Topic: 1. Rationale: Endometriosis affects 10–15% of all women of reproductive age [1] and 70% of women with chronic [10]. Unfortunately, for many of these women there is often a delay in diagnosis of endometriosis resulting in unnecessary suffering and reduced quality of life. It causes, through pain and , a significant problem for sufferers, their families and society as a whole. There is no conclusive evidence to explain its aetiology although our understanding of the basic pathophysiology is improving. However, there remains a substantial lack of understanding in all areas of disease.Recently the problem of endometriosis has become especially actual due to the increase of frequency of this pathology, implementation of modern diagnostic and therapeutic methods in to practice that’s why the aim of the practical lecture is the study of etiopathogenesis of endometriosis, methods of its diagnostic and treatment. Many doctors, both general practitioners and specialists, find endometriosis difficult to manage. Equally, many patients are dissatisfied with the care they receive. 1. 2. Objectives (are described in the terminology of professional activity, taking into account the system of classification of the objectives of the respective levels of cognitive, emotional and psychomotor spheres): -To analyze the main clinical picture of endometriosis. -To explain the pathogenesis of the development of the endometriosis, taking into account the anatomical and morphological and physiological features of the female genital organs. -To suggest tactics of management of patients with endometriosis of and . -To classify the endometriosis according to current morphological and clinical classifications (ICD). -To interpret data of laboratory and instrumental examinations in endometriosis. -To draw a diagram of “patient route” and “plan of examination” with the endometriosis indications of localization --To make the analysis of the methods of differential diagnosis, justification and formulation of preliminary diagnosis, as well as current approaches to the management of endometriosis in women, the principles of surgery, conservative treatment, rehabilitation measures -To make up the models of clinical cases with in women with reproductive age.

3. The basic level of expertise, skills, abilities, required for learning the topic

(interdisciplinary integration ) The name of the previous Acquired skills disciplines Normal Anatomy Structure of female genital organs. Topography of abdominal organs and pelvic organs. Histology Histological structure of the , and in normal and in pathological conditions. Notmal Physiology Physiological changes occurring in the hypothalamic- pituitary-ovarian system of women and target organs of the sex hormones action at different ages. Microbiology, Immunology Specific and nonspecific protective factors, antiviral immunity Pathological Anatomy Morphological structure of all types of benign tumors of the female genital organs. Pathological Physiology Hormonal changes in the body during the menstrual cycle and disorders of the microbiota of the female reproductive system. Operative Surgery The main types of surgery on the female genital organs. Mechanisms of therapeutic action of physical factors (electric current, refrigerants, laser radiation, phototherapy). Pharmacology Groups of medications that affect the function of the hypothalamus, pituitary gland, ovaries, adrenal glands; mechanism of pharmacological action of hormonal, hemostatic, anti-inflammatory, antiviral drugs. The name of the previous Acquired skills disciplines Normal Anatomy Structure of female genital organs. Topography of abdominal organs and pelvic organs. External female genital organs. Internal female genital organs. Blood supply of the genital organs. Suspensive, fixative and supportive apparatus of the uterus. Histology Histological structure of the cervix, vulva and endometrium in normal and in pathological conditions. Normal Physiology Physiological changes occurring in the hypothalamic-pituitary-ovarian system of women and target organs of the sex hormones action at different ages. Microbiology, Immunology Specific and nonspecific protective factors of FRS, antiviral immunity Pathological Physiology\ Hormonal changes in the body during the menstrual Anatomy cycle and disorders of the microbiota of the female reproductive system. Operative Surgery The main types of surgery on the female genital organs. Mechanisms of therapeutic action of physical factors (electric current, refrigerants, laser radiation, phototherapy).

4. Tasks for independent work in preparation for the lesson and in class.

4.1. The list of the basic terms, parameters, characteristics which the student should master at preparation for employment:

The term Definition Endometriosis – benign hormone-dependent disease, which is based on heterotopias of endometrium (glandular and

stromal components), the signs of which are nonspecific inflammation and elevated levels of enzymes on the background of disturbances of hypothalamic-pituitary-ovarian system, immune balance in the presence of genetic predispositions. Adenomyosis. endometriosis of corpus uteri

Dysmenorrhea a combination of local pain and general state disturbance during mensis is painful sexual intercourse due to medical or psychological causes.

