Methods for examining gynecological patients. Information about previously suffered diseases of the female genital area

Anatomy

External genitalia (vulva)

The labia majora form the skin borders on the sides of the vulva and are analogous to the scrotum in men. In front they come into contact with the anterior eminence (pubic symphysis, eminence of Venus), in the back - with structures related to the posterior commissure. Medial to the labia majora are the labia minora, covered laterally by hair-free skin, and medially by the vaginal mucosa. The anterior junction of the labia minora forms the foreskin of the clitoris, the posterior junction forms the frenulum of the labia.

Pelvic floor muscles (pelvic diaphragm)

Muscles, elevating the anus, form the muscular pelvic floor and include mm. pubococcygeus, puborectalis, iliococcygeus And coccygeus. Distal to the levator anus muscle are the superficial muscles that make up the urogenital diaphragm. Lateral to these muscles are t. ischiocavernosus. Mm. bulbocavernosus And transverse the perineal muscles, intertwining medially, originate from the pubic symphysis.

Internal genitalia

The muscles on the pelvic side are represented by mm. iliacus, psoas And obturator internus. The blood supply comes from the internal iliac arteries, except for the middle sacral artery. The internal iliac and hypogastric arteries divide into anterior and posterior branches. The anterior branch of the hypogastric artery gives rise to the obturator, uterine, superior and middle cystic arteries. Innervation is provided by the sciatic, obturator and femoral nerves.

Gynecological history

The gynecological history should include the patient's age, date of last menstrual period, number of pregnancies, births and abortions, general health and last method of contraception used.

Physical examination

A gynecological examination includes examination of the mammary glands, abdomen and pelvis, external genitalia with recording of the results, examination of the vagina in the speculum and taking a smear from the cervical canal cytological examination. After removing the speculum, a bimanual pelvic examination is performed. Then - rectovaginal examination.

Diagnostic tests

Cytological examination of the cervical canal

Performed from the age of 18 or earlier if the patient is sexually active. Most women and patients who have had a total hysterectomy for a cervical tumor should have this procedure done annually. For pathologies not associated with neoplasms of the cervical canal, the vaginal vault is examined cytologically every 3-5 years.

The classification of cervical pathology is presented in table. 39.1.

Atypical smears or smears with signs of severe inflammation are repeated after 3 months. If the atypical picture in the smears persists, colposcopy is indicated, which makes it possible to distinguish dysplasia from neoplasia.

Tissue biopsy

A tissue biopsy for suspected lesions of the vulva, vagina, cervix and uterus should be carried out in a specialized institution. A vulvar biopsy is done after infiltrating the biopsy area with a small amount of 1% lidocaine solution using an appropriate (27) gauge needle. In contrast, ectocervical biopsy does not require anesthesia. Endometrial biopsy should be performed only in an appropriate medical institution; before the procedure, it is necessary to ensure that the patient is not pregnant.

Examination of vaginal discharge

Pathological vaginal discharge is subject to examination. Normal vaginal pH is 3.8-4.4; at a pH of 4.9 or more, examination for bacterial and protozoal infections is indicated.

The wet native preparation is placed on the mounting table of the microscope in a small amount of saline and under a coverslip. Motile trichomonas are characteristic of vaginal trichomoniasis, “key cells” are characteristic of bacterial vaginitis, the presence of leukocytes indicates various inflammatory diseases of the vagina, cervix and urinary tract, such as gonorrhea, chlamydia. A 10% potassium hydroxide solution is added to the sample and vaginal material for re-examination. Potassium hydroxide lyses cellular material and makes it possible to see the mycelium characteristic of candidiasis vaginitis.

Table 39.1. Classification for cytological examination of the cervix (USA)

MATCHING PATTERN

Satisfactory for research
Satisfactory for research, but limited... (specificity)
Unsatisfactory... (specificity)

Within normal limits
Benign cell changes (see descriptive diagnosis)
Abnormal epithelial cells (see descriptive diagnosis)

DESCRIPTIVE DIAGNOSIS OF BENIGN CELL CHANGES

Trichomoniasis (Trichomonas vaginalis)
Fungal infections
Predominance of coccal flora
Contains actinomycetes (Actinomyces sp.)
Contains herpes simplex virus

REACTIVE CHANGES

Changes caused by inflammation
Atrophy combined with inflammation
Irradiation
Intrauterine contraception

EPITHELIAL CELLS, ANOMALIES, SQUAMOUS CELLS

Atypical squamous cells, poorly differentiated
Squamous intraepithelial cell damage in the early stages of development, including human papillomavirus
Significant stage of development of squamous intraepithelial damage, including moderate and severe dysplasia, carcinoma in situ
Squamous cell carcinoma

Glandular cells

Endometrial cells, cytologically benign in postmenopause Atypical glandular cells, poorly differentiated
Endocervical adenocarcinoma
Endometrial adenocarcinoma
Ectopic adenocarcinoma
Nonspecific adenocarcinoma

Hormonal fingerprint smear consistent with age and history
Hormonal smear fingerprint that does not correspond to age and medical history
Hormonal examination is impossible due to... (reasons)

Suspicion of gonorrhea arises in the presence of gram-negative intracellular diplococci found in the vaginal mucus with Gram staining. When cultured with gonococci, gonorrhea is confirmed; pathogen, cultivated on “chocolate” agar.

