Where is the endometrium located: endometrium | anatomy | Britannica
Endometriosis | Johns Hopkins Medicine
What You Need to Know
- Endometriosis is derived from the word “endometrium,” which is the tissue that lines the uterus. Patients with endometriosis have endometrial-type tissue outside of the uterus
- Endometriosis affects an estimated 2 to 10 percent of American women between the ages of 25 and 40.
- Women with endometriosis are more likely to have infertility or difficulty getting pregnant
- Symptoms of endometriosis may include: excessive menstrual cramps, abnormal or heavy menstrual flow and pain during intercourse.
- Laparoscopy, a minimally invasive surgical procedure, can be used to definitively diagnose and treat endometriosis.
Endometriosis is a common gynecological condition affecting an estimated 2 to 10 percent of American women of childbearing age. The name of this condition comes from the word “endometrium,” which is the tissue that lines the uterus.
During a woman’s regular menstrual cycle, this tissue builds up and is shed if she does not become pregnant. Women with endometriosis develop tissue that looks and acts like endometrial tissue outside of the uterus, usually on other reproductive organs inside the pelvis or in the abdominal cavity. Each month, this misplaced tissue responds to the hormonal changes of the menstrual cycle by building up and breaking down just as the endometrium does, resulting in small bleeding inside of the pelvis. This leads to inflammation, swelling and scarring of the normal tissue surrounding the endometriosis implants.
When the ovary is involved, blood can become embedded in the normal ovarian tissue, forming a “blood blister” surrounded by a fibrous cyst, called an endometrioma.
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Causes of Endometriosis
The causes of endometriosis are still unknown. One theory suggests that during menstruation, some of the tissue backs up through the fallopian tubes into the abdomen, a sort of “reverse menstruation,” where it attaches and grows. Another theory suggests that endometrial tissue may travel and implant via blood or lymphatic channels, similar to the way cancer cells spread. A third theory suggests that cells in any location may transform into endometrial cells.
Endometriosis can also occur as a result of direct transplantation—in the abdominal wall after a cesarean section, for example. Additionally, it appears that certain families may have predisposing genetic factors to the disease.
Where Endometriosis Can Occur
The most common sites of endometriosis include:
The fallopian tubes
Ligaments that support the uterus (uterosacral ligaments)
The posterior cul-de-sac, i. e., the space between the uterus and rectum
The anterior cul-de-sac, i.e., the space between the uterus and bladder
The outer surface of the uterus
The lining of the pelvic cavity
Occasionally, endometrial tissue is found in other places, such as:
Abdominal surgery scars
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Risk Factors of Endometriosis
While any woman may develop endometriosis, the following women seem to be at an increased risk for the disease:
- Women who have a first-degree relative (mother, sister, daughter) with the disease
- Women who are giving birth for the first time after age 30
- Women with an abnormal uterus
The following are the most common symptoms for endometriosis, but each woman may experience symptoms differently or some may not exhibit any symptoms at all. Symptoms of endometriosis may include:
- Pain, especially excessive menstrual cramps that may be felt in the abdomen or lower back
- Pain during intercourse
- Abnormal or heavy menstrual flow
- Painful urination during menstrual periods
- Painful bowel movements during menstrual periods
- Other gastrointestinal problems, such as diarrhea, constipation and/or nausea
It is important to note that the amount of pain a woman experiences is not necessarily related to the severity of the disease. Some women with severe endometriosis may experience no pain, while others with a milder form of the disease may have severe pain or other symptoms.
Relationship of Endometriosis to Infertility
Endometriosis is considered one of the three major causes of female infertility. According to the American Society for Reproductive Medicine, endometriosis can be found in 24 to 50 percent of women who experience infertility. In mild to moderate cases, the infertility may be temporary. In these cases, surgery to remove adhesions, cysts and scar tissue can restore fertility. In other cases — a very small percentage — women may remain infertile.
How endometriosis affects fertility is not clearly understood. It is thought that scar tissue from endometriosis can impair the release of the egg from the ovary and subsequent pickup by the fallopian tube. Other mechanisms thought to affect fertility include changes in the pelvic environment that results in impaired implantation of the fertilized egg.
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For many women, simply having a diagnosis of endometriosis brings relief. Diagnosis begins with a gynecologist or other health care provider evaluating a patient’s medical history and completing a physical examination, including a pelvic exam. A diagnosis of endometriosis can only be certain, though, when the doctor performs a laparoscopy, biopsies any suspicious tissue and the diagnosis is confirmed by examining the tissue beneath a microscope. Laparoscopy is a minor surgical procedure in which a laparoscope, a thin tube with a camera at the end, is inserted into the abdomen through a small incision. Laparoscopy is also used to determine the location, extent and size of the endometrial growths.
Other examinations that may be used in the diagnosis of endometriosis include:
Ultrasound: A diagnostic imaging technique that uses high-frequency sound waves to create an image of the internal organs
CT scan: A noninvasive diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce horizontal, or axial, images — often called slices — of the body to detect any abnormalities that may not show up on an ordinary X-ray
MRI scan: A noninvasive procedure that produces a two-dimensional view of an internal organ or structure
Stages of Endometriosis
A staging, or classification, system for endometriosis has been developed by the American Society of Reproductive Medicine. The stages are classified as follows:
Stage 1: Minimal
Stage 2: Mild
Stage 3: Moderate
Stage 4: Severe
The stage of endometriosis is based on the location, amount, depth and size of the endometrial tissue. Specific criteria include:
The extent of the spread of the tissue
The involvement of pelvic structures in the disease
The extent of pelvic adhesions
The blockage of the fallopian tubes
The stage of the endometriosis does not necessarily reflect the level of pain experienced, risk of infertility or symptoms present. For example, it is possible for a woman in stage 1 to be in tremendous pain, while a woman in stage 4 may be asymptomatic.
Endometriosis Treatment Options
Specific treatment for endometriosis will be determined by your health care provider based on:
Your overall health and medical history
Extent of the disease
Your tolerance for specific medications, procedures or therapies
Expectations for the course of the disease
Your opinion or preference
Your desire for pregnancy
If symptoms are mild, health care providers generally agree that no further treatment, other than pain medication, is necessary.
In general, treatment for endometriosis may include:
“Watchful waiting” to observe the course of the disease
Pain medication: nonsteroidal anti-inflammatory drugs, such as ibuprofen or other over-the-counter analgesics
Hormone therapy, including:
Oral contraceptives, with combined estrogen and progestin (a synthetic form of progesterone) hormones, to prevent ovulation and reduce menstrual flow
Gonadotropin-releasing hormone agonist, which stops ovarian hormone production, creating a sort of “medical menopause”
Danazol, a synthetic derivative of testosterone (a male hormone)
Surgical techniques that may be used to treat endometriosis include:
Laparoscopy (also used to help diagnose endometriosis): A minor surgical procedure in which a laparoscope, a thin tube with a lens and a light, is inserted into an incision in the abdominal wall; using the laparoscope to see into the pelvic area, the doctor can often remove the endometrial growths.
Laparotomy: A more extensive surgery to remove as much of the displaced endometrium as possible without damaging healthy tissue
Hysterectomy: Surgery to remove the uterus and possibly the ovaries
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Easing the Pain of Endometriosis
Simple tips that can help ease the pain of endometriosis include:
- Rest, relax and meditate.
- Take warm baths.
- Prevent constipation.
- Get regular exercise.
- Use a hot water bottle or heating pad on your abdomen.
Sometimes, a combination of therapies is used, such as conservative surgery (laparoscopy or laparotomy), along with hormone therapy.
Some women also benefit from alternative treatments used in conjunction with other medical and surgical therapies for the treatment of endometriosis. These include:
- Traditional Chinese medicine
- Nutritional approaches
- Allergy management
- Immune therapy
It is important to discuss any or all of these treatments thoroughly with your health care provider, as some may conflict with the effectiveness of others.
US Pharm. 2011;36(9):17-18.
Uterine-Lining Tissue That Grows Outside the Uterus
The interior of the uterus is lined with a mucous membrane known as the endometrium. Each month, estrogen and progesterone stimulate the endometrial cells to grow and thicken in order to prepare for possible implantation of a fertilized egg. If a fertilized egg is not implanted during a monthly cycle, the endometrial lining breaks down and is shed during menstruation.
Endometrial tissue sometimes develops in other areas of the body, resulting in a condition known as endometriosis. This tissue may occur in the ovaries, fallopian tubes, bladder, rectum, bowel, or pelvic or abdominal cavity. Even though the tissue is located outside the uterus, it responds to monthly hormonal changes by breaking down and bleeding as if it were part of the shedding endometrium. Swelling and the eventual breakdown and bleeding of endometriotic tissue can cause pelvic or lower back pain, bleeding into surrounding tissue, and scarring. Many women with endometriosis experience symptoms, but sometimes the disease is asymptomatic. Damage caused by endometriosis cannot be reversed and may lead to scarring, cyst formation, or infertility.
Endometriosis treatment depends upon the patient’s age, extent of pelvic involvement, symptom severity, and desire for pregnancy. Mild pain sometimes can be controlled by nonsteroidal anti-inflammatory drugs (e.g., ibuprofen, naproxen). Monthly cycles may be manipulated by using estrogen and progesterone to control endometrial growth, breakdown, and bleeding. Gonadotropins can shut down the ovaries’ production of estrogen, but they have side effects. If pregnancy is desired or if medications do not relieve symptoms, surgery to remove the endometrial tissue and surrounding scar tissue is an effective alternative. Another option is partial or total hysterectomy, which cures endometriosis in most patients.
Pain Severity Does Not Indicate the Severity of Disease
Endometriosis, a condition in which the tissue lining the inside of the uterus also grows elsewhere in the body, is usually diagnosed when a woman is in her mid-20s to mid-40s, but probably begins much earlier. Women who have not had children or who have a close relative with endometriosis are at greater risk, as are women whose menstrual cycles are less than 28 days or whose periods last longer than 7 days.
It is unclear why endometriosis occurs or why endometrial cells develop outside the uterine lining. During menstruation, these cells may be transported backward through the fallopian tubes and into the pelvic or abdominal cavity. Another theory is that endometrial cells enter the bloodstream or lymph system during normal endometrial shedding and are transported to other parts of the body.
Symptoms and Diagnosis
Symptoms of endometriosis do not always occur, even with extensive disease. The severity of symptoms such as pain is not necessarily related to the severity of the condition. Mild endometriosis may cause serious pain in one woman, while in another significant disease may go unnoticed until a physician is consulted for infertility. Most women with endometriosis have some degree of pelvic pain. Pain may occur just before menstruation begins, during menstrual bleeding, while having a bowel movement or urinating, or during sexual intercourse. The pain is caused by endometrial-tissue breakdown and scar-tissue formation in the area. In many cases, the bleeding and scarring cause permanent adhesions (scar tissue attaching two separate organs) in the pelvic region. Sometimes, an endometrioma (cyst made of endometrial tissue) forms on the ovary.
Endometriosis is diagnosed by symptom history, pelvic examination, transvaginal ultrasound, and/or pelvic laparoscopy. In laparoscopy, a small tube with a lighted camera is inserted into the pelvic cavity; during the procedure, a piece of tissue may be biopsied to confirm diagnosis, or endometrial tissue may be removed.
Treatment is based on symptom severity, disease involvement, and desire for pregnancy. Nonsteroidal anti-inflammatory drugs may be used for mild pain, but they do not treat the cause of endometriosis. Hormone-containing medications can ease the pain and control the cyclic swelling, bleeding, and scarring of endometrial tissue, but they have side effects and do not reverse existing scarring.
Using birth control pills continuously for up to 9 months and then stopping them briefly to permit menstruation can relieve symptoms by creating an artificial pregnancy state. In fact, many pregnant women experience relief from endometrial pain because of the hormonal shift. Side effects of this therapy include nausea, breast tenderness, and spotting.
Gonadotropin-releasing hormone (GnRH) may be used to shut down the ovaries’ production of estrogen, similar to what occurs in menopause. GnRH causes menopausal symptoms such as hot flashes and bone-density loss. Progestin, which stops menstruation by working against estrogen’s effects, also may be used, but it may cause moodiness, weight gain, and bloating.
Surgical removal of endometrial tissue and surrounding scar tissue typically is reserved for severe cases that do not respond to hormone therapy or for infertile patients wishing to conceive. Endometriosis is permanently cured in about 50% of patients; in the rest, symptoms may return within a year.
