medical science does not stand still, and today for the timely identification of various gynecological diseases Physicians, along with the traditional long-tested methods, use a number of the latest techniques to get a more accurate idea of ​​the origin, nature of the course and degree of development of gynecological pathologies. In the arsenal of a doctor in our time there is a large number of diagnostic methods female diseases, the main ones being:

anamnesis;

· grade general condition;

inspection;

laboratory diagnostics;

instrumental diagnostics;

Anamnesis and assessment of general condition

What is an anamnesis? Anamnesis - a set of information that the doctor finds out by questioning the patient. Anamnesis data is obtained at a gynecologist's appointment and is used to select a diagnostic method, as well as to prescribe the necessary therapy. When collecting an anamnesis from women suffering from diseases of the reproductive system, specialists pay attention to the patient's complaints, age, lifestyle and quality of nutrition, the presence of bad habits, living and working conditions. Important for the correct diagnosis are information about previous diseases, the nature of the contraceptive methods used, the number of births and abortions or other operations on the genitals. In the process of collecting necessary information the gynecologist gets a general idea of ​​the history of the disease present today.

What does a general health assessment include? To assess the general condition of the patient, the doctor needs to have information about the presence mental disorders and disruption of the metabolism, about the existing cardiovascular diseases and predisposition to the development of malignant neoplasms. The gynecologist begins the assessment of the general condition of a woman with an external examination, paying attention to the physique, height and body weight, as well as to the features of the distribution of adipose tissue. During external examination, special attention is paid to assessing the condition skin- their color, the nature of hair growth, increased porosity and more. At this time, the condition of the mammary glands, lymph nodes is carefully examined, the lungs are auscultated and a thorough palpation of the abdomen is performed.

Communication with the patient is an integral part of the work of any doctor, the ability to correctly ask a question and listen carefully to the answer to it in most cases helps in making an accurate diagnosis. Today, many specialized sites provide an online gynecologist service that will help you get answers to many questions.

How is the inspection carried out? This diagnostic method includes examination of the external and internal genital organs with the help of special tools. In most cases, a gynecologist's examination is performed on a gynecological chair - the patient's legs lie on special supports, and the buttocks are on the edge of the chair. This position allows you to carefully examine the vulva and easily insert instruments into the vagina to diagnose the condition of the internal female organs.

When examining the external genitalia, the gynecologist pays attention to the size of the large and small labia, as well as the condition of the mucous membranes. The size of the clitoris, the nature of the hairline and the condition of the perineum are of no small importance for the diagnosis. At the time of examination of the external genitalia, it is possible to identify the occurrence of inflammation, tumors, warts, scars and fistulas - these pathologies can “tell” a lot to a specialist about the presence of certain diseases in the body, especially of an infectious nature. When examining the external genital organs, the gynecologist will offer the woman to push, which will make it possible to find out if there is a problem with the prolapse of the uterus and vagina.

Why is it necessary to examine the internal genital organs? Inspection inner walls the gynecologist produces the vagina and cervix using mirrors. These studies are usually carried out before bimanual diagnostics. Examination by mirrors is indicated only for those women who are sexually active. This method helps to recognize the presence of diseases of the cervix (erosion, polyps and other pathologies), during such an examination, smears are taken to detect violations of the microflora and to conduct cytological studies. Examination with mirrors allows, if necessary, to conduct a biopsy of various neoplasms of the vagina and cervix.

What is a bimanual study? Bimanual examination, that is, examination with the help of hands, is carried out after removing the mirrors. This method consists in palpation of the walls and arches of the vagina, as well as the cervix. Bimanual diagnostics allows you to determine volumetric neoplasms and anatomical changes in the internal genital organs of a woman.

Laboratory diagnostics

In practice, laboratory studies are used to detect various pathogens and to identify the degree of oncogenicity of pathological processes. The main methods laboratory diagnostics today are PCR diagnostics, bacterioscopic and cytological studies.

Why do you need PCR diagnostics? PCR diagnostics is a method that allows you to determine the presence of the disease, even if there is a small amount of pathogen DNA molecules. This method helps to identify the occurrence in the body of such dangerous viral infections as various types of hepatitis, HIV, herpes, papillomavirus, chlamydia, mycoplasmosis, gonorrhea and others. These PCR infections are extremely dangerous for human health and life, so it is very important to determine their presence on early stage, and PCR diagnostics will become an indispensable assistant for this.

What is the essence of bacterioscopic and cytological studies? Bacterioscopic studies are used to diagnose various inflammatory diseases. Their results help to accurately determine the etiology of the inflammatory process. Bacterioscopy determines the degree of purity of the vagina, therefore douching and vaginal treatment are prohibited before it is carried out. medicines. This method consists in taking a smear from the urethra with a specially designed instrument, posterior fornix vagina and cervical canal and sent to the laboratory for research. Bacterioscopic examination is indicated before any gynecological operations.

Cytological studies are aimed at detecting the occurrence oncological diseases in the early stages of development. To do this, smears are taken from the surface of the cervix or cervical canal. To conduct such studies, you can also use the material obtained by taking a puncture from bulk neoplasms. The development of the pathological process in this case is recognized by the morphological features of the structure of cells, by the ratio of individual groups and the location of cellular elements in the test preparation.

Data laboratory research enable the gynecologist to determine the cause of the development of any pathological process and prescribe a treatment suitable for each specific case. The online gynecologist service will help you understand the results of the tests and seek help from a specialist in time. Research in gynecology in our time is aimed primarily at preventing the occurrence of diseases of the female genital organs, so a timely visit to a specialist and periodic gynecological examinations will save you from health problems in the future.

Instrumental diagnostics

The main methods of instrumental diagnostics today are: colposcopy of the cervix, ultrasound, computed (CT) and magnetic resonance imaging (MRI).

What is a colposcopy? Such a research method as colposcopy is used today quite widely and is characterized by high diagnostic efficiency. This method allows you to assess the condition of the vulva, the walls of the vagina and the surface of the cervix using a special device - a colposcope, which gives an increase in the object by 30-50 times. Colposcopy of the cervix allows you to identify precancerous conditions in the early stages of development, makes it possible to choose the right site for a biopsy, helps to control the treatment process.

Now in practice, two methods of this instrumental examination are used: simple and extended colposcopy. A simple one allows you to determine the main parameters of the state of the cervix - its size, color, relief of the mucous membrane, as well as the state of the mucous epithelium. An extended colposcopy differs from a simple one in that the cervix is ​​treated with a 3% solution before examination. acetic acid, causing short-term edema of the epithelium and a decrease in blood flow. This makes it possible to see pathologically altered cells and clearly define areas for biopsy.

What is the essence of ultrasound, CT and MRI? These diagnostic methods are non-invasive, so they can be used to detect pathologies, regardless of the patient's condition. Ultrasound today is most often used to monitor the intrauterine development of the fetus, as well as for the early diagnosis of diseases of the uterus, its appendages and the detection of abnormal development of the internal genital organs.

Gynecological examination is an objective assessment of the health of a woman of any age. The meaning of the survey is invested in visual inspection, sampling for analysis, and instrumental research. Each patient should undergo preventive examination 1-2 times a year. If the patient's history contains any chronic diseases pelvic organs, suspected STIs, then visits to the gynecologist should be made at least 1 time in 3 months. This will quickly prevent the development of exacerbations and identify other pathologies at the very beginning of development.

Types of diagnostic examination

The tactics of examining a patient completely depends on her age, status, and the final goal of the study. All research methods in gynecology are classified in several areas and ways to achieve diagnostic goals. There are rectal, rectovaginal, vaginal (bimanual) examination with and without a mirror.

Usually gynecologists use several types of examinations at once for more reliable information. An examination of the genital organs is performed using an examination with gynecological instruments and is necessary to compile a holistic clinical picture. The color of the skin and mucous membranes, the condition of the skin, the presence of rashes or irritation, hair growth, the nature of the discharge, and the smell are taken into account.

Examine the contours of the anatomical structures, exclude the presence of pathologies or tumor-like formations by palpation of the outer walls of the vagina from the side of the peritoneum and from the inside with a finger. The gynecologist takes into account the condition of the perineum, perianal region and urethral canal. Some types of inspections include:

The smaller size of the uterus may indicate its infantility or the course of menopause. An increase in the size of the uterus is possible during pregnancy or tumors. The shape of the uterus during pregnancy has a spherical appearance, and with neoplasms - pathologically altered contours.

It is important to support a gynecological examination with laboratory results and instrumental examination data.

It is important to correctly convey the goals that are achieved during the study, for example, the exclusion of diseases, preparation for pregnancy, routine preventive examination, and so on.

Indications for examination and necessary tests

It is not always necessary to look for special reasons to visit a gynecologist, but many women usually neglect preventive examinations and go to the doctor already upon the discovery of symptoms of a disease or upon ascertaining the fact of pregnancy. The following conditions may serve as additional indications for examination:

Before examination, the doctor visually evaluates the patient's figure, the amount of hair in intimate places, hormonal status. It is important to remember that you need to answer the doctor's questions honestly, because this is part of diagnostic measures and will provide a more accurate clinical picture. For example, it is necessary to answer questions about sexual life, the nature of menstruation, about a partner, about the presence of serious diseases in history (for example, STIs).

