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Topic: Endometriosis 1 Topic: Endometriosis 1. Rationale: Endometriosis affects 10–15% of all women of reproductive age [1] and 70% of women with chronic pelvic pain [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 infertility, 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 uterus and ovaries. -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 adenomyosis 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 cervix, vulva and endometrium 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 Dyspareunia is painful sexual intercourse due to medical or psychological causes. “Chocolate” cyst of ovary 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, cervical canal 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, vagina, 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:
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