Treatment of precancerous diseases of the female genital organs. Clinical tactics for managing patients with various forms of background and precancerous diseases of the cervix

Vaginal leukoplakia

Dystrophic changes in the vaginal mucosa, developing against the background of mild chronic inflammation, helminthic infestation, diabetes, and hormonal disorders.

The disease manifests itself in the form of slightly raised plaques or white spots of varying sizes in the area of the labia, clitoris or perineum.

Kraurosis of the vulva

The disease develops against the background of mild chronic inflammation, helminthic infestation, diabetes, and hormonal disorders. There is wrinkling and atrophy of the external genital organs, thinning of their mucous membrane, which takes on the appearance of parchment paper, narrowing of the entrance to the vagina, and atrophy of the hair follicles.

Vaginal papillomas

Papillary growths in the vaginal area, non-bleeding, soft. Sometimes multiple growths may appear. The cause of the disease is chronic inflammatory processes of the female genital organs, panillomovirus.

Cervical diseases

Predisposing factors for the development of precancerous diseases and cervical cancer are early onset of sexual activity (15-18 years); sexual activity with multiple sexual partners, extramarital contacts; first pregnancy and childbirth before age 20 or after age 28; a large number of abortions (5 or more, especially out-of-hospital); chronic inflammation of the vagina and cervix (especially chronic trichomoniasis).

A special risk group consists of women with pathological processes in the cervix:

Cervical erosion

Sharply defined, devoid of epithelium, bleeding surface. Manifests itself in the form of profuse leucorrhoea, contact bleeding during and after sexual intercourse.

Cervical polyp

It is characterized by the presence of an outgrowth of the mucous membrane of the canal or the vaginal part of the cervix. Patients with cervical polyps, as a rule, complain of leucorrhoea, bloody discharge from the genital tract, and pain in the lower abdomen. Cervical polyps are precancerous conditions.

However, removal of a polyp is not a radical cure, since it is known that the focus of tumor growth can arise from externally unchanged areas of the mucous membrane of the cervix, which indicates the appearance in all its areas of common prerequisites for the occurrence of both polyps and malignant tumors. Complicating the situation and increasing the risk of tumor degeneration of polyps is concomitant chronic inflammation of the cervix.

Leukoplakia of the cervix

A spot or large area of whitish color. Patients complain of copious or scanty white discharge.

Diseases of the uterine body

Women with early (before 12 years) or late (after 16 years) puberty have a certain predisposition to the occurrence of precancerous diseases and uterine cancer; early (before 40 years) or late (after 50 years) menopause; women who are not sexually active, have not become pregnant, have not given birth, and often suffer from inflammatory diseases of the genital area.

It is necessary to take into account heredity, since it has been established that a predisposition to ovulation disorders, obesity, diabetes mellitus and uterine cancer can be inherited.

Predisposing factors include, first of all, ovulation disorders, which cause primary or secondary infertility and are accompanied by the development of endometrial hyperplastic processes.

Polycystic ovary syndrome (Stein-Leventhal syndrome)

This disease is characterized by a long-term high concentration of estrogen in the blood, often leading to the development of hyperplastic processes in the uterus and sometimes to the development of endometrial cancer.

Recurrent glandular endometrial hyperplasia

A typical precancerous disease, which manifests itself as irregularities in the menstrual cycle with very heavy periods. Sometimes uterine bleeding or spotting occurs during the intermenstrual period or during menopause.

Endometrial polyps

The disease is manifested by long and heavy menstruation, frequent premenstrual bleeding from the genital tract. The causative factors for the occurrence of a pathological process in the endometrium are various kinds of stress, hormonal disorders, chronic inflammatory diseases of the female genital area, and hereditary burden of tumor diseases.

Malignant degeneration of polyps is observed against the background of concomitant metabolic disorders, obesity and diabetes. Removal of a polyp is not a radical method of cure, since it is known that the focus of tumor growth can arise from externally unchanged areas of the endometrium, which indicates the appearance in all its areas of the same prerequisites, both for the occurrence of polyps and malignant endometrial tumors.

Uterine fibroids

A benign tumor of the uterus, consisting of muscle and connective tissue elements. In the conditions of modern stressful life, accompanied by excessive stress and toxic environmental influences, the frequency of this disease in women has increased sharply.

The causes of the disease are frequent abortions, pathology of the cardiovascular system, liver disease, and hormonal disorders. Oncological alertness is caused by growing fibroids with an increase in myomatous nodes during menopause and menopause.

Obesity and diabetes mellitus are common precursors to uterine cancer. Therefore, identifying and treating not only overt, but also latent diabetes mellitus in women with any of the listed diseases is an important preventive anti-cancer measure.

Ovarian diseases

It is well known that there is a high incidence of malignant and borderline ovarian tumors in women who have previously undergone surgery for benign tumors and tumor-like formations of the ovaries, or after removal of one of the ovaries, when the risk of developing a tumor in the remaining ovary increases. The incidence of malignant ovarian tumors in women who have previously undergone surgery for various gynecological and breast diseases increases sharply.

Various long-term changes and irregularities in the menstrual cycle are conditions that precede malignant changes in the ovaries.

An increased risk group includes women who have previously taken hormones for a long time to suppress the estrogenic function of the ovaries.

To date, the most difficult distinction remains between ovarian tumors and inflammatory processes of the uterine appendages. According to various clinics, 3-19% of patients with malignant ovarian tumors are under observation with an erroneous diagnosis of “chronic inflammation of the uterine appendages,” and in 36% of cases, chronic inflammatory processes in the appendages are diseases associated with ovarian tumors. In addition, in some cases, these inflammatory processes play the role of a cause that provokes malignant transformations in benign ovarian tumors.

Benign tumors and tumor-like formations of the ovaries are represented by a large number of different forms. Patients' complaints and symptoms of the disease depend on the size and location of the tumor. Most often, patients complain of changes or disturbances in the menstrual cycle, pain in the lower abdomen, less often in the lower back and rectum, which is often the reason for erroneous treatment “for radiculitis” or “for hemorrhoids”. Large tumors are manifested by the presence of palpable formations of the appendages, pain, and abdominal enlargement. It must be remembered that any benign ovarian tumor can undergo transition to malignant.

