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Гиперпластические процессы эндометрия: современная тактика ведения пациенток
Гиперпластические процессы эндометрия: современная тактика ведения пациенток
Габидуллина Р.И., Смирнова Г.А., Нухбала Ф.Р. и др. Гиперпластические процессы эндометрия: современная тактика ведения пациенток. Гинекология. 2019; 21 (6): 53–58. DOI: 10.26442/20795696.2019.6.190472
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Аннотация
Цель. Изучить современное состояние проблемы гиперпластических процессов эндометрия.
Материалы и методы. В статье представлен обзор литературы по результатам поиска исследований в электронных ресурсах MEDLINE, EMBASE, Cochrane Library и eLIBRARY.
Результаты. Основными факторами риска возникновения гиперпластических процессов эндометрия и их малигнизации в настоящее время являются возраст и ожирение. Приведены современная классификация гиперплазии эндометрия Всемирной организации здравоохранения (2014 г.) и альтернативная классификация атипической гиперплазии эндометрия EIN (Endometrial intraepithelial neoplasia – эндометриальная интраэпителиальная неоплазия). Освещены вопросы диагностики гиперпластических процессов эндометрия. Согласно современным международным стандартам только гистологическая оценка эндометрия позволяет с уверенностью выставить диагноз «гиперплазия эндометрия». Для улучшения визуализации полипов эндометрия рекомендовано трансвагинальное ультразвуковое исследование дополнить допплеровским исследованием или внутриматочным контрастированием. Представлена тактика ведения пациенток в зависимости от гистологического диагноза в соответствии с со-временными международными рекомендациями. Профилактика гиперпластических процессов эндометрия заключается в нивелировании факто-ров риска их возникновения, в частности модификации массы тела.
Заключение. В обзоре представлен рациональный подход к профилактике, диагностике и лечению гиперпластических процессов эндометрия, включая гормональную терапию и хирургические методы.
Ключевые слова: гиперплазия эндометрия, полип эндометрия, факторы риска, классификация, терапия, прогестины.
Материалы и методы. В статье представлен обзор литературы по результатам поиска исследований в электронных ресурсах MEDLINE, EMBASE, Cochrane Library и eLIBRARY.
Результаты. Основными факторами риска возникновения гиперпластических процессов эндометрия и их малигнизации в настоящее время являются возраст и ожирение. Приведены современная классификация гиперплазии эндометрия Всемирной организации здравоохранения (2014 г.) и альтернативная классификация атипической гиперплазии эндометрия EIN (Endometrial intraepithelial neoplasia – эндометриальная интраэпителиальная неоплазия). Освещены вопросы диагностики гиперпластических процессов эндометрия. Согласно современным международным стандартам только гистологическая оценка эндометрия позволяет с уверенностью выставить диагноз «гиперплазия эндометрия». Для улучшения визуализации полипов эндометрия рекомендовано трансвагинальное ультразвуковое исследование дополнить допплеровским исследованием или внутриматочным контрастированием. Представлена тактика ведения пациенток в зависимости от гистологического диагноза в соответствии с со-временными международными рекомендациями. Профилактика гиперпластических процессов эндометрия заключается в нивелировании факто-ров риска их возникновения, в частности модификации массы тела.
Заключение. В обзоре представлен рациональный подход к профилактике, диагностике и лечению гиперпластических процессов эндометрия, включая гормональную терапию и хирургические методы.
Ключевые слова: гиперплазия эндометрия, полип эндометрия, факторы риска, классификация, терапия, прогестины.
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Aim. To study the current state of the problem of endometrial hyperplastic processes.
Materials and methods. The article presents a review of the literature on the search results of research in the electronic resources MEDLINE, EMBASE, Cochrane Library and eLIBRARY.
Results. The main risk factors for endometrial hyperplastic processes and their malignancy are currently age and obesity. A modern classification of WHO endometrial hyperplasia (2014) and an alternative classification of atypical endometrial hyperplasia EIN are presented. The issues of diagnosis of endometrial hy-perplastic processes are covered. According to modern international standards, only the histological assessment of the endometrium allows us to confidently set the diagnosis of endometrial hyperplasia. To improve the visualization of endometrial polyps, a transvaginal ultrasound study should be supplemented with a Doppler study or intrauterine contrasting. Presented tactics of patient management, depending on the histological diagnosis in accordance with modern inter-national recommendations. Prevention of endometrial hyperplastic processes consists in leveling the risk factors for their occurrence, in particular the modification of body weight.
