It is the duty of every woman to know about it and be able to feel her body.

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What is menstruation?

Menstruation(from Latin mensis - month, menstruus - monthly), menstruation or regula are part of the menstrual cycle of the female body. During menstruation, the functional layer of the endometrium (uterine lining) is shed, accompanied by bleeding. The countdown of the menstrual cycle begins on the first day of menstruation.

Why do we need periods?
The menstrual process is a period when the uterine epithelium is renewed every month.

During this process, irreversible changes occur in the epithelium, and it is removed from the body, since it can no longer be used. Instead, a new epithelium is formed in the body, which is successfully involved in internal processes.

Functional purpose:

Degeneration of cells. The menstrual process allows you to renew epithelial cells, which provides an important role for the reproductive ability of a girl.

Natural protective. The menstrual process involves a separate layer of the uterus, which is responsible for analyzing problems in eggs that are not fertilized and preventing the implantation of these eggs. Such eggs are excreted from the body along with the epithelium every month.

Menstrual blood does not clot and has a darker color than the blood circulating in the vessels. This is explained by the presence of a set of enzymes in menstrual blood.

Menstrual blood is the liquid discharge from the vagina during menstruation. Strictly speaking, the more correct term is menstrual fluid, since its composition, in addition to blood itself, includes the mucous secretion of the glands of the cervix, the secretion of the vaginal glands and endometrial tissue.

The average volume of menstrual fluid released during one menstrual cycle is, according to the Great Medical Encyclopedia, about 50-100 milliliters.

However, the individual spread ranges from 10 to 150 and even up to 250 milliliters.

This range is considered normal; more abundant (or, conversely, scanty) discharge may be a symptom of the disease. Menstrual fluid is reddish-brown in color, slightly darker than venous blood.

The amount of iron lost through menstrual blood is relatively small for most women and cannot on its own cause symptoms of anemia.

In one study, a group of women exhibiting symptoms of anemia were examined using an endoscope. It turned out that 86% of them actually suffered from various gastrointestinal diseases (such as gastritis or duodenal ulcers, in which bleeding occurs in the gastrointestinal tract).

This diagnosis may have been missed due to erroneous attribution of iron deficiency to menstrual blood loss. However, regularly heavy menstrual bleeding in some cases can still lead to anemia.

Menstruation (and menstrual cycles in general) usually do not occur during pregnancy and lactation. And the absence of menstruation at the expected time is a common symptom that suggests pregnancy.

During menstruation, a woman may experience physical discomfort. Before menstruation, you may experience irritability, drowsiness, fatigue, a slight increase in heart rate, and during menstruation - a slight slowdown in heart rate.

Premenstrual syndrome

Some women experience emotional changes associated with menstruation.

Sometimes there is irritability, a feeling of fatigue, tearfulness, and depression. A similar range of emotional effects and mood shifts are also associated with pregnancy and may be due to a lack of endorphins.

Estimates of the incidence of premenstrual syndrome range from 3% to 30%. In certain rare cases, in individuals prone to psychotic disorders, menstruation may trigger menstrual psychosis.

It is important to know the days of your cycle, the description of which will help you get to know yourself better.

Every woman should know the female cycle by day, what happens on these days, because it will show when you are ready to conceive, when you are passionate or, on the contrary, cold, why your mood changes so much:

On the 1st day The uterus throws out the spent endometrium, that is, bleeding begins.

A woman may experience malaise and pain in the lower abdomen. To reduce pain, you can take No-shpu, Buscopan, Belastezin, Papaverine.

On the 2nd day heavy sweating begins.

On day 3 the uterus is very open, which can contribute to infection. On this day, a woman can also become pregnant, so sex should be protected.

From the 4th day The mood begins to improve, efficiency appears, as menstruation is nearing completion.

What is the cycle by day in the second half?

days, starting from 9th to 11th day considered dangerous, you may become pregnant.

They say that at this time you can conceive a girl. And on the day of ovulation and immediately after it is suitable for conceiving a boy.

At 12th Every day, women's libido increases, which entails a strong sexual desire.

When does the second half start?

From 14 days, when the egg begins to move towards the male principle, ovulation occurs.

