The endometrium is a fairly common pathology of the female reproductive system. It is usually diagnosed in young girls. This neoplasm is not characterized by typical symptoms, so representatives of the fair sex are in no hurry to consult a doctor. Lack of timely treatment can result in infertility or transformation of the polyp into a malignant tumor. In our article we will try to understand why these tumors develop and what treatment methods modern medicine offers.

Features of the pathological process

First, we should consider the structure of the female reproductive organ. The uterus consists of three layers: external serous, middle muscular and internal. The latter is otherwise called the endometrium and is a mucous membrane. It is this layer that usually attracts the attention of gynecologists.

The endometrium consists of a covering epithelium and a base with glands - the stroma. They constantly produce a secretion with an alkaline reaction, but its amount varies depending on the phase of the female cycle. During menstruation, only the covering epithelium is separated. The stroma always remains and serves as a source of future mucosal regeneration in the first half of the cycle.

A polyp is a tumor-like formation. Its development is most often preceded by focal proliferation of its mucous membrane leading to the formation of a polyp. Therefore, it has a structure similar to the endometrium - fibrous tissue and glands. From here we can distinguish the following types of benign neoplasms:

• glandular;
• fibrous;
• glandular fibrous polyp.

In the structure of the outgrowth, it is customary to distinguish between the body and the leg, which is penetrated by the smallest blood vessels. Its dimensions can vary from a few millimeters to 4-5 cm. In its shape, the neoplasm resembles a small mushroom.

In this article we will look in detail at the causes and methods of treating glandular polyps, since this type of pathology is diagnosed most often. The favorite place for its localization is the area of ​​the fundus or corners of the uterus.

Why does the disease occur?

Modern medicine cannot name the exact causes of the tumor. So she only has to make assumptions. It has been clearly established that a glandular polyp develops against the background of hormonal changes in a woman’s body. The growth gives a unique response to the effects of estrogen, repeating the reaction of the inner layer of the uterus. Hormonal imbalance can be of two types: absolute and relative. In the first case, the amount of estrogen produced increases due to ovarian tumors or persistence of the follicles. With relative hyperestrogenism, hormone levels may remain normal. However, the pathology develops due to a decrease in the antiestrogenic effect of progesterone with insufficient production.

Doctors also identify a group of factors, the presence of which increases the likelihood of a benign formation. These include:

• frequent abortions;
• diabetes;
• physical inactivity;
• excess body weight;
• inflammatory diseases of the genital organs.

Glandular fibrous polyp often develops in women with mental disorders.

First symptoms

Neoplasms of a non-hormonal nature practically do not manifest themselves. Violations may be accompanied by minor intermenstrual bleeding. When a polyp is a consequence of an infectious process in the body, the disease occurs in the form of low-grade inflammation.

Neoplasms of a hormonal nature that appear as a result of hyperplasia are manifested by increased menstrual bleeding. Therefore, such patients gradually develop iron deficiency anemia. If the size of the polyp is more than 2 cm, discomfort may occur during intimacy. Complaints of cramping pain are extremely rare.

The pathology described in the article has no characteristic symptoms. If one or more of the signs listed above appear, you should consult a doctor. Treatment must be started immediately, since in 3% of cases the glandular polyp has a tendency to malignancy.

Medical examination plan

A standard examination of a woman in a gynecological chair often turns out to be uninformative. A doctor cannot confirm a pathology based solely on its external manifestations. Basic screening includes the following instrumental diagnostic methods:

1. Ultrasound (the information content of the study is about 98%).
2. Study of uterine cavity aspirate (used to exclude the malignant nature of the neoplasm).
3. Hysteroscopy (helps assess the location and size of the polyp).
4. (allows you to determine the type of tumor).

Based on the results of the examination, the gynecologist makes recommendations for therapy.

How to treat the disease?

The only treatment option is removal of the glandular polyp. The operation is performed under general or local anesthesia. During the procedure, the doctor first expands the uterine cavity and then removes the tumor hysteroscopically. If there are several of them, a curettage procedure is recommended. After surgery, damaged areas of the uterus are cauterized with liquid nitrogen to prevent endometritis.

Recovery usually proceeds without complications. During the first 10 days after surgery, slight bleeding may occur. During this period, it is better to avoid intimate contacts. Additionally, the doctor may prescribe a course of antibiotics. All medications, as well as the duration of their use, are selected individually.

Is only drug therapy possible? endometrial problems are sometimes treated with hormonal medications. However, this method is only acceptable if the young woman is going to become a mother in the future. In addition, there should be no changes in the biopsy aspirate. After 40 years, such therapy is undesirable, since at this age the likelihood of developing oncological processes increases.

Treatment after removal of a glandular polyp

The success of the operation does not guarantee the absence of relapses in the future. The reason for this is hormonal changes in the woman’s body, which led to the development of pathology. Such processes can contribute to the re-formation of polyps.

What treatment is required in this case? As a rule, a woman is prescribed medications of the progesterone group. They allow you to reduce estrogen levels and eliminate the cause of the disease. Also, after surgery, it is necessary for preventive purposes to be examined by a gynecologist once a year. If no signs of relapse are detected within 12 months, the patient is removed from the dispensary register.

Possible complications

Treatment of glandular fibrous polyps should begin immediately after confirmation of the diagnosis. In the absence of proper therapy, non-cyclical or regular bleeding may occur. They negatively affect a woman’s intimate life and her well-being.

Polyps are considered especially dangerous during pregnancy. Neoplasms can lead to serious blood loss and premature placental abruption. Another unpleasant complication of pathology is the fetus. Therefore, it is important to undergo a full medical examination at the planning stage of the baby. If serious health problems are detected, a course of therapy is required.

Prevention measures

A glandular polyp, the treatment of which involves surgery, is a fairly common pathology. To avoid such health problems, a woman should follow the following recommendations:

• promptly treat gynecological diseases;
• lead a healthy lifestyle;
• use contraception and prevent abortions;
• undergo a preventive examination with a gynecologist twice a year.

There is no specific prevention of pathology. If suspicious symptoms appear, you should immediately seek help from a doctor. Self-medication is not recommended. Timely detection and removal of endometrial glandular polyp allows you to avoid complications in the future.

Endometrial polyp in the uterus: what is it and how to treat

An increase in the number of identified endometrial hyperplastic processes is associated with an increase in women's life expectancy, the number of neuroendocrine disorders and changes in lifestyle. This naturally leads to an increase in the number of cases of endometrial cancer. To reduce the risk, it is necessary to diagnose and treat promptly endometrial polyp in the uterus.

• Endometrial polyp in the uterus - what is it and how to treat
• Symptoms: what are the signs to suspect a polyp?
• Glandular polyp of the endometrium
• Endometrial fibrous polyp
• How to determine polyposis using ultrasound
• Treatment methods
  • Examination before surgery
  • Treatment after surgery
• Rehabilitation period
• Pregnancy after surgery

What is an endometrial polyp?

Very often, during pre- and postmenopause, benign pathological changes in the internal tissues of the uterus are detected, but they can also be detected in patients of childbearing age. The endometrium is a hormone-sensitive tissue, therefore absolute or relative changes in estrogen concentration can lead to the appearance of foci of hyperplasia - endometrial polyps (ICD-10 code N84).

Treatment of endometrial polyp in the uterus: hysteroresectoscopy surgery. Afterwards, the material is sent for histology, which determines the type of polyp and gives the doctor the opportunity to prescribe the correct treatment.

Endometrial polyp in the uterus: causes

Risk factors are conditions in which the ratio of estrogen and estrogen is disturbed. leads to increased proliferative effects of estrogen and increased division of endometrial cells. But the exact causes of endometrial polyps in the uterus are unknown.

Most often they are diagnosed in women with the following pathologies and conditions:

• dysfunction of the ovaries and chronic;
• syndrome;
• hyperplasia of the adrenal cortex;
• incorrect sex hormone therapy;
• extragenital disorders: obesity, diseases, liver pathologies;
• , frequent intrauterine manipulations (abortion, curettage).

If a diagnosis of endometrial polyp in the uterus is established, the causes of this condition are determined by the presence of gynecological pathology in the woman that can disrupt the balance of hormones. Some types of tumors can develop into cancer.

The classification of types of growths adopted in Russia is based on that proposed by WHO in 1975. According to it, histological types of polyps are distinguished:

• glandular;
• glandular-fibrous;
• fibrous;
• adenomatous.

It is impossible to predict how quickly a hyperplasia focus grows. The uterine cavity is normally slit-like and small in size; the hyperplastic process is not able to exert pressure on the myometrium and expand the uterus. Sometimes it may stop at a certain size and not grow anymore. What is much more dangerous is not its size, but the degree of cell differentiation: the lower it is, the higher the likelihood of transformation into malignant forms. The adenomatous process is more susceptible to this.

What symptoms can be used to suspect pathology?

When an endometrial polyp is suspected, symptoms vary in severity. Sometimes an asymptomatic course is possible when the size of the lesion is small, up to 1 cm.

The leading signs of endometrial pathology are uterine bleeding of several types:

• acyclic, which appear regardless of the phase of the monthly cycle;
• contact are observed after sex or examination by a gynecologist;
• menometrorrhagia - heavy menstrual flow.

Cramping pain in the lower abdomen can appear with large growths, torsion of the legs and tissue necrosis.

During reproductive age, the causes and symptoms of overgrowth often cause. The lack of ovulation, which accompanies most women with this pathology, is a consequence of hormonal imbalance. This means that it is impossible to say for sure whether it is possible to become pregnant without treatment. If a neoplasm forms against the background of an unchanged endometrium, then pregnancy can occur, but the risk of spontaneous termination is increased.

Important!

Women with a normal menstrual cycle may develop a functional polyp. It is formed in the second half of the MC and is capable of cyclical changes, like the rest of the endometrial layer. Such growths respond to the introduction of estrogens and progesterone.

Glandular polyp of the endometrium

Below the functional layer of the uterine epithelium, which is shed during menstrual bleeding, is the basal layer. Hyperplastic foci begin to form from it, gradually pushing apart and protruding tissue in the endometrium. Such formations are hormonally inactive and do not respond to stimulation with progesterone. They differ in structure from the surrounding tissues, this is especially noticeable in the second phase of the cycle. The histological variant is determined if it has developed endometrial glandular polyp functional type:

• secretory variant;
• proliferative variant;
• hyperplastic variant.

In women with preserved menstruation, the basal type of immature cells is typically identified, which does not respond to progesterone therapy. Against the background of such a polyp, it is capable of changing and forming a proliferative endometrium. Histology confirms the hyperplastic variant based on these features. If the study reveals that the tissue corresponds to the secretory or proliferative period of the cycle, it means that the lesion responds to the influence of the ovaries.

In a glandular polyp, the stromal component is poorly expressed; in most lesions, glandular tissue predominates. The stroma is loose connective tissue, represented by cells with tangles of blood vessels at the base. Polyps with focal stromal fibrosis can hardly be classified as glandular. The glands are located in it at different angles and differ in length.

Any type of polyp can form the adenomatous type. In this case, proliferating epithelial cells without atypia are detected focally or diffusely.

Ultrasound can suggest the presence of pathology. It has clear boundaries, expands the uterine cavity, the structure is homogeneous or with many inclusions. They are located in the area of ​​the mouths of the fallopian tubes or the fundus. Using ultrasound, you can identify a small polyp, only 0.2-0.4 cm.

Treatment of a glandular polyp in the uterus involves two stages - surgical removal and hormonal therapy. A simple and effective method - and removal of the endometrial polyp. If the feeding vessels have been removed and the attachment site has been coagulated or cauterized with liquid nitrogen, then there is no reason for resumption of growth. The dissected polyp is sent for histology to confirm the diagnosis.

When a glandular endometrial polyp is confirmed, treatment after removal involves taking hormonal drugs. These can be combined contraceptives and pure gestagens. The drugs are prescribed for a period of 3-6 months. The doctor will explain in detail how to treat the consequences of a polyp with stromal fibrosis using them. After this, the woman can plan both pregnancy and IVF. See photos of some drugs nearby.

Glandular fibrous endometrial polyp

Histological analysis of fragments of biopsy material from a glandular-fibrous neoplasm allows us to determine that the glands in it are randomly distributed and are in the stage of proliferation. The functionally active epithelium is not expressed, and in the cystic glands it is proliferative or does not function and is thickened. The stalk is rich in cellular elements with stromal fibrosis. The stromal component predominates over the glandular component.

The diagnosis indicates the type of polyp:

• indifferent option;
• retrogressive option.

The latter type is more typical for postmenopause (menopause). The proliferative type polyp is large in size - from 2.5 to 3.5 cm.

Treatment for glandular fibrous polyp of the endometrium also combined in the form of surgery and conservative treatment. During hysteroscopy, curettage of the uterine cavity is mandatory, which means a reduced risk of relapse. Since the causes of glandular fibrous polyp require treatment after removal, hormonal medications are prescribed for up to 6 months. After this, you can plan your pregnancy.

Endometrial fibrous polyp

The causes of this type of uterine polyp are similar to the others. In a fibrous endometrial polyp, the stroma predominates, glandular tissue is found sporadically, and there are few vessels. The basis of therapy is surgery. It is supplemented with treatment after removal: antibiotics and hormonal drugs are used.

Adenomatous endometrial polyp

This type of polyp is rare and is more common in women over 40 and postmenopausal. The size of the polyp is small, rarely up to 30 mm. It is possible to determine whether this is hyperplasia or a polyp only histologically. There is often a combination of pathology with fibroids. In older women, pathology can develop against the background of endometrial atrophy. The cells of an adenomatous polyp become younger in morphological structure. As the condition progresses, it transforms into adenocarcinoma.

Is surgery necessary for this condition?

Treatment is carried out comprehensively. Adenomatous endometrial polyp must be operated on to prevent its malignancy and metastasis.

How to determine pathology using ultrasound

On ultrasound, any type of neoplasm has characteristic general signs:

• clear boundaries of the focus;
• deformation of the middle linear part of the M-echo;
• expansion of the uterine cavity;
• acoustic effect in the form of signal amplification or weakening;
• round shape of formations;
• presence of cystic inclusions.

Important!

Ultrasound signs differ slightly depending on the type of polyp. This means that ultrasound can only determine the presence of growth of the formation, and the type and further treatment after removal of the endometrial polyp is determined by the results of histology.

Endometrial polyp removal

After diagnosing an endometrial polyp, treatment is selected depending on its histological type and the woman’s age. Removal of the endometrial polyp is a mandatory step in therapy. This is associated with a high risk of it developing into cancer. The polyp is also an obstacle to pregnancy in women of childbearing age.

Some suggest that the polyp may come out with your period. But that's not true. The source of tumor growth is the basal layer, which does not slough off during menstruation. On what day of the cycle the tumor is removed is decided by the doctor in each specific case. But the optimal period is considered to be the period when your period ends and no later than 10 days from its start. At this time, the endometrium is thin and its position and the stalk of the polyp are visually clearly visible. This allows you to correctly remove the polyp to healthy tissue and prevent its reappearance (relapse). During menstruation, resection can be performed for emergency indications.