“Chocolate” cyst of Emndometrial cysts of the ovaries as the small heterotopias may be either unilateral or bilateral with different diameters of the cysts (from 0.5 up to 10.0 cm in diameter). COC Combined oral contraceptives Gonadoliberin agonists. These preparations have a strong antigonadotropic action and bring on “medicamental castration”(diphereline, decapeptyl, zoladex, and nonapeptides: buserelin, leuprolein). Tumour markers CA-125, HE 4 are particularly useful in postmenopausal women suspected of having a malignant epithelial cell tumour.

4.2 Theoretical questions for the lesson: 1. Etiology and pathogenesis of endometriosis.

2. Frequency of endometriosis pathology.

3. Classification of endometriosis of female genitalia .

4. Main clinic symptoms for endometriosis of female genitalia.

5. Methods of diagnosis of endometriosis of female genitalia.

6. Main principles of therapy of endometriosis of female genitalia.

7. Indications for surgery of endometriosis of female genitalia.Laboratory

methods of endometriosis diagnosis.

8. Conservative methods of treatment. 9. Surgical methods of treatment.

4.3 Practical activities (tasks) to be performed on the lesson:

 Collect general and specific gynecologic anamnesis.  Make up a proper plan of examination to diagnose endometriosis.  Prepare a set of instruments to perform diagnostic scrapping of the uterine wall.  Perform speculum examination, vaginal examination, make the initial diagnostics.  Make up an individual plan of treatment of endometriosis.  Make up a plan of examination patient with endometriosis 4.3 Topic content

Endometriosis Endometriosis – benign hormone-dependent disease, which is based on heterotopias of endometrium (glandular and stromal components), the signs of which are nonspecific inflammation and elevated levels of enzymes on the background of disturbances of hypothalamic-pituitary-ovarian system, immune balance in the presence of genetic predispositions. Etiology and Pathogenesis Endometriosis is an estrogen-dependent disease. The origin of endometriosis foci and the reasons for its dissemination have not been completely studied yet. There are a couple of theories of endometriosis pathogenesis. І. The transport theory is based on lymphogenous, hematogenous, and iatrogenic (at surgical interventions, hysteroscopy, hysterosalpingography) dissemination. ІІ. The implantation theory is a theory of retrograde menstruation, which explains the retrograde ingress of endometrium cells into the abdominal cavity. The reasons for pathological implantation: - hypoluteinism (progesterone synthesis reduction); normally in the peritoneal fluid there is a high (higher than in blood) sex steroid concentration, which inactivates endometrioid cells; - protracted menstruation, constriction, and a wide uterotubal lumen lead to an increase in the amount of retrograde menstrual blood; - immune dyscrasia; - burdened heredity. ІІІ. The theory of celomic metaplasia (degeneration) of the peritoneal mesothelium in response to the irritant action of the endometrial tissue. ІV. The embryonal theory explains the dysembrioplastic genesis of endometriosis from the remains of the Mullerian ducts and primordial kidney. The risk factors include:

