All about the endometrium. Normal and pathological changes in the endometrium on ultrasound Management of patients with endometrial hyperplasia in postmenopausal women

The mucous membrane of the uterus that lines its cavity. The most important property of the endometrium is its ability to undergo cyclic changes under the influence of a changing hormonal background, manifested in a woman by the presence of menstrual cycle.

The endometrium is the mucous layer that lines the uterine cavity. That is, it is the mucous membrane of the internal hollow organ of a woman, intended for the development of the embryo. The endometrium consists of stroma, glands and integumentary epithelium, has 2 main layers: basal and functional.

• The structures of the basal layer are the basis for the regeneration of the endometrium after menstruation. There is a layer on the myometrium, characterized by a dense stroma, which is filled with numerous vessels.
• The functional thick layer is not permanent. He is constantly exposed to hormonal levels.

Genetics, as well as molecular biology and clinical immunology, are constantly evolving. Today, it is these sciences that have been able to significantly expand the understanding of cellular regulation and intercellular interaction. It was possible to establish that proliferative cellular activity is affected not only by hormones, but also by various active compounds, including cytokines (peptides and a whole group of hormone-like proteins) and arachidonic acid, or rather its metabolites.

endometrium in adults

A woman's menstrual cycle lasts approximately 24-32 days. In the first phase, under the influence of estrogen hormones, proliferation (growth) of the glands occurs. The secretion phase occurs under the influence of progesterone (after the rupture of the follicle and the release of the egg).

While the epithelium is being rebuilt under the influence of hormones, changes are also observed in the stroma. There is a leukocyte infiltration here, the spiral arteries are slightly enlarged.

Changes in the endometrium that occur during the menstrual cycle should normally have a clear sequence. Moreover, each phase should have an early, middle and late stages.

If changes in the structures of the endometrium during the cycle do not take into account a clear sequence, then most often dysmenorrhea develops, bleeding occurs. The consequence of such violations can be at least infertility.

Disruptions in the functioning of the central nervous system, pathology of the ovaries, adrenal glands, pituitary gland and / or hypothalamus can provoke disruptions in the hormonal background.

endometrium during pregnancy

A woman's hormones throughout her life actively influence the cell receptors of the uterine mucosa. At the time when any hormonal shift, the growth of the endometrium also changes, which often leads to the development of diseases. All kinds of proliferative disorders occur mainly under the influence of hormones that are produced by the adrenal glands and ovaries.

Pregnancy and the endometrium are closely related, because even the attachment of a fertilized reproductive cell is possible only to the mature walls of the uterus. Before implantation of the fetal egg, a decidua formed from stromal cells appears in the uterus. It is this shell that creates favorable conditions for the life of the embryo.

Before implantation, the secretory phase predominates in the endometrium. Stroma cells are filled biologically active substances, including lipids, salts, glycogen, trace elements and enzymes.

During implantation, which takes approximately two days, hemodynamic changes are observed, and significant changes are observed in the endometrium (glands and stroma). In the place where the fetal egg is attached, blood vessels expand, sinusoids appear.

Changes in the endometrium and the maturation of a fertilized egg must occur simultaneously, otherwise the pregnancy may be terminated.

Diseases of the mucous membrane of the uterus are common. In addition, pathologies of this kind are diagnosed in both children and adults, they can be almost asymptomatic, easily treatable, or, for example, on the contrary, provoke extremely unpleasant health consequences.

If we consider the most common endometrial diseases, then various hyperplastic processes should immediately be noted. It is these violations that occur mainly against the background of hormonal imbalance often before menopause. Clinical picture such disorders are bleeding, the uterus most often increases, the mucous layer thickens.

Changes in the structures of the endometrium, the appearance of formations - all this may indicate a serious failure, which is important to eliminate as soon as possible in order to exclude the development of complications.

The transformation of the endometrium is, of course, the most complex process of a biological nature, which concerns almost the entire neurohumoral system. Hyperplastic processes (HPE) are focal or diffuse proliferation of tissues, in which stromal and most often glandular components of the mucosa are affected. A significant role in the pathogenesis of HPE is also played by metabolic and endocrine disruptions. So, it is worth highlighting the dysfunction of the thyroid gland, immune system, fat metabolism, etc. That is why most women with obvious endometrial hyperplastic processes are diagnosed with a certain degree of obesity, diabetes and some other diseases.

provoke development hyperplastic processes endometrium can not only hormonal failures. Plays a role in this case and immunity, and inflammatory-infectious changes affecting the mucous membrane, and even problems with tissue reception.

As for the symptoms, endometrial hyperplastic processes can be manifested by bleeding, pain in the lower abdomen, although often the problem does not obvious signs. Predominantly hyperplastic processes of the uterine mucosa are accompanied by the absence of ovulation, from which such a sign of pathology as infertility appears.

endometrial hyperplasia

In the medical field, endometrial hyperplasia is a change in the structures and / or pathological growth of the glands. Also, these are violations, which can be:

• improper distribution of glands;
• structural deformation;
• growth of endometrial glands;
• there is no division into layers (namely, the spongy and compact parts are taken into account).

Endometrial hyperplasia predominantly affects the functional layer, the basal part of the uterine mucosa suffers in rare cases. The main signs of the problem are the increased number of glands and their expansion. With hyperplasia, the ratio of the glandular and stromal components increases. And all this happens against the background of the absence of cell atypia.

According to statistics, simple form endometrial hyperplasia degenerates into cancer in only 1-2% of cases. The complex form is several times more common.

Polyps of the mucous layer of the uterine cavity

Most of the hyperplastic processes of the endometrium are polyps, which are diagnosed in 25% of cases. There are such benign formations at any age, but mostly disturbed in the period before or after menopause.

Taking into account the structure of the endometrial polyp, several types of formations can be distinguished:

• glandular polyp (may be basal or functional);
• glandular fibrous;
• fibrous;
• adenomatous formation.

Glandular polyps are diagnosed mainly in women of reproductive age. Glandular fibrous - before menopause, and fibrous most often in the postmenopausal period.

At the age of 16-45 years, polyps can appear both against the background of endometrial hyperplasia and on normal mucosa. But after menopause, benign formations (polyps) are most often single, they can reach enormous sizes, bulge out of the cervix and even disguise themselves as neoplasms of the cervical canal.

Endometrial polyps appear mainly against the background of hormonal imbalance, which involves progesterone and estrogens. Doctors note the fact that polyps in women of reproductive age can develop after various surgical interventions on the uterus. Also, the appearance of polyps is associated with inflammatory diseases of the internal genital organs.

The clinical manifestations that indicate a polyp in the uterus are varied, but most often a woman has disruptions in the menstrual cycle. pain symptom rarely worried. Such a sign may appear only in some cases, for example, with necrotic changes in the formation. Endometrial polyps are diagnosed using ultrasound and hysteroscopy. Surgery is used to treat polyps. And polyps are treated mainly by a gynecologist, although consultations of an endocrinologist, venereologist and some other narrow specialists are possible.

Endometrial cancer and precancer are two different concepts and it is important to be able to distinguish between them. Only a competent attending physician can determine the type of endometrial disorders, based on the results of diagnostic manipulations and some other factors.

Endometrial precancer is adenomatous polyps and hyperplasia with pronounced atypia, in which cells may have an irregular shape, structure, etc. The following morphological features can be attributed to atypia of the uterine mucosa:

• The blood vessels are unevenly distributed, and thrombosis and/or stasis may be seen.
• The stroma is swollen.
• The number of glands that are located too close to each other increases. Sometimes the glands have pathological elongated outgrowths.
• With slight atypia, the cytoplasm is basophilic. With obvious atypia - oxyphilic.
• Hyperchromic nuclei, which may have an uneven or uniform distribution of the chromatin itself.

Endometrial hyperplasia without effective medical supervision and timely therapy with a simple form degenerates into cancer in 7-9% of cases (subject to the presence of atypia). As for the complex form, here the indicators are not comforting and they reach up to 28-30%. But it is important to know that not only the morphological form of the disease affects the appearance of precancer, but also various comorbidities, for example, those associated with the internal genital organs, the thyroid gland, etc. The risks increase if a woman with endometrial hyperplastic processes suffers from obesity, she was diagnosed with uterine fibroids, polycystic ovary syndrome or, for example, disorders in the hepatobiliary system, diabetes mellitus.

Diagnosis of pathologies of the endometrium

Hysterosalpingography, as well as transvaginal ultrasound are considered the most common diagnostic methods, which are prescribed for pathologies of the endometrium. As for a more in-depth examination, in this case, separate curettage and hysteroscopy can be performed. The attending physician can make a diagnosis at any stage diagnostic studies, but it can be accurately verified only after analyzing the results of histological examination.

Hysteroscopy is an accurate diagnostic procedure that allows you to fully visually assess the condition of the uterine cavity, the canal of its neck and the mouth of the tubes. Manipulation is performed using an optical hysteroscope.

Hysteroscopy for endometrial hyperplasia or other hyperplastic processes of the uterine mucosa is prescribed by the attending physician, the information content of this method is about 70-90%. Hysteroscopy is used to detect pathology, determine its nature, location. Also, the method is indispensable for curettage, when diagnostics of this type are prescribed before the procedure and immediately after, to control the quality of its implementation.

