CC BY
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ОСНОВНОЙ РАЗДЕЛ
УДК 615.125
Sheralieva S.ZH.
Khudoyberdieva A.M.
Komolddinovna S.A.
Andijan State Medical Institute Uzbekistan, Andijan city DIFFERENTIATED APPROACH TO THE TREATMENT OF WOMEN WITH GENITAL ENDOMETRIOSIS
Abstract: This article discusses a differentiated approach to the treatment of women with genital endometriosis.
Keywords: endometriosis, nature of the disease, pathogenesis, diagnosis
Under the conditions of modern ecological reproductive dissonance, endometriosis is a widespread disease. Although an accurate assessment based on literature data is difficult, in particular due to differences between the studied populations and the diagnostic methods used, it is assumed that endometriosis affects 5-10% of the female population. According to several sources, whose authors used different methodological approaches, approximately 5.5 million women in the USA and 16 million women in Europe suffer from endometriosis. The natural course of this disease is characterized by considerable diversity, and it is very difficult to predict it in every single woman, which reflects the complex pathogenesis that underlies it. For the majority of patients, the progressive nature of the disease is characteristic, and in the absence of effective treatment, there is a spread of the process and a greater severity of the clinical manifestations of endometriosis. Despite the widespread, ongoing scientific research, the emergence of new diagnostic methods and the improvement of existing ones, the diagnosis of endometriosis is associated with certain difficulties, due to the diversity of symptoms and the absence of highly specific markers. A variety of symptoms of endometriosis is the reason for the treatment of women to doctors of various specialties. Due to the lack of awareness, many experts underestimate endometriosis and the importance of its timely diagnosis and treatment. On average, the delay in diagnosing the disease is 7-12 years after the first symptoms appear [3]. During this time, some patients have time to undergo treatment at 5 or more specialists, ranging from a therapist, a gastroenterologist or a urologist, and ending with psychologists and osteopaths. Moreover, the disease can be mistakenly regarded as primary dysmenorrhea, especially in young women. This tactic often leads to the appointment of drugs, the use of which may contribute to the progression of endometriosis. The last reform in the field of medical education is designed to significantly expand the segment of general practitioners in medicine.
However, studies have shown that the knowledge of these specialists about endometriosis is limited, which directly affects the time of diagnosis. In a survey, 63% of general practitioners indicated that they felt insecure in the diagnosis and
subsequent management of patients with endometriosis. Half of them could not name the main symptoms of the disease, such as dysmenorrhea, dyspareunia, chronic pelvic pain and infertility. Only 38% of general practitioners indicated that they conduct a gynecological examination for suspected endometriosis, and only 23% recommend an MRI scan to confirm the diagnosis. Currently, the only way to reliably confirm the diagnosis and establish the degree of prevalence of the disease is surgical intervention. The lack of available non-surgical diagnostic methods to a certain extent makes it difficult to make a diagnosis and postpones the time of treatment [5]. This determines the relevance of research aimed at finding highly informative biomarkers for non-invasive diagnostics. Undoubtedly, the task of the obstetrician-gynecologist is the timely and complete diagnosis of endometriosis with the definition of the location, shape, degree of involvement in the process of adjacent organs. An individual approach is needed that takes into account reproductive plans, somatic pathology, the degree of the impact of the disease on the patient's quality of life, the risks of surgery and long-term hormonal therapy. Based on the above, the optimal method of treatment is chosen, the decision is made about the need for surgical intervention. There are various risk factors for endometriosis. The risk group includes women who have not had any pregnancies before, with dysmenorrhea, copious bloody discharge, short intervals between menstruations (proiomenorrhea) and prolonged heavy menstruations (hyperpolymenorrhea), patients with reduced immunity. Reduced physical activity is also associated with endometriosis. It is interesting to note that for most women with endometriosis, normal or low body weight is characteristic. Also, patients with a large number of freckles, nevi or blue eyes, have a higher chance of getting endometriosis. There is no doubt that women with a history of endometriosis are at risk of relapse and an increase in the incidence and severity of the disease. The debut of endometriosis at a younger age is prognostically unfavorable for the course of the disease. The patient has a large number of births, abortions or other intrauterine interventions in the history of increases the likelihood of detecting adenomyosis during examination.
The intensity of pain can vary considerably in different menstrual cycles from discomfort that does not require the use of painkillers, to a picture of an acute abdomen, leading to hospitalization and emergency surgery. In many cases, chronic pain leads to a decrease in the quality of life of the patient, asthenia of the body, decreased performance, emotional lability, dysthymia. In the diagnosis of endometriosis of great importance is the cyclical manifestations of the disease and the relationship of exacerbation with menstruation. This applies to pelvic pain, impaired bowel and bladder function, the appearance of discharge from postoperative scars. According to modern concepts, if a patient has been observed for a long time with irritable bowel symptoms or cystalgia and does not benefit from traditional therapy, it is necessary to make a differential diagnosis with bowel or bladder endometriosis. Also, one should not forget about the rare localization of extragenital endometriosis, for example, in brain tissue, which is accompanied by headaches and neurological disorders, aggravated during
menstruation, endometriosis in the lungs can manifest hemoptysis, spontaneous pneumothorax and hemothorax. Recently, it is increasingly possible to observe patients not only with endometriosis of the postoperative scar on the anterior abdominal wall after celiac therapy, but also with endometrial infiltrates at the site of trocar insertion after laparoscopy.
