The total duration of the cycle is 28 days, but in some cases it can last up to 35 days. It depends on the individual characteristics of the female organism.

The phases of the menstrual cycle are classified by the nature of cyclic changes occurring in the ovaries and endometrials (menstrual, proliferative and secretory). Follicular or menstrual stage begins from the first day of menstruation and is characterized by the production of gonadotropin-rilizing hormone in the hypothalamus of the brain. GNVG, in turn, stimulates the secretion of the follicularity and luteinizing hormone.

The menstrual phase is accompanied by bloody discharge from the uterus. If the egg fertilization did not occur, the endometrium layer is rejected, it is accompanied by bleeding, which can last 3-7 days. Women worry pulling many pain At the bottom of the abdomen.

About 20 follicles begin to form in the ovaries, but only one (dominant), reaching the size of 10-15 mm, ripens. The remaining cells are subjected to reverse development - artresia. The follicle continues to grow as long as the LG release occurs. On this, the first phase of the menstrual cycle ends, its duration is 9-23 days.

Ovulatory phase

On the 7th day of the cycle, the dominant follicle is determined, which in the process of growth reaches 15 mm and secretes estradiol.

The second phase of the menstrual cycle lasts 1-3 days and is accompanied by reinforced emission of luteinizing hormone. Lg causes an increase in the level of prostaglandins and proteolytic enzymes that contribute to the perforation of the follicle capsules followed by the output of the ripened egg. This process is called ovulation. A sharp increase in the secretion of LH can be observed from 16 to 48 hours, the yield of the eggs usually occurs after 24-36 hours.

Sometimes 2 phases of the menstrual cycle is accompanied by ovulatory syndrome. Follicle gap and expiration small number The blood in the cavity of the small pelvis is accompanied by pain at the bottom of the belly on the one hand. You can appear separating the selection of brown color, the basal temperature rises. Such symptoms are saved up to 48 hours. Acute pain syndrome is observed in women suffering from chronic inflammatory diseases organs of the gynecological sphere, and in the presence of an adhesive process.

The term of ovulation is unstable, endocrine disorders associated with diseases, psycho-emotional disorders can affect influence. Usually, the rupture of the follicle occurs on 6-16 days at the menstrual cycle, which is 28 days. If the cycle lasts 35 days, then ovulation can be on 18-19 days.

The next phase of menstruation lasts from the moment of ovulation and before the start of menstruation, lasts 14 days. After the release of the eggs, the follicle begins to accumulate fat cells and lutene pigment, gradually turning into a yellow body. This temporary iron of the internal secretion produces estradiol, androgens and progesterone.

The change in the hormonal balance affects the state of the endometrium (inner layer of the uterus). The lutein phase is characterized by the growth of endometral cells that secrete hormones. During this period, the uterus is prepared for the implantation of a fertilized egg.

If pregnancy occurs, the yellow body begins to produce progesterone hard. This hormone:

• contributes to relaxing the walls of the uterus;
• prevents its reduction;
• responsible for the secretion of breast milk.

The production of hormones with a yellow body continues until the placenta is formed.

In case the pregnancy does not occur, temporary iron ceases to work and collapses, it leads to a decrease in the level of progesterone and estrogen. In endometrial tissues, necrotic destruction of cells occurs, swelling processes are observed, menstruation begins.

The suppression of the secretion of FG and LH, gonadotropins stimulate the ripening of the follicle, the new ovarian cycle begins.

Uterine cyclic processes

The duration of the uterine cycle corresponds to the duration of the ovarian. Cyclic changes in the state of the uterus are classified:

• The menstrual period (desquamation) is accompanied by rejection of the endometrium and the release of it with blood from the rebound vessels. The duration of this stage is 3-7 days. The period of desquamation coincides with the death of a yellow body.
• The phase of regeneration begins in the period of desquamation, about 5-6 days. The restoration of the functional layer of the epithelium occurs due to the growth of the glands of the glands located in the basal layer.

• The proliferative phase coincides with the follicular and ovar stage of the ovarian cycle. This stage begins with the moment of growth of the follicle and developing Estrogen. Hormones contribute to update the epithelium and proliferation of the cells of the mucous membrane of the uterine glands. The thickness of the epithelium increases 3-4 times, and an increase in the size of the tubular glands of the uterus is occurring, but they do not distinguish the secret.
• The secretory stage is accompanied by the start of developing by the secretary of the uterine glands. This period coincides with the development of a yellow body in the ovaries, and continues from 14 to 28 day of the menstrual cycle. During the secretory phase in the walls of the uterus, protruding is formed. In the mucous membrane, the stock of trace elements begins to postpone, the activity of enzymes increases. Thus, favorable conditions for the development of the embryo are created. If the fertilization did not happen, the yellow body is destroyed, the functional layer of the endometrium is rejected and menstruation begins.

Cyclic changes also occur in the vagina. With the beginning of the follicular phase, the epithelium of the mucous membranes begins to grow, the secretion of mucin in the cervix is \u200b\u200bincreasing. Cervical mucus diluted and becomes similar to egg protein, the level of absorption is changed. This is necessary for easier promotion of sperm and increase their life expectancy. The cells of the epithelium into the vagina reaches the maximum thickness with the onset of ovulation, the mucoscent has a loose consistency. In the lutein phase, the proliferation stops and desquamation occurs under the influence of progesterone.

