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Treatment

With the development of obstetric and gynecological science, endocrinology, biochemistry, approaches to the treatment of endometriosis have also improved.

It is possible to note several stages in the evolution of drug treatment of this disease. One of them is the treatment of endometriosis with pseudopregnancy. Today it is already known that there is a lower concentration of hormone receptors in endometriotic tissue in comparison with normal endometrium and, accordingly, a difference in response to treatment is expected: the endometrial response to treatment cannot coincide with the response of endometrioid tissue. Although in some patients with endometriosis, the symptoms of the disease may decrease or the reproductive function may recover after treatment. These observations do not indicate a cure for endometriosis with pseudopregnancy. In addition, from the point of view of this concept, it seems strange that 9 months of pregnancy do not lead to complete endometrial necrosis, therefore, pregnancy is not a treatment for the disease.

Another method is the treatment of endometriosis with pseudomenopause, pseudomenopause cannot accurately reproduce the state of menopause. Menopause is known to be accompanied by low estrogen levels and high concentrations of gonadotropins, while danazole and releasing hormone agonists suppress ovarian estrogen production by reducing the release of pituitary gonadotropins (hypogonadotropic hypogonadism). Thus, this is only an inferior pseudomenopause.

There are operational and conservative methods of treating endometriosis. The latter are divided into hormonal and non-hormonal. The best results are achieved with the complex therapy of endometriosis and its combined treatment. The choice of treatment method in each case is carried out individually and depends on the age of the patient, marital status, interest in pregnancy, localization of the endometrioid process, the degree of its spread, the severity of the clinical course of the disease, the nature and degree of endocrine-immune disorders, as well as the sensitivity of the tissue of the endometriotic foci to hormonal therapy, which is due to their histological structure and the reception of hormones. Treatment is preceded by a mandatory examination in order to exclude cancer.

Pathogenetically substantiated complex therapy of patients with endometriosis should include the intake of high-calorie foods with the restriction of spicy and spicy dishes; stay in the fresh air and therapeutic exercises; the exclusion of mental, physical and emotional overload; the appointment of sedatives; immunocorrection; vitamin therapy; removal of foci of endometriosis; elimination of inflammatory reactions and pain; normalization of thyroid function, hypothalamic-pituitary-adrenal and sympathetic-adrenal systems, gonadotropic function of the pituitary gland; improvement of hemodynamics of the pelvic organs; normalization of the function of the genital apparatus; correction of neurological disorders, treatment of concomitant pathology.

Indications for surgical treatment of patients with internal endometriosis are:

1. Adenomyosis is a diffuse or nodular form of the disease, accompanied by myometrial hyperplasia.

2. Internal endometriosis in combination with hyperplastic processes of the ovaries and (or endometrial precancer).

3. The absence of a positive effect of conservative therapy for three months.

4. The presence of contraindications to hormone therapy - a tendency to thromboembolism, varicose veins and thrombophlebitis, arterial and venous circulation disorders, acute and chronic hepatitis, cirrhosis, diabetes mellitus, psychosis and psychopathy, epilepsy, migraine, hypertension.

5. The combination of internal endometriosis of the uterine body with other diseases of the internal genital organs requiring surgical intervention.

The volume of surgery is determined by the age of the patient, the state of her reproductive function, cervix and ovaries.

In the reproductive period, in the absence of interest in maintaining childbearing function, as well as in pre- and postmenopause, supravaginal amputation of the uterus or its extirpation is performed.

Young women who are interested in maintaining reproductive function undergo organ-preserving surgery - myometectomy.

Pathogenetic substantiation of drug therapy of endometriosis. Antiendometrioid drugs are antihormones that inhibit the system of regulation of reproductive function at various levels - from the hypothalamus to target organs. This action is carried out:

1) by inhibiting the biosynthesis of endogenous hormones;

2) neutralizing the effect of hormones in the circulating blood system using specific antibodies;

3) direct competitive intervention at the target cell level through blockade of the receptors of the latter.

Links of the pathogenetic effect in the treatment of endometriosis:

1. Correction of immune disorders.

2. Impact on the antioxidant system.

3. Suppression of prostaglandin synthesis.

4. Activation of the liver and pancreas.

5. Neurotropic effects.

6. The use of hormonal drugs.

Among the wide range of hormonal drugs used in clinical practice for the treatment of genital endometriosis, it is necessary to distinguish the following groups:

1) combined estrogen-progestogen drugs (oral contraceptives);

2) progestins;

3) antiestrogens;

4) antiprogestins;

5) gonadotropin inhibitors;

6) gonadoliberin agonists.