On the 16th day a woman may gain weight as her appetite increases.

Until 19 days the possibility of becoming pregnant remains.

From the 20th day“safe” days begin. What are “safe days”? That's right! "Safe" - in quotes!

These days, the possibility of getting pregnant decreases. Many women ask the question: is it possible for a woman to get pregnant before her menstrual cycle? The probability is low, but no one can give a complete guarantee.

The period of menstruation can change under the influence of many factors. No woman has an even cycle throughout her life. Even a cold, fatigue or stress can change it.

Many doctors warn that the body is capable of “giving out” repeated ovulation, so even 1 day before your period you can conceive a baby.

Menopause

Age of onset menopause(cessation of menstruation): the norm is 40-57 years, most likely - 50-52 years.

In temperate climates, menstruation lasts for an average of 50 years, after which menopause occurs; At first the regulations disappear for several months, then they appear and disappear again, etc.

There are, however, women who maintain menstruation until they are 70 years old. From a medical point of view, menopause is considered to have occurred if menstruation has been completely absent for a year.

What is the menstrual cycle?

Menarche.

First appearance of menstruation (menarche) in a woman it occurs at an average age of 12-14 years (with a range from 9-11 years to 19-21 years). Menstruation in hot climates begins between 11 and 15 years of age. In temperate climates - between 12 and 18 years of age and in cold climates - between 13 and 21 years of age.

The age of menarche reveals certain racial differences: for example, a number of studies have shown that Negroids experience menarche earlier than Caucasians living in the same socio-economic conditions.

After the first menstruation, the next one may be 2 or 3 months later. Over time, the menstrual cycle becomes established and lasts 28 days, but a cycle length of 21 to 35 days is normal. Only 13% of all women have a cycle of exactly 28 days. Menstruation lasts approximately 2-8 days. All discharge comes from the vagina.

On average, menstrual cycles usually begin between ages 12 and 15 and continue until approximately 45 to 50 years of age.

Since menstrual cycles are a consequence of changes in the ovary associated with the formation of oocytes, a woman is fertile only during the years that she has menstrual cycles. This does not mean that sexual activity stops with the onset of menopause - only fertility disappears.

For practical reasons, the beginning of the menstrual cycle is considered to be the day when menstrual bleeding appears.

Menstrual discharge consists of collapsing endometrium mixed with blood from ruptured blood vessels.

Before the onset of menstruation, the following phenomena are observed:

• nagging pain in the sacrum, often in the lower back;
• headaches;
• fatigue, weakness;
• nipple sensitivity;
• weight gain;
• Sometimes mucous discharge occurs.

Selection by day:

• 1 day - scanty discharge;
• 2.3 days - abundant;
• Day 4.5 - reduction in discharge;
• 6-7 days - cessation of menstruation.

The menstrual phase lasts on average for 3-4 days. It is followed by two other phases of the menstrual cycle - the proliferation phase and the secretion phase (luteal phase, or corpus luteum phase).

The secretion phase begins after ovulation and lasts about 14 days. The duration of the proliferation phase is variable, averaging 10 days.

So, the menstrual cycle is usually called a period of time, the beginning of which is consideredfirst day of menstruation, and at the end - the day before the next menstrual flow appears.

The normal menstrual cycle of a healthy woman has four phases, each lasting about 7 days. The duration of the entire cycle is 28 days. However, the duration of the menstrual cycle of 28 days is an average figure.

For each individual woman it can vary both up and down. But a cycle that lasts from 21 to 35 days is also considered normal.

If the cycle does not fit within these time periods, this is not the norm. In this case, you should contact a gynecologist and undergo a comprehensive examination under his guidance.

Phases of the menstrual cycle in more detail

The menstrual cycle consists of several phases. The phases of changes in the ovaries and endometrium are different. Each of them has its own characteristics and characteristics.

The preparation of the female body for gestation is characterized by cyclic changes in the endometrium of the uterus, which consist of three successive phases: menstrual, proliferative and secretory - and are called the uterine, or menstrual, cycle.