It is impossible to independently diagnose problems with the mucous membrane of the uterine cavity, even if the patient has the results of ultrasound or hysteroscopy. Only the attending physician, taking into account the age of the patient, the presence of concomitant chronic diseases and some other factors, will be able to accurately make the correct diagnosis. In no case should you try to determine the disease yourself, and even more so treat the disease without consulting a doctor. Alternative medicine in this case is not relevant and can only aggravate an already difficult state of health.

Ultrasound scanning of the transvaginal type is an absolutely safe non-invasive diagnostics. Modern Method allows you to almost accurately determine the problems associated with the structures of the endometrium, although the information content of the procedure may be influenced by some factors, including the age of the patient, the presence of some concomitant gynecological diseases and the type of hyperplastic processes. Ultrasound of the endometrium is best done in the first days after the menstrual cycle. But it will not be possible to accurately distinguish endometrial hyperplasia of the glandular type from atypical one using such a diagnosis.

Endometrium: normal after menopause may vary depending on various factors.

• The median uterine echo in its thickness up to 4-5 mm can be considered normal if the woman's menopause occurred no more than five years ago.
• If the postmenopausal period began more than five years ago, then a thickness of 4 mm can be considered the norm, but subject to structural uniformity.

Endometrial polyps in the uterus most often on ultrasound are ovoid or almost round inclusions with increased echo density. The informativeness of diagnostics for polyps is more than 80%. It is possible to increase the possibilities of ultrasound of the endometrium by contrasting the cavity.

Ultrasound is performed both in private clinics and in some state-run outpatient clinics. Should be considered given fact and ask the treating specialist about the best options for choosing an institution.

Also, the doctor on an individual basis can prescribe additional diagnostic methods if there are doubts about the diagnosis.

Biopsy of the endometrium

Aspirate from the uterine cavity can be examined using cytological and histological analyzes. Aspiration biopsy is often used as a control method in hormonal treatment, when using a special procedure to determine the effectiveness drug therapy. In malignant processes of the uterine mucosa, a biopsy allows you to accurately determine and make a diagnosis. The method helps to avoid curettage, which is carried out for diagnosis.

Hyperplastic processes of the endometrium: treatment

In women of all ages with pathologies of the endometrium, treatment should be comprehensive. The attending physician will definitely develop individual program and prescribe therapy, including, possibly, for:

• stop bleeding;
• full restoration of the menstrual cycle in women of childbearing age;
• achievement of subatrophy and atrophy of the uterine mucosa in women over 45 years of age.

An important role is played by the prevention of relapses.

Therapy of hyperplastic processes in menstruating women usually consists of hormonal treatment, which is prescribed after the diagnosis.

• In the event that a woman of reproductive age is diagnosed with endometrial hyperplasia (without cellular atypia), the following drugs are most often prescribed: combined oral contraceptives in tablets, Norethisterone and / or Dydrogesterone, Medroxyprogesterone, HPC (hydroxyprogesterone capronate).
• If hyperplasia is accompanied by cell atypia, then they can prescribe: Danazol, Gestrinon, Buserelin, Diferelin, Goserelin, etc.

It is important to take into account possible infectious causes the development of hyperplastic processes, because in this case, hormonal medications can be completely ineffective.

If there is a recurrence of hyperplastic processes (without obvious atypia) of the uterine mucosa, and hormonal medications do not therapeutic effect, then under certain conditions, the attending physician may prescribe endometrial ablation. This minimally invasive procedure is an alternative to classic endometrial scraping. During its implementation, the mucous membrane is removed or destroyed. But ablation is recommended only for women over 35 who do not plan to become pregnant again.

If a woman of reproductive age is diagnosed with uterine fibroids or adenomatosis in combination with hyperplastic processes of the uterine mucosa, then this is not a contraindication for ablation. Although doctors believe that the presence of such problems in a woman can negatively affect the results of treatment.

In the case when the patient is diagnosed with an atypical form of endometrial hyperplastic processes, hormone therapy is ineffective and a relapse occurs, surgical intervention is prescribed. Which operation will be recommended is decided only by the attending physician, taking into account the characteristics of the patient's state of health, the presence of concomitant chronic diseases, and even her age. The operation is assigned on an individual basis. It could be:

• Intervention on the ovaries (wedge resection) in women with polycystic ovary syndrome.
• Adnexectomy (with a neoplasm of the ovary, which has a hormone-producing nature).
• Hysterectomy.

Modern medicine offers many effective ways, thanks to which successful operations are carried out. But it is impossible to say in absentia which surgical intervention is suitable for a particular patient. Only a competent doctor, taking into account the results of diagnostic studies and the age of the woman, will be able to prescribe the truly correct therapy.

Treatment of hyperplastic processes in perimenopause

Premenopause is a stage at which the processes of fading of ovarian functions are already taking place, ovulation stops. This period begins after about 40-50 years. Its duration is about 15-18 months. At the very beginning of premenopause, the intervals between menstruation increase, their duration and abundance decrease.

If a patient is diagnosed with endometrial hyperplasia, for example, treatment will initially include hysteroscopy combined with endometrial curettage, which is done solely for diagnosis. Next, therapy is prescribed taking into account the morphological features of the endometrium and the presence of gynecological diseases. Scheme drug treatment and list hormonal drugs will also depend on the desire of the patient to maintain the menstrual cycle.

Among the medicines, it is worth highlighting Norethisterone, Dydrogesterone, Medroxyprogesterone, Danazol, Gestrinon, Buserelin, Diferelin, Goserelin, etc. They are prescribed depending on the presence or absence of atypia.

In the period of pre- and perimenopause, ablation can be prescribed. Hysteroscopic surgery is performed in cases where there are constant recurrences of hyperplasia of the mucous membrane of the uterine cavity (without cell atypia), and hormonal treatment cannot be prescribed due to any extragenital disease.

Management of patients with endometrial hyperplasia in postmenopausal women

If a woman who is in the postmenopausal period has spotting and there is a suspicion of endometrial pathology, a diagnostic separate curettage is prescribed. If the problem appeared for the first time, then with hyperplastic processes they are prescribed. If a hormone-producing ovarian formation is detected, surgical removal of the uterus with appendages is recommended. The recurrence of hyperplastic processes in the uterus in women can be the reason for the appointment of extirpation of the organ with appendages. If a postmenopausal woman for any reason this operation is contraindicated, then therapy with gestagens or ablation of the mucous layer is allowed. At this point, it is very important to monitor the patient's condition, constantly conduct diagnostic echography. An endometrial biopsy is also ordered.

With hormone therapy, the attending physician comprehensively recommends antiplatelet agents, hepatoprotectors and anticoagulants in order to significantly reduce the risks of complications.

Targeted polypectomy is a modern and effective method treatment of women who are diagnosed with an endometrial polyp. Complete removal of the formation is allowed only under the condition of hysteroscopic control. In addition, such an intervention should involve not only mechanical endoscopic instruments, but also laser technologies, as well as electrosurgical elements.

Doctors recommend electrosurgical excision of the formation, in cases where the polyp is defined as parietal and fibrous. It is also important to note the fact that women in the premenopausal period are recommended to combine polypectomy with mucosal ablation. After the endometrial polyp in the uterus is removed, hormones are prescribed. Moreover, therapy can have a different scheme of application, which is compiled taking into account the age of the patient and the morphological features of the remote formation.

Synechia inside the uterus

Intrauterine adhesions can partially or completely affect the cavity of the organ. Doctors put forward three main theories regarding the causes of this pathology:

• trauma;
• infections;
• and neurovisceral factors.

The main reason for the appearance of synechia is mechanical damage to the basal part of the mucous membrane of the uterine cavity. Such injuries are possible during inaccurate curettage, abortion, childbirth. The appearance of synechia is often observed in patients after a frozen pregnancy or after various surgical interventions on the uterus.

According to their symptoms, synechia inside the uterus is specific. Signs of a problem may be amenorrhea and/or hypomenstrual syndrome.

Such adhesions cause infertility in women, often they do not allow the fetus to develop, which is why miscarriage is observed. As they say medical experts even small synechia in the uterus can negatively affect, for example, IVF.

Synechia is determined using some diagnostic manipulations. In this case, ultrasound, hysteroscopy, and also increasingly hysterosalpingography are used.

Synechia is treated only with the help of dissection. Moreover, the type of operation will always depend on the degree of patency of the uterine cavity and the type of union.

If it occurs after such a surgical intervention, then the woman is at risk for complications during gestation or delivery.

Over the past few decades, the number of patients suffering from uterine cancer has been constantly increasing, which is probably a consequence of the fact that women began to live longer and, accordingly, a longer period of menopause. The age of women affected by endometrial cancer ranges on average from 60 to 62 years.

The disease can develop in two pathogenetic variants - autonomously and as a hormone-dependent disease.

Autonomously developing endometrial cancer is found in less than 30% of cases. It is noted in those women who do not have disorders in the endocrine system. The problem develops along with atrophy of the mucous membrane, when it is not traced high level estrogen in the first period of the menstrual cycle.

It is believed that the appearance of an autonomous type of endometrial cancer is affected by depression of the immune system. Depressive immune changes consist in a significant decrease in the number of T-lymphocytes, when their theophylline-sensitive forms are suppressed, as well as in a significant increase in the number of lymphocytes in which receptors are blocked.

