Periods of a woman's life gynecology. Features of the reproductive system in different age periods of a woman's life
Book search ← + Ctrl + →2. Age periods of a woman's life
Having become acquainted with the anatomical and physiological features of the female genital organs in various age periods, it will be easier for you to understand many biological processes flowing in the body of a woman.
age, functional features The reproductive system of a woman is closely dependent on a number of factors. Great importance have primarily periods of a woman's life. It is customary to distinguish:
1) period prenatal development;
2) the period of childhood (from the moment of birth to 9-10 years);
3) puberty (from 9-10 years old to 13-14 years old);
4) adolescence (from 14 to 18 years);
5) the period of puberty, or childbearing (reproductive), age from 18 to 40 years; the period of transition, or premenopause (from 41 to 50 years);
6) the period of aging, or postmenopause (from the moment of permanent cessation menstrual function).
In the intrauterine period there is a laying, development and maturation of all organs and systems of the fetus, including the reproductive system. During this period, laying and embryonic development ovaries, which are one of the most important links in the regulation of the function of the reproductive system female body after birth.
During prenatal period various factors (intoxication, acute and chronic infections, ionizing radiation, medications etc.) can have a damaging effect on the embryo or fetus. These factors can cause malformations various bodies and systems, including the reproductive organs. Such congenital abnormalities in the development of the genital organs can lead to a violation of the functions characteristic of the female body. Malformations of intrauterine development that occur under the influence of the factors listed above may be accompanied by damage to various links in the regulation of the menstrual cycle. As a result, girls during puberty may experience various violations menstrual, and later reproductive function.
During childhood there is a relative rest of the reproductive system. Only during the first few days after the birth of a girl, she may experience the phenomena of the so-called sexual crisis ( bloody issues from the vagina, breast engorgement). This occurs under the influence of the cessation of placental hormones, which occurs after childbirth. In childhood, there is a gradual growth of the organs of the reproductive system, however, typical features for this age remain: the predominance of the size of the cervix over the size of the body of the uterus, tortuous the fallopian tubes, the absence of mature follicles in the ovaries, etc. During childhood, there are no secondary sexual characteristics.
puberty characterized relatively rapid growth organs of the reproductive system and, first of all, the uterus (mainly its body). In a girl of this age, secondary sexual characteristics appear and develop: a female-type skeleton (especially the pelvis) is formed, fat is deposited along female type, hair growth is noted first on the pubis, and then in armpits Oh. Most bright sign puberty is the onset of the first menstruation. Girls living in middle lane, the first menstruation appears at the age of 11-13 years. In the future, for about a year, menstruation may be irregular, and many periods occur without ovulation (the appearance of an egg). The beginning and formation of menstrual function occurs under the influence of cyclic changes in the nervous system and glands. internal secretion namely the ovaries. Ovarian hormones have a corresponding effect on the uterine mucosa, causing characteristic cyclic changes in it, i.e., the menstrual cycle. Teenage years also known as transitional, since at this time there is a transition to the onset of the period of puberty - the flowering of the function of the organs of the female reproductive system.
puberty is the longest in a woman's life. Due to the regular maturation of follicles in the ovaries and ovulation (release of the egg), as well as the subsequent development corpus luteum everything is created in the female body the necessary conditions for the onset of pregnancy. Regular cyclical changes occurring in the central nervous system, ovaries and uterus, which externally manifests itself in the form of regular menstruation, is the main indicator of the health of a woman of childbearing age.
premenopausal period characterized by a transition from the state of puberty to the cessation of menstrual function and the onset of old age. During this period, women often develop various disorders of menstrual function, the cause of which may be age disorders central mechanisms regulating the function of the genital organs.
Aging period characterized by the complete cessation of menstruation, the general aging of the female body.
The frequency of diseases of the genital organs in women is closely related to the age periods of their lives. So, during childhood, inflammatory diseases of the external genitalia and vagina occur relatively often. Common during puberty uterine bleeding and other menstrual disorders. During puberty, inflammatory diseases of the genital organs are most common, as well as menstrual irregularities. various origins, cysts of the genital organs, infertility. At the end of the childbearing period, the frequency of benign and malignant tumors of the genital organs increases. Less common during menopause inflammatory processes genital organs, but the frequency is significantly increased tumor processes and menstrual disorders (climacteric bleeding). In the postmenopausal period, more often than before, there are prolapse and prolapse of the genital organs, as well as malignant tumors. The age specificity of diseases of the female genital organs is mainly determined by the anatomical and physiological characteristics of the female body in separate periods life.
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Hygiene of a woman during menstruation3. protective barriers female body
It is customary to distinguish between several stages that successively replace each other: intrauterine, or embryonic, period, childhood, puberty, or puberty, reproductive period, or puberty, menopause and the period of old age.
prenatal period
At this stage of development, all fetal systems are formed, including the genital organs according to the female type. In the embryonic rudiments of the ovaries, primary follicles are laid, from which eggs will develop in the future.
Childhood
This period lasts from the birth of a girl to 8-9 years. Immediately after birth, under the influence of hormones released from the placenta, breast engorgement and bloody discharge from the vagina are possible. In the future, the hormonal background remains quite stable, the body and organs of the reproductive system grow.
Puberty
Puberty falls on the interval from 9-10 to 17-18 years. At this stage, restructuring begins hormonal system. Secondary sexual characteristics are formed: hair grows in the pubic area and armpits, development mammary glands, pelvic bones, distribution of subcutaneous fat according to the female type.