Menstrual phase - the first phase of the cycle

The menstrual phase, with a uterine cycle lasting 28 days, lasts an average of 5 days. This phase is bleeding from the uterine cavity that occurs at the end of the ovarian cycle if fertilization and implantation of the egg do not occur.

Menstruation is the process of shedding the endometrial layer. The proliferative and secretory phases of the menstrual cycle involve the processes of endometrial repair for possible implantation of the egg during the next ovarian cycle. The most unpleasant and often painful phase.

Proliferative or follicular phase - second phasecycle

The proliferative phase varies in duration from 7 to 11 days. This phase coincides with the follicular and ovulatory phases of the ovarian cycle, during which the level of estrogens, mainly est-radiol-17p, in the blood plasma increases.

The main function of estrogens in the proliferative phase of the menstrual cycle is to stimulate cell proliferation of tissues of the organs of the reproductive system with the restoration of the functional layer of the endometrium and the development of the epithelial lining of the uterine mucosa.

Proliferative (follicular) phase- the first half of the cycle - lasts from the first day of menstruation until the moment of ovulation. At this time, under the influence of estrogens (mainly estradiol), proliferation of cells of the basal layer and restoration of the functional layer of the endometrium occur.

The duration of the phase may vary. Basal body temperature is normal. Epithelial cells of the glands of the basal layer migrate to the surface, proliferate and form a new epithelial lining of the endometrium. In the endometrium, the formation of new uterine glands and the ingrowth of spiral arteries from the basal layer also occur.

During this phase, under the influence of estrogens, the endometrium of the uterus thickens, its mucus-secreting glands increase in size, and the length of the spiral arteries increases. Estrogens cause proliferation of the vaginal epithelium and increase mucus secretion in the cervix.

The secretion becomes abundant, the amount of water in its composition increases, which facilitates the movement of sperm in it.

At the beginning of the menstrual cycle, a woman’s body exhibits a very low concentration of the female hormones estrogen. Such a low level becomes a stimulus for the hypothalamus to produce special releasing hormones, which subsequently act on the pituitary tissue. It is in the pituitary gland that two main hormonal substances are produced that regulate the monthly cycle - follicle-stimulating hormone (FSH) and luteinizing hormone (LH).

These chemicals enter the bloodstream and reach the woman's ovarian tissue. As a result of this interaction, the ovaries begin to produce the same estrogens that are not enough in the body in the first days of the menstrual cycle. A high level of estrogen in the blood is necessary for the process of active growth of follicles (female germ cells) to start in the ovaries.

Stimulation of proliferative processes in the endometrium is associated with an increase in the number of progesterone receptors on the membrane of endometrial cells, which enhances proliferative processes in it under the influence of this hormone. Finally, an increase in the concentration of estrogen in the blood plasma stimulates the contraction of smooth muscles and microvilli of the fallopian tubes, which promotes the movement of sperm towards the ampullary part of the fallopian tubes, where fertilization of the egg should occur.

Every month, several such cells begin to mature in the female body, among which one dominant follicle stands out. It is the process of maturation and growth of the follicle that formed the basis for naming the first stage of the menstrual cycle, which is called follicular.

The duration of this stage may vary for each woman, but on average, with a 28-day cycle, follicle maturation takes about 14 days. The longer this stage lasts, the longer the woman’s entire menstrual cycle.

This period is considered the most unpredictable and the most “tender”. It is during the proliferative phase that the body responds sharply to all negative phenomena occurring to it.

Stress or illness can easily stop the process of follicle maturation and thereby lengthen the cycle, or, conversely, lead to rejection of the endometrium that has just begun to recover (imitation of menstruation).

Towards the end of the follicular phase, the level of FSH decreases, the middle of the cycle begins, and the body prepares for ovulation.

Video of the mechanisms of the menstrual cycle

Ovulation is the third phase of the menstrual cycle

It begins after a sharp surge of LH (luteinizing hormone), so-called luteinizing burst. After the dominant follicle bursts, an egg is released and begins its movement along the fallopian tube.

Once outside the follicle, the egg enters the fallopian or fallopian tubes (this process is called ovulation). The inner surface of the tubes is covered with villi, thanks to the movement of which the egg moves into the uterine cavity, preparing for fertilization and implantation.