 history of abnormal births,  gynecological operations,  abortions,  hormonal disorders,  the decline of immunological tolerance,  hereditary predisposition,  early menarche,  inflammatory diseases of the genitalia,  the first labor families in the older age,  use of hormonal contraceptives, of IUD, Classification 1. Internal (70–90 %) – of the uterine body, isthmus, and the interstitial parts of the uterine tubes. If the uterine walls thicken, internal endometriosis is called adenomyosis. 2. External (10–30 %): - peritoneal (of the ovaries, uterine tubes, small pelvis peritoneum); - extraperitoneal (of the uterine neck, , external genitals, retrocervical). The most widespread external endometriosis classification was worked out by А. Асоstа and co-authors (1973). According to this classification, there are differentiated such stages of external endometriosis. Minor forms: - isolated heterotopies on the pelvic peritoneum; - isolated heterotopies on the ovaries without adhesions and scars. Moderate endometriosis: - heterotopies on the surface of one or both ovaries with small cyst formation; - latent periovarial or peritubal abscess; - heterotopies located on the peritoneum of the extrauterine space with scarring process and uterus displacement without the large intestine being affected by the pathological process. Severe form of external endometriosis: - endometriosis of one or both ovaries with formation of cysts larger than 2 cm; - ovary affection with evident periovarial and/or peritubal scarring process; - uterine tube affection with deformation, scarring, blockade; - peritoneum affection with extrauterine space obliteration; - affection of the sacrouterine and peritoneum of the extrauterine space; - affection of the urinary tracts and/or bowels. Many countries of the world use the classification of the American Society for Reproductive Medicine (Table 1); this classification takes into account the extent to which affection has spread, affection depth, and severity degree at different endometriosis localization, for this purpose the numerical score of the indicated parameters is formed. There are singled out four stages of the disease: I – 1–5 points, II – 6–15 points, III – up to 16–40 points, IV – 40 points and more. Table 1 Endometriosis Classification (American Society for Reproductive Medicine) Endometriosis 1 cm 1–3 cm > 3 cm Peritoneum superficial 1 2 4 deep 2 4 6 Ovaries superficial 1 2 4 deep 4 16 20 Extrauterine partial –40 ompl 40 space obliteration ete Adhesions < 1/3 < 1/3–2/3 > 2/3 Ovaries soft 1 2 4 dense 4 8 16 Uterine tubes soft 1 2 4 dense 4 8 16 Note: A completely soldered fibrial part of the tube scores 16 points. Disorders of the general condition of the organism lead to a considerable decrease of women’s exercise performance. In order to improve the quality of the diagnostics of such disorders and rational choice of the treatment method there was offered a method of assessing the degree of severity of disorders of the general condition of the organism and exercise performance of the woman (numerical system) in endometriosis (Table 2). Table 2 Pain Intensity Assessment (according to C.M. Mac Laverty, R.W. Shaw, 1995) Pain Cause Intensity Score, points Pain in the pelvic region No. 0 not connected with coitus or Weak, sometimes 1 menstruation sensation of discomfort or pain before menstruation. Moderate, evident 2 discomfort during the most part of the cycle. Severe during the whole 3 menstrual cycle, the patients must take analgesics. No. 0 Weak, with some 1 disorders of working capacity. Moderate, makes the 2 patients stay in bed for a couple of hours a day, sometimes – loss of working capacity. Severe, makes the 3 patients stay in bed during the whole day or a couple of days. Dyspareunia No. 0 Weak, tolerable. 1 Moderate, so intensive 2 that makes the patients interrupt coitus. So severe that makes 3 the patients avoid coitus.

Topical classification

 І. Genital endometriosis . Internal endometriosis (adenomiosis) o Endometriosis of corpus uteri І,ІІ,ІІІ stages depth of invasion into endometrium : glandular, cystic, fibrous (focal, nodular, diffuse) form o Endomeetriosis of the cervical canal o Endometriosis of the isthmical part of the fallopian tubes . External endometriosis o Peritoneal endometriosis  of ovaries (infiltrative and tumor forms)  of fallopian tubes  of pelvic peritoneum (red, black, white form) o Extraperitoneal endometriosis  vaginal part of cervix  of vagina, vulva  retrocervical  of uterine ligaments  Parametrial, paravezical, paravaginal tissue with or without invasion into the bladder, rectum . External-internal endometriosis . Combinations of endometriosis (genital or extragenital pathology) II Extragenital endometriosis (gastrointestinal tract, urinary organs, skin, navel, postoperative wounds, lungs, pleura, etc. Symptoms include: pain (pelvic pain, algodismenorrhea, dyspareunia), infertility, hemorrhagic syndrome, long ineffective treatment of chronic genital inflammation, mental disorders, impaired function of adjacent organs, absence of symptoms. Typical symptoms include: dysmenorrheal, dyspareunia (sexual disorders), infertility, pelvic pain. Less typical symptom - dysheziya (disturbance of bowel movements), dark bloody discharges before and after menses, dysfunctional uterine bleeding, dysuria. More rare symptoms are frequent urge to urination, haematuria, bleeding from the rectum. Very rare symptoms are haemoptyzys (bloody cough), intestinal obstruction, edema of the kidney and ureter, skin nodes. Chronic pelvic pain. This is the most common symptom of endometriosis. The intensity depends on localization of ectopy (especially pronounced in endometriosis of isthmus, sacro- uterine ligaments, nodular form), the extent of the process, duration of disease, individual characteristics. Menstrual cycle disturbances include progressive algomenorrhea, menometrorragia, bloody discharges before and after menstruation, contact bloody discharges, irregular menstruation. The disease for a long time may be hiding under the mask of various pathological processes.

