Volume 03 Issue 01-2023
7
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
I
SSUE
01
P
AGES
:
07-13
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
ABSTRACT
The results of the assessment of ovarian reserve before and after the use of various methods of treatment based on
ultrasound (counting the number of antral follicles) and biochemical methods showed that the levels of anti-Müllerian
hormones and the number of antral follicles were lower in patients with bilateral ovarian disease, and were
significantly lower in the group with combined treatment. Pregnancy occurred within a year after the end of treatment
in 9 (12,7%) women of the first group and in 21 (22,6%) of the second group.
KEYWORDS
Ovarian cysts, hormonal and combined treatment, AMH, dienogest, endometrium.
INTRODUCTION
Endometriosis is one of the most common diseases of
the female genital area. Although its true prevalence in
the general population of women of reproductive age
is not clearly defined, according to the latest
epidemiological data, the detectability of the disease in
the group of women of reproductive age is 30%, while
the detection rate on sectional material approaches
53.7% [1]. In patients suffering from pelvic pain
syndrome, endometriosis is detected in 38.8%, and in
case of infertility
—
in 50% of cases [13,15,17,19,21,23].
An important fact is the financial costs necessary for
the treatment of this pathology. Thus, according to the
Research Article
OVARIAN ENDOMETRIOSIS: NEW ASPECTS OF TREATMENT
Submission Date:
January 09, 2023,
Accepted Date:
January 14, 2023,
Published Date:
January 19, 2023
Crossref doi:
https://doi.org/10.37547/ijmscr/Volume03Issue01-02
Norova K.M
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
8
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
I
SSUE
01
P
AGES
:
07-13
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
American Fertility Society, over the past 10 years, the
cost of treating patients with endometriosis has
increased by 61% [1].
Ovarian damage is considered one of the most
common manifestations of endometriosis. It occurs as
a result of the growth of the ectopic endometrium in
the ovary [3]. Being detected in 17-44% of the total
number of patients with endometriosis [89,160],
ovarian endometriosis (OE) ranks second among all
localizations of this pathology and first in the group of
external genital endometriosis (OGE) [1,3,5,7,9,11].
There is not a single epidemiological study showing the
frequency of the spread of ED in different periods of a
woman's life. It has recently been shown that EYA can
develop in adolescent girls before menarche [5]. This
supports the opinion that the early onset of
endometriosis, including ovarian damage, may develop
as a result of the casting of endometrial stem cells
during neonatal uterine bleeding in newborn girls [1].
ED has a negative effect on reproductive function,
often accompanied by generalization of the
pathological process [21]. The frequency of infertility in
patients with NGE reaches 50%, ranking third in the
structure of infertility, and has no tendency to
decrease [25]. An important feature of the course of
the disease is its recurrent nature. Relapses occur both
after surgical treatment and against the background of
hormone therapy and after its cancellation [4].
Repeated surgical interventions can cause irreversible
changes in the ovaries, leading to depletion of the
follicular reserve [2,4,6,8,10,12].
The facts described above suggest that the problem of
studying endometrioid ovarian cysts (ECTS) continues
to remain relevant because ECTS account for up to 59%
in
the
structure
of
genital
endometriosis
[14,16,18,20,22,25].
Despite numerous studies of various aspects of
endometriosis, there is currently no consensus on the
pathogenetic mechanisms and treatment regimens for
endometriosis. To date, the most promising areas in
the study of endometriosis are the study of molecular
biological characteristics of cells of the eutopic and
ectopic endometrium, markers of proliferation and
apoptosis, adhesion, angiogenesis and cell invasion,
analysis of genetic features in endometriosis and the
influence of epigenetic factors on the development of
this disease, which can contribute to further
understanding of etiopathogenesis to substantiate
new approaches to diagnosis and effective treatment.
The purpose of the study. Improvement of methods of
diagnosis and prevention of external genital
endometriosis based on the study of the pathogenesis
of relapses of endometriodic ovarian cysts.
MATERIAL AND METHODS
In accordance with the set goals and objectives, we
examined and treated 164 patients of reproductive age
with ovarian endometrioid formations. Depending on
the individually selected tactics and the treatment
performed, the patients were divided into two groups.