During the examination, the following methods of examination of gynecological patients can be applied:

If serious pathologies are detected, minimally invasive research methods and surgical intervention can be prescribed:

Only one analysis or procedure is not enough to make a diagnosis. To detect gynecological diseases or abnormal pregnancy carry out comprehensive examination carefully study the general clinical history of the patient.

Features of the diagnosis of STIs and bacteriological examination

A gynecological examination for STIs has some peculiarities, so it is very important to seek help immediately after questionable sexual intercourse. STIs are sexually transmitted infections, that is, infection occurs during sexual intercourse.

All sexually transmitted infections are classified into:

• infections caused by microbes(syphilis or gonorrhea);
• infections caused by protozoan microorganisms(trichomoniasis);
• hepatitis (B, C) or HIV.

Scabies, pubic pediculosis are common diseases transmitted through sexual contact.

A timely visit to the doctor will allow you to diagnose the disease and prevent its progression. The smear examination will be more effective when the infection has just joined. As other research methods, analyzes are used for sowing, deployed biochemical analysis blood. For the diagnosis of STIs, it is important to apply all diagnostic methods in combination. Treatment for STIs should be given to both partners. Only a comprehensive gynecological examination can accurately predict the course and success of the entire therapeutic treatment.

Bacteriological research involves growing bacteria in special conditions to study their resistance to certain drugs. The most common approach bacteriological research- bacterioscopy. To study the non-fixed bacterial microflora, two methods are used:

• flattened drop(finding of bacteria between glasses);
• hanging drop.

It is important to remember that unfixed bacteria are extremely contagious. A smear is used for bacterioscopy of fixed bacteria. The most common method of fixing the drug is heating it with a gas burner or using fixing compounds. In the laboratory, fixed bacteria are always stained.

Preparing for the inspection: rules and regulations

Before visiting a gynecologist, it is important to follow all the necessary measures and conduct proper preparation. All these simple rules will allow you to determine as accurately as possible gynecological problem, get full information from the test results, help the doctor prescribe adequate treatment. Before preparing for the visit, it is important to do the following:

A complete gynecological examination includes the disclosure of complete information about the status of one's life, about the number of sexual partners. During the reception, you should not hide facts that may be important for making a diagnosis. You need to trust the doctor in order to fully discuss the existing problem, establish an accurate diagnosis, and exclude relapses of the disease. Removing the psychological barrier should also become the rule for visiting the gynecological office.

STATE EDUCATIONAL INSTITUTION OF HIGHER PROFESSIONAL EDUCATION

OMSK STATE MEDICAL ACADEMY

FEDERAL AGENCY FOR HEALTH AND SOCIAL DEVELOPMENT

METHODOLOGICAL DEVELOPMENT

To a practical lesson with students on a cycle "obstetrics and gynecology"

SUBJECT: « EXAMINATION METHODS IN GYNECOLOGY. DEONTOLOGY IN MEDICINE»

1. TOPIC OF THE LESSON: Methods of examination in gynecology. Deontology in medicine

2. FORM OF ORGANIZING THE EDUCATIONAL PROCESS:

Practical lesson.

3. SIGNIFICANCE OF THE TOPIC:

It is necessary to teach students the methods of taking an anamnesis in gynecological patients, the methodology for conducting a gynecological examination. To acquaint with modern methods of examination in gynecology such as laparoscopy, hysteroresectoscopy, extended colposcopy and other methods used both in outpatient and inpatient settings.

4. PURPOSE OF TRAINING:

To introduce students to the methods of examination in gynecology

5. LOCATION PLACE:

Training room, OR&PM, gynecological department

6. LESSON EQUIPMENT

1. slides, film

2. Phantom.

3. Outpatient cards gynecological patients

4. Tables.

7. Issues studied in related disciplines

Department of Medical Biology with Fundamentals of Genetics

8. DURATION OF THE LESSON

Organizational part - 10 minutes.
Control of the initial level of knowledge - 25 minutes.

Theoretical understanding of the problem - 100 minutes.
Tasks for mastering the topic of the lesson - 25 minutes.
Conclusion - 20 minutes.

Questions for preparation:

1. Collection of anamnesis

2.Objective examination:

A) general inspection

b) examination of internal organs

3. Special gynecological examination:

a) looking in mirrors

b) bimanual examination

4. Methods of examination of gynecological patients on an outpatient basis

5.Modern methods research in gynecology

a) laparoscopy

b) diagnostic hysteroscopy, hysteroresectoscopy

c) echo - GSSG

d) extended colposcopy

Anamnesis and examination of gynecological patients

Scheme for collecting anamnesis of gynecological patients:
main complaints;
additional complaints;
past illnesses;
menstrual and reproductive functions, contraception;
gynecological diseases and operations on the genitals;
family history;
lifestyle, food, bad habits, working and living conditions;
history of present illness.

On examination, determine the type of physique:
female;
male (tall, broad shoulders, long torso, narrow pelvis);
eunuchoid (tall, narrow shoulders, narrow pelvis, long legs, short torso).
Significant deviations in body type give an idea of ​​the features of puberty. So, with hyperandrogenism in puberty a male or viril type of physique is formed, and in case of insufficiency of the hormonal function of the ovaries, the physique acquires eunuchoid features.
Phenotypic features: dysplasia and dysmorphia (micro- and retrognathia, arched palate, wide flat nose bridge, low auricles, short stature, short neck with skin folds, barrel-shaped rib cage etc.), characteristic of different clinical forms violations of the development of the sex glands.
Hair growth and skin condition: excessive hairiness, skin condition (increased sebum, acne, folliculitis, increased porosity), stretch marks, their color, number and location.
Condition of the mammary glands Key words: size, hypoplasia, hypertrophy, symmetry, skin changes. In a patient in a standing and lying position, sequential palpation of the outer and inner quadrants of the gland is performed. It is necessary to note the absence or presence of discharge from the nipples, its color, texture and character. brown discharge from the nipples or an admixture of blood indicate a possible malignant process or papillary growths in the ducts of the mammary gland; liquid transparent or greenish discharge is characteristic of cystic changes in the gland. The appearance of milk or colostrum with pressure on the areola in combination with amenorrhea or oligomenorrhea makes it possible to establish the diagnosis of galactorrhea-amenorrhea - one of the forms of hypothalamic reproductive disorders. In this situation, it is also necessary to exclude a prolactin-secreting pituitary adenoma.

Nodes in the mammary glands, determined by palpation, serve as an indication for ultrasound of the mammary glands and mammography.

Determination of body length and weight necessary to calculate the body mass index (BMI) - the ratio of body weight to the square of body length:

BMI = Body weight (kg) / Body length² (m)

The normal BMI of a woman of reproductive age is 20-26. BMI over 40 (corresponds to IV degree obesity) indicates a high probability of metabolic disorders.
With overweight, it is necessary to find out when obesity began: since childhood, in puberty, after the onset of sexual activity, after abortion or childbirth.

Abdominal examination carried out in the position of the patient lying on his back. On palpation, determine the size of individual organs, exclude ascites, flatulence, volumetric formations. Palpation begins with determining the position, texture and shape of the edge of the liver. The size of the liver is determined by percussion. Then, in a clockwise direction, the remaining organs are palpated abdominal cavity. This is followed by auscultation of the abdomen. Note intestinal peristalsis.
By palpation, the state of the abdominal wall is determined (tone, muscle protection, diastasis of the rectus abdominis muscles), painful areas, the presence of tumors, infiltrates in the abdominal cavity.
Examination of the abdomen can provide very valuable information. So, if a patient with a pelvic mass is found to have a mass in the epigastric or umbilical region, ovarian cancer with metastases to the greater omentum should be excluded.

Gynecological examination carried out on a gynecological chair. The patient's legs lie on supports, buttocks on the edge of the chair. In this position, you can examine the vulva and easily insert the mirror into the vagina.
Examination of the external genitalia: condition and size of small and large labia; condition of mucous membranes (juiciness, color, condition of cervical mucus); the size of the clitoris; hair development; condition of the perineum; the presence of pathological processes (inflammation, tumors, ulcerations, warts, fistulas, scars). Hypoplasia of the labia minora and labia majora, pallor and dryness of the vaginal mucosa indicate hypoestrogenism. Juiciness and cyanosis of the mucous membrane of the vulva, abundant transparent secretion are signs of hyperestrogenism. Hypoplasia of the labia minora, enlargement of the head of the clitoris, increase in the distance between the base of the clitoris and the external opening urethra(more than 2 cm) in combination with hypertrichosis indicate a congenital adrenogenital syndrome. They also pay attention to the gaping of the genital slit; inviting the woman to push, determine if there is any prolapse or prolapse of the walls of the vagina and uterus.
Examination of the vagina and cervix in the mirrors carried out by women who are sexually active. Timely recognition of cervical cancer, erosions, polyps and other diseases related to precancerous conditions is possible only with the help of mirrors. Particular attention is paid to the vaults of the vagina, since volumetric formations and genital warts are often located there. When viewed in mirrors, smears are taken for the flora, a cytological examination, a biopsy of volumetric formations of the cervix and vagina is possible.
Bimanual the study is carried out after removing the mirrors. Index and middle fingers one gloved hand (usually the right hand) is inserted into the vagina. The other hand (usually the left) is placed on the anterior abdominal wall. With the right hand, the walls of the vagina, its vaults and the cervix are palpated, any volumetric formations and anatomical changes are noted. Then, carefully inserting fingers into the posterior fornix of the vagina, the uterus is displaced forward and upward and palpated with the other hand through the anterior abdominal wall. The position, size, shape, mobility, consistency and mobility of the uterus are noted, attention is paid to volumetric formations.
Rectovaginal examination necessarily in postmenopause, as well as in all cases when it is necessary to clarify the condition of the uterine appendages. Some authors suggest that it be performed for all women over 40 years of age to exclude concomitant diseases of the rectum. Rectal examination determines the tone of the sphincters anus and the state of the pelvic floor muscles, exclude volumetric formations: internal hemorrhoids, tumor.