The most permanent treatment is hysterectomy (removal of the uterus). The ovaries may be removed as well, further reducing the chance of symptoms returning. The patient will no longer menstruate or be able to conceive, and endometriosis is highly unlikely to return.
Endometrium – an overview | ScienceDirect Topics
Endometrial Histology—Histologic Evaluation of an Endometrial Biopsy Sample
An endometrial biopsy sample can provide histologic evidence of uterine inflammation and provide information regarding the chronicity, severity, and distribution of the endometritis. This information is useful in developing a therapeutic plan for managing the endometritis. Histologic evaluation of an endometrial biopsy sample can also reveal the presence of periglandular fibrosis, cystic glandular distension, and lymphatic lacunae. In the mare there is a correlation between the character of the endometrial glands and the ability of the endometrium to carry a foal to term. 8 The secretions of the endometrial glands may be more important in maintaining the equine conceptus because functional placentation occurs rather late in the mare as compared to the cow and ewe. It is thought that periglandular fibrosis may interfere with gland function and be detrimental to the survival of the embryo. Therefore the histologic evaluation of an endometrial biopsy sample has prognostic value in predicting a mare’s ability to carry a foal to term.
An endometrial biopsy sample may be obtained at any time of the reproductive cycle of a nonpregnant mare. Samples can even be taken during estrus after breeding without interfering with pregnancy. Diestrous mares with a mature corpus luteum may experience luteolysis subsequent to the biopsy procedure. The mare should be restrained, its tail wrapped, rectum emptied, and the perineum cleansed. The pregnancy status of the mare must be ascertained because the biopsy procedure is contraindicated during pregnancy. The clinician should wear a clean or sterile shoulder-length examination sleeve covered by a sterile surgical glove. Sterile water-soluble lubricant is placed on the dorsum of the operator’s positioning hand and lower arm. The endometrial biopsy instrument has an overall length of 70 cm with an alligator forceps type of sample basket of 20 × 43 mm. The closed sampling end of the sterile biopsy instrument is carried through the caudal genital tract and, using the forefinger of the gloved hand as a guide, is passed through the cervix and into the uterine body. While holding the closed biopsy instrument stable and inside the uterus with the outside opposite hand, the gloved hand is withdrawn from the genital tract and placed into the rectum. By manipulations per rectum, the sample basket is positioned on the ventral aspect at the base of one of the uterine horns. The forceps are opened and an endometrial fold is pushed into the sides of the basket jaws per rectum. While the forceps are held closed, the instrument is withdrawn from the genital tract. Typically one can feel the biopsy instrument pull away from the uterine wall when the sample is incised. This procedure does not require anesthesia or tranquilization of the mare, because the equine uterus does not have sensory innervation. When sectioned and processed, the procured tissue sample should be large enough to provide endometrial sections with greater than 2 cm of linear lumen epithelium present for histologic evaluation. The biopsy sample should be placed into Bouin’s fixative and submitted for tissue processing. If tissue processing will be delayed for more than a few days, Bouin’s fixative should be replaced with fresh 10% formalin or 70% ethanol. Fixed tissue samples are embedded in paraffin, and a microscope slide is prepared and stained with hematoxylin and eosin. Tissue samples can also be fixed in 10% formalin, but this results in shrinkage of the tissue and a different cytologic detail. If specific areas of the uterus seem abnormal when examined by palpation or ultrasonography per rectum, additional endometrial biopsy samples can be obtained from those affected areas.
It is essential that the reproductive history of the mare, the stage of the estrous cycle, and character of the genital organs at the time of biopsy be supplied with the sample submission to the pathologist. Knowledge of this information and especially any recent breedings or uterine therapy is needed by the pathologist to develop an accurate epicrisis.
Interpretation of the histologic changes in the endometrial sample will discuss the patterns of distribution (widespread versus scattered) of lesions with regard to the frequency of changes (infrequent, moderately frequent, or frequent). The description of the anatomic pattern of lesion location may include the stratum compactum, stratum spongiosum, perivascular, or periglandular. Inflammatory cells in the sample may include neutrophils, lymphocytes, plasma cells, hemosiderophages, or eosinophils, and the character of the distribution of these cells may be focal, multifocal, diffuse, perivascular, or periglandular. Inflammatory lesions are classified as small (<120 μm), moderate (120 to 300 μm), or large (>300 μm). The severity of periglandular fibrosis is described by the number of layers of fibrosis present, slight (1 to 3 layers), moderate (4 to 10 layers), or severe (>10 layers).
A summary evaluation of the changes present in an endometrial sample was initially made by assigning the endometrium a classification in one of three endometrial categories (I, II, III).8 Studies were performed to determine the foaling rate of mares with endometrium in the different categories. Since 1986, classifications have been divided into four categories with an attempt to allow prognostication of the ability of the endometrium to carry a foal to term.9
The endometrium has little or no pathologic changes and is neither hypoplastic nor atrophic. The changes in this endometrium should not interfere with the ability of this endometrium to carry a foal to term. No abnormalities are present, and this endometrium would be expected to carry a foal to term at a rate of 80% to 90%.
The inflammatory changes are slight to moderate, diffuse infiltrations of the stratum compactum or scattered but frequent foci in the stratum compactum and stratum spongiosum (Figure 6-2). Fibrotic changes may be infrequent to frequent, scattered, and involve individual gland branches with less than three layers of fibrosis or fibrotic nests averaging less than two per 5.5-mm linear field in an average of four or more fields. Extensive lymphatic lacunae that cause changes in the uterus that can be detected by palpation per rectum would relegate the endometrium to category IIA. These changes are mild, and this endometrium would be expected to carry a foal to term at a rate of 50% to 80%.
The endometrium from any mare that has been barren for 2 or more years and has the changes consistent with a category IIA endometrium would be assigned to category IIB. Inflammation that is widespread, diffuse, moderately severe, and focal would be included. Fibrotic changes are more extensive, with up to four or more layers of fibrosis surrounding individual gland branches and two to four fibrotic nests per 5.5-mm linear field in an average of four or more fields. These changes are moderate, and this endometrium would be expected to carry to term at a rate of 10% to 50% (Figure 6-3).
Inflammatory changes are widespread, diffuse, and severe. This category also includes other changes that not only interfere with the ability of the endometrium to carry a foal to term but also cannot be improved by uterine therapy. Uniformly widespread periglandular fibrosis or greater than an average of five fibrotic gland nests per 5.5-mm linear field in an average of four or more fields will automatically relegate the endometrium to category III. These changes are severe, and this endometrium would be expected to carry to term at a rate of only 10%.
Histologic evaluation of an endometrial biopsy sample is routinely performed in barren mares after the end of the breeding season to determine the cause of their infertility so therapy can be instituted to correct any abnormalities. Regarding financial decision making, one may consider performing an endometrial biopsy before booking a mare to the stallion or deciding to perform expensive surgical corrective procedures. Mares with category III endometria are less likely to produce a foal, and the costs associated with getting them in foal may outweigh the probability of having only a 10% chance of carrying a foal to term. Knowledge of the histologic character of the endometrium during the breeding season can help when making decisions whether to breed or perform therapy at any particular time during the season.
Clinical Anatomy of the Uterus, Fallopian Tubes, and Ovaries
The uterus varies considerably in size, shape and weight depending on the status of parturition and estrogenic stimulation. The uterus is a fibromuscular organ that can be divided into the upper muscular uterine corpus and the lower fibrous cervix, which extends into the vagina. The upper part of the uterus above the insertion of the fallopian tubes is called the fundus. The narrow portion situated between corpus and cervix is known as the isthmus and lies approximately at the level of the course of the uterine artery and the internal os of the cervix. The endometrial cavity lies within the uterine corpus and is surrounded by a thick, muscular wall.
The musculature of the uterus is in several layers. There is an outer longitudinal layer (stratum supra-vasculare) continuing into the fallopian tubes and round ligaments. The vascular layer (stratum vasculare) consists of many interlacing spiral groups of smooth muscles and contains many blood vessels. An inner layer consists of muscle fibers arranged both longitudinally and obliquely.
The cervix, which protrudes into the vagina, is generally 2–3 cm long. The intravaginal portion of the cervix, known as the portio vaginalis, ordinarily is covered with nonkeritinizing squamous epithelium with a number of mucus-secreting glands (Fig. 2). The external os is the opening of the cervix within the vagina. Above the external os lies the fusiform endocervical canal, approximately 2 cm long and lined with columnar epithelium and endocervical glands. The intersection where the squamous epithelium of the exocervix and columnar epithelium of the endocervical canal meet, the squamocolumnar junction, is geographically variable and dependent on hormonal stimulation. It is this dynamic interface, the transformation zone, that is most vulnerable to the development of squamous neoplasia. In early childhood, during pregnancy, or with oral contraceptive use, columnar epithelium may extend from the endocervical canal onto the exocervix, a condition known as eversion or ectopy. After menopause, the transformation zone usually recedes entirely into the endocervical canal.
At the upper end of the endocervical canal at the junction with the uterine cavity is the internal os. The endocervical canal in the nullipara is lined by mucosa arranged in a series of folds. A vertical fold is present on the anterior and posterior cervical walls; from these, oblique folds radiate. These folds have been called the arbor vitae uteri or plicae palmatae. It was formerly thought that tubular glands descend vertically from the surface and divide into many branches forming compound racemose glands; however, secondary changes caused by the intense growth activity of the columnar cells result in the formation of tunnels, secondary clefts, and exophytic processes.
Fig. 2. Photomicrograph (low power) of the epithelial lining at the junction of the cervix and vagina in the human. The glands of the cervix are definitely evident. There are no glands underlying the squamous epithelium of the vagina. (After R. Shroder.)
The endometrial cavity lies above the internal cervical os. It is roughly triangular in shape and measures approximately 3.5 cm in length. Ordinarily, the anterior and posterior walls of the uterus lie in apposition so that little if any actual cavity is present. At each cornu or horn of the uterus, the cavity of the uterus becomes continuous with the lumen of a fallopian tube. Peritoneum covers most of the corpus of the uterus and the posterior cervix and is known as the serosa. Laterally, the broad ligament, a double layer of peritoneum covering the neurovascular supply to the uterus, inserts into the cervix and corpus. Anteriorly, the bladder lies over the isthmic and cervical region of the uterus.
The “positions” of the uterus are of considerable interest but of much less importance in gynecologic practice than 50 years ago. The most common position of the uterus in a nulligravid female is in moderate anteflexion or bent slightly anteriorly, and the uterus as a whole is inclined toward the symphysis in ante version against the bladder, adapting its position as the latter organ distends or empties (Fig. 3 and Fig. 4). In a variable number of women, the uterus is retroverted or inclined posteriorly or retroflexed toward the sacrum. Quite a few disabilities were attributed to these “malpositions” in the past including dysmenorrhea, functional uterine bleeding, backache, dyspareunia, and leukorrhea. Many normal uteri are in mid position, with the axis of uterus being almost parallel to the spine.
Fig. 3. Dissection showing the cephalic aspect of the female genitalia and their relationships.
Fig. 4. Transverse section of the abdomen above the crests of the ilia. This section is 1 inch above the pubis and extends through the disk between the sacrum and the last lumbar vertebra.
The peritoneum covers the uterus and is separated from the uterine musculature by a thin layer of periuterine fascia, which is a continuation and extension of the transversalis fascia. This mobile fascial layer is areolar tissue and is easily separated except for a midline seam or raphe between the uterus and bladder anteriorly and between uterus and peritoneum posteriorly at the level of the isthmus. Posteriorly it sweeps down over the posterior vaginal wall and the cul-de-sac.
The blood supply of the uterus is derived chiefly from the uterine arteries (Fig. 5). These arise from the hypogastric artery and swing toward the uterus, which they reach at approximately the level of the internal os (Fig. 6 and Fig. 7). Here the uterine arteries divide, the descending limb coursing downward along the cervix and lateral wall of the vagina. The ascending limb passes upward alongside the uterus and continues below the fallopian tube. Frequent anterior and posterior branches go to vagina, cervix, and uterus.
Fig. 5. Arterial blood supply of the normal tube, ovary, and uterus. (Courtesy of Dr John A. Sampson.) (From Norris: Gonorrhoea in Women. Philadelphia: Saunders.)
Fig. 6. Ventral view of a deep dissection of the urinary bladder and the blood supply to the left side of the internal genitalia, showing the relation of the uterine vessels to the ureter.
