium can be found along its edge.

In order to determine the density of the neck, the Krobak test is used: probing the ulcer with a metal probe. The sample is considered positive if the probe easily penetrates the tissue.

Syphilitic erosion is characterized by: 1) small sizes 5-10 mm, 2) round or oval shape, 3) saucer-shaped, weightless edges, 4) smooth shiny bottom; 5) red, sometimes with a grayish tint.

At the base of syphilitic erosion, a seal visible to the naked eye is determined, which raises the erosion above the surrounding tissues. Syphilitic erosion is painless, does not bleed on contact. The Croback test is negative. With mechanical action from erosion, the appearance of a transparent serous discharge is noted.

Undermined edges are characteristic of tuberculous erosion, and a multiplicity of lesions is also possible.

Cancer erosion is characterized by: 1) uneven raised roller-like edges; 2) crater-shaped bottom covered with necrotic plaque; 3) slight bleeding on contact.

An exophytic tumor is clearly seen against the background of a sharply deformed and hypertrophied sh. uterus of wooden density. The Krobak test is positive: the probe easily penetrates into the tumor tissue.

A decubital ulcer has sharply defined edges, its bottom is usually covered with a purulent coating.

2. Colposcopy (simple, advanced)

3. Cervicoscopy

4. Cytological research method.

If cervical cancer is suspected and with radiation erosion, a consultation with an oncogynecologist is necessary. If you suspect syphilitic erosion - a dermatovenereologist, for a tuberculous lesion of the uterus - a phthisiatrician.

Treatment.

Non-drug - in the presence of indications for stimulation of reparative processes in order to epithelialize erosion of traumatic and inflammatory origin, low-intensity radiation of a helium-neon session is used (10 sessions for 5-10 minutes).

Drug treatment - for the purpose of epithelialization, tampons with ointments with antibacterial, anti-inflammatory and regenerating effects (levosin, levomekol) are widely used.

In case of radiation erosion, ointments are applied topically, accelerating the processes of cellular regeneration and stimulating cellular and humoral immunity (methyluracil ointment 10%).

With cancerous erosion and with e. specific etiology, stimulation of reparative processes is not included in the complex of therapeutic measures.

Ectopia of the cervix- displacement of the boundaries of the cylindrical epithelium on the vaginal part of the uterus.

Etiology: acquired ectopia is considered as a polyetiological disease due to the influence of a number of factors. Allocate 1) exogenous and 2) endogenous factors. Exogenous factors include infectious, viral and traumatic. To endogenous - violation of hormonal homeostasis (menarche earlier than 12 years, menstrual cycle and reproductive function disorders), changes in the immune status (presence of chronic extragenital and gynecological diseases, occupational hazards).

The factor of hereditary predisposition, the possible influence of COCs and smoking on the development of ectopias of the uterus are still being discussed.

Clinic. Uncomplicated forms of ectopia of the uterus do not have specific clinical manifestations, and most often it is diagnosed during a preventive gynecological examination.

A complicated form of cervical ectopia is observed in more than 80% of cases. In a complicated form, ectopia is combined with inflammatory, precancerous processes in the uterus.

Diagnosis of pathology of the cervix:

1. examination of the cervix using vaginal mirrors.

2. Colposcopy (simple, advanced)

3. Cervicoscopy

4. Cytological research method.

Differential diagnostics carried out with cervical cancer; true erosions of the uterus.

Treatment:

Treatment goals: elimination of concomitant inflammation, correction of hormonal and immune disorders, correction of vaginal microbiocenosis, destruction of pathological changes in cervical tissues.

Non-drug treatment. Cryodestruction, laser coagulation, radiosurgery. The choice of method depends on the pathology with which the ectopia of the uterus is combined.

Diathermocoagulation.

Diathermocoagulation is based on the use of high-frequency current, which causes thermal melting of tissues, while the human body is included in the electrical circuit and heat is generated in the tissue of the cervix itself.