Usually, an autonomous form of the disease appears in women after 60 years. Risk factors for this type of disease have not been identified. Often it is observed in lean elderly patients, while hyperplastic processes are not previously observed. There is often a history of bleeding due to mucosal atrophy. The tumor is poorly differentiated, insensitive to hormonal treatment, early metastasis occurs and penetration into the myometrium.

The hormone-dependent form of the disease can be traced in approximately 70% of cases of morbidity. Its pathogenesis is influenced by prolonged hyperestrogenism, which often appears as a consequence of:

• anovulation;
• neoplasms in the ovaries;
• excessive peripheral conversion of androgens to estrogens - (observed in diabetes and obesity);
• effects of estrogen (observed with hormone replacement therapy through estrogens and the treatment of breast cancer with tamoxifen, resulting in the formation of metabolites with active estrogens).

For hormone-dependent endometrial cancer, there are the following risk factors:

• infertility and lack of childbirth throughout life;
• late menopause;
• overweight;
• diabetes;
• hereditary predisposition to a disease with metabolic endocrine pathogenesis - cancer of the breast, ovaries, uterus, colon;
• neoplasms in the ovaries;
• conducting estrogen monotherapy in the period after menopause;
• Tamoxifen (an anticancer drug) is used in the treatment of breast cancer.

Cancer classification

Endometrial cancer is classified according to how common it is. Classification is based on clinical findings and/or histological findings.

The classification of the disease is applied before surgery or in the case of inoperable patients. Depending on the stage, endometrial cancer is classified as follows:

• Stage 0 - in situ formation.
• Stage 1 - education is limited to the body of the uterus.
• 2 - does not go beyond the body of the uterus, but directly affects the neck of the hollow organ.
• 3 - penetrates into the small pelvis and grows within its boundaries.
• 4 - goes beyond the boundaries of the small pelvis and may affect nearby organs.
• 4A - the formation grows into the tissue of the rectum or bladder.

Histological data make it possible to identify the following morphological stages diseases:

• Stage 1A - located directly in the endometrium.
• 1B - tumor penetration into muscle layer no more than 1/2 of its thickness.
• 1C - penetration of the tumor into the muscle layer by more than 1/2 of its thickness.
• 2A - the formation affects the glands of the cervix.
• 2B - formation affects the stroma.
• 3A - the tumor penetrates the serous uterine membrane, metastasis to the ovaries or fallopian tubes is observed.
• 3B - education penetrates into the vaginal area.
• 3C - metastases in the pelvic and / or para-aortic lymph nodes.
• 4A - the formation affects the mucosa of the bladder or intestines.
• 4B - Distant metastases appear.

The doctor, based on the above classification and the data obtained after histology, makes up for patients (in postoperative period) an appropriate treatment plan.

In addition, there are 3 degrees of cancer differentiation, which depends on how pronounced the cellular atypia is. Differentiation happens:

• high;
• moderate;
• low.

Clinical picture of cancer

To some extent, the manifestation of the disease is associated with menstruation. In patients with a preserved cycle, endometrial cancer often manifests itself in the form of profuse and prolonged, usually acyclic menstrual bleeding. But in 75% of cases, endometrial cancer begins after menopause and causes bloody discharge, which can be both spotting, scanty, and abundant. During this period, they appear in 90% of patients, and only 8% of patients do not have any clinical symptoms of the development of a malignant tumor. You should know that in addition to bloody there may be purulent discharge from the vagina.

Pain occurs quite late, when endometrial cancer penetrates into the small pelvis. If the infiltrate compresses the kidneys, pain is most often felt in the lumbar region.

Postmenopausal women recommended ultrasound pelvic organs which must be completed annually. Women at risk for endometrial cancer should have an ultrasound every 6 months. This allows you to recognize pathologies such as cancer and endometrial hyperplasia in time, and start optimal treatment.

Homogeneous endometrium is the norm, and if even small inclusions are detected in its echo structure, the doctor suspects pathology and directs the patient for diagnostic curettage of the mucous membrane under hysteroscopy control. Also, an endometrial thickness of more than 4 mm is considered a pathology (if postmenopause occurs early, then more than 5 mm).

If there are clear echographic signs of malignant changes in the endometrium, the doctor prescribes a biopsy. Also, curettage of the mucous part for diagnosis and a hysteroscopy procedure are often shown.

If a woman has a disrupted menstrual cycle, there are signs of pathological changes in the endometrium, bleeding is observed in the period after menopause, then diagnostic curettage of the endometrium and hysterocervicoscopy are necessary. In 98% of cases, hysteroscopy performed after menopause is informative, and a thorough histological analysis of scrapings makes it possible to finally determine the disease.

When the diagnosis is established accurately, the woman is carefully examined to determine the stage of the disease and to select the optimal therapeutic tactics. In addition to laboratory tests, as well as a gynecological examination, the following is performed:

• echography of all organs located in abdominal cavity;
• colonoscopy and cystoscopy, chest x-ray, CT ( CT scan) and other studies, if necessary.

Treatment of patients with endometrial cancer is prescribed based on the stage of the disease and the state of the woman. Patients who have distant metastasis, the tumor has spread extensively to the cervix, has grown into the bladder and / or rectum, are inoperable. As for those patients who require surgery, for 13% of them surgical treatment contraindicated due to the presence of concomitant diseases.

Surgical treatment of the disease involves the removal of the uterus along with appendages. In the first stages of the development of endometrial cancer, a special operation can be prescribed, in which the integrity of the organ is not violated, that is, the uterus is removed through the vagina.

Lymphadenectomy is necessary because metastases that penetrate the lymph nodes do not respond to hormones.

The expediency of performing a lymphadenectomy is dictated by the presence of at least one of the following risk factors:

• spread of the tumor into the muscular layer of the uterus (myometrium) by more than 1/2 of its thickness;
• spread of education to the isthmus / cervix;
• the tumor extends beyond the boundaries of the uterus;
• the diameter of the formation exceeds 2 cm;
• if cancer with low differentiation is diagnosed, clear cell or papillary cancer, as well as serous or squamous cell type of the disease.

If the pelvic lymph nodes are affected, metastasis to the lumbar lymph nodes is detected in 50-70% of patients.

If a well-differentiated disease in stage 1A is diagnosed, radiation therapy is not required, in all other cases it is indicated, sometimes in combination with hormone therapy, which makes the treatment more effective.

Treatment of the disease in the 2nd stage of its development may include extended removal of the uterus, followed by radiation and hormone therapy. The doctor independently draws up a treatment regimen that will be most effective for the patient. The attending specialist can first carry out the appropriate therapy, and then the operation. In both cases, the result is almost the same, but the first one is preferable, since it makes it possible to more accurately determine at what stage the cancer process is.

Treatment of the disease, which is at stages 3 and 4 of its development, is selected only on an individual basis. Usually it begins with an operative intervention, during which the maximum possible reduction of the formation itself is ensured. After the operation, hormonal and radiation therapy is prescribed in the complex (with subsequent correction, if necessary).

Oncology prognosis

The prognosis for patients suffering from uterine cancer largely depends on the stage of the disease. In addition, the following factors are important:

• woman's age;
• type of tumor in terms of histology;
• size of education;
• tumor differentiation;
• depth of penetration into the muscle layer (myometrium);
• spread to the cervix;
• the presence of metastases, etc.

The prognosis worsens as the patient's age increases (it has been proven that survival rates also depend on age). Primary preventive measures to prevent endometrial cancer, as a rule, are aimed at eliminating factors that can potentially lead to the onset of the disease, namely:

• weight loss in obesity;
• compensation for diabetes;
• normalization of reproductive function;
• full restoration of menstrual function;
• elimination of all causes leading to anovulation;
• correct and timely surgical intervention in feminizing formations.

Preventive measures of the secondary type involve timely diagnosis and optimal treatment of all, including precancerous pathological processes occurring in the endometrium. In addition to well-chosen treatment and a thorough annual (or once every 6 months) examination with the obligatory passage of transvaginal echography, it is necessary to regularly observe a leading specialist and monitor your health.

Diagnosis and treatment of endometrial pathologies is the competence of a gynecologist-endocrinologist, especially if the problems appeared against the background of hormonal imbalance. Also, for example, with endometrial cancer, you need to consult an oncologist, a surgeon.

If a woman is worried about constant or recurrent pain in the lower abdomen, bleeding occurs regardless of the phase of the menstrual cycle, then it is advisable to immediately seek help from your local gynecologist. If this is not possible, you can initially visit a therapist who, if necessary, will refer the patient for a consultation with a narrower specialist.

The endometrium is inner shell uterus. It consists of basal and functional layers. The first is not subject to changes throughout the month, and the second is rejected every time with menstrual flow, and then grows again.

Often women do not think about the significance of the endometrium. Meanwhile, the course of pregnancy and health reproductive system depends a lot on his condition. It is he who creates the necessary conditions for attachment to the walls of the uterus of the fetal egg. And if its structure deviates from the norm, it can affect the course of pregnancy up to a miscarriage.

The structure of the endometrium changes throughout menstrual period. Closer to the regulation, it reaches its maximum thickness. If fertilization does not occur, then part of the uterine mucosa is shed along with the blood in critical days. And the glands begin to grow actively again. Together with the uterine epithelium, the unfertilized egg also leaves the body. Therefore, the regularity and volume of menstruation in women also depend on it.