Under the influence of LH, the cervical mucus softens and becomes looser, due to which sperm are freeprevent entry into the uterine cavity and tubes. The lifespan of an egg is 12-48 hours (while sperm live up to 5 days). If ovulation does not occur during this period, the egg dies.

Ovulation can be calculated and determined by the signs listed below:

1. The woman begins to experience strong sexual desire.
2. Basal temperature rises.
3. The number of discharges increases, they become mucous, viscous, but remain light and are accompanied by other symptoms.
4. Moderate, nagging pain may occur in the lower back.

If at this moment the egg and sperm meet, an embryo is formed and the woman can become pregnant.

As mentioned above, during the second stage the dominant follicle grows actively and rapidly. During this time, its size increases approximately five times, as a result of which the enlarged cell protrudes beyond the ovarian wall, as if protruding from it.

The result of such protrusion is the rupture of the follicle membrane and the release of the egg, ready for further fertilization. It is at this stage of the menstrual cycle that the most favorable period for conceiving a child begins.

Luteal (secretory) - the fourth phase of the menstrual cycle

Secretory (luteal) phase- second half - lasts from ovulation until the start of menstruation (12-16 days). The high level of progesterone secreted by the corpus luteum creates favorable conditions for embryo implantation. Basal body temperature is above 37 °C.

Changes occurring in the ovaries

The production of luteinizing hormone stops as suddenly as it began, immediately after ovulation. In place of the follicle, the corpus luteum is formed - a kind of endocrine organ that produces the pregnancy hormone - progesterone.

Changes occurring in the uterus

Progesterone promotes abundant blood supply to the already enlarged endometrium. The mucous membrane becomes softer and “stickier”, due to which the fertilized egg easily attaches to it.

If fertilization does not occur, the corpus luteum dies, progesterone ceases to be released, therefore, the endometrium is not supplied with blood so intensively, which leads to its death. The surface layer of the endometrium is torn off and, together with the dead egg, is released out. The first phase of the menstrual cycle begins - the poorest phase of female hormones, so women often become irritable and aggressive during menstruation.

In healthy women, ovulation occurs approximately in the middle of the menstrual cycle. By adding three days before and after ovulation, we get the optimal days for conceiving a child. The fact is that sperm can enter the uterine cavity before ovulation, but given their long life, fertilization can occur even if sexual intercourse took place 4-5 days before ovulation.

Women suffering from inflammatory diseases of the pelvic organs and endocrine disorders also have irregularities in the menstrual cycle. And even if its duration and regularity have not changed, some of the phases may shift or even fall out of the cycle.

The division of the menstrual cycle into proliferative and secretory phases is arbitrary, because a high level of proliferation remains in the epithelium of the glands and stroma in the early phase of secretion. Only the appearance of progesterone in the blood in high concentrations by the 4th day after ovulation leads to a sharp suppression of proliferative activity in the endometrium.

Sexual intercourse during menstruation

It has long been believed that due to increased vulnerability to various types of infections, sexual activity should be avoided during menstruation. According to modern recommendations, sexual activity during menstruation is not contraindicated, but due to a possible increased risk of transmitting sexually transmitted infections, it is recommended to use a condom.

Menstrual disorders

Menstrual irregularities are quite common and boil down to:

• Cessation or suspension (amenorrhea).
• Rejected or displaced bleeding (menstruatio vicaria).
• Strengthening (menorrhagia).
• Painful menstruation (dysmenorrhea, old algomenorrhea).

Suspension of menstruation depends on various conditions.

Conception stops the normal flow of blood and constitutes a physiological cause. Menstruation may stop when there is any significant loss of blood from another part of the body, in which case the menstrual blood is retained or removed by other means.

When stopping menstruation, it is necessary to keep in mind the reason that caused this abnormality. If after a cold, after emotional unrest, menstruation does not occur for a long time, then you need to see a doctor. Mechanical delay of menstruation deserves special mention; it occurs when the entrance to the vagina narrows, or when the vagina itself and the cervix narrow.