Possible complications: 1) bleeding, 2) stenosis and stricture of the cervical canal, 3) extravasation, telangiectasias and subepithelial hematomas 4) endometriosis 5) impaired tissue trophism 6) formation of rough scars 7) impaired reproductive function: a) infertility b) spontaneous miscarriages c) premature birth d) cervical dystocia during childbirth 8) exacerbation of inflammatory processes of the internal genital organs 9) menstrual irregularity 10) pain syndrome 11) prolonged course of reparative processes 12) cervical cancer 13) leukoplakia 14) relapses of the disease 15) thermal burns.

Cryodestruction

Liquid gases are used as a cooling agent: nitrogen, nitrous oxide, carbon dioxide.

The degree, speed and depth of cooling can be adjusted by falling different amounts of gas vapor and changing the duration of blood exposure. Cryoprobes of various shapes, which can be selected depending on the size of the pathological area, are frozen until a rim of frost appears around the tip at a distance of 2-2.5 mm. At the same time, a part of the c.c. is also processed. Under the influence of low temperatures in tissues, the following processes occur: 1) crystallization 2) concentration of electrolytes 3) denaturation 4) microcirculation disturbance and ischemia.

As a result of these changes, cryonecrosis occurs, which forms within 1-3 days. The zone of necrosis, both deep into the tissue and on the surface, is always less than the freezing zone. The advantage of the method is painlessness, due to the rapid destruction of sensitive nerve endings, bloodlessness, and the possibility of using it on an outpatient basis.

Flaws:

Insignificant depth of exposure, the impossibility of local removal of a local area with minimal trauma to the underlying tissues, a high frequency of relapses. In the study of individual results, 13% of women revealed traces of coagulation of the cervix.

Laser coagulation

Healing features:

After removal of the pathological focus, a zone of superficial coagulation necrosis is formed at the border. Due to the low penetrating power, the necrosis zone does not exceed 0.5-0.7 mm. The formation of a scab has significant differences from other methods: the entire pathological tissue is completely evaporated and the necrosis zone is formed within the healthy tissue. This contributes to the rapid rejection of the coagulation film loosely associated with the underlying tissues and an earlier start of regeneration. In addition, the absence or minimal damage to surrounding tissues, a slight leukocyte infiltration, a reduction in the phase of exudation and proliferation contribute to the rapid healing of the uterus with the absence of gross scarring and stenosis.

Ectropion - eversion of the mucous membrane of the cervical canal.

Etiology. In young women who have not had pregnancies and childbirth, ectropion has a functional origin. Congenital ectropion is rare. The reason for the acquired e. consider postpartum ruptures of the uterus.

Clinic

Ectropion has no specific clinical manifestations and is usually detected during a routine examination.

Diagnostics.

1. examination of the cervix using vaginal mirrors.

2. Colposcopy (simple, advanced)

3. Cervicoscopy

4. Cytological research method.

Treatment.

Treatment goals.

1) restoration of the anatomy and architectonics of the uterus

2) elimination of concomitant inflammation

3) correction of vaginal microbiocenosis

Surgical treatment is indicated for all patients with uterine ectropion. Perform excision or conization of the uterus. Reconstructive plastic surgery is recommended for severe uterine ruptures.

Leukoplakia- a pathological process associated with keratinization of stratified squamous epithelium. The term leukoplakia (translated from Greek) - a white plaque, was proposed by Schwimmer in 1887 and remains generally accepted in domestic literature and clinical practice to this day, but abroad, clinicians and pathologists prefer the term "dyskeratosis".

Classification.

Currently, the clinical and morphological classification of I, A, Yakovleva and B.G. is considered generally accepted. Kukute, according to which simple LBM is referred to as background processes, and LBM with atypia is referred to as precancerous conditions.

The etiology is not well understood.

Allocate endogenous and exogenous factors:

1) endogenous factors include a violation of hormonal homeostasis, a change in the immune status

2) exogenous factors - infectious, viral, chemical and traumatic effects.

It has been established that the occurrence of LSM in women of reproductive age is preceded by past inflammatory processes of the uterus and appendages with menstrual dysfunction. PVI of the genital organs is detected in more than 50% of patients with LSM. The role of hyperestrogenism in the pathogenesis of LSM has been proven.

Chemical and traumatic effects play an important role in the occurrence of LSM: more than a third of patients with LSM previously received intensive and inadequate treatment for uterine ectopia, 33% of patients with LSM underwent early diathermocoagulation. uterus.

