Intrauterine pathology includes hyperplastic processes of endometry; submucous myoma of the uterus; adenomyosis (internal endometriosis); septum in the uterus; synechiae; foreign bodies. Intrauterine pathology occupies a significant place in the structure of gynecological diseases.
Endometrial hyperplastic processes. Hyperplastic processes of the endometrium are understood to mean pathological diffuse or focal proliferation of the glandular and stromal components of the uterine mucosa, with a predominant lesion of glandular structures.
According to the WHO classification adopted in 1994, endometrial polyps are isolated, endometrial hyperplasia is simple and complex (complex), hyperplasia with cell atypia is simple and complex.
In our country, the terms “atypical hyperplasia” and “adenomatosis” are used interchangeably, and atypical hyperplasia is divided into degrees: mild, moderate and heavy.
Endometrial hyperplastic processes are possible at any age, but their frequency increases significantly in the period of perimenopause.
Pathogenesis. The leading place in the pathogenesis of endometrial hyperplastic processes is given? hormonal disorders in the form of relative or absolute hypeestro genesis in the absence of anti-estrogenic effect of progesterone or its insufficient effect. Causes of hyperestrogenia: anovulation due to the persistence or atresia of the follicles; hormone-producing structures of the ovaries (stromal hyperplasia, tekomatoz, granulocellular tumor, thecellular tumors); violation of the gonadotropic function of the pituitary gland; hyperplasia of the adrenal cortex; improper use of hormonal drugs (estrogens, antiestrogens). It is known that in patients with breast cancer, taking thamoxifen increases the frequency of hyperplastic processes and endometrial cancer.
In the pathogenesis of endometrial hyperplastic processes, metabolic and endocrine disorders occupy a large place: changes in fat metabolism, metabolism of sex hormones in the pathology of the hepatobiliary system and the gastrointestinal tract, immunity, and thyroid function. In this regard, in patients with endometrial hyperplastic processes, obesity, hyperlipidemia, diabetes mellitus, hypertension, and metabolic syndrome are often noted.
However, endometrial hyperplastic processes can also develop with intact hormonal ratios. A significant role in the development of endometrial hyperplastic processes is played by impaired tissue reception, infectious and inflammatory changes in the endometrium, and immune impairments. The development of glandular-fibrous polyps of the endometrium in 75% of cases occurs with undisturbed hormonal ratios, while in 95.3% of patients the endometrium is infected or there are signs of chronic inflammation.
The development of molecular biology, medical genetics, and clinical immunology in recent years has revealed a complex system of factors involved in cell regulation. The concepts of intercellular interaction and intracellular processes in hormone-dependent tissues have expanded. Thus, it was established that, along with estrogens, a number of biologically active compounds are involved in the regulation of the proliferative activity of endometrial cells, such as growth factors, cytokines, arachidonic acid metabolites, as well as a system of cellular and humoral immunity. It has been proven that an important role in tissue homeostasis and pathogenesis of proliferative diseases is an imbalance between cell proliferation and programmed cell death (apoptosis). The resistance of endometrial cells to apoptosis leads to the accumulation of altered and excessively proliferating cells, which is a characteristic feature of neoplastic changes in the endometrium.
Thus, the pathological transformation of the endometrium is a complex biological process that affects all parts of the neurohumoral system of a woman’s body.
Endometrial hyperplasia. The concept of “endometrial hyperplasia” histological; it includes excessive growth and structural changes in the glands of the endometrium, lack of separation into compact and spongy layers, impaired correct dissection in the stroma. As a rule, the functional layer of the mucous membrane of the uterus body undergoes hyperplastic changes, much less often the basal layer.
The main histological signs of glandular hyperplasia of the endometrium are reduced to “an increase in the number of glands ^ a change in their shape (the glands are enlarged), an increase in the ratio of stromal and glandular components in the absence of cytological atypia.
Simple endometrial hyperplasia without atypia enters cancer in 1% of cases, complicated without atypia 3 times more often.
Endometrial polyps are the most common type of endometrial hyperplastic process; occur with a frequency of up to 25%; malignancy in 2–3% of observations. Most often, endometrial polyps are detected in pre- and postmenopause.
The endometrial polyp is a benign lesion emanating from the endometrial oazad layer. Pathognomonic anatomical sign of the endometrial polyp – its base (leg).
Depending on the histological structure, there are jeledous (functional or basal type), glandular-fibrous, fibrous, and adenomatous endometrial polyps. Intensive proliferation of the glands and their epithelium with relatively high mitotic activity, atypia of glandular cells are characteristic of adenomatous polyps. Adenomatous polyps are referred to as precancerous conditions of the uterine lining.
Ferruginous polyps are most typical for the reproductive period, ferruterous fibrosis – for pre- and perimenopause, fibro-ferruterous and fibrous – for postmenopause.
In the reproductive and premenopausal periods of a woman’s life, endometrial polyps as a histologically independent form can be determined both against the background of endometrial hyperplasia and during normal mucosa of various phases of the menstrual cycle.
Postmenopausal endometrial polyps are usually solitary and can occur against the background of an atrophic mucosa. Sometimes during this period they reach a large size and, going beyond the cervix, imitate a polyp of the cervical canal.
Particularly noteworthy is the recurrent form of endometrial polyps. The concept of “recurrence” is unacceptable if hysteroscopic control was not used when removing the endometrial polyp earlier, because if you curet the uterine mucosa without hysteroscopy, you can leave the diseased tissue.