Fig. 7. Blood supply of the reproductive organs with relation to the ureter and trigone of the urinary bladder.
The ovarian artery, which ordinarily arises from the aorta, passes along the ovary, dividing into a number of branches. At several places in the broad ligament there are anastomotic connections between the tubal branch of the uterine artery and the ovarian artery. A branch of the uterine artery nourishes the round ligament. The veins generally accompany the arteries.
Using injection and microradiographic and histologic techniques to study the vascular anatomy of the uterus, Farrer-Brown et al.1 showed that the uterine arteries run a tortuous course between the two layers of the broad ligament along the lateral side of the uterus and turn laterally at the junction of the uterus and fallopian tube, run toward the hilum of the ovary, and terminate by joining the ovarian arteries. In the broad ligament each uterine artery supplies lateral branches that immediately enter the uterus and give off tortuous anterior and posterior arcuate divisions, which run circumferentially in the myometrium approximately at the junction of its outer and middle thirds. In the midline the terminal branches of both arcuate arteries anastomose with those of the contralateral side.
Each arcuate artery throughout its course gives off numerous branches running both centrifugally towards the serosa and centripetally towards the endometrium. The arteries to the serosa at first are directed radially and then frequently became more circumferential. There is a plexus of small arterial radicals with a radial distribution located immediately below the serosa. The inner two-thirds of the myometrium is supplied by tortuous radial branches of the arcuate arteries. They provide numerous branches terminating in a capillary network which surrounds groups of muscle fibers. An abrupt change in the density of the arterial pattern occurs at the junction of the basal layer of the endometrium with the subjacent myometrium. The endometrial vessels are relatively sparse in comparison with those of the myometrium at all stages of the menstrual cycle.
The uterus is partially supported by three pairs of ligaments. The paired round ligaments extend from the anterosuperior surface of the uterus through the internal inguinal rings and through the inguinal canals to end in the labia majors. They are composed of muscle fibers, connective tissue, blood vessels, nerves, and lymphatics. The round ligaments stretch with relative ease, particularly in pregnancy. The uterosacral ligaments are condensations of endopelvic fascia that arise from the posterior wall of the uterus at the level of the internal cervical os. They fan out in the retroperitoneal layer and attach broadly at the second, third, and fourth segments of the sacrum. They are predominately composed of smooth muscle but also contain connective tissue, blood vessels, lymphatics, and parasympathetic nerve fibers.2 The paired cardinal (Mackenrodt’s) or transverse cervical ligaments arise from the anterior and posterior marginal walls of the cervix and fan out laterally to insert into the fascia overlying the obturator muscles and the levator ani muscles. The cardinal ligaments form the base of the broad ligament. They are composed of perivascular connective tissue and nerves that surround the uterine artery and veins. The cardinal and uterosacral ligament complex is collectively called the parametrium.
The broad ligament is formed by folds of peritoneum covering the fallopian tubes, the infundibulopelvic vessels, and the hilus of the ovary. It contains a number of structures: fallopian tube, round ligament, ovarian ligament, uterine and ovarian blood vessels, nerves, lymphatics, and mesonephric remnants. Below the infundibulopelvic structures, the anterior and posterior leaves of peritoneum lie in apposition, leaving a clear space below the tube with its tubal branch of the uterine artery. This avascular area is useful to the surgeon in isolating the adnexal structures and in avoiding blood vessels while performing tubal ligations.
The endometrium lines the uterine cavity and is considered to have three layers: the pars basalis, the zona spongiosa, and the superficial zona compacta. The straight branches of the radial arteries of the uterus terminate in capillaries in the basal layer, while the spiral or coiled branches penetrate to the surface epithelium, where they give rise to superficial capillaries. Sinus-like dilatations of the capillaries in the superficial layer are called “lakes.” These vascular lakes and capillaries are drained by small veins.
The endometrium varies greatly depending on the phase of the menstrual cycle. Proliferation of the endometrium occurs under the influence of estrogen; maturation occurs under the influence of progesterone. The uterine endometrial cycle can be divided into three phases: the follicular or proliferative phase, the luteal or secretory phase, and the menstrual phase. The follicular, or proliferative phase, spans from the end of the menstruation until ovulation. Increasing levels of estrogen induce proliferation of the functionalis from stem cells of the basalis, proliferation of endometrial glands, and proliferation of stromal connective tissue. Endometrial glands are elongated with narrow lumens and their epithelial cells contain some glycogen. Glycogen, however, is not secreted during the follicular phase. Spiral arteries elongate and span the length of the endometrium.
After formation of the corpus luteum, the endometrial glands grow, become tortuous, and secrete. The luteal, or secretory, phase begins at ovulation and lasts until the menstrual phase of the next cycle (Fig. 8). At the beginning of the luteal phase, progesterone induces the endometrial glands to secrete glycogen, mucus, and other substances. These glands become tortuous and have large lumens due to increased secretory activity. The spiral arteries extend into the superficial layer of the endometrium. The spiral capillaries develop a terminal network of superficial capillaries. These changes result in the formation of a predeciduum prepared for the arrival of the trophoblast.
Fig. 8. Luteal phase endometrium.
In the absence of fertilization by day 23 of the menstrual cycle, the corpus luteum begins to degenerate and ovarian hormone levels decrease. As estrogen and progesterone levels decrease, the endometrium undergoes involution. During days 25–26 of the menstrual cycle, endothelin and thromboxin begin to mediate vasoconstriction of the spiral arteries. The resulting ischemia may cause menstrual cramps. By day 28 of the menstrual cycle, intense vasoconstriction and subsequent ischemia cause mass apoptosis of the functionalis, with associated bleeding. The menstrual phase begins as the spiral arteries rupture secondary to ischemia, releasing blood into the uterus, and the apoptosed endometrium is sloughed off (Fig. 9). During this period, the functionalis is completely shed. Arterial and venous blood, remnants of endometrial stroma and glands, leukocytes, and red blood cells are all present in the menstrual flow.
Fig. 9. Menstrual phase endometrium.
Data on the lymphatic vessels of the uterus have been coordinated by Reynolds.3 The entire uterus has a rich capillary bed as extensive as the blood capillary system. The lymphatic capillary bed is arranged in four zones: (1) the lower uterine segment with its rich supply of fine capillaries, (2) the subserosa of the corpus with a few lymphatics, (3) a deep subserosal network, and (4) a plentiful supply in the muscularis proper. These vessels increase greatly in number and size during pregnancy. The collecting system of the uterine lymphatics is formed from anastomoses of a lateral-uterine descending network of lymph vessels which unites with collecting vessels from the utero-ovarian pedicle and the external iliac area. Lymphatic drainage of the uterus and upper two-thirds of the vagina is primarily to the obturator and internal and external iliac nodes.
The fallopian tubes are bilateral muscular structures of paramesonephric duct origin. They are from 7 to 12 cm in length and usually less than 1 cm in diameter. The tubes or oviducts have a lumen that varies considerably in diameter. It is extremely narrow, being less than 1 mm at its opening into the uterine cavity. It is wider in the isthmus (Fig. 10) (2.5 mm) and in the ampulla (Fig. 11) is approximately 6 mm in diameter. The tube begins in the uterine cavity at the cornu and penetrates the myometrium (intramural or interstitial portion). The second portion is the relatively straight and narrow portion of the tube which emerges from the uterus posterior to and a little above the origin of the round ligament. The lumen of the narrow isthmus is relatively simple, with a few longitudinal folds. This portion of its tube is 2 or 3 cm long. There are three layers of musculature: the inner longitudinal, the middle circular layer, and the outer longitudinal layer. There is some evidence that the isthmus may act as a sphincter.
Fig. 10. Photomicrograph showing the isthmic portion of the fallopian tube; it is in this portion of the tube that spasm may occur and close the lumen. The mucosa is lined by columnar epithelium which surrounds the lumen. The columnar cells have cilia. The circular muscle layer is thickest at the isthmus and thinnest at the infundibulum.
Fig. 11. Photomicrograph (low power) of the ampullary portion of the fallopian tube. The mucosa forms folds which in transsection of the tube simulate glandular structures. There are, however, no true secreting glands in the oviduct.
The ampulla is the largest and longest portion of the tube, approximately 5 cm or more in length. The lumen enlarges from 1 or 2 mm near the isthmus to over a centimeter at the distal portion. The mucosa has multiple longitudinal folds. The ampulla is the portion usually involved in gonorrheal salpingitis and tubo-ovarian abscesses and is the site of most ectopic pregnancies.
At the distal end of the tube is the trumpet shaped infundibulum. The tube ends in a number of fimbriae or frond-like projections; the largest of these is ordinarily in contact with the ovary and is known as the ovarian fimbria. The peritoneal cavity in the female is connected with the exterior of the body through the patent distal end of the tube by way of the uterus and vagina. The ovum must enter through the open end of a tube if fertilization is to occur in the ampullary portion, where sperm have collected by migrating “upstream” against the current. This opening is of considerable clinical importance as blood, ascending infections, or pus can pass out of the tube to invade the abdominal cavity, with resultant pain, endometriosis, or pelvic infection.
The epithelial lining of the tube has been studied extensively by light and electron microscopy. On light microscopic examination, four types of cells can be readily seen. Secretory cells or nonciliated cells have a heavily granular cytoplasm and an oval nucleus. The ciliated cells have fine granular cytoplasms and are relatively square with large round nuclei. The intercalary or “placed-between” cells are long narrow cells with dark nuclei causing them to be called “peg cells.” The fourth type of cells are the small “indifferent” cells with large dark nuclei.
Pauerstein4 has reviewed and summarized the numerous studies on tubal ultrastructure. Two basic cell types have been described, ciliated and secretory. The ciliated cells have a clear cytoplasm with vesicular reticulum. Microvilli are seen extending from the luminal edge of the cell. The cilia themselves have two central filaments and nine double, lateral filaments. Secretory cells have a dark cytoplasm with fine granules. Darker secretory granules are prominent, with irregularly distributed endoplasmic reticulum. The tubal epithelium is responsive to the estrogen and progesterone levels during the menstrual cycle, pregnancy, and the menopause. The proliferative phase is characterized by elevated epithelium with ciliated and secretory cells of equal height. The luteal phase shows lower ciliated cells with higher and more prominent cytoplasm, sometimes with rupture and extrusion of the cytoplasm into the lumen. During menstruation and post-menstruation, cells are lower and smaller. During pregnancy, tubal epithelium remains low. There is considerable variation in postmenopausal changes in the tubal epithelium. Apparently significant secretory activity ceases, but the onset of atrophy is variable and deciliation may not occur until years after the menopause.
The principal blood supply of the tube is from the upper end of the uterine artery, which bifurcates and sends a large branch or ramus below the tube to anastomose with the ovarian artery. The proximal two-thirds of the tube is chiefly supplied by the uterine artery. The arterial supply is quite variable and there may be three branches (medial, intermediate, and lateral) or a branch from the uterine and another from the ovarian artery. Anastomoses between uterine and ovarian arteries in the mesosalpinx are variable but always present.
The venous system accompanies the arterial distribution. Capillary networks are to be found in subserosal, muscularis, and mucosal layers. The arrangement varies in different portions of the tube, but the venous plexuses become confluent in the subserosal layer. The lymphatic drainage runs along the upper edge of the broad ligament to the lymphatic network below the hilus of the ovary. From here the flow from uterus, tube, and ovary drains to the para-aortic or lumbar nodes.
The tube is provided with both sympathetic and parasympathetic innervation. Sympathetic fibers from T10 through L2 reach the inferior mesenteric plexus. Postganglionic fibers then pass to the oviduct. The fibers from the inferior mesenteric plexus pass to the cervicovaginal plexus, which in turn sends fibers to the isthmus and part of the ampulla. Some sympathetic fibers from T10 and T11 reach the celiac plexus and provide postganglionic fibers to the ovarian plexus, which supplies the distal ampulla and fimbriae. The parasympathetic supply is by vagal fibers from the ovarian plexus supplying the distal portion of the tube. Part of the isthmus receives its parasympathetic supply from S2, S3, and S4 via the pelvic nerve and the pelvic plexuses. The sympathetic innervation of the female pelvis is depicted in Fig. 12.
Fig. 12. Diagram of the sympathetic connections in the female pelvis, viewed from the front and above.