Pregnancy tests

An increased amount of β-subunits of human chorionic gonadotropin in the urine is determined. Serial determination of hormone levels is used in the treatment of threatened miscarriage, ectopic pregnancy, or trophoblastic diseases.

Pathological bleeding

The menstrual cycle varies from 21 to 45 days with bleeding duration from 1 to 7 days.

Bleeding in combination with pregnancy

Bleeding can occur in 25% of cases during a normal pregnancy, but should be considered as an impending miscarriage until the bleeding stops. In case of threatened miscarriage, the cervical The third canal is closed and the uterus is assessed from the perspective of anamnesis and gestational age. Abortion in progress is diagnosed when cervical canal opens and fetal tissue appears in the canal. Abortion is incomplete after partial expulsion of the fertilized egg. At incomplete abortion and during abortion, curettage is performed.

An ectopic pregnancy should be considered in any patient with positive test for pregnancy, pelvic pain and pathological uterine bleeding.

Trophoblastic diseases can also cause abnormal bleeding associated with a positive pregnancy test. Chorioadenoma ( hydatidiform mole) is assumed to be due to excessive enlargement of the uterus (based on a history of pregnancy) and the presence of grape-like tissue in the vagina. Ultrasound is used for diagnosis.

Dysfunctional uterine bleeding

It is characterized by irregular menstruation with rare long intervals of amenorrhea. As a rule, the cause is secondary ovarian failure. During the examination, a pregnancy test is necessary. The study reveals non-secreting or proliferative endometrium. If the bleeding is severe, curettage is required, but in most cases cyclic treatment with estrogen and progesterone is prescribed.

Secondary bleeding from neoplasms

Tumors of a benign and malignant nature affect the genital organs from the vulva to the ovaries and can cause abnormal bleeding. Dysfunctional bleeding in the group of patients of reproductive age is most often caused by leiomyoma (fibroma). Ultrasound of the pelvis and other methods of examining this area can make a diagnosis.

Bleedings combined with tumors of the fallopian tubes and ovaries are few in number; a tumor formation in the pelvis is almost always palpable.

Bleeding not related to the genital area

Genital bleeding can be combined with secondary coagulopathy when using systemic anticoagulants, causing abnormal clot formation and hemostasis disorders.

Pain

Pain combined with menstruation is defined as dysmenorrhea. Pain without a specific pathology is interpreted as primary dysmenorrhea. Secondary is combined with endometriosis, stenosis of the cervical canal and inflammation in the pelvis.
Acute pain in the pelvis occurs during an uncontrolled pregnancy, benign or malignant tumors, incomplete miscarriage or non-gynecological diseases.
Pregnancy pathologies include threatened miscarriage, ongoing abortion, and ectopic pregnancy.
Acute pain in the ovary is associated with the destruction of fibroids, torsion of an ovarian cyst or its tumor. Spontaneous rupture of an ovarian cyst is accompanied by very severe pain.
Secondary pain in inflammatory diseases is combined with fever and other manifestations of infection. The possibility of a non-gynecological disease should always be taken into account. Appendicitis and other acute pathology gastrointestinal tract may cause pain in the pelvis and abdominal cavity.
An accurate diagnosis is not always possible during the examination, so laparoscopy is used.

Neoplasm in the pelvis

In women of reproductive age, pregnancy should always be assumed when the uterus is enlarged. Ovarian enlargement occurs during ovulation and hemorrhage in the corpus luteum, which is palpable quite early and in some cases exists for several weeks. Abdominal and vaginal ultrasonography are useful.

An enlarged uterus may be associated with pregnancy, fibroids, adenoid fibroids, or a malignant tumor such as endometrial cancer or sarcoma. Ovarian enlargement is possible with endometriosis, ectopic pregnancy, tubo-ovarian abscess or benign (malignant) tumor.

Infections

Fungal infection

The most common cause of genital itching may be fungi of the genus Candida. Itching is more common when sugar diabetes, pregnancy or antibiotic use. Diagnosis is made by examining vaginal secretions and being treated local application of any drug from the imidazole group.

Pinworms are more common in little girls. Diagnosis is made based on the detection of adult worms or identification of eggs when microscopic examination material of the perianal folds collected on an adhesive plaster.

Trichomonas vaginalis - common cause of infection in the vagina: h Le- reading: Metronidazole 250 mg 3 times a day for 7 days. G

The skin of the genital organs is often affected pubic lice and itching. Treatment consists of using ointments according to the Kwell method.

