Internal, chronic and external endometriosis. Third degree of endometriosis: symptoms and treatment methods Surgical treatment of internal endometriosis

Endometriosis is becoming more common these days and the disease can occur in all women of childbearing age. This disease is characterized by the appearance of endometrial cells outside the uterine cavity.

There are 4 degrees of endometriosis based on the depth of invasion into the muscular lining of the uterus and distribution:

The first degree (I) – initial – is manifested by the germination of endometriosis to a shallow depth. The outbreak is single.

In the second degree ((II) moderate degree), the process extends to the middle of the myometrium. Several outbreaks.

The third degree ((III) medium) of endometriosis involves all the walls of the uterus in the defective process. Many outbreaks appear. Small endometrioid "chocolate cysts" (blood-filled growths) of one or, in rare cases, several ovaries may also be observed. Rarely, thin peritoneal adhesions appear.

In the fourth degree ((IV) severe), the parietal peritoneum and neighboring organs are affected. Many metastases. The ovaries are affected by endometrioid cysts, invasion of the vagina or colon, and tight junctions of organs.

With II – IV degrees of the disease, the uterus enlarges, this occurs because hyperplasia of muscle fibers is observed (its size depends on the size and number of cysts).

In degrees III – IV, the uterus is very painful on palpation, this is due to the fact that the isthmus of the uterus has been damaged.

Often, against the background of any degree of endometriosis, patients develop endometritis (inflammation of the uterine mucosa).

Endometriosis sometimes manifests itself in “minor” forms and severe ones, which complicates classification. For this reason, the exact line between the steps does not always exist.

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Symptoms of endometriosis at different degrees of the disease:

Painful menstruation, the duration of the menstrual cycle increases, menstrual discharge is dark in color, with blood clots.
Bleeding between menstruation, pregnant women often experience spontaneous abortion (miscarriage), pain during sexual intercourse.
Infertility, pain in the lower abdomen, disruption of the endocrine and immune systems.
in the vagina, deep in the pelvis, difficulty in defecating, pain may be accompanied by local itching, the appearance of brown discharge during sexual intercourse. In particularly severe cases, when the bladder is affected, hematuria may occur.

At different stages, there are several ways to treat this disease. Thus, in the early stages, drug treatment is used (hormonal drugs, aromatase inhibitors). In more severe cases, surgery is required. Surgical treatment is varied, depending on the woman’s age, the severity of the disease and the woman’s plans for having children. Previously, removal of the uterus and appendages was widely used in severe stages, but now it is used less and less. Doctors try to remove only the lesions and restore normal pelvic anatomy. Symptomatic treatment is also used - treatment of pain syndrome, since severe pain worsens the quality of life of women.

Endometriosis is a common non-tumor disease in women. Its varieties: internal and external. They differ in the organs affected. Internal endometriosis is a painful change in muscle tissue. Otherwise it is called adenomyosis. External endometriosis concerns tissue outside the uterus. It affects the perineum and ovaries.

Internal endometriosis of the uterus is a diffuse or focal change in the myometrium. When endometrial tissue grows to form nodules, the form of endometriosis is called nodular. Adenomyosis often occurs as a result of termination of pregnancy, curettage of the uterus for diagnostic purposes. During curettage, the connective tissue of the endometrium in its basal layer and the muscles adjacent to it are disrupted.

In this case, prerequisites arise for endometrial particles to enter the muscular layer of the uterus with the development of painful foci in it. Chronic endometriosis is an inflammation of the uterus caused by the proliferation of the endometrium.

Symptoms

One of the main signs of the disease is prolonged heavy menstruation, accompanied by pain. At the same time, the uterus grows, and menstruation is preceded by pain in the lower abdomen, which stops only a few days after its onset. Adenomyosis is characterized by a diffuse process, while the nodular form leads to local growth of endometrial tissue.

The nodular type of endometriosis causes, in addition to the described symptoms, disorders of the autonomic system, including nausea, vomiting, accompanied by pain in the head up to loss of consciousness.

The disease is often complicated by tumor diseases of the uterus and ovaries. An ovarian cyst may develop. This is how external endometriosis manifests itself.

Classification

As already mentioned, adenomyosis is accompanied by focal endometriotic lesions of the muscular layer of the uterus, called the myometrium. According to the depth of penetration, adenomyosis includes several stages.

Degrees of endometriosis.

First degree, if there is only one focus of endometrial growth. At this stage, the size of the myometrial lesion reaches 1 cm in depth.

Second degree: a number of small lesions affecting the myometrium up to the middle.

Third degree, when the lesion extends to the outer serous layer of the uterine membrane.

Endometriosis stage 4, when complete damage to all uterine layers develops, up to the parietal peritoneum.

Diagnostics

Only in very rare cases, internal endometriosis of the uterine body is diagnosed during examination by a gynecologist. A change in the shape of the uterus to a round one and an increase in its size are not sufficient for a confident diagnosis. Especially if the patient has stage 1 endometriosis.

A dynamic ultrasound examination can confirm the suspicion of the presence of endometriosis. It is capable, especially in the presence of a vaginal sensor, of identifying the location of the disease. Cases of focal forms of the disease can be found less frequently than diffuse lesions. It can sometimes be confused with newly emerging fibroids. Differential diagnosis is helped by testing for internal endometriosis. An increase in the activity of this marker usually occurs in severe cases of the disease.