Conclusion. This review offers a rational approach to prevention, diagnosis, and treatment of endometrial hyperplastic processes, including hormone therapy and surgical methods.
Key words: endometrial hyperplasia, endometrial polyp, risk factors, classification, therapy, progestins.
Materials and methods. The article presents a review of the literature on the search results of research in the electronic resources MEDLINE, EMBASE, Cochrane Library and eLIBRARY.
Results. The main risk factors for endometrial hyperplastic processes and their malignancy are currently age and obesity. A modern classification of WHO endometrial hyperplasia (2014) and an alternative classification of atypical endometrial hyperplasia EIN are presented. The issues of diagnosis of endometrial hy-perplastic processes are covered. According to modern international standards, only the histological assessment of the endometrium allows us to confidently set the diagnosis of endometrial hyperplasia. To improve the visualization of endometrial polyps, a transvaginal ultrasound study should be supplemented with a Doppler study or intrauterine contrasting. Presented tactics of patient management, depending on the histological diagnosis in accordance with modern inter-national recommendations. Prevention of endometrial hyperplastic processes consists in leveling the risk factors for their occurrence, in particular the modification of body weight.
Conclusion. This review offers a rational approach to prevention, diagnosis, and treatment of endometrial hyperplastic processes, including hormone therapy and surgical methods.
Key words: endometrial hyperplasia, endometrial polyp, risk factors, classification, therapy, progestins.
Полный текст
Список литературы
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[Budilova E., Lagutin M. Gendernye trendy prodolzhitel'nosti zhizni v Rossii i mire. Aist na kryshe. Demografich. zhurn. 2018; 7: 12–7 (in Russian).]
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27. Clark TJ, Stevenson H. Endometrial Polyps and Abnormal Uterine Bleeding (AUB-P): What is the relationship, how are they diagnosed and how are they treated? Best Pract Res Clin Obstet Gynaecol 2016 (40): 89–104.
28. Новикова О.В., Лозовая Ю.А. Показатели фертильности при рецидивах атипической гиперплазии и начального рака эндометрия после самостоятельной гормонотерапии. Международная научно-практическая конференция «Репродуктивные технологии в онкологии». Обнинск, 2015.
[Novikova O.V., Lozovaia Iu.A. Fertility indicators in relapses of atypical hyperplasia and initial endometrial cancer after independent hormone therapy. International Scientific and Practical Conference "Reproductive Technologies in Oncology". Obninsk, 2015 (in Russian).]
29. Collaborative Group on Epidemiological Studies on Endometrial Cancer. Endometrial cancer and oral contraceptives: an individual participant meta-analysis of 27 276 women with endometrial cancer from 36 epidemiological studies. Lancet Oncol 2015; 16 (9): 1061–70.
30. Africander D, Verhoog N, Hapgood JP. Molecular mechanisms of steroid receptor-mediated actions by synthetic progestins used in HRT and contraception. Steroids 2011; 76 (7): 636–52.
31. Wang Y, Nisenblat V, Tao L et al. Combined estrogen-progestin pill is a safe and effective option for endometrial hyperplasia without atypia: a three-year single center experience. J Gynecol Oncol 2019; 30 (3): e49.
32. Cibula D, Gompel A, Mueck AO et al. Hormonal contraception and risk of cancer. Hum Reprod Update 2010; 16 (6): 631–50.
33. Lu KH, Loose DS, Yates MS et al. Prospective multicenter randomized intermediate biomarker study of oral contraceptive versus depo-provera for prevention of endometrial cancer in women with Lynch syndrome. Cancer Prev Res (Phila) 2013; 6 (8): 774–81.
34. Ткаченко Л.В., Свиридова Н.И. Гиперпластические процессы эндометрия в пременопаузе: современные возможности гормональной коррекции и профилактики. Гинекология. 2013; 15 (2): 8–12.
[Tkachenko L.V., Sviridova N.I. Giperplasticheskie protsessy endometriia v premenopauze: sovremennye vozmozhnosti gormonal'noi korrektsii i profilaktiki. Gynecology. 2013; 15 (2): 8–12 (in Russian).]