In the early embryo, differentiation of gonadal tissue occurs anterior to the mesonephros and along the entire medial aspect of the urogenital ridge. The cranial portions of the gonadal ridge degenerate, leaving an indifferent genital gland near the mesonephros. Primitive germ cells originate in the epithelial lining of the dorsal part of the hindgut. They migrate to the gonad and are seen as radial strands extending into the mesenchymal tissue. The migrating cells consist of primordial egg cells and prospective granulosa cells (Fig. 13).
Fig. 13. Photomicrograph (low power) of the cortex of the ovary of a human infant. The cortex of the ovary has numerous primordial germ cells with relatively little stroma. The ovarian stroma is more abundant in the medulla, where the larger follicles are seen.
The glistening white ovaries are generally oval in shape but may vary in size, position, and appearance, depending on the age and the reproductive activities of the individual. The ovaries of a normal adult woman are 2.5–5 cm long, 1.5–3 cm thick, and 0.7–1.5 cm wide, with a weight of 3–8 g.2 The ovaries contain 1–2 million oocytes at birth. A woman will release up to 300 ova, on average, during her lifetime. Histologically the ovary is divided into the outer cortex and the inner medulla. The cortex consists of a cellular connective tissue stroma in which the ovarian follicles are embedded. The medulla is composed of loose connective tissue which contains blood vessels and nerves. The cortex is surrounded by a single layer of cuboidal epithelium called the germinal epithelium.5 Figure 14 shows a photomicrograph of a normal adult ovary.
Fig. 14. Low magnification view of the pre-ovulation human ovary. The germinal epithelium of the ovary rests upon the ovarian stroma. The primordial germ cells embedded in the stroma are in the cortex of the ovary.
In the nullipara, the ovary typically lies in the ovarian fossa, a depression in the pelvic wall below the external iliac vessels and in front of the ureter. A mesovarium attaches the ovary to the posterior wall of the broad ligament, while the posterior margin is free. The peritoneum does not cover the ovary proper, which is covered by germinal epithelium.
At either end the ovary is supported by ligaments. At the tubal pole the ovary is attached to the suspensory ligament, a fold of peritoneum which forms a mesentery for the ovary and contains the ovarian vessels. This suspensory ligament is often called the infundibulopelvic ligament. At the other pole is the uteroovarian ligament.
The hilus is the base of the ovary; at this point the ovarian blood vessels enter. The ovarian arteries arise from the abdominal aorta just below the renal arteries. They pass downward across the pelvic brim, cross the external iliac artery, and traverse the infundibulopelvic fold of peritoneum. Branches go to the ureter, round ligament, and tube and anastomose with the uterine artery.
As the ovarian artery passes through the mesovarium, it separates into multiple branches that enter the ovarian hilus. Each of these arteries divides into two medullary branches which cross the ovary. Cortical branches arise from the medullary branches and supply the cortex and follicles. Two prominent veins enter the hilus and, in general, follow the arterial pattern.
At the hilus venous drainage forms a pampiniform plexus, which consolidates to form the ovarian vein. On the right side the ovarian vein drains into the inferior vena cava, while the left ovarian vein drains into the left renal vein. The ovarian as well as the uterine blood supply frequently is anomalous.
The nerve supply derives from a sympathetic plexus accompanying the vessels of the infundibulopelvic ligaments.6 The plexus arises at the level of the tenth thoracic segment, but fibers from renal and aortic plexuses as well as from the mesenteric and celiac ganglia are present.
Hilus cells, which are nonencapsulated nests of large vacuolated cells, frequently are found in the hilus of the ovary. These cells are similar to the interstitial or Leydig cells of the testis.
Any discussion of the ovary should include those portions of the mesonephric (wolffian) tubules and duct that persist in the adult female as vestigial structures between the peritoneal layers of the broad ligament. The epoophoron lies in the mesosalpinx between the tube and the ovary. It usually consists of 8–20 small tubules which join a common duct at right angles. Ordinarily the longitudinal duct has blind ends, but it may be prolonged as Gartner’s duct. Mesonephric duct vestiges known as Gartner’s duct cysts may be found alongside the uterus, cervix, or vagina. Vestiges of the mesonephric tubules also may be present as clear pedunculated cysts below the fimbria of the tube.
Medial to the epoophoron lies the paroophoron, a rudimentary organ with a few scattered tubules. It likewise is of mesonephric origin. These mesonephric vestiges are of clinical importance, since they occasionally give rise to cysts which require surgical excision.
In the female embryo, primitive germ cells migrate from the epithelial lining of the hindgut and invade the subjacent layer of mesenchyma in the sexually undifferentiated gonad. These cells form radial cords and consist of primordial egg cells and cellular masses of prospective granulosa cells. As the fetus develops, the germinal cords become segregated into islands, each containing several germinal cells. At birth the full-term infant already has developing and degenerating follicles.
A primordial follicle consists of an oocyte with a layer of follicular cells surrounding it. When such a follicle is to undergo ovulation, marked changes occur in the egg and its follicular cells (Fig. 15). The ovum reaches its mature size as the antrum appears in the follicle. Concurrent with the growth of the oocyte, the granulosa cells proliferate and a multi-layered structure develops. An outer connective tissue sheath derived from the ovarian stroma is formed. This sheath is called the theca and subsequently divides into the theca externa and theca interna.
Fig. 15. Life history of the ovarian follicle. Approximately 1 of 300 follicles fully matures (as shown on lower line), ruptures, and becomes a corpus luteum. The other 299 become atretic. The final stage of both the atretic follicle and the corpus luteum is the corpus atreticum, with eventual reabsorption of this scar into the stroma of the ovary.
At first the developing follicle sinks deeper into the cortex, but as it increases in size it again returns to the surface. A theca cone develops, its axis pointing to the surface. At the same time the zona pellucida, a clear zone around the ovum, forms. An antrum or cell-free area containing follicular fluid develops. Surrounding the oocyte is a cluster of granulosa cells resembling a small mound, upon which the oocyte rests; this is called the cumulus oophorus (Fig. 16). As ovulation approaches, the follicle bulges and the wall thins. The basic mechanism which precipitates ovulation has not been determined; it is obviously hormone related.
Fig. 16. Graafian follicle of the human ovary. The eccentric location of the primordial germ cell is seen in the graafian follicle.
Following rupture of the follicle and extrusion of the ovum, bleeding occurs at the rupture site and a blood clot forms. This is called the corpus hemorrhagicum. Granulosa cells grow into this clot, and the resulting mass of cells is known as the corpus luteum (Fig. 17).
Fig. 17. Photomicrograph (low power) of the corpus luteum of the human ovary. The developing corpus luteum with the central hemmorrhagic area is contiguous to a graafian follicle.
Female Reproductive System: Structure & Function
How does the female reproductive system work?
The female reproductive system provides several functions. The ovaries produce the egg cells, called the ova or oocytes. The oocytes are then transported to the fallopian tube where fertilization by a sperm may occur. The fertilized egg then moves to the uterus, where the uterine lining has thickened in response to the normal hormones of the reproductive cycle. Once in the uterus, the fertilized egg can implant into thickened uterine lining and continue to develop. If implantation does not take place, the uterine lining is shed as menstrual flow. In addition, the female reproductive system produces female sex hormones that maintain the reproductive cycle.
During menopause, the female reproductive system gradually stops making the female hormones necessary for the reproductive cycle to work. At this point, menstrual cycles can become irregular and eventually stop. One year after menstrual cycles stop, the woman is considered to be menopausal.
What parts make-up the female anatomy?
The female reproductive anatomy includes both external and internal structures.
The function of the external female reproductive structures (the genital) is twofold: To enable sperm to enter the body and to protect the internal genital organs from infectious organisms.
The main external structures of the female reproductive system include:
- Labia majora: The labia majora (“large lips”) enclose and protect the other external reproductive organs. During puberty, hair growth occurs on the skin of the labia majora, which also contain sweat and oil-secreting glands.
- Labia minora: The labia minora (“small lips”) can have a variety of sizes and shapes. They lie just inside the labia majora, and surround the openings to the vagina (the canal that joins the lower part of the uterus to the outside of the body) and urethra (the tube that carries urine from the bladder to the outside of the body). This skin is very delicate and can become easily irritated and swollen.
- Bartholin’s glands: These glands are located next to the vaginal opening on each side and produce a fluid (mucus) secretion.
- Clitoris: The two labia minora meet at the clitoris, a small, sensitive protrusion that is comparable to the penis in males. The clitoris is covered by a fold of skin, called the prepuce, which is similar to the foreskin at the end of the penis. Like the penis, the clitoris is very sensitive to stimulation and can become erect.
The internal reproductive organs include:
- Vagina: The vagina is a canal that joins the cervix (the lower part of uterus) to the outside of the body. It also is known as the birth canal.
- Uterus (womb): The uterus is a hollow, pear-shaped organ that is the home to a developing fetus. The uterus is divided into two parts: the cervix, which is the lower part that opens into the vagina, and the main body of the uterus, called the corpus. The corpus can easily expand to hold a developing baby. A canal through the cervix allows sperm to enter and menstrual blood to exit.
- Ovaries: The ovaries are small, oval-shaped glands that are located on either side of the uterus. The ovaries produce eggs and hormones.
- Fallopian tubes: These are narrow tubes that are attached to the upper part of the uterus and serve as pathways for the ova (egg cells) to travel from the ovaries to the uterus. Fertilization of an egg by a sperm normally occurs in the fallopian tubes. The fertilized egg then moves to the uterus, where it implants to the uterine lining.
What happens during the menstrual cycle?
Females of reproductive age (beginning anywhere from 11 to 16 years of age) experience cycles of hormonal activity that repeat at about one-month intervals. Menstru means “monthly” – leading to the term menstrual cycle. With every cycle, a woman’s body prepares for a potential pregnancy, whether or not that is the woman’s intention. The term menstruation refers to the periodic shedding of the uterine lining. Many women call the days that they notice vaginal bleeding their “period,” “menstrual” or cycle.
The average menstrual cycle takes about 28 days and occurs in phases. These phases include:
- The follicular phase (development of the egg)
- The ovulatory phase (release of the egg)
- The luteal phase (hormone levels decrease if the egg does not implant)
There are four major hormones (chemicals that stimulate or regulate the activity of cells or organs) involved in the menstrual cycle. These hormones include:
- Follicle-stimulating hormone
- Luteinizing hormone
This phase starts on the first day of your period. During the follicular phase of the menstrual cycle, the following events occur:
- Two hormones, follicle stimulating hormone (FSH) and luteinizing hormone (LH) are released from the brain and travel in the blood to the ovaries.
- The hormones stimulate the growth of about 15 to 20 eggs in the ovaries, each in its own “shell,” called a follicle.
- These hormones (FSH and LH) also trigger an increase in the production of the female hormone estrogen.
- As estrogen levels rise, like a switch, it turns off the production of follicle-stimulating hormone. This careful balance of hormones allows the body to limit the number of follicles that will prepare eggs to be released.
- As the follicular phase progresses, one follicle in one ovary becomes dominant and continues to mature. This dominant follicle suppresses all of the other follicles in the group. As a result, they stop growing and die. The dominant follicle continues to produce estrogen.
The ovulatory phase (ovulation) usually starts about 14 days after the follicular phase started, but this can vary. The ovulatory phase falls between the follicular phase and luteal phase. Most women will have a menstrual period 10 to 16 days after ovulation. During this phase, the following events occur:
- The rise in estrogen from the dominant follicle triggers a surge in the amount of luteinizing hormone that is produced by the brain.
- This causes the dominant follicle to release its egg from the ovary.
- As the egg is released (a process called ovulation) it is captured by finger-like projections on the end of the fallopian tubes (fimbriae). The fimbriae sweep the egg into the tube.
- For one to five days prior to ovulation, many women will notice an increase in egg white cervical mucus. This mucus is the vaginal discharge that helps to capture and nourish sperm on its way to meet the egg for fertilization.
The luteal phase begins right after ovulation and involves the following processes:
- Once it releases its egg, the empty ovarian follicle develops into a new structure called the corpus luteum.
- The corpus luteum secretes the hormones estrogen and progesterone. Progesterone prepares the uterus for a fertilized egg to implant.
- If intercourse has taken place and a man’s sperm has fertilized the egg (a process called conception), the fertilized egg (embryo) will travel through the fallopian tube to implant in the uterus. The woman is now considered pregnant.
- If the egg is not fertilized, it passes through the uterus. Not needed to support a pregnancy, the lining of the uterus breaks down and sheds, and the next menstrual period begins.