Let's see how the structure of the endometrium changes during the month and what it depends on. In the first and partially in the second phases of the menstrual cycle, the inner lining of the uterus becomes three-layered. And on ultrasound, all the layers and the boundaries between them are clearly distinguished.

Since in the study all layers are visualized in the form of straight, clearly distinguishable lines, such an endometrium is called linear. in a normally functioning female body a similar phenomenon is present immediately after menstruation and partially in the second half of the cycle. This means that a woman is able to become pregnant. But if this type of mucosa is located at another time, then this is a sign of pathology.

Avascular endometrium is the uterine mucosa without blood vessels or poorly supplied with blood. This condition can lead to thinning of the inner shell of the organ responsible for the reproduction of offspring. And as a result, a woman will not be able to become pregnant or bear a child. If such words are present in the conclusion of the ultrasound, then you should consult with the local gynecologist. The doctor will tell you what measures to take in this regard.

Stages of development of the endometrium

Under the influence of female sex hormones, the thickness of the endometrium in the uterus constantly changes throughout the month. For pregnancy to occur, its value must correspond to the norm. Within 30 days after menstruation, the lining of the uterus increases from 4 mm to 2 cm in thickness. All indicators that go beyond these limits indicate deviations.

1. From the 4th to the 8th day - from 3 to 6 mm.
2. From the 8th to the 11th - 5-8 mm.
3. From the 11th to the 15th - 7 mm - 1.4 cm.
4. From the 15th to the 19th - 1–1.6 cm.
5. From the 19th to the 24th - 1–1.8 cm.
6. From the 24th to the 27th - up to 1.2 cm.

In order for the fertilized egg to be able to attach to the wall of the uterus, it needs a 7 mm layer of endometrium. determined by ultrasound, where the gynecologist gives direction. Any deviations in the structure of the mucous membrane of the reproductive organ indicate a disease that needs to be treated.

Thickening of the endometrial layer of the uterine body

If the endometrial cells begin to divide too actively, and the mucous layer in the uterus thickens, polyps form. This condition is called hyperplasia. Has a benign character. This deviation can be detected during a gynecological examination or ultrasound. AT healthy body this shouldn't happen.

Distinguish between simple and . At simple type a large number of glandular cells leads to the formation of cysts. The atypical form involves the degeneration of tissue from benign to cancerous.

Causes of endometrial thickening:

• frequent stress;
• violation of the secretion of hormones;
• malfunctions of the organs of the endocrine system;
• chronic form of endometritis;
• abortions;
• liver dysfunction;
• sexually transmitted infections;
• tumors or inflammation;
• long-term use of hormonal contraceptive pills.

Diagnosis of pathology

To make an accurate and detailed diagnosis, as well as to assess the condition and thickness of the uterine mucosa, they resort to the following types of information collection:

• gynecological examination;
• poll;
• Analysis of urine;
• blood test for hormones;
• smear from the vagina;
• transvaginal ultrasound;
• biopsy;
• histological examination of the endometrium;
• testing for intrauterine infections.

If, as a result of the examination, this pathology is detected, then antispasmodic and analgesic drugs are prescribed. Further treatment will depend on the severity of the disease and the age of the woman.

Therapy Methods

If the endometrium of the uterus is not changed globally, then the pathology can be cured with medication. In case of formation of cysts and polyps, prescribe combination therapy. It combines medication and surgery. Getting rid of the disease in an operative way is provided in the case of a neglected state of the reproductive system.

The choice of treatment method is made exclusively by the doctor. At the same time, he is based on his experience, the degree of growth of the inner layer of the uterus, the well-being and age of the woman.

Medical therapy

For the treatment of this disease, there are various groups drugs:

1. Hormonal birth control pills. They normalize the balance of hormones in the body. Such drugs are suitable for young nulliparous girls. They are drunk for at least 6 months according to a certain scheme. Thus, it is possible to establish the menstrual cycle, and the discharge becomes less abundant. Often used Logest, Marvelon, Regulon, Jeanine.
2. Chemical substitutes for progesterone. The use of such drugs will help get rid of the excessive growth of the uterine mucosa and bring it back to normal. After taking them, the arrival of menstruation becomes regular. At the same time, they help women of any age category with various types endometrial hyperplasia. The course of treatment lasts from 3 months to six months. The most popular and effective of the gestagens are Duphaston and Norkolut.
3. Gonadotropin-releasing hormone agonists. They are able to reduce cell division and even out the thickness of the uterine mucosa. Such drugs are sold in ampoules. Treatment for many of them involves an injection once a month.

Coagulation

Highly effective method fight the disease. There are several types of this minimally invasive intervention, which eliminates the pathological formation inside the uterus:

1. Electrocoagulation - the affected tissue is affected by electrical impulses. Manipulation is carried out under anesthesia and in the absence of menstrual flow. It is shown only to women who have given birth, since after it a scar remains on the cervix.
2. Laser ablation - the laser accurately burns out pathological areas on the affected organ. After this procedure, the tissue regenerates and recovers faster. After manipulation over the next few weeks, a clear grayish liquid is profusely excreted.
3. Chemical coagulation - a mixture of drugs is applied to the affected area, which destroys the pathological surface. The dead cells are rejected and leave the body after 2 days.
4. Radio wave vaporization - the overgrown endometrium evaporates under the influence of an electromagnetic beam directed at it. This method is harmless and suitable for all women.
5. Cryodestruction - the affected area is frozen under the action of liquid nitrogen, and then dies and leaves the uterine cavity.

The next day after the manipulation, pain in the abdomen is possible. But it will pass quickly. A month after the procedure, the violation of menstruation will be eliminated, and the woman will be able to become pregnant. A re-examination should be carried out six months after the procedure.

Scraping

This procedure is similar to . It is used to remove hyperplastic endometrium and polyps. Parts of the tissue are sent to the laboratory for analysis. They are checked for cysts, polyps, cancer-prone cells, and other abnormalities.

After the procedure, with excessive vascularization of the uterine mucosa, bleeding is possible. A couple of days a woman needs to lie down and stock up on sanitary pads. During the rehabilitation period, antibiotics and hormones are prescribed so that there is no inflammation after the operation and re-endometrial hyperplasia does not begin.

Treatment without surgery

This disease occurs due to an excess of estrogen hormones. Oral contraceptives, artificial analogues of progesterone or aGnRH are prescribed to equalize the hormonal background (these drugs were discussed above). But these drugs often have side effects. The gynecologist selects their dosage and regimen individually, based on the history and analyzes of the woman.

The installation of the Mirena intrauterine device does not allow the endometrium to grow in the uterus. Treatment occurs due to the release of a modern contraceptive into the uterine cavity of levonorgestrel. It is a synthetic analogue of progesterone. The term of the IUD is 5 years. Therapy with Mirena is carried out in parallel with other hormonal agents.

Complications and consequences

If the disease is detected in early stage development, it can be easily dealt with. The difficulty lies in the fact that early stages it hardly shows up at all. Therefore, in order to recognize it, you need to do an ultrasound of the uterus or get an appointment with an experienced gynecologist.

The most terrible and dangerous complications and consequences of endometrial hyperplasia are:

1. Infertility. Since the inner shell of the uterus is deformed, the fertilized egg simply cannot attach to it.
2. The degeneration of pathology into a malignant formation. The probability of transition of atypically altered cells to oncology is from 30 to 50%.
3. Disease relapses. After medical treatment, hyperplasia returns 2 times more often than after surgical treatment.
4. Anemia. This is an obligatory companion for the growth of the endometrium. If you do not detect and start getting rid of the disease in time, iron deficiency in the blood will definitely develop.

Preventive actions

In order to recognize the endometrium of the transitional type in time and prevent it from developing into a disease, it is necessary to regularly visit a gynecologist for examination, especially when painful periods and be sure to notify him of any changes. And for prevention purposes:

• use hormonal contraceptives;
• eat right, make sure that food is free of preservatives and dyes;
• plan pregnancy and avoid abortions;
• do not abuse strong alcoholic beverages and stop smoking;
• keep a regular sexual life with a permanent partner;
• follow the figure, avoiding any extremes.

According to world statistics, uterine cancer ranks 7th among malignant diseases. An analysis of the oncological situation in Russia in the last decade indicates a steady increase in the incidence of endometrial cancer, which by 2007 took the 2nd place among all malignant tumors in women. The proportion of uterine body cancer in the structure of malignant neoplasms morbidity per 100,000 female population of Russia in different regions ranges from 4.5 to 22.5. There is a steady increase in the incidence rate from 9.8 in 1990 to 13.9 in 2005, which corresponds to the 3rd place in terms of the increase in the incidence of malignant neoplasms. Currently, the increase in the number of newly diagnosed cases of uterine cancer is not inferior to that of breast tumors. In third world countries, the risk of developing uterine cancer is generally lower, while the mortality rate remains high. In North America and Europe, this disease is much more common, being the most common malignant tumor of the female reproductive system, and ranks 4th among all malignant neoplasms after breast, lung and colon cancer. The incidence of endometrial cancer at the age of 40 to 54 years increases sharply, the peak incidence occurs at the age of 60-64 years. The incidence of endometrial cancer and its dynamics in different countries taking into account the influence of migration processes and age, they indicate the specific features of the disease and the dependence of its occurrence on a complex of causes of endo- and exogenous nature.