Endometrial polyp in the uterus and treatment without surgery

Need to know!

Complete treatment without surgery is impossible. Traditional methods of treatment are not effective. There is no need to waste time searching for recipes and checking the effect of the remedies found.

There are minimally invasive techniques that minimally injure surrounding tissues, are not accompanied by bleeding and have a short recovery period after manipulation, for example.

Treatment without surgery for endometrial polyps in the uterus can be called laser removal. This method allows for resection of only pathological tissues without scar formation. When removing with a laser, you can select the required power and target the tissue. The disadvantage of this method is that in some cases the disease relapses after a few months.

Hysteroresectoscopy of endometrial polyp - what is it?

The main method of treating endometrial polyps in the uterus of all types, except adenomatous, is resectoscopy. Adenomatous polyp in patients over 45 years of age, it is an indication for hysterectomy. In nulliparous girls, they resort to hysteroresectoscopy of the endometrial polyp - this is an excision using a hysteroscope. Subsequently, hormonal medications are prescribed and it is recommended to become pregnant and give birth in the near future. If the adenomatous lesion recurs, the uterus is removed without appendages.

Hysteroscopy of endometrial polyp is the method of choice in the treatment of pathology.

Examination before surgery

If an endometrial polyp is detected in the uterus, surgery is scheduled as planned. Only bleeding and necrosis of the tumor are indications for emergency intervention. The routine examination includes:

• general blood and urine tests;
• coagulogram;
• blood type and Rh factor;
• biochemical analysis;
• testing for HIV and syphilis;
• Ultrasound of the pelvis.

According to indications, other additional examination methods are possible.

Hysteroscopy and its consequences

The removal operation is performed in the gynecology department in the operating room under general anesthesia. Local anesthesia is not used. After the polyp is removed, it is recommended to perform curettage of the uterine cavity. This is especially true for endometrial hyperplasia.

The postoperative period takes place in the ward. Awakening from anesthesia and diuresis (separation of urine) are monitored. Discharge after hysteroscopy of an endometrial polyp in the form of dark blood for 2-3 days. Then they lighten, become slimy with a slight tint of yellowness. They can last up to 10 days after removal.

Endometritis can be a consequence of hysteroscopy. If your body temperature rises, or discharge with an odor or pus appears, you should inform your doctor. Heavy bleeding a few days after hysteroscopy also indicates a deterioration of the condition and requires emergency medical attention.

A tissue sample from the polyp is sent for histology. The result is ready in approximately 7-10 days. Based on the analysis data, you can adjust further treatment and decide what to do next.

Treatment after endometrial polyp removal

Surgical manipulation is the first stage of medical care. Treatment after removal of an endometrial polyp in the uterus consists of the prevention of purulent-septic infection and hormonal correction. Non-hormonal treatment includes broad-spectrum antibiotics (Cefotaxime, Summed), vitamins. Nutrition should be balanced. Women who are overweight need to follow a diet.

Hormonal therapy includes the prescription of combined oral contraceptives for women under 40 years of age (Zhanin, Yarina, Regulon). Over 40 people use gestagenic drugs Duphaston, Utrozhestan.

Discharge after hysteroscopy of endometrial polyp: rehabilitation period

Menstruation after removal of an endometrial polyp may be delayed if curettage was not performed. The first menstruation after cleaning the uterine cavity appears after 28-30 days. In this case, the day of the operation is considered the first day of the cycle. When using hormonal drugs, there is practically no delay in menstruation.

Important!

For women who do not intend to become pregnant, have fibroids or are recommended to use an intrauterine device with the gestagen component "Mirena" as a treatment after removal of hyperplastic foci.

Endometrial polyp and pregnancy

Polyp and pregnancy are incompatible. The presence of a polyp in the uterus prevents it, even if conception has occurred. It is mechanical and... to the “unhealthy” endometrium and will be released along with menstrual flow. If the embryo implants, a miscarriage will occur in the early stages of pregnancy. Often, it is in nulliparous girls that endometrial polyposis is discovered as the cause of a long absence of pregnancy. give good prognosis for recovery and preservation of reproductive function.

Glandular polyp is a common clinical situation in gynecological practice. Glandular polypous structures have many types, depending on the localization of ingrowth, size and other clinical criteria. Depending on the type of polyp, the risks of complications associated with pathology increase. The absence of symptoms with endometrial growths does not always mean a benign course of the disease, but a malignant polyp always appears. A woman’s timely response to atypical signs largely determines the prognosis regarding cancer risks.

Endometrial polyps are tumor-like growths that grow inside the uterine cavity. Each polyp has its own structure: base (stroma), body and stalk. So, polyps can be on a long stalk or a flat, wide base. The latter option is most prone to malignancy.

The uterine cavity is lined with two types of epithelium, which, according to histological data, corresponds to the type of polypous neoplasms:

• Functional- hormone-dependent uterine layer, cyclically replaced;
• Basal- a non-hormone-dependent layer of the endometrium, which is the basis during menstruation.

The functional type of polyps is formed on the layer of the uterine mucosa, which is regularly renewed during menstruation. Functional polyps can be secretory, proliferative or hyperplastic.

The basal polyp forms on the stable inner layer of the endometrium and becomes more noticeable in the second phase of the menstrual cycle.

The risk of malignancy remains in both types of tumors. Thus, under the influence of multiple factors, the mucous membrane is constantly damaged, while the glands are modified structurally and morphologically, which contributes to their transformation.

Carrying out differential diagnosis allows you to evaluate each type of polyp individually and clarify the degree of oncogenic risks.

Classification and types

Modern classification makes it possible to differentiate each type of pathological growth according to structural and compositional criteria, which reflect the clinical situation in the following areas.

Glandular fibrous lesion in the uterus

This form is rarely diagnosed in young women of reproductive age, and even less often in postmenopausal women. Along with this, the appearance is more typical for women with a stable menstrual cycle.

The components consist of glandular foci of irregular shape and length. The lumens of the glands are quite stretched, resembling cystic cavities with uneven expansion. In the upper epithelial layers, the base of the polyp is saturated with a vascular component, and the stalk is denser, fibrous tissue is more concentrated in it.

The inflammatory process and disruption of normal blood circulation are disrupted in almost all cases.

Glandular-cystic endometrial type

The stroma or body of the neoplasm contains glandular tissue with cystic inclusions. The size of the polyp rarely exceeds 2 cm.

Among the main symptoms are:

1. Atypical discharge;
2. Heavy bleeding;
3. Infertility.

Usually it causes the spread of hyperplastic processes in the endometrium. Frequent complications are inflammation of the exudative filling of the cystic cavity, uneven growth of the polypous structure. Neoplasms can be localized or multiple.

Glandular polyp of the endometrium with focal stromal fibrosis

Stroma is the base of the growth, made of loose connective tissue. With the addition of hyperplastic processes and fibrotic changes, the structure of the stroma becomes vesicular and resembles a sponge. The structure often has a flat, wide base, a stroma.

Partial fibrous transformation of the base becomes the cause of malignancy of the tumor under special factors:

• Heredity;
• Regular inflammation;
• Degenerative processes of the entire lining of the uterine mucosa.

The growths have an oval or round shape, the surface is smoothed, not lumpy. The size of the neoplasm varies from 0.5 mm to 3.5 cm.

It is important! Regardless of the morphological appearance of the glandular type of neoplasm, the appearance of symptoms always signals:

• deterioration of the condition of the mucous membranes of the uterine endometrium,
• decreased function of the cells of the inner membranes.

Main types

The modern classification of endometrial growth allows clinicians to determine not only prognostic criteria for a woman’s future health, but also treatment tactics. After basic diagnostic procedures and clarification of the classification, the only correct treatment is usually prescribed.

Glandular endometrial polyp of basal type

Glandular growth of the endometrium occurs when there is abnormal growth of cells in the basal layer of the endometrium. As the polypous lesion grows, it penetrates into muscle and fibrous fibrous structures. Gradually, the neoplasm develops a base, body and leg.

In terms of the type of formation and growth process, functional and basal growths are similar to each other.

An important difference is:

• non-functionality of epithelial cells of the basal layer,
• lack of hormonal dependence on a woman’s menstrual cycle.

Among glandular basal neoplasms the following groups are distinguished::

• Indifferent- proliferation of neutral basal cells;
• Hyperplastic— growth of internal cells, formation of a kind of “underground” of the basal stroma;
• Proliferative- cell proliferation with the risk of subsequent inflammation.

Regardless of the type of pathological proliferation of endometrial mucosal cells, women are advised to remove the growth within healthy tissue (with a wide base) or cauterize the polyp stalk.

Hyperplastic version

In the glandular basal proliferation of cells, the base is poorly visible, which is expressed by a strong transformation of mucous tissue. Such growths resemble in appearance cauliflower inflorescences, a two-story structure with tangles of densely intertwined vessels. At the base, signs of hyperplastic changes in the endometrium are clearly visible.

Proliferative variant

With stable menstruation in women, the appearance of basal growths of the proliferative type is due to the absence of hormone dependence. Against the background of hyperplasia and a stable basis, the polyp is constantly transforming and growing, which contributes to the subsequent development of inflammation. Histologically, the functionality of the polyp is determined by its hyperplastic type.

If, during the study, the tissue corresponds to the secretory or proliferative cyclic period, then this means the reaction of the lesion to changes in the functionality of the ovaries.

Glandular growth of functional type

If the basal layer of the endometrium is non-functional and independent of hormonal surges, then the functional one undergoes constant renewal in the absence of an attached fertilized egg.

If fertilization fails during active ovulation, the cells of the functional layer come out along with menstrual bleeding. If there is insufficient detachment of the functional layer, the remaining fragments form supporting cells for future growth. Thus, a functional type of endometrial polyp gradually appears. As menstrual cycles progress, the tumor changes along with the functional layer.

Such polypous lesions are rarely of impressive size and tend to spread and localize in groups. In rare cases, characteristic symptoms develop. Glandular functional polyps are determined during a traditional gynecological examination.

The endometrium is built from two layers: basal (germ) and outer (functional). The functional layer is torn away from the basal layer in the absence of fertilization (during menstruation).

If the rejection process has not occurred completely, then neoplasms are formed on the remaining functional layer based on the existing glandular and supporting (stromal cells). This is a glandular tumor of the functional type of endometrium. A benign tumor undergoes the same changes as the entire mucous membrane of the uterus.

Secretory variant

Another type of functional growth is the secretory type of development, when serous exudate accumulates in the glandular ducts of the polypous focus.

Such cavities resemble cystic components and gradually expand and eventually form a cyst. The polyp is characterized by constant secretion of mucus from the cavity of the glandular ducts.

The sizes and clinical course of such polyps are identical; there is no fundamental difference. Gradually, the base of functional polyps becomes covered with fibrous scar tissue.

Glandular fibrous polyp of the endometrium of the basal type

This type of growth is localized on the surface of the endometrium and is predominantly benign in nature. The body of the polyp is centered on a thin stalk. A distinctive feature of glandular fibrous polyps is the abundant filling of the body and stroma with a vascular component. Microscopically, the structural filling of the polyp contains glandular tissue and muscle fibers.

Glandular fibrous tumors of the uterus are distinguished by their mature structure, as well as a variety of morphological options. The location of endometrial growths is usually chaotic and disorderly. The cells of the lining epithelium at the base of the polyp are secretory or inflammatory in nature. The stalk of the polyp has a wide vessel.

Retrogressive variant of the glandular-fibrous lesion of the endometrium

This type of polypous lesion is typical for menopausal women. The polyp has an impressive size of 2 to 3.5 cm. With age and as the tumor grows, symptoms increase, and the risks of malignancy of the growth increase.

Many variations of polypous neoplasms are not associated with risks of malignancy. The potential danger lies in the influence of negative factors much more than in the growth of the pathological focus.

Predisposing factors

Fibrous neoplasms have fibrous and glandular components in their structure.

The formation of the combined structure of uterine neoplasms is due to the following pathological processes:

1. Infectious lesions of the endometrial mucosa;
2. Hormonal disorders in the female body of various origins;
3. Changes in tissue reception processes due to disorders of the thyroid gland;
4. Regular gynecological procedures;
5. Pregnancy and childbirth (including pathologies: miscarriages, curettage, abortions).

The risk group includes young girls in the initial phase of the formation of the menstrual cycle, those who have had abortions, early pregnancy, as well as women of reproductive age and over 35 years of age. Hereditary burden, cases of uterine cancer in the family among close relatives - all this can provoke.

Clinical manifestations of a growing tumor and endometrial polyp with malignancy

The symptom complex due to the proliferation of uterine cells is usually weakly expressed due to the small volume, as well as the width of the uterine cavity. The clinical picture of a growing or malignant polyp has been studied quite well.

A peculiarity of the manifestation of the tumor is the absence of dependence on the morphological type. Typically, the intensity of manifestations directly depends on the size and location of the polypous lesion.

The following known manifestations are distinguished::

• Copious discharge of milky-white mucous secretion;
• Regular menstrual irregularities;
• Increased volume of menstrual bleeding;
• Painful sexual intercourse;
• Discharge of blood after sexual intercourse;
• Nagging pain in the lower abdomen, regardless of the period of the cycle;
• Difficulty conceiving;
• Early termination of pregnancy (miscarriage).

Mostly, a benign growth is asymptomatic, but with malignancy it always manifests itself with clear signs:

• Bloody issues;
• Constant aching pain radiating to the lower limbs, back, buttocks.

Malignancy of cells and ingrowth into mucous structures indicates the onset of tumor metastasis. Alarming symptoms usually lead women to the doctor due to persistence and increasing intensity.

Diagnostic measures

Usually, growths of the endometrium of the uterus can be detected during examination, provided they are located close to the cervical canal. The pharynx is examined using additional mirrors.

Other research methods are:

• intravaginal ultrasound examination;
• blood test for hormone levels;
• diagnostic hysteroscopy;
• laparoscopic research method.

During the examination, a fragment of the polyp can be obtained for further histological examination for atypical cancer cells. The last two diagnostic methods are often performed under local anesthesia using surgical instruments.

Treatment tactics

The main method of intervention is hysteroscopy or hysteroresectoscopy. During manipulation, the tumor is excised within healthy tissue, and the wound surface is cauterized with electrodes or a laser, but this is an expensive procedure. Recommendations after hysteroscopy of a uterine polyp.

Hysteroscopy of endometrial polyp using electroexcision on video:

In case of malignancy of the tumor, resection of the uterine cavity is performed with complete removal of the organ. The operation is performed regardless of the patient’s age to save the woman’s life.

Traditional treatment of glandular polyps of the uterus

Unfortunately, alternative medicine methods for polyps are ineffective. Douching with various herbal infusions, antiseptic treatment and the use of painkillers are only temporary and symptomatic.

Features of treatment after removal

After surgery and removal of polypous lesions, long-term medical treatment is required, which includes the following medications:

• Antispasmodics to prevent the development of stagnant blood accumulation (No-Shpa, Drotaverine, Papaverine);
• Antibacterial therapy to prevent secondary infection (Cifran-OD, Ceftriaxone, Sumamed);
• Hormone replacement therapy(progestin oral contraceptives: Tri-Mercy, Marvelon, Triquilar);
• Vitamin complexes- for general strengthening of the body and local immunity.