Special methods of diagnosis include: X-ray examination, ultrasound, endoscopic methods including hysteroscopy and oth., CT, MRI ( fiber – accuracy of diagnostics - 98-100%), cytological, histological (diagnostic accuracy 98-100%), determination of the levels of tumor markers (CA-125, HE - 4). Ultrasound is the best and affordable screening method. There may be difficulties in accurate diagnosis if adhesive processes are present, it is impossible to identify depth of the lesion of external genital and extragenital endometriosis In some of the cases the evaluation and visualization is not accurate. Hysteroscopy. This method is miniinvasive and highly informative. During the procedure there is a high incidence of diagnosing submucous nodes, adenomyosis, chronic , hyperplasia of endometrium, polyps. The procedure is done not only for diagnosis but as a surgical method of treatment too. There is a possibility to do biopsy or curettage, remove tumors or septas, separate adhesions. Laparoscopy has a high diagnostic accuracy with direct visualization, ability to biopsy and histological examination. If it is already diagnosed appropriate therapeutic rather than diagnostic laparoscopy is applied.

Endometriosis of vagina and perineum The symptoms are: pain in the vagina and in the pelvis from mild to severe, cyclic pain that is related to the MC, the pain may be accompanied by local itching. The diagnosis criteria are: during menses painful nodes may be palpated in the vagina, after the menstruation they decrease in size or disappear leaving scars, hystological investigation may be performed.

Endometriosis of the cervix During the speculum examination cyanotic cysts may be seen. To confirm the diagnosis colposcopy and biopsy is performed. The sysmptoms include dark bloody discharges from vagina before and after menses. This is the only form that the pain symptom is not present.

Endometriosis of the ovaries Emndometrial cysts of the ovaries as the small heterotopias may be either unilateral or bilateral with different diameters of the cysts (from 0.5 up to 10.0 cm in diameter). The symptoms include: pain especially before and during menses, infertility, disuria, dysheziya. In case of rupture of the cysts the pain is accompanied by vomiting, unconsciousness, elevated body temperature. Diagnoses. Bimanual examination: One or both sides tumors are palpated in the pelvis, inactive painful especially during menstruation, with bumpy surface, located at the sides or behind the uterus, with a dense capsule, limited mobility, often along with the uterus are palpated as one conglomerate. The other diagnostic measures include ultrasound, endoscopic methods (laparoscopy)( small size cyanotic nodes or cysts of various size).

Retrocervical endometriosis occurs relatively frequently. Behind the cervix a dense bumpy, sharp pain, formation of different size, limited in mobility is palpated. The symptoms are - severe pain syndrome, difficulties of bowel movement.

Extragenital endometriosis - endometriosis of the naval, endometriosis of the postoperative scar and others.

Adenomyosis.

Classification

I degree. – germination of mucosa to a depth of one field of view at low magnification of the microscope

o II degree - Germination mucosa to the middle of the wall thickness o III degree - the entire muscle layer is involved into the pathological process Symptoms. It is believed that the clinical manifestations occur in women with II and III degree and nodular form, whereas I degree is a histological finding during hysterectomy . The course may be asymptomatic - 19-40%, algomenorrhea - 76%, hypermenorrhea - 50-66%, "chocolate“ like vaginal discharges - 56%, increased dysmenorrhea - 30% (at a depth of myometrial lesions by more than 80%) , pelvic pain, metrorrhagia, dyspareunia, infertility. Diagnoses. Bimanual examination (a moderate increase in uterine anteroposterior size, tenderness, when nodular form dense nodes are palpated, painfulness and the value of which increase during menstruation), Ultrasound (increased anterio-posterior uterine size (80%), a thickening of one of the walls of uterus (81.8%), the presence of zone of increased echogenicity, occupying more than half the thickness of the (96%), hysteroscopy, hysterosalpingography, laparoscopy.