In the study of M.I. Yarmolinskaya found that more severe forms of the disease were more common in patients of older age groups [8], which confirms the literature data that endometriosis is a progressive disease. The survey results showed that 72.9% of patients with IHE of reproductive age were examined for infertility, which does not contradict the literature data. Moreover, the ratio of primary to secondary infertility was 2: 1. The analyzed data of previous years indicate a longer duration of infertility (mainly primary): from 7 to 9 years. In modern conditions, the duration of primary and secondary infertility to establish an endoscopic diagnosis ranges from 4 to 6 years. The obtained data once again emphasizes the need for an earlier referral to laparoscopic examination of patients with infertility to identify its causes. In patients with peritoneal endometriosis in the reproductive period, frequent somatic pathology attracts attention. Diseases of the gastrointestinal tract were noted in 49%, which often affects the effectiveness of drug oral therapy. Diseases of the upper respiratory tract (46%), a high incidence of recurrent herpetic infection (in 76% of women), and an aggravated allergic history (every third patient with endometriosis) were also observed, which may indicate defects in the immune system in NGE patients. Endocrine diseases were noted in 14.3% of patients. The most frequently observed diseases of the thyroid gland: of these, most patients found diffuse non-toxic goiter, as well as autoimmune thyroiditis (AIT) without impairing thyroid function and AIT with hypofunction of the thyroid gland (subclinical hypothyroidism). The results obtained confirm once again the need to examine the function of the thyroid gland in patients with genital endometriosis, especially those planning pregnancy. Breast diseases were detected in 22.1% of patients with NEG in the reproductive period. It is important to note that lactorrhea was detected in 27.6% of women with endometriosis, and 43.1% of them did not have any pregnancies in history. When studying the level of prolactin in this group, it was noted its significant increase relative to the control group, but the level of prolactin did not exceed the values of the upper limit of the norm, developed for healthy women. Of all the supernatants with a detectable level of CA-125 in 15.9% of cases, its value did not exceed the "critical threshold" of 35 U / ml, while in 84.1% of the samples a significant increase in the tumor marker was observed, and in 9 samples significantly: > 500 U / ml.
It is interesting to note that, according to Fedele et al. [20], immunohistochemical studies revealed the presence of CA-125 in 37.5% of endometrial specimens in patients with endometriosis, in 33% of endometrial specimens of the control group, and only in 10% in endometriotic foci. The data obtained suggest that the activity of endometrioid implants is different and confirms the need for an individual approach to the choice of postoperative drug
therapy in each patient. Analysis of the level of CA-125 in patients with symptoms of endometriosis before re-laparoscopy for a relapse in 2016 TOM LXV ISSUE 5 ISSN 1684-0461 Actual health problems 9 diseases showed the following: in 53.3% of patients, the level of this tumor marker was within normal values, although re-laparoscopy showed a relapse of the disease (mainly I-II prevalence), and only 46.7% of women with recurrent endometriosis had an increase in CA-125. There are interesting observations in the group of patients, where the content of CA-125 was compared in 7-10 days after surgical treatment and then on the background of drug therapy. It turned out that the increase in the level of tumor marker during therapy even to 30-35 U / ml of relatively low values (2-10 U / ml) taken 7-10 days after the operation (provided that the dynamics in the same laboratory were evaluated using identical methods for determining CA-125), significantly correlated with the recurrence of the disease (p <0.05), which was confirmed in the control laparoscopy [8]. The findings suggest that the routine determination of CA-125 has a low diagnostic value, while controlling the dynamics of CA-125 in the serum can serve as one of the criteria for evaluating the effectiveness of the combined treatment, as well as a factor in the early detection of endometriosis recurrence. The value of this method is especially high with respect to those forms of IEG, which are not manifested in the form of bulk lesions and, therefore, cannot be diagnosed by gynecological examination or by ultrasound. Such an early diagnosis of recurrence of the disease will allow repeated surgery, if it is indicated, with a lower extent of the process, and therefore with less technical difficulties, less risk of complications and with greater efficiency. It should be noted that the lack of an increase in the level of CA-125 in a single study cannot indicate the absence of genital endometriosis.
When detecting endometrial cysts, it was noted that in 55.9% of cases, the cysts were bilateral. For most patients with peritoneal endometriosis, both a significant increase in the volume of peritoneal fluid, which coincides with the literature data, and its serous-hemorrhagic character is characteristic. In adolescents and young women with initial signs of the disease, there are features of endometrioid heterotopias. In young patients, red, colorless, or white foci are usually found, in contrast to "powdery" heterotopies, often detected in adult women with endometriosis. Red endometrioid heterotopies were found to be the most active. Endometrioid heterotopies tend to progress over time: "tender" endometriotic foci transform into more characteristic coarse, bright heterotopies within 10 years from the moment of illness. According to Redwine, transparent and red foci appear on average 10 years earlier than blue heterotopies with wrinkled surfaces or black, colors of "burnt powder".
Also, do not forget about a thorough examination of the gastrointestinal tract in case of suspicion of this localization of endometriosis. In addition to colonoscopy, fibrogastroduodenoscopy is necessary to exclude gastric cancer, since Schnitzler's metastasis to the adrectal lymph nodes can produce a similar palpatory pattern during rectovaginal examination. A biopsy with subsequent histological examination allows differentiation of the endometriotic lesion of the
vagina with ulcerative colpitis, as well as oncopathology of the vagina and vulva. Identification of chronic pelvic pain syndrome in a patient dictates the need to act consistently and in stages, to use various laboratory and clinical methods, instrumental and hardware research methods in order to achieve the result - to determine the cause of pelvic pain. In addition to endometriosis, the cause of chronic pelvic pain and, consequently, the basis for the differential diagnosis may be Allen-Masters syndrome, inflammatory diseases of the pelvic organs, uterine fibroids, ovarian tumors or abnormalities of the internal genital organs. With the exception of gynecological pathology, patient counseling by related specialists is indicated. It is necessary to carry out a differentiated diagnosis with diseases of the gastrointestinal tract, primarily with irritable bowel syndrome, with diseases of the urinary system.