An accurate diagnosis can be made through a comprehensive examination of the patient’s blood for markers of endometriosis, ultrasound diagnostics, and computed tomography. In this case, it is necessary to take into account patient complaints about menstrual irregularities and specific pain that arise periodically.

Colposcopy helps to significantly facilitate diagnosis. Hysterosalpingography, performed on the 5th day of menstruation, is widely used. At this time, the mucous membrane does not interfere with the appearance of contrast material in the foci of endometriosis accessible from the uterine cavity.

Hysteroscopy performed on the 5th day of menstruation can provide a lot of information. If the menstrual cycle is disrupted, the analysis is carried out after curettage. Hysteroscopy shows in detail the inside of the uterus, the exits of the fallopian tubes, and the endometrial passages leading into the uterine cavity.

Laparoscopy is especially informative, allowing it to detect endometriosis at the beginning of its development.

Treatment

The treatment process aims to limit the development of the disease, reduce its manifestations and restore lost functions. Treatment methods can be conservative and surgical. Conservative therapy is divided into hormone replacement and non-hormonal. The specific treatment strategy is determined by the location of the endometriosis lesion, its size, and the severity of symptoms of endocrine and immune abnormalities. The patient's age and her plans for pregnancy are also important.

Conservative treatment can be effective if grade 1 internal endometriosis occurs.

Anti-endometrioid drugs provide serious help. As a rule, these are hormone antagonists that can suppress a woman’s reproductive system.

Antihormones for the treatment of endometriosis:

progestins;
estrogen antagonists;
progestin antagonists;
complex estrogen-gestagen drugs;
antigonadotropins;
antigonadotropin-releasing hormones.

In case of diffuse spread of internal endometriosis, they resort to hysterectomy; in the case of a nodular form of the disease, it is permissible to perform an operation that preserves the reproductive organs.

Surgical treatment

Nowadays, conservative treatment methods with hormone therapy give good results in the fight against the disease.

However, a number of forms of endometriosis require surgical intervention:

in the case of the retrocervical form of the disease;
if there is an endometrioid ovarian cyst;
if conservative therapy does not have an effect;
with a combination of adenomyosis with fibroids and uterine bleeding;
if there is a suspicion of an ovarian tumor;
with a nodular form of the disease;
with a diffuse type of adenomyosis (high stage);
if the functions of other organs are impaired.

Surgery usually involves laparoscopy, which involves minimally invasive surgery. More rarely, in complex cases, laparotomy is performed, requiring dissection of the peritoneal wall. Laparoscopy is performed using electrocoagulation or laser. Foci of endometriosis are cauterized or removed.

The results of treatment are determined by the extent of surgical intervention and the correct choice of hormonal treatment. Rehabilitation usually goes well. As a result, it is possible to restore reproductive function, significantly reducing pain during menstruation. In the future, the patient needs to be observed by a gynecologist, regularly performing ultrasound and monitoring the CA-125 marker in the blood.

Endometriosis is the growth of endometrial tissue in the area of the ovaries, uterine tubes and other organs of the genitourinary system. This pathology often causes miscarriage. Diagnosis and treatment of this disease is carried out by a gynecologist. Medications are prescribed, and sometimes it is necessary to resort to surgery. The prognosis of the disease is favorable, but when the first symptoms appear, you should consult a doctor.

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Endometriosis: description and causes of pathology

Endometriosis is an abnormal growth of the endometrium (tissue that is located in the cervix) beyond its limits, i.e., into the area of the ovaries, tubes, bladder, peritoneum and rectum, as well as other organs. This pathology occurs in women of reproductive age (25-40 years) and in girls during the formation of menstrual function. In addition, the disease can develop in women during menopause; this happens in 2-5% of cases.

The mechanism of development of this pathology is not fully known. A large number of researchers believe that in some women, menstrual blood with endometrial particles enters the abdominal area and fallopian tubes. Subsequently, the endometrium attaches to the tissues of various organs. Endometriosis is also associated with surgical termination of pregnancy, cesarean section, etc.

The structural features of the fallopian tubes and hereditary predisposition, i.e., transmission of the disease from mother to daughter, are high. Gene mutations can also affect the development of this pathology.

The following factors increase the risk of developing endometriosis:

smoking;
increased estrogen levels;
obesity;
metabolic disorders;
use of intrauterine contraceptives (spirals).

Endometriosis

Classification of the disease

There are several types of endometriosis, which are divided depending on location:

genital - in which heterotopias (parts of the endometrium) are located outside the inner layer of the uterus, i.e., on the tissues of the genital organs;
extragenital - localized outside the reproductive system.

Endometriosis of the genital form is divided into several subtypes:

peritoneal, which occurs when the ovaries, pelvic organs and fallopian tubes are affected;
extraperitoneal, which is located in the external genitalia, in the vagina, in the cervix;
interior, located in the muscles of the uterus, which acquire a spherical shape.

Depending on the depth of the lesions, there are four degrees of endometriosis:

1. Endometriosis of the first degree is characterized by the fact that the lesions are superficial and isolated.
2. During the second, their number deepens and increases.
3. In the third degree, cysts appear on two or one ovaries, as well as adhesions (connective tissue formations) on the peritoneum.
4. The last degree of the disease is characterized by the fact that the endometrium grows into the vagina and rectum, and the disease itself is difficult to treat.