The duration of hormonal therapy varies from 90 to 180 days. All this time, the woman must undergo regular examinations with a gynecologist, take blood tests for hormone levels at least once a month throughout the entire recovery course.

Prognostic criteria completely depend on the timeliness of diagnosis and removal of polypous lesions. Glandular-fibrous polyps are benign neoplasms that ultimately lead to disruption of the integrity of the mucous membranes of the uterus, provoke the development of inflammatory foci, and disrupt the reproductive function of the female body.

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Definition and classification:

The WHO histological classification (1975) (1,2) distinguishes three main types of endometrial hyperplastic processes:

1. glandular cystic endometrial hyperplasia
2. endometrial polyps (glandular, glandular-cystic, glandular-fibrous)
3. atypical endometrial hyperplasia (adenomatosis, diffuse or focal adenomatous hyperplasia, including adenomatous polyps)

The first two processes are considered background for the occurrence of endometrial cancer (frequency from 2 to 4%), and atypical hyperplasia, the morphological manifestation of which is a violation of cell differentiation, expressed in varying degrees of atypia within the epithelial layer, is considered precancer (the risk of malignancy is 25-30 %) (3).

In ICD-10, hyperplastic processes comprise the following headings (4):

● N85.0 Glandular hyperplasia of the endometrium (includes cystic, glandular-cystic and polypoid).

● N85.1 Adenomatous (atypical) endometrial hyperplasia.

● N 84.0 Polyp of the uterine body

Considering that the danger of a pathological process is determined by the presence or absence of cellular and nuclear atypia, the classification proposed by WHO in 1994 is currently most widely used in the world.

Hyperplasia (without atypia, typical):

● Simple hyperplasia without atypia.

● Complex hyperplasia without atypia (adenomatosis without atypia).

Atypical (atypical) hyperplasia:

● Simple atypical.

● Complex atypical or atypical (adenomatosis with atypia).

The concept of “complex hyperplasia” does not sound as scary as precancer, although it is clear that not every precancer becomes cancer, just as, conversely, “primary cancer” can be veiled behind a benign process. According to this classification, simple and complex hyperplasia are distinguished, depending on the degree of structural changes in the mucous membrane of the uterine body, and also take into account the presence or absence of cellular atypia.
Simple typical hyperplasia is the mildest and most common variant of hyperplasia, when histological examination reveals an increase in the number of glandular and stromal elements without structural changes in the endometrium. In the domestic literature, the equivalent of simple typical hyperplasia are the terms glandular and glandular-cystic endometrial hyperplasia. Glandular and glandular-cystic hyperplasia are considered a qualitatively benign process, but the degree of their severity varies somewhat: active proliferation of the glands and endometrial stroma is accompanied or not accompanied by dilation of the glands and the formation of cysts. Complex hyperplasia without atypia involves a change in the location of the glands, a change in their shape and size, a decrease in the severity of the stromal component, i.e., the presence of structural changes in the tissue in the absence of cellular atypia; this option corresponds to mildly expressed adenomatous hyperplasia. With complex hyperplasia, the endometrium, as with simple hyperplasia, is stimulated by estrogens, but “escapes” from hormonal control. Simple atypical endometrial hyperplasia is quite rare. A distinctive feature is the presence of atypia of gland cells; however, there are no structural changes in the glands. The glands themselves have a bizarre shape, on oblique sections resembling a “gland in a gland” picture; the epithelium demonstrates increased mitotic activity.
Complex atypical endometrial hyperplasia is characterized by pronounced proliferation of the glandular component, combined with symptoms of atypia both at the tissue and cellular level, but without invasion of the basement membrane of the glandular structures. There is clustering, layering and abnormal appearance of cells, loss of gland polarity and a back-to-back arrangement. The cytoplasm of epithelial cells is increased in size and eosinophilic; the cell nuclei are also enlarged and pale. Lumps of chromatin and large nucleoli are clearly identified. Mitotic activity increases, the number and range of pathological mitoses increase. Cellular atypia is accompanied by proliferation and distortion of the shape of the glands, sometimes with infiltration into the endometrial stroma. To determine the form and severity of atypical hyperplasia, the severity of atypia at the tissue, cellular and nuclear levels is taken into account. In the presence of tumor cell invasion beyond the pre-existing glandular structures, the changes are regarded as the beginning of invasion. Atypical endometrial hyperplasia occupies an intermediate position between the usual forms of glandular endometrial hyperplasia and cancer and is a precancerous process of the endometrium. In the absence of cellular atypia, the risk of malignancy of endometrial hyperplasia is low, no more than 1-3%, but the oncological potential of atypical hyperplasia is high and amounts to 30-50%. Atypical hyperplasia is currently considered as a process more often local than diffuse, arising against the background of typical de novo hyperplasia, and not being a stage of development of simple or complex hyperplasia.

There is no generally accepted classification of endometrial polyps. ICD-10 does not give types of polyps, only separating “adenomatous polyp” from the general group into the section of tumors of the female genital area. Depending on the histoarchetectonics, polyps are traditionally divided into glandular-fibrous and glandular. Pathologists distinguish two types of polyps: 1 - consisting of endometrium functioning parallel to the phases and even stages of the cycle and 2 - represented by hyperplastic endometrium (5,6). Some authors believe that only polyps containing basal-type glands that weakly respond to progestin effects are “true” (7). Polyps of the functional endometrium are more correctly considered polypoid hyperplasia. However, based on the histological definition, a polyp must have a blood vessel, regardless of the presence or priority of glandular, fibrous and other components. Other polyps are a special case. The following types of special endometrial polyps are distinguished:

● glandular polyps (functional), which are focal endometrial hyperplasia.

● The structural features of polyps in the isthmic section of the mucous membrane of the uterine body are described separately. It has been found that the glands of isthmic polyps can be lined with both endometrial and endocervical epithelium, and the vascular walls are rich in muscle tissue (16,17).

● adenomyomatous polyps (polypoid adenomyomas);

● “cystic atrophic” or “senile” (senile) polyps of the menopausal period;

● “tamoxifen-associated” polyps;

● decidual (placental) polyps;

● calcifications – probably as a result of chronic endometritis;

● submucous leiomyomas and calcifications are not polyps, but often require differentiation from them, as well as metaplasia, determined only by a pathologist. It should be noted that in cases of detection of metaplasia, as well as blastoma, an expert assessment of the histological material (slides) is necessary at the level of city and regional oncology clinics.

● metaplasia - a manifestation of impaired cellular differentiation, expressed in the appearance in the endometrium of epithelium that is uncharacteristic for the mucous membrane of the uterine cavity. Metaplasia often accompanies hyperplastic processes in the endometrium, incl. – atypical hyperplasia, can occur with endometrial carcinomas, but often occurs without connection with other pathological processes. Metaplasia itself should in no case be identified with obligate precancer and tumor and should not be regarded as evidence of their presence. However, there is no doubt that metaplasia, like hyperplasia, is a process against which the development of carcinoma is more likely. The following types of endometrial metaplasia are distinguished:

Squamous metaplasia. It is observed both in the glands and in the superficial endometrium, both with hyperplasia and in normally functioning mucosa. May be associated with endometrial polyps and submucous leiomyomas. Rarely, keratinization (“uterine ichthyosis”) occurs. Diffuse squamous metaplasia (adenoacanthosis) must be clearly differentiated from the relatively common well-differentiated adenocarcinoma with squamous metaplasia (the so-called adenoacanthoma), in which the squamous cell component of the tumor has a completely benign appearance (11).

Tubal (ciliated cell) metaplasia. It occurs in the superficial epithelium and glands when ciliated cells (and normally rarely “scattered” in the endometrial epithelium) increase significantly in number, and the lining becomes similar to that of the fallopian tube, which is the basis for the name of this type of metaplasia. Usually occurs with endometrial hyperplasia.

Papillary (syncytial papillary) metaplasia (hyperplasia). Observed in the surface epithelium of the uterine body. Often occurs with prolonged estrogen stimulation. In different cases, it is regarded not only as a metaplastic manifestation, but also as an expression of hyperplasia and, conversely, as a manifestation of damage against the background of acute endometrial rejection.

Mucinous metaplasia. A condition in which the endometrium becomes similar to the endocervical mucosa. Characteristic, in particular, in tamoxifen-induced polyps. It is important in terms of differential diagnosis with mucinous adenocarcinoma.

Clear cell (mesonephroid) metaplasia. Important in terms of differential diagnosis with clear cell (mesonephroid) adenocarcinoma.

Eosinophilic (oncocytic) metaplasia. Estrogen-induced condition. Requires differential diagnosis with atypical endometrial hyperplasia and extremely rare oncocytic carcinoma. The diagnosis of metaplasia is made in the absence of signs of nuclear atypia.

Intestinal metaplasia. A rare form in which the endometrium resembles the intestinal mucosa.

Epidemiology:

The frequency of endometrial hyperplastic processes in the structure of gynecological pathology is 3.8% (14). Hyperplastic processes of the endometrium are possible at any age, but their frequency increases significantly during perimenopause. It is accompanied by disturbances in menstrual and reproductive function and is considered a precancerous condition (13). Simple endometrial hyperplasia without atypia turns into cancer in 1% of cases, polypoid form without atypia - 3 times more often. Simple atypical endometrial hyperplasia without treatment progresses to cancer in 8% of patients, complex atypical hyperplasia - in 29% of patients. The most common type of endometrial hyperplastic process is polyps, occurring in gynecological patients with a frequency of 0.5 to 5.3% (15). Probably, such a scatter of data is due to the lack of a clear definition of an endometrial polyp and, accordingly, differences in the criteria for selecting gynecological patients for the study, including by age category. They occur at any age and also increase with age. The average age of patients with uterine polyps is 45.0+9.0 years (52). The average age of patients with fibroglandular polyps of the uterus, according to our data, is 46.9 years. Endometrial polyps become malignant in 2-3% of cases. As a cause of uterine bleeding in the clinic it reaches 30-40% (20). Endometrial cancer is the most common cancer of the female genital area; it is diagnosed in 15-20 cases per 100 thousand women every year and its predominant type (75%) is adenocarcinoma. Most cases of endometrial adenocarcinoma occur sporadically; only 5% of cases have a hereditary predisposition. There are two types of carcinogenesis of sporadic adenocarcinoma. About 80% of tumors are type I, occur between 20-54 years of age and depend on excess estrogen stimulation. The precursors of this particular type of tumor are hyperplastic processes of the endometrium.

Relevance of the problem:

Despite the introduction of endoscopic control during surgical removal of endometrial polyps, the relapse rate remains high. According to different authors, it varies from 25.9 to 78% (28,29,30,31). Polyps recur in 14.0% of women after hormonal therapy (50), in 46.0% endometrial polyps recur after separate diagnostic curettage, and even after hysteroresectoscopy, disease relapses occur in 13.5% (51). The average time for relapses to appear is 12.0±5.0 months after their removal (52).

Etiology and pathogenesis:

There is no consensus regarding the causes of endometrial hyperplastic processes, including polyps. Various theories have been proposed:

1. Inflammatory theory of the origin of uterine polyps:

2. Hormonal theory, mainly associated with hyperestrogenism (13,22, 60). Despite the fact that typical and atypical hyperplasia are considered fundamentally different processes, reflecting two paths of development of pathological proliferation - the path of hyperplasia and the path of neoplasia, one common factor lies in their pathogenesis - hyperestrogenism.
The endometrium, being a “target tissue” for sex hormones, is extremely sensitive to the action of estrogens. The latter, causing proliferative changes in the endometrium, in the absence of sufficient influence of progesterone, lead to the development of hyperplasia.
In addition to long-term excessive estrogenic influences, local growth factors are of great importance in the pathogenesis of endometrial hyperplastic processes. Estrogens stimulate the proliferation of normal, hyperplastic, or malignant endometrial cells in a variety of ways, including increasing the expression of their own receptors, up-regulating growth factors and/or their receptors, and inducing the FOS proto-oncogene. Estradiol induces the production and secretion in the endometrium of one of the most significant proliferative factors - insulin-like growth factor 1 (IGF-1).
Currently, mechanisms for the formation of feedback connections, both long (between the ovaries, hypothalamus and pituitary gland) and short (between the level of FSH, LH and releasing factors), have been identified. It is generally accepted that hyperplastic changes in the endometrium arise as a result of a violation of neuroendocrine regulation, as a result of which the ratio of gonadotropic and sex hormones changes dramatically. The formation of endometrial hyperplasia is based on a violation of ovulation, which occurs as a type of persistence (survival) of follicles or their atresia. Due to the lack of ovulation, the luteal phase of the cycle falls out. A decrease in the level of progesterone, which normally causes cyclic secretory transformations of the endometrium, leads to the fact that estrogens either as a result of a significant increase, or with prolonged exposure cause proliferative changes, or with prolonged exposure cause proliferative changes in the uterine mucosa. In the reproductive and premenopausal periods, persistence of follicles is more often observed. However, there may also be atresia of one or more follicles, which die before reaching maturity, and this leads to a decrease in the secretion of estrogen, which, in turn, stimulates the secretion of gonadotropins and causes the growth of new follicles and a new increase in estrogen. With follicular atresia, estrogen secretion is wavy and does not reach high levels, while at the same time there is a relative excess of estrogen due to a decrease in the antiestrogenic effect of progesterone. The prolonged action of estrogen leads to excessive proliferation of the endometrium: the mucous membrane thickens, the glands lengthen, and dilations form in them. As the body ages, the activity of the hypothalamic center, which regulates the secretion of FSH, increases. The secretion of FSH increases, causing a compensatory increase in the activity of the ovaries: the ovaries begin to secrete in increasing quantities instead of classical estrogens (estradiol and estrone), so-called non-classical phenolsteroids, which are produced mainly due to the proliferation of theca tissue.

The development of HPE is based on estrogenic stimulation - the same factor that ensures the normal phase of proliferation. However, in contrast to normal episodic or cyclical occurrence, with GPE there is either a persistent prolonged effect, especially when the level of progestin influence decreases. With the onset of menopause, the coordination of hypothalamic-pituitary activity is disrupted: the frequency and intensity of the release of FSH and LH changes, and ovarian dysfunction is formed. It has been proven that in healthy postmenopausal women, the functional activity of the ovaries continues, but at a lower level compared to the reproductive period. Against the background of physiological manifestations of postmenopause, organic diseases in the uterus and ovaries can also occur (10). The causes of hyperestrogenism are functional disorders in the ovaries (persistence and atresia of follicles), organic changes in the ovaries (follicular cysts, hyperplasia of theca tissue and chyle cells of the ovary, Stein-Leventhal syndrome, feminizing tumors), changes in the metabolism of sex hormones (obesity, cirrhosis of the liver , hypothyroidism), hyperplasia (adenoma) of the adrenal cortex, inadequate estrogen therapy. Thus, Ya. V. Bokhman notes that the source of hyperestrogenism (especially in menopause) should be considered excess body weight and the resulting increased aromatization of androgens into estrogens in adipose tissue. Thus, disorders of fat metabolism, nonspecific to the reproductive system, indirectly, through altered steroidogenesis, lead to hyperestrogenism and the occurrence of hyperplastic processes in the endometrium.