This period ends with the onset of monthly menstruation. After the first menstruation (menarche) for some time, menstruation is most often irregular, anovulatory cycles are possible. After 1-2 years, the menstrual cycles stabilize, and the woman enters next period of its development.
puberty
This is the longest stage in a woman's life. Cyclic hormonal changes in the body during this period occur regularly, which leads to the monthly maturation of follicles in the ovaries and the release of eggs from them (ovulation).
During each cycle in the body of a woman, all the necessary conditions are created for possible pregnancy. If the egg is not fertilized, the monthly cycle ends with the onset of menstruation. The average menstrual cycle lasts 28 days.
Menopause
The timing of the onset of menopause depends on many factors and is largely due to heredity. Normally, this period begins at the age of 45-50 years.
At the stage of premenopause, changes in the hormonal background lead to the fact that menstruation becomes irregular. Then comes menopause - a complete stop of ovarian function and the cessation of menstruation.
Postmenopause is the period from when a woman reaches menopause (1 year after last menstrual period) up to 65-69 years.
The synthesis of female sex hormones during menopause decreases. At normal flow menopause, this happens gradually, so the woman's body has time to adapt to the changes. With any violations during this process, a climacteric syndrome occurs, which is manifested by neuropsychic, endocrine, vegetative-vascular disorders.
Vegetative-vascular disorders lead to the appearance of hot flashes, chills, headache, sweating. Psycho-emotional disorders are manifested by irritability, sleep disturbance, depression, anxiety disorders.
Metabolic disorders are characterized by fluctuations in body weight, instability blood pressure increases the risk of developing osteoporosis.
old age
It lasts from 70 years to the end of a woman's life. During this period, the synthesis of female sex hormones remains consistently low, there is atrophy of the genital organs, the general aging of the female body.
Thesis
Karakhalis, Lyudmila Yurievna
Academic degree:
Doctor of Medical Sciences
Place of defense of the dissertation:
VAK specialty code:
Speciality:
obstetrics and gynecology
Number of pages:
INTRODUCTION
Chapter 1. MODERN VIEWS ON THE REPRODUCTIVE HEALTH OF WOMEN (REVIEW OF THE LITERATURE).
1.1. The reproductive system of women and its role in depopulation processes.
1.2. Assessment Methods reproductive health.
1.3. Hormonal relationships in violations reproductive health.
1.4. Factors affecting disorders in the reproductive system.
1.5. Increased body weight and its role in the regulation of the reproductive system.
1.6. Interaction immunological, biochemical and hormonal factors in reproductive health disorders.
Chapter 2. PROGRAM, MATERIALS AND RESEARCH METHODS.
2.1. Hormonal background of residents of the Krasnodar Territory.
2.2. Characteristics of the control group and comparison groups.
2.3. Laboratory methods research.
2.4. Study of psychological status.
2.5. Determining the impact of agroecological factors on reproductive health.
2.6. Ultrasonic method.
2.7. statistical method.
Chapter 3. REPRODUCTIVE SYSTEM OF RESIDENTS
KRASNODAR REGION AND ITS CHANGES.
3.1. Analysis of the demographic situation in the region and its components.
3.2. Reproductive health of women in the region at different age periods of life.
3.3 Impacts of agroecological and climatic and geographical factors on the reproductive system.
3.4 Psychological factors affecting reproductive health.
Chapter 4. MEDICAL FACTORS AFFECTING
REPRODUCTION.
4.1 Causal relationships in survey groups .
4.2 Impact of reproductive health on the course perimenopausal period.
Chapter 5. STATE OF THE REPRODUCTIVE SYSTEM IN DIFFERENT
AGE ON THE BACKGROUND OF CHANGES IN THE HUMORAL
HOMEOSTASIS.
5.1. General clinical characteristics of the survey groups.
5.2. Changes in hormone levels and carbohydrate metabolism.
5.3. Features of the immune status in women of different age groups with menstrual disorders.255.
5.3.1. Influence of menstrual irregularities on the leukogram indices of women of different age groups.
5.3.2 Age changes cellular immunity in women with menstrual dysfunction.
5.3.3 Comparative analysis indicators of cellular immunity in women with menstrual dysfunction relative to the corresponding! age control.
5.3.5 Comparative analysis of the content of leptin and cytokines in women with menstrual dysfunction in relation to the corresponding age control.
CHAPTER 6. TREATMENT PROGRAMS FOR DISORDERS
REPRODUCTIVE HEALTH IN DIFFERENT AGE PERIODS.
6.1 Correction of menstrual dysfunction through complex metabolic therapy and its effect on the course of pregnancy.
6.2 The use of COCs based on the developed system for determining hormonal status disorders.
6.3 Complex therapy in the perimenopausal period.
6.4 Changes in clinical and laboratory parameters during therapy in women with menstrual dysfunction and overweight.
Introduction to the thesis (part of the abstract) On the topic "The reproductive system of women in different age periods of life"
The health of a nation is determined by the health of people of childbearing age, their ability to reproduce offspring. Having signs of a crisis, the difficult demographic situation in modern Russia is an acute problem (Message to the Federal Assembly of the President of the Russian Federation, 2006), requiring the development effective programs support for motherhood, childhood, family. Socio-political transformations in Russia, which began in the last quarter of the last century, caused the deformation of many cultural and spiritual values, which also affected reproduction: a decrease in reproductive health, transformation of family lifestyle, negative trends in the state of health of different age groups, manifested differently in different regions of the country (Khamoshina M.B., 2006; Grigoryeva E.E., 2007). The implementation of the national project "Health" and the Concept of Reproductive Health of the Russian Federation will significantly change the situation, achieving not only a quantitative increase in children born, but also optimizing the health of living and future populations.