Gardenerellosis - the most common pathology caused by a pathogenic bacterium Gardenerella vaginalis. Vaginal discharge is scanty, gray-green in color with an unpleasant “fishy” odor. Diagnosis is made by detecting “clue cells” treatment carried out with metronidazole 500 mg per os every 12 hours.

Viral infections

Papillomavirus(human papilloma virus) causes genital warts. They consist of a single growing formation similar to a tubercle. Diagnosed by biopsy. IN treatment use cauterizing drugs, laser, cryo- or electrocautery.

Simple herpes manifested by the presence of painful blisters followed by ulceration. Initially, the infection is widespread; culturing the pathogen confirms the diagnosis. The attack can be interrupted and the interval between attacks lengthens when using acyclovir (Zovirax). The drug is prescribed per os no 200 mg 5 times a day. For patients with vulvar or vaginal ulceration as a result of a herpes infection, delivery by cesarean section is recommended.

Molluscum contagiosum causes a group of itchy nodules with an umbilical-shaped depression in the center. Treatment consists of removal with a cautery or curettage.

Pelvic inflammatory diseases

In the United States, approximately 1.5 million cases of pelvic inflammatory disease occur annually, the prevalence of which is limited to women who are actively sex life. Risk factors include: age under 20 years, having a large number of sexual partners, infertility and previous infections.

The most common microbes are gonococcus And chlamydia. Classic symptoms include fever, pain in the lower abdomen with tenderness on examination of the pelvis, and purulent vaginal discharge. Differential diagnosis includes acute appendicitis, ectopic pregnancy, gastrointestinal obstruction or perforation, and urolithiasis. The correct diagnosis is made on the basis of laparoscopy, ultrasonography and CT examination of the pelvis.

Treatment. Patients with peritonitis, high fever, or suspected tubo-ovarian abscess receive intravenous antibiotics.

The CDC recommends cefoxitin 2 g intramuscularly with probenecid per os or ceftriazone 250 mg intramuscularly, or an equivalent cephalosporin with doxycycline 100 mg per os twice daily for 10 to 14 days.

Treatment of patients in the hospital includes cefoxitin 2 g intravenously every 6 hours in combination with a large dose of gentamicin (2 mg/kg) intravenously, followed by a dose of 1.5 mg/kg every 8 hours. Doxycycline 100 mg orally twice daily for 10-14 days after the patient is discharged from the hospital. Another treatment option is clindamycin 900 mg IV every 8 hours with a high dose of gentamicin (2 mg/kg) IV, then 1.5 mg/kg IV every 8 hours. Patients discharged from the hospital receive doxycycline 100 mg twice daily per os. within 10-14 days.

Surgical treatment. Used for intraperitoneal rupture of tubo-ovarian abscess, abscess and chronic pain in the small pelvis.

For some period of time, in case of diffuse inflammation, hysterectomy with bilateral salpingo-oophorectomy was considered the operation of choice. Now, mainly in young women with unrealized reproductive function, a less radical operation is used.

Endometriosis

Endometriosis accounts for approximately 20% of all laparotomies in women of reproductive age. Most common between 30 and 40 years of age. Exact reason disease is unknown. There is a theory that the onset is related to degenerating menstruation.

The pathological appearance, often described as a "powder of fire" appearance, is bluish or black in color. The disease often affects the ovaries, and the process is bilateral. Other affected organs are the uterosacral ligaments, the abdominal surface of the deep parts of the small pelvis, the fallopian tubes and rectosigmoid region.

Many patients have no clinical symptoms, even with a significant spread of the process, while others suffer from severe pain, partial dysmenorrhea and sexual dysfunction. Often accompanied by infertility and dysfunctional bleeding.

The detection of neoplasms in the pelvis and painful nodes of the uterosacral ligament gives serious grounds to suspect endometriosis. Although endometriosis may be suspected at the onset of clinical manifestations, accurate diagnosis biopsy and imaging of the pathology is necessary, preferably by laparoscopy.

Treatment. The choice of treatment includes eliminating the disease with conservative or surgically. Cyclic oral contraceptives and conventional analgesics are often recommended for asymptomatic patients with minimal forms endometriosis. It is considered useful to use the pseudopregnancy state for the use of high-dose oral contraceptives.

Danazol (danocrine) is a weak oral androgen. The recommended dose is 400-800 mg daily for 6 months or longer. In recent years, gonadotropin-releasing hormone agonists have been used to simulate the state of pseudomenopause. Both danazol and gonadotropin-releasing hormone agonists are used in pre- and postoperative therapy in conjunction with surgical treatment.

Conservative surgery involves excision of all visible and accessible endometriosis nodes while preserving the patient's reproductive capabilities. Ovarian endometriosis, known as “chocolate cysts,” is treated with organ-sparing resection. Pregnancy rate after conservative surgery approaches 50%.

If extirpation is indicated, it is important to remove all ovarian tissue to prevent stimulation of residual endometriosis. Total hysterectomy with bilateral salpingo-oophorectomy and hormone replacement therapy for re-treatment if the first operation is ineffective is rarely used.