3. Genetic theory. Research in recent years has been associated with the discovery of pathological genes in endometrial cells (HNGIC-gene), which contribute to the formation of polyps (Dal. Sin. P., 1998). A key role in the development of endometrial hyperplasia and pathologically associated carcinomas is played by the inactivation (deletion or mutation) of the PTEN (PHosphatase and TENsin) suppressor gene, which blocks the cell cycle. Normally, estrogens activate the production of PTEN protein during the proliferative phase of the cycle. Inactivation of PTEN was noted in 63% of atypical hyperplasias and in 50-80% of endometrial adenocarcinomas. As with many tumors of other localizations, in atypical hyperplasia and endometrial cancer there is frequent inactivation of the p53 gene, which is responsible for DNA repair and apoptosis of cells with an irreversibly damaged genome. The vast majority (if not all) of endometrial polyps are foci of hyperplasia, probably associated with damage to the reception of steroid hormones in this area of ​​the stroma. According to another concept (which, however, does not change the clinical essence of the issue), an endometrial polyp is a benign mesenchymal tumor, represented by a monoclonal (actually tumor) proliferation of stromal cells, including a non-tumor glandular component. The specific cytogenetic abnormalities underlying this rearrangement of chromosome 6p21 are shown; 12р15; 6p12q, etc. A striking example of a genetic theory is Lynch syndrome, which has an autosomal dominant pattern of inheritance (77).

4. The modern concept of the development of HPE suggests the possible role of receptor disorders in the endometrium, as well as the levels of matrix metalloproteinases and cytokines in the endometrium. According to modern concepts, the presence of steroid hormone receptors is the most objective sign of hormonal sensitivity of a tissue (32, 33). Thus, the administration of progestins to patients with disseminated endometrial cancer, taking into account the receptor status of tumors, increased the remission rate from 30 to 50% (32).

5. Endocrine cells (apudocytes) in hyperplastic processes and endometrial cancer. Apudocytes are found in many organs, as well as in hormone-dependent tumors; they produce biogenic amines and peptide hormones - norepinephrine, melatonin, hCG, etc. Normal endometrium contains apudocytes in a small amount of 4-5 in 10 fields of view x 280, with LGE - 18% , with AGE – 25%, and with RE – 105%.

6. Metabolic theory.

The premorbid background is important, so among patients with GPE in 30% of cases a high degree of burden with extragenital diseases (diseases of the gastrointestinal tract, liver, hypertension) was revealed. Obesity, arterial hypertension, diabetes mellitus are the classic triad of risk factors for endometrial cancer (Bohman Ya.V.). In 50% of patients with HPE, fibroids (or) and endometriosis of the uterus precede it, and half of patients with endometrial polyps have previous cervical diseases. More than a third of patients had adverse effects on the organs of the reproductive system during intrauterine development, environmental factors: stress, climate change, occupational hazards.

Other authors associate the occurrence of endometrial polyps in postmenopause with hormone replacement therapy (79), as well as the drug Tamoxifen, taken by patients for 4-15 years for breast cancer (80).

Pathological anatomy:

Macroscopically, endometrial polyps can be single or multiple, round or oval, and vary in size from a few millimeters to several centimeters in diameter. They are attached to the wall of the uterus by a wide base or an elongated stalk. Microscopically (histologically), polyps differ in the ratio of tissue components, mitotic activity of cells (atypia) and a number of other important microscopic features. Histological examination of endometrial polyps is carried out according to the classification scheme proposed by O.K. Khmelnitsky. Fibrous-glandular, adenomatous, fibrous, glandular polyps of functional and basal types are identified. In polyps of the basal type, proliferative, hyperplastic, and indifferent variants are distinguished. This is how polyps with a greater or lesser composition of glandular tissue are distinguished, respectively, glandular, glandular-fibrous or predominantly fibrous endometrial polyps. According to data 19: Glandular-fibrous polyps were most often detected (69.4%), glandular polyps were found in 22%, glandular-cystic - in 5.5% and fibrous - in 3.1%. There were no foci of endometrial atypia in the polyps. Endometrial polyps were most often localized in the tubal angles of the uterus (40.1%), the fundus (19.7%) and the lateral wall (22%) of the uterus. According to data (18) conducted over 10 years in 11996 women: the population frequency of hyperplastic and tumor processes was 3.8%. Of these, glandular-cystic hyperplasia occurred in 41.6%, atypical - in 1.1%, glandular-cystic polyps - in 22.5%, glandular-fibrous - in 29.7%, fibrous - in 0.2%, adenomatous - in 0.4% and endometrial cancer - in 4.4%. Most often, endometrial pathology occurred in premenopause - population frequency 7.03%. During menopause it was observed in 3.92% and in reproductive age – in 1.88%. The most common pathology in the reproductive and menopausal periods was glandular cystic hyperplasia (1.19 and 3.62%, respectively) and in the postmenopausal period - glandular fibrous polyp (1.83%). Endometrial cancer during these periods was observed in 0.02, 0.27 and 0.26%, respectively, i.e. in the menopausal and postmenopausal periods it was detected approximately 13 times more often than in the reproductive period. Endometrial cancer (uterine cancer) is a fairly common pathology and ranks second among all malignant diseases of the female genital organs (18- 15 ). Statistical data in recent years indicate a significant increase in the incidence of endometrial cancer. In our country, its annual increase is approximately 6% per year (18- 16 ). There are 34,000 cases of endometrial cancer reported annually in the United States (18–20). According to Ya.V. Bohman (18-15) the peak incidence of uterine cancer occurs at 59 years of age, and only in 16% of cases it occurs during reproductive age (18-21). The mortality rate for endometrial cancer remains quite high, and according to aggregate data from 69 clinics around the world, the five-year survival rate is 66.6% (18-16). It is now known that in most cases, endometrial cancer is secondary and occurs against the background of precancerous diseases. So, G.M. Savelyev and V.N. Serov (18-25) observed the transition of benign neoplastic processes to cancer in 79% of patients, Ya.V. Bokhman (18-15) – 73% and T.V. Savinov (18-26) – 26%. G.M. Savelyev and V.N. Serov (18-25) Precancerous diseases include atypical hyperplasia, adenomatous polyps, glandular cystic hyperplasia in menopause (especially recurrent) or developing against the background of neuroendocrine disorders. Other types of endometrial pathology turn into cancer extremely rarely (18-25).

Uterine polyps are exophytic local glandular formations arising from the basal layer of the endometrium or endocervix, having a vascular pedicle (8; 9). Other authors (12) define an endometrial polyp as a benign tumor-like formation arising from the basal layer of the endometrium. The histological division of endometrial polyps into glandular (functional or basal type), glandular-fibrous, fibrous and adenomatous according to these definitions is not consistent. However, it has practical significance. because functional polyps, which are focal hyperplasia, often arise, respond well to treatment with gestagens and are not detected after the next menstruation. Consequently, an endometrial polyp is always a fibroglandular formation, everything else is a special type of endometrial polyp. Thus, Crum (2005) identifies the following as supporting diagnostic signs of a polyp in a scraping: 1 – fibrous collagenized stroma; 2 – thick-walled vessels in it; 3 – irregular architecture of the glands in the form of uneven lumens and areas of “crowding” of the glands (10). In the absence of signs of cellular atypia, this should not be the basis for the diagnosis of complex hyperplasia (adenomatosis) and EIN. On the other hand, areas of atypical hyperplasia (EIN) can sometimes be found in polyps, which can affect further management of the patient. It should be noted that patient management tactics should be individual - depending on the patient’s condition, concomitant pathology, the course of the background pathological process contributing to hyperestrogenism, the influence of medications and the histological picture. To correctly select management tactics, the histologist must answer the following questions: 1 – the presence or absence of hyperplasia as such; 2 – the presence of adenomatosis (complex hyperplasia), indicating its diffuse or focal nature; 3 – presence of atypia (atypical hyperplasia, EIN), also indicating the focal or diffuse nature of the lesion and the severity of atypical manifestations. From this point of view, it seems most important to collect the most complete material for histological examination during diagnostic curettage, which is very doubtful when performing hysteroscopy. According to some authors (12), the concept of “recurrence” of an endometrial polyp is unacceptable if hysteroscopic control was not previously used when removing an endometrial polyp, because when curettage of the uterine mucosa without hysteroscopy, pathologically altered tissue (legs or polyp bed) may be left behind. However, in reality, a hysteroscope is not available everywhere, in addition, relapse of the endometrial polyp without treatment occurs after 3-6 months, and during treatment, very rarely, after 3-6 years and against the background of cancellation of this treatment for one reason or another . In addition, the combination of endometrial polyp and endometrial hyperplasia, according to our data, occurs in 56.6% of cases. It is generally accepted that endometrial hyperplasia must be treated with the same medications. Anti-relapse treatment of endometrial polyps is mandatory and the main goal is to reduce the activity of proliferative processes of the endometrium and, accordingly, cancer alertness and cancer prevention.

Diagnostics:

The diagnosis is established based on an analysis of the clinical picture, ultrasound, endoscopic and necessarily pathomorphological examination of scrapings from the uterine cavity (3.12, 17, 21).

Ultrasound examination of the pelvic organs (outside bleeding) has great informative value. Increased Mach is the main prognostic marker of endometrial pathology. In menstruating women, the value of this indicator is determined by the phase of the menstrual cycle and normally reaches maximum values ​​in the late stage of secretion - the peak of secretory transformations in the mucous membrane of the uterine body is 16 mm. GE is characterized by an increase in the echogram of the endometrium to 2–3 cm. Recognition of GE is important for choosing a method of treatment and prevention of endometrial cancer.

Diagnosis of endometrial pathology includes mandatory ultrasound examination. Ultrasound is a simple, accessible and effective method for diagnosing endometrial pathology. Positive ultrasound results coincide with morphological data indicating endometrial pathology in 87% of cases, negative ultrasound results allow excluding endometrial pathology in 94% of cases, the specificity of the method is 89% (47). Our data on the specificity and sensitivity of ultrasound in diagnosing endometrial pathology coincide with the literature data.

There are many studies confirming the correspondence between the M-echo status and the results of histological examination of the endometrium (48). But if the accuracy of ultrasound diagnosis of simple endometrial hyperplasia is 88.4-97.3% (Fedorova E.V., 2000), then with complex hyperplasia the situation is not so clear. It is not uncommon for complex, and especially atypical hyperplasia, to be detected with small sizes of the M-echo, and suspicion of endometrial pathology arises when analyzing the structure of the M-echo and the accompanying clinical picture (49).

Interpreting the results of ultrasound examination and comparing them with the results of the histological report, a number of authors come to the conclusion that the echographic parameters of the endometrial condition reflect mainly the characteristics of the endometrial condition (Demidov V.N., 1990; Kuznetsova I.V., 1999; Pishchulin A A., Karpova E.A., 2001; Shilin D.E., 2004). Other researchers believe that the main role in changes in echographic parameters is played by the features of menstrual dysfunction, namely, the duration of delayed menstruation, bleeding, and the degree of profuse bleeding (Shakhlamova M.N., Bakhtiyarov K.R., 2005).

According to our data, the accuracy of ultrasound diagnostics increases when the clinical characteristics of the patient’s condition and her medical history are taken into account. In this case, the presence of abnormal uterine bleeding, as well as indications of them in the anamnesis, should be taken into account. Combined processing of clinical and ultrasound data increases diagnostic accuracy to almost 100% (45).

One of the significant criteria is the symmetry and thickness of the endometrium (M-echo index). Depending on the duration of postmenopause, an M-echo reading of 3-5 mm is considered normal. According to most authors, endometrial thickness in postmenopause exceeding 5 mm is considered as the leading echographic sign of endometrial pathology. Thus, 96.1% of patients with postmenopausal metrorrhagia greater than 5 mm had endometrial diseases, including cancer (78).

For diagnostic purposes, diagnostic curettage of the mucous membrane of the uterine body and subsequent histological examination of the resulting material are widely used. It is recommended to scrape the endometrium on the eve of the expected menstruation or at the very beginning of the appearance of bleeding. In this case, it is necessary to remove the entire mucous membrane, including the area of ​​the uterine fundus and fallopian tube angles, where foci of adenomatosis and polyps are often located.

The practice of recent years shows the significant diagnostic value of hysteroscopy. The method allows you to detect GE in the form of a thickened, unevenly folded surface of the endometrium of a pale pink or red color. With focal HE, similar changes are observed in the form of local foci. In polypoid GE, the protrusions of the thickened endometrium fill the uterine cavity. The removed mucous membrane is sent for histological examination with an accompanying form, where information about the patient is briefly stated (age, complaints, main symptoms, the nature of the menstrual cycle, duration of the disease, clinical diagnosis), which helps the morphologist to correctly evaluate the histological data. Histological examination is the most reliable method for diagnosing HE and determining the nature of this pathology. During histological and histochemical studies, the activity of GE is determined by the degree of mitotic activity of cells, the content of nucleic acids and other parameters. Repeated curettage of the mucous membrane of the uterine body should be carried out according to indications that are reasonably justified in each specific case (for example, control diagnostic curettage after completing a course of hormone therapy for adenomatosis and adenomatous polyps in women of reproductive age, recurrent bleeding in postmenopause, etc.).

To monitor treatment, as well as in order to screen women (dispensary examination), a cytological method is used to study the contents of the uterus obtained by aspiration. Aspiration is carried out in the second half of the menstrual cycle in compliance with the rules of asepsis. If the aspirate reveals actively proliferating cells in the glandular complexes, then these findings indicate GE. However, the aspiration cytological method does not provide a clear idea of ​​the nature of GE. Therefore, it is used mainly for the purpose of selecting patients for a more detailed study.

Clinical picture:

The main clinical manifestations of endometrial hyperplastic processes are dysfunctional (anovulatory) uterine bleeding, often acyclic in the form of metrorrhagia (after a delay in menstruation), less often menorrhagia (associated with menstruation). Bleeding is usually prolonged with moderate or profuse blood loss. Intense bleeding is often observed during anovulatory cycles during puberty (juvenile uterine bleeding), but can also occur in women of reproductive and elderly age. Sometimes intermenstrual bleeding appears.

It is important to note that the absence of clinical symptoms of endometrial hyperplastic processes (abnormal uterine bleeding) is more typical for severe forms of hyperplasia (complex and atypical). Simple endometrial hyperplasia almost always manifests itself in some form of abnormal bleeding. But even in the absence of clinical symptoms, we have never found, either according to archive data or clinical observations, cases of complex or atypical hyperplasia with a regular menstrual cycle with normal menstrual blood loss.

Consequently, the absence of menstrual irregularities during normal menstruation (in terms of duration and amount of blood lost) is reliable evidence of the normal state of the endometrium. On the other hand, the absence of abnormal uterine bleeding does not mean the absence of endometrial hyperplastic process, including atypical hyperplasia.