Sometimes bleeding appears in some part distant from the uterus, from the latter the flow can either be reduced or stopped, this phenomenon is called additional or deviated menstruation ( vicarious menstruation).

In such cases, discharge usually occurs in places lacking skin, for example in wounds, ulcers; also in the mucous membrane, eg mouth, nose.

Generally speaking, there is not a single point on the surface of the body where additional menstruation would not be observed. In this case, phenomena that are usual for menstruation take place in the ovaries.

At menorrhagia the flow is increased.

This happens with diseases of the uterus or neighboring organs:

• with inflammation of the uterus,
• with erosion of the cervix,
• when the broad ligaments are engorged, etc.;
• sometimes there are no uterine disorders, and increased discharge depends on the general deterioration of health.

Dysmenorrhea are called menstruation accompanied by pain.

With them, blood clots often pass away. During treatment, they pay attention to the cause that supports the irregularity of menstruation and try to eliminate it.

Features of personal hygiene during menstruation.

It is extremely important for women to maintain genital hygiene during menstruation.

Of course, you need to constantly monitor the cleanliness of your body, but if you have your period, then you should do this much more carefully.

It is recommended to wash the external genitalia at least 2-3 times a day with warm water and soap (washing), and wash in the shower daily. Warm baths, heating pads, and painkillers can reduce the discomfort of painful menstruation.

A woman’s performance during this period is preserved to some extent, but increased physical activity, hypothermia and overheating should be avoided.

Alcohol and spicy foods are contraindicated, since the latter increase uterine bleeding due to the rush of blood to the abdominal organs.

Rules of conduct during menstruation.

• Wash yourself several times a day.
• Change underwear whenever it gets dirty.
• Use special hygienic pads or tampons. Change them during the day at least once every 3 hours.
• Don't sleep with a tampon. This can lead to inflammation of the vagina.
• Or use one made from medical silicone. The bowl must be emptied at least once every 12 hours. You can sleep with a hypoallergenic menstrual cup.
• Eat right, take vitamins. They will help cope with psychological discomfort.

What is the difference between menstrual hygiene products? Which means are better?

As mentioned above, to maintain personal hygiene, teenage girls and women use disposable pads attached to their underwear and/or tampons inserted into the vagina.

In both cases, the tissue of the pad or tampon absorbs menstrual fluid, which in a humid and warm environment can cause the development of harmful pathogens and inflammation of the vagina, as well as the cause of TSS (Toxic Shock Syndrome).

In European countries, the USA and Canada, and now in Russia, reusable ones (service life up to 5 years) are becoming increasingly popular as personal hygiene products. This type of hygiene product does not absorb secretions, but collects them, so you can safely use the cup for up to 12 hours without replacement.

The cup practically hermetically protects the vagina, so you can swim with it in the pool and open water without fear of water getting inside and causing infection.

This means it can protect you all night or all day, no matter what you do!

Also, now reusable eco-pads made from natural materials are justifiably quickly gaining popularity.

After all, some women categorically do not want to use hygiene products that need to be inserted into themselves. For various reasons. Therefore, menstrual cups and tampons may not be suitable for them.

Women's health certainly does not improve from the use of pharmaceutical disposable hygiene products, because... there are a number of problems that they can cause... What to do?

Just for such a case, they are suitable as a convenient and more reliable and safe alternative.

Advantages of reusable pads:

• Saving. The manufacturer claims that with careful use, the service life is up to 5 years.
• Caring for the environment. The monthly amount of waste is reduced.
• Health benefits. Many women got rid of annoying itching and thrush by simply abandoning disposable synthetic hygiene products made from petroleum products using bleaches, fragrances, etc....
• Pleasant tactile sensations. They breathe.
• They do not create a greenhouse effect. Doesn't stick to the body.
• Do not cause discomfort or irritation.
• More reliable than disposable pads. They absorb better and more. They don't leak.
• They have a waterproof layer of waterproof material.
• The natural composition of the vast majority of reusable pads is cotton, viscose, bamboo, microfiber.

Where can I buy a menstrual cup?

This is truly a wonderful invention! The best thing that was invented for women.