Pathologist diagnostics of the endometrium status on biopsies / spitters V.A. Topchieva O.I. ; under. ed. prof. OK. Khmelnitsky. - Leningrad.

Diagnosis on biopsies endometrial is often great difficulties due to the fact that the same very similar microscopic picture of the endometrium is due to various reasons (O.I. Topchiyeva 1968). In addition, endometrial fabric is characterized by an exceptional variety of morphological structures, depending on the level of steroid hormones, secret-generable ovaries, and under the pathological conditions associated with the violation of endocrine regulation.

Pathoanatomic diagnostics of the endometrium status of biopsies: Methodical recommendations

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Pathological diagnostics of the status of endometrials on biopsies: Methodical recommendations / Snidishmen V.A., Topchieva O.I. -.

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Pathological diagnostics of the status of endometrials on biopsies: Methodical recommendations / Snidishmen V.A., Topchieva O.I. -.

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Pathoanatomic diagnostics of biopsies endometrial states

Accurate microscopic diagnostics on endometrial scrapings is of great importance for the daily work of the obstetrician-gynecologist. Biopsy (zoops) endometrials make up a significant part of the material sent by obstetric and gynecological hospitals for microscopic examination.

Diagnostics on biopsies of endometrial often represents great difficulties due to the fact that the same very similar microscopic picture of the endometrium is due to various reasons (O. I. Topchiyeva 1968). In addition, endometrial fabric features an exceptional variety of morphological structures, depending on the level of steroid hormones secreted by the ovaries, and in the pathological conditions associated with the violation of endocrine regulation.

Experience shows that the responsible and complex diagnosis of changes in the endometrium in the scrapings turns out to be full only if there is close contact in the work between the pathologist and the gynecologist.

The use of histochemical methods, along with the classical morphological methods of the study, significantly expands the possibilities of pathologist diagnostics and includes such histochemical reactions as a reaction to glycogen, alkaline and acid phosphatases, monoaminoxidase, and others. The use of these reactions allows you to more accurately assess the degree of disruption of estrogen balance and gestagens in the body Women, and also makes it possible to determine the degree and nature of the hormone sensitivity of the endometrium in hyperplastic processes and tumors, which is of great importance when choosing methods for the treatment of these diseases.

Methods of obtaining and preparation of material for research

Important for proper microscopic diagnostics on endometrial scrapings has the observance of a number of conditions during the material fence.

The first condition is the correct definition of time that is most favorable for the production of scraping. There are the following testimony for scraping:

• a) during sterility with suspicion of insufficiency of the function of the yellow body or an inhibular cycle - the scrapets takes 2-3 days before menstruation;
• b) with menorage, when slow motion of the endometrium mucosa is suspected; Depending on the duration of bleeding, the scrapets takes 5-10 days after the start of menstruation;
• c) with dysfunctional uterine bleeding type metro angry scraping should be taken immediately after the start of bleeding.

The second condition is technically correct implementation of the scraping of the uterus. The "accuracy" of the response of the pathologist largely depends on how the endometrium scraping is taken. If small, fragmented pieces of fabric come to study, it is extremely difficult or even impossible to restore the endometrium structure. This is eliminable with the right piece of scraping, the purpose of which is to obtain large unrecorded strips of the tissue of the mucous membrane. This is achieved by the fact that after holding a Kyu Retka along the wall of the uterus, it should be taken from the cervical of the canal each time, and the intricate the tedious of the muzzo is carefully folded into the gauze. In the event that the curette is not excreted every time, the mucosa separated from the wall during repeated movements of the cureti is crushed and part of it remains in the uterine cavity.

Full Diagnostic scraping of the uterus is made. After the expansion of the cervical canal is up to 10 numbers of the hegara expander. Usually scraping is carried out separately: first-cervical canal, and then the uterus cavity. The material is placed in a fixing liquid into two separate banks, marked from where it is taken from.

In the presence of bleeding, especially in women in the menopausal period or in menopause, you should scroll through the small curette of the tube angles of the uterus, remembering that it is precisely in these sites that the polynomials of the endometrium can be localized, in which the maligancy areas are most often found.

If, when scraping from the uterus, a large amount of tissue was removed, then it is necessary to send the entire material to the laboratory, and not part of it.

Tsugi. or so-called Rancheyskets They are taken in cases where it is necessary to determine the reaction of the uterus mucous membrane in response to the secretion of hormones with ovaries, to control the results of hormone therapy, when finding out the causes of the sterility of a woman. To obtain TsUGs, use a small curette without prior expansion of the cervical canal. When taking the TsUGA, it is necessary to carry out a curette until the bottom of the uterus, so that in the strip of the bar neighboring. The mucous membrane is up to bottom, that is, the lining all the separations of the uterus. To obtain the correct response of the Histologist on the Cugu, as a rule, it is enough to have 1-2 endometrium strips.

TSG methods in no way should be applied if available uterine bleedingSince in such cases it is necessary to have an endometrium to study from the surface of all the uterus walls.

Aspiration biopsy - Obtaining pieces of endometrium tissue by suction from the uterine cavity can be recommended for mass prophylactic examinations of women in order to identify prematubic states and endometrial cancer in "increased risk groups". At the same time, the negative results of aspiration biopsy do not allow! With confidence, reject the initial forms of asymptomatic flowing cancer. In this regard, with suspicion of cancer of the uterus, the most reliable and uniquely shown diagnostic method There remains [the complete scraping of the uterine cavity (V. A. Mandelstam, 1970).