Moreover, it should be understood that oligomenorrhea, being the “mildest” cycle disorder, is fraught with great danger. Patients with oligomenorrhea often do not see a doctor for a long time, while the duration of their anovulation increases, and the risk of developing GPE increases accordingly. While patients with uterine bleeding attract more attention from doctors, such women are given treatment aimed at stopping the bleeding and preventing its recurrence, with the goal of restoring ovulation or creating “progesterone protection,” which in itself is the prevention of the occurrence of GPE. Finally, oligomenorrhea is the most common manifestation of menstrual dysfunction in polycystic ovary syndrome, and the risk of severe hyperplasia in this condition is known to be high (45).

In most cases (12–56%), endometrial polyps are asymptomatic and are a diagnostic finding during screening ultrasound examination of the pelvic organs, but at the same time they occupy a leading place among the causes of uterine bleeding in postmenopause. Clinical manifestations of endometrial polyps in postmenopause are usually bloody discharge (from spotting to heavy discharge) (21). Large endometrial polyps may be accompanied by cramping pain in the lower abdomen. Often the only symptom may be radiating pain in the sacral area. Anemia of patients associated with this is possible. Endometrial hyperplasia is usually accompanied by infertility, the main cause of which is anovulation. PCOS, uterine fibroids, adenomyosis, and mastopathy are often noted as a combined pathology. Malignant transformation (malignization) of endometrial polyps is possible. The risk of malignancy of hyperplastic processes increases with metabolic disorders caused by extragenital diseases (obesity, impaired carbohydrate and lipid metabolism, dysfunction of the hepatobiliary system and gastrointestinal tract), accompanying the development of endometrial pathology (23). There is a frequent combination of endometrial polyps with inflammatory processes of the pelvic organs (14).

Organization of care for gynecological patients with endometrial hyperplastic processes.

For a clear organization of dispensary observation, consistency and continuity in the work of antenatal clinics, gynecological hospitals, cytological and radioisotope laboratories is necessary. The coordinating link (center) in this case should be a specialized endometrial pathology office, created on the basis of an oncology clinic, or one of the large city clinics with a cytological or radioisotope laboratory. When referring for a consultation to the coordinating (expert) center, doctors at antenatal clinics and hospitals must collect maximum information about the patient and draw up a diagnostic card with the results of all studies performed and attach pre-ordered slides with cytological and histological studies and conclusions for review by an expert pathologist. The duration of follow-up observation for patients in whom atypical hyperplasia or adenomatosis was found in endometrial scraping was 5 years. After cessation of hormonal therapy, 2 times a year a cytological examination of the contents of the uterus, a study with radioactive phosphorus, and a vaginal smear examination are indicated at each visit. If the indicators are favorable within a year after the end of treatment, a cytological examination of the aspirate and a study with radioactive phosphorus are carried out once a year for 5 years of clinical observation.
Women whose endometrial scrapings revealed polyps or glandular endometrial hyperplasia are removed from the dispensary register:
a) under the age of 45, after 1.5-2 years of a regular menstrual cycle;
b) over 45 years old, after 1.5-2 years of menopause.
A prerequisite for deregistration is positive results from studies monitoring the effectiveness of treatment.
In conclusion, it must be emphasized that an indispensable condition for clinical observation of patients is the registration of the nature of the menstrual cycle (or bleeding in menopausal women) and hormonal therapy (name of the drug, days of administration or oral administration, total dose of the drug).
Considering the high responsibility for the life and health of the patient, organ-preserving treatment of patients with AGE should be performed in specialized oncological institutions and ensure strict dynamic monitoring. The question of the need and advisability of hormonal therapy after polypectomy still remains controversial. The type of hormonal therapy and duration of treatment depend on the patient’s age, the morphological structure of the polyp, and the nature of the concomitant pathology. At the same time, long-term hormonal therapy, given its side effects, is unsuitable for many patients. When treating patients with PE, the same hormonal drugs are used as for other types of endometrial hyperplastic processes (COCs, progestins, Buserelindeno).

Tactics of management and treatment of patients with endometrial hyperplastic processes.
It is known that the outcome of endometrial hyperplastic processes is associated with the doctor’s tactics in relation to these patients. Treatment of endometrial hyperplastic processes, especially recurrent ones, is a responsible and complex task. It is necessary to emphasize the inadmissibility of leaving these patients without special treatment. The choice of treatment is sometimes purely individual, depending on the results of a comprehensive examination, the patient’s age, the severity of proliferative processes, etiological and pathogenetic features of the disease, the presence of concomitant genital and extragenital diseases, and individual tolerance to the drug.

Principles of treatment of endometrial hyperplastic processes:

• stopping bleeding;
• restoration of menstrual function during the reproductive period;
• prevention of relapse of the disease - a course of treatment - for 6 months under the control of ultrasound monitoring and cytomorphological examination (26);
• correction of metabolic and endocrine disorders.

Special attention should be paid to the tactics of managing patients during puberty. In girls who are not sexually active, with minor or moderate bleeding (or absence) and a hemoglobin level above 70 g/l, a progestin test can be performed according to the hemostasis scheme for juvenile bleeding. It should be taken into account that hormonal hemostasis with gestagens can initially increase bleeding and in patients with severe anemia it is advisable to carry out hemostasis with estrogens, followed by the administration of gestagens, COCs containing estrogens and progestins are more often used, and low-dose and triphasic contraceptives are ineffective, monophasic drugs containing ethinyl estradiol are recommended dose of 0.05 mg, and progestins of the norsteroid group. The drug is prescribed according to an individual hemostasis regimen, starting with 3 tablets per day and continuing in decreasing order, going up to 1 tablet per day until the end of the package (21 tablets). In the case of glandular polyps, they disappear, which is diagnosed by ultrasound after the next menstruation. In case of heavy bleeding and anemia (hemoglobin concentration in the blood below 70 g/l and/or hematocrit below 20%)), as well as repeated identification of an endometrial polyp by ultrasound, separate diagnostic curettage of the uterine cavity and cervical canal is performed (according to vital indications) , or hysteroscopy as a therapeutic and diagnostic procedure - removal of a polyp to obtain histological material and stop bleeding. Subsequently, starting from the 16th day after this, one of the progestogens of 1 or more menstrual cycles is used (for 10 days). When curettage, in order to avoid defloration, the hymen is injected with a solution of novocaine with lidase and small (children's) mirrors are used.

Some experts carry out conservative treatment during the reproductive and even menopausal periods, justifying this approach for small polyps (up to 1.5 cm in diameter, determined by ultrasound). Indeed, polyps larger than 1.5 cm, which some researchers consider a risk for cancer development (Costa-Paiva L et al., 2011; Wang JH et al., 2010) and cannot always be distinguished from endometrial hyperplasia, however, it is not necessary, because An M-echo of more than 1.5 cm is considered hyperplasia and is subject to separate diagnostic curettage of the uterine cavity and cervical canal. Not all authors agree with the M-echo size criterion (18), arguing that atypical hyperplasia and endometrial cancer do not always exceed 1.5 cm. In reproductive age, such tactics are risky in terms of diagnostic error, as a result of the lack of histological material. If in young women with all forms of hyperplasia, including atypical, the leading method of treatment is conservative, with the goal of restoring menstrual and generative functions, then in the premenopausal and postmenopausal periods, the indications for surgical treatment are expanding, especially for precancerous conditions of the endometrium. In women of childbearing age, as well as in premenopause and menopause, the main way to stop bleeding and for diagnostic purposes is separate diagnostic curettage of the mucous membrane of the uterus and the cervical canal. If it stops or significantly decreases, infusion-transfusion therapy is indicated. If there is no effect - laparotomy, supravaginal amputation, or hysterectomy (25). Curettage is an extremely strong irritant, the action of which affects the function of the gonads. After this, the ability of the uterus to respond to endo- and exogenous hormones significantly increases. In addition, curettage itself is of great importance during subsequent hormone therapy, as it helps remove pathologically altered mucosa. The pathogenetic approach to the treatment of patients with endometrial hyperplastic processes involves the use of hormonal agents aimed at eliminating or compensating for endocrine metabolic disorders. Hormonal therapy is necessary not only to stop uterine bleeding, but especially to prevent the development of uterine cancer. It is completely unacceptable to use hormones without a preliminary morphological study of the uterine mucosa. This method is most valuable in combination with hysteroscopy. Removal of the endometrium without hysteroscopy often leads to the leaving of pathological foci in the uterus and, consequently, to an erroneous diagnosis of recurrent disease, which, in turn, leads to unjustified surgical treatment. When choosing treatment methods, the clinician is primarily guided by the data of histological examination of endometrial scraping. In this regard, B.I. Zheleznov’s concept of the necessary contact between the clinician and the pathologist is completely undeniable, which contributes to a more correct decision on the choice of subsequent pathogenetic therapy, taking into account the morphological structure of the hyperplastic process. When sending the material for histological examination, information about previous curettages and ongoing (especially hormonal) therapy should be briefly reflected.

● In the absence of contraindications to hormone therapy in patients of reproductive age with endometrial hyperplasia without atypia, it is possible to use estrogen-gestagen drugs - combined oral contraceptives(COOK). Ethinyl estradiol is the most commonly used estrogen component. The progestogenic component is represented by derivatives of 19-nortestosterone: norethinodrel (1st generation), norethisterone, ethynodiol diacetate, linestrenol, levonorgestrel, norgestrel (2nd generation), desogestrel, gestodene, norgestimate (3rd generation) and dienogest, which does not contain an ethynyl group, derivatives of 17ɑ-hydroxyprogesterone - medroxyprogesterone acetate, cyproterone acetate, dydrogesterone; spirolactone derivative – drospirenone. The progesterone activity of levonorgestrel and norgestrel is 10 times higher compared to norethinodrel and ethynodiol diacetate. New derivatives of 19-norsteroids, third-generation progestogens - gestodene, desogestrel and norgestimate - are chemically similar to levorgestrel, but have a more pronounced selective effect on progesterone receptors, suppressing ovulation in lower doses than levorgestrel, norethisterone and norethindrel (35).

The effect of COCs on the endometrium as a whole is that in the mucous membrane of the uterine body there is a rapid regression of proliferative changes and premature (10th day of the cycle) development of defective secretory transformations, edema of the stroma with decidual transformation, the degree of which varies depending on the dose of the progestogen component ; With long-term use of COCs, temporary atrophy of the endometrial glands often develops.

It is advisable to prescribe COCs to women in the reproductive period with a normal body mass index, without severe metabolic disorders, and with glandular endometrial hyperplasia. The drugs must be microdosed. Treatment is carried out from the 5th to the 25th day of the cycle for 3-6 months. (in a cyclic mode (21 days with a 7-day break) for at least 6 months).

● For the treatment of hyperplastic processes of the endometrium (especially its precancerous conditions) it is used danazol– isoxal derivative of 17ɑ-ethynyl-testosterone with a predominant antigonadotropic effect. Danazol inhibits steroidogenesis in the ovaries, binds androgen- and progesterone-dependent receptors in the endometrium and suppresses the proliferative and secretory activity of endometrial (or endometrial-like) glands. Danazol is prescribed 400 mg per day from the first day of the cycle for 4-6 months (prerequisite: absence of pronounced metabolic disorders, normal body mass index). According to other data, 800 mg per day for 6-9 months (17).

● Progestins (progestogens, gestagens) reduce the concentration of tissue estradiol and increase the level of its metabolite, estrone, which competes with estradiol for the same nuclear sites (as is known, estrone has a less pronounced estrogenic effect). Thus, if the mechanisms of formation of steroid receptors are preserved in the hyperplastic endometrium, then the mucous membrane responds to the effects of exogenous progestins with a decrease or absence of cell proliferation. Accordingly, based on the receptor theory, with a lack of steroid receptors or their absence, there is a low reaction of the hyperplastic endometrium in response to the action of progestins. Artificial progestins actively bind to estrogen- and progesterone-binding receptors in target tissues, releasing androgen receptors, i.e. have direct antiestrogenic and antiprogesterone effects. Accordingly, failures associated with the administration of progestins and relapses of the disease are associated precisely with this mechanism (36):

The discussion of the results. The study showed that morphological variants of endometrial polyps with high levels of expression of receptors for estradiol and progesterone are more sensitive to hormonal effects. In patients with adenomatous endometrial polyps, a high level of expression of both estradiol and progesterone receptors has been established. At the same time, the effectiveness of hormonal treatment of this morphological form of polyps was 71.4%.
Fibrous glandular polyps were re-found in more than half of the patients (57.5%) during a control hysteroscopic examination of the uterine cavity. The level of expression of receptors for estradiol and progesterone in fibroglandular polyps is significantly lower than in adenomatous and glandular polyps. It is possible that the high frequency of recurrence of fibroglandular polyps is a consequence of the low content of hormone-binding receptor sites in the epithelial and stromal cells of this morphological form of polyps.
According to our data, favorable outcomes of hormonal treatment in patients with glandular polyps of the functional type were observed 20% more often than in patients with glandular polyps of the basal type.
The epithelium of glandular polyps of a functional type during the menstrual cycle responds to fluctuations in the level of plasma steroid hormones with structural changes similar to those that occur in the normal endometrium or in the healthy tissue surrounding the polyp. In all examined patients, the glandular epithelium in polyps of the functional type was in a state of secretory transformation, while the expression of estradiol receptors was more intense than the expression of progesterone receptors. The results obtained are consistent with the literature data on the dynamics of the level of sex steroid receptors in the secretory phase of the menstrual cycle. The dynamics of estradiol receptors appears to be as follows: the highest concentration is characteristic of the late proliferative phase and in the periovulatory period, followed by a decrease to a minimum in the late stage of the secretion phase. The level of progesterone receptors is considered to be maximum during the periovulatory period and until the middle of the luteal phase of the cycle, then, towards the end of the cycle, against the background of increasing concentrations of plasma progesterone, it gradually decreases. The content of estradiol receptors in the functional type polyp, in contrast to the normal endometrium, remained high.
An immunohistochemical study showed that the content of receptors for estradiol and progesterone in polyps depends on the morphofunctional properties of the glandular epithelium. According to the literature, the maximum content of estradiol and progesterone receptors is observed in the hyperplastic endometrium. The content of estrogen receptors in hyperplastic endometrium is 1.3–1.5 times higher than in adenocarcinoma, and more than 2 times higher than its content in normal endometrium. The level of progesterone receptors is lowest in tumor tissue, slightly higher in normal endometrium and maximum in hyperplastic endometrium. We have obtained similar data indicating that in glandular polyps of the proliferative and hyperplastic variants the level of progesterone receptors is significantly higher than in glandular polyps of the functional type, in which the glandular epithelium of the polyp and the surrounding normal endometrium was in a state of secretion. In the indifferent variant of glandular basal polyps, where the epithelium had a non-functioning low-prismatic, cubic or atrophic structure, the lowest level of receptors was observed. We believe that the morphological characteristics of the glandular epithelium may be a kind of marker of the level of expression of receptors for estradiol and progesterone in the tissue of endometrial polyps.