Clinical picture. The course is asymptomatic, there are no specific complaints.

Diagnostics

1. examination of the cervix using vaginal mirrors.

2. Colposcopy (simple, advanced)

3. Cervicoscopy

4. Cytological research method.

Treatment.

Non-drug - use diathermocoagulation, cryogenic exposure, laser destruction.

Drug treatment: conducting etiotropic anti-inflammatory therapy according to generally accepted schemes, correction of vaginal microbiocenosis, correction of hormonal disorders, correction of immune disorders.

Surgery. With a combination of LSM with a pronounced deformity and hypertrophy sh. uterus, it is advisable to use surgical methods of treatment: diathermocoagulation, knife, laser, ultrasonic or radio wave excision, or conization, amputation sh. uterus, reconstructive plastic surgery.

In 1968, Richart proposed to use the classification of precancerous conditions of the cervix in three degrees " cervical intraepithelial neoplasia (CIN). CIN I corresponds to mild epithelial dysplasia, CIN II to moderate, CIN III to severe epithelial dysplasia and intraepithelial carcinoma. The CIN I group should include the so-called flat warts associated with infection of the cervix with HPV. Etiological factors: early onset of sexual activity, the presence of a large number of sexual partners, childbirth at a very young age. HPV 16, 18 are carcinogenic factors, and types 31,33,35 are possible carcinogens.

Tobacco smoking plays an important role, some tobacco ingredients are found in high concentrations in the contents of the vagina. They have the ability to turn into carcinogenic agents - nitrosamines in the presence of a specific bacterial infection.

Among STIs in patients with CIN, the most commonly found are: HSV2, CMV, gardnerella, candida, mycoplasma, chlamydia. The association of CIN with bacterial vaginosis has been determined.

1. Light (simple) dysplasia. The cells of the overlying sections retain their normal structure and polarity. Mitotic figures retain their normal appearance and are located only in the lower half of the epithelial layer. The nuclear-cytoplasmic ratio is maintained in the volume characteristic of this layer of the epithelium. The epithelial cells of the upper section look mature and differentiated.

2. Moderate dysplasia is characterized by the detection of pathological changes in the epithelial layer in its entire lower half.

3. Severe dysplasia is characterized by the fact that in addition to significant proliferation of cells of the basal and parabasal layers, hyperchromic nuclei appear, the nuclear-cytoplasmic ratio is disturbed in the direction of increasing the nucleus; mitoses are common, although they retain their normal appearance. Signs of cell maturation and differentiation are found only in the most superficial section of the epithelial layer.

In intraepithelial pre-invasive cancer of the uterus, the entire layer of the epithelium is represented by cells that are indistinguishable from the cells of true invasive cancer.

Clinical manifestations are not pathognomonic. Almost half of the patients had no pronounced signs of damage to the cervix, the existing symptoms were due to concomitant gynecological diseases.

Complaints of leucorrhea, bleeding from the genital tract, pain in the lower abdomen and in the lumbar region.

Epithelial dysplasia can be observed on a visually unchanged neck, but more often they occur against the background of various lesions detected using additional techniques, including cytological examination of smears, colposcopy, targeted biopsy with simultaneous examination of scrapings of the mucous membrane of the c. The main role in the diagnosis of precancerous conditions of the uterine uterus is played by the histological examination of pathologically altered areas of the uterine uterus.

Treatment.

The type of therapy is determined individually depending on the type of pathology, the age of the patients, since in young patients the pathological process affects mainly the exocervix, and in the elderly - the cervical canal. In young patients, therapeutic measures are predominantly organ-preserving in nature.

In the inflammatory process, it is necessary to conduct a bacteriological and bacterioscopic examination of the vaginal flora. When a herpes infection, chlamydia, gardnerellosis is detected, it is advisable to conduct bacterial therapy followed by normalization of the vaginal microbiocenosis by using various biological preparations in the form of lacto- and bifidobacteria.

Patients who have mild dysplasia during examination can be subjected to dynamic observation with conservative treatment. In the absence of regression of pathological changes for several months, patients are shown an intervention such as diathermy coagulation, cryodestruction or laser evaporation of pathological changes in cervical areas.

