Basic research. Survey of patients in gynecology (gynecological history)



In the context of the economic crisis, low birth rate and high mortality rate, the problem of protecting and maintaining the reproductive health of the population is of particular importance. Unfortunately, recent statistics have been disappointing. Currently, the younger generation is at risk for the development of infertility. This primarily applies to children and adolescents who start sexual activity early, who use alcohol and drugs. Rates of early abortions have increased. So, out of 10 pregnancies, 7 end in abortions, and every 10 abortions are performed in girls aged 15-19! This leads to diseases of the reproductive system, in particular, the number of menstrual irregularities increases, and chronic inflammatory diseases of the female genital area occur.

Taking statistics data, we can conclude that by the beginning of the reproductive period, every teenager already has at least one chronic disease that directly or indirectly affects him. reproductive health. Many teenage girls often do not pay attention to any symptoms of gynecological diseases and do not seek help from a teenage gynecologist. We decided to analyze the causes of gynecological diseases in adolescent girls and study the types of such diseases. To do this, we met with the head of the antenatal clinic of the city hospital, gynecologist Tatyana Ivanovna Dmitrieva (Fig. 1)

Rice. 1. Meeting with the doctor

Tatyana Ivanovna agreed to consult us on the topic of the study and provided statistical data for the Kinelsky district, which are presented in Fig. 2.

Rice. 2. Statistical information

The diagram shows that in the Kinelsky district of the Samara region over the past 5 years there has been a decrease in the number of adolescent girls suffering from inflammatory diseases of the appendages, uterus, vagina, but the number of cases of erosion of the cervix has slightly increased. The most common is the violation of the menstrual cycle (34 cases). Encouragingly, the number of reported pregnancies in adolescence decreased from 95 cases in 2011 to 1 in 2015. Thus, we can conclude that adolescent girls in the Kinelsky district have become more responsible for their reproductive health.

Together with a gynecologist, a screening survey for adolescent girls was compiled. We asked the girls of our school to answer the questionnaire. The survey was conducted anonymously, a total of 46 people were interviewed.

According to the survey data, it was found that most of the girls in our school began menstruating at the age of 13-14, which is normal, for many, menstruation is accompanied by pain in the lower abdomen, which does not go away after the use of painkillers. Many called the drug "nosh-pa" the most effective. Only 4% of respondents have been sexually active since the age of 15, while they use contraceptive measures. The majority of respondents (85%) do not visit a gynecologist. It should be noted that 39% of the respondents drink alcohol and tobacco products. They also noted in their questionnaires that they often experience menstrual irregularities and pain during menstruation. Thus, it can be concluded that alcohol consumption and smoking adversely affect reproductive health. Most girls (93%) do not think about their reproductive health and do not take any measures to prevent gynecological diseases, believing that they are not needed. This may indicate a lack of awareness of girls about the causes and consequences of possible gynecological diseases.

Together with the doctor, a memo for girls was compiled, which we distributed among the high school students of our school:

1. A normal menstrual cycle should be regular after 28 + 7 days.
2. Bloody discharge from the genital tract during menstruation should be 5 + 2 days.
3. You can not live sexually during menstruation.
4. If there are any changes in the menstrual cycle, you should consult a doctor.
5. Menstruation should be moderate, painless.
6. During menstruation, it is necessary to observe the rules of personal hygiene.
7. Nicotine, alcohol, drugs cause not only various diseases in girls, but also affect the reproductive health and health of future generations.

The state of reproductive health is currently a subject of interest not only to medicine, but also to the entire world community, since it is directly related to the health of children, and, consequently, to the future of the state. Only by solving the problem of the health of young people entering reproductive age can we expect the birth of a healthy generation.

Reproductive health largely depends on the lifestyle of the girl. A healthy lifestyle, proper nutrition, moderate physical activity, exclusion of early sexual activity, stressful situations, prevention of sexually transmitted diseases (STDs), timely access to a gynecologist and examination are the basis for the prevention of gynecological diseases.

We believe that schools should carry out preventive work with adolescent girls about the need to maintain reproductive health. To do this, you can arrange meetings with a gynecologist. We hope that our memo will help girls maintain their reproductive health for years to come.

Literature:

1. Anikeeva L.L. Women's health and longevity. - M.: Eksmo, 2013
2. Gurkin Yu.A. Gynecology of adolescents. - M.: AST, 2000
3. Kazakova A.V., Spiridonova N.V., Lineva O.I. The main patterns of development of the reproductive system of girls. - S.: Etching, 2013
4. Nechas E. 1000 secrets of women's health. - M.: Vneshsigma, 2000
5. Under the editorship of Prilepskaya V.N. Sexually transmitted infections. - M.: GEOTAR-Media, 2014
6. Smirnova S.I. Gynecological diseases. - St. Petersburg: Owl, 2010
7. Tikhomirov A.A., Sarsania S.I. Inflammatory diseases of the female genital organs. - St. Petersburg: Owl, 2007.

Diagnosis and treatment of gynecological diseases are based on anamnesis data and objective research, which is carried out according to a certain system that allows you to identify the main facts and take into account all the details that will contribute to the correct diagnosis. It must be remembered that correct diagnosis and adequate therapy of gynecological diseases are possible only in the study of the whole body of a woman.

To examine women suffering from gynecological diseases, they use the collection of a general and special gynecological history, a general objective examination and special methods of gynecological examination.

What are the characteristics of history taking?

The collection of anamnesis in women with gynecological diseases is aimed at clarifying complaints, obtaining information about previous life and previous diseases. (anamnesis vitae), find out the development of the present disease (anamnesis morbi).

How to interview a patient?

The patient is interviewed according to the following plan.

1. Passport data, with special attention paid to the age of the patient.

2. Complaints of the patient.

3. Past diseases: diseases of childhood, infectious diseases (including Botkin's disease), diseases of various systems and organs, heredity, operations, injuries, allergic anamnesis, blood transfusions, diseases of the husband.

4. Living and working conditions.

5. Special obstetric and gynecological history:

The nature of menstrual, sexual, reproductive, secretory functions;

Transferred gynecological diseases and operations on the genitals;

Postponed urogenital and venereal diseases. In this case, it is also necessary to find out the functions of neighboring organs (genitourinary system, intestines).

6. The presence of pain and their nature.

7. Development of the present disease.

8. Summing up, establishing a preliminary diagnosis.

What is the significance of the patient's age for diagnosis?

Various gynecological diseases are often characteristic of a certain age. In childhood, inflammatory diseases of the external genital organs (vulvovaginitis) can be detected. During puberty, anomalies in the development of the genital organs, violations of the formation menstrual function. AT reproductive period often observed inflammatory diseases of the internal genital organs, tumors of the ovaries (cysts and cystomas), uterus (myoma), abnormal position of the uterus and injuries of the genital and neighboring organs, associated primarily with childbirth. In premenopause, menstrual dysfunction, precancerous and cancerous diseases of the female genital organs develop. In old age, prolapse and prolapse of the internal genital organs are often observed.

The anatomical features of the genital organs and their function are closely related to age-related changes in the female body, so some phenomena that are the norm for one age may be a pathology for another. So, amenorrhea in childhood and old age is a physiological phenomenon, and in the reproductive period it indicates significant disturbances in the body (unless it is associated with pregnancy and lactation - physiological amenorrhea).

In addition, the same symptom in different periods of a woman's life can be a manifestation of various diseases. Bleeding during puberty or the extinction of sexual function is usually associated with insufficiency or violation of the hormonal function of the ovaries. In childbearing age, the cause of bleeding is often abortion, uterine fibroids, inflammatory diseases of the uterus and its appendages, and other pathologies. In menopause, malignant neoplasms are the most common cause of bleeding.

What are the main complaints in women with gynecological diseases?

The main complaints of women with gynecological diseases are pain, leucorrhoea, bleeding, infertility (impaired fertility).

When interviewing, it is advisable to confine ourselves to clarifying the main symptoms without detailing their nature, occurrence and development. It is necessary to disclose the symptoms of gynecological diseases and their development consistently when familiarizing with the main functions of the female reproductive system. At the same time, violations of the sexual sphere (infertility, habitual miscarriages, itching, the appearance of a tumor in the external genital organs, in the vagina, in the abdomen, etc.), anomalies of the sexual feeling (anorgasmia, changes in libido, etc.), dysfunction of neighboring organs (urinary system, intestines), general disorders(poor health, weight loss, obesity, hot flashes, etc.).

What should be paid attention to when identifying the features of heredity?

In the process of collecting an anamnesis, information about a family history is revealed: general information about parents, brothers and sisters, their age and profession, their diseases (mental illness, alcoholism, blood and metabolic diseases, cases of malignant neoplasms).

What is the importance of identifying past illnesses?

Diseases suffered in childhood and during sexual development can adversely affect the development of the genital organs, the formation of menstrual function. Viral infections, frequent tonsillitis, tuberculosis can cause a delay in both general and sexual development, which is due to damage to the nervous and endocrine systems, the development of chronic intoxication and hypoxia in these diseases. Diphtheria with appropriate localization can cause stenosis or atresia of the vagina.

Elucidation of past diseases of the lungs, cardiovascular system, endocrine system etc. is of great importance for the prognosis of pregnancy and childbirth, the choice of methods of therapy for gynecological

diseases and the method of pain relief, if necessary, surgical treatment.

Particular attention should be paid to clarifying previous gynecological diseases, as they may be directly or indirectly related to the present disease.

Why is it necessary to know about past diseases of the sexual partner?

This is necessary to determine the causative agent of inflammatory diseases of the female genital organs. In this regard, sexually transmitted infections (STIs) are of great interest. The presence of TB in a husband may be important in establishing a diagnosis of genital TB. In addition, the husband's anamnesis helps clarify the causes of a fruitless marriage.

What is the importance of knowing the conditions of life and work?

Living conditions affect the development of not only the whole body of a woman, but also her reproductive system. To a large extent, the occurrence, course and outcome of extragenital and gynecological diseases, which can be the cause of anatomical and functional anomalies of the reproductive system, depend to a large extent on living conditions.

It is very important to find out the profession, working and living conditions of the patient, especially nutrition, since sometimes they can be the causes of certain diseases and contribute to their recurrence.

Unfavorable living and working conditions, the presence of occupational hazards (vibration; dustiness; work with chemicals; weight lifting, especially during puberty or shortly after childbirth; hypothermia; overheating; prolonged standing or sitting, etc.) contribute to the occurrence and adversely affect the course of such diseases as menstrual disorders, inflammatory diseases, position anomalies, precancerous and cancerous diseases of the genital organs, and many others.

Quantitative and qualitative nutrition determines the correct physical and sexual development of a teenage girl, and in the future, the normal reproductive function of a woman. Malnutrition is the cause of the development of rickets, malnutrition, late

puberty and underdevelopment of the genital organs, which can lead to dysmenorrhea, infertility, miscarriages, etc. In the reproductive period, insufficient, one-sided nutrition can also cause menstrual and reproductive disorders.

When collecting an anamnesis of life, it is also necessary to obtain information about bad habits (alcoholism, smoking, drug addiction, etc.), intolerance medicines previously produced by blood transfusions.

How is the function of the reproductive system evaluated?

The evaluation of sexual function must begin with the study of the characteristics of menstrual function, as it characterizes the state of the reproductive system and the whole body of a woman. Menstrual dysfunction can occur as a result of extragenital and gynecological diseases, so its study is of great importance for the diagnosis of these diseases.

When studying the features of menstrual function, it is necessary to identify the following data:

The time of the beginning of the first menstruation (menarche), its nature (soreness, degree of blood loss and duration);

After what period of time a regular menstrual cycle was established;

The duration of the menstrual cycle;

The duration of menstruation and the amount of blood loss;

Changes in the menstrual cycle after the onset of sexual activity, after childbirth and abortion;

Changes in the menstrual cycle due to this gynecological disease;

Date of last normal menstrual period.

What can cause menstrual irregularities?

Menstrual disorders that occur after the onset of sexual activity are most often a sign of inflammation of the endometrium and uterine appendages. Changes in menstruation after childbirth or abortion are also most often associated with inflammatory processes, with neuroendocrine disorders or other general violations.

With what diseases is it necessary to carry out a differential diagnosis of bleeding in a woman with gynecological pathology?

Bleeding from the genital tract is a symptom of many gynecological diseases: impaired uterine and ectopic pregnancy, dysfunctional uterine bleeding, uterine fibroids, adenomyosis, cancer of the cervix and uterine body, etc. Contact bleeding after intercourse can be a sign of cervical cancer, ectopia, cervical polyp, colpitis and other pathological processes.

What should be paid attention to when studying sexual function?

Sexual dysfunction can be with some functional disorders and gynecological diseases. The greatest tact must be exercised in taking this part of the history and answering the following questions.

1. The beginning of sexual activity.

2. Sexual feeling. sex drive (libido sexualis) and satisfaction (orgasmus) usually characterize the usefulness of a woman's sexual function, proper development sexual apparatus. The absence or decrease in sexual desire and satisfaction is observed in infantilism, intersexuality, after severe extragenital and gynecological diseases.

3. Violation of sexual intercourse. Painful sexual intercourse is a symptom of chronic inflammatory diseases of the uterus and its appendages, pelvic peritoneum, posterior cervical endometriosis, vulvovaginitis. Often, pain during intercourse is noted with hypoplasia of the genital organs, hysteria, vaginismus.

Bloody discharge after sexual intercourse is most often a sign of cervical cancer, which is due to the fragility of the cervical tissue in this pathology. It must be remembered that such bloody discharge can be observed with pseudo-erosion (ectopia), colpitis, polyps, tuberculosis of the cervix. With cicatricial narrowing, fusion (atresia) and absence (aplasia) of the vagina sex life is violated.

4. Contraception. It is necessary to find out whether a woman is protected from pregnancy or not, find out the method of contraception: natural methods, mechanical, chemical, intrauterine contraceptives (IUDs), oral contraceptives, etc., the duration and tolerability of contraception. Clarification of the nature of the means of counter-

conception can help clarify the causes of menstrual irregularities, the occurrence of inflammatory diseases of the female genital organs. So, for example, when using IUDs, it is possible to increase and increase the duration of menstruation, severe inflammation of the uterine appendages (salpingoophoritis) with the appearance of purulent saccular formations (pyosalpinx, tubo-ovarian abscess).

What is the importance of identifying the characteristics of a woman's reproductive function?

Identification of the features of a woman's reproductive function is of great importance for the recognition of gynecological diseases. In doing so, you need to find out the following:

The presence of pregnancies and the timing of the first pregnancy after the onset of sexual activity;

The number of pregnancies, their course and outcome (birth, abortion);

The course of childbirth and postpartum period;

The nature of the abortions (spontaneous, artificial), the timing of pregnancy, complications during and after the abortion.

Late onset of pregnancy (3-4 years after the start of regular sexual activity) indicates underdevelopment of the genital organs.

The onset of infertility after the first birth or abortion is most often a complication of the transferred inflammation of the uterine appendages (often of gonorrheal etiology).

The consequences of birth injuries of soft tissues (cervix, vagina, perineum) can be inflammatory diseases of the uterus and cervix, cicatricial deformities of the cervix, prolapse and prolapse of the genital organs. Ruptures of the cervix during childbirth contribute to its deformation with eversion of the mucous membrane of the cervical canal (ectropion) and the development of long-term erosions, which is a favorable background for the development of precancerous and cancerous conditions of the cervix.

What determines the need to study the secretory function of the female genital organs?

An important indicator of the state of the female genital organs is the secretory function. In a healthy woman, the secret is produced by the fallopian tubes, uterus, vagina, vaginal vestibule and

serves to physiologically moisturize the mucous membranes. In many gynecological diseases, there is a quantitative and qualitative change in the secret. Pathological discharge from the genital tract is called leucorrhoea (fluor albus). The nature of leucorrhea and the source of their formation are very important factors in the diagnosis of gynecological diseases.

What can be the source of whiter?

Violation of secretory activity can be observed in extragenital and gynecological diseases. The source of leucorrhoea are pathological processes in different parts of the reproductive system. In this regard, there are vestibular, vaginal, cervical, uterine and tubal leucorrhoea.

Vestibular whites are observed rather seldom. They are caused by hypersecretion of the sweat, sebaceous and mucous glands of the vulva and inflammation of the large vestibular (Bartholin) glands. Normally, the vestibule of the vagina is moistened with the secretion of the sebaceous and sweat glands, which accumulates in the folds of the genital area. Vestibular whites most often appear when the rules of personal hygiene are not observed; vulvitis or vestibulitis, especially with gonorrheal lesions of the large gland of the vestibule or urethra; ulcerative process (possibly malignant neoplasm) in the vulva; as a result of irritation of the vulva with a pathological secret from the overlying sections of the genital tract, as well as with diabetes and etc.

What is vaginal leucorrhoea and what are they formed from?