Ectopic pregnancy

Over the past 20 years, the number of ectopic pregnancies has increased significantly. Due to improved diagnostic methods and treatment approaches, maternal mortality has decreased. For women in the last 10 years of their reproductive period, the risk is more than 3 times higher than for women 16-26 years old. The history contains indications of salpingitis.

Clinically detect pain, often in combination with irregular uterine bleeding, tenderness of the uterine appendages, palpable in 50% of cases, and pain in the pelvis.

For diagnosis, the most important laboratory test is the test for determining the β-subunits of human human chorionic gonadotropin. Ultrasonography of the pelvis with a vaginal probe allows you to accurately differentiate between uterine and ectopic pregnancies. In emergency cases, the level of P-subunits of human chorionic gonadotropin is determined every 24-48 hours. In a normal pregnancy in the early stages, the level of the hormone doubles every two days. A vaginal test makes it possible to clinically determine pregnancy in the uterus or tube when the hormone level increases by more than 1000 times. In women who do not want to continue pregnancy, curettage of the uterus with examination of tissue can be diagnostic. If fetal tissue is absent, diagnostic laparoscopy is indicated.

Laparoscopy. One of the most important methods of diagnosis and surgical treatment, used over the past decades. Partial salpingectomy is now performed laparoscopically. For a significant period of ectopic pregnancy, total salpingectomy or linear salpingotomy is used.

Intra-abdominal operations. The same treatment is optimal for patients whose condition requires laparotomy.

Defects of the pelvic support (bottom)

Defects of the pelvic support (fundus) include uterine prolapse, cysto-, recto- and enteroceles, urethral avulsion, and vaginal prolapse after hysterectomy. This pathology occurs when birth injuries; conditions accompanied by increased intra-abdominal pressure, obesity, decreased estrogen levels, secondary tissue weakness due to hereditary factors or associated with malnutrition.

Uterine prolapse

Uterine prolapse is the descent of its appendages onto the pelvic bones and vagina. If the cervix protrudes at the entrance to the vagina, then this is partial prolapse. If the uterus completely prolapses, then it is total.

Cystocele and rectocele

The condition is caused by a hernial protrusion of the bladder and rectum into the vagina through a wide opening.

Enterocele

Hernial protrusion of intra-abdominal organs into the vaginal vault. Most often occurs after hysterectomy. Enteroceles are often misdiagnosed as rectoceles.

Urethral avulsion

At one time, avulsion of the urethra was called a urethrocele. When the urethra loses its normal support, it protrudes into the vagina. As a rule, there is a combination of urethro- and cystocele.

Stress urinary incontinence

Almost 40% of women over 60 years old have this pathology. Some forms can be corrected surgically, but are often combined with loss of the posterior uterovesical angle. Before surgery, patients should be examined using a cystometrogram.

Benign tumors

OVARIAN TUMORS
Follicular cysts

These are unruptured enlarged Graafian follicles; their rupture, twisting or spontaneous regression is possible.

Corpus luteum cyst

Can be of considerable size (10-11 cm). Rupture of the cyst leads to severe blood loss, and sometimes vascular collapse occurs. Complaints and examination data are similar to the clinical picture of ectopic pregnancy.

Endometrioma

Cystic forms of ovarian endometriosis.

Wolffian duct rudiment

Small single-chamber cysts that do not originate from the ovaries; enlargement and twisting are rarely noted.

Non-functioning tumors

Cystoadenomas

Serous cystadenomas - These are cysts with translucent walls containing clear fluid and simple ciliated epithelium. Adequate treatment represented by salpingo-oophorectomy or oophorectomy only. Mucous cystadenoma is a cystic tumor with viscous jelly-like contents. Malignancy of mucinous tumors is less likely than serous cystadenomas. About 20% of serous and 5% of mucous tumors have bilateral localization.

Some cystomas are classified as borderline tumors, or adenocarcinomas with low malignant potential. The prognosis is usually favorable. For a unilateral process in women of reproductive age, unilateral adnexectomy is used.

In a state known as abdominal pseudomyxoma, the abdominal cavity is filled with viscous mucus. The tumor grows from the mucous cystadenoma of the ovary or mucocele of the appendix. Histologically, benign local spread and infiltration of surrounding organs is determined. Treatment consists of bilateral removal of the ovaries and appendix.

Teratoma

It occurs at any age, but is more common in patients between 20 and 40 years of age. Usually these are benign dermoid cysts, sometimes they have a dense consistency and then become malignant.

In young women, ovarian cystectomy is preferable, if possible preserving the functioning tissue of the affected ovary. Cysts contain ecto-, meso- and endodermal tissues along with fat, which, if disseminated, can cause chemical peritonitis. A biopsy of the other ovary is performed when pathology appears. In approximately 12% of cases the tumor is bilateral.