Special methods for the study of gynecological patients

Functional diagnostic tests

Functional diagnostic tests used to determine functional status reproductive system still have lost their value.
Symptom "pupil" allows you to judge the production of estrogen by the ovaries. With a two-phase menstrual cycle, the external opening of the cervical canal from the 5th day of the cycle begins to expand, reaching a maximum by the time of ovulation. In the second phase of the cycle, the external uterine os begins to gradually close, and there is no mucus in its lumen.
Stretch symptom cervical mucus also allows you to judge the production of estrogen by the ovaries. The maximum stretching of the mucous thread from the cervical canal occurs at the time of ovulation and reaches 10-12 cm.
Karyopyknotic index (KPI)- the ratio of keratinizing and intermediate cells in a microscopic examination of a smear from the posterior fornix of the vagina. During the ovulatory menstrual cycle KPI is: in the first phase 25-30%, during ovulation - 60-80%, in the middle of the second phase - 25-30%.
Basal temperature(temperature in the rectum) depends on the phase of the menstrual cycle. With an ovulatory cycle with a full first and second phases, the basal temperature rises by 0.5 ° C immediately after ovulation and remains at this level for 12-14 days. The rise in temperature is due to the influence of progesterone on the center of thermoregulation (Fig. 1.3). If the second phase of the cycle is insufficient, the hyperthermic phase lasts less than 8-10 days, rises in steps or periodically falls below 37 ° C. During anovulation, the temperature curve remains monophasic (Fig. 1.4).

Rice. 1.3

Rice. 1.4

An accurate method for assessing ovarian function remains the histological examination of endometrial scrapings. Secretory endometrium, removed during curettage of the uterus 2-3 days before the onset of menstruation, with an accuracy of 90% indicates that ovulation has occurred.

Tissue biopsy and cytology

Biopsy- intravital taking of a small amount of tissue for microscopic examination for the purpose of diagnosis. In gynecology, excisional (excision of a piece of tissue), targeted (under visual control with a colposcope or hysteroscope) and puncture biopsy are used.
A biopsy is most often performed if a malignant tumor of the cervix, vulva, vagina, etc. is suspected. Cytological diagnostics. Cells obtained in smears from the cervix, punctate (volumetric formations of the small pelvis, fluid from the retrouterine space) or aspirate from the uterine cavity are subjected to cytological examination. The pathological process is diagnosed by the morphological features of the cells, the quantitative ratio of individual cell groups, the location of the cellular elements in the preparation.
Cytological studies are a screening method for mass preventive examinations of the female population, primarily in high-risk groups.

Determination of hormones and their metabolites

IN gynecological practice in the blood plasma, protein (lutropin - LH, follitropin - FSH, prolactin - Prl, etc.) and steroid hormones (estradiol, progesterone, testosterone, cortisol, etc.) are determined. In urine, androgen metabolites (17-ketosteroids - 17-KS) and pregnandiol, a metabolite of the corpus luteum hormone progesterone, are determined.
IN last years when examining women with manifestations of hyperandrogenism and performing hormonal tests, instead of determining 17-CS in urine, the content of dehydroepiandrosterone (DEA) and its sulfate (DEA-C) and 17-hydroxyprogesterone (17-OPN) - precursors of testosterone and cortisol, respectively, and testosterone itself. The determination of pregnandiol has also given way to the study of progesterone in the blood.
Functional trials. A single determination of hormones and their metabolites in the blood and urine is not very informative; these studies are combined with functional tests, which makes it possible to clarify functional state various parts of the reproductive system and find out the reserve capacity of the hypothalamus, pituitary gland, adrenal glands, ovaries and endometrium.
Test with gestagens determines the degree of estrogen and progesterone deficiency in diseases accompanied by amenorrhea. Intramuscularly injected 1 ml of 1% (10 mg) oil solution progesterone daily for 6-8 days or 1 ml of 2.5% (25 mg) oil solution of progesterone every other day (3 injections in total) or 2 ml of 12.5% ​​(250 mg) of oil solution of 17-hydroxyprogesterone capronate (17-OPK ) at the same time. The appearance of a menstrual-like reaction 2–4 days after the withdrawal of progesterone or 10–14 days after the administration of 17-OPK indicates a moderate estrogen deficiency and a significant progestogen deficiency. A negative test may mean a deep estrogen deficiency or organic changes in the endometrium (intrauterine synechia).
Test with estrogens and gestagens is carried out in order to exclude (confirm) a disease or damage to the endometrium (uterine form of amenorrhea) and to determine the degree of estrogen deficiency. Intramuscularly injected 1 ml of 0.1% (10 thousand units) folliculin oil solution daily for 7 days. Injections can be replaced by oral ethinyl estradiol (microfollin) at a dose of 0.1 mg (2 tablets) daily for 7 days. Then progesterone is administered in the doses indicated for the test with gestagens. 2-4 or 10-14 days after the administration of progesterone or 17-OPK, respectively, a menstrual-like reaction should begin. The absence of such a reaction indicates deep organic changes in the endometrium (damages, diseases). A positive result indicates a pronounced deficiency of endogenous estrogen, and not a pathology of the endometrium.
Dexamethasone test performed to determine the cause of hyperandrogenism in women with signs of virilization, primarily to exclude an ovarian tumor.
The test is based on the ability of dexamethasone (like all glucocorticosteroids) to suppress the release of ACTH by the anterior pituitary gland, as a result of which the formation and release of androgens by the adrenal glands are inhibited.
Small dexamethasone test: dexamethasone 0.5 mg every 6 hours (2 mg/day) for 3 days, total dose 6 mg. 2 days before taking the drug and the next day after its withdrawal, the content of testosterone, 17-OPN and DEA in the blood plasma is determined. If this is not possible, the content of 17-KS in the daily urine is determined. With a decrease in these indicators compared to the original by more than 50-75%, the test is considered positive, which indicates the adrenal origin of androgens, a decrease of less than 30-25% means the ovarian origin of androgens.
In case of a negative test, a large dexamethasone test is performed, taking dexamethasone 2 mg (4 tablets of 0.05 mg) every 6 hours for 3 days. (total dose 24 mg). The control of the study is carried out in the same way as with a small dexamethasone sample. A negative test result - the absence of a decrease in the level of androgens in the blood or urine indicates a virilizing tumor of the adrenal glands.
Functional tests to determine the level of impairment of the hypothalamic-pituitary system. Tests are carried out at normal or reduced content gonadotropins in the blood.
Test with clomiphene is carried out in diseases with chronic anovulation on the background of oligomenorrhea or amenorrhea. The test begins after a menstrual-like reaction caused by the intake of estrogens and progesterone. From the 5th to the 9th day from the onset of a menstrual-like reaction, clomiphene is prescribed at a dose of 100 mg per day (2 tablets of 50 mg). The result of the test is controlled either by the determination of gonadotropins and estradiol in the blood plasma before the start of the study and on the 5-6th day after the end of the drug, or by basal temperature and the appearance or absence of a menstrual-like reaction 25-30 days after taking clomiphene.
Positive test (increased levels of gonadotropins and estradiol, biphasic basal body temperature) indicates the preserved functional activity of the hypothalamus, pituitary gland and ovaries.
A negative test (no increase in the concentration of estradiol, gonadotropins in the blood plasma, monophasic basal temperature) indicates a violation of the functional sensitivity of the pituitary zone of the hypothalamus to the release of luliberin and the pituitary gland to the release of gonadotropins.
Test with luliberin carried out with a negative test with clomiphene. Intravenously administered 100 mcg synthetic analogue luliberin. Before the start of the drug administration and 15, 30, 60 and 120 minutes after the administration through indwelling catheter blood is taken from the cubital vein to determine the content of LH. At positive sample by the 60th minute, the LH content rises to numbers corresponding to ovulation, which indicates the preserved function of the anterior pituitary gland and impaired function of the hypothalamic structures.

Instrumental methods for the study of gynecological patients

Endoscopic methods

Colposcopy- a detailed examination of the vaginal part of the cervix, the walls of the vagina and the vulva through the optical lens system with a magnification of 6-28 times. During colposcopy, the shape, size of the cervix and external os, color, relief of the mucous membrane, the border of the squamous epithelium covering the cervix and the cylindrical epithelium of the cervical canal are determined.
With extended colposcopy, before examination, the cervix is ​​treated with a 3% solution of acetic acid, which causes short-term edema of the epithelium, swelling of the cells of the styloid layer, contraction of the subepithelial vessels and a decrease in blood supply. After a detailed examination, a Schiller test is carried out - the neck is lubricated with 3% Lugol's solution. Iodine stains the cells of a healthy squamous epithelium of the cervix in a dark brown color; thinned (atrophic) and pathologically altered cells with dysplasia of the cervical epithelium do not stain. Thus, zones of pathologically altered epithelium are identified and areas for cervical biopsy are indicated.
Colpomicroscopy- intravital histological examination of the vaginal part of the cervix. Produced by a contrast luminescent colpomicroscope or Hamou colpomicroscope (hysteroscope type).

