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ABSTRACT
In the algorithm of management of women with external genital endometriosis, it is advisable to include a study of
the quality of life using the developed questionnaire "Health profile of patients with endometriosis", as well as the
use of a visual analog scale (VAS) when assessing pain syndrome as a simple and objective criterion for assessing pain
in clinical practice.
KEYWORDS
ovarian cysts, hormonal and combined treatment, dienogest, endometrium.
INTRODUCTION
The problem of endometriosis in modern society
remains global and has great medical, scientific and
social significance [13,15,17,19,21,23]. According to
WERF, every 10th woman of reproductive age in the
world suffers from endometriosis. About 176 million
women aged 17 to 49 worldwide suffer from this
disease [1,3,5,7,9,11].
According to modern views on the problem of
external genital endometriosis, there are several
strategic tasks in clinical practice, on the solution of
which the outcome of the disease depends. One of the
problems is the negative impact of endometriosis
symptoms on the quality of life of women and the
problem of increasing it is one of the priorities.
Research Article
EARLY DIAGNOSIS OF OVARIAN ENDOMETRIOSIS
Submission Date:
January 09, 2023,
Accepted Date:
January 14, 2023,
Published Date:
January 19, 2023
Crossref doi:
https://doi.org/10.37547/ijmscr/Volume03Issue01-03
Mansurova D.O
Bukhara State Medical Institute Named After Abu Ali Ibn Sina. Uzbekistan
Khamdamovа М.Т
Bukhara State Medical Institute Named After Abu Ali Ibn Sina. Uzbekistan
Journal
Website:
https://theusajournals.
com/index.php/ijmscr
Copyright:
Original
content from this work
may be used under the
terms of the creative
commons
attributes
4.0 licence.
Volume 03 Issue 01-2023
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Currently , the developed methods for assessing the
quality of life involve the use of standardized
questionnaires . A number of authors have shown the
negative impact of the disease on women's social
activity, life activity, and sexual relations. However, in
most published studies, general questionnaires on
quality of life were used, which are not specific to a
specific nosology and do not reflect the relationship
with the true picture of the disease (Burry K.A., 2015).
There are few publications on the assessment of the
quality of life using a special questionnaire for patients
with endometriosis EHP-30. In addition, the work
carried out considers changes in the parameters of
quality of life either after surgical or drug treatment,
without considering complex therapy. Another
strategic objective is adequate surgical treatment and
adequate comprehensive postoperative therapy.
Surgical intervention 3 4 in endometriosis should be
the first stage of treatment, since the surgical method
of treatment has been and remains the only way to
remove the morphological substrate of endometriosis.
The operation performed by laparoscopic access is the
"gold standard" of surgical treatment. However, the
key issue of managing patients after surgery is the
problem of relapses. According to various researchers,
the frequency of relapses with the resumption of
symptoms after surgical treatment is: after 1-2 years -
15-21%, after 5 years - 36-47%, after 5-7 years - 50-55
[2,4,6,8,10,12].
It should also be noted the resistance of various
clinical forms to the treatment. Therefore, according to
the experts of the American Society for Reproductive
Medicine
(ASRM),
"endometriosis
should
be
considered as a chronic disease that requires the
development of a long-term management plan for the
patient in order to maximize the use of medication and
exclude repeated surgical interventions." The main
drugs used for the treatment of endometriosis, until
recently, were gonadotropin-releasing hormone
(GnRH) agonists. However, their long-term use is
limited due to the development of severe symptoms of
hypoestrogenism.
Hormonal
drugs
with
an
antiproliferative effect can be used as drug therapy. It
is known that the endometrium of patients with
endometriosis has distinctive features. The obtained
data on the increased proliferative activity of both
ectopic and eutopic endometrium were highlighted in
the works of Kiselev S.I. (2011), Sukhoi G.T. (2012),
Sonova M.M. (2019), Zarubina I.P. (2016), etc.