After all, 99% of those women who have tried a menstrual cup only regret that they only learned about such an ultra-modern product for feminine intimate hygiene only now!

After all, there are no gynecological contraindications for healthy women to use cups. Not at all!

And there are so many advantages of using a menstrual cup (compared to traditional feminine intimate hygiene products), we counted more than 30 of them, that they are all included in a separate article on our blog, which you can go to.

For maximum comfort, intimate hygiene also requires special products that can be gentle on microflora without causing dryness and irritation.

What product to use when washing or taking a shower should be determined individually; in many ways, the girl’s skin type plays a big role here.

For example, you should understand that any product has a highly alkaline composition and puts a lot of pressure on the skin, adding new tension to the body and preventing relaxation.

If a girl has dry skin, then the more alkali there is in the product, the more irritation of the skin it will lead to.

In such cases, it is recommended to refuse to use soap and give preference to gel products. Gels will remove all contaminants from intimate areas more gently, without causing the skin a new degree of irritation.

A wonderful product for daily use is a gentle intimate gel. .

The special formula gently cares for the skin and has a preventive and rejuvenating effect. Unlike ordinary gels and soaps, the product does not cause allergies or irritation. It contains provitamin B5, chamomile extract and aloe vera gel.

Chamomile extract helps relieve irritation and redness. The intimate gel has a delicate texture and a neutral odor. Foams well and is easily washed off even with a small amount of water. Gives cleanliness, a feeling of freshness and a feeling of comfort throughout the day.

The neutral formula allows you to maintain the natural pH balance. Does not contain aggressive surfactants (SLS, SLES)

We always have in stock a simply gigantic assortment of menstrual cups from various manufacturers.

Germany, Finland, Spain, Russia, China. Anatomical shape, with valve, cup sets...

Changes in hormonal levels (the content of estrogen and progesterone in the blood on different days of the ovarian cycle directly affect the condition of the endometrium, mucous membrane of the fallopian tubes, cervical canal and vagina. The mucous membrane of the uterus undergoes cyclic changes (menstrual cycle). In each cycle, the endometrium undergoes menstrual, proliferative and secretory phase. In the endometrium, there are functional (disappearing during menstruation) and basal (preserving during menstruation) layers.

Proliferative phase

The proliferative (follicular) phase - the first half of the cycle - lasts from the first day of menstruation until the moment of ovulation; at this time, under the influence of estrogens (mainly estradiol), proliferation of cells of the basal layer and restoration of the functional layer of the endometrium occur. The duration of the phase may vary. Basal body temperature is normal. Epithelial cells of the glands of the basal layer migrate to the surface, proliferate and form a new epithelial lining of the endometrium. In the endometrium, the formation of new uterine glands and the ingrowth of spiral arteries from the basal layer also occur.

Secretory phase

The secretory (luteal) phase - the second half - lasts from ovulation until the start of menstruation (12-16 days). The high level of progesterone secreted by the corpus luteum creates favorable conditions for embryo implantation. Basal body temperature is above 37 °C.

Epithelial cells stop dividing and hypertrophy. The uterine glands expand and become more branched. Glandular cells begin to secrete glycogen, glycoproteins, lipids, and mucin. The secretion rises to the mouth of the uterine glands and is released into the lumen of the uterus. Spiral arteries become more convoluted and approach the surface of the mucous membrane. In the superficial parts of the functional layer, the number of connective tissue cells increases, in the cytoplasm of which glycogen and lipids accumulate. Collagen and reticular fibers form around the cells. Stromal cells acquire features of decidual cells of the placenta. Thanks to such changes in the endometrium, two zones are distinguished in the functional layer: compact - facing the lumen, and deeper - spongy. If implantation has not occurred, a decrease in the content of ovarian steroid hormones leads to twisting, sclerosis and a decrease in the lumen of the spiral arteries supplying the upper two-thirds of the functional layer of the endometrium. As a result, blood flow in the functional layer of the endometrium deteriorates - ischemia, which leads to rejection of the functional layer and genital bleeding.

Menstrual phase

The menstrual phase is the rejection of the functional layer of the endometrium. With a cycle duration of 28 days, menstruation lasts 5+2 days.