Publication date: 2015-09-17 ; Read: 2168 | Page copyright infringement | Order writing work

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Practical gynecology

Guide for doctors

Medical News Agency

UDC 618.1 BBK 57.1 L65

Reviewers:

G.K. Stepankovskaya, Corresponding Member of the National Academy of Sciences and the Academy of Medical Sciences of Ukraine, Doctor of Medical Sciences, Professor, Department of Obstetrics and Gynecology No. 1, National Medical University named after. AA. Bogomolets;

AND I. Senchuk, doctor of medical sciences, professor, head. Department of Obstetrics and Gynecology of the Medical Institute of the Ukrainian Association of Traditional Medicine;

B. F. Mazorchuk, doctor of medical sciences, professor, head. Department of Obstetrics and Gynecology No. 1, Vinnitsa National Medical University. M.I. Pirogov.

Likhachev VC.

L65 Practical gynecology: A guide for doctors / V.K. Dashing-

chev. - M .: LLC "Medical Information Agency", 2007. - 664 p.: ill.

ISBN 5-89481-526-6

The practical guide provides modern ideas about the etiology and pathogenesis of the most common gynecological diseases, algorithms for their diagnosis and treatment, based on the principles of evidence-based medicine. The issues of inflammatory diseases of the female genital organs are described in detail with the characteristics of sexually transmitted infections; the problem of infertility and the use of modern reproductive technologies; all aspects of menstrual disorders, the course of menopause and postmenopause; background conditions, precancerous diseases and tumors of the female genital area; problems of endometriosis and trophoblastic disease; family planning methods; clinic, diagnostics and tactics of treatment in cases of "acute abdomen". The appendices provide information about modern pharmacological preparations, methods of herbal medicine, gynecological massage and therapeutic exercises.

For practicing doctors - obstetrician-gynecologists, family doctors, senior students, interns.

UDC 618.1 BBK 57.1

ISBN 5-89481-526-6 © Likhachev V.K., 2007

© Design. OOO "Medical Information Agency", 2007

List of abbreviations................................................... .......................................... 12

Chapter 1. Methods of examination of gynecological patients.......................... 16

1.1. Anamnesis................................................. ......................................... 17

1.2. Objective examination .............................................................. ..... 17

1.3. Special laboratory research methods ........ 22

1.3.1. Cytological diagnostics ............................................... 22

1.3.2. Tests of functional diagnostics of ovarian activity 22

1.3.3. Hormonal studies............................................... 25

1.3.4. Genetic research............................................... 27

1.4. Instrumental research methods .......................... 30

1.4.1. Probing the uterus .................................................................. ....... thirty

1.4.2. Diagnostic fractional curettage of the cervical canal and uterine cavity 30

1.4.3. Puncture of the abdominal cavity through the posterior

vaginal fornix.................................................................. ................ 31

1.4.4. Aspiration biopsy .................................................................. 31

1.4.5. Endoscopic research methods .......... 32

1.4.6. Ultrasound ........................................................ 35

1.4.7. X-ray methods of research ............... 37

1.5. Features of the examination of girls and adolescents ............ 39

Chapter 2............... 43

2.1. Mechanisms of development of inflammatory diseases

female reproductive organs .................................................................. ........ 43

2.1.1. Factors of occurrence of inflammatory diseases of the female genital organs 43

2.1.2. Mechanisms of biological protection of the female reproductive system from infection 44

2.1.3. Conditions that violate the barrier mechanisms of protection of the female reproductive system 45

2.1.4. The main links in the pathogenesis of inflammatory diseases of the female reproductive system 46

2.2. Characteristics of infections transmitted

sexually .............................................................. ......................... 48

2.2.1. Trichomoniasis .................................................. ................. 48

2.2.2. Gonorrhea................................................. ............................ fifty

2.2.3. Urogenital candidiasis .............................................. 54

2.2.4. Chlamydia ................................................................ ....................... 56

2.2.5. Mycoplasmosis and ureaplasmosis...................................... 60

2.2.6. Bacterial vaginosis.............................................................. 63

2.2.7 Infections caused by the herpesvirus family 66

2.2.8. Papillomavirus infection .............................................. 73

2.3. Clinic, diagnosis and treatment of individual forms
inflammatory diseases

female reproductive organs .................................................................. ...... 76