The first group included 71 women with endometrioid
ovarian cysts, who, according to international and
domestic clinical recommendations, underwent
empirical hormonal treatment with Dienogest at a
dose of 2 mg (the drug is officially registered in the
Russian
Federation
for
the
treatment
of
endometriosis). The duration of therapy is from 3 to 12
months. The second group consisted of 93 patients
who underwent combined treatment. In this group,
therapeutic
and
diagnostic
laparoscopy
with
cystectomy was performed at the first stage, hormone
therapy was performed at the second stage. The main
indications for therapeutic diagnostic laparoscopy
were: severe pain syndrome; the presence of
Volume 03 Issue 01-2023
9
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
I
SSUE
01
P
AGES
:
07-13
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
endometrioid ovarian cysts more than 3 cm (according
to examination and ultrasound of the pelvic organs);
infertility in combination with late reproductive age
(over 35 years). The criteria for inclusion in the study
were: reproductive age up to 35 years; primary and
recurrent ECI confirmed by ultrasound examination
(patients with cysts up to 3 cm were included in group
1 and more than 3 cm in group 2); clinical
manifestations of external genital endometriosis:
menstrual cycle disorders (meno- and metrorrhagia),
pain in the lower abdomen and lumbar region of
varying
intensity,
dyspareunia,
endometriosis-
associated infertility. Exclusion criteria from the study:
absence of ovarian endometriosis; the presence of
combined infertility factors (tuboperitoneal, uterine,
male); the patient's refusal to participate in the study.
A comprehensive examination of the patients included
the results of anamnestic and clinical data assessment;
ultrasound examination of the pelvic organs (on the
5th-7th day from the beginning of menstruation),
performed in 2D modes using devices "Madison X 8"
(Korea), "Fucuda Denshi" (Japan), related to the
contact scanning system using transabdominal and
transvaginal sensors with a frequency of 3.5 and 5.0
MHz; studies of the level of anti-Muller hormone
(AMH) in the blood serum (on the 3rd day of the
menstrual cycle) by enzyme immunoassay performed
before surgical treatment. To determine the level of
AMH, the Vector-BEST test system (Russia) was used;
the results obtained were compared with the
reference values of hormones for women of
reproductive age in the follicular phase of the
menstrual cycle: AMH - 1.00
–
10.60 ng/ml (regardless of
age). A study of the concentration of cancer markers
CA-12 was conducted using the test system "Vector-
BEST" (Russia); the obtained data were compared with
reference values of CA 125-0.0-35.0 IU/ml. Biometric
analysis was carried out using the Statistica 6 package
and the Microsoft Excel program. In all statistical
analysis procedures, the critical significance level p was
assumed to be 0.05. When studying menstrual
function, it was found that in all patients the average
age of menarche was 13.1 +1.2 years. The vast majority
of women
–
134 (81.7%) - had menstruation with
menarche. The analysis of reproductive function
showed that 98 (59.6%) patients had one or more
pregnancies, primary infertility was diagnosed in 66
(40.2%) patients, secondary infertility in 98 (59.6%).
Among the gynecological diseases previously suffered,
106 (64.6%) patients had inflammatory processes of
the uterine appendages, for which inpatient and/or
outpatient treatment was carried out, 64 (39.0%) had
abnormal uterine bleeding. The duration of
endometriosis in patients varied in the first group 2.4 ±
0.1 years, in the second
–
3.1 ± 0.1 years. The main
clinical manifestations of the disease were pelvic pain
of varying intensity in 62 (87.3%) patients of the first
group and 87 (93.5%) of the second; dysmenorrhea in
18 (25.4%) of the first group and 28 (30.1%) of the
second; dyspareunia in 9 (12.7%) patients of the first
group and 14(15.1%)
–
the second group. In 128 (78.1%)
women, the ovarian lesion was unilateral, in 36 (21.9%)
a bilateral pathological process was diagnosed. The
study of the results of clinical examination of patients
with endometrioid ovarian cysts did not reveal a
correlation of clinical manifestations of the disease
with the size of cysts. In patients of both groups,
complaints of pain in the lower abdomen, unrelated to
menstruation and sexual intercourse, and primary
infertility prevailed. All patients before and after
surgery were evaluated ovarian reserve, using
ultrasound and biochemical methods. During
transvaginal echography, antral follicles were counted
in real time, and the volume of the ovary was calculated
using sonograph software ("Madison X 8" (Korea) and
"Fucuda Denshi" (Japan). In addition, resistance
indices (IR) in the arteries feeding the ovaries were
evaluated in the mode of color Doppler mapping
Volume 03 Issue 01-2023
10
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
I
SSUE
01
P
AGES
:
07-13
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
(CDK). To assess the blood supply to the ovaries using
ultrasound Dopplerometry, three different vascular
regions were used in which blood flow velocity curves
were recorded: ovarian artery; ovarian gate; ovarian
parenchyma; ovarian cyst wall. Ultrasound diagnosis of
endometrioid ovarian cysts was established by
visualization of the following echo signs:
‒
single
‒
chamber formation of a rounded or oval shape; -
unevenly thickened wall from 1.0-6.0 mm;
‒
wall
hyperechoic inclusions of a homogeneous structure
with a diameter of 5-10 mm;
‒
hypo-, iso-, hyperechoic
contents with a non-displaced fine suspension;
‒
with
CDK
‒
single vessels in the wall with an IR of 0.5-0.6;
‒
no changes in the echostructure during dynamic
observation in different phases of the menstrual cycle.