Hysteroscopy- inspection with optical systems inner surface uterus. Hysteroscopy is diagnostic and operational. Diagnostic hysteroscopy is currently the method of choice for diagnosing all types of intrauterine pathology.
Indications for diagnostic hysteroscopy:
menstrual irregularities in various periods of a woman's life (juvenile, reproductive, perimenopausal);
bleeding in postmenopause;
suspicion of submucosal uterine fibroids,
adenomyosis,
endometrial cancer,
anomalies in the development of the uterus,
intrauterine synechia,
retained remains of the fetal egg,
foreign body in the uterine cavity
perforation of the uterine wall;
clarification of the location of the intrauterine contraceptive or its fragments;
infertility;
miscarriage;
control examination of the uterine cavity after operations on the uterus, cystic mole, chorionepithelioma;
evaluation of the effectiveness of hormone therapy and control of its implementation;
complicated course postpartum period.
Contraindications for hysteroscopy the same as for any intrauterine intervention: general infectious diseases(influenza, tonsillitis, pneumonia, acute thrombophlebitis, pyelonephritis, etc.); acute inflammatory diseases of the genital organs; III-IV degree of purity of the vagina; serious condition sick with illness of cardio-vascular system and parenchymal organs (liver, kidneys); pregnancy (desired); cervical stenosis; advanced cervical cancer; profuse uterine bleeding.
After a visual determination of the nature of the intrauterine pathology, diagnostic hysteroscopy can go into the operating room either immediately or delayed if preliminary preparation is necessary.
By complexity, hysteroscopic operations are divided into simple and complex.
Simple operations: removal of small polyps, separation of thin synechiae, removal of an IUD freely located in the uterine cavity, small submucosal myomatous nodes on a stalk, thin intrauterine septum, tubal sterilization, removal of hyperplastic uterine mucosa, remnants of placental tissue and fetal egg.
Complex operations: removal of large parietal fibrous polyps of the endometrium, dissection of dense fibrous and fibromuscular synechiae, dissection of a wide intrauterine septum, myomectomy, resection (ablation) of the endometrium, removal foreign bodies, embedded in the wall of the uterus, falloscopy.
Possible Complications diagnostic and operative hysteroscopy:
anesthetic;
complications caused by the medium for expanding the uterine cavity (fluid overload of the vascular bed, cardiac arrhythmia due to metabolic acidosis, gas embolism);
air embolism;
surgical (perforation of the uterus, bleeding).
Complications of hysteroscopy can be minimized if all the rules for working with equipment and apparatus, manipulation techniques and operations are observed.

Laparoscopy- Examination of the abdominal organs using an endoscope inserted through the anterior abdominal wall. Laparoscopy in gynecology is used both for diagnostic purposes and for surgical intervention.
Indications for elective laparoscopy:
infertility (tubal-peritoneal);
polycystic ovary syndrome;
tumors and tumor-like formations of the ovaries;
uterine fibroids;
genital endometriosis;
malformations of the internal genital organs;
pain in the lower abdomen unclear etiology;
prolapse and prolapse of the uterus and vagina;
stress urinary incontinence;
sterilization.
Indications for emergency laparoscopy:
ectopic pregnancy;
ovarian apoplexy;
acute inflammatory diseases of the uterine appendages;
suspicion of torsion of the leg or rupture of a tumor-like formation or ovarian tumor, as well as torsion of subserous fibroids;
differential diagnosis of acute surgical and gynecological pathology.
Absolute contraindications for laparoscopy:
hemorrhagic shock;
diseases of the cardiovascular and respiratory systems in the stage of decompensation;
uncorrectable coagulopathy;
diseases in which the Trendelenburg position is unacceptable (consequences of brain injury, damage to cerebral vessels, sliding hernia esophageal opening of the diaphragm, etc.);
acute and chronic hepatic and renal insufficiency;
cancer of the ovary and fallopian tube (with the exception of laparoscopic monitoring during chemotherapy or radiation therapy).
Relative contraindications to laparoscopy:
polyvalent allergy;
diffuse peritonitis;
pronounced adhesive process after undergoing operations on the organs of the abdominal cavity and small pelvis;
pregnancy late dates(more than 16-18 weeks);
large uterine fibroids (more than 16 weeks of pregnancy);
big sizes true ovarian tumor (diameter more than 14 cm);
suspicion of malignant neoplasms uterine appendages.

Contraindications to elective laparoscopic interventions:
existing or transferred less than 4 weeks ago acute infectious and colds;
subacute inflammation of the uterine appendages;
III-IV degree of purity of the vagina;
inadequate examination and treatment of a married couple by the time of the proposed endoscopic examination for infertility.
Complications of laparoscopy can be:
1) anesthetic
2) associated with the performance of manipulation:

Perforation of the abdominal organs with a Veress needle;

Emphysema of the omentum, subcutaneous and retroperitoneal tissue;

gas embolism;

mediastinal emphysema;

Wound of the main vessels;

Damage to the gastrointestinal tract and urinary system with the subsequent development of peritonitis.

The frequency and structure of complications are related to the qualifications of the surgeon and the nature of the interventions performed.
Prevention of complications in laparoscopic gynecology: careful consideration of absolute and relative contraindications; the experience of the endoscopist surgeon, corresponding to the complexity of the surgical intervention.

Ultrasonography

Ultrasound examination (ultrasound) is a non-invasive instrumental research method used in gynecology to diagnose diseases and tumors of the uterus, appendages, and to detect abnormalities in the development of the uterus. The latest models of ultrasound devices allow you to monitor the growth of the follicle, ovulation, register the thickness of the endometrium and identify its hyperplasia and polyps. With the help of ultrasound, normal sizes uterus and ovaries in women, girls and girls.
In gynecology, ultrasound is performed with abdominal and vaginal sensors. The use of vaginal sensors allows you to obtain more informative data on the state of the endometrium, myometrium, and the structure of the ovaries.

X-ray methods of research

Hysterosalpingography used to establish permeability fallopian tubes, detection of anatomical changes in the uterine cavity, adhesions in the uterus and in the pelvic area. Water-soluble contrast agents are used (verotrast, urotrast, verografin, etc.). The study should be carried out on the 5-7th day of the menstrual cycle, which reduces the frequency of false negative results.
X-ray examination skull is widely used in the diagnosis of neuroendocrine diseases. X-ray examination of the shape, size and contours of the Turkish saddle - the bone bed of the pituitary gland - is used to diagnose a pituitary tumor. Signs of a pituitary tumor: osteoporosis or thinning of the walls of the Turkish saddle, a symptom of double contours. If a pituitary tumor is suspected, a computed tomography of the skull is performed according to x-ray data.
Computed tomography (CT)- a variant of X-ray examination, which allows obtaining a longitudinal image of the area under study, sections in the sagittal and frontal or in any given plane. CT provides a complete spatial representation of the organ under study, the pathological focus, quantitative information about the density of a certain layer, thus making it possible to judge the nature of the lesion. The resulting images of structures do not overlap, and CT makes it possible to differentiate the image of tissues and organs by the density coefficient. The minimum size of the pathological focus, determined by CT, is 0.5-1 cm.
In gynecology, CT has not received such widespread use as in neuropathology and neurosurgery. CT of the sella turcica remains the main method for the differential diagnosis of functional hyperprolactinemia and prolactin-secreting pituitary adenoma.
Magnetic resonance imaging (MRI)- more informative method diagnostics in gynecology than CT. Currently used for differential diagnosis pathological formations in the pelvis with dubious ultrasound data.

Cytogenetic studies

Cytogenetic studies are carried out by geneticists. Indications: various forms absence and delay of sexual development, anomalies in the development of the genital organs, primary amenorrhea, habitual miscarriage of short terms, infertility, violation of the structure of the external genital organs.
Pathological conditions of the reproductive system can be caused by chromosomal abnormalities, gene mutations and hereditary predisposition to the disease.
Markers of chromosomal abnormalities are multiple, often erased somatic developmental anomalies and dysplasia, as well as a change in the amount of X-chromatin (sex chromatin). Sex chromatin is determined in the nuclei of cells of the surface epithelium in the scraping of the mucous membrane of the inner surface of the cheek. To detect chromosomal abnormalities, you can also determine Y-chromatin in the cells of the buccal mucosa. With a Y-chromosome in the karyotype, Y-chromatin is found in almost all cell nuclei. Sex chromatin determination is used as a screening test. The final diagnosis of chromosomal abnormalities can only be established based on the definition of the karyotype.
Indications for the study of the karyotype are, first of all, deviations in the amount of sex chromatin, short stature, multiple, often erased somatic developmental anomalies and dysplasia, as well as malformations in the family history, multiple deformities or spontaneous miscarriages in early dates pregnancy.
Determination of the karyotype is an indispensable part of the examination of patients with gonadal dysgenesis. The detection of the Y-chromosome or its segment in them indicates the presence of testicular tissue elements in the dysgenetic gonad and, therefore, a high risk (up to 30%) of malignant growth.