There are four stages of development of this disease:

1. First- the changes are minor.
2. Second- endometriosis develops up to 1/2 of the depth of the uterus.
3. Third- the entire thickness of the walls is affected, i.e. a diffuse form develops.
4. Fourth- pathology extends to the peritoneum.

Endometrioid lesions come in different shapes and sizes. They have a dark red, burgundy color and are separated from the tissues of the organ by scars of white connective tissue. At the beginning of the menstrual cycle they become pronounced. As the disease progresses, they can grow into the tissue or be located superficially, which facilitates diagnosis.

Main symptoms

In the initial stages, the disease is latent (without pronounced signs). Later, symptoms of endometriosis begin to appear, which are presented in the table.

Symptom	Description
Pain	Most women complain of pain in the pelvic area. Pain syndrome can develop in the patient during the menstrual cycle or be observed constantly. It occurs during inflammation against the background of this pathology. Menstruation is accompanied by severe pain in 40-60% of cases, especially in the first three days. This symptom is associated with bleeding into the cyst cavity and an increase in pressure in it, irritation of the abdomen and spasm of the uterine vessels. There are painful sexual intercourse (with the spread of endometriosis to the vaginal area, uterus and rectum) and pain during bowel movements and urination
Heavy menstruation	With this disease, heavy and prolonged (more than 7 days) menstruation is observed. Complications include anemia due to large blood loss, which is accompanied by weakness and pallor of the skin.
Infertility	Infertility occurs in 25-40% of people suffering from endometriosis. This is due to pathological changes in the ovaries and decreased immunity
Neurological disorders	Due to the fact that this disease causes compression of the nerves, patients may experience neurological and mental disorders. Increased tearfulness and irritability are possible. Headaches are common

There is a decrease in performance and concentration, dizziness and increased fatigue.

Diagnostics

Diagnosis of the disease is carried out on the basis of patient complaints, anamnestic data and examination. Vaginal, rectal and vaginal examinations are recommended. Thanks to colposcopy (examination of the vagina and its walls) and hysterosalpingoscopy (examination of the patency of the fallopian tubes), it is possible to clarify the location and shape of the lesion. When studying tumor markers, their increase in the blood is observed.

Ultrasound is used to monitor the dynamics of therapy. Spiral computed tomography allows you to assess the severity of damage to other organs. Laparoscopy (endoscopic examination) can be used to examine areas of endometriosis. Sometimes they resort to x-rays of the fallopian tubes and uterus.

Treatment

Treatment of the disease is carried out taking into account age, number of pregnancies and births, severity and location. It is necessary to take into account the presence/absence of concomitant pathologies. Therapy is carried out using medications and surgery.

Medicines

If a woman has an asymptomatic course of the disease, she is young or is in premenopause, and she needs to maintain or restore reproductive function, then drug therapy is indicated. Hormonal agents (estrogen-gestagen group) are prescribed. These medications suppress the production of estrogen and are effective at the initial stage of development of endometriosis.

You should not take medications on your own because they have side effects:

nausea;
vomit;
bloody discharge;
pain in the mammary glands.

It is permissible to use gestagens (progesterone, dydrogesterone). The course of treatment is from 6 to 8 months continuously. These medications are used at any stage of the pathology, and their use is accompanied by the appearance of a depressive state and intermenstrual bleeding.

Antigonadotropic drugs (danazol) are actively used, which suppress the production of gonadotropins. The duration of therapy is at least six months. If women have an excess of androgenic hormones, then this group of drugs is contraindicated. Side effects include increased sweating, changes in weight, increased oily skin, and increased growth of body hair.

Triptorelin and goserelin reduce the amount of estrogens. Antispasmodics and analgesics relieve pain (drotaverine).

Surgical intervention

In moderate to severe stages of the disease, surgery may be prescribed. In the absence of positive dynamics with drug therapy, heterotopias are removed.

Removal of the uterus (hysterectomy) or removal of the ovaries and tubes (adnexectomy) is indicated for women over 40 years of age.

There are cases of relapses (in 15-40% of patients). In this case, a repeat operation is performed.

Therapy with folk remedies

As a supplement to the main treatment, you can use folk remedies at home. It is recommended to use gray or blue clay as follows:

1. Place the lumps in a basin, add warm water and leave to soften overnight.
2. The liquid should be drained and the clay should be stirred until smooth.
3. Next, you need to place 500-700 g of clay in a pan and heat it in a water bath, and then put it on oilcloth.
4. You need to make a clay cake and apply it to your stomach, secure it with a woolen scarf and leave it for two hours.

The duration of therapy is 5-8 sessions.

Gynecological herbal collection is effective for endometriosis. To prepare the infusion you need:

1. Mix serpentine root, knotweed, nettle, calamus and cinquefoil in equal quantities.
2. Pour 400 ml of boiling water over the herbs (2 tbsp) and leave for 1-2 hours.

Directions for use: half a glass half an hour before meals. The course of treatment is 30-31 days.

In order to restore hemoglobin levels, it is recommended to use buckwheat flour, which should be washed down with warm milk three times a day, a tablespoon.