Vaginal leucorrhea are the most common. In a healthy woman, the vaginal mucosa is moistened with a liquid whitish discharge of 0.2 to 1.0 ml, resulting from the extravasation of fluid from the blood and lymphatic vessels and mucus produced by the epithelial cells of the endometrial glands. The amount and nature of the vaginal secretion of healthy women depend on their age and various physiological conditions (menstruation, pregnancy, sexual arousal, etc.). Normal physiological secretion of the vagina is of great biological importance - it promotes the process of fertilization and prevents the possibility of penetration of microorganisms into the upper genital tract. Vaginal secretions contain desquamated cells of stratified squamous epithelium, vaginal

Dederlein sticks (lactobacilli), leukocytes and other microflora. Dederlein sticks produce lactic acid from glycogen formed in the epithelium of the vagina. Lactic acid does not have a harmful effect on the vaginal mucosa, but prevents the development of pathogenic microflora, which easily penetrates from external environment.

What causes an increase in vaginal secretion?

An increase in vaginal secretion is observed with local inflammatory processes of the vagina, helminthic invasion (in children), in the presence of a foreign body in the vagina, perineal ruptures (gaping of the genital fissure), prolapse of the vaginal walls, urogenital and enterogenital fistulas, vaginal cancer and a number of extragenital diseases ( diabetes mellitus, cardiovascular disease, etc.). At the same time, given the quantity, consistency, color and smell of whiter, one can to a certain extent judge the cause of their occurrence. Foamy whites, as a rule, are caused by trichomonas colpitis. Sucrose leucorrhoea is characteristic of vaginal cancer.

In what cases do cervical, uterine and tubal leucorrhoea occur?

Cervical leucorrheaoccupy the second place in frequency (after vaginal) and are caused by a violation of the secretion of the cervical glands. Cervical leucorrhea often occurs with extragenital (tuberculosis, pathology of the endocrine glands, metabolic diseases) and gynecological diseases (acute, subacute and chronic cervicitis; cervical ruptures with the formation of ectropion; polyps of the mucous membrane of the cervical canal, cancer and tuberculosis of the cervix, etc. ). The nature of cervical whites - from clear or cloudy mucus to mucopurulent discharge.

Uterine (corporal) leucorrhoea. Normally, the uterine cavity does not contain a secret. The endometrium is slightly moistened with a mucous secretion. Uterine leucorrhea appears in pathological conditions and in some of them they have characteristic features. So, with endometritis, polyps, whites are mucopurulent in nature, with cancer of the body of the uterus - the color of meat slops, with submucous myoma- bloody, and with necrosis of the node, they acquire a brownish color and a putrid odor. Cottage cheese-crushed leucorrhoea is sometimes observed in tuberculous endometritis. Uterine leucorrhea (watery, liquid, colorless) in

elderly and senile age are often the first symptom of cancer of the uterine body.

Tube whitesare rare and, as a rule, are due to the periodic emptying of the so-called saccular tumors (hydro or pyosalpinx) through the fallopian tubes. In cancer of the tube, there may be an intermittent effusion of watery, lemon-yellow, or sanious fluid.

Changes in what neighboring organs are observed in women with gynecological diseases?

Diseases of the female genital organs are often accompanied by changes in the function of the bladder and rectum, which is due to the anatomical proximity and connections in the nervous, vascular and lymphatic systems of the genital and neighboring organs.

What are urinary tract dysfunctions?

In women with gynecological pathology, urination disorders are often detected: its frequency, urinary incontinence, difficulty urinating (up to delay), pain, burning and cramps during urination.

Frequent urination is often noted in the following cases:

Omission of the walls of the vagina, especially the front;

Inversions of the uterus backwards, when its neck is directed anteriorly and irritates the base of the bladder;

Uterine fibroids with nodes located along the anterior wall and in the isthmus;

Tumors of the ovary;

Cystitis and urethritis;

The transition of cancer of the body of the uterus to the bladder.

Urinary incontinence can be complete (with vesicovaginal fistulas) and incomplete (with various pathological processes).

Difficulty urinating may be due to a change in the position of the bladder and an inflection of the urethra, which are often observed with complete prolapse of the uterus, infringement of the retroreflected pregnant uterus, or with tumors of the internal genital organs.

Pain when urinating (often cutting) occurs as a result of inflammatory diseases of the bladder and urethra.

channel (urethritis). Pain at the beginning of urination is characteristic of urethritis (including gonorrhea), at the end - for inflammatory processes in the bladder area (cystitis). Pain during filling and emptying of the bladder is observed in pelvic peritonitis due to the transition of the inflammatory process to the peritoneum covering the bladder. Pain during urination is also noted during the transition to the bladder of malignant neoplasms of the uterus or ovaries.

What are the manifestations of bowel dysfunction in women with gynecological pathology?

Bowel dysfunction is usually manifested by constipation, pain, tenesmus, diarrhea, stool retention, etc.

Constipation occurs when the uterus bends backwards, tumors of the uterus and ovaries, as well as inflammatory processes, especially those localized in the pelvic tissue and peritoneum. Violation of defecation in these diseases occurs either due to a mechanical obstacle, or in a reflex way due to circulatory disorders. In inflammatory processes, a decrease in intestinal motility may be due to the transition of the inflammatory process to pararectal fiber or to the peritoneum of the rectum, intoxication, and when chronic course- changes in the functions of the autonomic nervous system.

Stool retention (more often in combination with flatulence) is characteristic of postoperative intestinal paresis and gynecological peritonitis.

Diarrhea (diarrhea) can be observed in the acute stage of inflammatory diseases, especially with septic pelvioperitonitis and parametritis, with an abscess breaking into the rectum or sigmoid colon, as well as with simultaneous tuberculous damage to the uterus, pelvic tissue and intestines.

Incontinence of feces and gases is a symptom of a complete rupture of the perineum and enterovaginal fistulas.

Pain during defecation sometimes occurs with inflammation of the uterine appendages, germination of the posterior cervical endometriosis in the rectum, but most often are satellites of the fissure anus and hemorrhoids.

Tenesmus can be in the presence of pus in the uterine-rectal (Douglas) space, with the threat of perforation of the pyosalpinx and pyovar, as well as with the transition of cancer of the cervix (body) of the uterus to the wall of the rectum.

What are the main causes of pain in women with gynecological pathology?

The most common cause of pain is an inflammatory process, leading to the formation of tissue edema, impaired lymph and blood circulation, and the formation of infiltrates. Often, pain occurs as a result of mechanical irritation of pain receptors with a tumor of the uterus or appendages, torsion of the tumor legs, hemorrhage into the cavity of organs or tumors, as well as in the presence of scars and adhesions after inflammation. The cause of pain can also be contraction and spasm of the muscles of the uterus during miscarriage, tubal abortion, "born" submucosal node, etc.

In malignant neoplasms, pain is late symptom and is caused by compression of nerve endings and general intoxication.

Where is pain most often located?

Patients with gynecological diseases note pain in the lower abdomen, which can radiate to the sacrum, coccyx, rectum, vagina, thighs, etc.

Pain in the vulva is observed with vulvitis, bartholinitis, kraurosis, etc.

Pain in the lower abdomen along the midline in most cases depends on diseases of the uterus, bladder, rectum, and sometimes come from the adnexa of the uterus displaced to the midline.

With the localization of pain on the side, it is necessary to distinguish between unilateral and bilateral pain. Right-sided pains are most often associated with diseases of the genital organs (right appendages and pelvic peritoneum), kidneys, ureters, appendix, hernia incarceration, etc. It must be remembered that pains localized below the line connecting the anterior superior pelvic spine and the navel generally indicate damage to the internal genital organs, and above this line - to diseases of the intestines, kidneys, etc.

Pain in the region of the sacrum and lower back is characteristic of inflammation of the periuterine tissue (parametritis), retrofixation of the uterus, and malignant tumors. Pain in the coccyx region is observed with chronic perimetritis and parametritis, as well as with a fracture of the coccygeal bones, arthritis, sciatica in the coccyx region (a painful point in the coccyx region is determined during rectal examination). Pain in the lower abdomen with a feeling of pressure on the bottom are observed in patients with prolapse and prolapse of the walls of the vagina and uterus.

What is the nature of the pain?

Pains are very diverse in nature, time of occurrence, degree, etc. By the nature of the pain symptom and the irradiation of pain, one can judge the disease of an urgent nature. So, cramping, intense pain in the lower abdomen with irradiation to the rectum is often a symptom of an interrupted tubal pregnancy. If available in abdominal cavity a significant amount of blood in patients appears phrenicus symptom - pain in the supraclavicular fossa. Cramping pain is due to contraction of the muscles of the uterus, which is observed during abortion, "born" submucosal node, ectopic pregnancy. The intensity of pain depends on the characteristics of the nervous system, the emotional state of the woman, the degree of involvement of nerve endings in the pathological process, stretching of the visceral peritoneum, metabolic disorders in the focus of inflammation, etc. The most severe pains are noted when the parietal peritoneum is involved in the pathological process, when the cancerous infiltrate compresses the nerve trunks of the small pelvis. The intensity of pain also depends on the specificity of the process. For example, when acute inflammation uterine appendages of gonorrheal etiology, pains are intense and prolonged, and with inflammation of the uterine appendages and peritoneum of tuberculous etiology, the patient notes slight pains even with a significant spread of the pathological process.

With endometriosis, pain can be both cyclic and acyclic in nature, intensifying on the eve and during menstruation, are acute, and in some cases permanent. Characterized by an increase in the intensity of pain over time. Pain can radiate to the back, sacrum, coccyx, rectum, perineum.

A more rare cause of pain may be a defect in the posterior leaf of the broad ligament of the uterus - Allen-Masters syndrome (Allen-Masters).

How important is the time of onset of pain?

The time of onset of pain is of great importance for the diagnosis of gynecological diseases. Regularly occurring pain in the middle of the menstrual cycle is due to ovulation (ovulatory pain). Increasing pain in the second half of the menstrual cycle and continuing during the first days of menstruation are typical for endometriosis. Pain during intercourse (dyspareunia)

most often caused by a chronic inflammatory process of the uterine appendages or retrocervical endometriosis.

It should be noted that pain emanating from the genital organs can reflexively affect the functions of the bladder, intestines, liver, kidneys, adrenal glands, pituitary gland, and the cardiovascular system.

With what diseases is it necessary to carry out a differential diagnosis of pain in women with gynecological diseases?

Differential diagnosis of pain is carried out with diseases of the skeleton, muscular, nervous systems and diseases of internal organs (often with appendicitis).

What is the end of the patient survey?

Interrogation of the patient ends with obtaining detailed information about the development of the present disease. It is necessary to find out the time of the onset of the disease and its relationship with one or another factor (menstruation, childbirth, abortion, cooling, general diseases, etc.), as well as obtain information about the development of the disease. The patient should be asked in detail about the course of the disease, the methods of diagnosis and treatment used, and their effectiveness.

Thus, as a result of a detailed survey, you can get enough information for a preliminary conclusion about the nature of the disease.

To clarify the diagnosis, it is necessary to conduct an objective study.

2.1. RESEARCH METHODS IN GYNECOLOGY

What is the purpose of objective research?

The purpose of an objective study of patients with gynecological diseases is to recognize diseases of the reproductive system and to determine the state of other organs and systems, therefore, it is necessary to conduct a study of the entire body of a woman, which is very important for identifying concomitant diseases and dysfunctions the most important organs, which may be associated with diseases of the genital organs.

What research methods are used in gynecological practice?

The following methods are usually used:

Common in medical practice: examination, palpation, percussion, auscultation, etc.;

Special research methods: examination of the cervix using mirrors, vaginal and recto-abdominal bimanual examination, probing, separate diagnostic curettage, hysteroscopy, laparoscopy, etc.;

Clinical laboratory and instrumental research methods.

What are the stages of the general objective examination of the patient?

In a general objective study, the type of constitution, the condition of the skin, general hair growth, a study of the organs and systems of the abdomen, and characterize the mammary glands are evaluated.

Along with the normal physique, there are the following body types of women (Fig. 2.1): 1) infantile (hypoplastic); 2) hypersthenic (picnic); 3) intersex; 4) asthenic.

Rice. 2.1.The main types of the constitution of women: 1 - infantile; 2 - hypersthenic; 3 - intersex; 4 - asthenic

Infantile type It is characterized by small (or medium, rarely high) growth, generally evenly narrowed pelvis, underdevelopment of the mammary glands, external and internal genital organs, late onset of menarche, and menstruation is irregular and painful.

Hypersthenic type differs in low (medium) growth with a well-developed subcutaneous fat layer, insignificant leg length compared to the length of the body, mild kyphosis of the back, high-lying lordosis and relatively narrow shoulder girdle. In most women, specific functions are not impaired.

intersex type characterized by insufficiently complete differentiation of sexual characteristics, which is reflected in the appearance of a woman and the functions of the genital organs. These women show physical and mental signs inherent in the male body: they have a rather high stature, a massive skeleton, a wide shoulder girdle, a pelvis that is close in shape to a man's, non-closing legs. Hair on the genitals is excessive and developed according to the male type. There is a lot of hair on the legs and around the anus. These women often have genital hypoplasia, menstrual dysfunction, sexual indifference and infertility.

Asthenic type the predominance of longitudinal dimensions, a decrease in the tone of the entire muscular and connective tissue systems are characteristic. Such women often have excessive uterine mobility and posterior kinks, pain in the sacrum, heaviness in the lower abdomen, painful menstruation, constipation, and decreased ability to work. After childbirth, due to the weakness of the ligamentous apparatus and muscles of the pelvic floor, prolapse of the walls of the vagina and uterus easily occurs.

What is the importance of the main anthropometric indicators?

Of great importance for the diagnosis of endocrine disorders is the knowledge of height and weight indicators, since, for example, with a deficiency or excess of body weight, menstrual irregularities can be observed. Body type is assessed using anthropometric curves (morphograms) according to Decourt and Doumic, who proposed to determine 5 sizes using a centimeter tape, stadiometer and pelvis (Fig. 2.2, 2.3):

A - circumference of the chest (during expiration), under the mammary glands, at the level articulatio sterno-xyphoidea;

B - the height of the greater trochanter of the thigh from the floor;

C - growth;

D - the distance between the large trochanters of the thighs; E - the distance between the humerus (shoulders) at the level of large tubercles.

Rice. 2.2.

______- "ideal" dimensions of a woman with a height of 161 cm;

The average size of a healthy man is 171 cm tall

Rice. 2.3.Morphogram (according to Decourt and Doumic):

_____- "ideal" dimensions for a man with a height of 171 cm;

The average size of a healthy woman is 161 cm tall

Assessment of body type using morphograms allows, first of all, to establish the possibility of a retrospective assessment of the features of the ratio of the levels of hormonal influences (estrogenic and androgenic) during puberty, which determine the size of individual parts of the body during the formation of the bone skeleton.

Body mass index is calculated by the formula:

woman's BMI reproductive age equals 20-26.

BMI over 30 is an average risk of developing metabolic disorders, over 40 is a high risk of metabolic disorders.

Why is it necessary to assess the degree of development of adipose tissue?

According to the degree of development and distribution of adipose tissue, one can judge the function of the endocrine glands. In the pathology of the hypothalamic region, the deposition of fatty tissue in the form of an apron is observed. Itsenko-Cushing's syndrome is characterized by the deposition of fat on the face, torso, back and abdomen. For the climacteric type of obesity, which is due to a sharp decrease functional activity ovaries, characterized by the deposition of fat on the shoulders, in the region of the VII cervical, I and II thoracic vertebrae, on the chest, abdomen and thighs.

What is the hair growth score?

Evaluation of the degree of severity and features of the distribution of the hairline make it possible to judge the hormonal activity of the ovaries, adrenal glands and the sensitivity of hair follicles to the action of androgens.

Normal hair growth in women is noted in the womb and in the armpits. The degree of its severity depends on the hormonal activity of the ovaries, adrenal glands, as well as on the sensitivity of hair follicles to the action of androgens.

What are the types of hair growth disorders?

There are several variants of hairline development disorders:

Hypertrichosis (hypertrichosis), characterized by pronounced hair growth in places characteristic of the female body (pubis, labia majora, armpits);

hirsutism (hirsutismus)- Increased male pattern hair growth. In women with hirsutism, there is hair growth on the face, interthoracic sulcus, areola, midline of the abdomen;

virilism (virilismus)- a set of signs observed in women, and characterized by the appearance of male features caused by the action of androgens.

How is the development of hairline on the patient's body assessed?

D. Ferriman and J. Galway proposed a special method for assessing the degree of hair in different parts of the body, according to which this indicator, depending on the severity of hair growth, is estimated in points.

The final assessment of the severity of the development of the hairline is the hirsute number, which is the sum of the indicators for the areas of the body (Table 2.1).

Table 2.1.Scale for the quantitative characteristics of hirsutism (according to D. Ferriman, J. Galway, 1961)

End of table 2.1

How is sexual development assessed?

To assess sexual development, it is necessary to take into account the degree of development of the mammary glands, pubic and axillary hair growth, and the characteristics of menstrual function. The degree of development of the mammary glands (Fig. 2.4):

Ma0 - the mammary gland is not enlarged, the nipple is small, not pigmented;

Ma1 - swelling of the areola, an increase in its diameter, pigmentation of the nipple is not pronounced;

Ma2 - the mammary gland is conical in shape, the areola is not pigmented, the nipple does not rise;

Ma3 - youthful breasts are rounded, the areola is pigmented, the nipple rises;

Ma4 - a mature breast of a rounded shape.