A great danger in terms of the occurrence of malignant ovarian tumors is fraught with long-term passive observation of patients for low-symptomatic or asymptomatic uterine fibroids.

Concluding the description of precancerous diseases, it is necessary to note once again that the nature of these diseases does not lie in a local pathological change in any particular area of tissue or organ. The reason for the appearance of precancerous conditions is always hidden more deeply and goes beyond the scope of the individual damaged organ.

Pathological formations in organs or tissues can be compared to the tip of an iceberg, when the bulk of painful changes remain hidden, but the most significant. For this reason, surgical treatment, which eliminates only the visible manifestations of the pathological process, is at least incomplete.

At the same time, precancerous changes in organs and tissues do not necessarily turn into cancer; they are completely reversible with the possibility of partial or complete restoration of the functions of all damaged organs. This is achieved by an integrated approach to the emerging disease with the involvement in treatment of all organs and systems involved in the pathological process, without dividing a single disease with various organ manifestations into separate parts, which, unfortunately, happens with traditional treatment by medical specialists.

It must be remembered that the main factors contributing to the further progression of precancerous changes in tissues include: maintaining a state of chronic inflammation in the altered organs or the pathological focus itself; chronic intoxication due to latent or chronic foci of infections, as well as chronic household or professional toxic exposures; long-term disturbances in the functioning of the endocrine glands with hormonal imbalance and changes in metabolism; chronic stress, depleting the nervous and immune systems.

It becomes clear that treating a precancerous disease is not an easy task, but with a correct assessment of all the changes present in the patient, it is completely solvable. At the same time, the conscious participation and medical discipline of the patient himself is a necessary condition, since any, even the most effective prescriptions and useful advice from a doctor, cannot by themselves cure the patient. His active participation is necessary. When treating a precancerous disease, taking into account its possibility of transition or, conversely, not transitioning into cancer, the patient’s intelligence often becomes a more important factor than his immunity.

Precancerous diseases can be facultative or obligate. Obligate precancer is an early oncological pathology, which over time tends to develop into cancer. In contrast, facultative precancerous diseases do not always develop into cancer, but require very careful monitoring. Moreover, the longer the treatment of an optional precancerous condition is delayed, the higher the likelihood of developing a malignant tumor. Find out in the article which ailments are classified as precancerous conditions.

Precancerous diseases: types and causes of development

The presence of a precancerous background does not at all indicate that it will absolutely turn into cancer. Thus, precancerous diseases turn into malignant ones only in 0.1–5% of cases. Diseases that fall under the category of precancerous include almost all chronic inflammatory processes.

precancerous diseases of the gastrointestinal tract;
precancerous skin diseases;
precancerous diseases of the genital organs in women.

Precancerous diseases of the gastrointestinal tract

The probable cause of cancer development is chronic gastritis, especially its anacid form. Atrophic gastritis poses a great danger; in this case, the incidence of cancer is 13%.

Menetrier's disease (tumor-stimulating gastritis) is also a precancerous disease - this disease is the cause of stomach cancer in 8-40% of cases.

The likelihood of a gastric ulcer becoming malignant depends on its size and location. The risk increases if the ulcer diameter exceeds 2 cm.

Pre-tumor pathology of the stomach includes gastric polyps, especially the group of adenomatous diseases more than 2 cm - here the possibility of transition to a malignant state is 75%.

Diffuse polyposis is an obligate precancer - in almost 100% of cases this precancerous disease develops into cancer. This disease is transmitted genetically and degeneration into a malignant state occurs at a young age.

Crohn's disease and ulcerative colitis are facultative precancers and are subject to conservative treatment.

Precancerous skin diseases

The following can degenerate into malignant tumors:

nevi;
chronic radiation damage to the skin;
late radiation dermatitis;
actinic keratoses;
senile keratoses and atrophies;
trophic ulcers, chronic ulcerative and vegetative pyoderma, which exist for a long time;
ulcerative and wart form of lichen planus;
cicatricial changes in the skin in areas of erythematous and tuberculous lupus
bordered precancerous hyperkeratosis of the red border of the lips, keloids.

Precancerous Dubreuil's melanosis, pigmented actinic keratoses, and epidermal-dermal border nevus have a high tendency to become malignant.

In 5-6% of cases, carcinomas develop from scars resulting from burns. Benign epithelial tumors that tend to become malignant are cutaneous horn (12-20% of cases) and keratoacanthoma (17.5%).

Although the likelihood that warts and papillomas will develop into malignant changes is quite low, there are still a number of cases where cancer develops from them.

Precancerous diseases of the female genital organs

The cervix is most often affected, followed by the ovaries in second place, followed by the vagina and external genitalia. At the same time, cervical polyps rarely degenerate into cancer, as they are accompanied by bloody discharge, which is why they are quickly diagnosed and promptly removed.

Erosion can be present in a woman for months or even years and not manifest itself in any way. If cervical erosion exists for a long time and is not treated, it can cause the development of a tumor. The main cause of cervical and uterine cancer is the human papilloma virus.

Ovarian cysts in the early stages in women are asymptomatic and can only be detected during a gynecological examination. Any recognized cyst must be removed.

Vaginal cancer develops due to leukoplakia. In women who neglect hygiene, leukoplakias turn into ulcers, which in the future can become the basis for the development of cancer. In advanced stages, treatment is difficult, especially if you refuse regular medical examination. It should be borne in mind that vaginal cancer is more dangerous than cervical cancer, therefore all chronic diseases of the vagina must be treated in a hospital setting.

Cancer is often the cause of a negligent attitude towards one’s health, and in many cases it is possible to prevent its development through regular examinations with doctors. To prevent such an outcome, you should be especially attentive to any deterioration in your health and visit specialists in a timely manner.