To get rid of pain, you can drink clover infusion (1 tablespoon of herb per 200 ml of water) three times a day, 1/2 cup. An infusion of boron uterus helps restore the menstrual cycle. Wintergreen is used for obstruction of the fallopian tubes, and wintergreen is used to prevent uterine bleeding.

Prevention and prognosis

To prevent endometriosis during sexual intercourse, you need to use hormonal contraceptives. It is recommended to be regularly examined by a gynecologist for the presence/absence of diseases of the reproductive system. If they are present, they must be treated promptly. If a woman has had an abortion, she also needs to be examined regularly.

Self-medication may lead to the formation of cysts and decreased patency of the fallopian tubes.

If the patient has no relapses for five years, we can talk about her complete recovery. In 60% of cases, recovery occurs after surgery in women 20-36 years old.

With endometriosis, ovarian cysts form, which are filled with old menstrual blood, which causes infertility. The probability of becoming pregnant after full recovery is 15-56% in the first six months to a year. Doctors note the negative impact of endometriosis on the course of pregnancy. This disease reduces the chances of bearing a child and often leads to miscarriage.

A pathological process that changes the development of the endometrium is called endometriosis. In essence, there is an uncontrolled proliferation of mucosal cells beyond their physiological size. It develops based on changes in a woman’s hormonal background. Cyclic development does not change, but due to the narrow openings of the exit tracts, it occurs with pain, bleeding, and spotting. Depending on the type of disease and the stages of its development, a classification of endometriosis is formed.

The endometrium is a unique tissue that makes up the uterine cavity. This mucous membrane is in constant development: it grows, changes, and during menstruation it is rejected and excreted from the body. Under certain factors, the endometrium can appear in other organs: ovaries, bladder, rectum.

According to statistical studies, endometriosis ranks third among gynecological diseases. It is second only to uterine fibroids and inflammatory processes. In young and middle-aged women, the disease occurs in 7 to 59%. 30% of women with this diagnosis require surgery. The main consequence of the disease is infertility.

Doctors cannot name the exact reasons influencing the occurrence of the pathology with complete certainty. But the fact that its development is influenced by certain factors has been reliably established. Here are some of them:

Carrying out artificial abortions and diagnostic curettages;
Operations on the uterus, appendages and fallopian tubes;
Exposure of the organ to laser beams, electroconization;
Plastic surgeries in the cervical area;
Difficult childbirth during which injuries occurred;
Inflammation of the endometrium and myometrium;
Benign tumors on the uterus;
Sexual intercourse during menstruation;
Engaging in heavy physical labor and lifting weights during menstruation;
Displacement of the uterus due to changes in adjacent organs.

It is known that women whose relatives have already had this disease are most often affected by the disease. Genetic studies that should identify the gene responsible for the occurrence of this pathology are still underway.

By localization

According to the place of occurrence, the pathology is divided into genital and extragenital forms.

Separately, in the genital form, there is a division of endometriosis into the following forms:

Peritoneal - occurs, affecting the fallopian tubes, ovaries, and can spread to the pelvic peritoneum;
Extraperitoneal – affects the lower parts of the reproductive system, namely: vagina, external genitalia, cervix;
Internal – the development of the disease occurs in the inner layer of the uterus. In this case, the uterus changes its shape, becomes like a ball, and increases in size to 5-6 cm.
Mixed - there are no clear boundaries of the localization of the disease. Most often it occurs when no attention was paid to the source of the pathology for a long time and no treatment was carried out.

In the extragenital form, the disease spreads to completely different organs: the abdominal cavity, lungs, skin, groin area, limbs, lymph nodes, brain, nerves. The extragenital form is divided into peritoneal (affects the ovaries, pelvic peritoneum and fallopian tubes) and extraperitoneal (localized in the external genitalia).

Internal endometriosis is the cause of infertility in every third woman.

Endometrial cells most often enter the body through the fallopian tubes. This is how they enter the pelvic cavity. Other routes for them are blood and lymphatic vessels. Through these channels, cells travel to more distant organs. Edometric cells can travel beyond their physiological boundaries during gynecological operations and cesarean section.

Very often the ovaries suffer from the endometrium, where diseased cells enter with the help of lymphatic vessels. The lesions are small spots or, conversely, large cysts. They contain blood inside and are the color of dark chocolate. Sometimes cysts rupture due to strong pressure on them. In this very place, pain and inflammation occur, and pathways open for cells to penetrate into the pelvic cavity.

Adhesions may appear in the membrane between the organs, which over time move to the serous membrane of the uterus. Damage to the rectum and sigmoid colon leads to the appearance of bloody discharge from the rectum during menstruation. Damage to some parts of the intestine can cause obstruction. Less commonly, endometriosis affects the kidneys and bladder.