Rice. 2.4.Development of the mammary glands: I - the first years of life; II - the beginning of puberty; III - the end of puberty; IV - reproductive period: a, b - in different phases of the cycle; c - during lactation

Hair stages:

Р0Ах0 - there is no hair on the pubis and in the armpits; P1Ax1 - single straight hair;

P2Ax2 - hair is thicker and longer, located in the central part of these areas;

P3Ax3 - hair on the entire triangle of the pubis and labia is thick, curly; the armpit is covered with curly hair.

The severity of the menstrual function:

Me0 - absence of menstruation;

Me1 - menarche during the examination;

Me2 - irregular menstruation; Me3 - regular menstruation.

After a visual assessment of these signs, the sex formula is calculated.

How is the sex formula calculated?

To calculate the sex formula, each attribute must be multiplied by its own coefficient for measurement in points, and then all indicators should be added.

P - 0.3; Ax - 0.4; Me - 2.1; Ma - 1.2. Below are examples of calculating the sex formula. The sexual formula at 12 years old is Ma3, P2, Ax1, Me0 = 3.6 + 0.6 + 0.4 + + 0 = 4.6.

The sexual formula at 17 years old is Ma3, P3, Ax3, Me3 = 3.6 + 0.9 + 1.2 + + 6.3 = 12.

Sexual formula at 7 years (with premature sexual development) - Ma2, P2, Ax0, Me2 = 2.4 + 0.6 + 0 + 4.2 = 7.2.

Sexual formula at 12 years old (with delayed sexual development) - Ma0,

P0, Ax0, Me0 = 1.2 + 0 + 0 + 0 = 1.2.

What should be paid attention to when examining the abdomen and what methods are used?

When examining the abdomen, it is necessary to pay attention to its size, configuration, swelling, symmetry, participation in the act of breathing. A change in the abdomen and its shape is observed with large tumors (myoma, cystoma), ascites, effusion peritonitis. In the presence of ovarian cystoma, the abdomen acquires a domed shape, and with ascites - a flattened shape ("frog" abdomen).

Palpation determines the tone of the muscles of the abdominal wall, the presence of muscle protection, diastasis of the rectus abdominis muscles, pain. Feeling the abdomen allows you to determine the size, shape, consistency, boundaries, mobility and soreness of tumors, as well as infiltrates. Muscular protection is detected in acute inflammation of the uterine appendages and pelvic peritoneum (pelvioperitonitis).

During percussion, the boundaries of tumors, infiltrates are clarified, the presence of free fluid in the abdominal cavity is determined. Percussion of the abdomen can be used for the differential diagnosis of parametritis and pelvioperitonitis. With parametrization, the boundaries of the infiltrate determined by percussion and palpation coincide, and with pelvioperitonitis, the percussion border of the infiltrate seems smaller due to gluing of intestinal loops over its surface.

Auscultation of the abdomen allows you to determine the presence of intestinal motility and its nature. A decrease in bowel sounds can be observed after complex gynecological operations, as this reduces intestinal motility. Violent peristalsis is noted with intestinal obstruction. The absence of peristalsis usually indicates intestinal paresis observed in peritonitis. Auscultation allows a differential diagnosis between large tumors of the internal genital organs and pregnancy.

What is the importance of breast examination?

The study of the mammary glands is of great importance, since a significant part of gynecological diseases is combined with diseases of the mammary glands (see Chapter 15).

How is a breast examination performed?

Inspection is carried out in a standing and lying position with sequential palpation of the outer and inner quadrants of the gland.

What should I pay attention to when examining the mammary glands?

It is necessary to pay attention to the degree of development of the mammary glands, the shape of the nipple, trophic changes in the skin. Thus, infantilism is characterized by underdevelopment of the mammary glands. On palpation, attention should be paid to the consistency of the glands, their compaction, soreness, the presence of discharge from the nipples, its color, texture and character. Discharges that are brown or mixed with blood indicate a possible malignant process or papillary growths in the ducts; liquid clear or greenish discharge is characteristic of cystic changes. Of great diagnostic value is the allocation of milk or colostrum. The presence of this type of discharge in amenorrhea or oligomenorrhea suggests the diagnosis of one of the forms of hypothalamic reproductive disorders - galactorrhea-amenorrhea and requires an in-depth examination to exclude or confirm prolactin-secreting pituitary adenoma.

Palpation of the mammary glands allows you to identify mastopathy, determine its form - fibrous, glandular, cystic or mixed.

Detection of seals requires additional examination methods to exclude a malignant neoplasm.

What are the additional methods of examination of the mammary glands?

The main method for an objective assessment of the state of the mammary glands is x-ray mammography, allowing to diagnose pathological changes in the mammary glands in 95-97% of cases. The method contributes to the detection of malignant tumors against the background of diffuse and nodular benign diseases, allows you to clarify the size and location of the tumor, to evaluate the effectiveness of conservative therapy. The method plays a great role in the detection of non-palpable tumors in the so-called preclinical phase of their development, in connection with which mammography has become an integral and main part of the examination of the mammary glands. The combination of mammography with cytological diagnostics increases the number of accurate diagnoses to 90% or more.

Ductographyused to assess the diameter, direction and contour of the ducts, to identify intraductal neoplasms, their size, number and shape.

More accurate methods for examining the breast are CT scan(CT) and Magnetic resonance imaging

(MRI).

Ultrasound procedure (ultrasound) is one of the informative research methods that allows you to identify the main forms of benign diseases of the mammary glands. The advantage of the method is the possibility of its use in pregnant women, lactating women, children and adolescents, as well as in young women under the age of 40 years. The disadvantages of ultrasound remain the difficulty in diagnosing microcalcifications - one of the first signs of malignancy, as well as low information content with excessive development of adipose tissue.

thermography- an absolutely harmless and simple research method, the principle of which is based on the temperature difference of the skin over damaged and undamaged areas, which is associated with the characteristics of the blood circulation of healthy and pathologically altered tissues. The application of the method, however, is limited by low resolution, the impossibility of detailing the structure of the mammary glands, the difficulty in identifying small, especially deeply located formations.

microwave radiothermometry allows you to determine the change in the deep temperature of tissues and organs, which is integral indicator the level of bioenergetic processes, and can serve as a relative indicator of their morphofunctional state.

Needle biopsy with subsequent cytological examination of the biopsy is used to diagnose fibrocystic mastopathy. The information content of this method is 93-95%.

The material for cytological examination is discharge from the nipples, scrapings-imprints from eroded surfaces or from cracks in the nipple area, punctate obtained from a nodular formation or a biopsy specimen of a suspicious area.

What is the mandatory research methods for women?

The obligatory methods of examination of women include: examination of the external genitalia; examination of the cervix using mirrors; vaginal; bimanual examination, as well as those performed according to indications - rectal, rectovaginal and combined rectovaginal-abdominal examination.

What is the preparation

to a gynecological examination?

Gynecological examination is carried out after emptying the bladder in the absence of intestinal overflow in horizontal position on a special gynecological chair.

For examination, sterile vaginal mirrors (preferably disposable), lifts, tweezers, instruments for taking smears, etc. are used.

A study of a woman with gynecological pathology is carried out in sterile rubber gloves, which are then destroyed after pre-treatment in a disinfectant solution.

How to start a gynecological examination?

The study begins with an examination of the external genital organs. The shape of the pubis, the nature of its hair growth (female, male or mixed type), the condition of the subcutaneous fat layer are assessed. At the same time, the inner surfaces of the thighs are examined in order to detect hyperemia, pigmentation, condylomas, varicose veins, etc. low, the presence of old tears, scars, fistulas), determine the degree of prolapse of the walls of the vagina (independent and with straining). It is necessary to inspect the anus for

identifying hemorrhoids, cracks, warts, ulcers, prolapse of the rectal mucosa, etc.

To examine the vestibule of the vagina, the labia are parted with the thumb and forefinger of the left hand. At the same time, attention is paid to the color, condition of the mucous membrane (pigmentation, ulceration), the nature of the vaginal discharge. Examine the clitoris (shape, size, developmental anomalies), external opening urethra(the condition of the mucous membrane, the presence of polyps, the nature of the discharge from the urethra), the paraurethral passages and the outlet ducts of the large glands of the vestibule of the vagina (the presence of inflammation, purulent plug), the hymen or its remains. After that, proceed to the internal study.

What is the significance of the study with the help of mirrors?

This study is very important for identifying the pathology of the vagina and cervix and is mandatory for every gynecological patient. It should be emphasized that a study using mirrors is performed before vaginal and bimanual examination, since a preliminary digital examination can change the nature of vaginal discharge or injure the mucous membrane of the cervix and vagina, which will lead to an incorrect interpretation of diagnostic data when using endoscopic examination methods (colposcopy, cervicoscopy , microcolposcopy, etc.). For research, several models of mirrors are used: cylindrical, folded, spoon-shaped, etc. (Fig. 2.5).

Rice. 2.5.Mirrors: 1 - spoon-shaped; 2 - folding

What to look out for

while examining with mirrors?

Pay attention to the following:

The condition of the walls of the vagina (the nature of folding and the color of the mucous membrane, the presence of ulcerations, growths, tumors, etc.);

The condition of the vaults of the vagina and cervix (size, shape - cylindrical, conical; shape of the external opening of the cervical canal);

The presence of pathological conditions (ruptures, eversion of the mucosa, erosion, endometriosis, etc.);

The nature of the vaginal discharge.

What is the technique of vaginal examination?

The study is carried out in rubber sterile gloves in a horizontal position of the patient on the gynecological chair after emptying the bladder and intestines.

Vaginal examination is performed using the index and middle fingers of one (right) hand inserted into the vagina. The labia majora are parted with the thumb and forefinger of the left hand, after which the index and middle fingers of the right hand are carefully inserted into the vagina. In this case, the thumb is directed to the symphysis, the ring finger and little finger are pressed to the palm, and the back side of their main phalanges rests on the perineum.

What is determined

during a vaginal examination?

With a vaginal (one-handed) examination, determine:

Condition of the pelvic floor muscles;

The condition of the large vestibular glands (inflammation, cyst, etc.);

The condition of the urethra (seal, soreness), and in the presence of inflammation in it, discharge is obtained by squeezing;

The condition of the vagina: volume, folding, extensibility, the presence of pathological changes (malformations, scars, stenosis, infiltrates, etc.). The features of the vaginal vaults are determined: depth, soreness. In the presence of free liquid in the pelvis, the posterior fornix may hang (protrude

vayut); with inflammatory processes in the uterine appendages, pelvic peritoneum and vaginal tissue, the vaults can be shortened, rigid, painful, etc.; - the state of the vaginal part of the cervix: size (hypertrophy, hypoplasia), shape (conical, cylindrical, cicatricial deformed, etc.), surface (smooth, bumpy), consistency (usual, softened during pregnancy, dense during cancer and etc.), position along the wire axis of the small pelvis (deflected backwards, anteriorly, to the right or left, lowered - the external pharynx is located below the spinal plane or raised - the external pharynx is above the spinal plane), the state of the external pharynx (closed or open, rounded or slit-like ), mobility (excessively mobile during omission and prolapse of the uterus, motionless or limited mobility during inflammation, advanced cancer, etc.), pain during displacement.

What is the purpose of a two-handed vaginal (combined) examination?

two-handed vaginal examination perform for a detailed acquaintance with the state of the vagina and pelvic floor, cervix, position of the uterus, its size, consistency, pain, mobility; the condition of the uterine appendages on both sides and the condition of the vaginal vaults.

Bimanual vaginal examination is a continuation of the vaginal examination and refers to the main method for recognizing diseases of the uterus, appendages, pelvic peritoneum and fiber (Fig. 2.6).

First of all, the uterus is examined. Both fingers of the hand are inserted into the anterior fornix, the neck is somewhat pushed back. With the palmar surface (not the tips) of the fingers of the outer hand through abdominal wall palpate directed

Rice. 2.6.Bimanual vaginal examination

while anteriorly the body of the uterus with the fingers of both hands. If the body of the uterus is tilted backwards, then the fingers of the outer hand are immersed deep in the direction of the sacrum, and the fingers inner hand are located in the rear vault.

What does the doctor determine when examining the uterus?

When examining the uterus, the doctor determines:

- position of the uterus- Normally, the uterus is in the small pelvis between the plane of the wide part of the small pelvis and the plane of the narrow part of the small pelvis, the body is tilted anteriorly and upwards, the vaginal part is turned down and backwards, the angle between the body and the cervix is ​​open anteriorly - the uterus is in position anteversio-anteflexio along the wire axis of the pelvis in the center of the small pelvis;

- the size of the uterus Normally, the length of the uterus in nulliparous women is 7-8 cm, in those who have given birth - 8-9.5 cm, the width in the bottom area is 4-5.5 cm, the anteroposterior size is 2.5 cm; from overall length uterus 1/3 falls on the body and 2/3 - on the neck (Fig. 2.7);

Rice. 2.7.Change in the size and shape of the uterus depending on age

- the shape of the uterus the uterus of an adult woman is pear-shaped, flattened in the anteroposterior direction, with a smooth surface; spherical shape often observed during pregnancy, adenomyosis (internal endometriosis), and incorrect - in the presence of fibroids, malformations, etc.;

- the consistency of the uterus normal - muscle density, softened - during pregnancy, pyometra, etc .;

- uterine mobility- normal - shifts when moving up, to the bosom, sacrum, to the left, to the right, if available adhesive process uterine mobility is limited or absent; excessive mobility is observed as a result of relaxation of the ligamentous apparatus during the prolapse and prolapse of the uterus;

- uterine tenderness- in the normal state, the uterus is painless, soreness is characteristic of inflammatory processes, malnutrition in the myomatous node, etc.

Having completed the examination of the uterus, proceed to the examination of its appendages. The fingers of the outer and inner hands are gradually moved from the corners of the uterus to the side walls of the pelvis.

A healthy fallopian tube is very thin and soft and is usually not palpable. Healthy ovaries are determined on the side of the uterus, closer to the wall of the small pelvis in the form of small oblong formations. Parametrium and broad ligament in healthy women are not determined. Examination of the appendages reveals volumetric formations(tumors of the ovary), infiltrates, adhesions.

The sacro-uterine ligaments are determined when the cervix is ​​pushed to the womb, especially when they change. Better these ligaments are determined by rectal examination.

We must always remember that in the cavity of the small pelvis, pathological processes can be detected that come not only from the genital organs (dystopic kidney, tumor of the bladder, intestines, omentum).

When is a rectovaginal, rectovaginal, and combined rectovaginal-abdominal examination performed?

Rectal examination is performed in cases where examination through the vagina is impossible (virginity, vaginismus, atresia, extensive ulcerative lesions of the vagina, developmental anomalies, stenosis) (Fig. 2.8). With tumors of the genital organs, especially with cervical cancer, in order to clarify the degree of spread of pro-

the process, in case of inflammatory diseases, to clarify the state of the sacro-uterine ligaments, pararectal tissue, etc., as well as in the presence of pathological discharge from the rectum (blood, mucus, pus), cracks, abrasions, etc., rectovaginal and (or) rectovagino-abdominal examination (Fig. 2.9).

Rice. 2.8.Rectal examination

Rice. 2.9.Combined rectovagino-abdominal examination

What are the additional research methods?

Additional include laboratory, instrumental, endoscopic and radiological research methods.

What research methods are laboratory?

Laboratory research methods in gynecology include: bacterioscopic, bacteriological, cytological, radioimmunological, immunological.

Where do they get the material for bacterioscopic, bacteriological and cytological studies?

For bacterioscopic examination, material is usually taken from the external opening of the urethra, cervical canal, posterolateral fornix of the vagina and rectum and applied in a thin uniform layer on 2 glass slides. After drying, one smear is stained with methylene blue, the other with Gram.

For bacteriological examination, material is sent from the cervical canal; as well as the contents obtained by puncture of the abdominal cavity through the posterior fornix of the vagina, and from the abdominal cavity during surgery. The material obtained from the cervix or from the uterine cavity, from the vagina, as well as ascitic fluid, tumor contents, etc. is subjected to research. The material placed in a sterile tube must be sent to the laboratory within 2 hours.

For cytological examination, the material can be taken from the surface of the vaginal part of the cervix, cervical canal, from uterine cavity, pleural and abdominal cavities. Material for smears is obtained using an Eyre spatula, special brushes (English - cervix brush)(Fig. 2.10), with aspiration of the contents of the uterine cavity (Brown syringe, pipel) or tumor, with paracentesis, as well as by smear-prints.

Rice. 2.10.Cervical cytobrush and cervical spatula

What is determined by the bacterioscopic method?

Bacterioscopic method - determination of the cellular composition (leukocytes, epithelium) and microflora of the contents of the vagina; possible pathogen in swabs taken from the cervical canal, vagina and urethra.

What is the purpose of bacteriological research?

The purpose of the study was to determine the pathogen, its quantitative characteristics and sensitivity to antibiotics in the material taken from the cervical canal, vagina, uterine cavity, abdominal cavity, etc. in acute and chronic inflammatory processes of the genitals. The material is inoculated on nutrient media, infect laboratory animals, chicken embryos or transfer

viable cell cultures sensitive to certain types of microorganisms. Bacterial inoculation on special nutrient media is simple and affordable. These media can also be selective, for example for gonococcus.

How is a smear evaluated during a bacterioscopic examination?