Practical gynecology

Guide for doctors

Medical news agency

UDC 618.1 BBK 57.1 L65

Reviewers:

G.K Stepankovskaya, Corresponding Member of the National Academy of Sciences and the Academy of Medical Sciences of Ukraine, Doctor of Medical Sciences, Professor, Department of Obstetrics and Gynecology No. 1 of the National Medical University. AA. Bogomolets;

AND I. Senchuk, Doctor of Medical Sciences, Professor, Head. Department of Obstetrics and Gynecology of the Medical Institute of the Ukrainian Association of Traditional Medicine;

B. F. Mazorchuk, Doctor of Medical Sciences, Professor, Head. Department of Obstetrics and Gynecology No. 1 Vinnitsa National Medical University named after. M.I. Pirogov.

Likhachev VC.

L65 Practical gynecology: A guide for doctors / V.K. Likha-

chev. - M.: Medical Information Agency LLC, 2007. - 664 p.: ill.

ISBN 5-89481-526-6

The practical guide provides modern ideas about the etiology and pathogenesis of the most common gynecological diseases, algorithms for their diagnosis and treatment, based on the principles of evidence-based medicine. The issues of inflammatory diseases of the female genital organs with characteristics of sexually transmitted infections are presented in detail; the problem of infertility and the use of modern reproductive technologies; all aspects of menstrual cycle disorders, menopause and postmenopause; background conditions, precancerous diseases and tumors of the female genital area; problems of endometriosis and trophoblastic disease; family planning methods; clinic, diagnosis and treatment tactics in cases of “acute abdomen”. The appendices provide information about modern pharmacological drugs, methods of herbal medicine, gynecological massage and therapeutic exercises.

For practicing doctors - obstetricians-gynecologists, family doctors, senior students, interns.

UDC 618.1 BBK 57.1

ISBN 5-89481-526-6 © Likhachev V.K., 2007

List of abbreviations................................................... .......................................... 12

Chapter 1. Methods of examination of gynecological patients.......................... 16

1.1. Anamnesis................................................. ........................................ 17

1.2. Objective examination......................................................... ..... 17

1.3. Special laboratory research methods........ 22

1.3.1. Cytological diagnosis.................................................... 22

1.3.2. Tests for functional diagnostics of ovarian activity 22

1.3.3. Hormonal studies................................................... 25

1.3.4. Genetic studies......................................................... 27

1.4. Instrumental research methods......................... 30

1.4.1. Probing the uterus................................................... ....... thirty

1.4.2. Diagnostic fractional curettage of the cervical canal and uterine cavity 30

1.4.3. Abdominal puncture through the posterior

vaginal vault......................................................... ................ 31

1.4.4. Aspiration biopsy......................................................... 31

1.4.5. Endoscopic research methods................................... 32

1.4.6. Ultrasound examination.................................................... 35

1.4.7. X-ray research methods......................... 37

1.5. Peculiarities of examination of girls and adolescents........... 39

Chapter 2. Inflammatory diseases of the female genital organs............... 43

2.1. Mechanisms of development of inflammatory diseases

female genital organs........................................................ ........ 43

2.1.1. Factors in the occurrence of inflammatory diseases of the female genital organs 43

2.1.2. Mechanisms of biological protection of the female reproductive system from infection 44

2.1.3. Conditions that violate the barrier mechanisms of protection of the female reproductive system 45

2.1.4. The main links in the pathogenesis of inflammatory diseases of the female reproductive system 46

2.2. Characteristics of infections transmitted

sexually ........................................................... ........................... 48

2.2.1. Trichomoniasis................................................... .................... 48

2.2.2. Gonorrhea................................................. ............................ 50

2.2.3. Urogenital candidiasis.................................................... 54

2.2.4. Chlamydia......................................................... ....................... 56

2.2.5. Mycoplasmosis and ureaplasmosis.................................................... 60

2.2.6. Bacterial vaginosis................................................... 63

2.2.7.Infections caused by the herpesvirus family 66

2.2.8. Human papillomavirus infection................................... 73

2.3. Clinic, diagnosis and treatment of individual forms
inflammatory diseases

female genital organs........................................................ ...... 76

2.3.1. Vulvitis........................................................ ........................... 76

2.3.2. Bartholinitis........................................................ .................... 80

2.3.3. Colpitis......................................................... ............................ 83

2.3.4. Cervicitis......................................................... ........................... 95

2.3.5. Endometritis......................................................... .................... 98

2.3.6. Salpingo-oophoritis......................................................... ......... 102

2.3.7. Parametritis................................................. .................... 118

2.3.8. Pelvioperitonitis......................................................... ........ 119

Chapter 3. Menstrual irregularities.................................................. 123

3.1. Neurohumoral regulation of reproductive

functions of a woman................................................... ................... 123

3.1.1. Physiology of the female reproductive system.. 123

3.1.2. Neurohumoral regulation

menstrual cycle................................................... .. 135

3.1.3. The role of prostaglandins in the regulation of the female reproductive system 136

3.1.4. Anatomical and physiological features of the functioning of the female genital organs

at different age periods................................... 137

3.2. Hypomenstrual syndrome and amenorrhea............................................ 141

3.2.1. General principles of examination and treatment of patients

with hypomenstrual syndrome and amenorrhea.... 145

3.2.2. General principles of patient treatment

with hypomenstrual syndrome and amenorrhea.... 146

3.2.3. Features of clinical manifestations, diagnosis and treatment of primary amenorrhea 151

3.2.4. Features of clinical manifestations, diagnosis and treatment of secondary amenorrhea 160

3.3. Dysfunctional uterine bleeding................................ 173

3.3.1. Clinical and pathophysiological characteristics of dysfunctional uterine bleeding 175

3.3.2. General principles of examination of patients with DUB. 178

3.3.3. General principles of treatment of patients with DUB.............................. 179

3.3.4. Features of DMK in different age periods.... 181

3.4. Algodismenorrhea......................................................... .................... 194

Chapter 4. Menopause and postmenopause.......................................................... 199

4.1. Physiology and pathophysiology of perimenopausal

and postmenopausal periods.................................................... 202