35. Kuhl H. New gestagens – advantages and disadvantages. Ther Umsch 2001; 58 (9): 527–33.
36. Merz M, Grunert J. Effects of an ethinyl estradiol/gestodene transdermal contraceptive patch on the endometrium: a single-center, uncontrolled study. Womens Health (Lond) 2014; 10 (1): 37–43.
37. Овсянникова Т.В., Куликов И.А. Контрацептивные и лечебные возможности эстроген-гестагенных препаратов. Гинекология. 2017; 19 (2): 5–8.
[Ovsiannikova T.V., Kulikov I.A. Contraceptive and medical possibilities of estrogen-hestagenic preparations. Gynecology. 2017; 19 (2): 5–8 (in Russian).]
38. Давыдов А.И., Новрузова Н.Х., Стрижаков А.Н. Гиперплазии эндометрия: анализ классификации ВОЗ 2014 и протокола RCOG & BSGE с позиций собственных результатов. Вопр. гинекол., акуш. и перинатол. 2018; 17 (4): 11–24.
[Davydov A.I., Novruzova N.H., Strizhakov A.N. Giperplazii endometriya: analiz klassifikacii VOZ 2014 i protokola RCOG & BSGE s pozicij sobstvennyh rezul'tatov. Vopr. ginekol., akush. i perinatol. 2018; 17 (4): 11–24 (in Russian).]
39. Stanczyk FZ, Archer DF. Gestodene: A review of its pharmacology, potency and tolerability in combined contraceptive preparations. Contraception 2014; 89 (4): 242–52.
40. Nappi G, Di Spiezio Sardo A. State-of-the-art Hysteroscopic Approaches to Pathologies of the Genital Tract. Tuttlingen: Endo Press, 2014.
[Clinical recommendations of the Ministry of Health of the Russian Federation "Uterine body cancer". 2018; p. 6 (in Russian).]
2. Подгорная А.С. Пролиферативные процессы эндометрия: современное состояние проблемы. Гомель: РНПЦ РМ и ЭЧ, 2017.
[Podgornaia A.S. Endometrial proliferative processes: current state of the problem. Gomel': RNPTs RM i ECh, 2017 (in Russian).]
3. Charalampakis V, Tahrani A, Helmy A et al. Polycystic ovary syndrome and endometrial hyperplasia: an overview of the role of bariatric surgery in female fertility. Eur J Obstet Gynecol Reprod Biol 2016; 207: 220–6.
4. Clement NS, Oliver TR, Shiwani H et al. Metformin for endometrial hyperplasia: a Cochrane protocol. BMJ Open 2016; 6 (8): e013385.
5. Royal College of Obstetrician and ginecologists. Management of Endometrial Hyperplasia. Green-Top Guideline No.67. RCOG/BSGE Joint Guideline – February 2016.
6. Armstrong AJ, Hurd WW, Elguero S et al. Diagnosis and Management of Endometrial Hyperplasia. J Minim Invasive Gynecol 2012; 19 (5): 562–71.
7. Burton ER, Sorosky JI. Recognition and Therapeutic Options for Malignancy of the Cervix and Uterus. Obstet Gynecol Clin North Am2017; 44 (2): 195–206.
8. GBD 2015 Obesity Collaborators, Afshin A, Forouzanfar MH et al. Health effects of overweight and obesity in 195 countries over 25 years. N Engl J Med 2017; 377 (1): 13–27.
9. Munro MG, Southern California Permanente Medical Group’s Abnormal Uterine Bleeding Working Group. Investigation of Women with Postmenopausal Uterine Bleeding: Clinical Practice Recommendations. Perm J 2014; 18 (1): 55–70.
10. Будилова Е., Лагутин М. Гендерные тренды продолжительности жизни в России и мире. Аист на крыше. Демографич. журн. 2018; 7: 12–7.
[Budilova E., Lagutin M. Gendernye trendy prodolzhitel'nosti zhizni v Rossii i mire. Aist na kryshe. Demografich. zhurn. 2018; 7: 12–7 (in Russian).]
11. Wise MR, Jordan V, Lagas A et al. Obesity and endometrial hyperplasia and cancer in premenopausal women: A systematic review. Am J Obstet Gynecol 2016; 214 (6): 689–97.