How many eggs does a woman have?
During fetal life, there are about 6 million to 7 million eggs. From this time, no new eggs are produced. At birth, there are approximately 1 million eggs; and by the time of puberty, only about 300,000 remain. Of these, only 300 to 400 will be ovulated during a woman’s reproductive lifetime. Fertility can drop as a woman ages due to decreasing number and quality of the remaining eggs.
Endometriosis: What is Endometriosis? Endometriosis Symptoms, Treatment, Diagnosis
Endometriosis: Symptoms, Treatment, Diagnosis
Affiliated: Endometriosis Frequently Asked Questions | Fertility | Gynecology
Endometriosis Overview: What is Endometriosis?
Endometriosis is a disease in which the endometrium (the tissue that lines the inside of the uterus or womb) is present outside of the uterus. Endometriosis most commonly occurs in the lower abdomen or pelvis, but it can appear anywhere in the body. Symptoms of endometriosis include lower abdominal pain, pain with menstrual periods, pain with sexual intercourse, and difficulty getting pregnant. On the other hand, some women with endometriosis may not have any symptoms at all.
Approximately 10% of reproductive-aged women have endometriosis. However, the true prevalence is unknown since the diagnosis requires laparoscopy (a surgery where a doctor looks in the abdomen with a camera through the belly button) to visualize and biopsy endometriosis lesions. Endometriosis is seen in 12-32% of women having surgery for pelvic pain, and in up to 50% of women having surgery for infertility. Endometriosis is rarely found in girls before they start their period, but it is seen in up to half of young girls and teens with pelvic pain and painful periods.
What Happens When You Have Endometriosis?
Causes of Endometriosis
The exact cause of endometriosis is unknown, but there are several theories that explain how and why endometriosis happens. Retrograde menstruation is one popular theory of its origin in which blood and tissue from a woman’s uterus travel through the fallopian tubes into the abdominal cavity during her period. Nearly all women have some degree of retrograde menstruation, but only a few women will get endometriosis. This may be due to differences in a woman’s immune system.
Another theory of endometriosis origin is called coelomic metaplasia, in which cells in the body outside of the uterus can undergo changes to become cells that line the uterus. This is a common explanation for endometriosis at unusual sites like the thumb or knee. Another possible explanation for endometriosis in locations far from the uterus is that cells from the lining of the uterus travel through blood vessels or the lymphatic system, thereby reaching other distant organs or body areas.
Endometriosis can also spread at the time of surgery. For example, a woman with endometriosis that undergoes a cesarean section could inadvertently have endometriosis implant in the abdominal incision so that she develops endometriosis in the scar from the surgery.
Endometriosis is much more common if a close relative also has the disease, so there may also be genes that influence endometriosis.
Why is Endometriosis Associated with Pain?
When a woman with endometriosis has her period, she has bleeding from both the cells and tissue inside the uterus, and also from the cells and tissue outside the uterus. When blood touches these other organs inside the abdomen, it can cause inflammation and irritation, creating pain. Scar tissue can also develop from the endometriosis and contribute to the pain.
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Why is Endometriosis Associated with Infertility?
Endometriosis and Fertility
Between 20 and 40% of women with infertility will have endometriosis. Endometriosis likely impairs fertility in two ways: first, by causing distortion of the fallopian tubes so that they are unable to pick up the egg after ovulation, and second, by creating inflammation that can adversely affect the function of the ovary, egg, fallopian tubes or uterus.
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How Endometriosis impacts fertility >
Symptoms of Endometriosis
Pain is the most common symptom of endometriosis. Women with endometriosis can experience pelvic or lower abdominal pain, pain with menses (dysmenorrhea), pain with intercourse (dyspareunia) and pain during bowel movements (dyschezia). Symptoms can be constant or “cyclical,” meaning that they worsen before and during the period, and then improve. Women may have constant pelvic or lower abdominal pain as well. Other symptoms include infertility, bowel and bladder symptoms (bloating, constipation, blood in the urine, or pain with urination), and possibly abnormal vaginal bleeding.
How is Endometriosis Diagnosed?
Some physicians may treat suspected endometriosis based on a woman’s symptoms or physical examination findings to see if they improve without proceeding to surgery. However, to formally diagnose endometriosis, a doctor must perform laparoscopy (surgery in which a doctor looks in the abdomen with a camera through the belly button) to visualize and biopsy suspected endometriosis lesions. Endometriosis lesions can vary in appearance. “Endometrioma” is the term for endometriosis within an ovary, and is often nicknamed “chocolate cyst” because the material inside the cyst looks like chocolate syrup.
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How is Endometriosis Treated?
The most conservative therapy for endometriosis is with medications. Non-steroidal anti-inflammatory medications, like ibuprofen, may help with the pain associated with endometriosis. Medications that control a woman’s hormones may also help with endometriosis pain. Some examples are oral contraceptive pills and gonadotropin releasing hormone (GnRH) agonists, the latter of which put women into a “temporary” menopause-like state.
Surgery can diagnose endometriosis, and it can also treat endometriosis via removal (excision) or burning (fulguration) of endometriosis lesions. With surgery, removal of scar tissue can alleviate pain and relocate the ovaries and fallopian tubes to their normal position in the pelvis. Surgery has been shown to help some women with endometriosis to become pregnant. If a woman with endometriosis is no longer interested in becoming pregnant, she and her doctor may decide to remove the ovaries and possibly the uterus. A woman cannot become pregnant if she does not have a uterus.
If a woman with endometriosis is having trouble getting pregnant, there are different medications and treatments available that can help her to become pregnant.
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Uterine Cancer: Introduction | Cancer.Net
ON THIS PAGE: You will find some basic information about this disease and the parts of the body it may affect. This is the first page of Cancer.Net’s Guide to Uterine Cancer. Use the menu to see other pages. Think of that menu as a roadmap for this complete guide.
About the uterus
The pear-shaped uterus is hollow and located in a woman’s pelvis between the bladder and rectum. The uterus is also called the womb. It is where a baby grows when a woman is pregnant. The uterus has 3 sections:
The cervix, which is the narrow lower section
The isthmus, which is the broad section in the middle
The fundus, which is the dome-shaped top section.
The uterus is made up of 3 layers: the endometrium (inner layer), the myometrium (the thickest layer composed almost entirely of muscle), and the serosa (the thin outer lining of the uterus).
During a woman’s childbearing years, her ovaries typically release an egg every month, and the endometrium grows and thickens in preparation for pregnancy. If the woman does not get pregnant, this endometrial lining passes out of her body through her vagina, a process known as menstruation. This process continues until menopause, when a woman’s ovaries stop releasing eggs.
About uterine cancer
Uterine cancer is the most common cancer occurring within a woman’s reproductive system. Uterine cancer begins when healthy cells in the uterus change and grow out of control, forming a mass called a tumor. A tumor can be cancerous or benign. A cancerous tumor is malignant, meaning it can grow and spread to other parts of the body. A benign tumor can grow but generally will not spread to other body parts.
Noncancerous conditions of the uterus include:
Fibroids: Benign tumors in the muscle of the uterus
Benign polyps: Abnormal growths in the lining of the uterus
Endometriosis: A condition in which endometrial tissue, which usually lines the inside of the uterus, is found on the outside of the uterus or other organs
Endometrial hyperplasia: A condition in which there is an increased number of cells and glandular structures in the uterine lining. Endometrial hyperplasia can have either normal or atypical cells and simple or complex glandular structures. The risk for developing cancer in the lining of the uterus is higher when endometrial hyperplasia has atypical cells and complex glands.
There are 2 major types of uterine cancer:
Adenocarcinoma. This type makes up more than 80% of uterine cancers. It develops from cells in the endometrium. This cancer is commonly called endometrial cancer. One common endometrial adenocarcinoma subtype is called endometrioid carcinoma. Treatment for this type of cancer varies depending on the grade of the tumor, how far it goes into the uterus, and the stage or extent of the disease (see Stages and Grades). Less common subtypes of uterine adenocarcinomas include serous, clear cell, and carcinosarcoma. Carcinosarcoma is a mixture of adenocarcinoma and sarcoma (see below).
Sarcoma. This type of uterine cancer develops in the supporting tissues of the uterine glands or in the myometrium, which is the uterine muscle. Sarcoma accounts for about 2% to 4% of uterine cancers. Subtypes of endometrial sarcoma include leiomyosarcoma, endometrial stromal sarcoma, and undifferentiated sarcoma. Learn more about sarcoma.
Cancer confined to the uterine cervix is treated differently from uterine cancer. Learn more about cervical cancer in a separate guide on this website. The rest of this section covers the more common endometrial (adenocarcinoma) cancer.
About genetics and family history of uterine cancer
A higher risk for uterine cancers can be inherited, meaning it is passed from generation to generation, or may skip a generation to appear in the next. This happens about 5% of the time. The syndrome most commonly associated with inherited uterine cancer is called Lynch syndrome. Lynch syndrome is also associated with several other types of cancer, including types of colon, kidney, bladder, and ovarian cancers.
When cells divide and multiply, DNA errors can occur. There are 6 proteins in the body that fix these errors. If 1 of these proteins does not work properly, errors in the DNA can accumulate and yield enough DNA damage that cancer may develop. This problem with DNA repair is called mismatch repair defect (dMMR). The main sign of Lynch syndrome is dMMR.
Cancer can be tested for Lynch syndrome through a special staining process called immunohistochemistry (IHC). Most cases of Lynch syndrome are due to deficiencies in 1 of 4 DNA repair proteins. Only these 4 proteins are routinely tested by IHC. If IHC shows that your cancer lacks 1 of these DNA repair proteins or if you have a family history of a cancer associated with Lynch syndrome, discuss this with your doctor and/or talk with a genetic counselor. However, IHC is a screening test, and further genetic tests are needed to confirm a diagnosis of Lynch syndrome. Not all people who have a tumor which lacks 1 or more of these DNA repair proteins has Lynch syndrome. The changes can also be due to a process called DNA methylation, which typically silences 1 of the more common dMMR genes in the tumor.
Family members may wish to be tested, too. People affected by Lynch syndrome should tell their doctors so they can receive increased screening for Lynch-associated cancers, such as more frequent colonoscopies. Other family members may consider preventive surgery for uterine and ovarian cancers.
If you have uterine cancer, ask your doctor if the cancer can be tested for Lynch syndrome and other possible inherited conditions. Learn more about Lynch syndrome in another section on this website.
Looking for More of an Introduction?
If you would like more of an introduction, explore this related item. Please note that this link will take you to another section on Cancer.Net:
The next section in this guide is Statistics. It helps explain the number of people who are diagnosed with uterine cancer and general survival rates. Use the menu to choose a different section to read in this guide.
Endometriosis Treatment | TS Clinic – Krasnodar
Endometriosis is the proliferation of endometrioid tissue beyond its normal localization. Normally, it is located only in the body of the uterus and forms its mucous layer, but with pathology, the endometrium spreads to other organs, which leads to the appearance of specific symptoms.
About 10% of the female population suffers from endometriosis, but only half of the patients seek medical help in a timely manner. Unfortunately, some women visit a doctor only when they discover the most formidable consequence – infertility.At the same time, timely diagnosis and complex treatment allow you to control the course of the disease and achieve remission.
Causes and development mechanism
The cause of endometriosis remains unknown. In medicine, there are several theories of the development of the disease and many predisposing factors. Among them are noted:
· Embryonic – endometriosis is a consequence of the displacement of the embryonic tissue, which is then transformed into endometrioid.
· Implantation – the cells of the endometrium of the uterus with menstrual blood are thrown into the fallopian tubes and abdominal cavity. In addition, it is assumed that this is possible after operations on the female genital organs.
· Metaplastic – the ability of the peritoneum (connective tissue covering organs and the abdominal wall) to transform into endometrioid tissue.
Among the risk factors, particular importance is attached to hormonal disorders, immunodeficiency states and genetic predisposition.In addition, there are also the so-called protection factors that prevent the development of the disease. These include multiple pregnancies, prolonged breastfeeding, good physical activity, and late onset of the first menses.
Regardless of the theory of occurrence, the very mechanism of development and progression of the disease is the same. When endometrioid cells enter a new place, they begin to grow there and function in the same way as the endometrium of the uterus. The endometrioid tissue is sensitive to the effects of sex hormones, therefore, in response to physiological hormonal fluctuations, the processes of proliferation and rejection begin in it.Clinically, this is manifested by bleeding and an increase in the volume of the affected organ, deformation of its anatomical structure and disruption of normal function.