The study of the functioning of the reproductive system at different age periods of a woman's life, the influence of climatic, geographical, agroecological factors on them, as well as the study of the changes in the functioning of the reproductive system occurring under their influence, are a very urgent task, which involves considering in the aggregate all age periods of a woman's life - from the antenatal period before menopause.
WHO in 2004 adopted the Global Strategy for reproductive health, giving Special attention professional activity and occupational health (Izmerov N.F., 2005; Starodubov V.I., 2005; Sivochalova O.V., 2005), declaring, in addition to the state environment and lifestyle, essential adverse effect harmful factors production on the reproductive function of women.
In connection with the peculiarities of the implementation of the reproductive function, the protection of the reproductive health of a woman in the Russian Federation suffering from adverse effects the impact of environmental and production factors, acquires special meaning(Sharapova O.V., 2003; 2006). An increasing proportion of teenagers who have whole line combined disorders of somatic and reproductive health (Kulakov V.I., Uvarova E.V., 2005; Prilepskaya V.N., 2003; Podzolkova N.M., Glazkova O.L., 2004; Radzinsky V.E., 2004 , 2006).
In the last 10 years, the gynecological morbidity of girls and adolescent girls has significantly increased and the age of patients has decreased, this is especially noticeable in the increase in the frequency of menstrual irregularities and neuroendocrine syndromes(Serov V.N., 1978, 2004; Uvarova E.V., Kulakov V.I., 2005; Radzinsky V.E., 2006): by 2007, the number of “menstrual disorders” in girls and by 56.4% - in adolescents. The predicted deterioration in the reproductive health of women of childbearing age in this regard determines not only the medical, but also the socio-economic urgency of the problem of optimizing the reproductive health of women.
Lack of a strategy to keep a woman away from her intrauterine development to old age leads to misinterpretation of existing age problems reproduction, the causal relationships of the formation of somatic, reproductive health and quality of life in the pubertal, reproductive and menopausal periods are not defined.
Correction of the identified violations, based on the determination of the relationship of the body systems responsible for its reproductive function, made it possible to present the pathogenesis of diseases and disorders of the reproductive system in a new way, improve its condition in different age periods, and reduce reproductive losses.
The purpose of the study: to develop and implement a set of milestone medical and recreational activities to improve and maintain reproductive health in different age periods of a woman's life in the current environmental and socio-economic conditions of southern Russia.
Research objectives:
1. to study the indicators of reproduction, reproductive and somatic health of the population of the Krasnodar Territory, depending on the agro-ecological and climate-geographic impact, psychological factors in the family and at work, the quality of medical care.
2. to establish the features of hormonal and immune homeostasis in different age periods, depending on environmental influences up to puberty and in combination with production - in the reproductive and menopausal periods of life.
3. define age features emergence and development gynecological diseases and disorders, their relationship with extragenital diseases.
4. to substantiate the concept of reproductive health formation in the specific environmental and socio-economic conditions of the Krasnodar Territory, taking into account the different agro-ecological load, the state of somatic and psychological health.
5. to develop an algorithm for improving the health of patients with reproductive health disorders based on the studies and evaluate its effectiveness.
6. develop and implement a system of organizational, treatment and diagnostic measures aimed at improving the state of the reproductive system of girls, adolescent girls, women of reproductive and menopausal periods, taking into account antenatal development, childhood and puberty, born and living in adverse conditions of agroecological impact and climatic and geographical influence of the habitat of the south of the Russian Federation.
Scientific novelty of the research.
A multivariate mathematical analysis of the influence climatic and geographical and agroecological factors on the formation and functioning of the reproductive system, gynecological morbidity, which contributed to the clarification of the reasons for the low reproduction of the population of the Krasnodar Territory. Expanded understanding of the pathogenesis of disorders in the reproductive system and features gynecological diseases at different ages in a woman's life.
The concept of formation of reproductive health in different age periods of women's life is substantiated, taking into account the agro-ecological load, psychological health, immunological and hormonal characteristics of the body.
For the first time, a significant relationship between the state of the reproductive system and immunological, hormonal features homeostasis depending on the presence extragenital diseases, including metabolic disorders.
Developed and implemented comprehensive program improvement of patients with disorders in the reproductive system by testing therapeutic and diagnostic measures based on new approaches to the pathogenesis of the formation of reproductive disorders.
The practical significance of the work.
Based on the analysis, a scientifically based system of measures was developed and implemented in the Krasnodar Territory to improve the state of reproductive health and reproductive potential of adolescents, women of the reproductive period to realize their reproductive function in the present and future, improve the state of somatic and gynecological health, quality of life of menopausal women.
Developed, tested and implemented on the territory of the region and the city of Krasnodar " A method for determining hormonal status disorders in women"(Invention No. 2225009 dated February 27, 2004) and "Method of hormonal contraception" (Invention No. 2222331 dated January 27, 2004), which made it possible to increase the use of COCs in the region by 69.7% and reduce the number of abortions by 63.4% , which is ahead of the rate of decline in the number of abortions in the Russian Federation by 34.8%.
An algorithm for clinical and laboratory examination of women in various age periods has been developed and put into practice, including a survey methodology based on specially designed questionnaires, the determination of hormonal, cytochemical and immunological parameters, which made it possible to develop and implement complex method treatment of reproductive health disorders, which is based on the complex of metabolic therapy we offer (decision on the grant of a patent for the invention 2006 113715/14 (014907) dated 04/21/2006).
A center for pediatric and adolescent gynecology, a school for women of late reproductive and perimenopausal periods in which, along with a gynecologist, the positions of a psychologist, andrologist, geneticist, dermatovenerologist, urologist and infectious disease specialist.