Among the risk factors for developing cancer of the body of the uterus, a small number of births or infertility, obesity, late menopause, and diabetes mellitus, mainly type 2, attract attention. In most cases, the risk of developing endometrial cancer is associated with various forms endometrial hyperplasia - 81.3%, dysfunction against the background of polycystic ovaries - 25%, endometrial polyposis - 5.3-25%, uterine myoma - 1.6-8%. AT recent times there is a significant increase in locally advanced forms of endometrial cancer, which is associated with ineffective measures for primary diagnosis. Issues of clarifying the diagnosis of endometrial cancer are the subject of close study.

In the pathogenesis of the disease, the theory of excessive estrogenic stimulation of the endometrium, combined with progesterone deficiency, plays a leading role. It is believed that excessive exposure to estrogens can lead to endometrial hyperplasia, which can progress to an atypical variant and, in 20-25% of cases, to a transition to adenocarcinoma. At the same time, the existing relationship between the degree of endometrial proliferation and the concentration of estrogens in the blood is observed up to a certain threshold value, and even intense proliferation is not in all cases accompanied by malignant transformation of the endometrium. The found correlation between estrogen content and DNA damage in normal and malignant endometrium makes us pay more attention to the role of molecular genetic and morphological factors in the formation different types uterine cancer. Endometrial cancer is characterized by a heterogeneous nature, which manifests itself at the level of both risk factors and its pathogenesis, which determines the features of the formation of risk groups in this disease.

Currently, to detect the pathology of the endometrium, diagnostic curettage of the uterine cavity, hysteroscopy and aspiration cytological examination are mainly used, as well as methods radiodiagnosis, among which the leading value is ultrasound (ultrasound). At the same time, there are no uniform methodically substantiated echographic criteria for invasive tumor growth. The introduction of new ultrasound technologies, such as pulsed Doppler, ultrasound angiography and three-dimensional image reconstruction, into the programs of integrated examination of patients, has significantly increased the efficiency of primary diagnosis and monitoring of patients with endometrial cancer in the process. specific therapy.

The purpose of this work was to study the possibilities of complex ultrasound using color Doppler and ( and EC), and three-dimensional image reconstruction in the primary and clarifying diagnosis of endometrial cancer.

Material and methods

We examined 139 patients aged 21 to 87 years with suspected endometrial cancer in the peri- and postmenopausal period. In 34 patients hyperplastic processes of the endometrium were revealed, in 105 - malignant processes of the endometrium. Average age patients with benign pathology was 42.6±7.2 years, patients with endometrial cancer - 65.4±7 years. In all cases, histological verification of the diagnosis was obtained.

All patients were comprehensively examined ultrasonic method using transabdominal (3.5 MHz convex probe) and transvaginal (6.5-7 MHz probe) accesses on modern ultrasonic devices Logiq S6 (GE, Healthcare) and Accuvix-XQ (Medison) according to a specific program using the latest ultrasound techniques, including dopplerometry of uterine vessels, color doppler and EC with three-dimensional image reconstruction. During transabdominal examination in patients with filled bladder assessed the state of the uterus and ovaries, determined the volume of the body and cervix, the width of the M-echo. With transvaginal ultrasound (TVUS), Doppler methods measured blood flow and resistance index in the uterine arteries, and assessed the intensity of intratumoral blood flow. At all stages of the study, the state of the structure of the endo- and myometrium, their relationship and homogeneity were determined. When focal changes were detected, their size, degree of prevalence and relationship with surrounding organs and structures were determined, a comparative assessment of the thickness of the uterine wall in the tumor zone and outside the localization zone of the tumor focus was carried out. If possible, the linear and volumetric parameters of the tumor, the clarity of its contours were accurately determined, and the condition of the adjacent mucosa was assessed. The main parameter for assessing the endometrium remains the change in its thickness. Endometrial volume is also used to most early diagnosis diseases. Its values ​​are more reliable in the differential diagnosis of cancer and benign hyperplastic processes than endometrial width measurements. The criteria for endometrial malignancy are values ​​of endometrial volume exceeding 13 cm 3 . It provides 100% sensitivity and 92% predictability positive test in the diagnosis of endometrial cancer.

The most important characteristics of the neoplasm of the endometrium were the degree and nature of its vascularization, which was assessed in the cine-loop mode in order to obtain the most complete and visual representation. A qualitative assessment of the blood supply was carried out by the number of color signals from the vessels of the neoplasm: hypovascular, moderately vascular, hypervascular. We used a technology with the conversion of volumetric data into a series of successive slices up to 0.5 mm thick. Purposeful Choice of certain sections from 3D volumetric data made it possible to select optimal sections of the body and uterine cavity and to assess their sizes as accurately as possible, to determine the relationship of the identified changes with the state of surrounding organs and tissues. The Volume CT View technology made it possible, on the basis of 3D scanning, to assess the contours and structure of the endometrium, the nature of its blood supply, and the use of the histogram option to accurately determine the vascularization index.

Special attention focused on assessing the depth of myometrial invasion, the possible transition of the malignant process to cervical canal and state of regional lymph nodes, which was of decisive importance in determining the stage of the disease and the choice of treatment tactics.

Results and discussion

As a result of the study, hyperplastic processes of the endometrium were identified in 34 patients, which we identified as separate nosological forms in accordance with WHO recommendations. In table. 1 shows the distribution of patients depending on the morphogenesis of the identified endometrial hyperplastic processes.

Table 1. Distribution of patients according to the type of endometrial hyperplastic processes.

Hyperplastic processes of the endometrium were manifested by menstrual cycle disorders of the type of menometrorrhagia, anemia of I-II degree. With benign pathology of the endometrium in 24 (71.4%) patients, an increase in the thickness of the M-echo on average 14.6 ± 3.2 mm was determined by ultrasound in the gray scale mode. In transvaginal echography, glandular cystic hyperplasia was defined as the formation of increased echogenicity, a homogeneous structure, with multiple punctate hypo- or anechoic inclusions up to 1.5 mm, sometimes with the effect of acoustic amplification. At atypical hyperplasia in the uterine cavity, a heterogeneous hyperechoic solid structure was detected. Polyps were defined as round, oval or oblong, in some cases on a long stalk, hyperechoic formations. different sizes, deforming the uterine cavity and clearly differentiating against the background of the liquid contents of the uterine cavity. Using pulsed Doppler mode, hemodynamic parameters in the uterine arteries were quantified, which were: MCC - 9.3±2.1 cm/s, resistance index - 0.56±0.05.

Using the color technique, intratumoral blood flow in glandular cystic hyperplasia was recorded in the form of single signals from vessels located along the periphery. With fibro-glandular polyps, a moderately pronounced venous and arterial peripheral blood flow with average peripheral vascular resistance was visualized. In 2 patients with glandular hyperplasia, pronounced hypervascularization of the endometrium was determined. In atypical hyperplasia, central and peripheral intratumoral blood flow of moderate intensity was recorded. In 5 patients with glandular cystic hyperplasia with atrophic endometrium, blood flow was not recorded. Characteristic signs of benign neoplasm, even in the presence of multiple polypoid growths, were the preservation of the shape of the uterine cavity, a clear definition of the outer contour of the endometrium, and a uniform distribution of myometrial vessels (Fig. 1 and 2).

Rice. one. TVUS, energy mapping mode. Glandular cystic hyperplasia of the endometrium.

Rice. 2. TVUS, energy mapping mode. Endometrial polyp.

Malignant pathology of the endometrium was diagnosed in 105 patients. 80% of those examined with this pathology were aged 50 to 69 years, of which 82 (78%) of them had malignant transformation of the endometrium accompanied by bloody discharge in postmenopause. Examination of patients with suspected endometrial cancer revealed an increase in the M-echo thickness to 18.1±6.7 mm. At stage Ia, the M-echo thickness was 11.5 ± 3.7 mm, at stage Ib - 15.8 ± 8.4 mm, at stage Ic - 17 ± 3.4 mm, at stage II - 21 ± 4.1 mm, at stage III - 27 ± 2.0 mm, at stage IV - more than 30 mm. The staging of uterine cancer was carried out according to the International Classification of Cancer (FIGO, 1988). In table. 2 compared a certain histotype of endometrial cancer with the stage of the disease.

table 2. Comparison of the histotype and stage of endometrial cancer.

Tumor histotype	Stage						Total
	Ia	Ib	ic	II	III	IV
Adenocarcinoma:
highly differentiated	12	3	3	4	2	1	25
moderately differentiated	22	6	2	6	6	2	44
poorly differentiated	5	-	-	1	3	1	10
sero-papillary	3	-	-	1	3	1	8
clear cell	-	1	-	-	-	1	2
Glandular squamous cell carcinoma	1	1	-	2	1	-	5
Sarcoma	2	-	1	1	3	2	9
acanthoma	1	1	-	-	-	-	2
Total	46	12	6	15	18	8	105

As can be seen from Table. 2, more than 60% of patients were diagnosed with stage I uterine cancer, and 46 patients were stage Ia. Patients with common forms of malignant diseases of the uterine body accounted for 23%. In most cases (89 patients, 85%), adenocarcinoma was diagnosed. varying degrees differentiation.