Depending on the nature of the microbial flora, there are 4 degrees (Fig. 2.11) of the purity of the vagina:

I degree of purity - only squamous epithelium cells and lactobacilli (Doderlein sticks) are visible under a microscope, there are no leukocytes, pH is acidic (4.0-4.5);

II degree of purity - less lactobacilli, many epithelial cells, there are single leukocytes (up to 10), pH - acidic (5.0-5.5). I and II degrees of purity are considered normal;

III degree of purity - few lactobacilli, coccal flora and comma variabile dominate, many leukocytes (10-30), pH - slightly alkaline (6.0-6.5);

IV degree of purity - there are no vaginal sticks, a motley bacterial flora prevails, there are single Trichomonas, a lot of leukocytes, few epithelial cells; pH - slightly alkaline.

Rice. 2.11.Four degrees of purity of the vagina

III and IV degrees of vaginal purity indicate the presence of a pathological process and require a quantitative bacteriological study or quantitative PCR (qualitative PCR is only useful for detecting flora that should never be in the vagina and endocervix: treponema, gonococci, chlamydia, Trichomonas).

What ensures the maintenance of eubiosis of the female genital tract?

The maintenance of the normal microflora of the vaginal contents (eubiosis) is facilitated by anatomical, physiological, hormonal, immunological and symbiotic factors:

What refers to the anatomical and physiological factors of maintaining eubiosis?

These include:

Separation of the vagina and the external environment due to the physiological hypertonicity of the muscles of the perineum, the narrowing vulvar ring, the contact of the small and large labia;

A clear distinction between lower and upper divisions genital tract (heterogeneity of the epithelium, thickening of mucus), which greatly limits the possibility of intracanalicular spread of infection;

Hormone-dependent cyclic changes in the epithelium.

What kind hormonal factors contribute to the maintenance of eubiosis?

Maintaining a normal degree of cleanliness is explained by the ability of the vagina to self-cleanse, which depends on the functional activity of the ovaries. The stratified squamous epithelium of the vaginal wall is a hormone-dependent tissue, so the self-cleansing system of the vagina functions due to the cyclic influence of estrogens in the first phase of the cycle and progesterone in the second. Under the influence of estrogens, glycogen is synthesized in the epithelium of the vagina, which is necessary for the formation of lactic acid. Lactic acid bacteria break down glycogen in the epithelium with the formation of lactic acid, the concentration of which in the vaginal contents reaches 0.3-0.5%, which creates a vaginal pH in the range of 4-4.5. This degree of acidity, being optimal for the life of normal microflora

vagina, inhibits the development of microorganisms penetrating from the external environment. Hydrogen peroxide formed at the same time inhibits the growth of anaerobic microorganisms.

How does the microflora of the genital tract change under the influence of progesterone?

In the second phase of the menstrual cycle, under the influence of progesterone, desquamation and cytolysis of the stratified squamous epithelium occur. In connection with menstruation, there is a qualitative and quantitative change in the microflora of the genital tract. A few days before it, the content of facultative bacteria decreases by almost 100 times, while the number of anaerobic bacteria sharply increases. This condition continues during menstrual bleeding and a week after it.

It must be remembered that the III degree occurs in women of reproductive age who are sexually active, at the beginning and at the end of the menstrual cycle, as well as in girls before puberty and in women in menopause. This is explained low content estrogen in the body, which leads to the absence of the surface layer of the vaginal mucosa. As a result, the acidity of the vaginal contents decreases and pathogenetic conditions are created for the development of opportunistic and pathogenic microflora.

What applies to immune mechanisms ensuring eubiosis of the female genital tract?

A powerful obstacle to pathogenic infections is cellular immunity and the local humoral immune defense system, which is based on secretory immunoglobulin A (IgA), produced by the cells of the mucous membrane of the cervix and vagina. Increased activity in the secretions of complement and lysozyme, which, like secretory IgA, promote bacteriolysis, prevents the cytoadhesion of microorganisms to the mucosa. The level of secretory immunological resistance of the genitals, in particular IgA, is regulated by the intensity of antigenic irritation of the mucous membranes by acidophilic lactoflora.

What is the symbiotic factor for maintaining eubiosis?

Symbiosis refers to the mutually beneficial coexistence of microorganisms and the woman's body. At the same time, bacteria create colonization protection against pathogenic microbes in the genital tract, while receiving nutrients, help in the fight against competitive flora, and in some cases, immunological tolerance from the macroorganism.

Saprophytic microflora is considered as an integral part of the host organism involved in the degradation and synthesis of foreign and native substances, the metabolism of nitrogenous and carbohydrate compounds.

What properties allow bacteria to grow on the vaginal mucosa?

The presence of a certain bacterium in the vaginal biotope is determined by two main properties - adhesiveness and resistance. Adhesion is provided special devices bacterial cells (fimbriae, pili) and lekins - glycoproteins, covalently attached to epithelial receptors. The receptor activity of the vaginal epithelium during the menstrual cycle in relation to a number of microorganisms is a variable value. On the epithelial cells of the vagina during the period of ovulation, there is an increase in receptors, and in the late luteal phase - a significant decrease. The number of receptors is limited, and bacteria have to compete for them. If the receptors are occupied by bacteria that make up the normal flora of the genital tract, then the adhesion of pathogenic infections becomes more difficult.

Having fixed on receptors, microorganisms produce glycocalyx - a polysaccharide film that envelops and protects them. Microorganisms attached and covered with glycocalyx are ten times more stable compared to being in a free state.

What are the factors of colonization immunity?

Factors of colonization immunity include:

Competition for adhesion to the epithelium;

acid environment;

Hydrogen peroxide (H 2 O 2), formed during the metabolism of glycogen;

Antagonistic activity against competitive flora;

Increased immunological reactivity and general non-specific resistance of the macroorganism;

Stimulation of reparative processes in mucous membranes.

What is the purpose of a cytological examination?

The method is one of the most important diagnostic methods(oncocytology) and is used for early diagnosis of pathological changes in the epithelium - Pap-test.

Who should be subjected to a cytological examination?

All women with identified pathology of the cervix, and in the absence of such - women older than 30 years. Preventive examination of the cervix with a cytological examination to detect precancerous diseases and preclinical cervical cancer should be carried out up to 40 years once every 3 years and after 40 years - once a year.

What are the types of cytology?

According to the method of obtaining the material, puncture (study of punctates), exfoliative (study of secretions and excreta), excochleation (study of scrapings taken with tampons, sharp objects from lesions) and aspiration (study of aspirates) cytology are distinguished.

What material is subjected to cytological examination in gynecology?

Scraping from the cervical canal and the vaginal part of the cervix, aspirate or scraping from the posterior lower fornix of the vagina, scrapings from the affected areas of the vulva, external pharynx, aspirates from the uterine cavity, ovarian punctures or neoplasms in the vaginal wall are examined.

What tools are needed to take the material?

To obtain the material, you need: Eyre's spatula (designed to obtain ectocervical smears and smears of the posterior fornix), spirette (a special aspiration device designed for ecto- and endocervical aspiration and post-

tcoital tests), screen (for taking endocervical swabs), endobrush (for taking endometrial smears), nylon brushes (English - cervix brush), gynecological tweezers, forceps, grooved probe, Volkmann's spoons, gynecological mirrors, etc. All instruments must be sterile and dry.

What are the cytomorphological features of the normal mucous membrane of the cervix?

The stratified squamous epithelium of the vaginal part of the cervix in women of reproductive age is a highly differentiated tissue with a complex structure and functional features. The epithelium consists of 4 layers: basal, parabasal, intermediate (spiky) and superficial (keratinized) (Fig. 2.12; 2.13). The cells of the basal layer are small, round, sometimes oblong, 15-20 microns in diameter. Their nuclei are large, intensely stained, the cytoplasm is sharply basophilic in the form of a narrow rim. Normally, these cells are found in women in deep menopause.

Rice. 2.12.Schematic representation of the epithelium of the vaginal mucosa: 1 - layer of superficial cells (functional layer);

2 - intraepithelial layer;

3 - intermediate layer; 4 - para-basal layer; 5 - basal

layer

Rice. 2.13.Stratified squamous epithelium

Parabasal cells are round with clear contours, 15 to 18 µm in diameter. Cells lie freely, rarely in the form of clusters. The nuclei in them are intensely colored and located centrally. The cytoplasm is also intensely stained, basophilic, has the appearance of a thin border. They are found in pre- and postmenopausal women.

The cells of the intermediate layer can be round, oval or boat-shaped, with a diameter of 20-25 microns, with a high content of glycogen. They are located separately, less often in single-layer layers. The nuclei are large, with a uniform arrangement of chromatin and fine-grained cytoplasm.

Superficial cells have a polygonal shape and a diameter of 35-50 microns, their cytoplasm is pink, sometimes with tucked edges. The nuclei in them are small, small (pyknotic - less than 6 microns), dark in color due to the high content of chromatin with a central location. These cells are easily desquamated.

How is the cytological picture evaluated?

In a cytological study, the most important cytological features are considered to be polymorphism of cells and their nuclei, pronounced anisochromia of the cytoplasm and nuclei, an increase in the nuclear-cytoplasmic index, an uneven, rough arrangement, an increase in the number of nucleoli, and the detection of figures of mitotic division. The most widespread assessment of cytological changes according to Papanicolaou with the allocation of 5 groups:

Group I - there are no atypical cells, which corresponds to a normal cytological picture;

Group II - changes in the morphology of cellular elements caused by inflammation;

Group III - there are single cells with abnormalities of the cytoplasm and nuclei. In this case, repeated cytological examination or histological examination of the pathologically altered tissue or organ is necessary;

Group IV - individual cells are found with clear signs of malignancy: abnormal cytoplasm, altered nuclei, chromatin aberrations, an increase in the mass of nuclei;

Group V - smears contain a large number of typical cancer cells. The diagnosis of a malignant process is not in doubt.

2.1.1. Functional diagnostic tests

Functional diagnostic tests (TFD) are used to determine functional state reproductive system. These methods are easy to perform in any setting and include karyopyknotic index (KPI) calculation, pupil phenomenon, cervical mucus distension symptom (CRS), fern leaf symptom, measurement rectal temperature.

How is the examination of the patient according to the tests of functional diagnostics?

Morning rectal temperature is measured by the patient herself every morning, without getting out of bed, for 5-7 minutes for 2-3 cycles. Temperature indicators are recorded in the form of a graph. The normal menstrual cycle has two distinct thermal phases: hypothermic (below 37°C), which corresponds to the follicular phase, and hyperthermic (37.2-37.6°C), corresponding to the luteal phase of the cycle (Fig. 2.14).

Figure 2.14.Rectal temperature curve of a healthy woman with normal

menstrual cycle

What determines the nature of the temperature curve?

Temperature cyclic changes depend on the vital activity of the body, nutrition, concomitant extragenital and gynecological diseases and other conditions (therefore, it is necessary to note the reasons that can affect body temperature), but hormonal fluctuations are the basis. When the body is saturated

estrogen, the temperature decreases, and the maximum decrease corresponds to the maximum saturation, which is observed at the end of the first phase of the cycle just before ovulation. With an increase in progesterone levels, basal body temperature rises.

What underlies the symptom of "pupil" and "fern leaf" (test "arborization", crystallization), symptom of cervical mucus distention?

These tests are based on the study of the amount and physico-chemical properties of cervical mucus. Changes in the cervical mucus important role in the preparation of the fertilization process; they can serve as a criterion for the functional state of the female reproductive system. Due to the fact that the diagnostic value of the described tests increases with complex use, based on the phenomena of the "pupil", "fern leaf", stretching of mucus and its amount, one can judge the estrogen saturation of a woman's body during the menstrual cycle.

The assessment of these tests is carried out according to a three-point system or

in "+".

How is the "pupil" symptom assessed?

The "pupil" phenomenon is associated with a change in the amount of mucus depending on the estrogen saturation of the body and a change in the tone of the cervix. On the 8-9th day of MC, vitreous transparent mucus appears in the expanded external opening of the cervical canal. By the 10-14th day of the cycle, the opening of the cervical canal expands to 1/4 cm in diameter, rounds, becomes black, shiny. During a gynecological examination of the naked cervix using mirrors and the direction of a beam of light, the external pharynx with a protruding drop of mucus appears dark and resembles a pupil (positive "pupil" symptom). In the following days of the cycle, the amount of mucus decreases again, the mucus disappears, the cervix becomes dry ( negative symptom"pupil").

How is the symptom of tension (stretching) assessed?

To assess this indicator, it is necessary, after examining the symptom of the "pupil", to capture the cervical mucus with the branches of anatomical tweezers or forceps. After removing the tool

it is necessary to dilute its branches and measure how long the mucus stretches. The length of the thread of cervical mucus depends on the level of estrogen and reaches its maximum by ovulation.

How is the fern leaf symptom assessed?

The fern leaf symptom is based on the ability of cervical mucus to form crystals when dried and allows you to clarify the presence of ovulation. The reason for crystallization is considered to be changes in the physicochemical properties of mucus under the influence of estrogens (interaction of sodium chloride and polysaccharides, colloids and mucin, pH of mucus) (Fig. 2.15). After evaluating the symptom of cervical mucus stretching, it should be applied in a thin layer on a glass slide and dried at room temperature. After 15-30 minutes, the preparation without staining is examined under a microscope at low magnification. From the 1st to the 8th day of the menstrual cycle, the fern leaf symptom is negative. From the 9th day, the first signs of crystallization appear, which reaches its maximum by the 12-14th day. From the 17th-18th day, the pattern of crystallization loses its clarity, and from the 20th-22nd day, the mucus stops crystallizing (Fig. 2.16).

Rice. 2.15.Crystallization of cervical mucus

Rice. 2.16.Types of cervical mucus crystallization during the menstrual cycle: a - on the 10th day of the cycle; b - on the 14th day; c - on the 15th day; g - on the 22nd day

What changes occur in the epithelium of the vagina during the menstrual cycle?

The vaginal epithelium, like the endometrium, is subject to cyclical changes during MC. Particularly sensitive to hormonal influences the upper third of the vagina, which has an embryological relationship with the internal genital organs, since they develop from the Müllerian passages (as well as the uterus, ovaries and tubes).

At the beginning of the folliculin phase, the cells of the vaginal epithelium grow, mainly through the cells of the basal layer. As ovulation approaches, the cells differentiate, the number of epithelial layers increases due to intermediate cells. By ovulation, the epithelium reaches its maximum thickness due to the surface layer; loosening occurs. In the luteal phase, the growth of the epithelium stops and its desquamation occurs. During menstruation, the superficial and partially intermediate layers of the vaginal epithelium are shed.

What is hormonal cytodiagnosis based on?

The quantitative ratio of cells in a smear and their morphological characteristics are the basis of hormonal cytological diagnostics.

Cytological examination of the vaginal contents allows you to evaluate the CPI - the percentage of superficial cells with pyknotic nuclei to the total number of cells.

How is a smear prepared for this study?

The material must be taken before bimanual examination and vaginal manipulations, best of all from the lateral fornix using a Papanicolaou pipette, a Brown syringe, an Eyre spatula, tweezers, etc. A thin, even layer of material is applied to a glass slide, which is fixed with a Nikiforov mixture, followed by polychrome staining (hematoxylin and eosin). The finished product is studied under a light microscope with the calculation of the KPI.

The maturation index (IS) is also calculated - the percentage of superficial, intermediate and parabasal cells and the eosinophilic index (EI) - the percentage of cells with eosinophilic stained cytoplasm to cells with basophilic cytoplasm.

How else is a colpocytogram evaluated?

The following colpocytological types or reactions are distinguished.

First reaction.The smear contains predominantly basal cells and leukocytes. This type is characteristic of severe hypoestrogenism.

Second reaction.In the smear, basal and intermediate cells and leukocytes with a predominance of basal cells and leukocytes. This reaction is typical for significant estrogen deficiency.

Third reaction.The smear is represented by intermediate cells with single parabasal cells. The reaction is typical for moderate hypoestrogenism.

fourth reaction. The smear consists of keratinized cells, basal cells and leukocytes are absent. This smear characterizes sufficient estrogen saturation of the body.

On which days of the menstrual cycle should swabs be taken?

Smears are taken during the cycle daily, every other day or every 2 days - 10-25 serial smears (“long tape” of studies). You can take four smears (“short tape”): on the 7th day (early proliferative phase), on the 14th (late proliferative), 21st and 28th days of the cycle (secretory). The doctor evaluates other tests in parallel with taking smears for hormonal cytodiagnosis.

The total duration of the examination according to the tests of functional diagnostics is 3-4 months. and more (according to indications).

In table. 2.2 shows the main indicators of TFD during a normal menstrual cycle in women of reproductive age.

Table 2.2.Indicators of tests of functional diagnostics in the dynamics of the ovulatory cycle in women of reproductive age

End of table 2.2

The monophasic nature of the temperature curve, constantly high or low levels of other TFDs indicate a violation of the ovulation process (anovulatory menstrual cycles) and contribute to the diagnosis of hyper or hypoestrogenism.

What is cervical number?

Since the diagnostic value of the described tests increases with complex application, then, on the basis of the phenomena of the "pupil", "fern leaf", mucus tension and its amount, B. Insler (1970) proposed a table that allows estimating the so-called cervical index in points, which is very convenient use in everyday practice (Table 2.3).