12. Tanos V, Berry KE, Seikkula J et al. The management of polyps in female reproductive organ. Int J Surg 2017; 43: 7–16.
13. Pergialiotis V, Prodromidou A, Siotos C et al. Systemic hypertension and diabetes mellitus as predictors of malignancy among women with endometrial polyps: a meta-analysis of observational studies. Menopause 2016; 23 (6): 691–7.
14. Sobczuk K, Sobczuk A. New classification system of endometrial hyperplasia WHO 2014 and its clinical implications. Prz Menopauzalny 2017; 16 (3): 107–11.
15. Di Spiezio Sardo А, Di Carlo С, Minozzi S et al. Efficacy of hysteroscopy in improving reproductive outcomes of infertile couples: a systematic review and metaanalysis. Hum Reprod Update 2016; 22 (4): 479–96.
16 Travaglino A, Raffone A, Saccone G et al. Endometrial hyperplasia and risk of coexistent cancer: WHO versus EIN criteria. Histopathology 2019; 74 (5): 676–87.
17. Reed SD, Newton KM, Clinton L et al. Incidence of endometrial hyperplasia. Am J Obstet Gynecol 2009; 200 (6): 678.e1–678.е6.
18. Lacey JV, Chia VM. Endometrial hyperplasia and the risk of progression to carcinoma. Maturitas 2009; 63 (1): 39–44.
19. Iversen ML, Dueholm M. Complex non atypical hyperplasia and the subsequent risk of carcinoma, atypia and hysterectomy during the following 9–14 years. Eur J Obstet Gynecol Reprod Biol 2018; 222: 171–5.
20. Smith-Bindman R, Kerlikowske K, Feldstein VA et al. Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities. JAMA 1998; 280 (17): 1510–7.
21. Yuk JS, Shin JY, Moon HS, Lee JH. The incidence of unexpected uterine malignancy in women undergoing hysteroscopic myomectomy or polypectomy: A national population-based study. Eur J Obstet Gynecol Reprod Biol 2018 (224): 12–6.
22. Renaud MC, Le T. SOGC-GOC-SCC policy and practice guidelines committee, special contributors. Epidemiology and investigations for suspected cancer. J Obstet Gynaecol Can 2013; 35 (4): 380–1.
23. American Association of Gynecologic Laparoscopists. AAGL Practice Report: Practice Guidelines for the Diagnosis and Management of Endometrial Polyps. J Minim Invasive Gynecol 2012; 19 (1): 3–10.
24. Nieuwenhuis LL, Hermans FJ, Bij de Vaate AJM et al. Three-dimensional saline infusion sonography compared to two-dimensional saline infusion sonography for the diagnosis of focal intracavitary lesions. Cochrane Database Syst Rev 2017. Issue 5: CD011126.
25. Getpook C, Wattanakumtornkul S. Endometrial thickness screening in premenopausal women with abnormal uterine bleeding. J Obstet Gynaecol Res 2006; 32 (6): 588–92.
26. Ghoubara A, Emovon E, Sundar S, Ewies A. Thickened endometrium in asymptomatic postmenopausal women – determining an optimum threshold for prediction of atypical hyperplasia and cancer. J Obstet Gynaecol 2018; 38 (8): 1146–9.
27. Clark TJ, Stevenson H. Endometrial Polyps and Abnormal Uterine Bleeding (AUB-P): What is the relationship, how are they diagnosed and how are they treated? Best Pract Res Clin Obstet Gynaecol 2016 (40): 89–104.
28. Новикова О.В., Лозовая Ю.А. Показатели фертильности при рецидивах атипической гиперплазии и начального рака эндометрия после самостоятельной гормонотерапии. Международная научно-практическая конференция «Репродуктивные технологии в онкологии». Обнинск, 2015.
[Novikova O.V., Lozovaia Iu.A. Fertility indicators in relapses of atypical hyperplasia and initial endometrial cancer after independent hormone therapy. International Scientific and Practical Conference "Reproductive Technologies in Oncology". Obninsk, 2015 (in Russian).]
29. Collaborative Group on Epidemiological Studies on Endometrial Cancer. Endometrial cancer and oral contraceptives: an individual participant meta-analysis of 27 276 women with endometrial cancer from 36 epidemiological studies. Lancet Oncol 2015; 16 (9): 1061–70.