Brenner's tumor

These are rare fibroepithelial tumors. Epithelial elements are similar to Walthard's rudiments and appear in old age and have little potential for malignancy. Treatment: standard oophorectomy

Meige syndrome

Ascites with hydrothorax, considered in connection with benign ovarian tumors with fibrous elements (usually fibroma), constitute Meige's syndrome. The causes are unknown, but ascites fluid arises from the tumor due to impaired lymphatic drainage from the ovary. Syndrome being treated removal of fibroids.

Functioning tumors

Granulosa thecal cell tumor

Theca cell tumors (thecomas) are benign, but in the presence of granulosa cell elements they can become malignant. Granulosa cell tumors sometimes produce estrogen. Tumors occur at any age (from childhood to postmenopause), but more often in the elderly. Premature puberty or endometrial changes with a hormonally active tumor are combined. If the disease is detected in a woman of reproductive age and is limited to one ovary, then oophorectomy is sufficient. In elderly patients, the uterus and both ovaries are removed.

Sertoli-Leydig cell tumors (archenoblastoma)

A rare but potentially malignant tumor with androgen production and masculinization. Usually occurs in women of reproductive age. In patients young with damage to one ovary, unilateral oophorectomy is indicated. For elderly people with a bilateral process, hysterectomy and bilateral salpingo-oophorectomy are necessary.

Struma ovary

Occurs in the ovary in the presence of thyroid tissue as the predominant element; hyperthyroidism is possible.

Leiomyoma

The most common benign tumor in women, it never appears until menarche, grows during the reproductive period and regresses at menopause. Presents with pain, dysfunctional uterine bleeding, infertility, ureteral obstruction, bladder displacement and pressure symptoms.

Leiomyoma can undergo degenerative changes, including calcification, necrosis, fatty degeneration and rarely sarcoma: Malignancy occurs in less than 1% of cases. For symptoms of invasive growth, myomectomy, total abdominal hysterectomy, or transvaginal hysterectomy is indicated.

Adenomyosis

Adenomyosis is the growth of endometrial tissue in the myometrium, sometimes regarded as endometriosis of the uterine body. Thickening of the myometrium occurs, followed by enlargement of the uterus. Examination reveals dysmenorrhea with increasing uterine bleeding.

Polyps

Polyps are local hyperplastic growths of the endometrium, which usually cause bleeding after menstruation or menopause. Treatment consists of removing polyps.

Cervical lesions

Cervical polyps are often quite small and located with outside. They are removed on an outpatient basis. Naboth cysts are cervical cysts with mucous contents. Usually harmless, asymptomatic and do not require surgical treatment.

Pathology of the vulva

The term " leukoplakia" often used to refer to any white patches on the vulva. Lichen sclerosis and atrophy cause itching, which is not associated with premalignancy. Topical testosterone or steroid therapy reduces itching. Hypertrophic dystrophy can be benign (epithelial hyperplasia) or atypical, in which case dysplastic changes are detected.

Carcinoma in situ of the vulva is clinically and histologically similar to carcinoma in situ of the cervix. The changes are limited to the squamous (squamous) epithelium of the vulva and are sometimes interpreted as Bowen's disease. Paget's disease of the vulva, developing from apocrine glandular elements, is combined with itchy red rashes. Histologically, large foam Paget cells are visible, similar to breast cells. Both Bowen's disease and Paget's disease are components of vulvar carcinoma in situ, and treatment consists of wide excision of local tissue.

Malignant tumors

OVARIAN TUMORS
Ovarian carcinoma

Ovarian cancer is histologically divided into epithelial, germ cell and stromal. Every year, 21,000 cases of epithelial cancer are diagnosed in the United States. Average age The patients are 61 years old; the 5-year survival rate for this diagnosis is 37%.

Approximately 5% of patients with epithelial tumors come from families in which one or more first-generation relatives also had this pathology. In such families, prophylactic oophorectomy may be considered after the end of the childbearing period. However, primary peritoneal carcinomatosis also occurs in women after surgical intervention for prophylactic purposes.

The International Federation of Gynecologists and Obstetricians gives a classification of ovarian cancer presented in table. 39.2. Most women at the time of diagnosis have stage III of the development of the tumor process.

Treatment. Therapy for ecithelial forms of ovarian cancer consists of surgical resection based on the stage of the disease, followed by chemotherapy. Women with low-grade tumors in early stages (IA and IB) can only be treated with surgery. In a limited group of patients with unilateral lesions and histological confirmation of grade 1 or 2 differentiation, fertility can be preserved by adnexectomy and biopsy staging without removal of the uterus or contralateral ovary. In all other patients (stage IA, grade 3 and stage IB and higher), first surgical treatment (bilateral salpingo-oophorectomy, abdominal hysterectomy, staging and tumor resection).

Table 39.2. Stages of ovarian cancer. International Federation of Gynecologists and Obstetricians (1986)

Staging. The stage of the process determines the extent of resection during surgery or biopsy of all tissues for possible tumor growth.