Implementation preventive measures and treatment and diagnostic algorithms for improving the health of women in different age periods, outside and during pregnancy, led to a decrease perinatal mortality on the
5.3%, indicator stillbirths- by 10.6%, the maternal mortality rate has stabilized (13.1/100 thousand women).
Basic provisions for defense.
1. Reproduction of the population of the Krasnodar Territory at the end of XX - early XXI century is characterized by a decrease in the birth rate and an increase in mortality, negative indicators natural population growth, exceeding those in most territories of the Russian Federation, more than early start depopulation processes than in the country ("Russian cross" - since 1990).
2. In addition to the deterioration of socio-economic living conditions, demographic indicators may be affected by indicators of reproductive health that have deteriorated by the end of the 20th century (1999-2000): gynecological morbidity by 12.7% compared with 1990, menstrual disorders by 75.5%, an increase in the number of infertility in marriage by 16.9%, the frequency of absolute male infertility by 15%, kidney disease and urinary tract by 13.7%, neoplasms by 35.8%, malignant diseases women by 17.6%, including the mammary gland by 31.5%, the cervix and body of the uterus by 12.7%, and the ovaries by 15.2%. The frequency of diseases of the circulatory system increased by 50.7%, and diseases of the blood and hematopoietic organs- by 63%, including anemia - by 80.5%, diseases of the digestive system - by 45.2%, diseases of the endocrine system - by 64.3%, including diabetes by 15.3%, which may be the result of the ongoing agro-ecological load on the habitat, which is 4.5-5.0 times higher than the national average, while the level of oil products content is 1.5-2.5 times higher in 15 districts and cities of the region .
3. Gynecological morbidity, which has undergone significant changes in all age groups, is characterized by: the growth of childhood gynecological diseases due to the increase in inflammatory diseases evenly in all age groups (0-14 years old by 8.7%, 15-17 years old by 27.9%, 18-45 years old by 48.5%); increase benign ovarian tumors in age. 0-9 years only in those born to mothers with a long-term threat of miscarriage, who received various, including hormonal, drugs; Premature adrenarche in girls aged 6-8 years is highly correlated with the treatment of mothers with glucocorticoids during pregnancy. In general, girls and adolescent girls of the region are characterized by an increase in the age of menarche from 13.6 ± 1.2 years to 14.8 ± 1.5 years with a significant increase in the number of menstrual irregularities not only in puberty, but also reproductive periods: 15-17 years old -36% (ZPR - 15%, PPR - 21%); 18-35 years - 40%: amenorrhea - 5.7%, oligomenorrhea - 30-35%, dysmenorrhea - 23%, premenstrual tension syndrome - 17%, failure luteal phase - 14%. A significant increase in diseases of inflammatory origin, uterine fibroids, adenomyosis and their combination in the late reproductive period (36-45 years) with a decrease in menstrual irregularities may be the result of improper reproductive behavior.
4. Differences in the frequency of gynecological morbidity are due to living in areas with different intensity use of agrochemical fertilizers. Gynecological morbidity with a significant predominance of inflammatory and endocrine-determined diseases is higher in areas where the pesticide load is higher (2.0-2.5 MPC).
5. Psychological aspects reproductive health, differentiated at different age periods of a woman's life, are highly correlated with the presence of gynecological diseases and disorders: in prepuberty and puberty, low self-esteem and guilt prevailed due to delayed sexual development, late formation of secondary sexual characteristics, cosmetic defects, earlier pubarche, then in the reproductive period there is more often a feeling of guilt due to infertility in marriage, miscarriage, including the habitual one, not self-accusation prevails, but the search for reasons from the outside. After the birth of a child, these phenomena disappear, replaced by a sense of superiority over the remaining infertile peers. Sharp deterioration psychological status in the menopausal period is associated with both an increase in extragenital diseases and menopausal disorders. Women who had psychological problems in pubertal and reproductive periods, almost 100% are prone to depression in menopause. .
6. Hormonal homeostasis is characterized by different from the normative secretion of prolactin in all age groups: in prepubertal and puberty prolactin exceeds the national average by 5.7±0.3%; at the same time, it is significantly higher in obese girls and girls than in normal weight body, and in reproductive age its content is higher than the norm by 9.3±0.1%, with obesity - by 13.2±0.1%. In the menopausal period, prolactin levels decrease more rapidly than in the Russian Federation, at 49.2±0.3 years its level is lower by 42%, and at 55.1±0.7 years - by 61%.
7. Indicators of immune homeostasis are highly correlated with menstrual irregularities and body weight. With an increase in body weight in all age groups, a significant increase in leptin was found, most pronounced up to 18 years (3.7 times). When the menstrual cycle is disturbed, leptin decreases: its level significantly decreases in the reproductive age by 1.7 times, in the menopausal age - by 2.4 times, which correlates with the quantitative depression of the cellular link of immunity increasing with age. At overweight in reproductive age significantly (p<0,05) повышается число МС-клеток, а в возрасте старше 46 лет происходит отмена количественных дефектов клеточного иммунитета. При нарушениях менструального цикла с возрастом снижается содержание интерлейкина -4 и увеличивается концентрация интерлейкина-1(3, а при повышении массы тела - увеличение концентрации интерлейкина-4 и тенденция к снижению интерлейкина-1Р
8. Gynecological diseases and disorders occur the earlier, the smaller the weight of the girls are born. The low birth weight of daughters of mothers treated for a long time during pregnancies is noted in 72% of cases, in 78.8% it is combined with chronic and/or acute hypoxia. Violations immune status, frequent and long-term illnesses in childhood are associated with inflammatory diseases of the genitals (12%), violations of the formation of the menstrual cycle (17%), oligo- and dysmenorrhea (27%), premenstrual syndrome (19%), uterine bleeding during puberty (3%). Debut at reproductive age inflammatory diseases accounted for 20-24 years (70%), mainly as a result of induced abortion, IPPGT associated with frequent change of sexual partners. In the late reproductive and menopausal periods, abnormal uterine bleeding (40-44 years), endometrial hyperplasia (47 years), uterine fibroids (40 years), endometriosis (38-42 years) and their combination (41-44 years) predominate. The combination of genital and extragenital diseases in all age groups was 1:22.5: on average, there were 2.9 diseases per woman in the reproductive period, 3.1 in the late reproductive period, and 3.9 diseases in the menopausal period.