4.2. Pathology of the peri- and postmenopausal periods...... 206

4.2.1. Psychoemotional and neurovegetative disorders 207

4.2.2. Urogenital disorders and trophic changes in the skin 211

4.2.3. Cardiovascular disorders

and osteoporosis................................................... .................... 213

4.3. Diagnosis of menopausal syndrome.................................... 217

4.4. Drug therapy for peri-

and postmenopausal periods.................................................... 221

4.4.1. Hormone replacement therapy................................... 224

4.4.2. Selective estrogen receptor

modulators........................................................ .................... 231

4.4.3. Tissue-selective regulator of estrogenic activity - STEAR 232

4.4.4. Phytoestrogens and phytohormones.................................... 233

4.4.5. Androgens........................................................ ....................... 234

4.4.6. Systemic and local HRT for urogenital disorders 234

4.4.7. Prevention and treatment of osteoporosis...................... 235

4.5. Physiotherapy of peri-pathology

and postmenopausal periods.................................................... 238

4.6. Herbal medicine for pathology of peri-

and postmenopausal periods.................................................... 240

Chapter 5. Polycystic ovaries................................................................... 243

5.1. Characteristics of various forms

polycystic ovaries................................................................ ....... 243

5.1.1. Polycystic ovary disease.................................... 243

5.1.2. Polycystic ovary syndrome.................................... 245

5.2. Diagnosis of PCOS................................................... .................... 248

5.3 Treatment of PCOS.................................................... ........................... 252

5.3.1. Conservative methods of treatment................................... 252

5.3.2. Surgical methods of treatment................................... 256

5.3.3. Physiotherapy................................................. ................. 258

Chapter 6. Infertility............................................................................................. 260

6.1. Features of clinical manifestations,

diagnosis and treatment of various forms of infertility............ 262

6.1.1. Endocrine infertility................................................... 262

6.1.2. Tubal and tubo-peritoneal infertility..... 276

6.1.3. Uterine and cervical forms of infertility.................................. 282

6.1.4. Immunological infertility................................................... 283

6.1.5. Psychogenic infertility................................................... 285

6.2. Algorithm for diagnosing infertility.................................................... 285

6.3. Algorithm for the treatment of various forms of infertility................................. 287

6.4. Modern reproductive technologies................................... 290

6.4.1. In vitro fertilization.................................... 291

6.4.2. Other reproductive technologies........................ 294

6.4.3. Ovarian hyperstimulation syndrome.................................... 296

Chapter 7. Background and precancerous diseases of women

genitals................................................................................. 300

7.1. Background and precancerous diseases of the cervix

uterus........................................................ ........................................... 300

7.1.1. Etiopathogenesis of cervical diseases................................. 301

7.1.2. Classification of cervical diseases.............. 303

7.1.3. Clinic of cervical diseases.................................... 305

7.1.4. Diagnosis of background and precancerous diseases of the cervix 316

7.1.5. Treatment of background and precancerous

diseases of the cervix......................................................... 321

7.1.6. Clinical tactics of patient management

with various forms of background and precancerous
diseases of the cervix......................................................... 328

7.2. Hyperplastic processes of the endometrium (HPE).......... 331

7.2.1. Etiopathogenesis of HPE................................................................. ....... 331

7.2.2. Classification of GGE................................................... ...... 333

7.2.3. GPE Clinic......................................................... ................... 339

7.2.4. Diagnosis of GPE................................................... .......... 340

7.2.5. Treatment of GPE................................................... .................... 344

7.3. Hyperplastic and dysplastic processes
mammary gland (mastopathy)................................................... 359

Chapter 8. Benign tumors of the uterus and ovaries............................ 375

8.1. Uterine fibroids (UF)................................................... .......... 375

8.1.1. Etiology and pathogenesis of FM.................................................... 375

8.1.2. Classification of FM................................................... ....... 379

8.1.3. FM Clinic........................................................ .................... 381

8.1.4. Diagnostics of FM................................................... ............ 386

8.1.5. Treatment of FM.......................................................... .................... 391

8.2. Benign ovarian tumors................................... 399

8.2.1. Epithelial benign

ovarian tumors........................................................ .......... 404

8.2.2. Sex cord stromal tumors (hormonally active) 409

8.2.3. Germ cell tumors........................................................ 411

8.2.4. Secondary (metastatic) tumors................................. 414

8.2.5. Tumor-like processes................................................... 415

Chapter 9. Endometriosis......................................................................................... 418

9.1. Etiopathogenesis of endometriosis.................................................... 418

9.2. Morphological characteristics

endometriosis........................................................ ........................... 422

9.3. Classification of endometriosis................................................... 422

9.4. Clinic of genital endometriosis.................................... 425

9.5. Diagnosis of endometriosis................................................... ... 431

9.6. Treatment of endometriosis................................................... ............ 438

9.6.1. Conservative treatment............................................. 438

9.6.2. Surgery................................................ 445

9.6.3. Combination treatment......................................................... 447

9.6.4. Algorithms for the management of patients with various forms of endometriosis 449

9.7. Prevention of endometriosis................................................... 452

Chapter 10. Emergency conditions in gynecology........................................... 453

10.1 Acute bleeding from the internal genitalia

organs........................................................ ................................... 454

10.1.1. Ectopic pregnancy......................................... 454

10.1.2. Ovarian apoplexy................................................... 469

10.2. Acute circulatory disorders in tumors
and tumor-like formations of internal

genital organs........................................................ ............... 472

10.2.1. Torsion of the pedicle of the ovarian tumor.................................... 472

10.2.2. Eating disorder

fibromatous node......................................................... 474

10.3. Acute purulent diseases of internal

genital organs........................................................ .................... 476

10.3.1. Pyosalpinx and piovar, tubo-ovarian purulent tumor 476

10.3.2. Pelvioperitonitis......................................................... .. 486

10.3.3. Generalized peritonitis................................... 486

Chapter 11. Anomalies in the position of the internal genital organs................... 490

11.1. Anatomical and physiological features

position of the internal genital organs......................... 490

11.2. Anomalies in the position of the internal genitalia

organs........................................................ ................................... 491