Puncture of the abdominal cavity through the posterior fornix of the vagina

Puncture of the abdominal cavity through the posterior fornix of the vagina (Fig. 1.7) is performed in a hospital in cases where it is necessary to determine the presence or absence of free fluid (blood, serous exudate, pus) in the pelvic cavity.

Aspiration biopsy

An aspiration biopsy is performed to obtain tissue for microscopic examination. Its essence lies in the fact that the contents are sucked out of the uterine cavity using a tip placed on a syringe, or with a special Paypel tool.

Examination of children with gynecological diseases

The examination of children with gynecological diseases differs in many respects from the examination of adult women both in the psychological approach and in the methodology.
Most children, especially those who visit a gynecologist for the first time, experience some anxiety, fear, embarrassment and inconvenience in connection with the upcoming examination. When meeting with a girl and her relatives, even before the start of the examination, the doctor must establish psychological contact, reassure, achieve the girl's disposition and trust. It is better to conduct a preliminary conversation with the mother in the absence of the child, give the mother the opportunity to talk about the development of the disease in her daughter, and then ask additional questions to her, and then to the girl.
A general examination of girls is carried out according to the methodology adopted in pediatrics. The examination begins with clarification of complaints, anamnesis of life and disease. It is necessary to pay attention to the age, health of the parents, the course of pregnancy and childbirth in the mother of the examined girl, carefully find out the diseases suffered by the child during the neonatal period, early and later. They ask about the general reaction of the girl's body to previous diseases (temperature, sleep, appetite, behavior, etc.). This may give some idea of ​​the organism's reactivity. They also find out the conditions of life, nutrition, daily routine, behavior in a team, relationships with peers.
Then it is necessary to dwell in detail on the period of formation of the girl's menstrual function, to find out the nature of vaginal discharge that is not associated with menstruation.
An objective examination of a girl with a gynecological disease should begin with determining the main indicators of physical development in accordance with age (height, body weight, chest circumference, pelvic dimensions), then a general examination of organs and systems is carried out, the degree of sexual development, skin condition, character are noted. hair growth, development of subcutaneous adipose tissue and mammary glands.
A special examination includes an assessment of the development of secondary sexual characteristics; examination, palpation and percussion of the abdomen, if pregnancy is suspected - auscultation of the fetal heartbeat; examination of the external genitalia, hymen and anus; vaginoscopy; rectal-abdominal examination. If a foreign body of the vagina is suspected, a rectal-abdominal examination is first performed, and then a vaginoscopy.
Immediately before the examination, the girl must empty the intestines (cleansing enema) and bladder. Younger girls (up to 3 years old) are examined on a changing table, older girls - on a children's gynecological chair with a special device that allows you to change its depth. When examining girls in outpatient settings, as well as during the initial examination in hospitals, the mother or one of the closest relatives should be present.
When examining the external genital organs, the nature of hair growth is assessed (according to female type- horizontal hairline; By male type- in the form of a triangle with a transition to white line abdomen and inner thighs), the structure of the clitoris, large and small labia, hymen, their color, the color of the mucous membrane of the entrance to the vagina, discharge from the genital tract. A penis-like clitoris combined with male-pattern hair growth in childhood indicates congenital androgenital syndrome; growth of the clitoris during puberty - about an incomplete form of testicular feminization or a virilizing tumor of the gonads. Juicy hymen, swelling of the vulva, labia minora and their pink color at any age (childhood or puberty) indicate hyperestrogenism. With hypoestrogenism, underdevelopment of the external genitalia is noted, the mucous membrane of the vulva is thin, pale and dry. With hyperandrogenism during puberty, hyperpigmentation of the labia majora and labia minora, male-type hair growth, and a slight increase in the clitoris are noted.
Vaginoscopy- examination of the vagina and cervix using an optical device - a combined ureteroscope and children's vaginal mirrors with illuminators. Vaginoscopy is performed for girls of any age and allows you to find out the condition of the vaginal mucosa, the size, shape of the cervix and external os, the presence and severity of the “pupil” symptom, pathological processes in the cervix and vagina, a foreign body, malformations.
Vaginoscopy for girls in the "neutral" period is performed with a combined ureteroscope using cylindrical tubes of various diameters with an obturator. In the pubertal period, the examination of the vagina and cervix is ​​carried out with children's vaginal mirrors with illuminators. The choice of ureteroscope tube and children's vaginal mirrors depends on the age of the child and the structure of the hymen.
Bimanual recto-abdominal examination do all girls with gynecological diseases. Bimanual examination of young children should be carried out with the little finger, when examining older girls - with the index or middle finger, which is protected by a fingertip lubricated with petroleum jelly. The finger is inserted while straining the patient.
During a rectal examination, the condition of the vagina is ascertained: a foreign body, tumors, accumulation of blood, with a bimanual examination, the condition of the uterus, appendages, fiber and adjacent organs is determined. When palpation of the uterus, its position, mobility, soreness, the ratio of the size of the neck and body and the severity of the angle between them are examined.
So, with sexual infantilism in girls, the angle between the cervix and uterus is not pronounced, the uterus is located high in the small pelvis, the ratio of the size of the cervix and the body of the uterus is 1:1. With gonadal dysgenesis syndrome, instead of the uterus, middle line palpated roller-like cord. Unilateral enlargement of the ovary, especially on the eve of menstruation, requires a mandatory re-examination after the end of menstruation.
Rectal-abdominal examination is performed under anesthesia in children under 3-4 years old with genital injuries and in older girls with suspected tumor in the small pelvis.
When examining girls, asepsis and antisepsis are especially carefully observed due to the high susceptibility of children's genitals to infection. After the end of the external and internal examination, the external genital organs and the vagina are treated with a solution of furacilin (1: 5000). In case of irritation on the skin of the vulva, it is lubricated with streptocidal ointment or sterile petroleum jelly.
Depending on the nature of the disease, the following additional methods research.

Methods of functional diagnostics and hormonal studies(described above) are indicated for patients with juvenile bleeding, with the pathology of puberty and suspected hormonally active ovarian tumors.
Probing of the vagina and uterine cavity used to diagnose malformations, foreign body, suspected hemato - or pyometra.
Separate diagnostic curettage of the mucous membrane of the body of the uterus with hysteroscopy it is indicated both to stop uterine bleeding and for diagnostic purposes in case of poor prolonged spotting in patients with a disease duration of more than 2 years and with the ineffectiveness of symptomatic and hormonal therapy. Diagnostic curettage is done under short-term mask or intravenous anesthesia. The cervix is ​​exposed in children's mirrors with a lighting system. The cervical canal is expanded to the 8-9th Gegar number, and the endometrium is scraped out with a small curette No. 2.4. With proper diagnostic curettage, the integrity of the hymen is not violated.
Endoscopic methods (hysteroscopy, laparoscopy) do not differ from those in adults.
Ultrasound examination (ultrasound) of the internal genital organs. In recent years, in practical gynecology of childhood and adolescence, pelvic ultrasound has become widely used due to its safety, painlessness and the possibility of diagnostic observation. Ultrasound can diagnose genital malformations, ovarian tumors and other gynecological diseases.
In normal girls, the uterus is visualized by ultrasound as a dense formation with multiple linear and dot echo structures, which has the shape of an elongated ovoid and is located in the center of the small pelvis behind the bladder. The average length of the uterus in children aged 2 to 9 years is 3.1 cm; from 9 to 11 years old - 4 cm; from 11 to 14 years old - 5.1 cm. In girls over 14 years old, the length of the uterus is on average 6.5 cm.
ovaries healthy girls up to 8 years, they are located on the border of the entrance to the small pelvis and only by the end of the first phase of puberty they go deeper into the small pelvis, adjacent to its walls, and are visualized as ellipsoidal formations with a more delicate structure than the uterus. The volume of the ovaries in children aged 2 to 9 years averages 1.69 cm3, from 9 to 13 years old - 3.87 cm3, in girls over 13 years old - 6.46 cm3.