After the work of biopsy, a doctor sending material for the study must fill accompanying Direction L about the form offered by us.

The direction should indicate:

• a) the duration of the menstrual cycle, characteristic of this woman (21-28, or 31 days, cycle);
• b) the start date of bleeding (in the period of expected menstruation, ahead of time or late). In the presence of menopause or amenorrhea, it is necessary to specify its duration.

These are the value of the following data

• a) the constitutional type of patient (obesity is often accompanied by pathological changes in endometrial),
• b) endocrine disorders (diabetes, changes in the function of the thyroid gland and adrenal cortex),
• c) Did the patient of hormone therapy be subjected to what a hormone and which dosage?
• d) whether methods of hormonal contraception were used, the duration of using contraceptives.

Histological treatment Material 6IOs includes fixation in a 10% neutral solution of formalin, followed by dehydration and pouring into paraffin. You can also use the accelerated method of filling in paraffin on G.A. Merculus with fixation in formalin, heated to 37 ° C in thermostat in For 1-2 hours.

In everyday work, it is possible to limit the painting preparations with hematoxylin-eosin, van-Gizon, Mud Charmina or Alziane Oitam.

For a more subtle diagnosis of the state of the endometrium, especially in solving questions about sterility related to the defective ovarian function, as well as to determine the hormone-sensitivity of the endometrium in hyperplastic processes and tumors, it is necessary to use histochemical methods that allow to identify glycogen, to evaluate the activity of acidic, alkaline phosphatases and A number of other enzymes.

Cryostatic sections The endometrium obtained from non-fixed tissue, frozen at a temperature of liquid nitrogen (-196 °) can be used not only for research using conventional histological methods of color (hematoxylin-eosin, etc.), but also to determine the content of glycogen and the activity of enzymes in morphological structures mucous uterus.

For histological and histochemical studies with biopsy endometrial on cryostatic sections, the pathoanatomy laboratory must be equipped with the following equipment: MK-25 cryostat, liquid nitrogen or carbon dioxide ("dry ice"), Dewar vessels (or household thermos), pH meter, refrigerator on + 4 ° C, thermostat or water bath. To obtain cryostat sections, you can use the method developed by V.A. Polyshnikhnikov with employees (1974).

According to this method, the following stages of the preparation of cryostat sections are distinguished:

1. Endometrial pieces (without pre-washing with water and without fixation) are placed on a strip of filter paper moistened with water, and gently lowered into liquid nitrogen by 3-5 seconds.
2. Filter paper with frozen in nitrogen pieces of endometrial are transferred to the cryostat chamber (-20 ° C) and carefully with a few drops of water are fitted to the microtomes to the system.
3. 10 μm thick cuts obtained in a cryostate are mounted in a cryostat chamber to chilled substantive or covering glasses.
4. Framing of sections is carried out by melting of sections, which is achieved with the touch of the warm finge of the K.Nizhny surface of the glass.
5. Glass with flashes quickly (should not be made to frozen again) removed from the cryostat chamber, dried in air. And fixed in 2%, the glutaraldhyde solution (or vapor form) or in the formaldehyde mixture - alcohol - acetic acid - chloroform ratio in the 2: 6 ratio : 1: 1.
6. Fixed media are stained with hematoxylin-eosin, dehydrated, enlighten and enter into polystyrene or balm. The choice of the level of the studied histological structure of the endometrium is performed on time preparations (non-fixed cryostat sections) painted with toluidine blue or methylene blue and water prisoners. Their manufacturing takes 1-2 minutes.

For histochnotic determination of the content and localization of glycogen dried in air, cryostatic sections are fixed in cooled to + 4 ° C for 5 minutes, dried in air and painted according to the Mac-Manusa (Pier 1962).

To detect hydrolytic enzymes (acid and alkaline phosphatase), cryostat sections are used, fixed in cool to a temperature of + 4 ° C 2%. Neutral formal solution for 20-30 minutes. After fixing, the sections are rinsed in water and immersed in an incubation solution to identify the activity of acidic or alkaline phosphatases. The acid phosphatase is determined by Barkarka and Anderson (1963), and alkaline phosphatase - Berstone (BERSTON, 1965). Before conclusion, sections can be hematoxylin. Store drugs are necessary in the dark.

Changes in endometrials observed throughout the two-phase menstrual cycle

The mucous membrane of the uterus, lining her various sections - the body, and cervical, - has typical and functional features in each of these departments.

The endometrium of the bodies of the uterus consists of two layers: basal, deeper, located directly on the myometry of the I. Fast-functional.

Basal The layer contains a few narrow glands lined with cylindrical single-row epithelium whose cells have oval, intensively staining kernel hematoxylin. The reaction of the tissue of the basal layer on hormonal exposure is poorly and inconsistently.

From the fabric of the basal layer, the functional layer is regenerated after various disorders of its integrity: rejection into the menstrual phase of the cycle, during dysfunctional bleeding, after abortion, childbirth, and also after scraping.

Functional The layer is a cloth with a special, biologically due to high sensitivity to sex steroid hormones-estrogen and gestagenam, under the influence of which its structure and function changes.