11.3. Descent and prolapse of internal

genital organs........................................................ ............... 495

Chapter 12. Modern methods of contraception............................................. 504

12.1. Methods of natural family planning................... 505

12.2. Barrier methods of contraception.................................................... 509

12.3. Spermicides........................................................ ........................... 512

12.4. Hormonal contraception................................................... 513

12.4.1.Principles of prescribing oral hormonal contraceptives 514

12.4.2. Combined oral contraceptives. 519

12.4.3. “Pure” gestagens.................................................... ......... 525

12.4.4. Injectable contraceptives................................... 527

12.4.5. Implantation methods................................... 530

12.5. Intrauterine contraceptives.................................................... 530

12.6. Voluntary surgical contraception (sterilization) 533

12.7. Emergency contraception................................................................. 536

12.8. Principles for choosing a contraceptive method.................................... 538

Chapter 13. Gestational trophoblastic disease.................................... 543

13.1. Etiopathogenesis of gestational trophoblastic disease 544

13.2. Nosological forms of gestational trophoblastic disease 546

13.2.1. Bubble skid................................................... ....... 546

13.2.2. Chorionepithelioma (chorionic carcinoma)........... 553

13.2.3. Other forms of trophoblastic

illnesses........................................................ ........................... 560

13.3.................................................. ........................................................ Prevention of relapses of gestational
trophoblastic disease................................................... 561

Annex 1. Antibacterial agents................................................... ... 562

1.1. Classification and brief description

antibacterial drugs.................................................. 562

1.2. Antimicrobial agents effective against certain microorganisms 572

1.3. Doses and methods of administration of some antibiotics. 578

1.4. Combination of antimicrobial drugs........................ 583

1.5. Use of antibacterial drugs

during pregnancy and lactation................................... 584

Appendix 2. Direct acting antivirals.................................... 589

Appendix 3. Immunoactive agents......................................................... ........ 592

Appendix 4. Herbal medicine in complex treatment

gynecological diseases......................................................... ... 598

4.1. Menstrual irregularities.................................................... 598

4.2. Pathological menopause.................................... 606

4.3. Inflammatory diseases of female genitalia

organs........................................................ ..................................... 608

4.4. Fees that improve blood circulation in the small
pelvis and having antiseptic

and desensitizing properties................................... 613

4.5. Kraurosis of the vulva................................................... ........................ 615

Appendix 5. Gynecological massage................................................... ........ 616

5.1. Mechanism of action of GM......................................................... .......... 616

5.2. Indications, contraindications and conditions

GM. General GM methodology................................................... ........ 618

5.3. Features of GM technical methods depending on

from readings........................................................ ............................... 624

Appendix 6. Therapeutic gymnastics for gynecological

diseases........................................................ ................................... 637

6.1. Therapeutic gymnastics for unfixed retroflexion of the uterus 637

6.2. Therapeutic gymnastics for prolapse of the genital organs. 640

6.3. Therapeutic exercises for chronic inflammatory diseases of the female genital organs 641

6.4. Therapeutic exercises for dysmenorrhea.................................... 644

6.5. Therapeutic exercises for functional urinary incontinence 645

6.6. Therapeutic exercises in the preoperative period.... 646

6.7. Therapeutic exercises for pathological menopause........648

Appendix 7. Normal vaginal microflora.................................................... 650

Literature................................................. ........................................................ .... 655

Precancerous diseases are diseases that may give rise to malignant neoplasms. Precancerous diseases of the external genitalia include leukoplakia and kaurosis.

Leukoplakia– a dystrophic disease, which results in a change in the mucous membrane, accompanied by keratinization of the epithelium.
It is characterized by the appearance in the area of the external genitalia of dry white plaques of varying sizes, which are areas of increased keratinization followed by sclerosis and tissue wrinkling. In addition to the external genitalia, leukoplakia can be localized in the vagina and on the vaginal part of the cervix.

Kaurosis of the vulva– a disease characterized by atrophy of the mucous membrane of the vagina, labia minora and clitoris. It is a process of atrophy and sclerosis. As a result of atrophy and sclerosis, the skin and mucous membrane of the external genitalia shrink, the entrance to the vagina narrows narrowly, and the skin becomes dry and easily wounded. The disease is accompanied by persistent itching in the external genital area.

Background diseases of the cervix include:

Pseudo-erosion
True erosion
Ectropion
Polyp
Leukoplakia
Erythroplakia

Pseudo-erosion is the most common underlying disease of the cervix.
Objectively, a bright red, easily traumatic granular or velvety surface is detected around the pharynx. Pseudo-erosion has a characteristic colposcopic picture. There are congenital pseudo-erosion, which occurs during puberty with an increase in the production of sex hormones, and acquired pseudo-erosion, caused by inflammation or trauma of the cervix. Healing of pseudo-erosion occurs due to the overlap of the cylindrical epithelium with stratified squamous epithelium.

Along with pseudo-erosion, it sometimes occurs true erosion, which is a defect in the stratified squamous epithelium of the vaginal part of the cervix, occurs in diseases of the genital organs.

Cervical polyp is a focal overgrowth of the mucous membrane with or without underlying stroma. When examining the cervix, a soft, pinkish mass is found hanging from the cervical canal into the vagina. Muco-bloody discharge is characteristic.

Erythroplakia The cervix is an area of thinned epithelium, through which the underlying red tissue is visible.

Cervical dysplasia– morphological changes in the multilayered squamous epithelium of the vaginal part of the cervix, which are characterized by intense proliferation of atypical cells.

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Precancerous diseases include diseases characterized by a long-term (chronic) course of the degenerative process, and benign neoplasms that tend to malignize. Morphological precancerous processes include focal proliferation (without invasion), atypical epithelial growths, and cell atypia. Not every precancerous process necessarily turns into cancer. Precancerous diseases can exist for a very long time, and the cells do not undergo cancerous degeneration. In other cases, such a transformation occurs relatively quickly. Against the background of some diseases, for example papillary cysts, cancer occurs relatively often, against the background of others (kraurosis and vulvar leukoplakia) - much less often. The identification of precancerous diseases is also justified from the point of view that timely and radical treatment of these forms of diseases is the most effective prevention of cancer. Depending on the location of the pathological process, it is customary to distinguish between precancerous diseases of the external genital organs, cervix, uterine body and ovaries.