Epithelial ovarian cancer spreads along the peritoneum along lymphatic vessels. Most often, metastases are located in the omentum, para-aortic and pelvic (Lymph nodes. In case of ascites, it is necessary to take fluid for cytological examination. If there is no ascites, peritoneal lavages are performed while maintaining the water-electrolyte balance (injection of saline solutions or Ringer's solution) and lavage of the pelvic cavity , intestinal loops and subdiaphragmatic space.

Patients with histologically confirmed grade 1 or 2 tumors of one or both ovaries (stage IA or IB) do not require postoperative treatment. The 5-year survival rate in this group of patients exceeds 90%.

For grades 1-3 histologically, stage 1C clinically (peritoneal malignancy, tumor rupture, superficial discharge or ascites) or stage II, complete surgical removal of the tumor is possible, followed by a course of chemotherapy, irradiation of the entire abdominal wall or intraperitoneal administration of radioactive phosphorus (32 R). The 5-year survival rate approaches 75%.

Women with stages III and IV of the process require a course of chemotherapy with cisplatin or carboplatin in combination with alkylating drugs or alkaloids such as Taxol. The 5-year survival rate can exceed 20%, and the 10-year survival rate can exceed 10%.

Patients with little or no residual disease after primary surgery have a longer life expectancy on average than patients with non-removable tumor areas. Terms "reduction of tumor mass(decrease in tissue volume) or shield reduction" involve deliberate surgical removal of ovarian cancer, even if the operation is obviously non-radical. When the source of the disease after such resection of the tumor remains in the lymph nodes or plaques measuring less than 1-2 cm in diameter, this is called optimal treatment effect, with larger sizes - suboptimal.

Resection for advanced ovarian cancer. Successful resection of a tumor node 2 cm or less is possible in at least 50% of women with disease progression. Subsequent chemotherapy provides survival that is inversely proportional to the size of the unresected site and the time of the primary operation.

Planned reoperations. Repeated laparotomy. It is quite difficult to determine the recurrence of ovarian cancer during or after treatment. Although CT and MRI examinations detect both small and nodules 2-3 cm in diameter, no technique can detect small nodules. Repeated operations are used as planned for examination purposes. They are valuable in determining the need to continue therapy, timing of reoperation, and prognosis.

Other reoperations. Surgical resection of the tumor after chemotherapy or recurrence is called secondary cytoreduction.
The significance of secondary cytoreduction has not been established. If the patient fully responds to basic platinum combination treatment and the recovery period exceeds two years, reintroducing platinum chemotherapy is very effective. In such patients, surgical removal of the recurrent tumor will be beneficial.

Palliative surgical treatment. In most cases of advanced ovarian cancer, the cause of death is bowel dysfunction or obstruction. When intestinal obstruction occurs after a course of chemotherapy, the prognosis is poor. In patients with such manifestations, survival after surgical treatment is significantly reduced. Often, when treating such pathology, percutaneous or endoscopic positional gastrotomy is considered the best approach, intravenous administration liquids or parenteral.

Laparoscopy for ovarian cancer. Our ability to successfully resect large ovarian tumors using laparoscopic techniques is limited. However, the role of laparoscopy in staging and treatment malignant pathology the ovaries expand. For oophorectomy and removal of pelvic and para-aortic lymph nodes, endoscopic techniques are used.

Tumors with low malignancy potential

These are epithelial tumors with an average possibility of malignancy - between benign pathology and obvious malignancy. Most of them serous type, microscopically differ from invasive cancer by insufficient stromal growth. The average age at diagnosis of this pathology is approximately 10 years younger than that of patients with epithelial cancer. As a rule, stage I is diagnosed. Surgical treatment includes abdominal hysterectomy and bilateral salpingo-oophorectomy if childbearing is not possible; if persists, then unilateral salpingo-oophorectomy.

About 85% of patients with stage III or IV disease have a 5-year survival rate after complete surgical resection. There is little evidence that radiation and chemotherapy given after surgery improve survival.

Germ cell tumors

Tumors occur in women in the first 30 years of life and grow rapidly, manifesting as a distension symptom and a neoplasm in the abdominal cavity. The process is usually unilateral and tends to spread to the para-aortic lymph nodes.

Dysgerminoma is similar to testicular seminoma and consists of undifferentiated germ cells. Bilateral damage is observed in 10% of patients; the disease is rarely combined with an increase in the level of human chorionic gonadotropin or lactate dehydrohexase activity. It is the most common malignant tumor diagnosed during pregnancy

Other germ cell tumors: immature teratoma, endodermal sinus tumor, or tumor yolk sac, mixed tumors, embryonal carcinoma or choriocarcinoma. The first can be combined with an increase in the level of a-fetoprotein. Its increased concentration is detected in patients with endodermal sinus tumors and mixed tumors containing this component. Fetal carcinoma It increases the level of both a-fetoprotein and human chorionic gonadotropin; choriocarcinoma secretes the latter. In addition to complete resection of stage 1-1 underdeveloped teratoma and stage I dysgerminoma, All patients require a course of chemotherapy. Three courses of treatment with platinum and an etoposide-containing combination are sufficient for patients with a completely resected tumor. The recovery rate in this group of patients is close to 90%.