2.3.1. Vulvitis................................................. .............................. 76

2.3.2. Bartholinitis ............................................................ ................... 80

2.3.3. Colpitis................................................. ....................... 83

2.3.4. Cervicitis .................................................. ......................... 95

2.3.5. Endometritis .................................................. ................... 98

2.3.6. Salpingo-oophoritis .................................................. ......... 102

2.3.7. Parametritis................................................. ................... 118

2.3.8. Pelvioperitonitis .................................................. ........ 119

Chapter 3.................................................. 123

3.1. Neurohumoral regulation of reproductive

functions of a woman .................................................. ................... 123

3.1.1. Physiology of the female reproductive system.. 123

3.1.2. Neurohumoral regulation

menstrual cycle .................................................................. .. 135

3.1.3. The role of prostaglandins in the regulation of the female reproductive system 136

3.1.4. Anatomical and physiological features of the functioning of the female genital organs

in different age periods .............................. 137

3.2. Hypomenstrual syndrome and amenorrhea .............................. 141

3.2.1. General principles of examination and treatment of patients

with hypomenstrual syndrome and amenorrhea.... 145

3.2.2. General principles for the treatment of patients

with hypomenstrual syndrome and amenorrhea .... 146

3.2.3. Features of clinical manifestations, diagnosis and treatment of primary amenorrhea 151

3.2.4. Features of clinical manifestations, diagnosis and treatment of secondary amenorrhea 160

3.3. Dysfunctional uterine bleeding .............................. 173

3.3.1. Clinical and pathophysiological characteristics of dysfunctional uterine bleeding 175

3.3.2. General principles of examination of patients with DMC. 178

3.3.3. General principles for the treatment of patients with DMK .............. 179

3.3.4. Features of DMC in different age periods .... 181

3.4. Algodysmenorrhea .............................................. .................... 194

Chapter 4.......................................................... 199

4.1. Physiology and pathophysiology of perimenopausal

and postmenopausal periods....................................... 202

4.2. Pathology of the peri- and postmenopausal periods ...... 206

4.2.1. Psychoemotional and neurovegetative disorders 207

4.2.2. Urogenital disorders and trophic skin changes 211

4.2.3. Cardiovascular disorders

and osteoporosis .............................................................. .................... 213

4.3. Diagnosis of climacteric syndrome .................... 217

4.4. Drug therapy for the pathology of peri-

and postmenopausal periods....................................... 221

4.4.1. Hormone Replacement Therapy .................................. 224

4.4.2. Selective estrogen receptor

modulators ................................................. .................... 231

4.4.3. Tissue-selective regulator of estrogenic activity - STEAR 232

4.4.4. Phytoestrogens and phytohormones .............................. 233

4.4.5. Androgens ................................................................ ....................... 234

4.4.6. Systemic and local HRT for urogenital disorders 234

4.4.7. Prevention and treatment of osteoporosis .............................................. 235

4.5. Physiotherapy of the pathology of peri-

and postmenopausal periods....................................... 238

4.6. Phytotherapy of pathology of peri-

and postmenopausal periods....................................... 240

Chapter 5................................................................... 243

5.1. Characteristics of various forms

polycystic ovaries .............................................................. ...... 243

5.1.1. Polycystic ovary disease............................................... 243

5.1.2. Polycystic Ovary Syndrome .............................. 245

5.2. Diagnosis of PCOS .............................................. .................... 248

5.3 Treatment of PCOS............................................... ............................... 252

5.3.1. Conservative methods of treatment............................... 252

5.3.2. Surgical methods of treatment .............................. 256

5.3.3. Physiotherapy................................................. ................. 258

Chapter 6............................................................................................. 260