There are several classifications of endometriosis, assessing the origin, depth of the lesion, localization and other characteristics of the pathological process. In clinical practice, an anatomical classification is used, dividing endometriosis into genital and extragenital.The genital form is characterized by the proliferation of endometrioid tissue within the external or internal genital organs. The extragenital type of the disease is characterized by damage to other organs: intestines, lung tissue, brain, postoperative scars.
The genital form has several subtypes:
- Internal endometriosis – involvement in the process of only the body of the uterus, its isthmus and the interstitial part of the fallopian tube (the part of the tube that fits the body of the uterus)
- External endometriosis – damage to the uterine appendages, peritoneum around the pelvic organs, the posterior space, the cervix and the vagina.
Some forms of genital endometriosis (body of the uterus, ovaries, posterior space) have been assigned their own classification according to the stages and extent of the process.
The main symptom of the disease is pain syndrome. Its intensity depends on the phase of the menstrual cycle – it intensifies a few days before menstruation and becomes most pronounced during the period of menstrual bleeding.The pain has a pulling or aching character, is localized in the suprapubic region and can radiate to the lumbosacral region or perineum.
The clinical picture largely depends on the prevalence of the process. In the case of deep endometriosis with the involvement of the posterior space, there is severe soreness radiating to the perineum or rectum, the inner surface of the thigh. The pain intensifies while sitting, straining during bowel movements, lifting weights or engaging in heavy sports.
With the proliferation of endometrioid tissue in the genitourinary tract, dysuria is observed – painful urination, sometimes there is an admixture of blood in the urine. With endometriosis of the rectum, an admixture of blood is in the feces, which creates a false opinion in the patient about the presence of hemorrhoids or an anal fissure.
Pain syndrome is often localized in the lumbosacral spine. Often such patients are treated for a long time for vertebral lumboischialgia (pain in the lower back, radiating to the leg), but the therapy does not bring the desired effect.With endometriosis, dyspareunia is also observed – pain during and after intercourse.
An important characteristic of pain syndrome in endometriosis is its persistence – unlike a number of gynecological diseases, it does not go away for a long time. In relation to endometriosis, the term “chronic pelvic pain” is used – pain in the lower abdomen, perineum and lumbar region, which does not go away for more than six months.
Chronic pain in the pelvis causes asthenic syndrome.Constant soreness affects the patient’s quality of life: performance decreases, apathy and depressive mood appear, the ability to memorize new information or retain familiar information decreases, sleep is disturbed, irritability and tearfulness appear. Sexual activity and the quality of sexual life are significantly reduced due to the fear of pain and decreased libido.
A woman begins to constantly concentrate on the existing pelvic pains, is in a constant and painful expectation of their intensification, which leads to complete social maladjustment, changes in family and interpersonal relationships.
Another sign of endometriosis is bloody or bloody discharge from the genital tract. They appear between menstrual periods and range from scanty to profuse.
Heavy menstrual bleeding may also indicate endometriosis. They are more typical for endometriosis of the uterine body, but can also occur in other forms. Against the background of prolonged and heavy menstrual bleeding, secondary anemia often develops with typical symptoms: pallor of the skin, dizziness, general weakness, shortness of breath, exercise intolerance.
The most common reason for seeking medical help is infertility. The inability to conceive can be associated with two reasons:
- Anatomical deformation of the uterine appendages – thickening and narrowing of the lumen of the fallopian tubes against the background of an inflammatory process or adhesive disease, complete isolation of the ovaries with expanding adhesions, a decrease in the number of healthy eggs (ovarian reserve) from – for the growth of endometrioid cysts.
- The presence of pathologies often accompanying endometriosis – endocrine disorders, cysts and uterine fibroids, hyperplastic processes in the endometrium.
In case of fertilization and the beginning of embryo development, endometriosis has a negative impact on all stages of embryogenesis, which leads to early miscarriages and miscarriage.
The first stage of diagnosis – collection of anamnesis and patient complaints, obstetric and gynecological data. After the conversation, the doctor conducts a two-handed gynecological examination, which allows one to suspect endometriosis.The doctor determines the enlarged uterus, painful to palpation (feeling) before and during menstruation. During a gynecological examination, an oncocytological smear and smears for microflora are required. This makes it possible to exclude oncological processes in the cervix, assess the state of the vaginal environment and identify a number of infectious pathogens.
Ultrasound examination using a transvaginal probe is a mandatory diagnostic step. The ultrasound signs of endometriosis include an increase in the size of the uterus, the appearance of many cystic cavities in the muscle layer (myometrium).
Hysterosalpingography – an instrumental diagnostic method with the introduction of contrast agents into the uterine cavity and subsequent X-ray examination. Usually, hysterosalpingography is done 5-7 days after your period. Signs of endometriosis include enlargement of the uterine cavity, “erosion” and unevenness of the internal contours, leakage of contrast into the thin endometrioid passages.
The most informative diagnostic method is colposcopy and hysteroscopy – examination of the cervix and uterine cavity using imaging devices.When viewed in the uterine cavity, areas of bulging of the walls of the uterus, dark blue blotches or bleeding endometrioid passages are determined. During the examination, the doctor may take a biopsy for further histological examination.
In addition to instrumental studies, the doctor prescribes a number of tests to assess the general condition of the patient and identify endocrine disorders:
- General blood and urine tests
- Biochemical blood test
- Study of the hormonal profile (thyroid gland, sex hormones).
In some situations, an MRI examination of the pelvic organs and a diagnostic operation – laparoscopy – are performed.
Treatment of endometriosis is surgical and conservative. Surgical intervention involves the removal of endometrioid tissue while preserving the organ. For example, in the case of endometriosis of the ovary, its resection is performed – excision of the affected area, and in case of endometriosis of the cervix, conization is performed – removal of the tapered section of the cervix.
The question of removing a whole organ is considered only in case of extensive damage and the impossibility of treatment with other methods.
Drug treatment of the disease involves the appointment of agents that inhibit the endocrine function of the ovaries. For this purpose, appoint:
- Combined oral contraceptives containing estrogenic and gestagenic components
- Progestational agents
- Gonadotropin antagonists
- Analogues of gonadotropic releasing hormone
The choice of a specific drug and the duration of the course of treatment is determined only by the attending physician. In this case, the doctor takes into account the clinical symptoms, the prevalence of the process and the data of the study. The course of therapy takes place under the strict supervision of a physician. As part of the complex treatment, non-steroidal anti-inflammatory drugs, immunomodulators, hepatoprotectors, sedatives are also used.
Currently, the combined approach is considered the most effective and justified.It involves a course of drug therapy for several months, then the question of surgical treatment is considered. At the same time, while taking medications, the foci of endometriosis decrease, and the operation becomes less traumatic. In the postoperative period, a course of hormonal therapy is again prescribed to prevent the proliferation of endometrioid tissue.
treatment and symptoms, diagnosis of endometritis in Moscow, Clinical Hospital on Yauza
The article was checked by a doctor-obstetrician-gynecologist of the highest category Lisichkina E.G. is for general informational purposes only and does not replace specialist advice.
For recommendations on diagnosis and treatment, a doctor’s consultation is required.
- For the diagnosis and treatment of endometritis, the specialists of the Clinical Hospital on Yauza use both traditional safe methods (ultrasound, laboratory) and modern innovative techniques (aspiration biopsy of the endometrium, hysteroscopy).Hardware research is carried out on advanced high-precision equipment of recognized world leaders in the production of medical equipment.
- Our medical center employs obstetricians-gynecologists with extensive practical experience, which provides accurate differential diagnosis, allows us to develop a plan for the most effective treatment in compliance with medical protocols and taking into account the characteristics of the course of the disease of each patient. The treatment is carried out by methods of antibacterial, anti-inflammatory, hormonal therapy.
- With 100% accuracy, the method of endoscopic diagnostics (hysteroscopy) in combination with laboratory tests allows you to diagnose the disease
- Acute endometritis with timely access to the hospital gynecologist and the fulfillment of the prescriptions is completely curable without the development of complications
- In 90% of cases, early treatment of chronic endometritis completely restores the reproductive function of the uterus
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Causes of occurrence
Inflammation of the endometrium – the lining of the uterus – is called endometritis.The etiology of the disease can be both endogenous and exogenous. It can occur when the mucous membrane is infected and traumatized in the process:
- difficult labor, caesarean section;
- probing or curettage of the uterine cavity;
- examination of the uterus and fallopian tubes by the method of hysterosalpingography;
- endoscopic examination of the uterine cavity;
- long-term use of intrauterine contraceptives;
- at risk also includes women with frequent changes of sexual partners.
90,042 unprotected intercourse, especially during menstruation;
Endometritis can be the result of infectious diseases (tuberculosis, gonorrhea) or a weakened immune system. Often, postpartum endometritis, associated with a restructuring of the immune system of a pregnant woman, is autoimmune.
Distinguish between acute and chronic forms of the disease, each of which has its own etiology. Acute endometritis develops as a result of complicated childbirth, abortion, when using intrauterine contraception and usually makes itself felt within 3-4 days after the onset.
The sluggish form of chronic endometritis is most often associated with sexually transmitted infections. The disease can be caused by one pathogen or a group with a predominance of any kind. The most common causative agents of inflammation of the uterine mucosa are:
- Escherichia coli;
- diphtheria bacillus;
- tuberculous mycobacterium;
- viruses, protozoa.
Structural changes in the endometrium occur, and its normal functioning is disrupted. Changes in the lining of the uterus in chronic endometritis can be the cause of miscarriage or infertility.
Acute endometritis is characterized by rapid development with pronounced symptoms:
- pain in the lower abdomen;
- painful sensations when urinating;
- discharge with an unpleasant odor from the genital tract;
- fever, chills.
When the described symptoms appear, a timely appeal to the gynecologists of the Clinical Hospital on Yauza guarantees the cure of the acute form within 7-10 days. A gynecological examination reveals at this stage a painful moderately enlarged uterus, serous-purulent or sacral discharge.
The clinical picture of chronic endometritis depends on the duration of the inflammatory process and the depth of damage to the tissues of the uterine mucosa.The main symptoms of the chronic form of the disease:
- violation of the menstrual cycle;
- uterine bleeding;
- purulent and bloody discharge from the genital tract;
- painful sensations and heaviness in the lower abdomen, sacrum, perineum;
90,042 pain during intercourse;
The chronic form of the disease in the absence of treatment is dangerous with complications in the form of the appearance and growth of cysts and polyps, damage to the muscular layer of the uterus – myoendometritis, uterine leiomyoma, the development of endometrioid disease, the formation of purulent-inflammatory infectious foci in the pelvic organs, ectopic pregnancy, complications in carrying a fetus.
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Diagnosis of endometritis
Regular visits to the gynecologist at the Clinical Hospital on Yauza will ensure the detection of the disease at an early stage of development. If any symptoms of inflammation of the uterine mucosa appear, you should immediately consult a gynecologist. At the first consultation, the hospital’s obstetrician-gynecologist will take a history and conduct a physical examination.
Laboratory and apparatus examination
If endometritis is suspected, diagnostics may include the following instrumental and laboratory tests:
- Ultrasound of the uterus and appendages;
- hysteroscopy – a detailed examination of the uterine cavity using an endoscope with the possibility of carrying out therapeutic and diagnostic medical manipulations – taking a biopsy, removing a polyp, etc.;
- aspiration biopsy of the endometrium — taking endometrial samples for examination using a thin tube (“pipe”) inserted into the uterine cavity and negative pressure created in it by means of a piston;
- smears for flora, infections;
- blood test.
Instrumental examination is carried out on high-precision equipment of the best manufacturers of medical equipment in the world: ultrasound scanners Voluson S6 (General Electric Medical Systems, USA) and Accuvix A30 (Samsung Medison, Korea), mobile video system Tele Pack X Led (Karl Storz, Germany).
Treatment of endometritis at the Clinical Hospital on Yauza
In the department of gynecology and obstetrics of the hospital, the treatment of endometritis is carried out according to individual schemes for each patient. Etiotropic (aimed at eliminating the cause of the disease) pharmacotherapy, restorative and symptomatic agents, surgical intervention in the presence of intrauterine contraceptives or intrauterine adhesions are used.
Drug therapy includes antibacterial and anti-inflammatory drugs, the action of which is aimed at suppressing pathogenic microflora and arresting the inflammatory process.Hormone therapy is used in a number of cases to maintain and normalize the growth of the endometrium.