By depth and coverage area

Endometriosis is also divided according to the depth and area of the disease. The classification of endometriosis is as follows:

1st degree– lesions are superficial and isolated. The disease at this stage may not manifest itself in any way. However, sometimes minor symptoms may appear, for example, increased blood during menstruation, spotting between cycles;
2nd degree– the disease affects deeper layers, and there are also more lesions. Pain may appear in areas most affected by the endometrium. Surgical intervention at this stage is rarely used; they mainly resort to prescribing medications;
3rd degree– there are many lesions, they are deep, endometrioid cysts appear on one or two ovaries, thin adhesions may appear in the peritoneum. The endometrium selects more and more new places for itself, and the foci that arose earlier develop deeper and deeper. At this stage, they are increasingly resorting to surgery, since not treating the disease can bring it to the fourth stage;
4th degree– there are many lesions, they are very deep, on both ovaries there are large cysts, dense adhesions, organs are fused with each other (for example, germination of the vagina and rectum occurs). At this stage, the reproductive and excretory systems are completely affected. It is impossible to restore the reproductive system

The fourth stage of the disease is characterized by pronounced symptoms and is very difficult to treat.

Taking into account the diameter of the lesions, the depth and surface of their growth, the degree of edometriosis is assessed in points. According to the classification proposed by the American Fertility Society, in force since 1986, the points are distributed as follows:

1st degree (minimal changes) – 1-5 points;
2nd degree (minor changes) – 6-15 points;
3rd degree (pronounced changes) – 16-40 points;
4th degree (strong changes) – more than 40 points.

These stages of endometriosis and their classification by scores were developed to prescribe precise treatment and further monitor the result of such treatment. To date, the classification is the only internationally recognized classification of the stages of endometriosis.

Since 1984, medicine has separately identified the so-called “minor” forms of endometriosis. They are detected quite simply during laparoscopy by an experienced specialist. Small forms are not large in size, their diameter is 0.5 cm. The appearance of these forms is not accompanied by any clinical manifestations. In fact, these are single formations on the pelvic peritoneum or ovaries without the presence of adhesions or scars.

Medium and severe forms are distinguished separately. The latter include:

endometriosis of one or two ovaries with the formation of cysts;
the appearance of lesions on the ovaries with a pronounced periturbar process;
changes in the activity of the fallopian tubes (scarring, obstruction);
penetration of lesions into the pelvic peritoneum;
damage to the uterosacral ligaments;
diseases of the urinary tract and intestines.

Many doctors consider the American Fertility Society's classification to be limited to just a visual assessment of external damage. It does not take into account the clinical picture and functional changes.

Lesion of the retrocervical space

The disease develops in the following steps:

Foci arise and develop within their space – stage 1.
The disease progresses to the capture of the cervix and posterior wall of the vagina - stage 2.
The ligamentous apparatus of the sacrum and the ligaments supporting the uterus and the outer lining of the rectum are damaged - stage 3.
The disease spreads to the rectum, peritoneum, uterus with appendages, bladder - stage 4.

A biopsy is most often used to diagnose the disease.

Ovarian endometriosis

The disease is characterized by cystic formations with dark red contents. The degree of proliferation is assessed in points, taking into account the affected area, the diameter of the lesions and the depth of germination. Because of this pathology, adhesions are formed in the processes of the pelvic organs. Thus, the mobility and normal functioning of the ovaries, fallopian tubes, and also the uterus are threatened. Like other types of this pathology, the consequence of ovarian endmetriosis is menstrual irregularities and infertility.

There are also 4 degrees of pathology:

At the first stage, small pinpoint lesions appear on the surface of the ovaries and on the rectouterine cavity;
At the second stage, a single cyst with a diameter of 5-6 cm may appear, and the pelvic peritoneum is affected by small lesions;
The third stage is characterized by the formation of cysts of both ovaries with a diameter of more than 5-6 cm, lesions on the serous layer of the uterus, fallopian tubes, pelvic peritoneum, as well as the occurrence of adhesions;
The fourth stage is characterized by the development of large bilateral cysts with possible penetration of lesions into other organs.

Extragenital endometriosis is divided into intestinal, urinary, bronchopulmonary, and endometriosis of other organs.

Myometrial classification

According to the degree of damage, internal endometriosis of the uterus is also divided into four stages:

Initial stage (superficial germination of 2-4 mm into the thickness of the mucosa).
At the next stage, the lesions spread into the depth of half the muscle layer.
Next, the myometrium grows up to the serous membrane.
The last stage is characterized by germination of the walls of the uterus up to damage to the peritoneum.

The classification of endometriosis does not apply to the nodular form.

The affected lesions vary in shape and size. They can be round with a diameter of up to several millimeters, or they can be irregularly elongated and up to several centimeters long. Lesions can also be identified by color. They become dark cherry, separated from other tissues by connective, pale scars.

The affected areas become most noticeable during menstruation. Growing uncontrollably, they penetrate deep into the peritoneum and other internal organs. They can grow on the surface, or they can grow deep into organs.

Distant foci of the endometrium can be seen in the postoperative scar, in the navel, in the lungs, in the intestines.

First stage

When a disease is identified, the doctor, focusing on the classification of the development of the pathology, can immediately attribute it to one form or another. It’s good if a woman consulted a doctor at the very first symptoms that she noticed. However, it is very difficult to identify pathology at an early stage, since the symptoms are not clearly pronounced, and most often women attribute them to a slight malaise. The doctor may not notice any changes during an ultrasound scan, since they are not yet significant during this period.

Symptoms that should alert you: spotting that occurs between menstruation, shortening the duration of the menstrual cycle to 25-26 days.