The height of the functional layer in half-green women varies depending on the phase of the menstrual cycle: about 1 mm at the beginning of the proliferation phase and up to 8 mm in the secretion phase-at the end of the 3rd cycle week. In this period, a deep, spongy layer is most distinctly denoted in the functional layer, where the glands are closer, and the surface-compact, in which cyto-gene stromas prevails.

The basis of cyclic changes of the morphological picture of the endometrium observed during the menstrual cycle lies the ability of genital steroids-estrogen to cause characteristic changes in the structure and behavior of the tissue of the mucous membrane of the uterus.

So, Estrogen Stimulate the proliferation of glasses of glands and stroma, contribute to regenerative processes, possess the vasodilatory action and increase the permeability of endometrial capillaries.

Progesterone It has an action on endometrium only after the prior effect of estrogen. Under these conditions, gestagens (progesterone) cause: a) secretory changes in glands, b) decidual reaction of stroma cells, c) the development of spiral vessels in the functional layer of endometrial.

The above morphological features were based on the morphological division of the menstrual phase and stage data cycle.

According to modern ideas, the menstrual cycle is divided into:

• 1) Phase proliferation:
  • Early Stage - 5-7 Day
  • Central Stage - 8-10 Day
  • Late stage - 10-14 days
• 2) secretion phase:
  • Early Stage (the first signs of secretory transformations) - 15-18 day
  • Central Stage (the most pronounced secretion) - 19-23 days
  • Late stage (starting regression) - 24-25 days
  • Regress with ischemia - 26-27 days
• 3) Bleeding phase - menstruation:
  • Deskvamation - 28-2 day
  • Regeneration - 3-4 days

In assessing changes occurring in endometrials, respectively, the days of the menstrual cycle, must be considered:

• 1) the duration of the cycle in this woman (28- or 21-day cycle);
• 2) the term of ovulation that occurred, which in normal conditions is observed on average from 13th to the 16th day of the cycle; (Therefore, depending on the time of ovulation, the structure of the endometrial of one or another stage of the secretion phase fluctuates r; limits of 2-3 days).

Phase proliferation lasts 14 days, however, and in physiological conditions it can be elongated or shortened within 3 days. Changes observed in the endometrical phase of proliferation arise as a result of the action of the growing amount of estrogen secreted by the growing and ripening follicle.

The most pronounced morphological changes in the proliferation phase are marked in glands. At an early stage, the glands have a view of a straight or cast of convolve tubes with a narrow lumen, the contours of the glands are rounded or oval. The epithelium glands is a single-row low cylindrical, core oval, are located at the base of the cells are intensively painted with hematoxylin. In the late stage of the gland acquire winding, sometimes corkscrew outlines with a slightly advanced lumen. The epithelium becomes high prismatic, a large number of mitoses are observed. As a result of intensive division and increase the number of core epithelial cells, they are at different levels. For the epithelium cells of the early phase of the proliferation, the absence of glycogen and moderate activity of alkaline phosphatase is characteristic. By the end of the phase of the proliferation in the glands, the appearance of small dust-like glycogen granules and the high activity of alkaline phosphatase is noted.

In the stroma endometrial during the phase of proliferation there is an increase in dividing cells, as well as thin-walled vessels.

The structures of the endometrium corresponding to the proliferation phase observed in physiological conditions in the first half of the two-phase nicla can reflect.Gormonal disorders if they are detected:

• 1) during the second half of the menstrual cycle; This may indicate an annevulatory single-phase cycle or on an abnormal, elongated phase of proliferation with the late ovulation. In a two-phase cycle:
• 2) with iron hypeometrium hyperplasia in various sections of a hyperplasned mucous membrane;
• 3) Three dysfunctional uterine bleeding in women at any age.

The secretion phase, directly associated with the hormonal activity of the menstrual yellow body and the corresponding secretion of progesterone, lasts 14 ± 1 days. The shortening or elongation of the secretion phase is more than two days, in women in the reproductive period, should be considered as a pathological state, since such cycles are sterile.

Throughout the first week, the phase of secretion of the day of ovulation is determined by changes in the epithelium glands, while in the second week this day is most accurate to be determined by the state of the endometrium stroma cells.

So, on the 2nd day after ovulation (16th day of the cycle) in the epithelium glands appear Subnuclear vacuoles. On the 3rd day after ovulation (17th day of the cycle), subnuclear vacuoles push the kernels into the apical cells of the cells, as a result of which the latter are on the same level. On the 4th day after ovulation (18th day of the cycle), the vacuole is partially moving from the basal departments to the apical and the 5th day (19th day of the cycle) almost all vacuoles move to the apical cells of the cells, and nuclei are shifted to the basal Little departments. In the next 6th, 7th and 8th days after ovulation, i.e., on the 20th, 21st and 22nd days of the cycle in the cells of the epithelium glands, the pronounced processes of the apocryne secretion are noted, as a result of which apical " Paradise cells have as if notched, uneven. The absurpenses of the glands during this period are usually expanded, filled with eosinophilic secret, the walls of the glands become folded. On the 9th day after ovulation (23rd day of the menstrual cycle), the secretion of the glands is over.

The use of histochemical methods made it possible to establish that subnuclear vacuoles contain large granules of glycogen, which throughout the early and at the beginning of the average stage of secretion phase is thrown by apocryan secretion into the absurdity of the glands. Along with the glycogen in the lumen of the glands, acidic mucopolysaccharides are also contained. As the glycogen accumulates and the secretion of it in the absurd of the glands, a distinct decrease in the activity of alkaline phosphatase in the epithelium cells, which almost completely disappears to 20-23 day of the cycle.