Conclusion
A relationship has been established between the level of expression of steroid hormone receptors in endometrial polyps and the incidence of relapses.
It can be assumed that in patients with high expression of estradiol and progesterone receptors in polyp tissue, hormonal therapy will be more effective than in cases with average and low values ​​of the immunohistochemical index. The treatment of choice for patients with low levels of steroid hormone receptor expression may be cryodestruction or endometrial ablation.
According to the results obtained, hormonal therapy shown patients with adenomatous polyps in the absence of indications for surgical treatment, patients of reproductive age with functional type glandular polyps, proliferative and hyperplastic variants of basal type polyps in the reproductive period.

Hormone therapy inappropriate in the treatment of patients with fibroglandular polyps and glandular polyps of the basal type of the indifferent variant, characterized by a low content of estradiol and progesterone receptors.

In patients postmenopausal hormonal treatment not shown for any morphological form of the polyp.

In the perimenopausal period, approaches to choosing a treatment method should be comprehensive and take into account age, the nature of menstrual function and the patient’s desire to have or not have it, the woman’s hormonal type, the morphological structure of the epithelium of the glands in the polyp and the healthy tissue surrounding the polyp.

Under the influence of gestagens in the endometrium, inhibition of proliferative activity, secretory transformation of the mucosa, decidual reaction of the stroma, and with further use - atrophic changes in the glands and stroma occur successively. The introduction of synthetic progestins into clinical practice has opened up new possibilities for the treatment of patients with endometrial pathology. These drugs are usually divided into two groups:

1. testosterone derivatives (estrogen-gestagens), such as non-ovlon, eskluton, bisecurin, etc., they are not shown:
a) women who have undergone surgery for breast tumors, mastopathy, ovarian cystoma, conservative myomectomy;
b) women who have suffered thromboembolic disease, thrombophlebitis, hepatitis, cholecystitis;
c) in the presence of gastric or duodenal ulcers, varicose veins of the extremities, hypertension (grade 1a - and more severe forms);
d) women over 45 years old.

2. and progesterone derivatives (gestagens) - oxyprogesterone capronate, turinal, orgametril, etc. From a pharmacological point of view, there are differences between them. Estrogen - gestagens have an inhibitory effect on hypothalamic activity, reduce the release of FSH and thereby eliminate the persistence of the follicle - the effect of the estrogen component, the gestagen component included in these progestins promotes the secretory phase. Synthetic drugs with progesterone activity have a pronounced gestagenic effect, very similar to the action of progesterone under physiological conditions. By influencing the endometrium prepared by prolonged estrogen stimulation, they cause mucosal rejection, then, depending on age and duration of treatment, lead to cyclic secretory transformation or endometrial atrophy. When exposed at the cellular level, synthetic gestagens penetrate the cell membrane and form a complex with protoplasmic protein, which moves to the nucleus, then combines with DNA and RNA, and the type of protein molecules changes: new protein molecules are synthesized and the cell changes - from atypical to ordinary. Synthetic gestagens, along with a central regulatory effect, also have a local effect on specific hormone-binding receptors of the endometrium and ovaries, due to which the retention and accumulation of hormones occurs. The use of estrogen-gestagens, especially during the reproductive period in patients suffering from infertility, can cause a so-called rebound effect, that is, increased release of gonadotropin, and activation of ovarian function after discontinuation of the drug - removing the temporary inhibitory effect of synthetic progestins. Thus, treatment with synthetic progestins should be considered pathogenetic.
For patients under the age of 45-47 years, estrogen - gestatens are prescribed in a cyclic mode (from 5 to 25 days of the cycle) in order to maintain menstrual function. At an age close to menopause, it is recommended to take medications continuously. It should be noted that in the first months of taking estrogen-gestagens, side effects may be observed: breast engorgement, nausea, sometimes dizziness, weight gain, increased blood pressure, pain in the stomach. After 2-3 months, these phenomena usually disappear. The use of synthetic progestins (estrogen-gestagens) is contraindicated in cases of a tendency to blood clots (varicose veins, phlebitis), hepatitis, hypertension, migraines, neuroses, epilepsy, mastopathy. It is undesirable to prescribe these drugs to patients with diabetes mellitus, since the semi-synthetic estrogens (ethinyl estradiol, mestranol) that they contain aggravate these disorders. For such patients, according to Ya. V. Bokhman, it is recommended to use estrogens in combination with gestagens.

For the treatment of endometrial hyperplastic processes, natural micronized progesterone (Utrogestan, Iprozhin, Crinon, Prajisan, Progesterone, Progestogel) is used in a dose of 200-300 mg per day - more often in premenopause - from the 16th to the 25th day of the menstrual cycle (Crinon -1.125 g of gel (90 mg of progesterone) is administered intravaginally every other day from days 15 to 25 of the cycle. If necessary, the dose can be reduced or increased), less often from the 14th day of the cycle (12 days), in the reproductive period - from 16 to 25 -th day of the menstrual cycle; dydrogesterone (Duphaston) in a dose of 10-20 mg per day, more often in premenopause from the 5th to 26th day of the cycle, and in the reproductive period - from the 16th to 25th day of the menstrual cycle; hydroxyprogesterone caproate at a dose of 125 mg on the 17th and 21st days of the cycle; norethisterone (Norkolut, Micronor, Primolut-nor) 10-20 mg from the 16th to the 25th day of the cycle, or cyclic treatment regimens: hydroxyprogesterone capronate at a dose of 125 mg 250 mg on the 14th, 17th, 21st days of the cycle; norethisterone from the 5th to the 25th day of the cycle at a dose of 10-20 mg.

A high therapeutic effect, especially in the prevention of relapses of GPE, is noted by most researchers when using the domestic progesterone drug - oxyprogesterone capronate (hydroxyprogesterone capronate) (OPK). This drug has virtually no contraindications, which distinguishes it from synthetic estrogen-gestagens and androgens. Therefore, it can be used for high blood pressure, fibroids, the initial stages of uterine endometriosis, mastopathy, and obesity. Even long-term use does not increase the coagulating properties of the blood and helps reduce menopausal disorders. Along with oxyprogesterone capronate (17-OPK), another long-acting drug is widely used: medroxyprogesterone acetate Depo-Provera. (150-500 mg once a month. 3-6 months) Medroxyprogesterone (Medroxyprogesterone-LENS, Veraplex tablet 100, 250, 500 mg When endometrial cancer and kidney cancer the drug is taken at 200-600 mg/day, with breast cancer- 400-1200 mg/day. The daily dose is divided into 2-3 doses. Treatment is continued until signs of tumor progression appear.). An oil solution of Progesterone 2.5% 1 ml intramuscularly is rarely used on days 21, 22 and 23 of the cycle, or 1% from days 21 to 26 of the cycle.

It should be noted that failures associated with the prescription of progestins and relapses of the disease, deterioration of concomitant genital diseases (uterine fibroids) are associated with the fact that progesterone plays a significant role in its occurrence and growth, while estrogens play a supporting role. And although the treatment antigestogens (Genestril) For now, it is a contraindication in the presence of endometrial hyperplastic processes, but in combination with other drugs, in the future, it may be promising. ● A special place among progestogens is occupied by Gestrinone is a 19-norsteroid (Nemestran) , which is identical in chemical structure to natural steroids, has not only antigestagenic, but also antiestrogenic, antigonadotropic and antiandrogenic effects. Genestrion completely blocks stimulation of the endometrium, causing atrophic processes in it and, as a result, pseudomenopause. Gestrinone is used in a dose of 2.5 mg 2 times a week. For 6-9 months (drugs are prescribed continuously).

● The choice of drug depends on the patient’s age and the morphological state of the endometrium. In recent years, the possibility of using levonorgestrel, contained in intrauterine system (Mirena). At the same time, the local use of progestogen ensures the direct effect of levonorgestrel on the myo- and endometrium with minimal systemic influences. Its concentration in the endometrium is 470-1500 ng/g, which is almost a thousand times higher than that in blood serum. Mirena contains 52 mg of levonorgestrel, which has a release rate of 20 mcg per day, is injected into the uterus no later than seven days after the onset of menstrual bleeding, for a period of 5 years, and is a highly effective treatment for HPE (27). The mechanism for reducing menstrual blood loss is due to endometrial atrophy, a decrease in its vascularization, a decrease in the level of prostaglandins and inhibition of fibrinolytic activity. The use of a hormonal contraceptive is especially indicated for the category of women who raise the question of contraception from pregnancy or, due to the state of homeostasis, need to minimize the systemic effects of progestins. Our experience with the Mirena IUD turned out to be disastrous, due to the high cost and an unpleasant complication - prolonged bleeding, as a result, after 3 months of this adventure, women demanded to remove the IUD.

● Gonadotropin releasing hormone agonists (GnRH agonists). Competitively binds to the receptors of the anterior pituitary gland, causing a short-term increase in the level of sex hormones in the blood plasma; subsequently, the drug leads to a complete reversible blockade of the gonadotropic function of the pituitary gland, thus inhibiting the release of luteinizing and follicle-stimulating hormones. As a result, there is a suppression of the synthesis of sex hormones in the ovaries, which is manifested by a decrease in the concentration of estradiol in the blood to a level corresponding to oophorectomy or postmenopause. The concentration of estradiol remains reduced throughout the entire period of treatment, which leads to the cessation of its effect on the endometrium. The advantage of this group of drugs over other types of drug therapy is their higher efficiency and safety. The following drugs are convenient to use:

■ Goserelin acetate orZoladex in the form of a cylindrical depocapsule located in a special syringe containing 3.6 or 10.8 mg goserelin acetate(for subcutaneous administration) dosage and duration of treatment are selected individually for each patient, taking into account the disease and general condition. 1 injection monthly or 1 time every 3 months. Duration of treatment is up to 6 months. Used in the treatment of endometriosis, breast cancer, endometrial hyperplastic processes, uterine fibroids.

■ Nafarelin ( Sinarel) — A solution for intranasal use containing 0.002 g of nafarelin acetate in 1 ml in 10 ml spray bottles for 30 days of treatment. One press of the spray bottle provides the introduction of 200 mcg of product. The daily dose is 400 mcg, administered intranasally (into the nasal cavity) 2 times 200 mcg (morning and evening). Treatment should begin between the 2nd and 4th day of the menstrual cycle and continue for 6 months. An accompanying runny nose does not weaken the nasal absorption of nafarelin (absorption of the product by the nasal mucosa).
During use of the product, also after 8 months after its discontinuation, it is necessary to evaluate the functional state of the pituitary gland.

■ Triptorelin: Diferelin 0.1 mg – lyophilisate for subcutaneous administration; Diferelin 3.75 mg – lyophilisate for intramuscular administration; Diferelin 11.25 mg – lyophilisate for intramuscular administration. In everyday speech, both doctors and patients, for the sake of brevity, call the above varieties of the drug, adding numbers to the word “Diferelin” indicating the content of the active substance. Diferelin contains triptorelin pamoate as an active substance. However, its content in the lyophilisate is indicated in terms of pure triptorelin (dose 3.75 mg for subcutaneous administration). Analogues: Decapeptyl, Eligard, Lucrin depot. The effectiveness of treatment with triptorelin for both simple and complex hyperplasma reaches 86% (76).

■ Domestic preparation Buserelin-depot, administered intramuscularly at a dose of 3.75, provides a lasting therapeutic effect with a single intramuscular injection once every 28 days at a dosage of 3.75 mg. There is also an intranasal form of administration at a dose of 0.9-1.2 mg/day. The recommended duration of treatment is up to 6 months.

● If necessary, it is necessary to combine hormone therapy with drugs that regulate carbohydrate metabolism. In case of severe obesity, if there is no effect from a reduction diet and physical activity, treatment is possible metformin 0.5 M (Metfogamma, Glucophage, Metformin-Vero, Metformin-Richter, Formetin, Siofor, Formin Pliv, Vero-Metformin, Gliformin, Glycon, Glycomet, Metformin-BMS, Novoformin, Gliminfor, Dianormet, Glucophage, Bagomet, Orabet, Metformin hydrochloride, Metospanin) 1000-1500 mg/day for 3-6 months. The most pronounced clinical effectiveness of treatment of endometrial polyps in postmenopausal women with obesity in limiting the proliferative activity of the endometrium and recurrence of the pathological process is observed when combining hysteroresection of the polyp with a gonadotropin agonist, as well as combining hysteroresection of the polyp with metformin in the postoperative period (11).

For AGE in reproductive age, it is recommended to use Buserelin-depot for 6 months; it is possible to prescribe medroxyprogesterone acetate 100 mg 3 times a week for 6 months continuously or 17-OPK at a dose of 250 mg 3 times a week continuously. For AGE in premenopause, surgical treatment is indicated - hysterectomy. However, in case of severe concomitant pathology and contraindications to surgery, it is possible to use intrauterine intervention - ablation or resection of the endometrium. At the same time, most researchers consider the onset of uterine amenorrhea to be a criterion for the effectiveness of endosurgical treatment. The use of Buserelin-depot in preoperative hormonal preparation before endometrial ablation significantly facilitates the surgical technique and improves its long-term results.

● Despite the widespread use of synthetic estrogen - gestagens and gestagens in the treatment of GPE, the question of the use androgens is also relevant today. A number of authors (Ya. V. Bokhman, L. G. Tumilovich, etc.) regard the use of androgens as an auxiliary method in the treatment of patients with bleeding in menopause caused by hyperplastic processes of the endometrium. The limited use of androgens is explained by their weaker hemostatic effect compared to progestins, even when administered in large doses. Y. V. Bokhman suggests that after completing the course of progestin therapy, elderly patients should be treated with methyltestosterone 20 ml per day for 4-6 weeks.
L. G. Tumilovich considers it more appropriate to use long-acting androgens: sustanon-250 or omnandren (synonym), which has a pronounced anti-estrogenic effect and is administered once a month; 1 ml of 10% testenate solution is administered once every 2-4 weeks. The use of androgens for a long time causes virilization (hypertrichosis, deepening of the voice, acne on the skin) and increased libido. Androgens are not indicated:
a) women who have suffered thromboembolic disease or thrombophlebitis, varicose veins;
6) in the presence of hypertension (transient form and more severe forms);
c) women under 45 years of age.

For the treatment of hyperplastic processes, methandrostenolone, methylandrostenediol, etc., anabolic steroids, testosterone production, which have high anabolic activity and very low androgenic effect (about 100 times less than testosterone propionate) cannot be used.

● In women with infertility, at the next stage of complex treatment, ovulation induction is carried out for 4-6 consecutive cycles (regulation of the gonadotropic function of the pituitary gland, achievement of ovulation and pregnancy).

Conditions for hormonal treatment.

1. The need for repeated cytological and histological examinations of the endometrium during treatment (even with a good clinical effect, including according to ultrasound monitoring).

A) for atypical endometrial hyperplasia - histological examination of scrapings 2 months after treatment with 17-OPK, after the end of stage 1 of treatment and at its completion;

B) for glandular hyperplasia - cytological and histological examination of endometrial aspirate after 3 months of treatment and at the end of treatment.

2. If endometrial polyps are present, hormonal treatment should begin after their removal with mandatory revision of the tubal angles.