As the disease progresses, the woman begins to feel weakness, anemia, and dizziness. These symptoms occur against a background of constant, bloody discharge.

Pain may occur. The sensation of pain occurs either in only one place or throughout the lower abdomen. Most often, such unpleasant sensations occur if there are inflammatory processes accompanying the disease. Pain can be felt only before menstruation, or after lifting heavy objects. Pain is felt during menstruation, when the mucous membrane is rejected into the cyst cavity. In this case, there is an increase in pressure in its cavity and spasm of the uterine vessels.

In 15% of cases with endometriosis, women suffer from heavy and prolonged menstruation.

Stage 1 endometriosis is usually an incidental diagnostic finding that doctors discover during surgery to remove ovarian cysts or when removing uterine fibroids. The disease can be detected during laparoscopy, which is prescribed to determine the causes of pain.

At the first stage, pathology develops in the following forms:

diffuse - in which many small foci do not penetrate deeper than the uterine mucosa;
nodular - in which one or two nodules appear in the endometrium, not reaching the muscle layer.

The doctor performs an ultrasound before and after menstruation. The following symptoms may alert him: unevenness of the inner layer of the uterus, changes in the size of the uterus (one wall may be larger than the other), detection of small cavities with fluid, changes in vascular blood flow.

To confirm the diagnosis, additional examination methods are prescribed: a blood test for tumor markers, diagnostic hysteroscopy to take an endometrial biopsy.

Treatment at the first stage

In the first stage of the disease, you can also get by with the prescription of hormonal drugs. In this way, the doctor tries to stop the spread of the disease and prevent infertility. A woman must strictly follow all doctor’s instructions if she wants to achieve a speedy recovery and conceive a child.

The most commonly prescribed drugs are: Janine, Yarina, Siluet, Duphaston, Utrozhestan. To restore ovarian function and normalize endocrine levels, combination drugs are used. They are best suited for young women who dream of becoming pregnant in the near future.

It is extremely rare that a doctor resorts to prescribing strong drugs: Buserelin-Depot injections, Mirena hormonal coil. These drugs are used for women who do not plan to have children in the near future. If a woman manages to become pregnant during treatment, treatment is postponed until delivery. After the birth of the child, treatment should be continued.

Surgical treatment is not typical for the first stage of the disease.

is a benign invasion and proliferation of endometrial elements in the muscular layer of the uterus.

Traditionally, internal endometriosis is considered a local case of endometrioid disease -. At the same time, many authors describe it as an independent disease - adenomyosis.

Internal endometriosis: ICD-10 code

N80 Endometriosis
N80.0 Endometriosis of the uterus (adenomyosis, internal endometriosis)

Causes of development of internal endometriosis

Destruction intermediate zone myometrium during instrumental or surgical interventions on the uterus (abortion, cesarean section, “blind” endometrial curettage, intrauterine device, etc.)
Hereditary predisposition to tumor diseases, genetically determined failure of the intermediate zone of the myometrium.
Chronic inflammatory diseases of the uterus and appendages.
Immune and hormonal disorders.

Factors that increase the risk of developing adenomyosis:

Frequent instrumental intrauterine interventions (abortions, diagnostic curettages, etc.)
High infectious index.
Chronic somatic diseases: hypertension, obesity, diabetes, gastrointestinal diseases, allergies, etc.
Endocrine disorders.
High incidence of past gynecological diseases.
Shortened (less than 27 days) menstrual cycle, heavy, long periods.
Senior reproductive age.

Symptoms of internal endometriosis

Heavy, prolonged menstruation.
Algomenorrhea.
Pain varying intensity: lower abdomen, chronic pain in the pelvic area, in the lower back.

Other clinical signs of internal endometriosis

Increase in the size of the uterus. Feeling of a “big belly” during menstruation.
Spotting, bloody-brown (“chocolate”) discharge from the uterus a few days before and after menstruation.
Secondary anemia.
Acyclic spotting “chocolate” discharge after sexual intercourse, lifting weights.
Painful intercourse.
Miscarriage: early miscarriages, premature birth.
Infertility.

Main symptoms of internal endometriosis

Diagnosis of internal endometriosis

Objective gynecological examination

An experienced gynecologist will notice the classic signs of internal endometriosis during a routine bimanual examination:

Increase in the size of the uterus.
Change in the shape of the uterus (spherical or tuberous).
Rough surface of the uterus in the second phase of the menstrual cycle.
Painful uterus.

Ultrasound examination Transvaginal echography (ultrasound) is the initial method of instrumental diagnosis of internal endometriosis.

Despite the fairly high (up to 80-90%) diagnostic accuracy of ultrasound, the detection of grade 1-2 internal endometriosis by this method is associated with certain difficulties and is not always possible. When adenomyosis is combined with multiple fibroid nodes, the prognostic value of ultrasound is significantly reduced.

For a more accurate diagnosis of adenomyosis, ultrasound should be performed in the second half of the menstrual cycle, closer to the beginning of menstruation.

