Inflammatory diseases of the genital area in women are a significant and still unresolved problem of modern gynecology. The frequency of this pathology does not tend to decrease, these diseases still occupy a leading place in the structure of gynecological morbidity.
In recent years, the interest of researchers in a separate nosology related to inflammatory diseases of the pelvic organs, – chronic endometritis. Chronic inflammatory process in the endometrium is one of the main causes of menstrual dysfunction, miscarriage, infertility, unsuccessful IVF attempts, endometrial hyperplastic processes and sexual dysfunction.
Peculiarities of chronic endometritis
Chronic endometritis – this is a disease in which, as a result of persistent damage to the endometrium by an infectious agent, multiple secondary morphofunctional changes occur that disrupt the cyclic transformation and reception of the mucous membrane of the uterine cavity.
In recent years, there has been a trend towards an increase in the number of cases of chronic endometritis, which is obviously associated with the spread of sexually transmitted infections, the widespread and often irrational use of intrauterine contraception, an increase in the number of abortions and various intrauterine manipulations.
The features of chronic endometritis at the present stage are as follows:
- scarcity of symptoms;
- change in the etiological structure with an increase in the importance of opportunistic and viral flora;
- predominantly associative nature of pathogenic flora (at least in 91–96% of cases);
- increasing resistance to conventional treatments;
- disagreements in the definition of diagnostic criteria;
- inconsistency of clinical manifestations and examination data with morphological changes in the organ;
- the severity of the consequences for the reproductive sphere in the form of the formation of synechia and sclerosis of the uterine cavity, menstrual irregularities, prerequisites for the development of endometrial hyperplastic processes, miscarriage and infertility, IVF failures;
- reduction in the quality of life of women due to the many clinical manifestations of the disease (menstrual disorders, chronic pelvic pain, dyspareunia, leucorrhoea, psychological problems, etc.);
- long treatment times and high costs.
Clinical manifestations of chronic endometritis
Classification implies the division of chronic endometritis, taking into account the etiological factor (according to C. Buckley, H. Fox, 2002) into:
- non-specific (caused by opportunistic microorganisms: E. coli, streptococci, staphylococci, proteus, fecal enterococci, against the background of bacterial vaginosis, intrauterine contraception, radiation therapy);
- specific (causes chlamydia, gonococci, tubercle bacilli, mycoplasmas, viruses, fungi, protozoa, parasites).
Clinical manifestations of chronic endometritis are not pathognomonic. There are frequent uterine bleeding of a different nature: premenstrual, postmenstrual, intermenstrual. Quite frequent are complaints of pulling pains in the lower abdomen, dysmenorrhea and dyspareunia, serous and serous-purulent discharge from the genital tract are noted.
Diagnosis of chronic endometritis
Diagnosis of chronic endometritis is based on an integrated clinical approach using a number of anamnestic, instrumental and laboratory criteria. Detection of possible pathogens includes: bacterioscopy of a vaginal smear, femoflora, sowing of discharge from the vagina and cervical canal, sowing of the endometrium, sowing material from the removed intrauterine contraceptive, determination of specific microorganisms in a scraping from the cervical canal using molecular methods, as well as the determination of antibodies to pathogens PID.
Echographic criteria for chronic endometritis developed by V.N. Demidov, are regularly supplemented. Ultrasound examination is carried out on the 5-7th and 22-24th days of the menstrual cycle. The most common signs of the disease are: changes in the echostructure of the endometrium, expansion of the uterine cavity due to liquid contents, diffuse focal and cystic changes in the subendometrial zone of the myometrium, uneven closure line and asymmetry of the anterior and posterior walls of the uterus, thinning of the M-echo, visualization of gas bubbles in the cavity uterus.
Doppler uterine vessels is of particular importance in dynamic monitoring in order to assess the effectiveness of the treatment of the disease. Hysteroscopy by macroscopic features makes it possible to identify chronic endometritis in 35-60% of cases, therefore it is always necessary to conduct a morphological study of the endometrial biopsy, which is considered the "gold standard" diagnosis of this disease. In some cases, it is advisable to use an immunohistochemical method with the determination of the expression of a marker of plasma cells, the surface glycoprotein Syndecan-1 – CD138, which increases the accuracy of morphological verification of chronic inflammation in the endometrium by 25–30%.
Treatment of chronic endometritis
Assessment of the hormonal status is necessary for adequate subsequent rehabilitation of patients and for resolving the issue of the nature of hormonal therapy at the second stage of treatment.
At the first stage of treatment of chronic endometritis, it is necessary to eliminate the damaging agent or, in the case of viral invasion, reduce its activity, for this purpose etiotropic preparations, taking into account the sensitivity of the isolated flora, as well as immunotropic agents.
In modern conditions, antibiotics should be used only when signs of an exacerbation of the disease appear, and their prescription during remission is unreasonable, since it often leads to the development of dysbacteriosis, superinfection and aggravation of the already existing inflammatory process in the uterus.
An important aspect of treatment – this is the normalization of the vaginal microbiocenosis. To this end, topical antiseptics, acid preparations, eubiotics and probiotics have been proposed.
The second stage of treatment of chronic endometritis – restoration of the morphofunctional potential of the tissue and elimination of the consequences of secondary damage: correction of metabolic disorders and the consequences of acidosis, restoration of hemodynamics and activity of the endometrial receptor apparatus. For this purpose, various options for metabolic therapy (vitamins, antiplatelet agents, antihypoxants, enzymes, amino acids), physical factors, hormonal drugs (combined hormonal contraceptives, HRT), spa treatment are used.
For the treatment of chronic nonspecific endometritis, procedures of intrauterine administration of a polyvalent bacteriophage and an infrared laser have recently been used, which makes it possible to realize an antimicrobial effect through a specific directed action on a wide range of possible pathogens of the inflammatory process in the uterine cavity in the absence of a significant systemic effect.
In the proposed method, the course of treatment begins after the end of menstruation, on the 5th & ndash;7th day of the menstrual cycle. Bacteriophages are injected into the uterine cavity three times a day. After emptying the bladder, the patient is placed on the gynecological chair. Under aseptic conditions, 4-7 ml of a liquid preparation of a polyvalent pyobacteriophage is slowly injected into the uterine cavity through a thin flexible catheter using a syringe, depending on the size of the uterus and the patient's response to the injection. After that, a tampon moistened with bacteriophage is introduced into the posterior fornix of the vagina to prevent leakage of the drug and to realize its antimicrobial action at the level of the vaginal mucosa. Then a session of laser therapy is performed. Such sessions are carried out daily, the total duration of the course of treatment – 7–10 days.
The method allows to increase the effectiveness of treatment by improving microcirculation in the pelvic organs, normalizing the trophism of the inner lining of the uterus, eliminating edema and endometrial infiltration, suppressing the growth of nonspecific microflora, optimizing factors of local and general immunity, reducing the frequency of possible systemic side effects.
With the combined use of laser radiation and bacteriophages, taking into account their complex positive effect on the focus of chronic nonspecific inflammation and the body, it is possible to refuse the appointment of antibacterial chemotherapy drugs, antiplatelet agents, immunostimulants, which has a significant economic effect.
According to the article by T.M. Motovilova, T.S. Kachalina, T.A. Anikina. RMJ, 2013, No. 14, p. 751–754, http://www.rmj.ru.
Share:
Add a comment