Cervical cancer

Every year in the United States, about 16,000 cases of cervical cancer are registered, and 5,000 patients die. Risk factors: multiple sexual partners, early age first sexual intercourse, early first pregnancy. It is believed that the human papillomavirus identified in cervical dysplasia and carcinoma in situ, as well as all previous factors, can cause invasive cancer with metastasis to the lymph nodes.

A screening program can reduce the incidence of invasive cancer in countries where cervical cytology testing is widely used. The use of this method increases the frequency of detected premalignant intraepithelial diseases, dysplasia and carcinoma in situ.

80% of all cervical cancers are squamous cell (squamous cell, squamous cell) and grow at the border of squamous and columnar epithelium. The remaining malignant tumors of the cervix grow from the endocervical canal and are classified as adenosquamous, or adenosquamous, carcinomas. Other rare histological variants that have a poor prognosis are neuroendocrine small cell carcinoma and pure cell carcinoma. The latter is often combined with maternal intake of diethylstilbestrol.

Staging. The International Federation of Gynecologists and Obstetricians determines the stages of cervical cancer based on clinical examination, intravenous pyelography and chest radiography, which is presented in Table. 39.3. In addition to patients with stage IVA and distant metastatic tumors, in the United States all patients with stage IV continue to receive primary cervical therapy.

Treatment.Intraepithelial or preinvasive diseases. If pathological changes are found during cytological examination of the cervix, patients should undergo colposcopy and biopsy.

Cervical intraepithelial neoplasia is treated in several ways. Significant epithelial damage and a higher level of dysplasia result in a high failure rate. The most favorable treatment method is vaginal or abdominal hysterectomy. Surgery is usually reserved for patients with an advanced process or high-grade epithelial damage. It is performed when the disease relapses after conservative therapy in patients who have other indications for hysterectomy. In most cases of this pathology, a cervical biopsy is indicated.

Table 39.3. International classification of cervical cancer

More conservative treatments for cervical intraepithelial neoplasia include snare wire excision, laser ablation, and cryosurgery.

Microinvasive cervical cancer. The International Federation of Gynecologists and Obstetricians divides microinvasive cancer into “early” invasive cancer (stage IA1) and a tumor that is less than 5 mm in thickness and has a lateral extension of 7 mm (stage IA2). Differences between stages IA2 and IB according to International classification are not adequate, since both require regional therapy from the moment of detection of metastases in the lymph nodes.

Many doctors prefer the original Society of Gynecologic Oncology system, in which a stage IA tumor (microinvasive cancer) can spread more than 3 mm and have incomplete invasion of the capillary or lymphatic space. Stage IB includes all other clinically confirmed cervical cancers. The advantage of this classification is that there is a clear separation of stage I in the two treatment groups. Simple or superficial hysterectomy without lymphadenectomy is sufficient treatment for stage IA. The 5-year survival rate in these patients is close to 100%. In selected cases, cervical cone biopsy or electrosurgical excision may help.

Early invasive cervical cancer (stages IB and ON THE). Tumors of these stages have a risk of developing metastases to the pelvic (10-15%) and periarrheal (5%) lymph nodes. An effective method of treatment in at0t, reri-fi is radical hysterectomy with pelvic lymphadenectomy and subsequent radiation therapy.

Predominantly local cervical carcinoma (stages IIB-IVA). These types of carcinomas are primarily treated with radiation therapy" with Treatment consists of a combination of external therapy of the small pelvis (teletherapy) from a powerful energy source and a local dose delivered to the cervix and parametrium; applications with cesium are used. The recovery rate in the PV and IIIB groups is 65 and 35%, respectively.

Recurrence of ovarian cancer. Local recurrences after previous surgery are being treated more effectively external and internal radiation therapy. Recurrence of distant metastases may get treatment palliatively with local radiation or chemotherapy.

ENDOMETRIAL CANCER

The most common malignant pathology of the female genital organs. In the United States, 33,000 new cases are diagnosed annually, and 4,500 patients die.

Risk factors: obesity, sugar diabetes, hypertension, low parity history, early menarche, late menopause. Excess estrogen is important for the development of endometrial cancer and its precancerous diseases, such as endometrial hyperplasia. Women who have excess estrogen during menopause have a 6-fold increased risk of endometrial cancer if they do not use progesterone-type drugs.

Endometrial hyperplasia is divided into single And complex, with atypia or without her. Atypical complex hyperplasia most likely gives rise to frank adenocarcinoma. The preferred treatment method is hysterectomy. Women with somatic diseases (in this case, surgical treatment is not possible) are treated with progesterone-type drugs, such as megestrol or medroxyprogesterone acetate. Both endometrial hyperplasia and carcinoma are often accompanied by uterine bleeding during postmenopause or menopause.