6.1. Features of clinical manifestations,

diagnostics and treatment of various forms of infertility............. 262

6.1.1. Endocrine infertility............................................... 262

6.1.2. Tubal and tubal-peritoneal infertility..... 276

6.1.3. Uterine and cervical forms of infertility .................. 282

6.1.4. Immunological infertility .................................... 283

6.1.5. Psychogenic infertility .............................................. 285

6.2. Algorithm for diagnosing infertility....................................... 285

6.3. Algorithm for the treatment of various forms of infertility....................... 287

6.4. Modern Reproductive Technologies ...................... 290

6.4.1. In vitro fertilization.............................. 291

6.4.2. Other Reproductive Technologies .................................. 294

6.4.3. Ovarian Hyperstimulation Syndrome....................... 296

Chapter 7

genitals................................................................................. 300

7.1. Background and precancerous diseases of the cervix

uterus ................................................. ...................................... 300

7.1.1. Etiopathogenesis of diseases of the cervix ............... 301

7.1.2. Classification of diseases of the cervix .............. 303

7.1.3. Clinic of diseases of the cervix .......................... 305

7.1.4. Diagnosis of background and precancerous diseases of the cervix 316

7.1.5. Treatment of background and precancerous

diseases of the cervix .............................................. 321

7.1.6. Clinical management of patients

with various forms of background and precancerous
diseases of the cervix .............................................. 328

7.2. Hyperplastic processes of the endometrium (HPE) .......... 331

7.2.1. Etiopathogenesis of HPE .............................................. ...... 331

7.2.2. GGE classification .............................................................. ...... 333

7.2.3. GPE clinic .................................................. ................... 339

7.2.4. Diagnosis of HPE .............................................. ........... 340

7.2.5. Treatment of HPE .............................................................. .................... 344

7.3. Hyperplastic and dysplastic processes
mammary gland (mastopathy) .............................................. 359

Chapter 8............................ 375

8.1. Uterine fibromyoma (FM) .............................................. .......... 375

8.1.1. Etiology and pathogenesis of FM .............................................. 375

8.1.2. FM classification .................................................................. ...... 379

8.1.3. Clinic FM .............................................. .................... 381

8.1.4. FM diagnostics .................................................. ............ 386

8.1.5. Treatment of FM ....................................................... .................... 391

8.2. Benign tumors of the ovaries .............................. 399

8.2.1. Epithelial benign

ovarian tumors ................................................................ .......... 404

8.2.2 Sex cord stromal tumors (hormonally active) 409

8.2.3. Germinogenic tumors.............................................. 411

8.2.4. Secondary (metastatic) tumors .................. 414

8.2.5. Tumor-like processes.............................................. 415

Chapter 9......................................................................................... 418

9.1. Etiopathogenesis of endometriosis............................................... 418

9.2. Morphological characteristics

endometriosis ............................................................ ...................... 422

9.3. Classification of endometriosis............................................... 422

9.4. Clinic of genital endometriosis.............................. 425

9.5. Diagnosis of endometriosis.................................................... ... 431

9.6. Treatment of endometriosis .............................................................. ............ 438

9.6.1. Conservative treatment............................................. 438

9.6.2. Surgery................................................ 445

9.6.3. Combined treatment .................................................. 447

9.6.4. Algorithms for managing patients with various forms of endometriosis 449

9.7. Prevention of endometriosis............................................... 452

Chapter 10........................................... 453

10.1 Acute bleeding from the internal genitalia

organs................................................. ................................... 454

10.1.1. Ectopic pregnancy .................................. 454

10.1.2. Apoplexy of the ovary .................................................... 469

10.2. Acute circulatory disorders in tumors
and tumor-like formations of internal

sexual organs .................................................................. ................. 472

10.2.1. Torsion of the pedicle of an ovarian tumor .............................. 472

10.2.2. malnutrition

fibromatous node .............................................................. 474

10.3. Acute purulent diseases of the internal

sexual organs .................................................................. ................. 476

10.3.1. Pyosalpinx and pyovar, tubo-ovarian purulent tumor 476

10.3.2. Pelvioperitonitis .................................................. .. 486

10.3.3. Widespread peritonitis.............................. 486

Chapter 11................... 490

11.1. Anatomical and physiological features

position of the internal genital organs ........................ 490

11.2. Anomalies in the position of the internal genitalia

organs................................................. ................................... 491

11.3. Omission and prolapse of internal

sexual organs .................................................................. ................. 495