The most common and widely used marker of
proliferation in tissues is Ki-67. According to published
data and presented at the 11th International Congress
on Endometriosis in 2011 in Montpellier, a promising
group of drugs for the long-term treatment of
endometriosis with antiproliferative action 4 5 are
progestins and their representative drug dienogest,
which appeared in 2012 in our country. There are few
studies in the world evaluating its effectiveness and
pathogenetically justifying its inclusion in the therapy
of endometriosis. However, new data are needed for
widespread implementation into practice. Another
important problem of endometriosis is the delay in its
diagnosis. According to a global multicenter global
study on 5 continents in 16 countries, the delay in
diagnosis of the disease is on average up to 7 years
(WERF, 2015). The study of the causes leading to such
a long delay in establishing a diagnosis is a promising
direction of modern scientific research. It is known that
the main clinical manifestations of endometriosis
manifest in the form of pelvic pain in 40-70%, infertility
in 25-40% of cases and menstrual disorders
[14,16,18,20,22,25].
Pain often increases during sexual intercourse and
during menstruation. Pain during sexual contact often
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forces the patient to avoid sexual activity, and severe
dysmenorrhea leads to loss or decrease in working
capacity. The first manifestations of the disease occur
during the period of time when women receive
education, build a career, partner relationships and
create a family. Pain syndrome and infertility, partial
disability have an extremely negative impact on the
quality of life, hinder the disclosure of potential and the
full realization of women's opportunities. This makes it
possible to consider endometriosis a socially significant
disease related to the key problems of the 21st century.
According to Adamyan L.V., 2015 and Chapron C. et al.,
2016, there is a tendency in modern society towards
late and minimal realization of reproductive function in
young women. Regular menstruation for a long period
of time and frequent casting of endometrial cells into
the abdominal cavity can increase the risk of
endometriosis. This point of view is indirectly
confirmed by the increase in the frequency of NGE in
recent decades, which may be associated with an
increase in the social activity of a woman, which causes
a delay in the age of the first birth, a reduction in the
number of pregnancies and a short lactation period. In
this connection, modern women menstruate on
average 10 times more than their ancestors. The study
of the peculiarities of reproductive function and social
factors in women with endometriosis will allow the
formation of risk groups of patients and timely
influence the progression and outcome of the disease.
The above literature data indicate the expediency of in-
depth study of the medical problem of endometriosis,
taking into account social factors.
The purpose of the study
Improving the effectiveness of treatment and
prevention of endometriosis, taking into account
significant medical and social factors.
MATERIALS AND METHODS
The dissertation includes materials of observation of
280 women with external genital endometriosis who
were examined and treated in gynecological
departments of the bases of the Department of
Reproductive Medicine and Surgery of the FPDO.
Inclusion criteria: the presence of a verified diagnosis
based on laparoscopy and histological examination,
reproductive age. Exclusion criteria: malignant
neoplasms, severe, chronic extragenital pathology in
the stage of decompensation, systemic diseases.
All patients with external genital endometriosis were
divided into 2 groups depending on the presence of
pain syndrome. 152 (54%) patients were included in
group 1 with the presence of pain syndrome, 128 (46%)
patients were included in group 2 without pain
syndrome. In group 1 with pain syndrome, depending
on the type of hormone therapy received in the
postoperative period, two subgroups of the subjects
were identified. Subgroup 1A included 38 patients with
the presence of pain syndrome who received
leuprorelin acetate (3.75 mg intramuscularly once
every 28 days). The first injection was carried out in the
period from the 1st to the 5th day of the menstrual
cycle. Subgroup 1B included 38 patients who received
dienogest (2 mg per day orally in a continuous mode).
Surgical treatment was carried out in the proliferative
phase of the cycle. The total duration of treatment
with leprorelin and dienogest was 6 months.
In order to quantify pain symptoms, determine the
severity and intensity of pain, a Visual analog Scale
(VAS) was used, representing pain gradations from 0
(no pain) to 100 points (unbearable pain). Each patient
was asked to make a mark on this line corresponding
to the intensity of the pain she was experiencing at the
moment. Every centimeter on the visual analog scale
corresponds to a certain score. In the course of the
study, a questionnaire was developed and used to
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Servi
study the quality of life of endometriosis patients
"Health profile of endometriosis patients" based on a
specialized questionnaire on endometriosis EHP-30.