9. The concept of RH formation in specific climatic, geographical, environmental and socio-economic conditions of the Kuban provides for the interdependence of ante- and intranatal factors, low birth weight as an integral indicator of prenatal distress, high infectious index, aggravated heredity, high allergization, extragenital and gynecological morbidity in all age periods of life women and the possibility of correcting predicted and detected disorders using the developed algorithm of diagnostic and treatment measures.
10. The algorithm for improving the reproductive system is based on the optimization of the required clinical examination girls and women of childbearing age with the necessary volume of laboratory diagnostic methods in groups at high risk of reproductive health disorders and traditional treatment of identified and prevention of predicted diseases. This makes it possible to reduce gynecological morbidity at the age of up to 18 years by 29%, at the age of early reproduction by 49.9%, in the late reproductive period by 35% and in the menopausal period by 27.6%.
11. The developed and implemented system of organizational and treatment and diagnostic measures makes it possible to generally improve reproductive health in various age groups: in 2004-2006, maternal mortality was consistently 2 times lower than the national average, perinatal mortality was reduced by 1.3 times, the stillbirth rate was reduced by 10 .6%, infant mortality from congenital anomalies decreased by 1.1 times, the number of infertile marriages decreased by 19.6%, the birth rate increased by 3.7%, the number of abortions decreased by 9.9%, the number of women using effective methods increased contraception by 69.7%.
Approbation of research results and publication.
The main provisions of the dissertation were reported at the Russian Scientific Forum " Maternal and child health"(Moscow, 2005), Republican scientific forums "Mother and Child" (2005, 2006), Kuban congresses of obstetricians and gynecologists (2002, 2003, 2004), international conference "Immunology of reproduction: theoretical and clinical aspects" (2007), International conference "Therapeutic aspects of modern hormonal contraception"(2002), congresses of obstetricians and gynecologists of the North Caucasus (1994, 1998) and European congresses on contraception (Prague, 1998; Ljubljana, 2000; Istanbul, 2006),
The results of the study are presented in 41 publications, including 11 publications in journals recommended by the Higher Attestation Commission of the Russian Federation; methodological guide for doctors Algorithm for prescribing hormonal contraceptives» (regional department health care), monographs " Reproductive health of women in the Krasnodar Territory: ways to improve it» (2007).
Implementation of the research results.
The results are implemented in the work of: the Department of Health of the Krasnodar Territory (department of assistance to mothers and children), Regional Clinical Hospital No. 1; Regional Perinatal Center, Regional Family Planning Center, City Multidisciplinary Hospital No. 2 of Krasnodar, as well as in antenatal clinics, obstetric and gynecological hospitals in Krasnodar and the Krasnodar Territory. The developed complex is used in the work of endocrinologists, neurologists dealing with reproductive health problems. The data obtained are used in the educational process at the Department of FPC and teaching staff of KSMU for training obstetrician-gynecologists, general practitioners, clinical interns and residents, as well as at the Department of Obstetrics, Gynecology and Perinatology of KSMU.
A short-term training program on topical issues was developed, tested and introduced into the educational process of the departments of obstetrics and gynecology of KSMU reproduction, including issues of a systematic approach, management of patients with disorders in different age periods, as well as infertility and miscarriage.
The structure and scope of the dissertation.
The dissertation consists of an introduction, an analytical review of the literature, a description of the program, research materials and methods, four chapters of the materials of our own research, justification and evaluation of the effectiveness of the measures taken, a discussion of the results,
Dissertation conclusion on the topic "Obstetrics and Gynecology", Karakhalis, Lyudmila Yurievna
1. The reproduction of the population of the Krasnodar Territory at the end of the 20th and beginning of the 21st century has unidirectional trends with the country as a whole, significantly differing in the earlier onset of depopulation processes (the “Russian cross” is being implemented in 1990) and significantly higher rates of natural population decline, which is determined climatic and geographical the peculiarities of the region, the exorbitant agrochemical load in most of the territory of the region, the consumption of food and water containing toxicants.
2. The deterioration of RP is due to the constantly increasing gynecological incidence in all age periods of life: the total figures are 12.4% up to 18 years, 45.8% are at the age of 18-45 years, over 45 years - 41.8%.
3. The "peak" of gynecological morbidity at the age of 0-18 years falls on the age of 15.4±1.2 years, 18-45 years - 35.2±1.1 years, over 45 years - 49.7±0.8 years.
4. The somatic health of the female population is characterized by a significant excess of statistical indicators for the Russian Federation: diseases of the cardiovascular system - by 4.7%;, respiratory diseases - by 11.3%, diseases of the gastrointestinal tract - by 17.6%, endocrine pathology - by 5.9%, diseases of the mammary glands by 3.7%.
5. Infertile marriage, the frequency of which increases from 13.7% in 2000 to 17.9% in 2006, is an integral indicator reproductive troubles in the region, due not only to socio-economic, agro-ecological, climatic and geographical impact on the environment, but also psychological changes in personality, family, society, most pronounced in girls with gynecological diseases and disorders and in women in barren marriages.