Treatment. Endometrial cancer by stages, according to the classification of the International Federation of Gynecologists and Obstetricians, is presented in table. 39.4. Stage I of the disease is successfully treated with abdominal hysterectomy and bilateral salpingo-oophorectomy. Radiation therapy may be required, which when used before surgery reduces the risk of recurrence.

Metastases to the pelvic lymph nodes occur in patients in 12% of cases and are limited to the uterus. Risk factors for tumor spread to lymph nodes include significant histological grade of involvement (G2, 03); low level progesterone receptors, deep endocervical invasion, adnexal extension, endocervical extension, and uncommon histological variants such as papillary serous or clear cell carcinoma. In the latter cases with a high probability of spread to the pelvic lymph nodes (histological level 3 lesion, involvement of "/3 layers of the myometrium or uterine serosa, high risk of histological subtypes), the common iliac and para-aortic lymph nodes, especially those lying lateral to the radiation field, should be examined.

An important element in determining the stage of the process is a cytological examination of the abdominal fluid. In approximately 12% of patients, malignant cells are found during examination, which increases the risk of developing intra-abdominal insufficiency (pathology of the abdominal organs). In patients with PV and III stages disease is being considered o radiation therapy pelvis in the preoperative period (if surgical treatment is impossible or difficult).

Radiation becomes the method of choice when there is a high risk surgical intervention, but the results are worse than after surgery. Progressive endometrial cancer or its relapse is sensitive to therapy with progesterone drugs or tamoxifen in 30% of the control group of patients.

VULVA CANCER

Among all cancers of the female genital area, vulvar cancer accounts for 5%.

Risk factors: elderly age, smoking, previous intraepithelial or invasive (squamous or squamous cell) cancer of the cervix or vagina, chronic vulvar dystrophy, immune deficiency. In preinvasive and invasive squamous carcinomas of the vulva, a DNA virus resembling human papillomavirus has been detected and identified. Vulvar squamous carcinoma spreads through the lymphatic system.

In 1988, the International Federation of Gynecologists and Obstetricians identified the stages of vulvar cancer, presented in table. 39.5.

Table 39.4. Stages of uterine cancer. International Federation of Gynecologists and Obstetricians (1988)

Treatment. For most vulvar carcinomas, the preferred treatment is radical vulvectomy and inguinal lymphadenectomy through separate incisions.

Squamous or squamous vulvar cancer less than 2 cm in diameter, no more than 1 mm in thickness and histological grade 1 or 2 is associated with a very small risk of developing metastases to the inguinal lymph nodes; deep and wide excision is sufficient for adequate treatment. In such cases, inguinal lymphadenectomy may not be performed.

IN last years locally progressive pathology of the vulva is also successful being treated external focused irradiation combined with radiosensitive drugs such as cisplatin and 5-fluorouracil. At the end of the combination therapy, the affected surface is widely excised.

Rare vulvar tumors

Medanoma. Lesions less than 1 mm thick or Clark II can be treated conservatively with wide local excision. The effectiveness of inguinofemoral lymphadenectomy remains controversial.

Intraepithelial diseases. These include Bowen's disease, papulosis, vulvar intraepithelial neoplasia, and carcinoma in situ, which can be successfully treated by wide excision of the affected epithelium. In cases of diffuse intraepithelial disease, a so-called cutaneous vulvectomy and skin thickness dissection may be required. Carbon dioxide laser and electrosurgical loop are effective.

Paget's disease is an uncommon epithelial or invasive process characterized by the presence of distinct Paget's cells in the affected epithelium.

Treatment This type of lesion consists of wide excision. IN in rare cases Paget's disease is combined with underlying invasive adenocarcinoma, then radical vulvectomy and revision of the groin area are indicated.

Bartholin's gland carcinoma accounts for less than 1% of all cases of vulvar malignancy and is treated in the same way as squamous adenocarcinoma.

Gynecological surgeries

Scraping

Cervical dilatation and uterine curettage was one of the most common surgical procedures performed in the United States because it provided a diagnosis for dysfunctional bleeding. Manipulation is necessary to stop profuse uterine bleeding. Indicated for the removal of endometrial polyps or treatment at the end of pregnancy, as well as for the removal of placental tissue after abortion or childbirth. The main complication of curettage is uterine perforation, which is diagnosed by the absence of resistance during stretching or by curettage at the point where perforation can be expected. Tactics treatment is of a wait-and-see nature. In recent years, aspiration curettage has become popular for incomplete abortion, chorionic adenoma and therapeutic abortion.

Endoscopic surgery

For many years, endoscopic techniques have been used to perform tubal sterilization and tubal restoration. Currently, the technique is used in the treatment of endometriosis, ectopic pregnancy, uterine fibroids, and pelvic pain.

Laparoscopy is absolutely contraindicated in cases of intestinal obstruction, severe ileus, very large abdominal tumors, diaphragmatic hernia and severe cardiopulmonary disease. Relative contraindications: massive obesity, severe intestinal diseases and multiple previous abdominal surgeries in history.