In stroma Characteristic changes for the secretion phase begin to appear on the 6th, 7th day after ovulation (20th, 21st day of the cycle) in the form of a perivascular decidua-like reaction. This reaction in the cells of the strass of the compact layer is most pronounced and is accompanied by an increase in cell cytoplasm, they acquire polygonal or rounded outlines, glycogen accumulation is observed. The secretion phase characteristic of this stage is also the appearance of spiral vessels, not only in the deep departments of the functional layer, but also in the surface compact layer.

It should be emphasized that the presence of spiral arteries in the endometrium functional layer is one of the most reliable signs that determine the full gestagne effect.

On the contrary, subnuclear vacuolaization in the epitheliums of the glands is not always a sign indicating that the ovulation has occurred and the secretion of progesterone in the yellow body.

Subnuclear vacuoles can sometimes be detected in the glands of mixing of the hypoplastic endometrial at D.Is-functional uterine bleeding in women of any age, including the period of menopause (O. I. Topchieva, 1962). However, in endometrial, where the occurrence of vacuoles is not criticized with ovulation, they are contained in separate glands or in the gland group is usually only in the cells. Vacuol themselves have a different value, most often they are small.

In the late stage of the secretion phase, from the 10th day after Ov-Lyashiya, i.e., on the 24th day of the cycle, in whey, with the start of the yellow body regression and a decrease in the level of progesterone in the blood in the endometrium, morphological signs of regression are observed, and on 26 And on the 27th day they join signs of ischemia. As a result of wrinkling, the stroma of the functional layer of the gland acquire star-shaped outlines on transverse sections and saws on longitudinal.

In the phase of bleeding (menstruation) in endometrials, desquamation and regeneration processes occur. The morphological feature characteristic of the endometrial of the menstrual phase is the presence, in the penetrated hemorrhages, the disintegrating tissue of the sleeved glands or their fragments, as well as the trangles of the spiral arteries. Full rejection of the functional layer usually ends on the 3rd day of the cycle.

The endometrial regeneration occurs due to the proliferation of the cells of the basal departments of the glands and ends for 24-48 hours.

Changes endometrial in disruption of the endocrine function of the ovaries

From the point of view of etiology, pathogenesis, as well as taking into account the clinical symptoms, morphological changes in endometrials arising from violation of the endocrine function of the ovaries can be divided into three groups:

1. Changes endometrial in violation of secretion Estrogenic hormones.
2. Changes in endometrials in violation of secretion progestive hormones.
3. Changes in the mixed type endometrial, in which structures reflecting the impact of estrogen and progestative hormones are simultaneously found.

Regardless of the nature of the violations of the endocrine function of the ovaries listed above, the most common symptoms with which clinicians and morphologists are found are Uterine bleeding and amenorrhea.

A special place in its extremely important clinical meaning is occupied by uterine bleeding in women in menopause Since among a variety of reasons, such bleeding, about 30% turn out to be malignant neoplasms Endometrium (V.A. Madelshtam 1971).

1. Changes in endometrial in violation of the secretion of estrogenic hormones

Violation of the secretion of estrogenic. Normonov manifests itself in two basic forms:

a) in the insufficient number of estrogen and the formation of non-functioning (resting) endometrial.

In physiological conditions, the restochy endometrium briefly exists during menstrual cycles-after the regeneration of the mucous membrane before the start of proliferation. Non-functioning endometrium. Also also in women of elderly, when the hormonal function of the ovaries is eased and is the stage of transition to atrophic endometrium. Morphological signs of non-functioning endometrials - glands have the kind of straight or slightly convoluted tubes. Epithelium is low, cylindrical, basophilina cytoplasm, elongated kernels, occupy most of the cell. Mitoses are absent or found extremely rare. Stromrom is rich in cells. When proteinating these changes, the endometrium from the non-functioning turns into atrophic with small glands lined with cubic epithelium.

b) in the long secretion of estrogen from persistent follicles, accompanied by anoint monophasic cycles. The elongated single-phase cycles arising from the long-term persistence of the follicle lead to the development of the dormriconal proliferation of endometrial type Ironistical or iron phones hyperplasia.

As a rule, endometriums under the vocal proliferation is thickened, its height reaches 1-1.5 cm or more. Microscopically lacks the separation of endometrial on the compact layers and spongy, there is also no correctness of the distribution of the glands in the stroma; Characters of cyutally applied glands. The amount of glands (more precisely ferrused tubes) does not increase (as opposed to atypical iron hyperplasia - adenomatosis). But due to the enhanced proliferation of the gland, they acquire an argument form and on a cut, passing through separate turns of one and that. More than a glandular tubule, the impression of a large amount of glands is created.

The structure of the iron hyperplasia of the endometrium, which does not contain a car-shaped extended glands, is called ". Excellent hyperplasia".

Depending on the severity of proliferative processes, the ferrous hyperplasia of the endometrium is divided into "active" and "rest" (which correspond to the states of "acute" and "chronic" estrogen). For the active form, a large number of mitoses are characterized in both the cells of the epithelium gland and in the cells of stroma, the high activity of alkaline phosphatase and the appearance of the clusters of "bright" cells in the glands. All these signs indicate intensive estrogen. The stimulation ("acute estrogen").