As a result of high-precision differential diagnostics and complex treatment, obstetricians-gynecologists of the hospital:
- restore the regenerative capacity of the endometrium;
- eliminate foci of chronic infectious and inflammatory processes;
- cure existing complications and prevent new ones;
- restore menstrual and reproductive function of the uterus.
The course of the treatment process is under the constant supervision of the attending physician, who, if necessary, corrects the appointment on the basis of control examinations and analyzes.
The best way to prevent endometrial inflammation is to take care of a woman about her own health: timely treatment of gynecological diseases, regular examinations by a gynecologist.
You can sign up for a consultation with the specialists of the Department of Gynecology and Obstetrics of the Clinical Hospital on Yauza through a special form on the website or by calling the phone number indicated on this page.
You can see prices for services in the price list or specify by phone, indicated on the website.
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Dyuzheva E.V. Principles of individual hormonal preparation of the endometrium in patients with ineffective IVF attempts // Obstetrics and gynecology.2011.
E.A. Kogan Molecular and morphological aspects of endometrial receptivity disorders in chronic endometritis // Archives of Pathology. 2012.
Implantation window | Useful from the clinic “Genom” in Kaliningrad
The transfer of the embryo to the uterus is the final stage of the IVF protocol. Now the embryo has to attach itself to the endometrium – the inner layer of the uterus.This process is called implantation. If it goes well, then pregnancy will occur. A prerequisite for successful implantation is the presence of a receptive endometrium and a high-quality blastocyst.
A blastocyst is an embryo that has reached 5-6 days of development. At this “age”, with natural conception, it enters the uterus from the fallopian tube. The blastocyst has the highest implantation potential.
The word receptivity means receptivity.The receptive endometrium is susceptible to embryo implantation and is able to receive it. The endometrium is considered optimal for implantation, the thickness of which is 9-11 mm, and the structure of the uterine mucosa is three-layered. Reproductologists call this endometrium “beautiful, lush”. In it, as in a perinka prepared by the uterus, the embryo is to penetrate.
The period of maximum receptivity of the endometrium is called the “implantation window”. The opening of the implantation window occurs in the natural menstrual cycle on the 6-10th day after ovulation, which corresponds to the 20-24th day of the menstrual cycle.It remains open for about 2 days.
The opening of the implantation window is accompanied by the appearance of pinopodia – these are smooth protrusions of the surface epithelial cells of the endometrium. Having reached their maximum size, they form folds, resembling flowers or mushrooms. The functions of the pinopodia are not fully understood, but it is assumed that it is they that contribute to the emergence of close contact between the blastocyst and the surface of the uterus.
If the process of pinopodia formation is disturbed, the “implantation window” may shift in time.If there are not enough pinopodia, the “implantation window” will be defective. All this can lead to a negative IVF result. The reasons for such phenomena can be hormonal imbalance, the infectious process of the genital area, surgical interventions.
The following stages of implantation are distinguished:
– orientation of the blastocyst in the uterine cavity relative to the site of future implantation,
– adhesion (sticking) on the surface of the endometrium
– invasion (introduction) into the uterine cavity
The process of embryo implantation (from the moment of its attachment to the uterine mucosa and until it is completely immersed in it) takes about 40 hours.During implantation, a biochemical “dialogue” occurs between the embryo and the endometrium. The blastocyst secretes substances that allow the uterus to “sense” its presence. By the quality of the biochemical impulses sent by the embryo, the endometrium determines its quality. A complete blastocyst should be morphologically normal and have the correct set of chromosomes. Such an embryo pinopodia begin to attract, in every possible way contributing to its implantation. If the blastocyst is genetically defective or with external defects, the endometrium can reject it.
During IVF, there is an opportunity to create ideal conditions for embryo implantation and the development of further successful pregnancy. So, in case of displacement of the implantation window, the embryos are frozen. This process is called cryopreservation. In the next cycle, the endometrium is artificially prepared for implantation using special preparations. When the mucous membrane is ready to accept the embryo, the transfer is carried out.
Cryopreservation allows preimplantation genetic testing of the embryo or PGT.The purpose of the method is to identify genetic abnormalities in the embryo prior to transfer to the uterus. Thanks to OGT, it became possible to transplant a blastocyst with a normal genetic makeup, which increases the chances of IVF success, a successful pregnancy and the birth of a healthy baby.
The impressive positive experience of reproductologists and embryologists “Genome” allows achieving high rates of pregnancy rates as a result of IVF protocols.
90,000 Uterine cancer or endometrial cancer
Uterine cancer, or endometrial cancer, is a malignant tumor that develops in the lining of the uterus.Without timely treatment, the formation grows into the muscular layer of the uterus and beyond into neighboring organs and can give distant metastases.
Causes of endometrial cancer:
Factors contributing to the development of uterine cancer:
- Lynch syndrome is a genetic syndrome that increases the risk of developing cancer of the uterus, ovaries and colon.
- Hormone therapy for breast cancer (tamoxifen).
- Taking hormones (estrogens) after menopause.
- Comorbidities: diabetes mellitus, hypertension, polycystic ovary syndrome.
- Absence of children.
If one or more of these symptoms occur, you should immediately consult a gynecologist or gynecological oncologist:
- Vaginal bleeding after menopause.
- Intermenstrual bleeding in young women.
- Foul-smelling vaginal discharge.
- Heavy and irregular periods after 40 years.
- Pelvic pain.
- Stage 1: the tumor is localized only in the body of the uterus, without leaving it.
- Stage 2: The tumor spreads to the cervix.
- Stage 3: the tumor passes into the pelvic cavity, lymph nodes in the small pelvis or vagina.
- Stage 4: The tumor extends beyond the pelvis.
Examination for suspected uterine cancer begins with an examination by a gynecologist or gynecological oncologist.
Biopsy, or endometrial aspiration (pipel biopsy) is performed on an outpatient basis at the reception of a gynecologist. During the procedure, the doctor receives endometrial tissue for further research in the laboratory and an accurate diagnosis. Another manipulation that helps to obtain biomaterial for laboratory analysis is curettage of the uterine cavity.
When examining women of postmenopausal age, the method of ultrasound is informative to determine the thickness of the endometrium (the inner layer of the uterus).In the presence of a thin inner layer of the uterus (less than 4 mm), the likelihood of an oncological process is minimal, but its thickening does not always mean the development of uterine cancer.
Treatment of uterine cancer
Today, in our clinic, it is possible to use all modern methods of treating uterine cancer.
Removal of the uterus, cervix, ovaries and fallopian tubes (laparoscopic, abdominal surgery or with the latest generation robot) is necessary in almost all cases of tumor detection in elderly patients.A biopsy of the lymph nodes (pelvic and paraaortic) or their complete removal followed by analysis of the biomaterial in the laboratory is required in most cases. This allows you to accurately determine the stage of endometrial cancer for optimal planning of postoperative treatment, and also makes it possible to prescribe menopausal hormone replacement therapy for patients with severe menopause (under the supervision of an EMC gynecologist-endocrinologist).
Robotic treatment for uterine cancer has several advantages:
- minimal blood loss and tissue trauma and, as a result, minimal recovery period.
- safety: damage to thin nerve branches and fibers, as well as blood vessels, is excluded, all functions of the pelvic organs are preserved.
- The highest possible precision of the operation: on the robot, it is possible to carry out the most complex operations even in those areas that remain inaccessible to the surgeon’s hands.
If uterine cancer is detected in young patients (if the disease is detected at the initial stage), hormonal treatment with preservation of the uterus and ovaries is possible in complex therapy.This gives the patient a chance to give birth to her child in the future. The scheme of drug therapy of the initial stage of endometrial cancer with preservation of fertility in the EMC includes the use of an intrauterine hormonal device Mirena. The duration of treatment in most cases is 6 months. After recovery, the patient is managed by EMC reproductive specialists for the implementation of reproductive function.
In parallel, constant monitoring is carried out by a gynecological oncologist for the timely detection of a possible relapse of the disease.At EMC, it is possible to carry out repeated courses of hormonal treatment with preservation of fertility, however, after the implementation of reproductive function, it is recommended to remove the uterus. The question of preserving the ovaries at a young age is decided individually.
Young patients diagnosed with uterine cancer in EMC are offered additional examination to exclude Lynch syndrome.
Radiation therapy is sometimes required after surgery for uterine cancer. As a rule, in such cases, only internal radiation therapy (brachytherapy) or external selective radiation therapy (IMRT) is sufficient.
Chemotherapy in combination with radiation therapy is sometimes indicated in later stages and with certain histological forms. The choice of treatment tactics in such cases is taken at a specialized oncological council with the participation of gynecological oncologists, chemotherapists, radiologists, pathomorphologists, and radiation diagnostics specialists. At EMC, such a council is called the Tumor Board.
After the end of treatment, the patient is recommended to visit the gynecological oncologist every 3 months for 2 years, then every 6 months for 5 years, then once a year.At the EMC clinic, supervision is carried out by the oncogynecologist who performed the operation.
In case of recurrence of uterine cancer, radiation or chemotherapy is performed, in some cases – surgery.
Advantages of contacting EMC
- Doctors with experience in the best foreign clinics. Diagnostics and treatment according to European and American protocols.
- The EMC Clinic of Oncogynecology is headed by the only full member of the American Society of Gynecologists-Oncologists, certified Russian and American gynecological oncologist-surgeon Vladimir Nosov in Russia.
- Organization of Tumor Board meetings with the participation of gynecological oncologists, chemotherapists, radiologists and other specialists
- Organ-preserving treatment for benign, borderline and some malignant gynecological diseases.
- The fastest possible rehabilitation of patients after surgery.
How to decipher the results of ultrasound of the uterus?
Having received the results of the ultrasound, you may be interested in what exactly the doctor wrote. Let’s find out in more detail what the main terms that ultrasound specialists write in their conclusions mean.
Position of the uterus.
The body of the uterus is in a certain position in the pelvis. Normally, the body of the uterus is tilted anteriorly, and the fold between the body of the uterus and the cervix forms an angle. In the conclusion of the ultrasound, this situation can be described by two Latin words: “anteversio” and “anteflexio”.This is the usual (normal) position of the uterus. If in the conclusion of the ultrasound it is written that the body of the uterus is in the “retroversio” position, “retroflexio” this means that the uterus is deflected posteriorly and there is a posterior bend of the uterus. Bending of the uterus posteriorly can indicate some diseases, adhesions in the small pelvis, and sometimes can cause infertility.
Size of the uterus.
Ultrasound can determine 3 sizes of the uterus: transverse size, longitudinal size and anterior-posterior size. The longitudinal size (length of the uterus) is normally 45-50 mm (for women who have given birth up to 70 mm), the transverse size (width of the uterus) is 45-50 mm (for women who have given birth up to 60 mm), and the anteroposterior size (thickness of the uterus) normally 40-45 mm.Slight deviations in the size of the uterus are found in many women and do not indicate an illness. However, too large the size of the uterus can indicate uterine fibroids, adenomyosis, pregnancy.
The thickness of the inner layer of the uterus (endometrium) is determined by ultrasound using M-echo. The thickness of the endometrium depends on the day of the menstrual cycle: the fewer days are left until the next period, the thicker the endometrium. In the first half of the menstrual cycle, the M-echo ranges from 0.3 to 1.0 cm, in the second half of the cycle, the thickness of the endometrium continues to grow, reaching 1.8-2.1 cm a few days before the onset of menstruation.If you have already had menopause (menopause), then the thickness of the endometrium should not exceed 0.5 cm. If the thickness of the endometrium is too large, this may indicate endometrial hyperplasia. In this case, you need an additional examination in order to exclude uterine cancer.
The structure of the myometrium.
Myometrium is the muscular, thickest layer of the uterus. Normally, its structure should be uniform. The heterogeneous structure of the myometrium may indicate adenomyosis. But do not be afraid ahead of time, as to clarify the diagnosis, you will need an additional examination.
Uterine fibroids on ultrasound
Uterine fibroids is a benign tumor that almost never develops into uterine cancer. With the help of ultrasound, the gynecologist determines the location of the fibroid and its size.
For fibroids, the size of the uterus is indicated in weeks of pregnancy. This does not mean that you are pregnant, but that the size of your uterus is the same as the size of the uterus at a certain stage of pregnancy.