Chapter 12............................................. 504

12.1. Methods of natural family planning ............................... 505

12.2. Barrier methods of contraception.............................. 509

12.3. Spermicides ................................................................ ......................... 512

12.4. Hormonal contraception................................................... 513

12.4.1 Principles of prescribing oral hormonal contraceptives 514

12.4.2 Combined oral contraceptives. 519

12.4.3. "Pure" gestagens ............................................... ......... 525

12.4.4. Injectable contraceptives .............................. 527

12.4.5. Implantation methods................................................... 530

12.5. Intrauterine contraceptives ................................................... 530

12.6. Voluntary surgical contraception (sterilization) 533

12.7. Emergency contraception .................................................................. 536

12.8. Principles for choosing a method of contraception .............................. 538

Chapter 13.................................... 543

13.1. Etiopathogenesis of gestational trophoblastic disease 544

13.2 Nosological forms of gestational trophoblastic disease 546

13.2.1. Bubble skid .............................................................. ...... 546

13.2.2. Chorionepithelioma (chorioncarcinoma) ........... 553

13.2.3. Other forms of trophoblastic

illness ................................................. ...................... 560

13.3.............................................. ................................................. Prevention of recurrence of gestational
trophoblastic disease .............................................. 561

Attachment 1. Antibacterial agents .................................................................. ... 562

1.1. Classification and brief description

antibacterial drugs .............................................. 562

1.2. Antimicrobial agents effective against individual microorganisms 572

1.3. Doses and routes of administration of some antibiotics. 578

1.4. Combination of antimicrobials .............................. 583

1.5. The use of antibacterial drugs

during pregnancy and lactation .................................. 584

Appendix 2 Antivirals of direct action .............................. 589

Appendix 3 Immunoactive drugs .................................................................. ........ 592

Appendix 4 Phytotherapy in complex treatment

gynecological diseases .................................................................. ... 598

4.1. Menstrual irregularities.............................................. 598

4.2. Pathological climacteric period .............................. 606

4.3. Inflammatory diseases of the female genital

organs................................................. ............................................... 608

4.4. Collections that improve blood circulation in small
pelvis and having antiseptic

and desensitizing properties .............................................. 613

4.5. Kraurosis of the vulva .............................................. ......................... 615

Appendix 5 Gynecological massage .............................................................. ........ 616

5.1. Mechanism of action of GM .............................................................. ........... 616

5.2. Indications, contraindications and conditions

GM. General methodology of GM .............................................. ........ 618

5.3. Features of GM techniques depending on

from testimonies .................................................. ............................... 624

Appendix 6 Therapeutic exercises for gynecological

diseases ................................................................ ................................... 637

6.1. Therapeutic exercises for non-fixed retroflexion of the uterus 637

6.2. Therapeutic exercises for the prolapse of the genital organs. 640

6.3. Therapeutic exercises for chronic inflammatory diseases of the female genital organs 641

6.4. Therapeutic exercises for dysmenorrhea ....................................... 644

6.5. Therapeutic exercises for functional urinary incontinence 645

6.6. Therapeutic exercises in the preoperative period.... 646

6.7. Therapeutic exercises for pathological menopause ........ 648

Appendix 7 Normal microflora of the vagina .............................................. 650

Literature................................................. ................................................. .... 655

No one knows the unambiguous cause of oncological disease with one or another localization. But, there are a number of pathologies that are considered precancerous and, without proper timely treatment, can provoke the development of a malignant tumor. So, cervical cancer can have causes not only in the form of the human papillomavirus or exposure to carcinogens, but also chronic pathologies that have not been treated for years.

Most pathologies of the female genital organs, which are considered precancerous diseases, respond well to treatment. And with timely therapy, they do not give a single chance to develop an oncological process, but in the case of a negligent attitude to health and lack of treatment, the disease will sooner or later degenerate into a cancerous tumor.

Cervical cancer

Oncology can be formed as a result of the lack of treatment of the following pathologies:

• cervical erosion;
• polyps;
• leukoplakia;
• cervical dysplasia, its deformation, etc.