The "resting" form of iron hyperplasia corresponding to the state of "chronic estreaction" occurs in conditions of long-term exposure to the low level of estrogenic hormones. Under these conditions, the endometrium fabric acquires the similarity of the similarity of S.-binding, non-functioning endometrial: the epithelium cores are intensely painted, basophilic cytoplasm, mitoses are very rare or not found at all. The "resting" shape of the hardware hyperplasia is most often observed in the menopacteric period - when the ovarian function is fired.

It should be remembered that the occurrence of iron hyperplasia-especially its active form-in women after many years. After the occurrence of menopause, with a tendency to relapses, should be regarded as an unfavorable factor in relation to the possible occurrence of endometrial cancer.

It is also necessary to be borne in mind that the discharmal. The endometrium proliferation may occur in the presence of cilioepithelial and pseudomocyne cysts of the ovary, both malignant and benign, as well as in some other ovary neoplasms, for example, with a Brenner tumor (M. F. Glazunov 1961).

2. Changes to endometrial in violation of the secretion of gestagens

The violation of the secretion of the hormones of the menstrual yellow body appears both. In the form of the insufficient secretion of progesterone, and when it is enhanced and long secretion (the persistence of the yellow body).

Hypolyteine \u200b\u200bcycles in the insufficiency of the yellow body in 25% of cases are shortened; Ovulation usually occurs in a timely manner, but the secretory phase can be shortened to 8 days. The menstruation is associated with the premature death of an inferior yellow body and stopping the secretion of protesterone.

Histological changes in endometrials in hypolyteinic cycles are inenenial and insufficient secretory transformation of the mucous membrane. Thus, for example, unless before the onset of menstruation, Yaa 4th week of the cycle, along with glands, peculiar to the late stage of the secretion phase, there are glands, sharply lagging in their secretory function and corresponding only to the beginning phasesecretion.

Pre-comdonal transformations of connective tissue cells are being expressed extremely weakly or absent at all, spiral vessels are underdeveloped.

Persistence of a yellow body may be accompanied by a full secretion of progesterone. And the elongation of the phase of secretion. In addition, there are cases with reduced progesterone secretion with a coarse yellow body.

In the first case, changes arising in endometrials were named Ultranchanstrual hypertrophy and have similarities with structures observed during the pregnancy of the early term. The mucule is thickened to 1 cm, the secretion is intense, there is a pronounced decidua-like transformation of the stroma and the development of spiral arteries. Differential diagnosis with disturbed pregnancy (in women of reproductive age) is extremely difficult. The possibility of the occurrence of such changes and endometrials of women of the menopausal period (which pregnancy can be excluded).

In the case of a decrease in the hormonal function of the yellow body, when it is subjected to incomplete gradual regression, the process of rejection of the endometrium slows down and is accompanied by an elongation phase bleeding in the form of menorahia.

The microscopic pattern of the endometrium scrapings obtained during such bleeding after the 5th day, it seems very motley: the sections of necrotic tissue are found in the scraping, sections in the state of reverse development, secretory and proliferative endometrium. Such changes in endometrials can be detected in women with acyclic dysfunctional mortgage bleeding in the menopausal period.

Sometimes the effect of low concentrations of progesterone leads to a slowdown in its rejection, involution, i.e., the reverse development of deep departments of the functional layer. This process creates conditions for returning the endometrium to the initial structure, which was before the start of cyclic changes and occurs three amenorrhea, due to the so-called "hidden cycles" or hidden menstruation (E. I. Kvater 1961).

3. Endometrium "Mixed Type"

Endometrium is called mixed if it contains structures in its fabric, simultaneously reflecting the impact of estrogen and gestagenic hormones.

Two forms of mixed endometrials are distinguished: a) mixed hypoplastic, b) mixed hyperplastic.

The structure of mixed hypoplastic endometrial represents a motley picture: the functional layer is poorly developed and is represented by the iron of an indifferent type, and the tact of sections with secretory changes, mitoses are extremely rare.

Such endometries occurs in women of reproductive age with the pituitary glands, in women in a menopausal period with dysfunctional uterine bleeding, during bleeding in menopause.

An endometrial gland hyperplasia with pronounced signs of the effects of gestage hormones can be attributed to the hyperplastic mixed endometry. If among the tissues of the iron hyperplasia of the endometrium along with typical glands reflecting the estrogen effect, there are areas with groups of ammond glands, in which secretory signs, then such an endometrial structure is called a mixed form of iron hyperplasia. Along with the secretory changes in the glands, there are also changes in the stroma, namely: focal deciduous conversion of connective tissue cells and the formation of spiral vessels.

Preiodine and Endometrial Cancer

Despite the greater inconsistency of data on the possibility of endometrial cancer against the background of iron hyperplasia, most of the authors believe that the possibility of direct transition of iron hyperplasia in endometrial cancer is unlikely (A. I. Silver 1968; J. V. Bokhmai 1972), but unlike the usual (Typical) Endometrium Hyperplasia Atypical Form (adenomatosis) is considered by many researchers as a presets (A. I. Silver 1968, L. A. Novikova 1971, etc.).

Adenomatosis is a pathological proliferation of endometrial, in which traits characteristic of hormone hyperplasia are lost and atypical structures that have similarities with malignant growths appear. Adenomatosis is separated by the prevalence of diffuse and focal, and according to the severity of proliferative processes - on the unaware and pronounced forms (B.I. Iron, 1972).