3. The formation of the menstrual cycle should begin from 2-3 days of cessation of bleeding after diagnostic curettage.

4. In premenopausal women with hyperplastic processes, “hormonal hemostasis” is contraindicated.

5. The criterion for cure of endometrial hyperplasia is the absence of pathological changes in the biopsy specimen during control hysteroscopy with endometrial biopsy.
● Surgery shown:

• hyperplastic processes of the endometrium and neoplasms of the appendages;
• uterine fibroids, adenomyosis and recurrent glandular endometrial hyperplasia;
• recurrent glandular hyperplasia of the endometrium, endometrial polyps in postmenopause in the absence of effect from hormonal therapy for 3-4 months (extirpation of the uterus with appendages). In case of recurrent endometrial hyperplasia without atypia, the impossibility of hormone therapy due to concomitant extragenital pathology, hysteroscopic surgery is indicated - endometrial ablation;
• Ineffectiveness of hormone therapy, impossibility of regular monitoring;
• atypical endometrial hyperplasia in the absence of effect from hormonal therapy for 2 months and the occurrence of a relapse during control studies - extirpation of the uterus and appendages.
• the presence of atypical hyperplasia in menopausal patients, especially with neuroendocrine disorders. However, in many cases, patients of this age have significant aggravating circumstances in the form of severe concomitant extragenital diseases, and surgery can be a greater risk than the disease itself. In these cases, long-term hormonal therapy is carried out under careful dynamic monitoring.

The method of choice for treating patients with low levels of expression of steroid hormone receptors may be cryodestruction or ablation of the endometrium, especially for patients with recurrent endometrial polyps in the premenopausal and postmenopausal periods with bleeding during hormonal treatment. Previously, the method of intrauterine administration of a 5% iodine solution according to Grammaticati (10-30 procedures) was used. Currently, hysteroscopic ablation of the endometrium is used, the condition for which is the absence of ovarian pathology, and not a frequent complication, for repeated diagnostic curettages when bleeding occurs - synechia in the uterine cavity (12).

Significant adjustments to the treatment tactics of patients with hyperplastic processes of the endometrium were made with the introduction into clinical practice of hysteroresectoscopy, methods of electrosurgical ablation of the uterine mucosa, and laser destruction of the endometrium. When ablation of the endometrium with the basal layer under the control of hysteroresectoscopy, the uterine cavity is obliterated, and uterine amenorrhea occurs, in which proliferation of the endometrium is impossible. Preoperative preparation of the endometrium includes both medicinal (hormonal) and mechanical (vacuum aspiration) methods. Hormonal preparation of the endometrium before resectoscopy is carried out with the help of progestogens (dydrogesterone, norethisterone), antiprogestins (gestrinone), gonadotropin inhibitors (danazol), GnRH agonists (goserelin, decapeptyl, nafarelin, buserelin). Analysis of literature data shows that hysteroresectoscopy is an effective method of treating endometrial precancer, which is an alternative to hormonal therapy and radical surgery in certain clinical situations.

The treatment tactics for endometrial hyperplastic processes are as follows. In reproductive age: for simple endometrial hyperplasia (endometrial hyperplasia without atypia, endometrial glandular polyps), treatment is most often carried out with COCs (from the 1st to the 21st day of the cycle - 3-6 months) and gestagens (phase 2) norethisterone (Norkolut, Micronor, Primolut-nor) 5-10 mg, dydrogesterone (Duphaston) at a dose of 10-20 mg per day (from the 16th to 25th day of the cycle) or from the 5th to 25th day of the cycle (3-6 months); less often with prolonged progestins - medroxyprogesterone and hydroxyprogesterone capronate - 250 mg IM on the 14th and 21st days of the cycle 3-6 months. For relapses of the disease and precancer (endometrial hyperplasia with atypia, adenomatous polyps), prolonged progestins are used: hydroxyprogesterone capronate 500 mg IM 2 times a week for 6-9 months; medroxyprogesterone 200-400 mg IM once a week for 6-9 months; anti-releasing hormones – goseriline, triptorelin, buserilin 3.6 mg subcutaneously once every 28 days, 3 injections; gestrinone 2.5 mg 2-3 times a week for 6-9 months; danazol 600 mg daily for 6-9 months. Premenopausal women: COC treatment is not recommended. For simple hyperplasia: (progestins, prolonged progestins, anti-releasing hormones - according to indications and at the discretion of the doctor) in the same doses for 6 months. For hyperplasia with atypia and adenomatous polyps: buserilin (endonasal spray) 0.9 mg/day 3 times a day for 6-9 months; goseriline 10.8 mg subcutaneously once every 12 weeks, 2 injections; goseriline, triptorelin 3.6 mg subcutaneously once every 28 days, 4-6 injections; medroxyprogesterone 400-600 mg IM once a week, 6-9 months; gestrinone 2.5 mg 2-3 times a week for 6-9 months; danazol 600 mg daily for 6-9 months; Hydroxyprogesterone capronate 500 mg IM 2 times a week for 6-9 months. In postmenopause they are used: for endometrial hyperplasia without atypia: norethisterone 10 mg daily for 9-12 months; medroxyprogesterone 20 mg daily for 9-12 months; medroxyprogesterone 400-600 mg IM once a week for 9-12 months; Hydroxyprogesterone capronate 250-500 mg IM 2 times a week for 9-12 months. For atypical endometrial hyperplasia: the same drugs and in the same doses, but 12 months + Gestonorone capronate (Depostat, Primostat, Gestoporona caproate) – prolonged gestagen 200 mg intramuscularly once a week. Relapses in postmenopause are an indication for hysteroscopic ablation of the endometrium or extirpation of the uterus and appendages; amputation is also acceptable if there is no pathology of the cervix.

Endometrial polyps are especially difficult because... It is not always possible to radically remove them using diagnostic curettage, especially when localized in pipe corners. Some authors generally believe that this is not possible without the use of hysteroscopic equipment (12). For polypectomy, mechanical endoscopic instruments, electrosurgical technology and laser are used. After polypectomy in postmenopause, treatment is prescribed for 6 months: Norethistirone 5 – 10 mg/day; Hydroxyprogesterone capronate 250 mg 1-2 times a week; Medroxyprogesterone from 10 to 30 mg/day.
Attention. In case of hyperplastic processes of the endometrium, treatment with physical factors is contraindicated(17). Gynecological diseases in women with a history of endometrial hyperplastic processes can be treated only with the help of those physical factors that do not enhance the estrogenic activity of the ovaries (3). In the literature, the following additional methods of treating GE are found. Considering the frequent central genesis of uterine bleeding, therapy aimed at normalizing the activity of the central nervous system is indicated: tincture or decoction of valerian, minor tranquilizers (seduxen, trioxazine, elenium 1 tablet 1-2 times a day), Shcherbak collar, circular shower, conifers baths, massage of the collar area. In asthenic conditions, in parallel with restorative therapy, it is advisable to prescribe pearl, sea or sodium chloride baths. The duration of sedative therapy is from 2 to 4 weeks.
Patients with a history of inflammatory processes of the uterine appendages must undergo a course of anti-inflammatory therapy: autohemotherapy with calcium glucanate 10 procedures - 10.0 intravenously, microenemas with chamomile (50 ml of chamomile decoction) at night No. 10, B vitamins intramuscularly or subcutaneously No. 10, electrophoresis with potassium iodide, lidase, zinc No. 6-12, ultrasound. For anovulatory uterine bleeding caused by follicular atresia, bitemporal electrical stimulation and copper electrophoresis are indicated. We also pay special attention to the correction of concomitant diseases: carbohydrate metabolism disorders and thyroid diseases.

An extremely important aspect of the problem of endometrial hyperplastic processes is the management tactics of these premenopausal patients. Based on the principle of the fundamental differences between simple hyperplasia without atypia and atypical hyperplasia, treatment measures should be structured differently. The neoplastic nature of the changes inherent in atypical hyperplasia dictates the need for a radical surgical approach to it in premenopause. On the other hand, the presence of simple hyperplasia reflects to a greater extent anovulatory ovarian dysfunction, and to a lesser extent the true pathology of the endometrium. Considering the low potential for malignancy in simple hyperplasia without atypia, it should be considered advisable to carry out hormonal therapy in this group of patients. The recurrence rate of simple hyperplasia in late premenopause is quite high (46), which is confirmed by our data. Hormonal therapy does not at all relieve the patient from the possibility of relapses. However, the high frequency of relapses is due, rather, to the persistence of anovulatory ovarian dysfunction (quite natural from the point of view of age) than to the persistence of endometrial pathology. Therefore, the main direction of therapeutic interventions should be focused on creating adequate progesterone protection of the endometrium until the cessation of menstrual function.

Issues of treatment of complex hyperplasia without atypia should be resolved individually. In premenopause, a radical surgical approach seems more appropriate, but in individual cases, in women in the age group 40-44 years old who want to carry out reproductive function, hormonal therapy seems justified.

Treatment of endometrial hyperplastic processes is undoubtedly an urgent problem in modern gynecology. But the problem of preventing endometrial diseases seems no less significant. Based on the data obtained during our work, measures to prevent endometrial hyperplastic processes in premenopause should be carried out during the reproductive period and include the correction of metabolic disorders, normalization of body weight, treatment of endocrine disorders and menstrual dysfunction.

Further study of the pathogenesis, clinical and laboratory features of endometrial hyperplastic processes, the development of new diagnostic and treatment methods should reduce the incidence of endometrial cancer and mortality from this disease (45).

Purpose of the study.

To analyze the occurrence of relapses of endometrial polyps depending on treatment methods, age and concomitant gynecological and extragenital diseases. Justify the feasibility of anti-relapse treatment. Based on the research conducted, to develop differentiated and effective methods of treating patients with endometrial polyps.

Research objectives:

1. To study the gynecological history of patients and analyze the relationship between the occurrence of endometrial polyps and the presence of various gynecological diseases, the number of pregnancies, births, the presence of abortions and miscarriages.
2. To study the relationship between the occurrence of endometrial polyps and relapses with the presence of various infections of the reproductive system.
3. To analyze the structure of treatment for these women and the frequency of relapses in them with and without treatment.
4. Analyze the effect of various hormonal drugs used during the treatment of polyps or other genital pathologies on the occurrence of relapses.

Scientific novelty:

A comprehensive assessment of patients with endometrial polyps was carried out, including a study of the cause of the appearance of endometrial polyps and the occurrence of relapses, a study of the influence of various factors (such as the woman’s age, a history of genital and extragenital pathologies, the presence of abortions and miscarriages, the presence of various infections) on the appearance of endometrial polyps. Particular attention is paid to studying the use of hormonal drugs for the treatment of various diseases in these women, including the treatment of polyps, their effectiveness and further impact on the condition of the uterus (the appearance or absence of relapses).

Materials and methods:

Research results:

It should be borne in mind that only the doctor chooses the method of treating endometrial hyperplastic processes, based on his experience and knowledge. There is no universal method of treatment and there cannot yet be any standards, because... there is too much to consider. For example, when trying to decide on age criteria, we came across the so-called. late reproductive age - up to 50 years, or not everywhere there are good ultrasound machines, or hysteroscopes with the possibility of biopsy, resection and ablation, not all patients are willing to pay for expensive treatment methods, examinations and medications, and not all are ready for control intrauterine interventions .

Analysis of literary data and age parameters showed different ages of onset of different periods in women, but their criteria or symptoms are known and generally accepted.

Accordingly, for young and never-given women of the reproductive period up to 35 years of age, conservative management is acceptable at the first stage when diagnosing endometrial hyperplastic processes by ultrasound; for women of the reproductive period who have given birth and (or) after 35 years of age, such tactics are not advisable, and after 40 years of age - contraindicated. The point of carrying out conservative tactics is to avoid invasive intervention with possible risks and cure typical forms of hyperplasia. However, it is always possible to miss primary endometrial cancer without previous endometrial hyperplasia. On the other hand, an attempt at conservative tactics will not cure complex hyperplasia and endometrial cancer and is unlikely to worsen the prognosis of the disease, and with dynamic observation, there is always the opportunity to revise it. The first stage involves separate diagnostic curettage of the uterine cavity and cervical canal, preferably under the control of hysteroscopy.

The next step in choosing a measure of anti-relapse treatment is the data of a morphological study:

Endometrial polyps: 1. glandular – a. functional type (options: proliferative, secretory), b. basal type (variants: proliferative, hyperplastic, indifferent); 2. fibroglandular; 3. fibrous; 4. adenomatous.

Endometrial hyperplasia: 1. glandular; 2. glandular-cystic; 3. endometrial adenomatosis; 4. atypical endometrial hyperplasia.

According to our data, it should be noted that in 56.6% of cases there is a combination of hyperplasia and endometrial polyps, which determines the importance of taking the maximum amount of test material in order to avoid diagnostic errors and choose the right management tactics. And the main thing is the presence of atypia. In cases of detection of precancer (atypical hyperplasia, adenomatous polyps, glandular-cystic hyperplasia in menopause (especially recurrent) or developing against the background of neuroendocrine disorders), as well as metaplasia, we refer the patient (with all examinations and histological slides) to the oncology clinic for expert examination. assessments. Most cases of atypical hyperplasia become the reason for surgical treatment; 85% of hysterectomies are performed precisely for this indication. Such tactics are determined, firstly, by the high risk of malignancy of atypical hyperplasia, and, secondly, by the possibility of inadequate diagnosis during endometrial biopsy. When examining removed uteruses, it turned out that 11% of endometrial cancer, after curettage of the endometrium, was previously identified as endometrial hyperplasia (in the vast majority of cases, atypical hyperplasia). In other cases, anti-relapse treatment is prescribed. The effectiveness of treatment is monitored after its completion. The control method depends on the initial morphological diagnosis. For complex endometrial hyperplasia without atypia, diagnostic curettage under hysteroscopy control is recommended 3 weeks from the onset of the first menstrual bleeding. Simple hyperplasia without atypia does not require morphological control. Clinical observation, including assessment of the rhythm of menstruation and ultrasound examination, is quite sufficient. The recurrence rate of endometrial hyperplasia after taking COCs ranges from 7 to 16%. The correct choice of hormonal therapy in patients with endometrial hyperplastic processes allows one to avoid surgical intervention and, at the same time, significantly reduce the incidence of uterine cancer. Combined oral contraceptives are one of the methods for treating endometrial hyperplasia, which, with the correct selection of the drug, provides control of the condition of the endometrium, good tolerability and long-term protective effect (60). We believe that at the present stage all standards and algorithms are advisory in nature. Our task was, based on our experience in anti-relapse treatment, to find the most effective treatment methods and move away from those that are more likely to cause relapses of the disease. An analysis of publications in recent years has shown that the original concept of “progesterone protection” has not been justified and treatment with gestagens does not solve the problem of relapses of hyperplastic processes, and sometimes, on the contrary, the administration of gestagens worsens the course of the disease, for example, they contribute to the growth of accompanying myomatous nodes, more frequent occurrence of relapses of the disease, than with treatment with antireleasing hormones. According to the literature, the lack of effect of gestagen therapy for GPE varies from 25.9% to 78.0%. In most cases, gestagens are prescribed based on experience and capabilities, essentially by trial and error (blind method), it is interesting to prescribe them taking into account the results of the binding activity of gestagens with progesterone-binding sites as a result of individual testing of the affinity of progesterone receptors obtained from the endometrium of patients before the start of treatment and taking into account the results of the binding activity of gestagens with progesterone-binding areas of the endometrial cytosol of a particular patient (67).