Precancerous diseases of the female genital organs. These include hyperkeratoses (leukoplakia and kraurosis) and limited pigmented formations with a tendency to growth and ulceration.

Leukoplakia of the vulva usually occurs during menopause or menopause. The occurrence of this pathology is associated with neuroendocrine disorders. The disease is characterized by the appearance of dry white plaques of varying sizes on the skin of the external genitalia, which can spread significantly. Phenomena of increased keratinization (hyperkeratosis and parakeratosis) are observed, followed by the development of a sclerotic process and tissue wrinkling. The main clinical symptom of leukoplakia is persistent skin itching in the external genital area. Itching is caused by scratching, abrasions and small wounds. The skin of the external genitalia is dry.

To treat this disease, ointments or globules containing estrogen drugs are used. In case of pronounced changes and severe itching, it is permissible to use small doses of estrogen orally or by injection. Along with the use of estrogens, diet (light plant foods, reduced consumption of table salt and spices) is of great importance. Hydrotherapy (warm sitz baths before bedtime) and medications that affect the central nervous system have a calming effect.

Kraurosis of the vulva is a dystrophic process that leads to wrinkling of the skin of the external genitalia, the disappearance of fatty tissue of the labia majora, subsequent atrophy of the skin, sebaceous and sweat glands. Due to the wrinkling of the tissues of the vulva, the entrance to the vagina sharply narrows, the skin becomes very dry and easily wounded. The disease is usually accompanied by itching, which leads to scratching and secondary inflammatory tissue changes. Kraurosis is observed more often during menopause or menopause, but sometimes occurs at a young age. With kraurosis, the death of elastic fibers, hyalinization of connective tissue, sclerosis of the connective tissue papillae of the skin with thinning of the epithelium covering them, and changes in nerve endings occur.

The ethnology of vulvar kraurosis has not been sufficiently studied. It is assumed that the occurrence of kraurosis is associated with a violation of tissue chemistry, the release of histamine and histamine-like substances. As a result of the effect of these substances on nerve receptors, itching and pain appear. Of great importance is dysfunction of the ovaries and adrenal cortex, as well as changes in the metabolism of vitamins (especially vitamin A). There is a neurotrophic theory of the occurrence of vulvar kraurosis.

For treatment, it is recommended to use estrogen hormones in combination with vitamin A. Some menopausal patients experience good results when using estrogens and androgens. To normalize the trophic function of the nervous system, a novocaine solution is injected into the subcutaneous tissue of the vulva using the tight creeping infiltrate method, a presacral novocaine blockade is performed, and the vulva is denervated by dissecting the pudendal nerve. In especially severe cases of the disease, if all described methods of therapy are unsuccessful, they resort to extirpation of the vulva. As a symptomatic remedy to reduce itching, you can use 0.5% prednisolone ointment or ointment with anesthesin. If areas suspicious for cancer are detected, a biopsy is indicated.

PRE-CANCER DISEASES OF THE CERVIX. Dyskeratoses are characterized by a more or less pronounced process of proliferation of stratified squamous epithelium, compaction and keratinization (keratinization) of the surface layers of the epithelium. In relation to malignancy, leukoplakia with a pronounced proliferation process and beginning cell atypia are dangerous. With leukoplakia, the mucous membrane is usually thickened, separate whitish areas are formed on its surface, which sometimes, without clear boundaries, pass into the unchanged mucous membrane. Leukoplakia sometimes looks like whitish plaques protruding on the surface of the mucous membrane. These areas and plaques are tightly fused to the underlying tissues. Leukoplakia of the cervix is very often asymptomatic and is discovered accidentally during a routine examination. In some women, the disease may be accompanied by increased secretion (leucorrhoea). In cases of infection, the discharge from the genital tract becomes purulent in nature.

Erythroplakia is characterized by atrophy of the superficial layers of the epithelium of the vaginal part of the cervix. The affected areas usually have a dark red color due to the fact that the vascular network located in the subepithelial layer is visible through the thinned (atrophied) layers of the epithelium. These changes can be observed especially well when examined using a colposcope.

Cervical polyps rarely develop into cancer. Oncological alertness should be caused by recurrent cervical polyps or their ulceration. Cervical polyps are removed and subjected to histological examination. For recurrent polyps, diagnostic curettage of the mucous membrane of the cervical canal is recommended.

Cervical erosions (glandular-muscular hyperplasia) can be classified as precancerous processes with a long course, relapses, increased proliferation processes, and the presence of atypical cells. An eroded ectropion can also create conditions for the development of cancer. Ectropion occurs as a result of damage to the cervix during childbirth (less commonly, abortion and other interventions) and its deformation due to scarring. With ectropion, the inverted mucous membrane of the cervical canal comes into contact with the acidic contents of the vagina, and pathogenic microbes penetrate into its glands. The resulting inflammatory process can exist for a long time, spreading beyond the external pharynx and contributing to the appearance of erosion. Treatment of erosive ectropion is carried out according to the rules for the treatment of erosions. Treatment of the concomitant inflammatory process is carried out, colposcopy, and, if indicated, a targeted biopsy with histological examination of the removed tissue. In case of erosion, diathermocoagulation and electropuncture are performed in the first circle of the gaping pharynx. After the scab is rejected and the wound surface heals, a narrowing of the gaping pharynx and the disappearance of erosion are often observed. If after diathermocoagulation the cervical deformity does not disappear, plastic surgery can be performed. In the absence of a lasting effect and recurrence of erosion, indications for surgical intervention arise (cousoid electrical excision, amputation of the cervix).

Precancerous diseases of the uterine body. Glandular hyperplasia of the endometrium is characterized by the proliferation of glands and stroma. Not all glandular hyperplasia of the mucous membrane of the uterine body is a precancerous condition; The greatest danger in this regard is the recurrent form of glandular hyperplasia, especially in elderly women.