Erosion

Erosion is a common pathology in women. It occurs in both very young girls and older women. The disease consists in violation of the integrity of the epithelium of the cervix, in the occurrence of an ulcer. Pathology may not manifest itself for a long time, but without therapy, cervical erosion can develop into cancer. In order to exclude this possibility, it is necessary to undergo a preventive examination by a gynecologist at least once every six months. If there is erosion, the doctor will prescribe treatment, as a rule, it consists in cauterizing the ulcer with liquid nitrogen or current.

The procedure is performed without hospitalization, without the use of anesthesia and takes no more than 10-20 minutes. The only prerequisite before cauterization is to take a sample of erosive tissue for histological analysis, in order to exclude the fact that cervical erosion has developed into cancer.

Informative video: E rosia - precancerous disease of the cervix

Erosion can occur for a number of reasons:

• hormonal imbalance;
• weakened immune system;
• inflammatory processes in the genitals of a woman;
• mechanical damage to the cervical mucosa.

Erosion has no characteristic symptoms. Basically, women do not feel discomfort, pain or other manifestations and learn about the presence of a problem after examining a gynecologist. In rare cases, when there are significant mucosal lesions, bloody or bloody discharge may appear after or during intercourse. In this case, you should immediately contact a specialist.

In addition to cauterization with electric current or freezing with liquid nitrogen, other methods can be proposed in the treatment of erosion, such as radio waves or a laser. The latest therapies are the most modern, and have a limited number of side effects.

Leukoplakia

In addition to uterine erosion, cervical treatment can also occur due to other diseases, one of which is leukoplakia. The disease consists in the defeat of the mucous membrane of the lower genital tract of a woman. Visually, such changes are characterized by compaction and keratinization of the epithelium layer, on which a white or dirty gray coating appears.

Leukoplakia can be of several types:

• erosive- in this case, cracks or small sores form on the surface of the white plaque;
• flat- the most asymptomatic form, as a rule, does not show any signs of its existence. With the course of the disease, whitish foci appear that do not rise above the epithelium and do not cause pain. Basically, this form is found on examination by a doctor;
• warty- the foci in this case rise above the epithelium in the form of small growths. They can overlap one another, thus, the walls of the cervix become tuberous. This form is considered the most dangerous and most often degenerates into a cancerous tumor.

If a pathology is detected, the affected tissue is always taken for histological analysis using. The exact causes of the development of leukoplakia have not yet been studied reliably.

Informative video: Leukoplakia of the cervix

The symptomatology of the disease depends on its form. So, for example, the warty form often brings discomfort, pain and a burning sensation. In the erosive form, patients notice sanious discharge, especially after intercourse, and sometimes itching. The flat form rarely manifests itself, except for the presence of a white coating, which can only be seen by a doctor during examination.

For the treatment of pathology, the following methods can be proposed:

• chemical coagulation;
• cryodestruction;
• radio wave surgery;
• electrocoagulation;
• laser application.

polyps

Benign formations in the form of polyps can be transformed into the development of a cancerous tumor without timely therapy. Polyps are pear-shaped or villous growths. They can be attached to the mucous membrane on a wide base or a thin leg. They can be single or multiple.

Cancer development

By themselves, polyps do not harm the body, but they can cause the development of oncology or uterine bleeding, and therefore require timely treatment. Therapy consists in the removal of these growths, most often a radical method is used for this - a polypectomy.

Fibromyoma of the uterus

A common disease among women, characterized by the formation of a benign tumor in the uterus from its muscular layer. For a long time, fibromyoma does not manifest itself until it reaches a significant size. With large nodes, the tumor can be palpated by the doctor even through the abdominal cavity. This form is dangerous with bleeding and degeneration into cancer. Of the symptoms, pain is noted in the back, buttocks and lower abdomen. The pain appears as a result of the large weight of the fibromyoma and its pressure on the nerve endings. Bowel and bladder disorders can also be diagnosed.

Informative video: Fibromyoma - tumor of the uterus

Therapy depends on the size of the fibromyoma and individual indicators. As a rule, they resort to the surgical method.

Each of the described pathologies with timely diagnosis responds well to treatment. But, without therapy, there is a high probability of developing cancer, and it will be much more difficult to cope with this pathology. For prevention purposes, doctors recommend systematic visits to profile examinations by a gynecologist. Don't be indifferent to your health!