The following schemes were used:

dihydrogesterone 10 mg 2 times a day, from 5 to 25 days of the cycle for 6 months;

norethisterone - 1 tablet 2 times a day, from 5 to 25 days of the cycle for 6 months;

medroxyprogesterone acetate - 1 injection IM every 28 days for 3 months

Moreover, the best results were obtained when treating medroxyprogesterone acetate (no relapses after 3-6 months). However, the use of this drug during the reproductive period, as well as continuous regimens of gestagens or COCs, often causes prolonged bleeding, and subsequently difficulties in restoring the normal menstrual cycle. Therefore, the “suppression” mode is best used in premenopause.

Treatment with progestins increases the risk of breast cancer, so dynamic monitoring is necessary - regular examination, ultrasound, mammography.

The average period of recurrence of an endometrial polyp without anti-relapse treatment is 3 months, and with treatment 3 years.

Considering that some researchers consider the feasibility of anti-recurrent treatment of endometrial polyps to be questionable, we decided to analyze the frequency of occurrence of fibroglandular polyps according to the histological picture, as well as the combination of polyps and hyperplasia in the histological picture. Glandular polyps are found mainly in reproductive age, fibroglandular polyps in premenopause, and fibrous polyps in menopause and postmenopause, but any histological variants can occur at any age. The combination of endometrial polyp and endometrial hyperplasia, according to our data, occurs in 56.6% of cases. It is generally accepted that endometrial hyperplasia must be treated with the same medications. Anti-relapse treatment of endometrial polyps is mandatory and the main goal is to reduce the activity of proliferative processes of the endometrium and, accordingly, cancer alertness and cancer prevention. We conducted our own analysis of relapses after separate diagnostic curettage of the uterine cavity and cervical canal. It turned out that relapses occur in 90% without treatment and in 60% with treatment. Moreover, of these 60% - 70% when treated with progestins only, 20% when treated with anti-releasing hormones for 3-6 months. and in 10% with preliminary treatment with anti-releasing hormones for 3-6 months with continued treatment with progestins. Moreover, in the latter case, relapses occurred when treatment was discontinued, after 3-5 years by a doctor, or independently. Moreover, the same results were obtained during treatment during the reproductive period and premenopause, with the subsequent prescription of COCs or progestins, or periodic change of one to the other, depending on the individual conditions of treatment. It should be noted that we are talking about anti-relapse treatment of fibroglandular polyps without atypia, after separate diagnostic curettage in the reproductive and premenopausal periods. In menopause and near menopause, we also used anti-relapse treatment, mainly with progestins, in a “suppression” mode for 3-6 or more months, under the control of hormonal studies and the end of treatment was determined over time - a significant increase in FSH, LH and a decrease in estradiol, those. menopause. In cases with juvenile bleeding and in some cases in reproductive age, diagnostic curettage was dispensed with, monitoring by ultrasound and clinical picture. Carrying out hemostasis and a progesterone test, followed by ultrasound after the next menstruation and over time. It should be noted that such tactics are risky, but justified by the fact that fibrous and other polyps, including precancer, cannot be cured, but it is possible to avoid intervention and risks, including anesthetic ones. Obesity is an important risk factor for complex endometrial hyperplasia or cancer in premenopausal women with abnormal uterine bleeding because It is known that adipose tissue is capable of secreting atypical estrogens and creates hyperestrogenism (13,75). Therefore, we pay special attention to the treatment of obesity - diet, physical activity, Goldline, Meridia, Lindaxa, Slimia, Reduxin) 1 capsule once a day No. 90. We pre-check blood glucose, lipids and weigh regularly. The frequency of overweight patients with hyperplastic processes reaches 30%. According to the inflammatory theory, sanitation of chronic foci of infection is necessary, especially in the reproductive period, and to a lesser extent in premenopause. Some authors note almost 100% diagnostic value of ultrasound + clinical picture even in premenopause. However, there is a high risk of encountering oncology and therefore we adhere to the inadmissibility of a conservative approach (without curettage). The best regimen for anti-relapse treatment of endometrial polyps turned out to be: At reproductive age: 3-6 months. Anti-releasing hormones for 3-6 months, with a transition to progestins (phase 2), or COCs, or in alternation, without interruptions or cancellations, for life, until the onset of menopause, confirmed by hormonal studies. The best recommendation is to plan your pregnancy. In menopause, or an age close to menopause, progestins are used in suppression mode; in case of detection of pure fibrous polyps and relapse, anti-relapse treatment “in suppression mode” is carried out only based on the results of hormonal studies, after cryodestruction or ablation of the endometrium. However, we believe that in any case, to suppress the proliferative effect of estrogens, it is still advisable after removal of a fibrous polyp to treat with Depo-Provera 150, 500 mg once a month. 3-6 months Having received stable menopause, confirmed (blood - FSH, LH, estradiol). We plan to prescribe the following as an anti-relapse treatment for endometrial hyperplastic processes: Conbriza 1 t once a day and Metformin (for obesity) 1 t once a day for 6 months. The most common endometrial pathology in elderly and senile patients (postmenopausal) is glandular fibrous polyps (92%) (72), including an increased risk of malignancy. In addition (72):

Particularly difficult are the tactics of managing postmenopausal patients, especially if it was not possible to perform diagnostic curettage due to atresia of the cervical canal. In this case, in the absence of bleeding, we conduct dynamic ultrasound screening and prescribe treatment with Depo-Provera 150, 500 mg intramuscularly for 3-6 months However, the use of progestins during this period increases the risk of developing breast cancer, so it is proposed to use an alternative to progestins - Bazedoxifene, a selective estrogen receptor modulator that prevents estrogen-induced endometrial hyperplasia in clinical trials. The molecular mechanisms responsible for the antiproliferative effect are not fully understood, but are associated with the regulation of estrogen and progesterone. FGF18 (Fibroblast growth factor 18, a protein encoded by the FGF18 gene in humans, is associated with the development of uterine cancer) (73). Pfizer under the trademark Viviant in the USA and Conbriza in the EU Conbriza tablets (Bazedoxifene) 20 mg No. 28

Indications for use. Currently, Conbriza (Bazedoxifene) remains an approved drug for the treatment of osteoporosis, but expansion of its therapeutic indications is being considered. Since the effectiveness of the drug has been confirmed by laboratory tests and its safety has also been proven.. Take it today Conbriza(Bazedoxifene) is recommended as a treatment and prevention of osteoporosis. It is used, among other things, during the postmenopausal period in women. The combination of Bazedoxifine with estrogens Aprela is currently undergoing phase 3 trials. Cannot be used during reproductive age. We plan to prescribe it as an anti-relapse treatment for endometrial hyperplastic processes Conbriza 1 t once a day and Metformin 1 t once a day for 6 months. in postmenopause after diagnostic curettage of the uterine cavity.

There is information about obtaining positive results using ASD-2 Dorogov's Suppositories.

Practical significance:

An algorithm has been developed for the most effective management of patients with endometrial polyps, depending on the woman’s age, morphological data, ultrasound data and the presence of concomitant pathologies.

It has been practically proven that anti-relapse treatment is justified, since the frequency of relapses of endometrial hyperplastic processes is significantly reduced.

Theoretical significance:

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Glandular polyp of the endometrium is one of the common types of pathology, along with the glandular-fibrous form. This type of neoplasm is typical for women of reproductive age and on average accounts for 30–40% of all cases.

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Endometrial polyp is a common pathology in women of the reproductive and menopausal periods and is a type of glandular-cystic or atypical endometrial hyperplasia. It has the appearance of a raised formation (growth) and may consist of adenomatous (glandular) cells and connective tissue cells.

Clinically, the neoplasm can remain undetected for a long time without causing any symptoms. This poses a great danger, since there are known cases of malignancy - the degeneration of a benign polyp into a malignant form.

What is an endometrial polyp?

Uterine lining

The endometrium is one of the three linings of the uterus. The outer membrane is called the perimetrium (or serosa). The middle, largest lining of the uterus, the myometrium, consists of smooth muscle cells (myocytes).

The inner lining is the endometrium. It is represented by two layers of cells: basal and functional. The cells of the basal layer have a small number of receptors for hormonal substances, due to which they are practically not susceptible to hormonal influences. The basal layer is the basis for the overlying functional layer.

The most superficial layer is functional, the cells of which are most sensitive to any hormonal changes in a woman’s body. It is rejected along with menstrual blood during menstruation, and after its end it is completely restored with the help of the basal layer.

How does growth occur?

A polyp is formed only from the mucous membrane of the uterus - the endometrium, as a result of hyperplastic processes. Due to intensive growth, the endometrium grows in height, forming a nodular neoplasm consisting of a stalk and a body.

As the growth forms, blood vessels begin to sprout, providing blood supply. Thus, its size can range from a few millimeters to 5–6 centimeters or more.

Types of polyps

Since the endometrium contains several types of cells, the neoplasm is formed with a predominance of one of them. Polyps are identified:

• adenomatous (glandular): growth with a predominance of glandular cells;
• fibrous: formation is formed by connective tissue cells;
• glandular-fibrous: the composition includes equally both connective tissue cells and glandular cells.

Features of a glandular polyp

The endometrial glandular polyp is largely represented by glandular cells, and to a lesser extent by stromal cells.

Depending on the layer from which it was formed, two types are distinguished:

The functional growth is highly sensitive to any hormonal changes, so its shape and structure can change along with the healthy endometrium throughout the menstrual cycle.

Based on histological type, pseudopolyps are divided into the following types:

• proliferative;
• secretory.

Glandular neoplasms are extremely rare and are considered the most dangerous, as they are prone to malignant transformation, especially in postmenopausal women, against the background of neuroendocrine and metabolic disorders.

The risk of degeneration into a malignant form increases in proportion to size. With a size of 1.5 cm, the probability of transformation is 2%, 1.5–2 cm – 2–10%, more than 2 cm – malignancy occurs in more than 10% of cases.

The number of polyps in the uterus may also indirectly indicate the risk of transformation. Thus, single neoplasms rarely malignize (1–2%), multiple ones more often (20%), diffuse (familial) malignancy very often (80–100%).

Reasons for the development of pathology

The reasons for the formation of a functional and basal polyp are somewhat different.

Functional form

Since the functional layer is most susceptible to hormonal changes, formations of the functional type increase against the background of hormonal disorders, namely with hyperestrogenism.

The causes of dishormonal conditions can be:

• frequent stress;
• obesity, hypertension;
• diabetes mellitus, thyroid diseases and other neuroendocrine pathologies;
• hyperestrogenism arising from inadequate therapy with estrogen-containing drugs;
• injuries and inflammatory processes of the uterine mucosa (endometritis);
• some other gynecological diseases.

Basal form

The basal layer is practically not subject to hormonal influences, therefore dishormonal conditions do not play a key role in the development of a basal type endometrial polyp.

A common cause of occurrence is injury to this layer and some other pathologies:

• abortion;
• fractional diagnostic curettage;
• prolonged presence of the intrauterine device in the uterine cavity, its incorrect installation;
• conducting a biopsy of the internal walls of the uterus without high-quality sterilization of instruments, inaccurate implementation;
• diseases of the immune system: allergies, autoimmune pathologies, especially those involving the vascular wall, immunodeficiency states;
• inflammatory processes in the uterus caused by sexually transmitted infections and some other pathogens;
• complicated obstetric history (miscarriages, termination of pregnancy, complicated childbirth).

Symptoms

The beginning of the formation of a neoplasm almost always goes unnoticed, since during this period the woman does not observe any symptoms, and ultrasound methods cannot visualize it.

Reaching a certain size, a polyp can provoke the following symptoms:

• intense pain before and during menstruation;
• the appearance of bloody discharge long before the onset of menstruation (intermenstrual bleeding). A woman can detect spotting on her underwear on any day of the menstrual cycle: at the beginning, in the middle or just before menstruation;
• delay of menstruation followed by copious discharge of menstrual blood;
• pulling pain in the lower abdomen;
• dyspareunia (pain during sexual intercourse);
• spotting after sexual intercourse, physical activity, stress;
• lack of a regular menstrual cycle.

Menopausal women may experience bleeding from the genital tract. At this age, this is a formidable sign, which often indicates oncological processes in the gynecological area.

Diagnostics

If at least one of the symptoms appears, you should immediately contact a gynecologist. Based on complaints, anamnesis, results of a bimanual gynecological examination and speculum examination, the doctor will be able to suspect this pathology.

Laboratory research methods

To make a diagnosis, the doctor prescribes a hormonal study: determining the amount of estrogens, progesterones, follicle-stimulating hormone, luteinizing hormone, thyroid hormones, adrenal glands and others. The material is collected on different days of the cycle.

Additionally, tumor markers can be studied, especially in menopausal and postmenopausal women.

Instrumental research methods

Instrumental research methods are mandatory; they allow you to visualize the neoplasm, perform a biopsy with further examination of the tissue for benignity or malignancy.

The following types of instrumental studies are used:

• Ultrasound examination of the pelvic organs (ultrasound). The method allows you to assess the condition of the endometrium, the presence of hyperplastic processes and neoplasms in it;
• endoscopic examination using a hysteroscope (hysteroscopy). A hysteroscope is a special optical device that is inserted into the uterine cavity and allows you to examine its mucous membrane in detail.

During hysteroscopy, it is possible to perform a targeted biopsy of the tumor for its subsequent cytological and histological examination.

Another option is fractional diagnostic curettage. Tissue fragments isolated during the procedure are also sent to the laboratory to evaluate the cellular and tissue composition.

Cytological and histological studies are necessary to assess the degree of cell differentiation, the presence or absence of their malignancy and to determine further tactics for managing the patient.

Therapy

Most often, a glandular polyp is treated surgically.

During the operation, the gynecologist inserts a hysteroscope into the uterine cavity, after a growth is visualized in the field against the background of pathologically unchanged endometrium, it is precisely removed mechanically or using laser ablation, electrocoagulation, etc.

If fractional diagnostic curettage was performed at the diagnostic stage and the polyp turned out to be functional, further surgical intervention is not required.

In postmenopausal women, especially with frequent relapses and multiple polyps, extirpation of the uterus and appendages is recommended, since these factors significantly increase the risk of malignancy of neoplasms.

If the results of a cytological examination of the material taken during a biopsy indicate malignancy and there are signs of an oncological process, the treatment differs from the usual and must be carried out by a gynecological oncologist.

Complications

A timely and adequately untreated glandular polyp can cause the following complications:

• infertility, miscarriage, placental abruption, fetal hypoxia during pregnancy;
• metrorrhagia (uterine bleeding) with the development of anemia;
• addition of infection or disruption of blood supply with the development of necrosis;
• malignancy, adenomatous transformation.

For early detection of endometrial hyperplastic processes and other gynecological pathologies, it is necessary to visit a gynecologist regularly (at least once a year), try to eliminate risk factors, and promptly treat gynecological diseases.

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