Table 2.3.Cervical index score

Cervical index 0-3 points indicates a sharp, 4-6 points - moderate estrogen deficiency, 7-9 points - sufficient, and 10-12 points - their increased secretion.

What other research method refers to the tests of functional diagnostics?

Endometrial scraping examination is one of the most common TFD. Material for analysis is most often obtained by curettage, which must be complete, which also gives a therapeutic effect, for example, with dysfunctional uterine bleeding (DUB).

You can also use the vacuum aspiration method as it is less traumatic and gives good results. When evaluating histological preparations, the morphological features of the functional layer of the endometrium, the nature of the structure of the stroma and glands, as well as the features of the glandular epithelium are taken into account.

It should be remembered that the presence of inflammatory diseases of the genitals, especially the vagina, cervix and uterus, limit the value of TPD.

What are the additional methods for studying the hormonal status?

Determination of hormones and their metabolites. To determine the content of gonadotropins, steroid hormones of the ovaries and adrenal glands in the blood, radioimmunological and enzyme immunoassay methods are used. The study of the content of hormones in the urine is carried out less often. The exceptions are 17-corticosteroids (17-CS) and pregnandiol. 17-KS are androgen metabolites with a ketone group at the 17th carbon atom, dehydroepiandrosterone and its sulfate, androstenedione and androsterone.

To diagnose early pregnancy (especially if an ectopic pregnancy is suspected), β-hCG in the blood is determined, which, together with transvaginal ultrasound, is the “gold” standard for diagnosing ectopic pregnancy.

In trophoblastic disease, the level of hCG in the urine is examined.

What functional pharmacological tests and for what purpose are used to clarify the level of damage to the endocrine system?

Functional pharmacological tests. A single determination of hormones and their metabolites in the blood and urine is not very informative, therefore, these studies are often combined with functional pharmacological tests, which makes it possible to clarify the functional states various departments reproductive system and find out the reserve capacity of the hypothalamus, pituitary gland, adrenal glands, ovaries and endometrium.

Hormonal tests also help to clarify the level of damage to the endocrine system (hypothalamic-pituitary system, ovaries, adrenal cortex).

The most commonly used functional tests with gestagens; estrogens and gestagens; dexamethasone; clomiphene; luliberin nom.

What is a progesterone test for?

progesterone test it is applied for:

Determining the level of estrogenic saturation of the body with amenorrhea;

Determining an adequate response of the endometrium to the action of progesterone and the features of rejection of the uterine mucosa with a decrease in the level of this hormone.

For this, gestagens are used: orgametril (linesterol), duphaston (dihydrosterone) 10 mg per day for 10 days. The total dose of the drug should be at least 100 mg, which corresponds to the level of progesterone secretion in the II phase of the cycle. Along with oral gestagens, a 1% solution of progesterone is used, 1 ml per day for 10 days, or a solution of 17-hydroxyprogesterone capronate (17-OPC), 125-250 mg once intramuscularly. The reaction is regarded as natural if, 3-7 days after the end of taking the progestogens, moderate spotting appears (the so-called menstrual-like reaction) that persists for 3-4 days. The absence of a menstrual-like reaction indicates a sharp decrease in the level of estradiol, the absence of proliferative processes in the endometrium, or the complete absence of the endometrium.

What hormonal tests are carried out

with a negative progesterone test?

In case of a negative progesterone test, it is necessary to carry out cyclic test with sequential administration of estrogen and progesterone. Estrogens: microfollin (ethinyl estradiol 50 mcg in 1 tablet), premarin (conjugated estrogens 625 mg in 1 tablet) are prescribed for 10-12 days until the cervical number increases to 10 or more points. Then prescribe gestagens in the above dose. The appearance of a regular menstrual-like reaction indicates the presence of an endometrium that is sensitive to the action of hormones. The absence of bloody discharge (negative cyclic test) indicates the uterine form of amenorrhea (intrauterine synechia - Asherman's syndrome).

You can also test with synthetic estrogen-progestin drugs, such as marvelon ((ethinylestradiol 0.03 mg and levonorgestrel 0.15 mg in 1 tab.), Silest (ethinylestradiol 0.03 and norgestimate 0.25 mg in 1 tab. ), femoden (ethinylestradiol 0.03 mg and gestodene 0.075 mg in 1 tablet), demulen (ethinylestradiol 0.035 mg and ethinodiol diacetate 1 mg in 1 tablet), trisiston, or triquilar (ethinylestradiol 0.03 mg and levonorgestrel 0.05 mg or ethinylestradiol 0.04 mg and levonorgestrel 0.075 mg or ethinylestradiol 0.03 mg and levonorgestrel 0.125 mg in 1 tablet), which are prescribed 1 tablet (pellet) per day for 21 days. The appearance after 3-5 days of a regular menstrual-like reaction indicates about the normal reception of the endometrium to steroid hormones.

Which patients are tested with clomiphene?

Test with clomiphene carried out in patients with irregular menstruation or amenorrhea after an induced menstrual-like reaction. For this, 50 mg of the drug is prescribed from the 5th to the 9th day of the cycle. The test is considered positive if 3-8 days after the end of taking clomiphene, an increase in basal temperature begins, which is a sign of sufficient synthesis of steroids in the follicle and preserved reserve capacity of the pituitary gland. The response to the introduction of clomiphene can be assessed by the results of ultrasound of the follicle and endometrium. With a negative clomiphene test, it is recommended to increase the dose of the drug to 100 mg in the 2nd cycle and up to 150 mg in the 3rd cycle. Further increase in dose is not advisable.

With a negative test with clomiphene, a test with gonadotropins is indicated.

What is the purpose of the metoclopramide test?

Test with metoclopramide carried out for the differential diagnosis of hyperprolactin states. After a preliminary determination of the initial level of Prl, 10 mg of metoclopramide is administered intravenously, followed by blood sampling after 30 and 60 minutes. With a positive test at the 30th minute, the level of PL in the blood plasma increases by 5-10 times, which indicates the preserved prolactin-secreting function of the pituitary gland. A negative reaction (the absence of an increase in the level of PL in the blood plasma) is characteristic of a prolactin-secreting pituitary tumor.

Why is a dexamethasone test performed?

Dexamethasone test carried out to clarify the genesis of hyperandrogenism. For this purpose, 0.5 mg of dexamethasone is prescribed every 6 hours for 2 days. 2 days before the test and on the 2nd day after taking the drug, daily urine is collected to determine the level of 17-KS or dehydroepiandrosterone sulfate (DEA-S).

With a positive test, the levels of 17-KS or DEA-C are reduced by more than 50%, which indicates the presence of functional disorders of the adrenal cortex. With a negative test, i.e. with a drop in the level of 17-KS and DEA-C by less than 25-50%, the tumor genesis of hyperandrogenism is diagnosed.

What tests are used to determine the function of the pituitary and ovaries?

Gonadotropin releasing hormone (RG-GN) test. The main indication for this test is to clarify the issue of damage to the pituitary gland in amenorrhea of ​​central origin. Evaluation of the sample with RG-GN is carried out on the basis of the study of the content of FSH and LH in the blood using radioimmune or enzyme immunoassay methods. In the presence of a tumor or necrosis of the pituitary gland, the test with RG-GN is negative, i.e. there is no increase in FSH production. If the test indicates the normal function of the pituitary gland, then the amenorrhea of ​​the central genesis is due to damage to the hypothalamus.

FSH testused to determine the functional state of the ovaries (with amenorrhea, delayed sexual development, etc.). For this, pergonal is used (75 IU FSH and 75 IU LH). After the administration of the drug, the content of estrogen in the blood is determined for 10 days and the dynamics of TFD is monitored. A positive test indicates normal ovarian function.

Test with choriogonin (chorionic gonadotropin in ampoules of 500, 1500 and 5000 IU) is used to clarify the condition of the ovaries. Choriogonin is prescribed intramuscularly for 5 days at 1500-5000 IU. The results are evaluated by an increase in the content of progesterone in the blood and basal temperature above 37? If the ovaries are able to respond functionally to the stimulating effect of choriogonin, after its administration, the formation of the corpus luteum hormone is enhanced, which indicates the central genesis of disorders. Negative test results confirm the presence of primary ovarian inferiority.

What tests are performed to determine the function of the adrenal glands?

Adrenocorticotropic hormone (ACTH) test carried out to determine the functional state of the adrenal cortex. The introduction of ACTH 40 IU intramuscularly for 2 days causes a sharp increase in the content of 17-KS in the urine with the adrenal genesis of the disease and a slight increase in the ovarian one.

To diagnose hyperandrogenism, instead of the previously widely used method for determining 17-KS (androgen metabolites) in the urine, the content of dehydroepiandrosterone and 17-hydroxyprogesterone (testosterone precursors) and testosterone itself are currently determined in the blood.

What serves as an object

for histological examination?

Test with ACTH analog - synacthen-depot (tetracosactide 1 mg in 1 ml) - is carried out in order to exclude late manifestations of a defect in the adrenal enzyme 21-hydroxylase in carriers of the mutant allele.

What serves as an object

for histological examination?

Usually, for histological examination, the removed tissue of the mucous membrane of the cervical canal and the mucous membrane of the body of the uterus, obtained during separate diagnostic curettage, biopsies, as well as the removed organ or part of it, are sent.

What are the indications for immunological

and medical genetic research methods?

Immunological studies used in the study of the pathogenesis of certain forms of infertility in inflammatory diseases. Tuberculin tests are widely used to diagnose tuberculosis.

Study of immunoreactivity (Early ght-inducedProteins, EYP-test). The levels of autoantibodies to the MBP, S100, ASVR14/18 and MP65 proteins in fresh blood serum are determined, which are expressed as a percentage (arbitrary units) of the reaction level of the control serum (standard) with the indicated proteins. Physiological values ​​of immunoreactivity in more than 95% of healthy individuals are in the range from -25% to +30% of the level of the reference reaction with the same proteins (the "reaction rate" of natural antibodies to the proteins used).

The results of the ELIP-test are defined as normo-, hypo- and hyperreactivity. The values ​​of the determined indicators do not depend on the presence or absence of pregnancy.

Medico-genetic methods are indicated for violations of sexual development, some forms of menstrual irregularities, habitual miscarriage of short terms, infertility, malformations of the genital organs, gonadal dysgenesis, etc.

What are the cytogenetic research methods?

These methods include:

Determination of sex chromatin and karyotyping;

Carrying out chromosomal analysis;

Biochemical studies that make it possible to identify hereditary disorders metabolism associated with enzymopathy;

Drawing up a genealogical chart that allows you to assess the likelihood of certain hereditary traits in members of the family under study.

What are markers chromosomal abnormalities?

Markers of chromosomal abnormalities are multiple, often erased somatic developmental anomalies and dysplasia, as well as changes in sex chromatin, which is determined in cell nuclei

surface epithelium of the mucous membrane of the inner surface of the cheek, removed with a spatula (screening test). Final Diagnosis chromosomal abnormalities can only be established based on the definition of the karyotype.

What are the indications for a karyotype study?

Indications for the study of the karyotype are deviations in the amount of sex chromatin, short stature, multiple, often erased somatic developmental anomalies and dysplasia, as well as malformations, multiple deformities or spontaneous miscarriages in early pregnancy in a family history.

Determination of the karyotype is an indispensable condition for the examination of patients with gonadal dysgenesis.

Serological studies are based on an antigen-antibody reaction and give indirect indications of infection. These include determining the level of specific immunoglobulins of various classes (IgA, IgG, IgM) in blood serum by enzyme immunoassay (ELISA).

The reaction of PIF and indirect immunofluorescence (INIF) is used to identify the pathogen with fluorescent microscopy.

DNA diagnostics. Currently, for the diagnosis of sexually transmitted diseases, the method of DNA diagnostics or polymerase chain reaction(PCR). The study is subjected to scrapings of epithelial cells, blood, serum, urine and other biological secretions. The method is based on complementary completion of the DNA template, carried out in vitro using the DNA polymerase enzyme.

Determination of the GP gene Shb. The GP IIIa gene is located on the long arm of chromosome 17 and is represented by two allelic forms, PLA1 and PLA2. The gene is determined in the patient's blood and is of great practical importance for the early diagnosis and prediction of the development of a number of gynecological diseases (myoma, endometriosis, etc.).

Definition of tumor markers. For early (preclinical) diagnosis and for differential diagnosis of tumor processes, the determination of tumor-associated antigens CA-125, CEA, CA-19-9, MCA in the patient's blood is used, which makes it possible to detect malignant formations of the ovaries and uterus in 84-87%.

RO test (growth-tumor test). In order to improve and simplify the diagnosis of malignant tumors in the early stages of the process, a new universal diagnostic test for tumor growth- RO-test, which is also proposed to be used as a screening method for the formation of groups of increased risk of tumor formation in gynecological patients for the purpose of early diagnosis of benign and malignant tumors. This is an early diagnostic method based on the discovery of an embryonic surface antigen in the membrane of a cancer cell, which is a universal marker for cells of all malignant tumors. This gene is detected using a special indicator serum. The RO test makes it possible to detect various human tumors with almost equal efficiency, regardless of its location and at any clinical stage of the development of the process.

The highest RO-test values ​​were found in endometrioid cysts, serous ovarian cystomas, especially in malignant tumors of the genitals. The determination of the RO test in combination with oncological markers (CA-125, CEA, CA-19-9) for the diagnosis of tumors of the female genital organs is very informative. Thus, an increase in the RO test and CA-125 indicates the appearance of a relapse of the disease.

What methods are instrumental?

Probing of the uterus. This method is used to determine the patency of the cervical canal, the length of the uterus, the presence of a tumor in it, polyps, deformation of the uterine cavity, anomalies in the development of the uterus, as well as before intrauterine interventions, amputation of the cervix, etc.

The uterine cavity is probed with a flexible metal uterine probe (Fig. 2.17) 20-30 cm long, at one end of which there is a button-like thickening, and the other end is made in the form of a flat handle. The probe has centimeter divisions, which makes it possible to use the probe as a measuring instrument.

Rice. 2.17. Uterine probe

Probing of the uterus is performed under strict aseptic and antiseptic conditions. Probing requires spoon-shaped mirrors, a lift, bullet forceps, forceps and a uterine probe.

After a bimanual examination, the cervix is ​​exposed using mirrors and fixed with bullet forceps, and then carefully

a probe is introduced into the cervical canal and the uterine cavity. It is important to note that with anteflexia of the uterus, the button of the probe is directed anteriorly, with retroflexion - posteriorly. Inserting the probe into the uterine cavity to the bottom, determine the length of the uterus, the shape of the cavity, the presence of deformations (tumors), roughness (polyps) of the septum in it (Fig. 2.18).

Rice. 2.18.Probing the uterus with a bellied probe

What are the complications of probing the uterus?

When probing are possible: perforation, bleeding, infection.

When is uterine probing contraindicated?

Probing for diagnostic purposes is contraindicated:

In acute and chronic inflammatory diseases of the uterus and appendages;

If there is an established or suspected pregnancy;

With a decaying tumor of the cervix.

What is the purpose of conducting a test with bullet tongs?

Test with bullet tongs. This method is used in cases where a mobile tumor is found in the abdominal cavity and it is necessary to clarify the relationship of the tumor with the genital organs. For this, you need: spoon-shaped mirrors, a lift, bullet tongs (Fig. 2.19). Under aseptic conditions, the cervix is ​​exposed and bullet forceps are applied to the front lip, after which the mirrors are removed and

the index and middle fingers (or one finger into the rectum) are inserted into the vagina, and the lower pole of the tumor is pushed upward through the anterior abdominal wall with the left hand. At the same time, the assistant pulls on the bullet forceps, displacing the uterus downwards (Fig. 2.20). In this case, the leg of the tumor emanating from the genital organs becomes more accessible for palpation.

For palpation, you can apply another technique. Bullet forceps are left hanging freely, and by external methods of palpation, the tumor is displaced upward, to the right, to the left. If the tumor comes from the genital organs, then the forceps are drawn into the vagina when the tumor is moved, and with a tumor of the uterus, the movement of the forceps is more pronounced than with a tumor of the appendages. If the tumor comes from other organs of the abdominal cavity (kidney, intestines), the forceps do not change their position.

What is the procedure for cervical biopsy?

Biopsy of the cervix consists in excision with a scalpel of a wedge-shaped area, including both all altered and unchanged tissue during pathological processes of the cervix, vagina, vulva and external genital organs (Fig. 2.21). The following instruments are required for biopsy production: spoon-shaped mirrors, elevator, bullet forceps, scalpel, scissors, needle holder, suture

Rice. 2.19. bullet tongs

Rice. 2.20.Test with bullet tongs

Rice. 2.21.Biopsy of the cervix

material. Under aseptic conditions, the cervix is ​​exposed using mirrors, bullet forceps are applied to both sides of the area to be removed. A wedge-shaped piece of tissue is excised with a scalpel, followed by the application of an absorbable suture (sutures) to the wound. The resulting material is placed in a container with a 10% formalin solution and sent to the laboratory. Tissue for examination can also be obtained by cone-shaped diathermoexcision, excision with a CO 2 laser and a radioknife.

What is the technique for taking an endometrial train?

Material for research is obtained by aspirating the contents of the uterine cavity, and in its absence - by flushing (2-3 ml of isotonic sodium chloride solution is injected into the uterine cavity, followed by its suction and centrifugation).