The questionnaire includes 67 questions and is divided
into 2 parts: a basic part suitable for all women and a
modular part. The basic part includes the following
scales: pain syndrome, vital activity, emotional
component, social functioning, self-esteem. The
modular part includes such scales as work, relationship
with children, sex life, infertility, attitude to health
workers, attitude to treatment. Each scale of the basic
and modular parts is calculated according to formulas
on a scale from 0 to 100: 0 is the best possible health
status, 100 is the worst possible health status.
The majority of patients (90%) with external genital
endometriosis were of active reproductive age. At the
same time, in the group with pain syndrome,
endometriosis was diagnosed a little earlier at the age
of 29 0.1 years due to the presence of pain symptoms
(dysmenorrhea, dyspareunia, HTB), which significantly
reduce the quality of life and require medical
diagnostic laparoscopy to verify the diagnosis and
surgical treatment. In patients of group 2, which
included mainly women with no pain syndrome,
diagnostic laparoscopy was more often performed to
determine the cause of infertility at the age of 32 0.35
years.
In the study, much attention was paid to the study of
the social status of patients with endometriosis. Social
status is the position that a person occupies in society.
A person can be the owner of several social statuses.
Such parameters of social status as the level of
education, the presence or absence of a family, data on
the place of residence and the level of total income per
1 family member per month were studied. The analysis
of the results showed that the average age of patients
in group 1 was 29.71±7.72, in group 2 of the study -
32.15±7.62 (p≤0.05).
The data obtained indicate the presence of a
statistically significant strong direct correlation
between the severity of pain syndrome and the
negative impact on working capacity in women with
endometriosis with Spearman's rank correlation
coefficient r=0.649 (p=0.001). In addition, the study
obtained similar data and noted the presence of a
direct correlation during the correlation analysis
between the severity of the pain syndrome and the
effect on the parameter "vital activity"(r=0.63 and
p=0.001), between the severity of the pain syndrome
and the negative impact on sexual life (r=0.47 and
p=0.001). Thus, our study proved that pain syndrome in
endometriosis is a key parameter that has a negative
impact on the quality of life of patients.
The data obtained show that by the end of treatment,
the intensity of pain significantly decreased in patients
of both groups equally (p < 0.05). There were no
differences in this indicator. In the group with GnRH a
treatment, significantly more pronounced side effects
were observed compared to the group taking
dienogest. The same data were obtained in the studies
of Harada T. et al., (2007), Cosson M. et al., (2002),
Strowitzki T. (2010). Dienogest is a new therapeutic
agent for our country specifically for the treatment of
endometriosis, which dictates the need to study the
effect of the drug in the population of Uzbek women.
According to the recommendations of the SOGC
Clinical Practice Guideline (2008), as well as the latest
consensus on the management of patients with
endometriosis
(MONTPELLIER,
2011),
oral
monotherapy with progestins refers to 1-line therapy.
Our study showed that the results of treatment with
dienogest and leuprorelin from the standpoint of
resolving pelvic pain and improving quality of life
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Servi
indicators are comparable. However, the tolerability of
dienogest was significantly better compared to that
when using leuprorelin due to the few side effects and
better tolerability of dienogest. Our study showed the
high effectiveness of dienogest therapy in women with
pain syndrome, few side effects, which contributes to
the choice of optimal treatment for endometriosis.
CONCLUSIONS
1. Statistically significantly reduced quality of life
indicators were noted in women with endometriosis.
At the same time, women in the group with pain
syndrome had significantly lower quality of life
indicators compared to the group without pain
syndrome in the following categories: "pain", "vital
activity", "emotional state", "social functioning", "self-
esteem", "work life", "relationships with children",
"sex life".
2. In the algorithm of management of women with
external genital endometriosis, it is advisable to
include a study of the quality of life using the
developed questionnaire "Health profile of patients
with endometriosis", as well as the use of a visual
analog scale (VAS) when assessing pain syndrome as a
simple and objective criterion for assessing pain in
clinical practice.
3. In order to prevent relapses and improve the quality
of life, it is advisable to carry out complex treatment,
including surgical intervention followed by hormone
therapy with the inclusion of the drug dienogest along
with analogues of Gn-Rg.
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