Echo signs of internal endometriosis

The uterus is round in shape.
In the myometrium, hyperechoic zones of various sizes are detected, often round in shape.
Inside zones of increased echogenicity, anechoic (cystic) cavities can be found, sometimes large up to 3 cm, filled with fine suspension (symptom of “honeycomb”).
The anteroposterior dimensions of the uterus are enlarged or one of the walls of the uterus is unevenly thickened.
Defects of the basal layer of the endometrium: jaggedness, uneven thickening or thinning. The boundaries between the endometrium and myometrium are unclear.
Hypo- and hyperechoic stripes in the myometrium, located close to each other, perpendicular to the scanning plane (echoic linear striations).

Echogram. Diffuse internal endometriosis Magnetic resonance imaging

MRI of the uterus is a more accurate (compared to ultrasound) method of instrumental diagnosis of adenomyosis. Due to the high cost, this study is optional. However, many authors believe that MRI should become a standard diagnostic procedure in cases of high-grade algomenorrhea because this symptom always suggests internal endometriosis.

In addition, MRI can detect the disease at an early stage of its development. An important diagnostic MRI sign of adenomyosis is thickening of the intermediate zone of the myometrium by more than 12 mm (the norm is 2-8 mm).

MRI of the pelvis – internal endometriosis Hysteroscopy

This method of diagnosing adenomyosis is based on visual inspection of the inner surface of the uterus using endoscopic equipment.

Signs of internal endometriosis during hysteroscopy:

Deformation, expansion of the uterine cavity.
Against the background of the pale pink mucous membrane of the uterus, the mouths of the bleeding endometriotic ducts are visible.
The walls of the uterus have an uneven rocky topography - the phenomenon of “wave” or ridge formation.

To diagnose internal endometriosis, hysteroscopy is performed
on days 6-9 of the menstrual cycle.

In the case of adenomyosis, the most informative is hysteroscopy with mandatory targeted biopsy suspicious area of the myometrium.

Diagnostic hysteroscopy and biopsy are always followed by separate diagnostic curettage mucous membrane of the uterus and cervical canal (under mandatory hysteroscopy control). All removed endometrial tissue and myometrial biopsy are sent for histological examination.

The final diagnosis of internal endometriosis is made after confirmation by histological conclusion

Internal endometriosis in 31-56% of cases is combined with other pathological transformation of the endometrium (including malignant). But most often - from the uterus (up to 85% of cases).

Degrees of internal endometriosis

The severity of the diffuse form of internal endometriosis is determined by the degree of damage to the uterus:

Ι degree - invasion of the endometrium into the myometrium is limited to the intermediate zone (submucosal layer of the myometrium).
ΙΙ degree - the depth of endometrioid ectopia does not exceed half of the myometrium (up to the middle of the thickness of the muscular layer of the uterine wall).
ΙΙΙ degree - damage to the largest part or all of the muscular layer of the uterus up to the outer serous membrane.
ΙV degree - the pathological process extends beyond the uterus and spreads to the parietal peritoneum of organs adjacent to the uterus.

Internal endometriosis stage 1

It is usually asymptomatic and often becomes a random histological finding or is predicted based on MRI results.

Asymptomatic grade 1 adenomyosis does not require special treatment. The patient is recommended to have a healthy lifestyle and follow-up with a gynecologist once every 6 months.

Internal endometriosis stage 2

And at this stage of the disease, the symptoms of internal endometriosis are not always noticeable. Therefore, the disease can be detected accidentally (during a routine ultrasound, during an examination of a patient with complaints of infertility).

But more often, grade 2 adenomyosis is accompanied by algomenorrhea, polymenorrhea, pelvic pain, “chocolate” spotting, and dyspareunia.

In some cases, the only sign of pathology is infertility or miscarriage.

The uterus at this stage of the disease is of normal size or slightly enlarged (does not exceed 5-6 weeks of pregnancy).

For asymptomatic forms of grade 2 adenomyosis, treatment is not carried out - dynamic observation is recommended.

In case of mild symptomatic course, it is permissible to prescribe monophasic COCs, for example, progestins, including intrauterine ones. Evaluation of the effectiveness of hormonal treatment - every 3-6 months.

For pelvic pain or algomenorrhea, short courses of NSAIDs are also prescribed.

Read more about drug treatment for internal endometriosis below.

Internal endometriosis grade 2-3

Accompanied by pain hyperpolymenorrhea, an increase in the size of the uterus, infertility (in 50% of cases) and other signs characteristic of adenomyosis.

The choice of treatment - hormonal or surgical - is individual. It depends on the severity of the disease, the age and reproductive plan of the woman, and the gynecological and somatic pathology accompanying adenomyosis.

Internal endometriosis grade 3-4

This advanced stage of the disease is accompanied by severe symptoms and requires surgical treatment.

The scope and access of surgical intervention, postoperative replacement or anti-relapse hormonal therapy is prescribed strictly individually, if necessary and according to indications.

Endometriosis of any localization is similar to a tumor with a chronic course and autonomous growth of pathological foci.

Therefore, a true cure for this disease is possible only with the most complete surgical removal of absolutely all endometrioid ectopia. In the case of internal endometriosis, this effect is achieved total removal of the uterus.

But if the disease affects young women interested in preserving reproductive function, they have to look for other, less radical, organ-preserving treatment methods.

Drug hormonal treatment of internal endometriosis

No drug cures internal endometriosis completely. Hormonal therapy only temporarily suppresses the disease.

Drug therapy for internal endometriosis is justified in young nulliparous women.