In our study, the degree of tumor differentiation correlated with the stage of the disease: in high, moderately differentiated adenocarcinoma, the process was mainly limited to the body of the uterus. Poorly differentiated, serous-papillary and clear cell adenocarcinomas were observed at stages II, III and IV with tumor spread outside the organ. Stage I squamous cell carcinoma was diagnosed in 2 patients, stages II and III - in 3. The combination of adenocarcinoma and endometrial stromal sarcoma was detected in 9 patients, of which 5 had stages III and IV of the disease. Main ultrasound signs endometrial cancer in transabdominal and transvaginal studies in the B-scan mode, one can consider an increase in M-echo, which is not characteristic of this patient, unevenness and heterogeneity of the endometrium, in addition, a higher echogenicity of its structure as a whole or of a detected focal formation compared to unchanged myometrium, the presence of an uneven, external contour, penetrating to a different depth. In cases of significant local spread of the tumor, visualization of a hypoechoic rim around the neoplasm or the absence of a border between the tumor focus and the myometrium is possible. In our study, an assessment of the invasive growth index (IGI) was carried out - the ratio of the volume of the altered endometrium (AIE) to the volume of the uterine body was determined. The data obtained are presented in table. 3. The calculation of these indicators was possible only in stage I endometrial cancer, when the border of the altered endometrium was determined quite clearly (Fig. 3).

Table 3. Echographic parameters of the uterus and M-echo in endometrial cancer of different stages.

At stage Ia, the volume of the endometrium was 4.2±2.2 cm3, IIR - 11.9±4.2, at stage Ib AIE - 8.3±4.6 cm3, IIR - 7.5±5.4 cm3, at Ic stage of AIE - 15.4±5.3 cm3, IIR - 4.3±2.9. As shown in Table. 3 data, there is a clear increase in the volume of the endometrium and a decrease in the values ​​of IIR as the degree of tumor invasion into the myometrium increases. For the majority of patients with endometrial cancer, its localization in the area of ​​the uterine fundus or one of the tube angles was characteristic. Tumor necrosis with deformation of the uterine cavity and the presence of fluid in it were determined at stages III and IV of the process.

Based on the literature data, we have identified three main types of growth invasive cancer endometrium.

1. The development of multiple highly differentiated tumor foci against the background of hyperplastic processes of the entire endometrium.
2. The development of one highly differentiated tumor focus, surrounded by a hyperplastic mucosa over a short distance.
3. The development of one moderately or poorly differentiated tumor focus against the background of an atrophic mucosa.

An exophytic form of tumor growth was detected in 15% of cases. Exophytic tumor growth is characterized by the absence of deformation of the uterine cavity, clear boundaries of the endo- and myometrium, or the detection of a formation in the lumen of the uterine cavity. In 85% of cases, an endophytic form of growth with invasion into the myometrium was noted. Violation of the integrity of the hypoechoic rim in endometrial cancer is a specific sign of invasion into the myometrium. Endophytic tumor growth leads to asymmetry and deformation of the uterine cavity. With a deep infiltrative process, the 2nd variant was noted in 30%, the 3rd variant - in 70% of cases. With ultrasound, the possibility of a clear definition of the form of tumor growth was available only on initial stages diseases. In stage Ia endometrial cancer, in the case of ultrasound in the B-mode, a homogeneous hyperechoic structure of the median M-echo was determined, and in 69.5%, heterogeneity of the endometrial structure was detected due to inclusions of a rounded shape, with even, in some cases fuzzy contours, increased echogenicity, the average size which was 6.3±3.8 mm. The boundaries of the endometrium in all cases at stage I of the disease were defined as clear and even.

Table 4. Hemodynamic parameters in benign and malignant pathology endometrium.

Note. * - R<0,05

In our observations, it was possible to differentiate the 1st and 2nd types of development of the tumor process in the usual B-mode only in 10 patients. In other cases, due to the significant local spread of the tumor, these differences were not determined. With a deep infiltrative process at stages III and IV of the disease, the thickness of the M-echo exceeded 27.0 mm. The boundaries between the tumor and myometrium in all cases were fuzzy, the contours were uneven, and in 61 (58.0%) patients, the boundaries of the tumor were not determined up to the outer contour of the uterus. The structure of the M-echo in 30.3% of cases was homogeneous hyperechoic, in 20.1% - homogeneous hypoechoic, and in 50% - heterogeneous, predominantly hyperechoic. The echostructure of the tumor could also have different echogenicity: in 44.6% of cases it was homogeneous hyperechoic, in 10.4% - homogeneous hypoechoic, in 45.0% - mixed.

We have evaluated the quantitative indicators of hemodynamics, performed with the help in the uterine arteries and vessels of the tumor. In table. 4 shows a comparative characteristic of hemodynamic parameters in benign and malignant pathology of the endometrium.

As can be seen from the above data, the hemodynamics of regional blood flow in endometrial cancer is accompanied by a tendency to increase the rate of blood flow in the uterine vessels and a statistically significant decrease in the peripheral resistance index in tumor vessels, which can characterize the activity of intratumoral blood flow. MCC in the uterine arteries depended on the volume of the uterine body, which could be associated with the presence of fibroids, and the nature of tumor vascularization. Indicators of intratumoral blood flow and IR did not statistically depend on the histotype of endometrial cancer.

Rice. 4. TVUS, energy mapping mode. Stage I endometrial cancer. The focus of hypervascularization is determined along the anterior wall of the uterus.

Rice. 5.

Rice. 6. TVUS, color doppler, longitudinal scanning. Stage Ia endometrial cancer. Infiltrative formation of a hyperechoic structure in the fundus of the uterus with reduced vascularization.

When analyzing the nature and degree of vascularization of endometrial cancer, assessed using the CDI and EC modes, different variants of intraendometrial blood flow were determined. Pathological endometrial vascularization occurred in 92 (87.6%) patients with endometrial cancer. In other cases, even in the presence of characteristic ultrasound signs of a malignant lesion, the intratumoral blood flow was not visualized by the methods used. With a tumor of the uterine body, three main variants of blood supply (A, B, C) were identified, while there was a certain dependence of the pattern of CDC and EC with the stages and selected forms of tumor growth. The intensity of blood flow in the endometrium and the tumor node, determined in the CDI and EC modes, depended on the type of tumor growth and could be most clearly represented in the cine-loop mode. Tumor blood flow zones are detected in endometrial cancer in more than 90% of cases (Fig. 4-8).

It was found that variant A was typical for stage Ia: with infiltration of the myometrium to a depth of 5 mm, which was determined in 33.8% of cases and was characterized by an uneven increase in intraendometrial blood flow due to a local increase in the number of color spots with different color intensity, in the absence of color loci in the subendometrial zone. The same variant was typical for the exophytic form of growth with an intratumor type of neovascularization.

Rice. 7. TVUS, TsDK. Stage IV endometrial cancer. Hypervascularization of the formation of a heterogeneous structure in the region of the left uterine angle. Endometrial and intratumoral blood flow is determined.

Rice. eight. TVUS, combination of B-mode and energy mapping mode. Stage IV endometrial cancer. A focus of hypervascularization along the posterior wall of the uterus with hypervascular endometrial blood flow.

Option B (47.6%) was characterized by a total increase in intraendometrial blood flow due to a large number of randomly located color loci, with a simultaneous local increase in the number of color signals in the subendometrial zone. In 27.5% of cases, moderate vascularization of the tumor was determined, combined with rich vascularization of the myometrium. This variant was detected in 78.3% of patients with a mixed form of endometrial cancer.

Option C (19.6%) was characterized by a slight increase in intraendometrial blood flow with a significant total increase in the number of color signals in the subendometrial zone. This variant was characteristic of the endophytic form of growth (92.5%) and was accompanied by intense intra- and peritumoral blood flow.

Although no direct correlation was found between the severity of tumor blood flow and the stage of the disease, as well as the degree of differentiation, the presence of a detectable zone of neovascularization corresponded to a higher stage of the process. Hypovascular and moderately pronounced blood flow in the endometrium was observed in patients with highly differentiated adenocarcinoma.

She did not register neovascularization of the pathological process in 12.4% of cases. The reason for this could be the removal of a small tumor as a result of preliminary diagnostic curettage of the uterine cavity and in highly differentiated adenocarcinoma that arose against the background of endometrial atrophy.

Due to the construction of the frontal planes, it made it possible to more accurately determine the state of the endometrium, to establish its asymmetry. A disorganized vascular pattern, detected by three-dimensional angiography in a three-dimensional block, when combining scanning modes, was an important additional sign of a malignant lesion of the endometrium. The most accurate results in assessing the degree of invasion of endometrial carcinoma are achieved using three-dimensional reconstruction in the ultrasound angiography mode (Fig. 9-11). An important sign of common invasive processes is the presence of zones of local increased vascularization in the myometrium adjacent to tumor zones.

Rice. nine. Ultrasound performed using Multi-slice view technology. On layered sections, it becomes possible to accurately determine the structure of the endometrium and its vascularization.