Treatment The choice of treatment strategy depends on the age of woman, localization and extent of the disease, severity of symptoms and duration of illness, fertility and the need to restore fertility, the effectiveness of previous treatment, presence of comorbidity, common therapeutic approaches. The methods of treatment include surgical therapy, hormonal therapy, during menopause if minimal manifestations of the disease are present expectant management, auxilary (for all symptoms) therapy, IVF- if infertility

Conservative therapy includes hormonal therapy, non-specific anti- inflammatory therapy, medications that affect the central nervous system, immunomodulators, antioxidants, vitamin, medications that support the function of gastrointestinal and hepatobiliary systems, physiotherapy treatment, treatment of comorbidity. According to the consensus for the treatment of chronic pelvic pain syndrome and endometriosis (2002) the first line of treatment include Monophasic COC + nonsteroidal anti-inflammatory therapy if treatment failure. The second line of treatment is surgery (laparoscopic or laparotomy) treatment. In our country the second-line treatment should be considered a destination of agonist of gonadotropin-releasing hormone after failure are surgical treatment is performed. If untreated, the disease progresses with the development of common tumor forms, malignant degeneration.

Indications for surgical treatment of endometriosis are

 internal endometriosis combined with hyperplastic processes of ovaries and / or endometrial precancerous  adenomyosis (diffuse or nodular form) accompanied by hyperplasia of endometrium  Endometrial ovarian cysts (larger than 5 cm)  No effect of conservative treatment, which was carried out continuously for 6 months  pathological involvement of other organs and systems with violation of their functions  purulent lesions of the uterus, affected by endometriosis  endometriosis of navel  adhesions of the in ampullar departments with infertility  endometriosis of the postoperative scar  presence of somatic pathology, which precludes long-term hormone therapy With the ineffectiveness of hormone therapy, infertility, malignant forms of internal endometriosis, suspected malignancy In reproductive age – organ retaining surgery by laparotomy or laparoscopy access, conservative treatment, treatment of infertility, in perimenopause – radical surgery.