In order to determine the ovarian reserve, we used the
determination of the level of anti-muller hormone
(AMH) in the blood serum on the 3rd day of the
menstrual cycle before treatment and 1,3,6 and 12
months after treatment. Results and discussion In the
majority of observations in 128 (78.1%) patients,
endometrioid cysts were single-chamber, rounded in
shape. The average diameter varied from 9.7 to 159 mm
(on average
–
42.7± 1.6 mm). In 36 patients,
endometrioid cysts were found in both ovaries, in 79
cases they were localized on the left, in 49
–
in the right
ovary. There were no fundamental differences in the
microstructure
according
to
ultrasound
of
endometrioid implants in patients with different
clinical course of endometriosis. In order to assess the
effectiveness of the treatment, patients of both
groups underwent dynamic ultrasound monitoring and
hormonal status study before the start of treatment
and in terms of 1, 3, 6 and 12 months after the start of
therapy.
The analysis of the results indicates both the presence
of a certain pattern of variations in the ovarian reserve,
and the absence of significant differences in a number
of parameters of the compared groups. Thus, the
volume of ovaries in the group of patients who
underwent surgical treatment was lower than in
patients after conservative treatment. Of course, the
volume of the ovaries is one of the reliable markers of
their functional ability: it is quite logical that with a
decrease in the volume of the ovaries, the number of
antral follicles decreases. This postulate is reflected in
our research. Along with a decrease in ovarian volume,
there was a significant decrease in the number of antral
follicles in patients after surgical treatment: 2.9±0.4
versus 3.9±0.2 in the 1st group of women. In a study by
C.M. Ercan et al. (2010), when assessing blood flow in
the ovaries, a significant decrease in dopplerometric
parameters of peripheral vascular resistance (IR) was
found in patients after surgical treatment of
endometrioid ovarian cysts [24]. In particular, by the
3rd month of follow-up, PI decreased from 2.22±0.46 to
1.76±0.51; IR increased from 0.81±0.06 to 0.88±0.13. In
a similar study, G.Pados et al. no such pattern was
found [21]. We also have not established a reliable
probability of differences in the so-called carbon-
independent indices of peripheral vascular resistance.
In our opinion, this is due to the relatively small
diameter of the ovarian vessels, the identification of
which is difficult and therefore differs in a certain
subjectivity. To date, the assessment of the level of
AMH is rightfully considered the leading criterion of
ovarian reserve. According to many researchers, in this
regard, the assessment of the secretion of AMH level
has the greatest sensitivity. The results of our study
showed that the level of AMH in women of group 1
before treatment was 3.02± 0.3 ng/ml, group 2 - 2.4±0.1
ng/ml.
It is known that the level of AMH correlates with the
number of antral follicles, which is explained by the
fact that, unlike other hormonal markers of the ovarian
reserve, AMH expression is less affected by FSH than
Volume 03 Issue 01-2023
11
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
I
SSUE
01
P
AGES
:
07-13
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
E2 expression. It is believed that this is caused by the
fact that AMH is secreted not only by antral, but also
by primary and preantral follicles that are not affected
by FSH [20,23,25]. As can be seen from Table 2, in our
studies, the values of AMH varied in both groups. Thus,
the minimum values of AMH in patients of the
compared groups were 2.26 and 0.98 ng/ml after 12
months, and the maximum values of AMH
–
3.02 and
2.4 ng/ml in groups 1 and 2, respectively, were at the
beginning of the study. In general, according to the
main indicators (ovarian volume, number of antral
follicles, AMH concentrations), the ovarian reserve in
group 1 patients was significantly higher than in
women after combined treatment. The problem of
surgical treatment of patients with ovarian
endometriosis is quite acutely discussed in the modern
literature [12,11,23,25]. Most authors have a negative
attitude to "traditional" cystectomy (complete
hatching of an ovarian cyst) in women interested in
preserving
reproductive
function,
since
the
consequences of such operations are partial (less often
complete) loss of primordial follicles. Thus, in the study
of N.G. Mishieva et al. it is stated that any ovarian
resection negatively affects the ovarian reserve [14].