What is the technique of separate diagnostic curettage of the uterine mucosa?

Diagnostic curettage of the mucous membrane of the body of the uterus and the mucous membrane of the cervical canal is widely used in gynecological practice to determine the state of the endometrium and the mucous membrane of the cervical canal and is one of the types of biopsy. It is produced for uterine bleeding, which causes a suspicion of a malignant tumor (cancer, choriocarcinoma), for suspected remnants of the fetal egg, endometrial polyposis, and also to determine the cause of menstrual irregularities (cyclic and acyclic bleeding unclear etiology). With the saved rhythm of the menstrual cycle, curettage is performed 2-3 days before the next menstruation with acyclic bleeding (during bleeding). For curettage, spoon-shaped vaginal mirrors, a uterine probe, a set of Hegar dilators, a set

curettes. Under aseptic conditions, spoon-shaped mirrors are inserted into the vagina and the cervix is ​​fixed with bullet forceps. With separate scraping, first, with a small curette without expansion, the mucous membrane of the cervical canal is scraped, the resulting scraping is placed in a container with a 10% formalin solution. Then, to clarify the position of the uterus and the length of its cavity, probing is performed. The cervical canal is expanded with Hegar dilators, after which the second (large) curette is used to sequentially scrape the mucous membrane of the uterine body from the bottom to the cervical canal. The uterine corners are especially carefully scraped. Scraping is performed up to the basal layer; the resulting scraping is also placed in a container with a 10% formalin solution and sent to the laboratory together with the first scraping.

Separate diagnostic curettage is contraindicated in acute and subacute inflammatory processes, gonorrheal endocervicitis.

What is a puncture of the abdominal cavity through the posterior fornix of the vagina?

Puncture of the abdominal cavity through the posterior fornix of the vagina - a widespread and effective diagnostic research method to determine the nature of the fluid (pus, blood, exudate) contained in the recto-uterine cavity (Fig. 2.22).

Rice. 2.22.Puncture through the posterior fornix of the vagina

Indications for puncture are:

Suspicion of an interrupted ectopic pregnancy;

Apoplexy of the ovary;

Abscess of the uterine appendages (pyovar, pyosalpinx), if its lower pole is close to the back of the vaginal fornix;

Inflammatory diseases accompanied by the formation of exudate in the recto-uterine cavity, in order to identify the nature of the exudate and laboratory, cytological and bacterial studies.

If a malignant tumor of the uterine appendages is suspected, puncture is contraindicated, since it can lead to metastasis of tumor cells.

Puncture of the abdominal cavity through the posterior fornix can be performed in two ways: using mirrors and using fingers. The first method is more often used, for which they use spoon-shaped mirrors, bullet forceps, forceps, a 10 ml syringe, a puncture needle 10-12 cm long with a wide lumen. After treatment of the vulva and vagina with 40% alcohol and 2% iodine solution, the cervix is ​​exposed using mirrors, fixed by the back lip with bullet forceps and pulled forward and upward. In the center of the posterior fornix along the midline (between the sacro-uterine ligaments), a thick needle is inserted, put on a syringe, to a depth of 1-2 cm or deeper in the presence of infiltrates. The liquid is sucked off with a piston, while slowly removing the needle.

Trial cutting. Transsection for diagnostic purposes is currently rarely performed, when it is impossible to determine the nature of the disease by other research methods.

What methods are endoscopic?

Endoscopic research methods include:

Vaginoscopy - widely used in pediatric gynecology;

Colposcopy is the first endoscopic method that has found wide application in gynecological practice. Colposcopy allows you to make a detailed examination of the vaginal part of the cervix, the walls of the vagina and the vulva under a magnification of 10-30 times and determine the place for the production of targeted biopsy;

Hysterocervicoscopy reveals intrauterine pathology and monitor therapy

Laparoscopy - examination of the pelvic organs and abdominal cavity against the background of pneumoperitoneum;

Chromolaparoscopy - the introduction of methylene blue into the uterine cavity to assess the patency of the fallopian tubes during laparoscopy.

What is the purpose of a colposcopy?

The purpose of a colposcopic examination is to study the features of the external genitalia, vagina and cervix using an optical system under magnification to increase the information content of clinical and cytological data.

What is the method of colposcopy based on?

The method is based on identifying differences in relief and blood vessels in the epithelium unchanged and affected by the pathological process.

What are the objectives of a colposcopy?

The tasks of colposcopy are:

Primary and secondary cancer screening;

Determination of the nature and localization of the pathological process on the cervix, vagina, vulva;

Justification of the need for additional morphological (cytological, histological) research methods;

Determining the place and method of taking material for additional research (biopsy, conization of the cervix);

Determination of the method of treatment of the identified pathology;

Evaluation of the effectiveness of the therapy;

Dispensary observation of women at risk of developing pathology of the cervix, vagina and external genital organs, as well as with background and precancerous conditions for the timely treatment and prevention of visual forms of gynecological cancer.

How is a colposcopy performed?

Colposcopy is performed before bimanual examination or other manipulations. Clockwise or first inspect the front and then the back lip.

What are the types of colposcopy?

There are simple colposcopy (survey), extended, color (chromocolposcopy), luminescent and microcolposcopy.

What is evaluated during a simple colposcopy?

A simple (survey) colposcopy is performed at the beginning of the study, and it is a purely indicative method. After removing the discharge from the surface of the cervix and without treating it with any substances, the shape and size of the cervix, its surface, the presence of old tears and their nature, the features of the external os, the border of the squamous and cylindrical epithelium, the color and relief of the mucous membrane, the features of the vascular drawing, evaluate the nature of the discharge, and also take material for cytological, bacterioscopic, bakeriological studies.

What is an extended colposcopy?

An extended colposcopy is performed after a simple colposcopy, which involves the use of special markers (3% acetic acid solution and Lugol's solution) to treat the cervix, which allows the observation of a number of epithelial and vascular tests. For better visualization of the colposcopic picture, color filters of the colposcope are used: blue and yellow - to study the epithelial cover, green - to identify the vascular network.

How is an extended colposcopy performed?

First, a 3% solution of acetic acid is applied to the vaginal part of the cervix with a swab. After 30-60 s, coagulation of extracellular and intracellular mucus occurs, short-term edema of the epithelium occurs, swelling of the cells of the spinous layer, subepithelial vessels contract, and blood supply to tissues decreases.

The reaction of vessels to a solution of acetic acid is of great diagnostic importance. It is known that the wall of vessels in malignant processes and retention formations is devoid of a muscular layer and consists only of endothelium, therefore, newly formed vessels do not react to acetic acid (negative reaction). Normal vessels, including vessels in inflammatory processes, respond to acetic acid: shrink and disappear from view.

The second stage of extended colposcopy is Schiller's test with Lugol's solution. Under the action of Lugol's solution, the mature stratified squamous epithelium, rich in glycogen, is stained in dark brown color, which indicates the normal condition of the cervix. When the epithelium is damaged, the content of glycogen in it changes, and the treated area looks more lightly colored (iodine-negative), and the test is considered positive. Iodine-negative are the following epithelial structures of the cervix: prismatic (cylindrical) and metaplastic (turned from it) epithelium, areas of dysplasia, elements of cancer. In addition, areas of thinned squamous epithelium are not stained due to a sharp decrease in the thickness of the intermediate layer, the cells of which are rich in glycogen, and the inflamed mucous membrane. Schiller's test makes it possible to accurately determine the localization and boundaries of the pathological process, but does not allow to differentiate its nature.

What is chromocolposcopy?

A modification of extended colposcopy is chromocolposcopy. Chromocolposcopy - staining of the vaginal part of the cervix with various dyes (methylene blue and hematoxylin) followed by a colposcopic examination.

When using methylene blue, the unchanged stratified squamous epithelium is stained light blue, the foci of dysplasia and early cancer are intense blue, and the ectopic prismatic epithelium and areas of true erosion are not stained.

With a hematoxylin test, the unchanged stratified squamous epithelium becomes pale purple, the prismatic epithelium without metaplasia turns pale blue, the areas of leukoplakia look pale white, the areas of malignancy turn intense blue. The use of chromocolposcopy allows, along with the clarification of the pathological process, to determine the outer boundaries of the lesion.

What is colpomicroscopy?

Colpomicroscopy is an intravital histological examination of the mucous membrane of the cervix using an optical device that allows you to examine the epithelial cover under magnification.

I eat 160-280 times and subepithelial vessels at a depth of 70 microns. The method allows you to study the structure of tissues without violating the integrity of its cells.

Before examination, the cervix is ​​washed with isotonic sodium chloride solution. A 0.1% solution of toluidine blue or hematoxylin is used for staining. With luminescent colpomicroscopy, a solution of acridine orange is used as a marker of the cervix. Explore the structural features of the nuclei and cytoplasm of the surface layers of the epithelium. The method is not informative enough to assess the state of the endocervix and in a number of pathological conditions (vaginal stenosis, necrotic changes and hemorrhagic syndrome from the tissues of the cervix). Unlike the histological method, it is impossible to make a differential diagnosis of carcinoma in situ and invasive cancer, since there is not enough information about the morphology of the surface layer of the epithelium for this.

What are the indications for cervicohysteroscopy?

The indications are:

Pathological uterine bleeding in patients of the perimenopausal and postmenopausal periods, due to the presence of submucous / intramural uterine fibroids, endometrial polyps, endometrial hyperplasia, endometrial cancer, adenomyosis, intrauterine contraceptives (IUDs);

Infertility (primary infertility, pathological changes during metrosalpingography, examination before IVF, habitual miscarriages) caused by uterine fibroids, endometrial polyps, Asherman's syndrome, obliteration of the fallopian tubes, abnormal development of the uterus (intrauterine septum, bicornuate uterus, uterus doubling, etc.);

Determination of the location of the IUD and foreign bodies in the uterine cavity;

Pathology of pregnancy (pregnancy against the background of ICH, embryoscopy, localization of the placenta, ectopic pregnancy, remnants of the fetal egg, postpartum hemorrhage);

Pathology of the cervix (polyps of the cervical canal, examination of the border of the stratified squamous epithelium, pathology of the vessels of the cervix);

Control study after surgical interventions (hysteroresection of submucosal fibroids, conservative myomectomy, caesarean section, dissection of the intrauterine septum, separation of intrauterine synechia);

Endometrial cancer - to determine the prevalence of the process, control the effectiveness of treatment (in case of refusal of surgical treatment);

Monitoring the effectiveness of sterilization (visualization of occlusion of the fallopian tubes).

What are the contraindications for cervicohysteroscopy?

Distinguish between absolute (insufficient qualifications of the surgeon, inadequate instrumentation, untrained patient, advanced cervical cancer, acute inflammatory diseases of the pelvic organs) and relative (chronic cervicitis and / or endometritis, active uterine bleeding, cervical stenosis, concomitant extragenital pathology in the stage of decompensation) contraindications.

What can be combined with cervicohysteroscopy?

Cervicohysteroscopy can also be combined with minor surgical interventions such as targeted endometrial biopsy with biopsy forceps; removal of single, small polyps of the endometrium and endocervix using hysteroscopic scissors and grasping forceps; point electrocoagulation of the bases of small polyps of the endometrium and endocervix with a buttoned monopolar electrode; laser destruction of the bases of small polyps; removal of the IUD, as well as the removal of submucosal nodes of uterine fibroids.

What are the possible complications of cervicohysteroscopy?

Complications during diagnostic and operative hysteroscopy can be caused both by the environment for expanding the uterine cavity (liquid overload of the vascular bed, cardiac arrhythmia, air embolism), and surgical complications(perforation of the uterus, bleeding).

What are the indications for laparoscopy?

Indications for laparoscopy are the need for differential diagnosis of tumors of the uterus and appendages, tumors and tumor-like formations of the uterine appendages of inflammatory etiology, suspicion of sclerocystic ovaries, external endometriosis, anomalies in the development of internal genital organs, as well as to clarify the causes of infertility and pain of unclear etiology.

What are the indications for emergency laparoscopy?

Emergency indications for laparoscopy are the need to differentiate such acute surgical and gynecological diseases as acute appendicitis, suspected rupture of the pyosalpinx or ovarian cyst, ovarian apoplexy, tubal pregnancy (progressive or impaired), torsion of the ovarian cyst legs, uterine perforation.

At present, it is widely operative laparoscopy, with the help of which about 75% of all gynecological operations are performed in the world.

Which methods are

to radiological?

X-ray of the bones of the skull and the Turkish saddle widely used in neurodiagnostics endocrine diseases. The study of the shape, size and contours of the Turkish saddle - the bone bed of the pituitary gland - is necessary for the diagnosis of a pituitary tumor.

Chest X-ray - a mandatory method of examination for trophoblastic disease.

Hysterosalpingography (HHA) or metrosalpingography(MSG). Most often, HSG is performed to determine the patency of the fallopian tubes, submucosal or centropetal growth of the myomatous node, as well as to diagnose anomalies and malformations, internal endometriosis (adenomyosis), etc. (Fig. 2.23). For the production of HSG, spoon-shaped mirrors, a lift, bullet forceps, a forceps, a uterine probe, a uterine cannula, a 10 ml syringe, a water-soluble contrast agent are needed.

in, for example, trazograph, urotrast (60% amidotriosate sodium solution), cardiotrast, omnipak (iohexol), etc. The study is carried out in the x-ray room in the horizontal position of the patient. Under aseptic conditions, the cervix is ​​exposed using mirrors, fixed by the anterior lip with bullet forceps, and after careful probing, the uterine cannula is inserted into the cervical canal, to which a syringe with a contrast agent is connected. Under the control of an X-ray television installation, 5-6-8 ml of a contrast agent is injected into the uterine cavity, followed by radiography. When determining the patency of the pipes, a 2nd picture is taken after 5-10 minutes, and according to indications, the 3rd picture is taken after 24 hours.

HSG is contraindicated in acute and subacute inflammatory diseases, erosion, III and IV degree of purity of vaginal contents, suspected pregnancy, and allergy to iodine.

What other research methods are used in gynecological practice?

Vasography.Using this method, you can see the structure of the vascular network and identify pathological conditions. Aqueous solutions are used as a contrast medium. organic compounds iodine. Depending on which vascular system is filled with a contrast agent, the study is called arteriography, venous or phlebography and lymphangiography. This method is used in oncogynecology to determine the prevalence of malignant neoplasms of the genitals.

CTused in gynecological practice for the diagnosis of small (up to 1 cm) neoplasms of the pituitary gland and pathological changes in the internal genital organs.

Rice. 2.23. GHA. Adenomyosis

MRI (NMR)has become widespread in gynecological practice for the differential and topical diagnosis of neoplasms, fistulas, malformations and other pathologies.

Radioisotope research - one of the methods for diagnosing the state of the endometrium using the radioactive isotope of phosphorus 32P. The method is based on the property of malignant tumors to accumulate radioactive phosphorus more intensively than the surrounding unaffected cells.

What are the indications for ultrasound?

ultrasoundserves to diagnose diseases and tumors of the uterus, appendages, detect abnormalities in the development of the uterus, to control the growth of the follicle, the thickness of the endometrium (Fig. 2.24).

Transabdominal (with a filled bladder as an acoustic window) and transvaginal technique (with an empty bladder) are used. A transvaginal examination is preferable, since it allows you to get more detailed information about the state of the endometrium (thickness, the presence of pathology), identify a short-term uterine pregnancy (2-2.5 weeks), evaluate the uterus (structural features, size, localization and size of fibroids and etc.), ovaries (size, condition of the follicular apparatus, pathological changes, etc.), fallopian tubes (presence of tubal pregnancy, hydrosalpinx, etc.), identify a small amount of free fluid in the recto-uterine (Douglas space) and much more. There are no contraindications for ultrasound.

Rice. 2.24.ultrasound. Ectopic pregnancy. Twins

What is the purpose of echohysterography?

echohysterography (EGG). The method is based on the introduction of a liquid contrast agent into the uterine cavity, which creates an acoustic window in the uterus and allows you to more accurately determine structural changes in endometrial hyperplastic processes, defects on the 5-7th or 23-25th days of the menstrual cycle, subject to the conditions and contraindications for intrauterine interventions. As a contrast medium, a sterile isotonic sodium chloride solution, Ringer's lactate, glycine or hyperechoic contrast are used, which are injected into the uterine cavity using a uteromat that provides a continuous supply of fluid.

• Survey of patients in gynecology (gynecological history)

Survey of patients in gynecology (gynecological history)

Acquaintance with the patient during the first filling of the medical history requires a courteous, attentive, benevolent attitude from the doctor, not allowing haste. Asked questions, gestures, all the manners of the doctor should not contain a hint of this or that judgment regarding the behavior of a woman; accurate information should be encouraged, moralizing and dogmatic views should be avoided. Since the doctor's views on the role of women in society may differ from those of the patient, everything that confuses her, makes her helpless or dependent should be avoided. The doctor must recognize the independent value of her personality and encourage independence.

To be established and specified in detail initial complaint sick. The individual characteristics of the patient are judged on the basis of data on education, work, living conditions, etc.

Menstrual history includes age at menarche in the patient (and other family members); frequency, regularity, duration and volume of secretions; the presence of pain or other symptoms during and before menstruation; the facts of abnormal bleeding and the dates of the last two periods are also noted. Further questions concern the nature of sexual life, sexual orientation and possible related problems. They note the transferred venereal diseases, as well as herpes and condyloma. It is necessary to find out the possibility of pregnancy, the patient's attitude to contraceptives, the degree of her awareness of them and the experience of using them.