Consensus statement for the management of chronic pelvic pains and endometriosis (Gambone J., Mittman B. et al., Fertil. Steril., 2002): - the first-line treatment: monophase COCs + nonsteroid anti-inflammatory therapy; if the treatment is ineffective: - the second-line treatment: surgical (laparoscopic or laparotomic) treatment. Extensive clinical material allowed studying the effectiveness of such groups of preparations as gestagens (gestrinone, norethisterone acetate, provera, linestrenol, dydrogesterone), antigonadotropins (danazol), gonadotropin-releasing hormone agonists (decapeptides: tritorelin, goserelin; nonapeptides: buserelin, leuprolein), whose application ultimately brings to hypoestrogenia and, as a consequence, to the involution of pathological implants. Hormonal Treatment of Endometriosis Notes: 1) 24+4 (24-day intake, 4-day interval); 2) 42+7 ( 42-day intake, 7-day interval); 3) 126+7 (126-day intake, 7-day interval); 4) all the preparations are contraindicated in pregnancy and lactation. Medical indications to the application of COCs (M. Silltm et al., 2001) on prolonged schedule are endometriosis, premenstrual syndrome, dysfunctional uterine bleedings, anemia, polycystic ovary syndrome, hemophilia, “menstrual” migraine. Antigonadotropins cause artificial pseudomenopause. Their action consists in blocking the release of FSH and LH, their basal secretion level being preserved. Gonadoliberin agonists. In the last decade, there have been successfully used such decapeptides: diphereline, decapeptyl, zoladex, and nonapeptides: buserelin, leuprolein. These preparations have a strong antigonadotropic action and bring on “medicamental castration”. Their application requires additional correction of menopausal vegetovascular and metabolic disorders. The maximal term of uninterrupted intake of the preparations makes 6 months. Antiestrogens. Tamoxifen, toremifene (fareston) are administered only in case of high or moderate hyperestrogenism. The dose makes 10 mg twice a day during 6 months. In hypoestrogenism tamoxifen stimulates estrogen synthesis. Prostaglandin inhibitors. Since endometrioid foci have few estrogen- and progesterone-binding receptors, the hormonal treatment may be ineffective. Inactivation of these receptors is connected with a high concentration of prostaglandins F2a in pathological implants. Therefore administration of nonsteroid anti-inflammatory preparations, which block cyclooxygenase synthesis and increase the sensitivity of endometriosis foci to the action of gestagens, is pathogenetically expedient. Enzymotherapy. There are provided independent enzymotherapy courses in the intervals between other medicamental treatment techniques or in combination with gestagens, and also in the rehabilitation of postoperative patients. Enzyme preparations provide both immunomodulatory and local effects (microcirculation improvement, edema elimination, hematoma and adhesion resorption). Immunotherapy – systemic application of immunomodulators, which promote endogenous production of IL-12 and gamma-interferon. It is expedient to resort to acupuncture and hardware-controlled physiotherapy. Physiotherapeutic procedures aim at the activation of metabolic processes, reduction of inflammatory phenomena, prevention of hereditary process development, restoration of regulating bonds between the control centers and target organs of the reproductive system (laser therapy, pulse sequence ultrosund, constant and alternating magnetic fields, iodine and zinc electrophoresis, radon baths in hyperestrogenism, microclyster and vaginal irrigations). In sterile women after hormonal treatment of endometriosis there is applied the therapy aimed at hormonal disbalance correction and ovulation stimulation. If the conservative treatment of endometriosis is ineffective, surgical treatment is administered (laparoscopy or laparotomy). The surgical treatment of GE has always been and remains the only technique, which allows removing the morphological substrate of endometriosis mechanically or eliminating it by means of laser, electrical, or thermal influence. Medicamental therapy in the pre- and postoperative period makes it possible to optimize the results of surgical treatment. As for the choice of intervention volume, it is believed in recent years that even at extensive endometriosis in women concerned with reproductive function restoration one should follow the principles of reconstructive conservative surgery and resort to radical operations only in the cases, when all other possibilities of both surgical and medicamental treatment have been exhausted. The technique and volume of surgical intervention are chosen individually. The purpose of laparoscopic treatment is the removal of all visible foci and restoration of normal anatomical correlations in the . The treatment of generalized and combined forms of endometriosis with dysfunction or endometriosis affection of the adjacent organs (ureters, bowels, urinary bladder). If endometrioid cysts are large, endometriosis is combined with other gynecological disorders, their adequate treatment requires the application of surgical methods, and at the same time there are no conditions to perform the operation in full volume laparoscopically – the method of choice is laparotomy. There are differentiated absolute and relative indications to the surgical treatment of patients with internal endometriosis. Absolute indications include combination of GE with diseases of the internals, which require surgical intervention (hyperplastic processes of the ovaries and/or endometrial precancer, uterine leiomioma, with rapid growth; severe dysplasia of the uterine neck, atypical , endometrioid ovarian cysts larger than 5 cm, the ovaries function invariably, pathological involvement of other organs and systems with their dysfunction, suppurative involvement of the affected by endometriosis, adhesive process with involvement of the ampullar parts of the uterine tubes, which accompanies endometriosis that is the main reason for sterility; endometriosis of the navel, endometriosis of the postoperative scar, combination of endometriosis with some anomalies of the genital organs, a somatic pathology excluding the possibility of continuous hormonal therapy). Among relative indications there are differentiated the presence of asymptomatic uterine leiomyoma in combination with atypical endometrial hyperplasia at the age younger than 40, the 3rd degree of GE spread, ineffective medicamental treatment, which has been uninterruptedly conducted during 6 months. In internal 3rd degree endometriosis (adenomyosis), when the endometrioid tissue extends through the full thickness of the myometrium to the serosa, hormonal treatment is ineffectual, therefore in such cases surgical treatment is indicated – partial hysterectomy, and in endometriosis of the isthmical-cervical part – complete hysterectomy. At endometriosis of the uterine neck in patients of the childbearing age, if there are solitary superficial foci, it is expedient to remove them by means of cryo- or laser destruction followed by colposcopic monitoring and hormonal treatment. The method of choice in the treatment of sterility must be endoscopic interference. The advantages of this method are being minimally traumatic and with the least blood loss, safety if one follows the rules of surgical technique and the surgeon has sufficient experience, and also shortening of the postoperative period. The most important advantage of this method is the visual control, which allows complete elimination of endometriosis foci. Electrocoagulation of solitary endometriosis foci is carried out with the use of mono- and bipolar electrodes. Small (up to 2 cm) endometryomas are to be incised, the doctor evacuates the contents, thoroughly enucleates the membrane of the tumor- like formation and coagulates its bed. Sometimes in order to remove endometryoma one resects the ovary. Endometrioid implants are often located close to the vital organs, which creates certain difficulties for the coagulation of such implants because of the hazard of affecting adjacent organs and anatomical structures. By indications laparoscopic coagulation is possible and, in some cases, transaction of the sacrouterine ligaments, which allows decreasing pain syndrome. Treatment efficiency criteria: no relapses of the disease, reproductive function recovery, positive dynamics of life quality.