A.V. Morozova and A.I. Ishchenko, studying the results
of the use of assisted reproductive technologies (ART)
in patients after endosurgical treatment for
endometrioid ovarian cysts, came to the conclusion
that the frequency of pregnancy in women who
underwent surgery on the ovaries was 2 times lower
compared to that in women who did not have
operations on the appendages of the uterus,
–
21 and
42%, respectively [15]. According to a number of
authors, in patients with endometriodic cysts of
relatively small size (up to 3 cm in diameter), it is
advisable to refrain from surgical intervention either
before pregnancy [15], or to carry out treatment after
receiving a woman's own genetic material in an ART
program. A decrease in ovarian reserve during surgical
treatment of ovarian endometrosis is shown in studies
by G. Pados et al. (2010). In their work, as markers of
ovarian reserve, they relied on ultrasound parameters
–
the number of antral follicles, ovarian volume,
parameters of peripheral vascular resistance (IR),
which were studied 6 months after surgery. If,
according to the last three indicators, it was not
possible to detect significant differences in the
compared groups, the number of antral follicles was
significantly higher in the group of women who were
treated with endometrioid ovarian cysts using a three-
stage method: 4.36±0.8 and 2.38±0.78 (p = 0.002),
respectively [25]. Conclusion Our studies confirm the
ambiguity of approaches to the choice of treatment
method for patients with endometriodic ovarian cysts.
This is especially important for patients with unrealized
reproductive function, since surgical treatment of
endometriosis can worsen the fertility problem. In this
regard, surgical principles of treatment of patients
with endometriodic ovarian cysts should be based on
the most careful attitude to the ovaries. In certain
situations (relapses of endometrioid cysts, single
ovarian cyst), it may be more appropriate to use less
traumatic methods of aspiration treatment of cysts
under the control of transvaginal echography. This
issue requires further study.
REFERENCES
1.
Alammari R., Lightfoot M., Hur H.C. Impact of
Cystectomy on Ovarian Reserve: Review of the
Literature. J Minim Invasive Gynecol. 2017
Feb;24(2):247- 257.
2.
Andres M.P., Borrelli G.M., Ribeiro J., Baracat E.C.,
Abrao M.S., Kho R.M. Transvaginal Ultrasound for
the Diagnosis of Adenomyosis: Systematic Review
and Meta-Analysis. J Minim Invasive Gynecol. 2018
Feb;25(2):257-264.
Volume 03 Issue 01-2023
12
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
I
SSUE
01
P
AGES
:
07-13
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
3.
Muhkhayohon
Tukhtasinovna
Khamdamovа,
Munira Muroтovna Baratovа .Modern concepts on
the etiopatogenesis of background and precancer
diseases of the cervix. ScienceAsia 48 (2022): 31-38
doi: 10.2306/ scienceasia1488-1295.2022.SE009
4.
Barreta A, Sarian L, Ferracini AC, Eloy L, Brito ABC,
de Angelo Andrade L, Derchain S. Endometriosis-
Associated
Ovarian
Cancer:
Population
Characteristics and Prognosis. Int J Gynecol
Cancer. 2018 Sep;28(7):1251-1257.
5.
Chandra A., Rho A.M., Jeong K., Yu T., Jeon J.H.,
Park S.Y. et al. Clinical experience of long-term use
of
dienogest
after
surgery
for
ovarian
endometrioma. Obstet Gynecol Sci. 2018;61(1):111-
117.
6.
Khamdamova M. T. Еchographic feat
ures of the
range of variability in the size of the uterus and
ovaries in women of menopausal age using oral
and injectable forms of contraception //American
Journal of Medicine and Medical Sciences. - 2020. -
N10 (8). - P.580-583.
7.
Khamdamova M. T.Еchogr
aphic features variability
in the size and shape of the uterus and ovaries in
women of the second period of adulthood using
various
contraceptives
//Asian
Journal
of
Multidimensional Research - 2020.
–
N9 (5). - P.259-
263.
8.
Khamdamova M. T.,Rabiev S. N. Аna
tomical and
clinical
correlations
of
fetal
development
assessment in women with different div types
and height // ScienceAsia 48 (2022): 23-29 doi:
10.2306/ scienceasia1488-1295.2022.SE008.