Adenomatous polyps are characterized by a large accumulation of glandular tissue. In this case, the glandular epithelium may be in a state of hyperplasia. Precancerous diseases of the endometrium are expressed in lengthening and intensification of menstruation, as well as the occurrence of acyclic bleeding or spotting. The appearance of a suspicious symptom should be considered! bleeding during menopause. The detection of endometrial hyperplasia or adenomatous polyps in a patient during this period should always be considered as a precancerous process. In younger women, endometrial hyperplasia and adenomatous polyps can be considered a precancerous condition only in cases where these diseases recur after curettage of the uterine mucosa and subsequent correct conservative therapy.

A special place among precancerous diseases of the uterus is occupied by hydatidiform mole, which often precedes the development of chorionepithelioma. Based on clinical and morphological features, it is customary to distinguish the following three groups of hydatidiform mole: “benign”, “potentially malignant” and “apparently malignant”. In accordance with this classification, only the last two forms of hydatidiform mole should be classified as a precancerous condition. All women whose pregnancy ended with a hydatidiform mole should be monitored for a long time. In such patients, an immunological or biological reaction should be periodically performed with whole and diluted urine, which allows timely fasting! make a diagnosis of chorionepithelioma.

Precancerous diseases of the ovaries. These include some types of ovarian cysts. Most often, cilioepithelial (papillary) cystomas undergo malignant transformation, and pseudomucinous ones are much less common. It should be remembered that ovarian cancer most often develops precisely because of these types of cysts.

21) precancerous diseases of the female genital organs see question 20.

Damage to the genital organs

In the practice of obstetrics and gynecology, injuries to the genital organs outside the birth act are observed quite rarely. They are classified as follows:

ruptures during sexual intercourse;

damage caused by foreign bodies in the genital tract;

injury to the external genitalia and vagina of a domestic or industrial nature caused by any sharp object;

genital bruises, crush marks;

stab, cut and gunshot wounds of the genitals; damage due to medical activities.

Regardless of the cause of the damage, determining its volume requires a thorough examination in a hospital setting, which includes, along with the initial examination, special methods (rectoscopy, cystoscopy, radiography, ultrasonography and nuclear magnetic resonance imaging, etc.).

The varied nature of injuries and complaints, many variants of the course of the disease depending on age, constitution and other factors require individual medical tactics. Knowledge of generally accepted tactical decisions allows the emergency physician to begin emergency measures at the prehospital stage, which will then be continued in the hospital.

Damage to the female genital organs associated with sexual intercourse. The main diagnostic sign of injury to the external genitalia and vagina is bleeding, which is especially dangerous when the cavernous bodies of the clitoris (corpus cavernosus clitoridis) are damaged. Rarely, the cause of bleeding requiring surgical hemostasis can be a rupture of the fleshy vaginal septum. Usually one or more sutures are placed on the vessels, injected with novocaine and adrenaline hydrochloride. Sometimes short-term pressure on the vessel is enough.

With hypoplasia of the external genitalia, their atrophy in older women, as well as in the presence of scars after injuries and ulcers of inflammatory origin, the rupture of the vaginal mucosa can extend deeper into the external genitalia, urethra and perineum. In these cases, a surgical suture will be required to achieve hemostasis.

Vaginal ruptures can occur due to an abnormal position of the woman’s body during sexual intercourse, violent sexual intercourse, especially in a state of intoxication, as well as when foreign objects are used in violence, etc. A typical injury in such circumstances is a rupture of the vaginal vaults.

Doctors often observe extensive damage to the external genitalia and adjacent organs. Forensic practice abounds in such observations, especially when examining minors who have been raped. Characterized by extensive ruptures of the vagina, rectum, vaginal vaults, up to penetration into the abdominal cavity and intestinal prolapse. In some cases, the bladder is damaged. Delayed diagnosis of vaginal ruptures can lead to anemia, peritonitis and sepsis.

Injuries to the pelvic organs are diagnosed only in a specialized institution, therefore, at the slightest suspicion of injury, patients are hospitalized in a hospital.

Damage due to penetration of foreign bodies into the genital tract. Foreign bodies introduced into the genital tract can cause serious problems. From the genital tract, foreign bodies of various shapes can penetrate into adjacent organs, pelvic tissue and the abdominal cavity. Depending on the circumstances and purpose for which foreign bodies were introduced into the genital tract, the nature of the damage may vary. There are 2 groups of damaging objects:

introduced for medicinal purposes;

introduced for the purpose of producing a medical or criminal abortion.

The list of circumstances and causes of damage to the genital tract at the everyday level can be significantly expanded: from small objects, often of plant origin (beans, peas, sunflower seeds, pumpkins, etc.), which children hide during games, and modern vibrators for masturbation to random large objects used for the purposes of violence and hooliganism.

If it is known that the damaging object did not have sharp ends or cutting edges, and manipulations are stopped immediately, then you can limit yourself to observing the patient.

The leading symptoms of genital trauma: pain, bleeding, shock, fever, leakage of urine and intestinal contents from the genital tract. If the damage occurred in an out-of-hospital setting, then of the two decisions - to operate or not to operate - the first is chosen, since this will save the patient from fatal complications.

The only correct solution would be hospitalization. Moreover, due to the unclear nature and extent of the injury, even in the presence of severe pain, anesthesia is contraindicated.

Many difficulties associated with the provision of ambulance and emergency medical care for trauma, blood loss and shock can be successfully overcome if, in the interests of continuity at the stages of medical evacuation, the ambulance team, when deciding to transport the patient, transmits information about this to the hospital where the patient will be delivered.

Injury to the external genitalia and vagina of a domestic or industrial nature caused by any sharp object. Damage of this nature is caused by various reasons, for example, falling on a sharp object, attack by cattle, etc. There is a known case when, while skiing from a mountain, a girl ran into a stump with sharp branches. In addition to the fracture of the ischial bones, she had multiple injuries to the pelvic organs.