7. Materials for self-control: 7.2 TESTS 1.Lately menstruations at patient gained character hyperpolimenorrhea. She complains on brown excretions and a few days after, menstruations are painful. In history – 3 artificial abortions. Bimanual examination: the uterus is insignificaly enlarged. A hysterosalpingography – infiltration of contrast inside the uterine wall. Previous diagnosis? A. endometriosis of uterus body B. cancer of uterus body C. myoma D. endometriosis of uterus cervix E. horiocarcinima 2.A patient was admitted to the hospital with complaints of periodical pain in the lower part of abdomen that gets worse during menses, weakness, malaise, nervousness, dark bloody smears from vagina directly before and after menses. Bimanual examination revealed that uterus body is enlarged, appendages cannot be palpated, posterior fornix has tuberous surface. Laparoscopy revealed: ovaries, peritoneum of rectouterine pouch and pararectal fat have "cyanotic eyes". What is the most probable diagnosis? A. disseminated form of endometriosis B. polycystic ovaries C. chronic D. tuberculosis of genital organs E. ovarian cystoma 3.A 28 year old woman has bursting pain in the lower abdomen during menstruation; chocolate-like discharges from vagina. It is known from the anamnesis that the patient suffers from chronic adnexitis. Bimanual examination revealed a tumour-like formation of heterogenous consistency 7х7 cm large to the left from the uterus. The formation I restrictedly movable, painful when moved. What is the most probable diagnosis? A. endometrioid cyst of the left ovary B. follicular cyst of the left ovary C. fibromatous node D. exacerbation of chronic adnexitis E. tumour of sigmoid colon 4.A 42-year-old woman has had hyperpolymenorrhea and progressing algodismenorrhea for the last 10 years. Gynaecological examination revealed no changes of uterine cervix; discharges are moderate, of chocolate colour, uterus is slightly enlarged and painful, appendages are not palpable, the fornices are deep and painless. What is the most likely diagnosis? A. uterine endometriosis B. uterine carcinoma C. subserous uterine fibromyoma D. endomyometritis E. adnexal endmetriosis 5.A 32-year-old patient consulted a doctor about being inable to get pregnant for 5-6 years. 5 ago the primipregnancy ended in artificial abortion. After the vaginal examination and USI the patient was diagnosed with endometrioid cyst of the right ovary. What is the optimal treatment method?

A. surgical laparoscopy B. anti-inflammatory therapy C. conservative therapy with estrogen-gestagenic drugs D. hormonal therapy with androgenic hormones E. sanatorium-and-spa treatment 6.A 20-year-old female with Mьllerian agenesis is undergoing laparoscopic appendectomy by a general surgeon. You are consulted intraoperatively because the surgeon sees several lesions in the pelvis suspicious for endometriosis. You should tell the surgeon which of the following? A. endometriosis may arise in patients with Mllerian agenesis as a result of coelomic metaplasia B. endometriosis cannot occur in patients with Mьllerian agenesis since they do not have a uterus C. endometriosis is common in women with Mьllerian agenesis since they have menstrual outflow obstruction D. endometriosis probably occurs in patients with Mьllerian agenesis as a result of retrograde menstruation E. endometriosis cannot occur in patients with Mьllerian agenesis because they have a 46,XY karyotype 7.A patient presents to you for evaluation of infertility. She is 26 years old and has never been pregnant. She and her husband have been trying to get pregnant for 2 years. Her husband had a semen analysis and was told that everything was normal. The patient has a history of endometriosis diagnosed by laparoscopy at age 17. At the time she was having severe pelvic pain and dysmenorrhea. After the surgery, the patient was told she had a few small implants of endometriosis on her ovaries and fallopian tubes and several others in the posterior cul-de-sac. She also had a left ovarian cyst, filmy adnexal adhesions, and several subcentimeter serosal fibroids. You have recommended that she have a hysterosalpingogram as part of her evaluation for infertility. Which of the patient’s following conditions can be diagnosed with a hysterosalpingogram? A. B. endometriosis C. subserous fibroids D. minimal pelvic adhesions E. ovarian cyst 8.You have just performed diagnostic laparoscopy on a patient with chronic pelvic pain and dyspareunia. The patient had multiple implants of endometriosis on the uterosacral ligaments and ovaries and several on the rectosigmoid colon. At the time of the procedure, you ablated all of the visible lesions on the peritoneal surfaces with the CO2 laser. But because of the extent of the patient’s disease, you recommend postoperative medical treatment. Which of the following medications is the best option for the treatment of this patient’s endometriosis? A. danazol B. continuous unopposed oral estrogen C. dexamethasone D. gonadotropins E. parlodel 9.A 28-year-old nulligravid patient complains of bleeding between her periods and increasingly heavy menses. Over the past 9 months, she has had two dilation and curettages (D&Cs), which have failed to resolve her symptoms, and oral contraceptives and antiprostaglandins have not decreased the abnormal bleeding. Which of the following options is most appropriate at this time? A. perform hysteroscopy B. perform a hysterectomy C. perform endometrial ablation D. treat with a GnRH agonist E. start the patient on a high-dose progestational agent 10.You are treating a 31-year-old woman with danazol for endometriosis.You should warn the patient of potential side effects of prolonged treatment with the medication. When used in the treatment of endometriosis, which of the following changes should the patient expect? A. lighter or absent menstruation, since danazol causes endometrial atrophy B. occasional pelvic pain, since danazol commonly causes ovarian enlargement C. heavier or prolonged periods, since danazol causes endometrial hyperplasia D. more frequent Pap smear screening, since danazol exposure is a risk factor for cervical dysplasia E. caused by the inflammatory effect of danazol on the endocervical and endometrial glands