30. Africander D, Verhoog N, Hapgood JP. Molecular mechanisms of steroid receptor-mediated actions by synthetic progestins used in HRT and contraception. Steroids 2011; 76 (7): 636–52.
31. Wang Y, Nisenblat V, Tao L et al. Combined estrogen-progestin pill is a safe and effective option for endometrial hyperplasia without atypia: a three-year single center experience. J Gynecol Oncol 2019; 30 (3): e49.
32. Cibula D, Gompel A, Mueck AO et al. Hormonal contraception and risk of cancer. Hum Reprod Update 2010; 16 (6): 631–50.
33. Lu KH, Loose DS, Yates MS et al. Prospective multicenter randomized intermediate biomarker study of oral contraceptive versus depo-provera for prevention of endometrial cancer in women with Lynch syndrome. Cancer Prev Res (Phila) 2013; 6 (8): 774–81.
34. Ткаченко Л.В., Свиридова Н.И. Гиперпластические процессы эндометрия в пременопаузе: современные возможности гормональной коррекции и профилактики. Гинекология. 2013; 15 (2): 8–12.
[Tkachenko L.V., Sviridova N.I. Giperplasticheskie protsessy endometriia v premenopauze: sovremennye vozmozhnosti gormonal'noi korrektsii i profilaktiki. Gynecology. 2013; 15 (2): 8–12 (in Russian).]
35. Kuhl H. New gestagens – advantages and disadvantages. Ther Umsch 2001; 58 (9): 527–33.
36. Merz M, Grunert J. Effects of an ethinyl estradiol/gestodene transdermal contraceptive patch on the endometrium: a single-center, uncontrolled study. Womens Health (Lond) 2014; 10 (1): 37–43.
37. Овсянникова Т.В., Куликов И.А. Контрацептивные и лечебные возможности эстроген-гестагенных препаратов. Гинекология. 2017; 19 (2): 5–8.
[Ovsiannikova T.V., Kulikov I.A. Contraceptive and medical possibilities of estrogen-hestagenic preparations. Gynecology. 2017; 19 (2): 5–8 (in Russian).]
38. Давыдов А.И., Новрузова Н.Х., Стрижаков А.Н. Гиперплазии эндометрия: анализ классификации ВОЗ 2014 и протокола RCOG & BSGE с позиций собственных результатов. Вопр. гинекол., акуш. и перинатол. 2018; 17 (4): 11–24.
[Davydov A.I., Novruzova N.H., Strizhakov A.N. Giperplazii endometriya: analiz klassifikacii VOZ 2014 i protokola RCOG & BSGE s pozicij sobstvennyh rezul'tatov. Vopr. ginekol., akush. i perinatol. 2018; 17 (4): 11–24 (in Russian).]
39. Stanczyk FZ, Archer DF. Gestodene: A review of its pharmacology, potency and tolerability in combined contraceptive preparations. Contraception 2014; 89 (4): 242–52.
40. Nappi G, Di Spiezio Sardo A. State-of-the-art Hysteroscopic Approaches to Pathologies of the Genital Tract. Tuttlingen: Endo Press, 2014.
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2. Podgornaia A.S. Endometrial proliferative processes: current state of the problem. Gomel': RNPTs RM i ECh, 2017 (in Russian).
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Авторы
Р.И. Габидуллина*1, Г.А. Смирнова2, Ф.Р. Нухбала1, Е.В. Валеева1, Ю.И. Орлова1, А.А. Шакиров1
1 ФГБОУ ВО «Казанский государственный медицинский университет» Минздрава России, Казань, Россия;
2 ГАУЗ «Городская клиническая больница №7», Казань, Россия
*ru.gabidullina@yandex.ru
1 Kazan State Medical University, Kazan, Russia;
2 City Clinical Hospital №7, Kazan, Russia
*ru.gabidullina@yandex.ru
1 ФГБОУ ВО «Казанский государственный медицинский университет» Минздрава России, Казань, Россия;
2 ГАУЗ «Городская клиническая больница №7», Казань, Россия
*ru.gabidullina@yandex.ru
________________________________________________
1 Kazan State Medical University, Kazan, Russia;
2 City Clinical Hospital №7, Kazan, Russia
*ru.gabidullina@yandex.ru
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