Radiographic and radiopaque research methods
In pediatric gynecology, as well as in adults, an X-ray examination of the skull is used and extremely rarely (according to strict indications) hysterosalpingography using a special small children's tip for suspected tuberculosis of the genitals or anomalies in the development of the genital organs in girls over 14-15 years old.
Of great importance for the diagnosis of gynecological diseases is x-ray examination hands to determine bone age with its subsequent comparison with passport data. Special tables indicate the timing and sequence of the appearance of ossification and synostosis between the metaphyses and epiphyses of long tubular bones depending on age.
This method of examination allows to identify the pathology of ossification - violations of its pace and sequence, which are influenced by hormonal influences, as well as factors of heredity and nutrition.
In pediatric gynecology, as well as in adults, computed tomography and magnetic resonance imaging are used for differential diagnosis. In young children and in patients with various mental affects, studies are carried out with mandatory anesthetic assistance (drug sleep after parenteral administration of drugs).
To conduct hysterosalpingography, hysteroscopy, diagnostic curettage and laparoscopy, KTR and MRI, it is necessary to obtain the consent of the patient's parents, about which to make an appropriate entry in the medical history.
In addition to the above methods of examination, cytogenetic research is widely used to diagnose a number of gynecological diseases (determination of sex chromatin, according to indications - karyotype). It is indicated for violations of somato-sexual development (violation of sexual differentiation, delayed sexual development, etc.).
Bacterioscopic examination secretions from the genital tract are made after examining the genital organs. Vaginal discharge is examined in all girls, discharge from adjacent organs (urethra, rectum) is examined depending on the nature of the disease (for example, if gonorrhea, trichomoniasis is suspected). The material is taken with a grooved probe or a rubber catheter. Before inserting the instrument with a cotton ball moistened with a warm isotonic sodium chloride solution, wipe the entrance to the vagina, the external opening of the urethra and the area of ​​the anus. Tools for taking the material are inserted into the urethra to a depth of about 0.5 cm, into the rectum - to a depth of about 2-3 cm, and into the vagina - if possible to the posterior fornix. The results of the study are evaluated taking into account the age of the girl.

At history taking in gynecological patients pay attention to:

Age;

Family history;

Lifestyle, nutrition, bad habits, working and living conditions;

Past illnesses;

menstrual and reproductive function, the nature of contraception;

Gynecological diseases and operations on the genitals;

History of present illness.

When taking anamnesis, special attention should be paid to patient's complaints. The main complaints in gynecological patients are pain, leucorrhoea, bleeding from the genital tract, infertility and miscarriage. First, they find out the time of the appearance of the first menstruation (menarche), menstruation was established immediately or after some time, what is their duration and amount of blood loss, the rhythm of the appearance of menstruation. Then they clarify whether menstruation has changed after the onset of sexual activity (coitarche), childbirth, abortion, how menstruation occurs during a real illness, when was the last menstruation and what are its features.

All numerous violations of menstrual function can be divided into amenorrhea and hypomenstrual syndrome, menorrhagia, metrorrhagia and algomenorrhea.

Amenorrhea - lack of menstruation; observed before puberty, during pregnancy and lactation. These types of amenorrhea are a physiological phenomenon. Pathological amenorrhea occurs after the establishment of the menstrual cycle due to general and gynecological diseases of various origins.

Hypomenstrual syndrome It is expressed in a decrease (hypomenorrhea), shortening (oligomenorrhea) and a decrease (opsomenorrhea) of menstruation. Usually this syndrome occurs in the same diseases as pathological amenorrhea.

menorrhagia - bleeding associated with the menstrual cycle. Menorrhagia occurs cyclically and is manifested by an increase in blood loss during menstruation (hypermenorrhea), a longer duration of menstrual bleeding (polymenorrhea) and disturbances in their rhythm (proyomenorrhea). Relatively often, these violations are combined. The occurrence of menorrhagia may depend both on a decrease in uterine contractility due to the development of inflammatory processes (endo- and myometritis), tumors (uterine fibroids), and on ovarian dysfunction associated with improper maturation of follicles, corpus luteum or lack of ovulation.

metrorrhagia - acyclic uterine bleeding that is not associated with the menstrual cycle and usually occurs with various disorders of ovarian function due to impaired ovulation processes (dysfunctional uterine bleeding), with submucosal uterine myoma, cancer of the body and cervix, hormonally active ovarian tumors and some other diseases.

Menometrorrhagia - bleeding in the form of heavy menstruation, continuing in the intermenstrual period.

Algodysmenorrhea - painful menstruation. Pain usually accompanies the onset menstrual bleeding and are less common throughout menstruation. Painful menstruation is the result of underdevelopment of the genital organs (infantilism), incorrect position of the uterus, the presence of endometriosis, inflammatory diseases of the internal genital organs, etc.

Pathological discharge from the genitals is called whiter. Beli can be both a symptom of gynecological diseases and a manifestation of pathological processes not related to the reproductive system. Beli can be scarce, moderate, plentiful. They can be milky, yellowish, green, yellow-green, gray, "dirty" (with an admixture of blood) color. The consistency of whiter is thick, viscous, creamy, foamy, curdled. It is important to pay attention to the smell of secretions: it may be absent, it can be pronounced, sharp, unpleasant. The patient is asked if the amount of discharge increases during certain periods of the menstrual cycle (especially in connection with menstruation), whether the discharge is associated with sexual intercourse or a change of partner, does not appear

whether contact bleeding after intercourse, as well as under the influence of provoking factors (after stool, weight lifting).

Grade reproductive (childbearing) function the patient allows you to get data about her gynecological well-being or trouble.

It is important to find out:

At what year of sexual life and at what age did the first pregnancy occur;

How many pregnancies there were and how they proceeded, whether there was a cystic drift, ectopic pregnancy and other complications;

How many births there were and when, were there any complications during childbirth and in the postpartum period, if so, which ones, was there an operational benefit;

How many abortions (artificial in the hospital, according to medical indications, community-acquired, spontaneous) and when, were there any complications during the abortion or in the post-abortion period, what treatment was carried out;

When was the last pregnancy, at what age, how did it proceed and how did it end: urgent or premature birth, artificial or spontaneous abortion, were there any complications during childbirth (abortion) or in the postpartum (post-abortion) period, if any, then what, than and how the patient was treated.

During inspection, the following characteristics are determined.

Body type: female, male (tall, long torso, broad shoulders, narrow pelvis), eunuchoid (tall, narrow shoulders, narrow pelvis, long legs, short torso).

Phenotypic features: retrognathia, arched palate, wide flat nose bridge, low auricles, short stature, short neck with skin folds, barrel chest, etc.

Hair growth and condition of the skin.

Condition of the mammary glands. Assessment of the mammary glands is an obligatory component in the work of an obstetrician-gynecologist. Examination of the mammary glands is carried out in two positions: 1st - the woman is standing, her arms hang down along the body; 2nd - raises his hands and puts them on his head. On examination, the following are evaluated: the size of the mammary glands, their contours, symmetry, the condition of the skin (color, presence of edema, ulceration), the condition of the nipple and areola (size, location, shape, discharge from the nipple or ulceration). Discharge from the nipple can be watery, serous, hemorrhagic, purulent, milky. Hemorrhagic discharge is characteristic of intraductal papilloma, purulent - for mastitis, milky - for hyperprolactinemia of various origins. In the presence of secretions, it is necessary to make a smear-imprint on a glass slide.

X-ray mammography is the most common and highly informative method breast research. Plain mammography is advisable in the 1st phase of the menstrual cycle. Application-

This method is contraindicated in women under 35 years of age, as well as during pregnancy and lactation.

For the differential diagnosis of a number of diseases of the mammary glands, artificial contrasting is also used - ductography. This method is used to diagnose intraductal changes. An indication for ductography is the presence of bloody discharge from the nipple.

For the study of young women, the most informative is ultrasound (ultrasound). Its promising addition is dopplerometry. Ultrasound in combination with color Doppler mapping (CDC) allows you to identify tumor vessels. Currently, computed tomography (CT) and magnetic resonance imaging (MRI) are also used to diagnose diseases of the mammary glands.

Determination of body length and weight needed to calculate body mass index (BMI).

BMI \u003d Body weight (kg) / Body length (m 2 ).

Normally, the BMI of a woman of reproductive age is 20-26 kg / m 2. An index of more than 40 kg/m 2 (corresponds to IV degree of obesity) indicates a high probability of metabolic disorders.

With overweight, it is necessary to find out when obesity began: from childhood, at puberty, after the onset of sexual activity, after abortion or childbirth.

Abdominal examination can provide very valuable information. It is carried out in the position of the patient lying on his back. When examining the abdomen, pay attention to its size, configuration, swelling, symmetry, participation in the act of breathing. If necessary, the circumference of the abdomen is measured with a centimeter tape.

Palpation of the abdominal wall is of great practical importance, especially for the establishment of pathological neoplasms. Tension of the anterior abdominal wall is an important symptom of peritoneal irritation; observed in acute inflammation of the uterine appendages, pelvic and diffuse peritonitis.

Percussion complements palpation and helps to determine the boundaries of individual organs, the contours of tumors, the presence of free fluid in the abdominal cavity.

Auscultation of the abdomen is of great diagnostic value after cerebrosection (diagnosis of intestinal paresis).

Gynecological examination carried out on a gynecological chair. The patient's legs lie on supports, buttocks - on the edge of the chair. In this position, you can examine the vulva and easily insert the mirror into the vagina.

The normal (typical) position of the genital organs is considered to be their position in a healthy sexually mature non-pregnant and non-nursing woman, who is in an upright position, with the bladder and rectum emptied. Normally, the bottom of the uterus is turned upward and does not protrude above the plane of the entrance to the small pelvis, the area of ​​​​the external uterine os is located at the level of the spinal plane, the vaginal part of the neck

uterus is located downwards and backwards. The body and cervix form an obtuse angle, open anteriorly (position anteverzio And anteflexio). The bottom of the bladder is adjacent to the anterior wall of the uterus in the isthmus, the urethra is in contact with the anterior wall of the vagina in its middle and lower thirds. The rectum is located behind the vagina and is connected with it by loose fiber. Top part the posterior wall of the vagina (posterior fornix) is covered by the peritoneum of the recto-uterine space.