Estrogen-progestogen drugs (oral contraceptives). Preparations of this class represent a combination of synthetic analogues of estrogen and progesterone. Depending on the content of synthetic steroids in the preparation, OK is isolated with monophasic (rigevidone, anteovin) and multiphase (tri-regol) action.

Progestogens. “Pure” progestogens - synthetic compounds that are identical to natural progesterone in chemical structure and mechanism of action on the reproductive system, are divided into two groups:

1) hydroxyprogesterone derivatives - medroxyprogesterone, megestrol and chlormadinone;

2) derivatives of 19-nortestosterone - norethinodrel, norethisterone, norgestrel, levonorgestrel.

Artificial progestogens actively bind to estrogen- and progesterone-binding receptors in target tissues, while releasing androgen receptors, i.e. have direct antiestrogenic and antiprogesterone effects.

The dose of progestogens needed to treat endometriosis depends on the type of drug and the severity of the pathological process. So, dydrogesterone, linestrenol, norethisterone acetate is prescribed at 5-10 mg / day from the 5th to the 25th day or from the 16th to the 25th day of the menstrual cycle; the optimal dose of medroxyprogesterone acetate is 30-50 mg / day when taken orally or intramuscularly, 150 mg of the deposited substance every 2 weeks.

Antiprogestins. Gestrinone is a synthetic steroid, identical in chemical structure to natural steroids.

Gestrinone is a 3rd generation norsteroid that has not only antigestagenic, but also antiestrogenic, antigonadotropic effects. The antiprogestin effect of gestrinone is to block the relationship between endogenous progesterone and progesterone-binding receptors in the tissues, since it acts primarily through progesterone receptors, in which blockade is carried out.

Antiestrogens - a non-steroidal compound that has agonistic and antagonistic actions in relation to estrogens. The antiestrogenic effect of tamoxifen is associated with the blocking of estrogen-dependent receptors in target cells, as well as the suppression of the synthesis of prostaglandins, which are responsible for the growth and maturation of follicles.

Gonadotropin Inhibitors
The pharmacological effect of danazol is manifested in the development of artificial pseudomenopause.

The antigonadotropic effect of the drug is to block the peak emissions of FSH and LH while maintaining their basal secretion level. The drug also suppresses a compensatory increase in gonadotropins in response to the reduced estrogen saturation caused by it. Danazole reduces the production of sex steroid-binding globulin by the liver, and also separates testosterone from the latter, thereby increasing the concentration of free testosterone in the body. Therefore, danazol inhibits steroidogenesis in the ovaries, binds androgen- and progesterone-dependent receptors in the endometrium, and inhibits the proliferative and secretory activity of the endometrial (or endometrioid) glands. Its optimal dose is 400 mg / day.

Side effects of the drug are mainly due to its androgenic effect.

Gonadotropin releasing hormone agonists. The use of synthetic agonistic analogues of the releasing factor of the gonadotropin hormone (such as dehapeptil, zoladex, sinarel) leads to the development of drug "castration".

Treatment of endometriosis with these drugs is problematic and remains at the stage of further study.

Criteria for choosing hormone replacement therapy for endometriosis. The normal course of processes in the reproductive system is ensured by the integrity of the hypothalamic-pituitary-ovarian system and the presence of certain relationships between its individual links. It is known that in the hypothalamus, in addition to specific nuclei projecting mainly onto the adenohypophysis and differing in their ability to neurocrinium, there are nonspecific formations that provide coordination of respiratory, cardiovascular and psychoemotional reactions. The activity of those and other hypothalamic nuclei is in close interconnection.

In recent decades, hormonal drugs have been used to treat endometriosis, which, through selective exposure to various levels of the reproductive system, cause their inhibition and contribute to the regression of endometrioid heterotopia. Therefore, turning off any link in the reproductive system can lead to disturbances in the holistic activity of the hypothalamus, which entails a change in relationships in the emotional, vegetative, metabolic-endocrine, somatic systems and the appearance of psycho-vegetative disorders.

In the presence of hyperplastic processes in the mammary glands, preparations containing an estrogen component are excluded. The management of patients is agreed with the mammologist.