In other cases, hormonal agents, if necessary, are prescribed after surgical treatment as anti-relapse therapy.

According to many clinicians, truly effective hormonal suppressive treatment of adenomyosis is possible only with 1-2 degrees of spread of the disease

Today, the following groups of hormonal drugs are used in the treatment of internal endometriosis:

A-GnRH - analogues of gonadotropin-releasing hormone: Nafarelin, Buserilin, Leuprorelin, Triptorelin.
Antigonadotropins: Danazol, Gestrinone.
Progestins: Medroxyprogesterone, Dienogest (), Levonorgestrel.

Modern A-GnRH drugs are recognized as the most effective. They are called the “gold standard” for conservative treatment of endometriosis of any location.

Some hormonal treatment regimens for internal endometriosis

/consultation with a doctor is required/

Preparation	Trade Name	Methods of administration and dosage
Triptorelin	Decapeptyl-depot Diferelin
Goseriline	Zoladex	3.6 mg intramuscularly once every 28 days. Only 3-6 injections
Leuprorelin acetate	Lucrin-depot	3.75 mg intramuscularly once every 28 days. Only 3-6 injections
Nafarelin	Sinarel	Nasal spray. 400 mcg daily for 3-6 months
Danazol	Danoval Danol	1 capsule (200 mg) orally, 2 times a day, daily, continuously for 6 months
Gestrinone	Nemestran	1 capsule (2.5 mg) orally, 2 times a week, continuously for 6 months
Medroxy- progesterone acetate	Provera	10 mg 3 times a day, orally, for 6 months continuously
Dienogest	Byzanne	2 mg 1 time per day, orally, continuously, no more than 15 months
Levonorgestrel	Hormonal intrauterine spiral LNG-IUD "Mirena"	Installed inside the uterus for up to 5 years. Used to treat stages 1-2 of adenomyosis in women not interested in pregnancy

Both antigonadotropins and GnRH A suppress menstrual function - creating a state of “medicated menopause” or pseudomenopause. Despite their high effectiveness against adenomyosis, treatment with these drugs is accompanied by many unwanted side effects and symptoms of menopause. Therefore, the duration of their use is strictly limited to six months.

After discontinuation of GnRH A, menstrual and reproductive function is restored independently within 6-12-36 months. Remission of the desired disease lasts up to 5 years or more. During this period, the woman manages to give birth to a child or approach natural menopause with the reverse development (involution) of the disease.

Recurrence of internal endometriosis after conservative therapy is an indication for surgical treatment.

Surgical treatment of internal endometriosis

Even taking into account all the complexity and imperfections of drug treatment of adenomyosis, radical surgical treatment of internal endometriosis - removal of the uterus - is carried out exclusively according to strict indications

Indications for surgical treatment of adenomyosis:

There is no positive effect from hormonal therapy during the first 3 months of treatment.
Adenomyosis grade 2-3 in combination with ovarian tumors, fibroids, endometrial hyperplasia or other uterine pathology requiring surgical treatment.
Adenomyosis of 2-3 degrees with symptoms of hyperplastic transformation of the muscular layer of the uterine wall.
Adenomyosis, resistant to conservative treatment, accompanied by uterine bleeding and secondary anemia.
Cystic form of adenomyosis.

Scope of surgical intervention for diffuse form of internal endometriosis:

Supravaginal amputation of the uterus - supracervical or subtotal hysterectomy (with or without appendages).
Complete removal or extirpation of the uterus - total hysterectomy (with or without appendages).

Hysterectomy. Scope of surgery for adenomyosis

A supravaginal hysterectomy is less dangerous than a total hysterectomy. Therefore, when choosing the extent of surgical intervention, it is extremely important to adequately assess the feasibility of preserving the cervix and ovaries. Oncologists definitely recommend removing the fallopian tubes.

Options for surgical access in surgery for internal endometriosis:

Laparoscopy.
Laparotomy.
Vaginal access in combination with laparoscopy.

Hysterectomy. Online access routes

Laparoscopy traditionally occupies a priority place in the surgical treatment of internal endometriosis.

Advantages of laparoscopy:

Minimal trauma.
Significant reduction in postoperative rehabilitation time.

If the vaginal part of the cervix is intact (not involved in disease), laparoscopic supracervical hysterectomy (LSH) is recommended. Otherwise, a total laparoscopic hysterectomy (TLH) is performed.

Contraindications to laparoscopy for adenomyosis:

Suspicion of a late-stage malignant process.
Combination of internal endometriosis with widespread endometriosis of another location.
Severe extragenital pathology.
Pronounced adhesions of the abdominal cavity.
Relative contraindication: the size of the affected uterus is more than 12 weeks of pregnancy.

Scheme for identifying and treating internal endometriosis

Complications of the disease

Patients with internal endometriosis should undergo regular examination by a gynecologist at least once every 3-6 months. Timely therapy will prevent progression of the disease.

Severe consequences of long-term adenomyosis:

Uterine bleeding.
Severe secondary anemia.
Damage to neighboring organs.
Infertility.
Severe pain syndrome, severe limitation of physical activity, inability to have sexual activity.
Malignancy.

According to oncologists, patients with internal endometriosis are at high risk for developing endometrial, ovarian and breast cancer.