The normal position of the female genital organs is ensured by:

Own tone of the genital organs;

The relationship between the internal organs and the coordinated activity of the diaphragm, abdominal wall and pelvic floor;

The ligamentous apparatus of the uterus (suspension, fixation and support).

Own tone of the genital organs depends on the proper functioning of all body systems. A decrease in tone may be associated with a decrease in the level of sex hormones, a violation of the functional state of the nervous system, and age-related changes.

Relationships between internal organs(intestine, omentum, parenchymal and genital organs) form a single complex as a result of their direct contact with each other. Intra-abdominal pressure is regulated by the friendly function of the diaphragm, the anterior abdominal wall and the pelvic floor.

Suspension apparatus make up round and wide ligaments of the uterus, own ligament and suspensory ligament of the ovary. The ligaments provide the median position of the uterine fundus and its physiological inclination anteriorly.

TO fixing apparatus include sacro-uterine, utero-vesical and vesico-pubic ligaments. The fixing device ensures the central position of the uterus and makes it almost impossible to move it to the sides, backwards and forwards. Since the ligamentous apparatus departs from the uterus in its lower section, physiological inclinations of the uterus in different sides(lying position, full bladder, etc.).

Support apparatus it is represented mainly by the muscles of the pelvic floor (lower, middle and upper layers), as well as by the vesico-vaginal, rectovaginal septa and dense connective tissue located at the side walls of the vagina. The lower layer of the pelvic floor muscles consists of the external sphincter of the rectum, bulbous-cavernous, ischiocavernosus, and superficial transverse perineal muscles. The middle layer of muscles is represented by the urogenital diaphragm, the external urethral sphincter and the deep transverse muscle that lifts the anus.

Examination of the external genitalia: condition and size of small and large labia; the condition of the mucous membranes ("juiciness", dryness, color, condition of the cervical mucus); the size of the clitoris; the degree and nature of the development of the hairline; condition of the perineum; pathological processes (inflammation, tumors, ulcerations, warts, fistulas, scars).

They also pay attention to the gaping of the genital slit; inviting the woman to push, determine if there is any prolapse or prolapse of the walls of the vagina and uterus.

Examination of the vagina and cervix in the mirrors(Fig. 1.1) is carried out by women who are sexually active. Timely recognition of diseases of the cervix, erosions, polyps and other pathologies is possible only with the help of mirrors. When viewed in mirrors, swabs are taken for microflora, for cytological examination, a biopsy of pathological formations of the cervix and vagina is also possible.

Bimanual (two-handed vaginal-abdominal) examination carried out after removing the mirrors. The index and middle fingers of one hand (usually the right one), wearing a glove, are inserted into the vagina. The other hand (usually the left) is placed on the anterior abdominal wall. With the right hand, the walls of the vagina, its vaults and the cervix are palpated, volumetric formations and anatomical changes are determined. Then, carefully inserting fingers into the posterior fornix of the vagina, the uterus is displaced forward and upward and palpated with the other hand through the anterior abdominal wall. They note the position, size, shape, consistency, sensitivity and mobility of the uterus, pay attention to volumetric formations (Fig. 1.2).

Rectovaginal examination necessarily in postmenopause, and also if it is necessary to clarify the condition of the uterine appendages. Some authors suggest that it be performed for all women over 40 years of age to exclude concomitant diseases of the rectum. During rectal examination, the tone of the sphincters of the anus and the condition of the muscles of the pelvic floor, volumetric formations (internal hemorrhoids, tumor) are determined.

Special research methods

Functional diagnostic tests

Functional diagnostic tests used to determine the functional state of the reproductive system have not lost their value so far. According to the tests of functional diagnostics, one can indirectly judge the nature of the menstrual cycle.

The symptom of the "pupil" reflects the secretion of mucus by the glands of the cervix under the influence of estrogens. On pre-ovulatory days, mucus secretion increases, the external opening of the cervical canal opens slightly and, when viewed in mirrors, resembles a pupil. In accordance with the diameter of the mucus visible in the neck (1-2-3 mm), the severity of the "pupil" symptom is determined as +, ++, +++. During the period of ovulation, the "pupil" symptom is +++, under the influence of progesterone to last day the menstrual cycle, it is +, and then disappears.

The symptom of stretching of the cervical mucus is associated with its character, which changes under the influence of estrogens. The extensibility of the mucus is determined with the help of forceps, which take a drop of mucus from the cervical canal and, pushing the branches apart, look at how many millimeters the mucus is stretched. The maximum stretching of the thread - by 12 mm - occurs during the period of the highest concentration of estrogens, corresponding to ovulation.

Karyopyknotic index (KPI) - the ratio of keratinizing and intermediate cells in a microscopic examination of a smear from the posterior fornix of the vagina. During the ovulatory menstrual cycle, CPI fluctuations are observed: in the 1st phase - 25-30%, during ovulation - 60-80%, in the middle of the 2nd phase - 25-30%.

Basal temperature - the test is based on the hyperthermic effect of progesterone on the thermoregulatory center of the hypothalamus. In the ovulatory cycle, the temperature curve has two phases. With full-fledged 1st and 2nd phases, the basal temperature rises by 0.5 ° C immediately after ovulation and stays at this level for 12-14 days. In case of insufficiency of the 2nd phase of the cycle, the hyperthermic phase is less than 10-8 days, the temperature rises in steps or periodically drops below 37 °C. At various types anovulation, the temperature curve remains monophasic (Fig. 1.3, 1.4).

Indicators of tests of functional diagnostics during the ovulatory cycle are given in table. 1.1.

Indicators of functional diagnostic tests during the ovulatory menstrual cycle

Basal (rectal) temperature during a normal 2-phase menstrual cycle

Basal (rectal) temperature during 1-phase (anovulatory) menstrual cycle

An accurate method for assessing ovarian function is a histological examination of endometrial scrapings. Secretory changes in the endometrium, removed by scraping the uterine mucosa 2-3 days before the onset of menstruation, with an accuracy of 90%, indicate ovulation that has occurred.

Laboratory diagnostics of causative agents of inflammatory diseases of the genital organs

This diagnosis is represented by bacterioscopic, bacteriological, cultural, serological, molecular biological methods. Bacterioscopic (microscopic) examination based on microscopy of stained or native smears taken from the posterior fornix of the vagina, cervical canal, urethra, according to indications - from the straight line

intestines. Before taking a smear, it is not recommended to douche, inject drugs into the vagina. The material for research is taken with the help of a Volkmann spoon, applying it in a thin uniform layer on two glass slides. After drying, one smear is stained with methylthioninium chloride (methylene blue ♠), the other with Gram stain. Microscopy of a native smear is performed before it dries. Evaluate the presence of epithelium in the preparations, the number of leukocytes, erythrocytes, the morphotype of bacteria (cocci, coccobacilli, lactobacilli), the presence of diplococci located extra- and intracellularly.

In accordance with the results of the study, four degrees of purity of the smear are distinguished:

I degree - single leukocytes are determined in the field of view, rod flora (lactobacilli);

II degree - 10-15 leukocytes in the field of view, against the background of rod flora there are single cocci;

III degree - leukocytes 30-40 in the field of view, few lactobacilli, cocci predominate;

IV degree - a large number of leukocytes, lactobacilli are absent, the microflora is represented by various microorganisms; may be gonococci, Trichomonas.

Pathological smears are considered III and IV degrees of purity.

Serological studies are based on the antigen-antibody reaction and give indirect indications of infection. TO serological methods diagnostics include the determination of the level of specific immunoglobulins of various classes (IgA, IgG, IgM) in the blood serum by enzyme immunoassay (ELISA). The reaction of direct (PIF) and indirect (NPIF) immunofluorescence is used to identify the pathogen with fluorescent microscopy. In practice, serological methods are used to diagnose infections such as toxoplasmosis, measles, rubella, parotitis, genital herpes, syphilis, hepatitis B and C, urogenital and chlamydial infections.

Molecular biological methods allow identification of a microorganism by the presence of specific DNA segments. Of the various options for DNA diagnostics, the polymerase chain reaction (PCR) method, which allows the identification of various infectious agents, is most widely used.

Bacteriological diagnostics is based on the identification of microorganisms grown on artificial nutrient media. Material for research is taken from the pathological focus (cervical canal, urethra, abdominal cavity, wound surface) with a bacteriological loop or a sterile swab and transferred to a nutrient medium. After the formation of colonies, microorganisms are determined and their sensitivity to antibiotics and antibacterial drugs is assessed.

Tissue biopsy and cytology

Biopsy- intravital taking of a small amount of tissue for microscopic examination for the purpose of diagnosis. In gynecology, excisional biopsy (excision of a piece of tissue) is used (Fig. 1.5), targeted biopsy - under the visual control of an extended colposcopy or hysteroscope, and puncture biopsy.

Most often, a biopsy is performed if a malignant tumor of the cervix, vulva, vagina, etc. is suspected.

cytological diagnosis. Cells are subjected to cytological examination in smears from the cervix, in punctate (volumetric formations of the small pelvis, fluid from the retrouterine space) or aspirate from the uterine cavity. The pathological process is recognized by the morphological features of cells, the quantitative ratio of individual cell groups, the location of cellular elements in the preparation.