Obstetric history includes the number of pregnancies, their timing and outcome, and in case of complaints of infertility - its possible causes. In the presence of pain, it is necessary to describe in detail their localization, time of occurrence, intensity, irradiation, strengthening or weakening factors, as well as the relationship pain symptoms with the functioning of the gastrointestinal tract or urinary tract. Note the presence of fever.

After that, they begin to ask questions about past diseases, including cases of hospitalization or surgery, find out the details of operations in the abdominal cavity and small pelvis. Detect cases of radiation therapy for benign diseases (eg, mastitis, thymus enlargement, menorrhagia, or skin pathology) or possible exposure to diethylstilbestrol in women who were pregnant during the period of its use (1947-1971), or their daughters, born at this time.

The woman's general health, including her psychological status, is assessed, with particular attention to depression or anxiety, and drug use. Note any changes in body weight, abnormally increased appetite (bulimia), anorexia nervosa. Find out what drugs and how often the patient took, paying attention to allergic reactions and drugs that affect the current condition, as they may be contraindicated in the recommended therapy or during pregnancy. Get information about the use of tobacco, alcohol and other psychoactive drugs.

Due to the fact that gynecological diseases are often accompanied by lesions of the urinary tract, it should be noted the frequency and disorders of urination, urination at night (nocturia), urinary incontinence and prolapse of the vaginal walls. Possible symptoms from the gastrointestinal tract are also noted: changes in the usual bowel habits, stool color, anorexia, nausea, vomiting, abdominal pain, intolerance to certain foods, possible signs of liver damage (currently or in the past).

Assess the condition of the mammary glands, including their enlargement and the presence of pain. The study of the general endocrine status includes the identification of abnormal hair growth, lactation and other signs of hormonal disorders. They also collect information about bleeding, anemia, phlebitis, and other blood clotting disorders, which may provide a clue to explaining abnormal menstrual bleeding and then avoiding hormonal treatment. The choice of therapy is influenced by the state of the cardiovascular system, a history of heart disease, hypertension, data on smoking, the content of cholesterol and triacylglycerols in the blood. Drugs used for migraine and epilepsy may be contraindicated during pregnancy.

Family history helps to identify hereditary diseases; this is especially true for ovarian, uterine and breast cancer, diabetes, polyps and bowel cancer, and various genetic defects.

Ed. N. Alipov

"Survey of patients in gynecology (gynecological history)" - an article from the section

At the first stage of the examination, a correctly collected anamnesis allows to identify characteristic symptoms diseases. Anamnesis data is the basis for prescribing additional special methods of research and making a preliminary diagnosis. Only on the basis of a generalization of the results of clinical laboratory and instrumental methods research, the clinician can correctly establish the diagnosis and develop adequate treatment tactics. To obtain the most informative information about the patient and reduce the time of the examination allows compliance with a certain scheme for collecting anamnesis.

COMPLAINTS

The applied patients often have quite a lot of complaints, among which the most common are pain, leucorrhoea, bleeding from the genital tract, menstrual irregularities. In addition to the main complaints, there are also accompanying ones, which the patients report after additional leading questions. Comparison of the age and appearance of the patient is extremely important.

AGE

The influence of adverse factors, including the disease, on the appearance of the patient is taken into account. It should be noted that various gynecological diseases are more often confined to certain age periods. Important for clarifying the nature of gynecological pathology are information about the transferred somatic diseases(infectious, extragenital), their course, surgical interventions (injuries, operations).

PAST ILLNESSES

Clarifying the nature of past diseases is important in the sense that some of them, such as diseases of childhood, can affect the function and condition of the genital organs much later, during puberty. Often, a high index has an adverse effect on the formation of the functions of the centers of regulation of the reproductive system infectious diseases. This contributes to the occurrence of disorders of the menstrual cycle and reproductive function and the development of neuroendocrine diseases. Diseases that have a protracted course, recurrent and chronic, autoimmune disorders can cause the development of disorders of hormone metabolism in the liver. The use of glucocorticoid drugs in a number of concomitant diseases can cause amenorrhea or oligomenorrhea. Treatment of neuropsychiatric diseases with neuroleptic drugs of the phenothiazine series can cause suppression of ovarian function and cause amenorrhea-lactorrhea. When collecting an anamnesis, the nature of work and living conditions should also be clarified.

SOCIO-ECONOMIC CONDITIONS OF WORK AND LIFE, HARMFUL FACTORS (ENVIRONMENTAL, SMOKING, DRUGS, ALCOHOL)

Information about the profession and the nature of the working conditions of the patient is of great importance for establishing possible cause diseases of the genital organs. Intense exercise, poor diet, occupational hazards may cause various violations menstrual cycle, anovulation, infertility. Appointment is contraindicated hormonal contraception or estrogen-containing drugs to patients who smoke more than 20 cigarettes per day over the age of 35 years. Many researchers note an increase in the frequency of miscarriage among women living in northern and remote areas compared to the European part of the Russian Federation and the average for Russia. This is explained by the complexity of the processes of adaptation to severe climatic conditions, as well as the difficulties of providing specialized care in remote areas. When conducting a survey of a patient, it is necessary to take into account the hereditary conditionality of many diseases.

FAMILY HISTORY

Clarify the presence of mental illness, endocrine disorders (diabetes, adrenal pathology, hyperthyroidism, etc.), tumors (myoma, ovarian, breast, intestinal cancer), pathology of the cardiovascular system in relatives of the first, second and more distant generations. In addition to the usual family history questions, menstrual irregularities, infertility, excessive hair growth find out if the next of kin have hirsutism, obesity, oligomenorrhea, cases of early miscarriage. For the diagnosis of gynecological diseases essential have data on menstrual, reproductive, secretory, sexual functions.

MENSTRUAL FUNCTION

The age of onset of menarche - the first menstruation - is one of the main signs of puberty in the female body. On average, the age of onset of menarche is 12–13 years and depends on the physical development of the body, nutrition, previous diseases, and hereditary factors. A later age of menarche, combined with a delay in physical development, may indicate a delay in sexual development. You can think about PPS in cases of discrepancy (advance) of biological age to the calendar one and at the onset of menarche before the age of 12.

If the patient is in the postmenopausal period, specify the age at which menopause occurred. Menopause is the last menstrual period, which occurs on average at the age of 50.8 years. Before the onset of menopause, the premenopausal period is distinguished. The premenopausal period and two years after menopause constitute the perimenopausal period. After menopause and until death, women distinguish the postmenopausal period.

The concept of menstrual function includes the duration of the menstrual cycle - the period from the first day of the previous menstruation to the first day of the next menstruation. Normally, the duration of the menstrual cycle is 28+-5 days, and the duration of menstruation is 5+-2 days with a blood loss of 50 to 150 ml. In the absence of gynecological pathology, menstruation is not accompanied by painful sensations and impaired well-being. As a result of a violation of the functions of neurohumoral regulation, in the presence of organic pathology genital organs and systemic diseases, menstrual dysfunction occurs. In this regard, patients may present complaints associated with various changes in the menstrual cycle:

• lack of menstruation for several months;
• change in the volume of blood loss (more or less) and the nature of the discharge ( liquid blood or clots) during menstruation;
• change in the nature of the menstrual cycle (regular or irregular);
• the appearance of intermenstrual (acyclic) blood discharge;
• pain syndrome before, during and after menstruation. Classification of menstrual irregularities:
• menorrhagia - prolonged and heavy menstruation;
• metrorrhagia - irregular bleeding between periods;
• polymenorrhea - frequent menstruation, when the interval between them is less than 21 days;
• hypermenorrhea - abundant regular menstruation;
• menometrorrhagia - prolonged menstruation in combination with bleeding in the intermenstrual period;
• amenorrhea - absence of menstruation for more than 6 months;
• oligomenorrhea - rare menstruation, when the interval between them exceeds 35 days;
• opsomenorrhea - scanty menstruation.

Menstrual disorders can be symptoms of functional disorders of the pituitary gland, ovarian dysfunction, proceeding according to the type of anovulation with atresia and persistence of the follicles. The main organic causes, manifested by menstrual irregularities, can be such gynecological diseases as: MM, especially with submucosal nodes, adenomyosis - good known cause painful menstruation, in addition, can be the cause of heavy menstruation.

Cervical and/or endometrial polyps or HPE can cause intermenstrual bleeding that results from irregular shedding of the endometrium. Malignant tumors the cervix or body of the uterus may also manifest itself as bleeding. Bleeding after intercourse is most common in cervical cancer. Postmenopausal bleeding should always be taken seriously, as it can be a manifestation of uterine cancer. Hormonally active tumors, such as granulosa cell tumor of the ovary, are often accompanied by uterine bleeding due to the release of significant amounts of estrogens. Less commonly, tumors such as adrenoblastoma produce enough estrogens or androgens to affect the menstrual cycle.

Described rare causes bleeding, for example, from arteriovenous formations of the uterus. PID can cause profuse or irregular uterine bleeding, mainly due to a local inflammatory response of the endometrium. PID can affect the ovaries and secondary to uterine bleeding. The cause of acute bleeding can also be an injury to the lower genital tract. During sexual intercourse, tears of the vagina are possible. Collecting anamnesis in such cases is difficult. We should not forget about bleeding from the gastrointestinal tract and urinary tract.

Bleeding can be a manifestation of endocrine diseases. Menstrual irregularities are observed with hypo or hyperthyroidism, diabetes mellitus, adrenal diseases, hyperprolactinemia. Most likely, these diseases affect the feedback mechanisms that regulate the secretion of GnRH by the hypothalamus, gonadotropins by the pituitary gland, and sex hormones by the ovaries. A common cause of uterine bleeding, especially in adolescents admitted with this pathology, is hemostasis disorders: von Willebrand disease, idiopathic thrombocytopenic purpura, and deficiency of coagulation factors II, V, VII, and X. Liver disease can affect estrogen metabolism. In addition, the synthesis of coagulation factors in the liver may be reduced. In kidney disease, the excretion of estrogen and progesterone decreases. Often leads to the development of uterine bleeding taking steroid hormones, antipsychotics, anticoagulants and cytostatics.

If uterine bleeding occurs in a woman of childbearing age, it should always be borne in mind that its cause may be related to pregnancy. Complaints of bleeding may hide spontaneous abortion, ectopic pregnancy, trophoblastic disease, postpartum hemorrhage.

REPRODUCTIVE FUNCTION

Obstetric history data should include information on the number of children, their age, birth weight, the number of spontaneous and induced abortions, the timing of pregnancy, when they occurred, and complications. When interviewing, it is important to obtain information about the pathology during pregnancy, childbirth and the postpartum period. Gynecological diseases can be both the cause of reproductive disorders (infertility, spontaneous abortions, labor anomalies, etc.), and their consequences (inflammatory diseases that occur after abortion and childbirth, neuroendocrine disorders after heavy bleeding in parturient women and puerperas, the consequences of obstetric injuries and etc.).

SECRETORY FUNCTION

Patients' complaints about subjective sensations associated with a change in the nature of vaginal discharge make it possible to assess the secretory function. Careful clarification of these data can help the specialist in the correct assessment of the disease, since often the patients themselves do not always attach due importance to this phenomenon. It is known that in healthy women there is no visible discharge from the genital tract. Pathological secretion (leucorrhoea) can be a manifestation of diseases of different parts of the genital organs. There are tubal leucorrhea (emptying hydrosalpinx), uterine, or corporal (endometritis, polyps, initial stage endometrial cancer), cervical (endocervicitis, ectropion with an inflammatory reaction, erosion, polyps, etc.). Most often, vaginal leucorrhea is observed, which occurs as a result of the introduction of pathogenic microbes (violation of the hygiene of sexual intercourse, gaping of the genital gap after perineal ruptures, etc.), unindicated douching, and the use of irrational contraceptives. Noteworthy data on the sexual function of patients.

SEXUAL FUNCTION

Familiarization with sexual function includes information about the presence of pain, about possible secretions after intercourse. Pain syndrome during intercourse is typical for such gynecological diseases as: endometriosis (especially retrocervical), inflammatory diseases (colpitis, salpingo-oophoritis). With vaginismus, patients report pain even when trying to have sexual intercourse. Contact bleeding can be one of the symptoms of cervical cancer, erosion (pseudo-erosion), cervical polyp, colpitis and other pathological processes. Find out if the patient is using contraceptives.

CONTRACEPTION

It is necessary to clarify the type of contraception used by the woman, its effectiveness and side effects. These data make it possible to avoid complications that may arise as a result of the irrational use of contraceptives (inflammatory diseases, menstrual dysfunction, etc.). It is known that in many women the occurrence of menstrual bleeding contributes to the use of IUDs. Menstruation may become more abundant and prolonged. It is believed that the introduction of IUD increases the serum level of plasminogen activator, leading to increased fibrinolysis. However, new generation IUDs that release progesterone reduce blood loss and can be used as therapeutic agents.

POSTED GYNECOLOGICAL DISEASES

Obtaining information about past gynecological diseases and operations completes the collection of anamnestic information. Data obtained on previously transferred gynecological diseases should contain information about the methods of treatment and the drugs used. Often, in gynecological diseases, violations of the functions of neighboring organs are observed: diseases of the urinary tract (urethritis, cystitis, etc.) and intestines (hypotension, constipation, etc.). Before proceeding to the examination, it is necessary to briefly summarize the history data, in this regard, special attention is paid to the history of the present disease.

HISTORY OF THE PRESENT ILLNESS

They specify the duration of the disease, the factors that contributed to the onset of the disease, analyze the results of the examination and treatment.
An objective examination of patients includes the study of the state of their body as a whole (general examination) and the state of the abdominal organs and, mainly, the pelvic organs (gynecological examination).

• Sharafutdinova N.Kh.
• Mustafina G.T.
• Kandarova D.F.

Keywords

WOMEN / REPRODUCTIVE BEHAVIOR / DISEASES OF THE FEMALE GENITAL ORGANS/ LIFESTYLE

annotation scientific article on medicine and health care, the author of scientific work - Sharafutdinova N. Kh., Mustafina G. T., Kandarova D. F.

The article presents the results of a survey of 750 women who applied to the antenatal clinic for preventive medical examinations. Among the surveyed women, the majority were between the ages of 20 and 40, 16.3% were unmarried, 16.1% were divorced. Of the respondents, 185 (36.9%) women noted the fact of termination of pregnancy and 275 (54.8%) the presence of childbirth. There were 603 abortions and 562 births for 750 examined women. The ratio of births to abortions was 0.9:1.0. With age, the proportion of women who terminated a pregnancy increased and the proportion of women who terminated a pregnancy several times increased. The number of abortions was less among women with higher education. The survey made it possible to establish that 33.1 out of 100 respondents had been ill with sexually transmitted diseases. The prevalence of inflammatory diseases of the female genital organs was 80.2 per 100 respondents, including 9.2 had salpingitis, 4.9 had oophoritis, 10.5 had salpingo-oophoritis, 5.5 had acute endometriosis, and 39.2 had cervical erosion.

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REPRODUCTIVE HEALTH AND BEHAVIOR OF WOMEN ACCORDING TO SURVEY AND MEDICAL EXAMINATION

The article presents the results of the survey of 750 women attending antenatal clinics to undergo preventive medical examinations. Most of them were aged 20 40, 16.3% were single, and 16.1% were divorced. Among the respondents, 185 women (36.9%) reported the fact of miscarriage and 275 (54.8%) the availability of labor. There were 603 miscarriages and 562 deliveries per 750 surveyed women. Birth-abortion ratio was 0.9:1.0. With age, the proportion of women who has terminated their pregnancy increases, and the proportion of women who has terminated their pregnancy more than once also increases. The number of abortions was lower among women with higher education. Questioning revealed that 33.1 out of 100 respondents had sexually transmitted diseases. The prevalence of inflammatory diseases of the female genital organs was 80.2 per 100 respondents, including salpingitis in 9.2 cases, oophoritis in 4.9, salpingo-oophoritis in 105, 5.5 had acute endometriosis and 39.2 cervical erosion.

The text of the scientific work on the topic "Reproductive health and behavior of women according to questionnaires and medical examinations"

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UDC 618.17:303.621.3

© N.Kh. Sharafutdinova, G.T. Mustafina, D.F. Kandarova, 2014

N.Kh. Sharafutdinova1, G.T. Mustafina2, D.F. Kandarova1 REPRODUCTIVE HEALTH AND BEHAVIOR OF WOMEN ACCORDING TO QUESTIONNAIRE AND MEDICAL EXAMINATIONS

"SBEI HPE "Bashkir State Medical University" of the Ministry of Health of Russia, Ufa 2GBUZ "City Clinical Hospital No. 21", Ufa

The article presents the results of a survey of 750 women who applied to the antenatal clinic for preventive medical examinations. Among the surveyed women, the majority were between the ages of 20 and 40, 16.3% were not married, 16.1% were divorced. Of the respondents, 185 (36.9%) women noted the fact of termination of pregnancy and 275 (54.8%) the presence of childbirth. There were 603 abortions and 562 births for 750 examined women. The ratio of births to abortions was 0.9:1.0. With age, the proportion of women who terminated a pregnancy increased and the proportion of women who terminated a pregnancy several times increased. The number of abortions was lower among women with higher education. The survey made it possible to establish that 33.1 out of 100 respondents had been ill with sexually transmitted diseases. The prevalence of inflammatory diseases of the female genital organs was 80.2 per 100 respondents, including 9.2 had salpingitis, 4.9 had oophoritis, 10.5 had salpingo-oophoritis, 5.5 had acute endometriosis, and 39.2 - cervical erosion.