6. Gynecological the incidence of girls and adolescent girls is highly directly correlated with frequent and prolonged treatment of the threat of miscarriage in their mothers, mainly with preparations of corpus luteum hormones (low weight - 3.9%, macrosomia - 12.9%, adrenarche 24.2%). The influence of chronic hypoxia during pregnancy and / or acute hypoxia during childbirth on the development of MS, in particular ZPR, should be considered proven. The same contingents are characterized by a decrease in the immune status, an increase in infectious (ARVI, chickenpox, scarlet fever) and somatic morbidity of allergic and endocrine origin.
7. Endocrine-determined diseases, tending to increase, have reached values in women of reproductive age comparable to inflammatory diseases: 29.4% and 32.1%. Dominant in the structure of gynecological morbidity are fibroids, adenomyosis, their combination, MC disorders, abnormal uterine bleeding with corresponding age peaks. The predominance of inflammatory diseases in the age group of 20-24 years is associated with abortion of the first pregnancy, frequent change of sexual partners and high prevalence of STIs.
8. Features menopausal period of the Kuban residents should be considered its earlier onset (47.6±1.5 years), manifested by psychological (37.8±2.6 years), vegetative-vascular (38.5±3.4 years) and urogenital(41.7±2.4 years) disorders. Significantly more frequent somatic morbidity (2-2.5 per 1 woman), on average, 1 woman has 3.1 diseases in the reproductive and 3.9 in the menopausal periods.
9. Features of hormonal homeostasis of all women with endocrine-related diseases of the genital organs are changes in prolactin excretion: increased up to 45 years (pubertal and reproductive) and reduced in the menopausal period. In all age periods, the level of prolactin excretion correlates with the excretion of cortisol, testosterone, 17-OP. Significant differences in the interaction of these hormones in women with and without obesity (p<0,05).
10. Hormonal effects are metabolically realized through leptin and cytokines, especially altered in obesity in the reproductive and perimenopausal periods: leptin increases 3.7 times, interleukins - 1.7-2.1 times.
11. Disrupted relationships of endocrine-metabolic regulation of homeostasis are transformed into a pronounced immune failure(the level of interleukins decreases by 7.9%, lymphocytes - by 5.1%, leukocytes - by 1.2%, the content of immunocompetent lymphocytes in almost all gynecological diseases, which may explain the high incidence of chickenpox in women with MC disorders in the reproductive period of life.
12. The concept of the formation of RH in specific environmental, climatic and geographical conditions of the Kuban is based on the idea of the interdependence of the causal determinants identified by this study heredity, drug load on the body of the future girl's mother, leading to an increase in gynecological morbidity in childhood and adolescence, associated somatic and infectious diseases of immunocompromised children and adolescents, an almost twofold excess of the total morbidity in reproductive age and one and a half times in menopausal. In combination with the agrochemical load, increased insolation, the harmful effects of industrial production, a decrease in material well-being in families and psychological changes in attitudes towards reproduction in society, the problem of the reproductive health of women in the Krasnodar Territory can be considered as an interdisciplinary one. multifactorial a problem that requires urgent measures by state authorities, changes in the organizational foundations of medical care for women of all age groups, and social interaction between educational, humanitarian and religious organizations.
13. The system of organizational and treatment and diagnostic measures developed on the basis of this concept, based on the priority use of methods for optimizing medical care to improve the condition of the reproductive system of girls, adolescent girls, women of fertile and menopausal ages, using modern technologies for diagnosing and treating reproductive disorders, creating new structural and functional institutions (adolescent health center) with simultaneous treatment of gynecological, andrological, somatic, urological diseases and psychological rehabilitation, identification of risk groups and extended laboratory studies of homeostasis in risk groups of reproductive disorders, including rational contraceptive The policy allowed to reduce the maternal mortality rate, improve perinatal indicators, reduce the incidence of children under 18 years old by 6.8%, 18-45 years old - by 10.2%), 46 years and older - by 4.9%. I I
1. Clinical examination girls in a children's clinic should be carried out with the participation of a pediatric gynecologist, especially in risk groups for violations of the formation of the reproductive system: children from mothers treated for a long time during pregnancy, with an increased drug load.
2. predictive and an early diagnostic criterion for the state of the reproductive system is the combined determination of the excretion of prolactin, 17-OP, testosterone. Their abnormal values should provide for an in-depth study of the excretion of leptin, interleukins and the determination of the immune status. First of all, girls who already have metabolic changes in areas with unfavorable agro-ecological conditions and the harmful influence of other production factors are subject to in-depth examination. It is advisable to conduct a continuous staged clinical examination of girls, adolescent girls, women of childbearing age for timely prediction, detection and treatment of disorders of RH and gynecological morbidity.
3. A further reduction in the number of abortions, especially during the first pregnancy, is possible only with the joint participation in the education of adolescents of education workers (secondary schools, vocational schools), health care (territorial women's consultations, youth centers), public and religious organizations.
4. Staged clinical examination of women of childbearing age can be effective only with a full comprehensive examination of girls at the age of 18 when she moves from the stage of a children's polyclinic (pediatric gynecologist) to an adult network - a territorial polyclinic and antenatal clinic. Further medical examination, the scope of examination and treatment should be determined by the state of somatic and reproductive health, the presence of harmful environmental factors and the psychological status of patients.
5. Treatment of gynecological diseases, timely carried out by traditional methods, allows to achieve a cure for uterine fibroids - absolute with surgery and up to 60% with conservative methods of treatment, inflammatory diseases of the genitals in 31.4%, MC disorders in groups under 18 years of age in 49.9% , in the reproductive period - in 39.8%>, in perimenopausal- 27.6%.