The possibilities of the ultrasound method in the diagnosis of endometrial cancer have their limitations due to the fact that hyperplastic processes and the initial stages of the disease do not have specific differential diagnostic signs. Concomitant uterine bleeding with fibrin formation complicates the identification of endometrial thickening zones. Certain difficulties arise in determining the depth of myometrial invasion in the early stages of endometrial cancer up to 5 mm, as well as in cases of concomitant adenomyosis. Ultrasound does not accurately determine the volume of a cancerous lesion in women with large and multiple submucous myomatous nodes that deform the uterine cavity.

Rice. ten. TVUS, energy mapping mode. Ultrasound performed using Oblique view technology. 3D volume data allow to clarify the state of the endometrium and the nature of endometrial and subendometrial vascularization.

Rice. eleven. Multiplan reconstruction mode. Volume CT view. 3D data allows you to determine volumes as accurately as possible.

findings

Ultrasound examination using pulsed Doppler, color Doppler, energy mapping and three-dimensional image reconstruction is a highly informative method for non-invasive refining diagnosis of endometrial pathology. The results obtained testify to the high efficiency of the methods used in the differential diagnosis of benign and malignant processes. Ultrasound angiography and three-dimensional reconstruction of the image in endometrial cancer contribute to obtaining additional and very important information about the features of the tumor process, the depth of tumor invasion into the myometrium, and the nature of the detected neovascularization makes it possible to predict the growth rate of the neoplasm.

The use of modern ultrasound technologies makes it possible to solve the problems of intranosological diagnosis of endometrial cancer at a completely new qualitative and quantitative level, as well as to monitor patients in the process of specific treatment.

Literature

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The endometrium of the uterus is a mucous layer that is located inside the uterine body, completely lines its cavity and provides a large number of blood vessels. He plays a major role in the menstrual period.

The main function of the endometrium is to create a favorable environment and conditions for the attachment of the fetal egg inside the body of the uterus.

If it is too thin or thickening is noted, then the pregnancy will not be able to proceed normally, a miscarriage is possible in this situation. Treatment of any pathological process should be carried out exclusively by a specialist, after a preliminary examination.

Endometrium - what is it?

The endometrium of the body of the uterus is the mucous layer of the organ, which creates favorable conditions for the attachment of the fetal egg. It changes during the entire menstrual period, that is, its thickness. The greatest thickness falls on the last days of the cycle, and the smallest - in the first days.

Due to the influence of adverse factors, the endometrium of the organ can become thin, this condition will prevent the attachment of the embryo, and can also provoke infertility in a woman. There are cases when the egg is attached to a thin layer, but after a while an arbitrary miscarriage occurs. Proper treatment will help get rid of the problem, favorably conceive and endure the baby.

The norm of the thickness of the endometrium of the uterus

As mentioned earlier, the endometrium and its thickness changes throughout the menstrual period. Each phase of the cycle corresponds to a certain layer thickness. All changes occur under the influence of female sex hormones.

For pregnancy to occur, the thickness of this layer must be normal. The norm of the endometrium of the body of the uterus for the attachment of a fertilized egg is 0.7 cm.

You can determine this parameter using an ultrasound scan, which is assigned to a woman at a certain period of the cycle.

Any deviations from the norm may indicate that the pathology is progressing, the causes of this process can be varied.

Thin layer of endometrium in the uterus

Hypoplasia or a thin layer of the endometrium of the uterine body is a deviation from the norm. Pathology manifests itself in the form of underdevelopment of the upper or lower mucous membrane of the organ. Such a violation leads to the impossibility of attaching a fertilized egg.

Causes of hypoplasia:

Symptoms of hypoplasia may not appear at the initial stage, and the pathology is determined only during a gynecological examination.

Symptoms of the disease of the mucous layer of the body:

Thin endometrium and pregnancy cannot be combined. This pathology provokes violations of the reproductive function and can lead to absolute infertility. In such a situation, treatment should be carried out immediately to exclude serious consequences.

Timely therapy can increase the chance of bearing and giving birth to a healthy baby.

Thickening of the endometrial layer of the uterine body

In gynecology, there is also such a definition as hyperplasia, which indicates a thickening of the mucous layer and the formation of polyps. This pathology has a benign course.

It is possible to determine the deviation of the thickness from the norm during a gynecological examination, as well as using ultrasound. Treatment may not be carried out if infertility is not observed and there are no symptoms of pathology.

Hyperplasia is of a simple type and atypical form. Simple hyperplasia is characterized by the predominance of glandular cells, leading to the development of cystic formations. Treatment includes not only the use of drugs, but also surgery. Polyps, depending on the cellular structure, can be glandular, fibrous, mixed type.

The pathology of the mucous layer of the uterine body of an atypical form includes the progression of adenomatosis. Histological analysis shows changes in tissue structure. Adenomatosis is more related to a malignant disease.

Thickening of the layer can be provoked by such various reasons:

Many experts are also of the opinion that such causes as hormonal failure, tumor progression, inflammatory processes, diseases of the endocrine system, and sexually transmitted infections can also cause hyperplasia.

Also, pathology occurs as a result of long-term use of contraceptives that contain exclusively estrogens.

Symptoms of hyperplasia:

1. Violation of menstruation (the cycle becomes longer or vice versa reduced).
2. Smearing of blood, which is noted in the patient a few days before menstruation.
3. Bleeding with clots.
4. Excretion of blood during intercourse.
5. Changes in the duration and profusion of discharge during menstruation.

Treatment is carried out either in a conservative way (sometimes, in combination, it is also carried out with folk remedies), or with the help of an operation. If therapy is abandoned or carried out untimely, the following complications may occur:

Prevention of this disease includes:

• exclusion of unplanned pregnancy and abortion;
• proper and healthy lifestyle;
• reduction of stressful situations;
• timely treatment of diseases and pathologies of the reproductive system, as well as the endocrine system.

Pathology, symptoms, causes and treatment

In modern medicine, there are several pathologies of the mucous layer of the body of the uterus, each of which has certain causes, symptoms and methods of treatment.

Diagnosis of pathology

If a woman has signs of the disease, then it is necessary to undergo a thorough examination, take a blood and urine test. During a gynecological examination, a specialist may find that the endometrium has become thin or, on the contrary, thickened, the uterus has changed shape and is in good shape. The patient is also advised to:

The norm is when the indicators of ultrasound and analyzes are within acceptable values.

Is treatment possible without surgery?

Treatment of the disease can be carried out conservatively and surgically. Surgical intervention is carried out only in advanced situations.

Conservative therapy includes medication and folk remedies. The choice of hormonal drugs will depend on the age category of the patient, the desire to have children in the future, and the stage of the disease.

Treatment with folk remedies is carried out under the supervision of a specialist, the course is selected individually, depending on many factors. The patient may be recommended nettle, calendula, wild rose, yarrow, plantain. These herbs will help stop bleeding. Hirudotherapy is also prescribed, which has a positive effect on blood clots.

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01/19/2017 "Articles"

AUTHOR: Dueholm, C. Møller, S. Rydbjerg, E. S. Hansen, G. Ørtoft, P.G.Leone, D.Timmerman, T.Bourne, L.Valentin, E.Epstein, S.R.Goldstein, H.Marret, A.K.Parsons, B.Gull, O.Istre, W.Sepulveda, E.Ferrazzi, T.Van den Bosch

Transvaginal ultrasound examination is of great importance in the diagnosis of endometrial cancer in women with postmenopausal bleeding. Women with an endometrial thickness ≤ 4 mm measured by transvaginal scanning have a low risk of developing endometrial cancer (1 in 100 if they are not on hormone replacement therapy; 1 in 1000 if they are on therapy). In women with postmenopausal bleeding and endometrial thickness ≥ 5 mm, there is a high risk of endometrial cancer (1 in 4 cases), so a quality intrauterine scraping should be obtained for histological analysis. Ultrasonography may provide information on the individual risk of malignancy in postmenopausal women with bleeding and endometrial thickness ≥ 5 mm.

Our study included women with postmenopausal bleeding and endometrial thickness ≥ 5 mm, which was measured with a transvaginal transducer. The study was conducted at the University Hospital in Aarhus (Denmark) between November 2010 and February 2012. All women underwent transvaginal scanning (TVS) and gel infusion sonography (GIS). All were scheduled for hysteroscopy with resectoscopy biopsy and additional curettage to assess intrauterine pathology (Table 1).

Table 1. Patient selection scheme for the study.

Transvaginal Scan (TVS)

TVS was performed on a Voluson E8 Expert equipped with an endovaginal transducer (6-12 MHz) according to the scanning protocol. Doppler parameters were preset, standardized (frequency 6 MHz, Doppler power gain 50, dynamic range 10 dB; persistence 2, map color 1, filter 3).

The TVS scan included visual assessment of the following parameters, as determined by the International Endometrial Tumor Analysis Group (IETA): endometrial thickness, its echogenicity (hyper-, hypo-, and isoechoic, homo/heterogeneous); cystic component (yes/no), if present, smooth or uneven margins; borders of the endometrium (smooth or uneven, homo-/heterogeneous); closure line (yes / no), interrupted (yes / no).

Power Doppler analysis included a visual assessment of the following parameters: vessels present (yes / no), presence of a dominant vessel (yes / no), if there is a dominant vessel, then single (yes / no) or double (yes / no), origin (focal / multifocal) multiple vessels (yes/no); ramifications (yes / no), if there are ramifications, then ordered / disordered, circular direction of vessels (yes / no). We assessed subjectively: large vessels (yes/no), color doppler (yes/no), vessel density (yes/no).