Despite the significant variety of morphological signs of adenomatosis, most of the forms found in the practice of the pathologist has a number of characteristic morphological signs.

The glands are very convulsions, often have. Meal branches with numerous papillary protrusions in the lumen. Sevements of the gland are closely located near each other, almost not separated by the connective tissue. Epithelial cells They have large or oval, elongated, pale staining kernels with signs of polymorphism. The structures corresponding to the endometrial adenomatosis can be detected by a large length or limited areas against the background of the endometrium glandular hyperplasia. Sometimes in the glands are detected by the nest of the arranged groups of light cells having a morphological similarity with a flat epithelium - adenosacanthosis. The foci of pseudo-globular structures are sharply excluded from the cylindrical epithelium of glands and connective tissue stroma cells. Such foci can occur not only with adenomatosis, but also at the endometrium adenocarcinoma (adenocantoma). In some rare adenomatosis forms in the epithelium of the glands, a large number of "bright" cells (fixed epithelium) is accumulated.

Significant difficulties arise from a morphologist when trying to conduct differential diagnosis between prolonged proliferative forms of adenomatosis and highly differentiated embodiments of endometrial cancer. For pronounced adenomatosis forms, an intensive proliferation and an atipatism of ferrous epithelium is characterized in the form of an increase in cell size and nuclei, which allowed Hertigu et al. (1949) Name such forms of adenomatosis of the "zero stage" of endometrial cancer.

However, due to the lack of clear morphological criteria for this form of endometrial cancer (unlike the similar shape of the cervical cancer), the use of this term in the diagnosis of endometrial scrapings is not justified (E. Novak 1974, B. I. Zheleznov 1973).

Endometrial cancer

Most of the existing epithelial classifications malignant tumors Endometrium is based on the principle of the degree of severity of the tumor differentiation (M.F. Glazunov, 1947; P.V. Simpovsky and O.K. Khmelnitsky, 1963; E.N. Petrova, 1964; N.A. Kraevsky, 1969).

The same principle is based on the first International Classification Endometrium cancer developed by the World Health Organization Expert Group (Polesen and Taylor, 1975).

According to this classification, the following morphological forms of endometrial cancer are distinguished:

• a) adenocarcinoma (highly moderate and low-differentiated forms).
• b) lateral (mesonephroid) adenocarcinoma.
• c) flat-cell carcass.
• d) iron-flat flower cell (mucoepidermoid) cancer.
• e) undifferentiated cancer.

It must be emphasized that more than 80% of the malignant epithelial tumors of the endometrium are adenocarcinoma of varying degrees of differentiation.

A distinctive feature of tumors with histological structures The highly differentiated endometrial cancers are that the glands of the tumor, although they have signs of atypics, nevertheless resemble the usual endometrial epithelium. The ferret of the epithelium endometrium with papillary growth is surrounded by scarce layers of connective tissue with a minor amount of vessels. The glands are highlighted with high and low-prismatic epithelium with a weakly pronounced polymorphism and relatively rare mitosis.

As the differentiation decreases, ferrous cancers lose signs characteristic of endometrial epithelium, the ferrous structures of alveolar, tubular or papillary structure, which do not differ in their structure from ferrous cancers of other localization begin to prevail.

According to histochemical features, highly differentiated ferrous cancers resemble the endometrium epithelium, since it contains glycogen in a significant percentage and give a reaction to alkaline phosphatase. In addition, the indicated forms of endometrial cancer have high sensitivity to hormone therapy with synthetic gestagenis preparations (17-oxyprogesterone Kapronoate), under the action of which secretory changes are developing in tumor cells, glycogen is accumulated, alkaline phosphatase activity is reduced (V. A. Sanishnikov, Ya. V. Bochman, O. F. Che-Peak 1976). Significantly less than the similar differentiation effect of gestagenov develops in cells of moderately-effect-rented endometrial cancers.

Changes in endometrials when prescribing hormonal drugs

Currently, estrogen and gestagenov preparations for the treatment of dysfunctional uterine bleeding are widely used in gynecological practice for the treatment of dysfunctional uterine bleeding, as well as contraceptives.

Using various combinations of estrogen and gestagens can be artificially obtained in human endometrial morphological changes inherent in the phase of the menstrual cycle with normally functioning ovaries. The principles underlying the hormone therapy of dysfunctional uterine bleeding and amenorrhea are based on common laws, characteristic of estrogen and gestagenis on normal human endometrials.

The introduction of estrogen leads, depending on the duration and dose, to the development of proliferative processes in the endometrium, up to the iron hyperplasia. For long use Estrogen on the background of proliferation may occur abundant acyclic uterine bleeding.

The introduction of progesterone in the proliferative phase of the cycle leads to the braking of the proliferation of the epithelium glands and suppresses ovulation. The effect of progesterone to the proliferating endometrium depends on the duration of the introduction of the hormone and manifests itself in the form of the following morphological changes:

• - Stage of "Stopped Proliferation" in the glands;
• - atrophic changes in glands with decidu-like transformation of stroma cells;
• - Atrophic changes in the epithelium glands and stroma.