Keywords: women, reproductive behavior, diseases of the female genital organs, lifestyle.

N.Kh. Sharafutdinova, G.T. Mustafina, D.F. Kandarova REPRODUCTIVE HEALTH AND BEHAVIOR OF WOMEN ACCORDING TO SURVEY AND MEDICAL EXAMINATION

The article presents the results of the survey of 750 women attending antenatal clinics to undergo preventive medical examinations. Most of them were aged 20 - 40, 16.3% were single, and 16.1% were divorced. Among the respondents, 185 women (36.9%) reported the fact of miscarriage and 275 (54.8%) the availability of labor. There were 603 miscarriages and 562 deliveries per 750 surveyed women. Birth-abortion ratio was 0.9:1.0. With age, the proportion of women who has terminated their pregnancy increases, and the proportion of women who has terminated their pregnancy more than once also increases. The number of abortions was lower among women with higher education. Questioning revealed that 33.1 out of 100 respondents had sexually transmitted diseases. The prevalence of inflammatory diseases of the female genital organs was 80.2 per 100 respondents, including salpingitis in 9.2 cases, oophoritis in 4.9 , salpingo-oophoritis in 105, 5.5 had acute endometriosis and 39.2 - cervical erosion.

Key words: women, reproductive behavior, diseases of the female genital organs, lifestyle.

Women's reproductive health is one of the important tasks healthcare systems. It consists in carrying out a complex of preventive and therapeutic measures.

Among the indicators of women's health, a special place is occupied by gynecological morbidity, which affects reproductive function, maternal mortality, generative function, performance, child and perinatal mortality.

One of the most common gynecological diseases is vulvovaginal candidiasis caused by fungi of the genus Candida. Inflammatory diseases of the female genital organs occupy a leading position among all gynecological diseases, more than half of the patients are faced with such a diagnosis. At present, the urgency of this problem is obvious and is associated with a high level of sexually transmitted diseases, the spectrum of which

ryh expanded due to a large number of bacterial, viral and protozoal infections. The main causative agents of these infections are chlamydia, ureaplasma, microplasma, fungi, Trichomonas, gonococci, human papillomaviruses, Escherichia coli, genital herpes. Gynecologists identify the most common inflammatory diseases, these are: specific and nonspecific colpitis, endocervicitis, candidiasis, condylomatosis, trichomoniasis, chlamydia, chronic endometritis, chronic inflammation of the uterine appendages. Most often, inflammatory diseases occur in young women who often change sexual partners. Predisposing factors for the development of diseases include: chronic intoxication, alcoholism and drug addiction, chronic foci of infection, hypothermia, physical and mental overload.

Material and methods

A survey was conducted of 750 women who applied to antenatal clinics of the state budgetary healthcare institution of the Republic of Bashkortostan "City Clinical Hospital No. 21" in Ufa. In addition to questions establishing the demographic characteristics of women (age, level of education, marital status), the questionnaire included questions on women's employment, reproductive behavior, the presence of sexually transmitted diseases, past inflammatory diseases of the female genital organs,

alcohol consumption and tobacco smoking, etc. In order to study the prevalence of diseases of the female genital organs, the results of medical examinations of women conducted by doctors of women's consultations were also analyzed. The results of the questionnaire and medical examination were recorded in the medical observation card. The prevalence of diseases of the female genital organs was analyzed for 100 examined. The research materials were subjected to expert evaluation and mathematical-statistical processing according to the generally accepted methodology. Variation statistics methods were used to process the research materials.

Results and discussion

The distribution of the surveyed by age showed that among them the main share was occupied by women in the age groups of 20-24 years old (16.3%), 25-29 years old (35.1%), 30-34 years old (17.1%) and 35 -39 years (10.4%). The average age of the examined women was 32.4±0.5 years.

A study of the marital status of women indicates that 52.8% are in their first marriage, 1.8% are in their second marriage, 10.2% live in a civil marriage, 16.3% are not married, 16.1% are divorced , 2.8% widows. Women were in a civil marriage mainly at the age of 30-34 years (14.0%) and 35-39 years old (23.1%), divorced women were more at the age of 40-44 years (29.0%) (Table 1 ).

Table 1

Distribution of respondents by marital status and age, %

Age groups, years First marriage Second marriage Civil union Single Divorced Widow Total

15-19 7,7 - 7,7 61,5 3,1 - 100,0

20-24 47,6 3,7 8,5 35,4 4,9 - 100,0

25-29 56,8 2,3 9,1 13,6 18,2 - 100,0

30-34 62,8 1,2 14,0 9,3 11,6 1,2 100,0

35-39 50,0 1,9 23,1 5,8 19,2 - 100,0

40-44 51,6 - 6,5 9,7 29,0 3,2 100,0

45-49 61,1 - 5,6 11,1 16,7 5,6 100,0

50-54 70,0 - - - 20,0 10,0 100,0

55-59 57,1 - - - 21,4 21,4 100,0

60+ 15,0 - - 25,0 25,0 35,0 100,0

Total... 52.8 1.8 10.2 16.3 16.1 2.8 100.0

social status and the level of education is a significant factor in shaping women's health and their reproductive behavior. Among the women surveyed, 39.0% were with higher education, 10.2% with incomplete higher education, 38.9% with secondary specialized education, 10.0% with secondary general education and 2.0% with primary education.

Study of reproductive behavior

of women showed that 60.0% of the respondents did not terminate the pregnancy and 45.2% did not have a childbirth. 21.5% of women had a pregnancy interruption once, 7.5% - twice, 5.8% - three times, 3.1% - four times, 2.2% had five or more abortions (Table 2).

The average age of those who terminated pregnancy once was 33.4±0.4 years, twice - 38.0±1.8 years, three times - 45.7±2.3 years, four times - 42.4±1.8 of the year.

Distribution of women by the number of abortions and childbirth, %

table 2

Reproductive Number of abortions

behavior was not 1 2 3 4 5 6 or more

Abortions 60.0 21.5 7.5 5.8 3.1 0.6 1.6

Childbirth 45.2 33.5 18.3 2.4 0.4 0.2 -

Distribution of women by the number of births: 33.5% of women had one birth, 18.3% had two births, 2.4% had three births, 0.4% gave birth four times, 0.2% of women gave birth five times . Of the women surveyed, 185 (36.9%) noted the fact of termination of pregnancy and 275 (54.8%) the presence of childbirth. There were 603 abortions and 562 births for 750 examined women. The ratio of births to abortions was 0.9:1.0.

The number of abortions was higher among women with secondary specialized education compared to women with higher education. Thus, among women with higher education, there were 5.2% who terminated pregnancy 2 times, and

among women with secondary specialized education - 8.8% (the difference is not statistically significant, p>0.05), who interrupted four times and more than 1.6 and 4.2%, respectively (p>0.05). Among persons with secondary specialized education there were women who terminated their pregnancy more than 10 times.

We analyzed the number of abortions depending on the age of women. At the age of 15-19 years, 20.0% of the respondents indicated the presence of abortion, at the age of 20-24 there were 15.1%, at 25-29 years - 31.6%. With age, the proportion of women who terminated pregnancy increased and the proportion of women who terminated pregnancy several times increased (Table 3).

Table 3

Age groups, years Number of abortions Total

none 1 2 3 4 5 or more

15-19 80,0 6,7 6,7 6,7 - - 100,0

20-24 84,9 14,0 1,2 - - - 100,0

25-29 68,4 17,8 7,9 2,6 2,0 1,4 100,0

30-34 63,0 24,7 8,2 1,4 1,4 1,4 100,0

35-39 32,6 34,8 15,2 13,0 4,3 0,0 100,0

40-44 26,9 46,2 11,5 3,8 - 11,4 100,0

45-49 40,0 33,3 6,7 20,0 - - 100,0

50-54 10,0 40,0 - 20,0 20,0 10,0 100,0

55-59 25,0 - - 33,3 33,3 8,3 100,0

60 years and older 60.0 21.5 7.5 5.8 3.1 2.2 100.0

The incidence of the population is studied by different methods. One of the more available methods is to obtain data on morbidity according to the data of negotiability. Morbidity can also be studied through questionnaires and medical examinations. Thus, we studied the frequency of occurrence of diseases per 100 people both according to the survey of respondents and according to the results of medical examinations.

The survey made it possible to establish that 33.1 per 100 respondents indicated that

that they had been ill with sexually transmitted diseases, including 14.4 indicated chlamydia, 12.3 - ureaplasmosis, 9.3 - mycoplasmosis, 4.7 - trichomoniasis (Table 4). A small number of respondents noted that they had gonorrhea (2.1 per 100 respondents) and syphilis (1.9).

The prevalence of chlamydia

ureaplasmosis, mycoplasmosis is more common in women aged 15-19 years, 30-34 years and 40-44 years.

Table 4

Prevalence of sexually transmitted diseases per 100 women surveyed

Age groups, years Chlamydia Ureplasmosis Mycoplasmosis Trichomoniasis Gonorrhea Syphilis Did not get sick

15-19 20,0 13,3 33,3 - - - 66,7

20-24 11,6 14,0 7,0 4,7 - - 58,1

25-29 19,6 9,6 7,6 3,2 3,2 1,3 72,0

30-34 20,5 11,5 10,3 6,4 2,6 5,1 56,4

35-39 16,0 18,0 8,0 10,0 6,0 4,0 70,0

40-44 10,7 25,0 21,4 7,1 - - 36,7

45-49 23,5 5,9 8,5 5,9 - 5,9 47,1

50-54 5,4 10,0 6,4 - - - 70,0

55-59 7,1 7,1 6,4 - - - 64,3

60 years and older 47.1 5.9 17.6 - - - 47.1

total 14.4 12.3 9.3 4.7 2.1 1.9 66.9

The prevalence of inflammatory diseases of the female genital organs, according to the answers of the respondents, was 80.2 per 100 respondents, including 9.2 had salpingitis, 4.9 had oophoritis, and 10.5 had salpingo-ophoritis.

rit, 5.5 - acute endometriosis, 39.2 - erosion of the cervix. Thus, cervical erosion was the most common disease (Table 5).

The prevalence of diseases of the female genital organs according to the survey, per 100 respondents

Table 5

Age groups, years Salpingitis Oophoritis Salpingoophoritis Acute endometritis Cervical erosion Other inflammatory diseases

15-19 - 13,3 - 6,7 20,0 33,3

20-24 8,1 3,5 3,5 1,2 29,1 14,0

25-29 7,9 5,7 12,7 3,8 37,6 7,6

30-34 8,4 1,3 12,8 3,8 48,7 6,4

35-39 12,0 2,0 8,0 8,0 48,0 6,0

40-44 7,1 3,6 21,4 10,7 50,0 14,3

45-49 5,9 17,6 17,9 - 29,4 5,9

50-54 - 10,0 20,0 20,0 50,0 -

55-59 - - 21,4 50,0 14,3 -

60 years and older 5.9 11.8 - 17.6 29.4 17.6

Total... 9.2 4.9 10.5 5.5 39.2 10.0

Previously transferred salpingitis was indicated mainly by young women. At the age of 20-24, there were 8.1 out of 100 respondents, at 25-29 years old - 7.9, at 30-34 years old - 8.4, at 35-39 years old - 12.0. Women of older age groups indicated the past salpingo-oophoritis disease: at the age of 40-44 years - 21.4, at 45-49 years - 17.9, at 50-54 years - 20.0, at 55-59 years - 21, four. Women aged 50-54 years (20.0 out of 100 respondents) and 55-59 years old (50.0 out of 100 respondents) more often indicated endometritis. On the contrary, the presence of a history of cervical erosion was more often indicated by women aged 30-49 years.

One of the criteria for reproductive behavior is the use of contraceptives to prevent unwanted pregnancy. Contraception, being a method of family planning, can simultaneously be considered a way to prevent abortion and related complications. Therefore, contraception has not only medical, but also social significance.

A survey of women showed that women

more often use the barrier method of preventing pregnancy. Among those aged 15-19 years old, there were 26.7 per 100 respondents, at the age of 20-24 years old - 47.7, at 25-29 years old - 50.7, at 30-34 years old - 39.7, at 35 -39 years old - 41.3, at 40-44 years old - 38.5. In second place in terms of frequency of use were hormonal contraceptives. They are used by 26.7 out of 100 women aged 15-19, 24.4 - at the age of 20-24, 15.0 - at the age of 25-29 (Table 6). Fewer women in all age groups use candles, calendar method and vaginal ring. The largest number of women using the vaginal ring and the calendar method was in the age group of 35-39 years (10.9 and 26.1 per 100 respondents).

Of the surveyed, 72.1% do not smoke, 8.9% - previously smoked, but do not smoke at the time of the survey, 6.8% - smoke constantly, 9.9% - smoke occasionally. Alcohol is consumed by 66.5% of the surveyed. Moreover, the majority indicated that they consume wine - 40.0%, wine and beer - 2.5%, beer - 8.5%, cognac - 5.0%, vodka - 4.9%.

Table 6

Distribution of women using contraceptives, by age, per 100 respondents

Age groups, Oral Barrier method Vaginal Calendar Suppositories, Others (spiral)

yo (condom) ring spermicide method

15-19 26,7 26,7 - 6,7 6,7 6,7

20-24 24,4 47,7 2,3 1,2 4,7 7,0

25-29 25,0 50,7 2,0 13,2 3,9 3,3

30-34 24,7 39,7 2,7 16,4 6,8 11,0

35-39 28,3 41,3 10,9 26,1 2,2 2,2

40-44 30,8 38,5 11,5 - 7,7 23,1

45-49 6,7 - 6,7 26,7 20,0 6,7

According to medical examinations, we analyzed the prevalence of diseases of the female genital organs. The results showed that 29.9 cases of diseases were detected per 100 examined (Table 7). by the most

common diseases were acute and chronic vaginitis (9.1 cases per 100 examined), erosion and ectropion of the cervix (6.4 cases per 100 examined).

Table 7

The prevalence of diseases of the female genital organs according to medical examinations, per 100 examined_

Age-Related Fibroids Chr. sal- Sub-Dost- Vulvo- Endo- Incomplete- Erosion and Other Violations- Femdom Cyst

groups, years of the uterus pingitis and ry and hr. vaginitis metriosis vy-ektropis-vos-pal. infertile ovary

oophoritis vaginitis fall of the uterus on the cervix bol. cervical menopause die

15-19 - 13,3 40,0 - 13,3 - 33,3 - - 13,3

20-24 - - 19,8 2,3 2,3 - 2,3 2,3 - 2,3 -

25-29 - 2,6 3,3 2,6 - - 1,3 - - - -

30-34 - 5,5 9,6 2,7 - - 8,2 - - - -

35-39 4,3 4,3 8,7 4,3 - 6,2 4,3 - 4,3 4,3

40-44 - - 15,4 15,4 - - 15,4 - - - -

45-49 26,7 6,7 - - - - - - 13,3 - -

50-54 - - - - - - - - 20,0 - 20

55-59 16,7 - - - - 16,7 - - 33,3 16,7 -

60+ 11,8 - - - - - - - - - -

Total. 2.1 2.8 9.1 2.6 1.3 0.4 6.4 0.9 1.7 1.3 1.3

Among women aged 15-19 years, the most common diseases were subacute and chronic vaginitis (40.0 out of 100 examined), erosion and ectropion of the cervix (33.3), at the age of 20-24 years - subacute and chronic vaginitis ( 19.8), at the age of 30-34 - also subacute and chronic vaginitis (9.6). In the older age groups of women, uterine fibroids and menopausal disorders were detected.

Thus, a sociological survey of women made it possible to establish the reproductive behavior and health of women depending

from demographic characteristics and to reveal that 603 abortions and 562 births occurred per 750 women surveyed. The ratio of births to abortions was 0.9:1.0. Of the 100 women surveyed, 33.1 suffered from sexually transmitted diseases, 80.0 had inflammatory diseases of the female genital organs, and 29.9 out of 100 examined women had chronic diseases of the female genital organs during medical examinations. The survey also showed that women are more likely to use the barrier method of preventing pregnancy.

Sharafutdinova Nazira Khamzinovna - Doctor of Medical Sciences, Professor, Head. Department of Public Health and Health Organization with the course of the Institute postgraduate education GBOU VPO BSMU of the Ministry of Health of Russia. Address: 450000, Ufa, st. Lenina, Z. Tel./fax 272-42-21.

Mustafina Gulnara Talgatovna - chief physician of the City Clinical Hospital No. 21, Ufa. Address: 450071, Ufa, st. Lesnoy proezd, 3. Tel./fax 232-32-88.

Kandarova Dinara Failevna - postgraduate student of the Department of Public Health and Organization of Health Care with the course of the Institute of Postgraduate Education, SBEI HPE BSMU of the Ministry of Health of Russia. Address: 450000, Ufa, st. Lenina, 3.

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