6. Barren marriage, timely diagnosed with proper examination and the use of assisted reproductive technologies, it makes it possible to achieve the birth of the desired child in almost 85% of cases, including tubal pregnancy - 32.7%, ovarian - 16.8%, male infertility - 21.7%, insemination - in 9.6% and IVF - in 19.2%.
7. An increase in the number and severity of diseases of the reproductive system of menopausal age provides for the timely recovery of women in late reproductive age, in relation to the conditions of the Kuban at 39-43 years old - “ peak gynecological morbidity»: tumors of the uterus and ovaries - 39.7 years, endometriosis - 40.3 years, erosion of the cervix - 42.3 years.
8. HRT for menopausal disorders, based on the conscious choice of the method by the patient herself, lasting 3-5 years, including in somatically burdened women with individual selection of the drug, taking into account the route of administration, allows leveling the psychological problems of menopause in 70%, urogenital - in 87% , vegetative-vascular - in 80%, metabolic-endocrine - in 17%, there is no significant increase in DMZH and diseases of the circulatory system and gastrointestinal tract. The increase in prolactin that occurred before menopause is leveled by the appointment dopaminergic phytopreparations.
Staged clinical examination of girls, adolescent girls, women of fertile and menopausal age, taking into account socio-economic, environmental, psychological factors of life, carried out by the joint activities of doctors of various specialties, can reduce the incidence: up to 18 years in general by 49.9%, 18- 35 years old - by 39.9%, 36-45 years old - by 31.6%, 46 years and older - by 27.7%.
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Periods of development of the female body.
It is customary to distinguish seven periods: 1) the period of antenatal, or intrauterine, development; 2) the period of childhood (from the moment of birth to 9-10 years); 3) puberty, or puberty (from 9-10 years old to 15-16 years old); 4) adolescence (from 16 to 18 years); 5) the period of puberty, or reproductive (from 18 to 40 years); 6) the period of premenopause, or transitional (from 41 to 50 years); 7) the period of aging, or postmenopause (from the moment of persistent cessation of menstrual function).
1.In the intrauterine period laying, development and maturation of all organs and systems of the fetus, including the reproductive system. In the antenatal period, the laying and embryonic development of the ovaries take place, which are one of the most important links in the regulation of the function of the female reproductive system in the process of postnatal ontogenesis.
2. During childhood there is a relative rest of the reproductive system. Only during the first few days after the birth of a girl, under the influence of the cessation of exposure to placental steroid hormones (mainly estrogens), she may develop the phenomena of the so-called sexual crisis (bloody discharge from the vagina, engorgement of the mammary glands). In childhood, there is a gradual growth of the organs of the reproductive system, however, typical features for this age remain: the predominance of the size of the cervix over the size of the body, the tortuosity of the fallopian tubes, the absence of mature follicles in the ovaries, etc. During childhood, there are no secondary sexual characteristics.
3. puberty characterized by a relatively rapid growth of the organs of the reproductive system and, first of all, the uterus (mainly its body), the appearance and development of secondary sexual characteristics, the formation of the female type of the skeleton (especially the pelvis), the deposition of fat according to the female type, the growth of hair, first on the pubis, and then in the axillaries depressions. The most striking sign of puberty is the onset of the first menstruation (menarche). The appearance and formation of menstrual function occur under the influence of cyclic secretion of releasing factors of the hypothalamus, gonadotropic hormones of the pituitary gland and steroid hormones of the ovaries. Ovarian hormones have a corresponding effect on the uterine mucosa, causing characteristic cyclic changes in it (proliferation, secretion, desquamation).
4. puberty is the longest. Due to the regular maturation of follicles in the ovaries and ovulation, followed by the development of the corpus luteum during this period, all the necessary conditions for pregnancy are created in the female body. The most clearly expressed indicators of the normal functioning of the reproductive system of a woman during puberty are specific cyclic changes that occur in the central nervous system, ovaries and uterus, which externally manifests itself in the form of regular menstruation.
5. premenopausal period characterized by a transition from the state of puberty to the cessation of menstrual function and the onset of old age. During this period, women often develop various disorders of menstrual function, the cause of which is age-related violations of the central mechanisms that regulate the function of the genital organs.
In a woman's life, periods can be distinguished that are characterized by certain age-related anatomical and physiological features: 1) childhood; 2) puberty; 3) the period of puberty; 4) menopause; 5) menopause and 6) postmenopausal period. Childhood is the period of life up to 8 years, in which the specific functions of the ovaries do not appear, although estrogens are synthesized. The uterus is small. The cervix is longer and thicker than the size of the uterus; fallopian tubes are tortuous, thin, with a narrow lumen; the vagina is narrow, short, the mucous membrane of the vagina up to 7 years is thin, the epithelium is represented by basal and parabasal cells. The external genitalia are formed, but the hairline is absent. During the first year of life, the size of the uterus decreases (by the end of the 1st year, the mass of the uterus is 2.3 g, its length is 2.5 cm). In the future, there is an increase in the mass of the uterus, and by the age of 6 it weighs 4.0 g. The ratio of the length of the cervix and the body of the uterus at the end of the 1st year is 2:1, by 5 years - 1.5:1, at 8 years - 1, 4:1. Gonadotropin-releasing hormone (GT-RH) is produced in the hypothalamus in very small amounts. The pituitary gland produces and releases FSH and LH. The gradual formation of feedback begins. However, the hypothalamic-pituitary-ovarian system is characterized by immaturity. The immaturity of the nuclei of the hypothalamus is manifested by the high sensitivity of the anterior pituitary gland and the neurosecretory nuclei of the mediobasal hypothalamus to estradiol. It is 5-10 times higher than in women of reproductive age, and therefore small doses of estradiol inhibit the release of gonadotropins by the adenohypophysis. By the age of 8 (the end of the childhood period), the girl has formed all 5 levels of the hypothalamic-pituitary-ovarian (HTU) system, the activity of which is regulated only by the negative feedback mechanism. Estradiol is released in very small amounts, the maturation of the follicles is rare and unsystematic. The release of GT-RG is episodic, synaptic connections between adrenergic and dopaminergic neurons are not developed, the secretion of neurotransmitters is insignificant. The release of LH and FSH by the adenohypophysis has the character of separate acyclic emissions.