A wounding object can penetrate the genitals directly through the vagina, perineum, rectum, abdominal wall, damaging the genitals and adjacent organs (intestines, bladder and urethra, large vessels). The variety of injuries corresponds to their multisymptoms. It is significant that under the same conditions, some victims develop pain, bleeding and shock, while others do not even experience dizziness, and they get to the hospital on their own.

The main danger is injury to internal organs, blood vessels and contamination of the wound. This can be detected already during the initial examination, noting the leakage of urine, intestinal contents and blood from the wound. However, despite the large volume of damage and involvement of the arteries, in some cases the bleeding may be insignificant, apparently due to crushing of the tissue.

If, during a prehospital examination, an object that caused injury is found in the genital tract, it should not be removed, as this may increase bleeding.

Bruises of the genital organs, crushing. These injuries can occur, for example, in traffic accidents. Large hemorrhages, even open wounds, can form

to be in tissues compressed by two moving hard objects (for example, in the soft tissues of the vulva relative to the underlying pubic bone under the influence of a hard object).

A feature of bruised wounds is the large depth of damage with a relatively small size. The threat is posed by damage to the cavernous bodies of the clitoris - a source of severe bleeding, which is difficult to undergo surgical hemostasis due to additional blood loss from places where clamps are applied, needle pricks and even ligatures.

Long-term pressing of the injury site to the underlying bone may not give the expected results, but it is still used during transportation to the hospital.

Bleeding may also be accompanied by an attempt to achieve hemostasis by injecting a bleeding wound with a solution of novocaine and adrenaline hydrochloride. It should be borne in mind that damage to the external genitalia due to blunt force trauma is more often observed in pregnant women, which is probably due to increased blood supply and varicose veins under the influence of sex hormones.

Under the influence of trauma with a blunt object, subcutaneous hematomas can occur, and if the venous plexus of the vagina is damaged, hematomas are formed that spread in the direction of the ischiorectal recess (fossa ischiorectalis) and the perineum (on one or both sides).

Vast cellular spaces can accommodate a significant volume of flowing blood. In this case, blood loss is indicated by hemodynamic disorders up to shock.

Damage to the external genitalia may be accompanied by injury to adjacent organs (polytrauma), in particular fractures of the pelvic bones. In this case, very complex combined injuries can occur, for example, rupture of the urethra, separation of the vaginal tube from the vestibule (vestibulum vulvae), often with damage to the internal genital organs (separation of the uterus from the vaginal vault, formation of hematomas, etc.).

In case of polytrauma, it is rarely possible to avoid transection and limit oneself to conservative measures. The multiple nature of the injuries is an indication for emergency hospitalization in the surgical department of a multidisciplinary hospital.

Stab, cut and bullet wounds of the genitals are described in violent acts against a person on sexual grounds. These are usually simple wounds with cut edges. They can be superficial or deep (the internal genital and adjacent organs are damaged). The topography of the internal genital organs is such that it provides them with fairly reliable protection. Only during pregnancy, the genital organs, extending beyond the pelvis, lose this protection and can be damaged along with other abdominal organs.

There are almost no comprehensive statistical data regarding the frequency of bullet injuries to the internal genital organs, but in modern conditions women can become victims of violence. Therefore, this type of injury is not completely excluded in the practice of an emergency physician.

The experience of military conflicts has shown that the majority of wounded women with damage to the pelvic organs die in the prehospital stage from bleeding and shock. Bullet wounds are not always assessed adequately. The task is easier with a through wound. If there are entrance and exit openings of the wound canal, it is not difficult to imagine its direction and the likely extent of damage to the internal genital organs. The situation is completely different when there is a blind bullet wound.

When making a decision, the emergency physician must proceed from the assumption that the injury caused multiple injuries to internal organs until the contrary is proven. In this regard, it is most appropriate to hospitalize the wounded woman in a multidisciplinary hospital with urgent surgical and gynecological departments.

Bullet wounds are especially dangerous during pregnancy. Injuries to the uterus usually cause significant blood loss. An injured pregnant woman must be hospitalized in the obstetric department of a multidisciplinary hospital.

23) preparing the patient for gynecological surgery, planned and emergency

Surgical treatment has become widespread in gynecology. The success of the operation depends on various factors.

First among them is the presence of precise indications for surgical intervention. In the event that the disease threatens the life and health of the patient and this danger can only be eliminated through surgical intervention, the operation will be indicated and its implementation will be justified.

It is necessary to take into account not only the indications, but also contraindications for surgery, which may be associated with pathology of other organs. Contraindications to surgery are considered both when surgical treatment is planned and when there is an emergency need for surgery. General contraindications to operations are acute infectious diseases, such as tonsillitis, pneumonia, however, in the case of an ectopic pregnancy or bleeding, surgical intervention will have to be resorted to. Elective surgeries in case of acute infectious process will be postponed.

In order for the outcome to be favorable, it is necessary to carry out a whole range of therapeutic and preventive measures before the operation, during it and in the postoperative period.

In preparation for surgery, an examination is carried out, concomitant diseases are identified, and the diagnosis is clarified. Then, during these activities, the method of pain relief, the extent of surgical intervention are selected, and the patient is prepared for surgery. Preparation consists of psychoprophylaxis and the right emotional mood. Also, in some cases, it is necessary to carry out preventive treatment of concomitant diseases.

In connection with the above, preparation for surgery can take from a few minutes in an emergency to several days or weeks in elective operations. It should be noted that part of the examination or treatment can be carried out on an outpatient basis, before the patient is admitted to the hospital.

There is a standard set of studies that every patient must undergo before surgery. It includes a medical history, general and special objective examinations, as well as laboratory and additional tests: general urine and blood tests, determination of platelet count, blood clotting time and bleeding duration, prothrombin index, biochemical studies (for residual nitrogen, sugar, bilirubin, total protein), it is necessary to determine the blood type and Rh affiliation.

An X-ray of the chest organs, an electrocardiogram, and a determination of the Wasserman reaction are also required. In addition, smears from the vagina are examined for flora, as well as from the cervical canal for atypical cells. HIV testing is mandatory.