Cytological examination is a screening method for mass preventive examinations of women in high-risk groups for the development of cancer.

Cytological examination of cervical smears under a microscope is used as a screening method, but has insufficient sensitivity (60-70%). There are various systems for evaluating its results.

In Russia, a descriptive conclusion is often used. The most commonly used system is the Papanico-Lau (Pap test). The following classes of cytological changes are distinguished:

I - normal cytological picture;

II - inflammatory, reactive changes in epithelial cells;

III - atypia of individual epithelial cells (suspicion of dysplasia);

IV - single cells with signs of malignancy (suspicion of cancer);

V - complexes of cells with signs of malignancy (cervical cancer).

Determination of hormones and their metabolites

In gynecological practice, protein hormones are determined in blood plasma: lutropin (luteinizing hormone - LH), follitropin (follicle-stimulating hormone - FSH), prolactin (Prl), etc .; steroid hormones (estradiol, progesterone, testosterone, cortisol, etc.); in the urine - excretion of androgen metabolites (17-ketosteroids - 17-KS) and pregnane-diol - a metabolite of the corpus luteum hormone progesterone.

In recent years, when examining women with manifestations of hyperandrogenism, the levels of androgens, adrenal hormones are examined; their precursors in blood plasma and metabolites in urine - testosterone, cortisol, dehydroepiandrosterone (DHEA) and its sulfate (DHEA-S), 17-hydroxyprogesterone (17-OPN), 17-KS. The determination of pregnandiol has given way to a study of the level of progesterone in the blood.

Functional trials

A single determination in the blood and urine of hormones and their metabolites is uninformative; these studies are combined with functional tests, which allows you to clarify the interaction of various parts of the reproductive system and find out the reserve capabilities of the hypothalamus, pituitary gland, adrenal glands, ovaries and endometrium.

Test with estrogens and gestagens is carried out in order to exclude (confirm) a disease or damage to the endometrium (uterine form of amenorrhea) and to determine the degree of estrogen deficiency. Intramuscular injections of ethinyl estradiol (Microfollin ♠) are administered at a dose of 0.1 mg (2 tablets of 0.05 mg) daily for 7 days. Then progesterone is administered in the doses indicated for the test with gestagens. 2-4 or 10-14 days after the administration of progesterone or HPA, respectively, a menstrual-like reaction should begin. A negative result (lack of reaction) indicates deep organic changes in the endometrium (damages, diseases); positive (onset of a menstrual-like reaction) - for a pronounced deficiency of endogenous estrogens.

Dexamethasone test is carried out to determine the cause of hyperandrogenism in women with clinical manifestations of virilization. With signs of virilization, it is first necessary to exclude an ovarian tumor.

The test with dexamethasone is based on its ability (like all glucocorticosteroid drugs) to suppress the release of adrenocorticotropic hormone (ACTH) by the anterior pituitary gland, as a result of which the formation and release of androgens by the adrenal glands are inhibited.

Small dexamethasone test: dexamethasone 0.5 mg every 6 hours (2 mg / day) for 3 days, the total dose is 6 mg. 2 days before taking the drug and the next day after its withdrawal, the content of testosterone, 17-OHP and DHEA in the blood plasma is determined. If this is not possible, the content of 17-KS in the daily urine is determined. With a decrease in these indicators compared to the original by more than 50-75%, the test is considered positive, which indicates an adrenal origin

androgens; a decrease after the test of less than 30-25% indicates the ovarian origin of androgens.

In case of a negative test, a large dexamethasone test: taking 2 mg of dexamethasone (4 tablets of 0.05 mg) every 6 hours (8 mg / day) for 3 days (total dose - 24 mg). The control is the same as for the small dexamethasone test. A negative test result - the absence of a decrease in androgens in the blood or urine - indicates a virilizing tumor of the adrenal glands.

Functional tests to determine the level of impairment of the hypothalamic-pituitary system. Samples are carried out with a normal or low content of gonadotropins in the blood.

Test with clomiphene used for diseases accompanied by chronic anovulation on the background of oligomenorrhea or amenorrhea. The test begins after a menstrual-like reaction caused by the intake of estrogens and progesterone. From the 5th to the 9th day from the onset of a menstrual-like reaction, clomiphene is prescribed at a dose of 100 mg / day (2 tablets of 50 mg). The information content of the test is controlled by determining the level of gonadotropins and estradiol in the blood plasma before the test and on the 5-6th day after the end of the drug, or by basal temperature and the appearance or absence of a menstrual-like reaction 25-30 days after taking clomiphene.

A lot depends on a woman's health. This is the well-being of her family, the health of her children. That is why it is necessary to pay special attention to the examination, not only in the presence of complaints, but also as preventive examination. Currently, many modern research methods are used, which make it possible to detect pathology at an early stage and start treatment as soon as possible. Diagnostics in Israel is carried out using the most advanced equipment. detected at an early stage are easily treatable.

Colposcopy

This modern research method allows you to examine the cervix using a special lens system, which makes it possible to obtain an increase of 5-25 times. With the help of colposcopy, it is possible to determine the shape and size of the cervix, to study the relief of the mucous membrane, the border of the transition of the squamous epithelium to the cylindrical one. With conventional colposcopy, only microscopic examination is performed, and with extended colposcopy, special chemicals are used. So, for example, Lugol's solution, acetic acid, iodine is used. By processing the cervix in this way, it is possible to identify areas altered by the pathological process.

Hysteroscopy

With the help of this study, you can examine the inner surface of the body of the uterus. Hysteroscopy is the most highly informative method for diagnosing intrauterine pathology. Diagnostic hysteroscopy is indicated for suspected benign or malignant tumors, the appearance spotting c, in violation of the menstrual cycle in some periods of a woman's life. The study is also informative in the diagnosis of obstetric pathology, for example, with a delay in the fetal egg, miscarriage, diagnosing the condition after, the presence of chorionepithelioma, and assessing the course of the postpartum period. Hysteroscopy can be used to assess the effectiveness of hormone therapy, assess the location intrauterine device.

Operational hysteroscopy can be performed to remove intrauterine polyps, separation. With the help of this study, the removal of the intrauterine device and other foreign bodies is carried out. In congenital pathology, hysteroscopy is used to cut the intrauterine septum. This multifunctional diagnostic method is used for various pathological conditions in gynecology.

Laparoscopy

With the help of this diagnostic method, it is possible to examine the organs of the abdominal cavity from the inside. carried out without the use of large incisions. With this diagnostic procedure, only a few small punctures a couple of millimeters long are used. An endoscope is inserted into the pelvic cavity, on which a special video camera is fixed. With the help of such optical system it is possible to diagnose tubal-peritoneal infertility, assess the condition of the ovaries in polycystic disease, and identify tumor formations. Laparoscopy can detect congenital malformations of the genital organs, diagnose endometriosis. In addition, at this study a procedure such as a biopsy may be performed. In this case, a suspicious tumor formation is taken. The tissue sample is then sent for histological examination. At the same time, under a microscope, the degree of differentiation of the tumor tissue, the type of tumor, and the degree of its spread are assessed. Laparoscopy can also become not only a diagnostic method, but also be used for the purpose of surgical intervention. So laparoscopic operations are carried out with the development intrauterine pregnancy, the development of acute inflammatory diseases of the uterus and ovaries. Thus, differential diagnosis between gynecological and surgical pathology is carried out.

Ultrasonography

Ultrasound examination of the pelvic organs is an indispensable diagnostic method in gynecology. Using this research method, you can set the size of the ovaries, uterus, monitor the development of the follicle, the thickness of the endometrium at different periods of the menstrual cycle. Modern gynecological examination can be carried out in two ways. In an abdominal examination, a study of the genital organs is performed through the anterior abdominal wall. More detailed information about the state of the uterus, ovaries can be obtained using vaginal ultrasound.

Hysterosalpingography

This x-ray examination is carried out with the use of a contrast agent. Such special drug inserted into the uterine cavity. Thus, it is possible to examine the patency of the fallopian tubes, to identify anatomical changes in the uterine cavity. This research method plays an important role in the detection of adhesions in the pelvic cavity. The most optimal results are obtained by conducting a study on the 5-8th day of the menstrual cycle.

Magnetic resonance imaging

This modern research method helps to differential diagnosis between many pathological processes in the pelvic cavity, to determine the current state of the organs with unclear ultrasound results.

CT scan

With the help of this, it is possible to obtain a section of the organ under study, for example, the uterus in various planes. Thus, the doctor receives the necessary information about the location of the focus of the pathological process, its prevalence, structure. By using computed tomography it is possible to detect and investigate formations up to 0.5 cm in size.

polymerase chain reaction

This research method is indispensable in the diagnosis various diseases genitals. To conduct such a study, biological material is taken: a swab from the vagina, blood, urine. Using this highly sensitive method for detecting infectious pathogens, even minimal amounts of pathogen DNA can be detected. PCR is highly effective for detecting bacteria (ureaplasmas, mycoplasmas), protozoa (chlamydia), viruses (human papillomavirus, cytomegalovirus), fungi (candida). The detection of such infections is necessary in the diagnosis of various pathologies of the female genital organs.

Modern methods for diagnosing gynecological diseases make it possible to identify them at an early stage of development (for example,) and start on time effective treatment in Israel.

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