The period of puberty (puberty) lasts from 8 to 17-18 years. During this period, the maturation of the reproductive system occurs, the physical development of the female body ends. Enlargement of the uterus begins at 8 years. By the age of 12-13, an angle appears between the body and the cervix, open anteriorly (anteflexio), and the uterus occupies a physiological position in the small pelvis, deviating anteriorly from the wire axis of the pelvis (anteversio). The ratio of the length of the body and the cervix becomes equal to 3:1.
In the first phase of the pubertal period (10-13 years), an increase in the mammary glands (thelarche) begins, which ends by the age of 14-17. By this time, hair growth (pubis, armpits), which began at 11-12 years old, ends. In the epithelium of the vagina, the number of layers increases, cells of the surface layer appear with pycnosis of the nuclei. The microflora of the vagina changes, lactobacilli appear. There is a process of maturation of the hypothalamic structures, a close synaptic connection is formed between the cells that secrete liberins (GT-RG, somatoliberin, corticoliberin, thyroliberin) and neurotransmitters. The circadian (daily) rhythm of GT-RG secretion is established, the synthesis of gonadotropins increases, their release becomes rhythmic. An increase in the release of LH and FSH stimulates the synthesis of estrogens in the ovaries, and the number of receptors sensitive to sex steroid hormones in all organs of the reproductive system increases. Achieving a high level of estradiol in the blood stimulates the release of gonadotropins. The latter completes the maturation of the follicle and the process of ovulation. This period ends with the onset of the first menstruation - menarche.
In the second phase of the pubertal period (14-17 years), the maturation of the hypothalamic structures that regulate the function of the reproductive system is completed. The circoral (hourly) rhythm of GT-RG secretion is established, the release of LH and FSH by the adenohypophysis increases, and the synthesis of estradiol in the ovaries increases. A positive feedback mechanism is being formed. The menstrual cycle becomes ovulatory. The time of onset and course of puberty is influenced by internal and external factors. Internal factors include hereditary and constitutional factors, health status, body weight; to external - climatic conditions (light, geographical location, altitude), nutrition (content of proteins, vitamins, fats, carbohydrates, microelements in food).
The period of puberty (reproductive period) takes a period of time from 16-17 to 45 years. The function of the reproductive system is aimed at regulating the ovulatory menstrual cycle. By the age of 45, the reproductive system fades, and by the age of 55 - the hormonal activity of the reproductive system. Thus, the duration of the functional activity of the reproductive system is genetically coded for the age that is optimal for conceiving, bearing and feeding a child.
Menopausal period (premenopausal) - from 45 years to the onset of menopause. According to the hypothesis put forward in 1958 by V. M. Dilman and developed in his subsequent works (1968-1983), during this period, aging of the hypothalamus is observed, which is manifested by an increase in the threshold of its sensitivity to estrogens, a gradual cessation of pulsating rhythmic synthesis and the release of GT- RG. The mechanism of negative feedback is disturbed, the release of gonadotropins increases (an increase in the content of FSH from the age of 40, LH from the age of 25). Dysfunction of the hypothalamus exacerbates disorders of the gonadotropic function of the pituitary gland, follicle and steroidogenesis in the ovaries. Increases the formation of catecholamines in the brain tissues. Probably, there are age-related changes in the receptor apparatus - a decrease in estradiol receptors in the hypothalamus, pituitary gland and target tissues. Violation of the transmission of nerve impulses is associated with age-related degenerative changes in the endings of dopamine and serotonergic neurons of the hypothalamus and suprahypothalamic structures. The process of oocyte death and atresia of primordial follicles accelerates, the number of layers of granulosa cells and theca cells decreases. A decrease in the formation of estradiol in the ovaries disrupts the ovulatory release of LH and FSH, ovulation does not occur, and the corpus luteum does not form. Gradually, the hormonal function of the ovaries decreases and menopause occurs.
Menopause is the last menstrual period, which occurs on average at the age of 50.8 years.
The postmenopausal period begins after menopause and lasts until the death of a woman. In the postmenopausal period, the level of LH increases 3 times, and FSH - 14 times compared with secretion in the reproductive period. In deep postmenopause, the formation of dopamine, serotonin, and norepinephrine decreases. The main pathway for the synthesis of estrogen becomes extraovarian (from androgens), and estrone becomes the main estrogen: 98% of it is formed from androstenedione secreted in the stroma of the ovaries. In the future, only 30% of estrogen is formed in the ovaries, and 70% in the adrenal glands. 5 years after menopause, single follicles are found in the ovaries; the weight of the ovaries and uterus decreases. By the age of 60, the mass of the ovaries decreases to 5.0 g, and the volume to 3 cm3 (at the reproductive age, the average volume of the ovaries is 8.2 cm3).
Literature
Obstetrics: A textbook for medical schools. 4th ed., add./E. K. Aylamazyan