With the joint introduction of estrogen and gestagens, changes in endometrial depend on the quantitative ratio of hormones, as well as the duration of their administration. Thus, for the endometrium proceeding, the daily dose of progesterone, causing secretory changes in glands in the form of accumulation of glycogen granules, is 30 mg. In the presence of a pronounced iron hypertension hyperplasia to achieve a similar effect, it is necessary to introduce 400 mg.Progesterone daily (Dallenbach-Helvig, 1969).

For the morphologist and clinician-gynecologist, it is important to know that the selection of dosages of estrogen and gestagennes in the treatment of disorders of the menstrual cycle and the pathological states of the endometrium should be carried out under histological control, by the fence of repeated endometrial tsugs.

When using combined hormone contraceptives in the normal endometrium, women occur regular morphological changes, depending first of all from the duration of the use of the drug.

First of all, there is a shortening of the proliferative phase with the development of defective glands, in which abortive secretion is developing. These changes are related to the fact that when receiving these drugs, the gestagens contained in them inhibit the processes of proliferation in glands, as a result of which the latter do not reach their full development, as is the case at a normal cycle. Secretor changes developing in such glands have an abortive unexpected character,

Another typical feature of changes in endometrials in the reception of hormonal contraceptives is a sharply pronounced foci, the distruting of the morphological picture of the endometrium, namely: the existence of various but degrees of maturity of glands and stroma, not corresponding to the day of the cycle. These patterns are characteristic of both proliferative and secretory phases of the cycle.

Thus, when receiving combined hormonal contraceptives in the endometrium of women, pronounced deviations from the morphological picture of the endometrium of the corresponding phases of the normal cycle occur. However, as a rule, after the abolition of drugs, the gradual and complete restoration of the morphological structure of the mucous membrane is observed (the exception is only cases when the drugs were taken very long - 10-15 years).

Changes in endometrials arising during pregnancy and its interruption

With the occurrence of pregnancy, the implantation of a fertilized egg - blastocysts occurs on the 7th day after ovulation, i.e. on the 20th - the 22nd day of the menstrual cycle. At this time, the overdometrium strassment reaction is still very weak. The most rapid formation of decidual tissue occurs in the implantation zone blastocysts. As for the endometrium changes outside the implantation, the decidual tissue becomes distinctly expressed only from the 16th day after ovulation and fertilization, i.e., when menstruation has already been delayed for 3-4 days. This is observed in endometrials equally both during pregnancy uterine and ectopic.

In the decidual shell, the cutting wall of the uterus in all its length, with the exception of the blastocyst implantation zone, distinguish the compact layer and spongy layer.

In the compact layer of deciduals of the fabric in the early pregnancy, there are two types of cells: large, bubble-shaped with a pale-colored core and smaller cells of oval or polygonal shape with a darker core. Large decidual cells are the final form of the development of small cells.

The spongiosis layer differs from the compact exceptionally strong development of glands, which closely add each other and form fabric, general form Which may have some similarity with the adenoma.

With histological diagnosis on scraps and tissues that highlighted spontaneously from the uterine cavity, it is necessary to distinguish between the cells of the trophoblast from decidual cells, especially when the question is about the differential diagnosis between the uterine and ectopic pregnancy.

Cells trophoblast The components of the reservoir, polymorphic with the predominance of small polygonal. There are no vessels, fibrous structures, leukocytes in the reservoir. If there are single major syntial formations among the cells that make up the reservoir, it immediately decides the question of belonging to his trophoblast.

Cells Decidual Fabrics also have different sizes, but they are larger, oval. Homogenic cytoplasm, pale; Bubble cores. In the reservoir of decolation fabrics contain vessels and leukocytes.

With a pregnancy impairment, the formed cloth decidual O. Babes is necrotic and is usually completely discouraged. If pregnancy is violated in early terms, when the decidual fabric is even finally undeveloped, it is subjected to reverse development. An undoubted sign that the endometrium fabric was subjected to reverse development after pregnancy disturbed in early terms, the presence in the functional layer of clubs of spiral arteries. A characteristic, but not an absolute sign is also the presence of the arya-stella phenomenon (the appearance of cells with a very large hyperchromic kernel).

With a violation of pregnancy, one of the most important issues on which the morphologist has to be answered is the question of uterine or ectopic pregnancy. The absolute signs of the uterine pregnancy are the presence of a chorion vault, decidual fabric with invasion of chorial epithelium, the deposition of fibrinoid in the form of foci and heavyness in the decidual tissue and in the walls of venous vessels.

In cases where a decidual fabric is detected in the scraping without chorion elements, it is possible in the uterine and at ectopic pregnancy. In this regard, both a morphologist and a clinician doctor should be remembered that if the scraping was made not earlier than 50 days after the former last menstruation, when the area of \u200b\u200bthe arrangement of the fetal egg is large enough, then in the uterine form of pregnancy, the chorion naval is detected almost always. The absence of them gives reason to assume an ectopic pregnancy.

With an earlier period of pregnancy, the absence in the scrap elements of Chorion does not always indicate an ectopic pregnancy, since it is impossible to exclude unnoticed spontaneous miscarriage: during bleeding, a small flicer egg could be entirely standing out before scraping.

All-Union Scientific and Methodical Center for the Pathology Manufacture of Human Morphology Institute of AMN USSR
Leningrad State Order of Lenin Institute of Improvement of Doctors. CM. Kirov
I Leningrad Orders of the Labor Red Banner Medical Institute. I. P. Pavlova

Editor - Professor O. K. Khmelnitsky