SITUATIONAL TASKS 1.A 39-year-old G3P3 complains of severe, progressive secondary dysmenorrhea and menorrhagia. Pelvic examination demonstrates a tender, diffusely enlarged uterus with no adnexal tenderness. Results of endometrial biopsy are normal. Which of the following is the most likely diagnosis? 2.A 28-year-old woman, gravida 0, presents for evaluation of worsening chronic pelvic pain. She had been diagnosis with endometriosis by diagnostic laparoscopy 6 years prior but had been lost to care since that time. She reports cyclic, left-sided pelvic pain that is no longer controlled with NSAIDs. On physical examination, she is noted to have thickening and nodularity of her left uterosacral and her cervix is deviated to the right. She has no uterine, cervical, or right adenexal tenderness. She is noted to have 5 cm left adenexal mass, which is tender to palpation and fi xed to the pelvic sidewall. Transvaginal ultrasound demonstrates a 4.5-cm complex left ovarian cyst consistent with an . The next best step in management of this patient is? 3.A 36-year-old woman, gravida 0, with a history of endometriosis noted at a laparoscopy performed for pelvic pain 5 years ago presents for a second opinion for evaluation of worsening pelvic pain. Her endometriosis has been poorly controlled with combined oral contraceptives. Over the past 8 months she has noted worsening dysmenorrhea, dyspareunia with deep penetration, and increased constipation. She also states that her endometriosis is making her urinate two to three times a night. She has been taking NSAIDs maximum dose daily with little relief. She has taken GnRH agonists in the past year for treatment for endometriosis without relief of her symptoms. Your next step would be? 4.A 40-year-old woman, gravida 3, para 3, presents for severe central dysmenorrhea, 8/10 in severity associated with menorrhagia. Her pain is nonradiating, she has no exacerbating or mitigating factors. She fi nds little relief with NSAIDs. Her pain has been getting progressively worse since the cesarean delivery of her last child, 2 years prior. That delivery was complicated by chorioamionitis, endometritis, and subsequent wound infection. Transvaginal ultrasound demonstrated an 11-cm enlarged uterus without obvious pathologic fi ndings. MRI of the pelvis is signifi cant for adenomyosis. The patient reports that she has completed her childbearing. What is her appropriate plans of care ? 5.A 32 y.o. woman consulted a gynecologist about having abundant long menses within 3 months. Bimanual investigation: the body of the uterus is enlarged according to about 12 weeks of pregnancy, distorted, tuberous, of dense consistence. Appendages are not palpated. Histological test of the uterus body mucosa: adenocystous hyperplasia of endometrium. Optimal medical tactics?