The size of uterine fibroids can be different on different days of the menstrual cycle.So, in the second half of the cycle (especially shortly before menstruation), myoma increases slightly. Therefore, an ultrasound scan for uterine fibroids is best done immediately after menstruation (on the 5-7th day of the menstrual cycle).
The location of uterine fibroids can be intramural (in the wall of the uterus), submucous (under the inner lining of the uterus) and subserous (under the outer lining of the uterus).
Endometriosis of the uterus (adenomyosis) on ultrasound
Endometriosis of the uterus, or adenomyosis, is a disease in which cells like endometrial cells invade the muscle layer.
In case of adenomyosis on ultrasound of the uterus, the doctor discovers that the myometrium (muscle layer of the uterus) has a heterogeneous structure with heterogeneous hypoechoic inclusions. Translated into Russian, this means that in the muscular layer of the uterus there are areas of the endometrium, which has formed bubbles (or cysts) in the myometrium. Very often, with adenomyosis, the uterus is enlarged.
Pregnancy on ultrasound
Ultrasound of the uterus during pregnancy is an extremely important stage of diagnosis. Here are just a few of the benefits of an ultrasound scan during pregnancy:
- Helps to determine the duration of pregnancy and the size of the fetus
- Helps to clarify the location of the fetus in the uterus
- Helps to identify an ectopic pregnancy
- Helps to monitor the development of the fetus and identify any abnormalities in time
- Helps to determine the sex of the child
- Used for screening the first trimester of pregnancy
- Used to perform amniocentesis
How to decipher the results of an ultrasound of the ovaries?
Ultrasound of the ovaries determines the size of the right and left ovary, as well as the presence of follicles and cysts in the ovary.The normal size of the ovaries is on average 30x25x15 mm. A deviation of a few millimeters is not a sign of illness, as one or both ovaries may enlarge slightly during the menstrual cycle.
Ovarian cyst on ultrasound
An ovarian cyst on ultrasound looks like a rounded bubble, the size of which can reach several centimeters. With the help of ultrasound, the doctor can not only determine the size of the ovarian cyst, but also suggest its type (follicular cyst, corpus luteum cyst, dermoid cyst, cystadenoma, and so on.
Polycystic ovary ultrasound. With polycystic ovaries, their sizes significantly exceed the norm, which is noticeable during an ultrasound scan. The volume of the ovary also increases: if the normal volume of the ovary does not exceed 7-8 cm3, then with polycystic ovaries it increases to 10-12 cm3 or more. Another sign of polycystic ovary disease is a thickening of the ovarian capsule, as well as the presence of many follicles in the ovary (usually 12 more with a follicle diameter of 2 to 9 mm).
In our center you can undergo the following ultrasound examinations:
- abdominal organs, kidneys, adrenal glands
- uterus and ovaries, folliculometry, mammary glands
- prostate gland, urinary bladder with determination of residual urine, scrotum
- salivary glands
- lymph nodes, soft tissues
- vessels of the neck and brain,
- veins and arteries of the lower extremities
- knee and shoulder joints
- Ultrasound of internal organs for children from 3 years of age and older
How often and what kind of ultrasound should be done to monitor your health?
Ultrasound of the uterus
Ultrasound examination of the uterus is a diagnostic procedure that allows you to identify possible pathological processes of the uterus and its appendages.Most often, this procedure is carried out at different stages of pregnancy or when planning the conception of a child. Depending on some features, this procedure can be carried out by various techniques.
IN WHAT CASES IS UTERINE Ultrasound Shown
Experts recommend that women undergo an ultrasound examination of the uterus once a year for a routine examination. Such a periodicity of examinations makes it possible to detect most of the pathological processes in the early stages.
Also, ultrasound of the uterus is indicated in the following cases:
- Suspected pregnancy. In the early stages, pregnancy is confirmed using ultrasound diagnostics and a blood test for hCG.
- Diagnostics of the ectopic pregnancy. Ultrasound helps the doctor to exclude the pathological location of the ovum.
- Identification of the cause of infertility. If a woman cannot become pregnant on her own for six months or more, doctors may prescribe an ultrasound examination of the uterus and appendages to assess their condition and exclude possible pathologies.
- Irregular cycle, pain. If a girl complains of an irregular menstrual cycle, pain in the lower abdomen or discomfort during sexual intercourse, the uterus must be examined by means of an ultrasound examination.
- This procedure can also be performed after childbirth to see how the uterus contracts after pregnancy. In addition, preventive examinations are indicated if there is a history of fibroids.
Favorable time for ultrasound
In order to achieve the most reliable indicators, it is required to visit the examination of the uterus on favorable days of the menstrual cycle.Experts strongly recommend to carry out this procedure from the 5th to the 8th day of the cycle. This is due to the fact that on other days the endometrium of the organ is thickened, therefore it is more difficult to detect pathologies.
Main types of ultrasound of the uterus
In medical practice, there are several types of ultrasound examination of the uterus:
Transabdominal diagnostics. A genital scan is performed through the abdominal wall. This technique helps to detect formations as small as 1 cm.Such an examination is also carried out in 2-3 trimesters of pregnancy.
Transvaginal diagnostics. This technique allows you to study in more detail the structure of the uterus and ovaries and identify possible ailments. Not performed if the patient has no experience of sexual intercourse.
Transrectal method. This technique is carried out extremely rarely: only in cases where the girl is not sexually active, and the examination cannot be performed abdominal.
What type of research is right for you – the gynecologist will tell you.
How to properly prepare for an ultrasound of the uterus
The rules for preparing for an ultrasound examination depend on which type of ultrasound is selected for diagnosis.
Vaginal ultrasound. This technique requires practically no training. It is enough to carry out hygienic procedures and empty the bladder immediately before the examination.
Ultrasound examination through the rectum. Transrectal ultrasound requires emptying the stomach, bladder, and rectum.A couple of hours before the ultrasound, perform an enema or use laxatives, having previously discussed this with your doctor.
Ultrasound through the abdominal wall. When implementing this technology, you need to be well prepared. Start following your diet three days in advance to avoid gas and bloating, which can interfere with your diagnosis and affect the truthfulness of your results. You need to come to the study on an empty stomach, that is, after waking up, you should not eat food. Take carminative drugs if you have a tendency to gas.Ask your doctor if you need to empty your bladder before diagnosis – depending on the clinical situation, the study is done with either a full or empty bladder.
How the procedure is carried out
Of the listed methods of carrying out the procedure for patients, the most convenient and comfortable is the method of examination through the abdominal wall. In this case, the woman lies down on the couch, exposes her belly and lowers her trousers. The doctor applies a special gel to the skin and begins the study.
Transvaginal examination does not bring pain, but sometimes it causes discomfort to the patient. To carry out the diagnosis, a woman lies down on a couch and bends her knees. A hypoallergenic condom is put on the sensor and lubricated with a special gel, then carefully inserted into the vagina.
If a girl is to undergo an ultrasound examination through the rectum, she should lie on her side. Next, the procedure is the same as for a vaginal examination, only the sensor is inserted into the anus.
In total, diagnostics are carried out in 15-20 minutes. The patient receives the research results immediately.
Interpretation of results
If the genital organ does not have pathologies, the results should be as follows:
- The uterus is pear-shaped or more rounded;
- The dimensions of the organ at reproductive age in the absence of pregnancies should be 45-34-46 mm, but if a pregnancy was previously observed – 51-37-50 mm;
- The cervix should be flat, have a homogeneous structure, clear boundaries.Its dimensions are on average 25-45 mm in length, and do not exceed 30 mm in thickness.
- The size of the ovaries should be 25-40 mm in length, in thickness – from 10 to 20 mm, while the width should be no more than 15-30 mm.
- Echogenicity is homogeneous.
- Normal endometrial layer up to 8 mm.
- Small amounts of mucus may be found in the cervical canal.
Please note that during pregnancy, the above norms may be different, they are individual in nature, depending on the duration of pregnancy.
Thanks to this study, it is possible to identify endometriosis, organ developmental anomalies, polyps, fibroids, neoplasms of various etiologies. Often, with the help of an ultrasound scan, a specialist finds out what exactly prevents the successful conception of a child.
Question from: Irina – Clinic Health 365, Yekaterinburg
Question to the Gynecologist
Question from Irina
I am 50 years old, I live in Chelyabinsk. Doctors suggest removing the uterus (hysterectomy).
Tell me, is it possible in this situation to apply myomectomy or otherwise save the uterus?
If not, is it possible to remove the uterus laparoscopically?
Best regards, Irina.
P.S. if necessary, I can send in electronic form all the analyzes.
ultrasound from 08/05/2010.
GE Logiq 7, Internal probe 3.5 – 11.5 MHz
First day of last menstruation – 03/28/2010. Cycle day – NMC.
The uterus is located typically, in the midline, in the anteflexio, the shape of the uterus is pear-shaped,
the contours are clear, uneven, the uterus is enlarged due to the volumetric formations in the myometrium, the size of the body of the uterus is 84 * 60 * 75 mm.The echogenicity of the myometrium is average, the structure of the myometrium is heterogeneous, multiple nodes of myoma with a diameter of up to 14-53 mm are visualized throughout the myometrium, the location is interstitial subsequent; the largest nodes along the posterior wall 44 mm and 53 mm with central growth, reduced echogenicity, deforming the uterine cavity, in the region of the bottom there is a subserous node 31 mm; prmi CDK there is a weak blood flow of the peripheral type in the nodes of the posterior wall.
The arcuate veins of the myometrium are not dilated. The venous plexuses of the pelvis are not dilated.
ENDOMETRY is visualized clearly, up to 4.3 mm thick, the contours are clear, uneven, the echogenicity of the endometrium is average, the echogenicity of the adjacent myometrium is average, the structure of the endometrium is two-layered. The structure of the endometrium does not correspond to the phase of the menstrual cycle.
The UTERINE CAVITY is deformed by the nodes of the myometrium, the IUD of the Lipps type is visualized in the cavity, the IUD is located correctly.
NECK of the uterus of normal size, the shape of the neck is cylindrical, the contours are clear, even, the structure of the neck is homogeneous, there are no inclusions.
RIGHT OVARY is located typically, up to 28 * 19 mm in size, the echogenicity is average, the contours are clear, even, the structure of the ovary is homogeneous, typical – several small follicles are visualized.
RIGHT UTERINE TUBE without visible structural changes.
LEFT OVARY is located intimately to the uterus, in the body area, up to 30 * 21 mm in size, the echogenicity is average, the contours are clear, even, the structure of the ovary is homogeneous, typical – several small follicles are visualized.
LEFT UTERINE TUBE without visible structural changes.
DOUGLASOVO SPACE does not contain free liquid.
Multiple myoma of the uterine body with
central growth of nodes along the posterior wall
Date 05/12/2010 Time
Under aseptic conditions, the cervix was taken on bullet forceps.
The length of the uterine cavity along the probe is 10 cm. Straight, sharply to the front and to the left.
A hysteroscope was inserted into the uterine cavity.
The uterine cavity is deformed due to the submucous, interstitially located myomatous node emanating from the posterior wall, the fundus of the uterus.
The dimensions of the knot are 5 cm and 3 cm. Behind the knot in the bottom of the IUD – only visualized (handwritten illegible).
Mucosa: pale pink, thin. The vascular pattern is not pronounced.
The mouth of the fallopian tubes is not traced.
Separate curettage was performed under the control of hysteroscopy. The
VMK could not be deleted. Scrapings were sent for cytological and histological examination.
Multiple submucous-interstitial myoma of the uterine body with severe deformation of the uterine cavity.Foreign body in the uterine cavity.
Scheduled surgical treatment is indicated.
RESULT OF HISTOLOGICAL STUDY
Date of collection 05/12/2010.
The material is taken superficially. The endometrial glands are convoluted, arranged somewhat randomly, in some places the number of their sections is increased, lined with prismatic double and pseudo-row epithelium, mitoses are found in the nuclei of epithelial cells, the stroma is compact, focal fibrosis.Scraping from the cervical canal contains endometrial tissue.
Probably there is a transitional endometrium.
Date of issue of the analysis 05/19/2010.
In our Clinic it is possible to perform an operation with a laparoscopic approach. To resolve the issue of the volume of surgical intervention, you need to make an appointment with the operating gynecologist of the highest category L.Fadeeva.P. By phone 270-17-17. Larisa Pavlovna will answer all your questions and prescribe the entire volume of the necessary examination before the operation.
Sileva Yu.V., gynecologist