9.
Khamdamova M. T.Somatometric characteristics
of women of the first and second period of
adulthood using different contraceptives with
different div types // The american journal of
medical sciences and pharmaceutical research -
2020.
–
N8 (2).- P.69-76.
10.
Khamdamova
M.T.,Barotova
М.М.
Modern
concepts about diseases of the cervix // Biology
and Integrative Medicine . ISSN 2181-8827 2022.
№1январ–
феврал (54).С.70
-77.
11.
11.Khamdamova M. T. Age and individual variability
of the shape and size of the uterus according to
morphological and ultrasound studies //Problems
of
biology and medicine. 2020, №1 (116).
-
Р.283
-286.
12.
12.Khamdamova
M.
T.
Аge
echographic
characteristics of the uterus and ovaries in women
of the first and second period of middle age //
Biology and integrative medicine. ISSN 2181-8827
2020. №2
- March-April (42).-
Р.75
-86.
13.
Khamdamova M. T.Аnthropometric characteristics
of the physicalstatus of women in the first
andsecond period of middle age // New day in
medicine. 2020. -
№ 1 (29).
-
Р.98
-100.
14.
Khamdamova
M.
T.Аge
echographic
characteristics of the uterus and ovaries in
womenof the first and second period of middle age
// Biology and integrative medicine .
–
Bukhara.
2020. №2 (42)
-
Р.75
-86.
15.
Evropejskoe
rukovodstvo
po
lecheniju
dermatologicheskih
zabolevanij
[European
guidelines the treatment of dermatological
diseases]. In A.D. Kacambas, T.M. Lotti (ed.); per. s
angl. 2-e izd. Moscow: MEDpress-inform, 2009 736
p.
16.
Khamdamov I.B., Khamdamov A.B. Сlassification
and properties of mesh explants for hernioplasty
of hernial defects of the anterior abdominal wall
(review) // Biology and integrative medicine. ISSN
2181-
8827 2021. №5 –
март
-
апрель (52).C.12
-22.
17.
Khamdamov
I.B.,
Khamdamov
A.B.
Еndovideosurgical hernioplasty in women of fertile
age // New day in medicine. 2021. №6 (38/1).P.25
-27.
18.
Хамдамова М.Т. Ультразвуковая особенности
трехмерный эхографии в оценке состояния
эндометрия и полости матки у женщин первого
Volume 03 Issue 01-2023
13
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
I
SSUE
01
P
AGES
:
07-13
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
периода среднего возраста применяющие
внутриматочные контрацептивные средства //
Биология ва тиббиёт муаммолари.
-
Самарканд,
2020. -
№2 (118).
-
С.127
-131.
19.
Khamdamova M. T. Ultrasound аssessment оf
changes in the endometrium of the uterus in
women of the first and second period of middle
age
when
using
intrauterine
and
oral
contraceptives // Биомедицина ва амалиёт
журнали. –
Ташкент, 2020.
-
№2.
-
8 часть.
-
С.79
-
85.
20.
Khamdamova M. T., Barotova М.М. Сlinical aspects
of the use of laser photodynamic therapy in
cervical pathology // American Journal of Medicine
and Medical Sciences 2021, 11(4): 353-355 DOI:
10.5923/j.ajmms.20211104.19
21.
Хамдамова М.Т. Индивидуальная изменчивость
матки и яичников у женщин применяющие и не
использующие
различные
виды
контрацептивные средства // New day in
medicine. - 2020. -
№ 3 (31).
- C. 519-526. (14. 00.02;
№22).
22.
Khamdamova M. T.,Urinova Sh.A. Innovative
method of teaching students of thedepartment of
gynecology // New day in medicine. 2022 №2(40),
march, april , Р.432
-435.
23.
M. T. Khamdamova, S.N. Rabiev. Somatometric
characteristics of pregnant women with different
div types. Europe's Journal of Psychology 2021,
Vol.
17(3),
215-220
https://doi.org/10.5998/ejop.5473
24.
M.T. Khamdamova, S.N. Rabiev. Anatomical and
clinical
correlations
of
fetal
development
assessment in women with different div types
and height. ScienceAsia 48 (2022): 23-29 doi:
10.2306/ scienceasia1488-1295.2022.SE008
25.
Grzelak M.M., Chmura L., Wrobel P.M., Adamek D.,
Lankosz M., Jach R., Welter E. Investigation of the
role and chemical form of iron in the ovarian
carcinogenesis process. J Trace Elem Med Biol.
2020;60:126500.