In many clinical situations, complex treatment of endometriosis is performed. Often, endometriosis is combined with hyperprolactinemia. In this case, the use of tamoxifen (cytosonium) of 10 mg daily for 6–9 months at the same time as parlodel 2.5 mg daily in the first 3 months is effective. When combining endometriosis with uterine myoma and hyperprolactinemia, it is recommended to take tamoxifen 10 mg daily for 9-12 months in combination with parlodel 2.5 mg daily for 6 months under the control of serum prolactin concentration. Tamoxifen blocks the estrogen receptors of the cytoplasm of cells of endometriotic foci.

The appointment of medications should be preceded by psychotherapy. Reception of sedatives (preparations of bromine, valerian, motherwort herb) and small tranquilizers (tazepam) is recommended at the end of the 2nd phase of the cycle for 2-5 days.

An obligatory component of the complex therapy of patients with endometriosis is the use of radon waters, which have anti-inflammatory, analgesic and absorbable effects, normalize the hormonal function of the hypothalamic-pituitary-ovarian system, favorably affect the central nervous system and contribute to the elimination of neurological manifestations and consequences of endometriosis.

The widespread use of pulsed magnetic fields created by special devices. Its use significantly improves hemocirculation in the pelvic organs, has a normalizing effect on the hypothalamic-pituitary-ovarian system.

Of the enzyme preparations, lidase, ronidase, chymotrypsin, chymopsin are used. All enzyme preparations can be prescribed in the form of electrophoresis, intramuscularly or subcutaneously.

Vitamin therapy is widely used in the complex treatment of endometriosis: retinol (vitamin A), thiamine (vitamin B1), pyridoxine (vitamin B6), ascorbic acid and vitamin K. Vitamin A is used for 200,000 IU daily in the second half of the menstrual cycle for 2-3 months. Vitamin B1 is recommended to be taken 5-10 mg 3 times a day in the first half of the menstrual cycle for 3 months. Vitamin B6 is used 2 mg 2 times a day by mouth or 1 ml of a 5% solution intramuscularly in courses of 10-14 days. Vitamin C is prescribed at a dose of 500 mg 2 times a day in the 2nd phase of the menstrual cycle for 3 months. Vitamin K is recommended for menometrorrhagia in the first 2 days of the menstrual cycle, 0.015 g 2 times a day.

Reconstructive treatment and prevention. The objectives of postoperative rehabilitation treatment are the prevention of postoperative complications, the prevention of relapse of the disease, the elimination of secondary functional disorders.

After surgery, rehabilitation treatment is recommended, which includes physiotherapeutic methods of exposure. Apply electrophoresis of iodine and zinc by a sinusoidal modulated or fluctuating current (15 procedures). Subsequently, cervical-facial region galvanization, endonasal galvanization, pulsed magnetic field, exercise therapy are prescribed, according to indications - hyperbaric oxygenation, iodine-bromine baths and vaginal irrigation.

Hormonal drugs are prescribed in case of incomplete removal of endometriotic heterotopia and preservation of pain.

The results of treatment depend on the severity and degree of prevalence of the process, the volume and radicality of the surgical intervention, the usefulness of hormonal and rehabilitation therapy, the degree of violation of the reproductive system before surgery.

Prevention of endometriosis consists in preventing stressful situations leading to a “mistake” in the biorhythm of the functioning of the hypothalamic-pituitary-ovarian system and other endocrine organs. To prevent increased retrograde throwing of menstrual blood into the organs of the abdominal cavity and pelvis on the days of menstruation, excessive physical activity should be avoided, and the number of vaginal examinations should be limited. In case of cervical atresia, it is necessary to restore the patency of the cervical canal as soon as possible. It is important to combat abortion, to perform intrauterine interventions according to strict indications, under the guise of gestagen or estrogen-gestagen drugs. Care should be taken with the uterus during bimanual gynecological examination and during operations. After operations involving opening the uterine cavity, prophylactic hormone therapy should be carried out for 2-3 months. It should limit the use of diathermosurgical interventions on the cervix, replacing them with cryodestruction and laser treatment.

For the prevention of cervical endometriosis, diathermosurgical interventions to treat erosion should be carried out in the second half of the menstrual cycle, shortly before menstruation, and laser vaporization or cryodestruction on the 5-7th day of the cycle.

Intrauterine contraception should be avoided in young women with a family history with an unfavorable endometriosis, women should use progestogen and estrogen-progestogen contraceptive drugs more widely.
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