The GIS was carried out after TVS. We used a small flexible sterile catheter equipped with a 10 ml syringe containing Instillagel® (E.Tjellesen A/S, Lynge, Denmark) which was inserted into the uterine cavity. In patients with an obstructed cervix, we used a small Hegar dilator. The introduction of the gel into the uterine cavity was performed under ultrasound control.

The uterine cavity was then scanned in the sagittal and transverse planes, assessing the same parameters as for conventional TVS. Also assessed were: the presence of a mass, its localization, and the percentage of endometrial involvement (i.e., ≤ 25% of the surface is damaged) (yes/no); surface structure of local damage (uniform / uneven); the structure of the general surface of the endometrium (smooth, polypoid, uneven).

Hysteroscopy

Outpatient hysteroscopy was performed in all patients using local or general anesthesia. In 112 patients, hysteroscopy was performed immediately after ultrasound, in other patients at the next visit within 3 weeks after ultrasound. During hysteroscopy, attempts were made to remove all tissue from the uterine cavity. Three to five endometrial samples were taken from one patient.

Calculation of the risk of developing endometrial cancer according to the point system

(Risk of endometrial cancer score (REC score))

Based on our analyzes, we developed a risk scoring system for endometrial cancer (Figure 1). The scoring system included body mass index (≥30 = 1 point), endometrial thickness (≥10mm = 1 point), (≥15mm = 1 point), presence of vascularization, dominant vessel (present = 1 point), multiple vessels (present = 1 point), large vessels (present = 1 point) and densely spaced vessels (present = 1 point), discontinuous endometrial zone (present = 1 point) and uneven surface of the endometrium in GIS (present = 1 point). Adding these values ​​is the risk score for endometrial cancer. A score of 3 for TVS or 4 for GIS showed good scan results and correctly diagnosed a high rate of endometrial cancer in about 90% of all patients.

Fig.1. Schematic representation of the definition of the risk of developing endometrial cancer according to the point system.

Ultrasound examination parameters of the endometrium are determined by the International Endometrial Tumor Analysis Group (IETA)

Thickness of the endometriummeasured in the sagittal plane. Calipers should be placed at the border of the endometrial-myometrial layer, perpendicular to the midline of the endometrium (Fig. 2). When fluid is present, then the thickness of the individual parts of the endometrium is measured and their sum is recorded (Fig. 2b).

Fig.2. Schematic and ultrasound image of the measurement of the endometrium in the norm (a), and in the presence of intrauterine fluid (b).

Echogenicity of the endometriumcompared with the echogenicity of the myometrium, as hyperechoic, isoechoic or hypoechoic.

Homogeneity of the endometrium evaluated by its structure. “Homogeneous” endometrium is homogeneous and has a three-layer structure (Fig. 3). “Heterogeneous” endometrium is described if there is structural heterogeneity, asymmetry, or cystic formations (Figure 4).

Fig.3.“Homogeneous” endometrium: (a) schematic representation of a three-layered endometrium, (b) hypoechoic, (c) hyperechoic, (d) isoechoic.

Fig.4.“Heterogeneous” endometrium: cystic formations with smooth edges are visualized against a homogeneous background (a), cystic formations with uneven edges are observed against a homogeneous background (b), a heterogeneous background without cystic areas (c), cystic formations with smooth edges are present against a heterogeneous background ( d) and on a heterogeneous background, cystic formations with jagged edges (e).

The endometrium is considered "linear" if the line of closure of the sheets of the endometrium is defined as a straight line; and “non-linear” if the closure line is visualized as “jagged” or “interrupted” or absent altogether (Fig. 5).

Fig.5. The line of closing of the sheets of the endometrium: “linear” (a), “serrated” (b), “interrupted” (c) and one that is not visualized (d).

The endometrial-myometrial region is described as “smooth”, “uneven”, “interrupted”, or “indeterminate” (Fig. 6).

Fig.6. Endometrial-myometrial region: “smooth” (a), “uneven” (b), “interrupted” (c) and “indeterminate” (d).

The intrauterine fluid is described as anechoic, isoechoic, mixed echogenicity (Figure 7).

Fig.7. Intrauterine fluid: (a) hypoechoic, (b) isoechoic, (c) mixed echogenicity.

Doppler assessment

Doppler settings should be adjusted to provide maximum sensitivity (ultrasound frequency at least 5.0 MHz, pulse repetition frequency (PRF) 0.3-0.9 kHz, vessel wall filter 30-50 Hz, Doppler color enhancement should be reduced to until all color artifacts are gone).

Doppler is assessed by the presence of blood flow: 1 point is given when there is no flow of color signals in the endometrium; 2 points - if only minimal blood flow can be detected; 3 points - when moderate blood flow is present; and score 4 when there is significant blood flow (Figure 8) .

Fig.8. Endometrial blood supply assessment: 1 point is given - when there is no blood flow (a); 2 points - there is minimal blood flow (b); 3 points – moderate blood flow is present (s); and 4 points - significant blood flow is determined (d).

The vascular pattern in the endometrium shows the presence or absence of a “dominant vessel”. A “dominant vessel” is defined as one or more vessels (arteries and/or veins) that leak into the endometrium (Figure 9). The dominant vessel may have ramifications in the endometrium, described as ordered or disordered/chaotic. Several dominant vessels may originate from a single vessel (“focal” origin), or from multiple vessels in the endometrio-myometrial layer (multifocal origin). Other vascular structures within the endometrium include 'scattered' vessels (single color signals in the endometrium with no apparent origin) and circular direction of the vessels (Figure 9).

Fig.9. Vascular models: “dominant” vessel without branching (a) and with branching (b); several vessels that are of “focal” origin (two or more vessels sharing a common stem) (c) and “multifocal” origin (large vessels that have different stems) (d); “scattered” vessels (single color signals in the endometrium, but without visible origin) (e) and circular direction of vessels (f).

Gel infusion sonography (GIS)

The endometrium is described as "smooth" if the inner surface of the endometrium is smooth, "wavy" if there are several concave shallow areas, or "polypoid" if there is a significant concavity towards the uterine cavity. The endometrium is "uneven" - if the surface of the formation is turned into the uterine cavity in the form of a cauliflower, or as a sharply jagged tissue (Fig. 10).

Fig.10. Endometrial contour: “smooth” (a), “wavy” (b), “polyp-shaped” (c) and “uneven” (d).

Intrauterine formations

Anything that protrudes into the uterine cavity is called intracavitary formations. Intracavitary masses should be described as endometrial masses or lesions arising from the myometrium.

The degree of endometrial involvement is determined based on the percentage of the total surface of the involved endometrium. An endometrial mass is described as “spread” if it covers 25% or more of the endometrial surface, and “localized” if it covers less than 25% of the surface (Figure 11). The type of “localized” endometrial formation is calculated by the ratio between the diameter of the base at the level of the endometrium (a) and the maximum diameter of the diameter of the formation (b). If a / b coefficient<1 описывается, как образование на «ножке», и как образование на “широкой основе”, если коэффициент равен 1 или больше (Рис.12).

Fig.11. Assessment of the degree of damage to the endometrium: "localized" education captures less than 25% of the surface of the endometrium (a), and "common" education captures 25% or more of the surface (b).

Fig.12.“Localized” type of formation during GIS or with already existing fluid in the uterine cavity. A/b ratio<1 указывает на образование на «ножке» (а) и а / b соотношение ≥ 1 указывает на “широкую основу “(b), где максимальный диаметр основания образования находится на уровне эндометрия и представляет максимальный поперечный диаметр образования.

The echogenicity of the mass is defined as either "homogeneous" or "heterogeneous" (the latter including cystic lesions).

The contour of the formation is defined as “smooth” or “uneven” (Fig.13).

Fig.13. The contour of the formation with GIS or with already existing fluid in the uterine cavity is “smooth” (a) and “uneven” (b).

Upon detection of formations in the uterine cavity arising from the myometrium (usually fibroids), their echogenicity and the proportion of the formation that penetrates into the uterine cavity are determined.

Subserous fibroids should be classified according to specific planes passing through the largest diameter of the fibroid, as described by Leone et al.: Grade 0 (G0) - the fibroid protrudes completely into the cavity; Grade 1 (G1) - ≥ 50% broad base of fibroids protrudes into the uterine cavity; and Grade 2 (G2) with intrauterine fibroids<50% (рис.14).

Fig.14. Part of the fibroid protrudes into the uterine cavity with GIS or with pre-existing fluid in the uterine cavity: 100%, class 0 (a) ≥ 50%, class 1 (b)<50%, класс 2 (c).

DISCUSSION

We have built a scoring system (REC) that allows you to effectively distinguish between benign and malignant endometrial growths. The REC scoring system correctly identified neoplasms in nine out of 10 postmenopausal women with endometrial thickness ≥ 5 mm. A scoring approach can be used to reduce the number of invasive procedures.

We have used terms and classifications defined by the International Endometrial Tumor Analysis Group (IETA) that can be used to measure and describe uterine pathology. The main purpose of this work is to create a list of terms and definitions that can be used both in the daily practice of doctors and in scientific research. For research, we recommend using a device from GE.