W. Beck

"Phases of the menstrual cycle" article from the section

Article outline

The endometrium is the inner mucous membrane of the uterus, penetrated by a thin and dense network of blood vessels. It supplies the reproductive organ with blood. The proliferative endometrium is a mucous membrane that is in the process of rapid cell division before the start of a new menstrual cycle.

The structure of the endometrium

The endometrium has two layers. Basal and functional. The basal layer remains virtually unchanged. It promotes the regeneration of the functional surface during the menstrual cycle. It consists of cells that are as adjacent to each other as possible, equipped with a thin but dense vascular network. up to one and a half centimeters. Unlike the basal layer, the functional layer is constantly changing. Because during menstruation, labor, surgery, diagnosis, it is damaged. There are several cyclic stages of the functional endometrium:

1. Proliferative
2. Menstrual
3. Secretory
4. Presecretory

The stages are normal, successively replacing each other, according to the period passing in the woman’s body.

What is the normal structure?

The condition of the endometrium in the uterus depends on the phase of the menstrual cycle. When the time of proliferation comes to an end, the main layer reaches 20 mm, and is practically immune to the influence of hormones. When the cycle just begins, the endometrium is smooth and pinkish in color. With focal areas of the active layer of the endometrium that has not separated, remaining from the previous menstruation. Over the next seven days, a gradual thickening of the proliferative endometrial membrane occurs due to active cell division. There are fewer vessels, they hide behind the grooves that appear due to heterogeneous thickening of the endometrium. The thickest mucous membrane is on the posterior uterine wall, at the bottom. On the contrary, the “baby place” and the anterior uterine wall change minimally. The mucous layer is about 1.2 centimeters. When the menstrual cycle ends, normally the active covering of the endometrium is completely shed, but as a rule, only part of the layer is shed in some areas.

Forms of deviation from the norm

Violations of the normal thickness of the endometrium occur either due to natural causes or are pathological. For example, in the first seven days after fertilization, the thickness of the endometrial covering changes - the baby's place becomes thicker. In pathology, thickening of the endometrium occurs during abnormal cell division. As a result, an extra mucous layer appears.

What is endometrial proliferation

Proliferation is a phase of rapid cell division in tissues that does not exceed standard values. During this process, the mucous membrane is regenerated and grows. The new cells are not of an atypical type; normal tissue forms on them. Proliferation is a process characteristic not only of the endometrium. Some other tissues also undergo the process of proliferation.

Causes of proliferation

The reason for the appearance of the endometrium is of a proliferative type, due to the active rejection of the active layer of the uterine mucosa. After this, it becomes very thin. And it should be regenerated before the next menstruation. The active layer is renewed during proliferation. Sometimes, it has pathological causes. For example, the proliferation process occurs with endometrial hyperplasia. (if hyperplasia is not treated, it prevents you from getting pregnant). With hyperplasia, active cell division occurs and the active layer of the uterine mucosa thickens.

Phases of endometrial proliferation

Endometrial proliferation is an increase in the cellular layer through active division, during which organic tissues grow. At the same time, the mucous layer in the uterus thickens during normal cell division. The process lasts up to 14 days, it is activated by the female hormone - estrogen, synthesized during the maturation of the follicle. Proliferation consists of three stages:

• early
• average
• late

Each stage lasts a certain period of time, and manifests itself differently on the mucous layer of the uterus.

Early

The early stage of endometrial proliferation lasts from five to seven days. During this period, the endometrial cover is covered with a cylindrical cell epithelial layer. The glands are dense, straight, thin, round or oval in diameter. The epitheal glandular layer is located low, the cell nuclei at the base are oval, painted in a bright red hue. Connecting cells (stroma) are spindle-shaped, their nuclei are large in diameter. The blood vessels are almost straight.

Average

The average stage of proliferation occurs on the eighth – tenth day of the cycle. The epithelium is lined with tall prismatic epithelial cells. At this time, the glands bend a little, the nuclei turn pale, become larger, and are located at different levels. The number of cells formed through indirect division increases. The connective tissue swells and becomes loose.

Late

The late stage of proliferation begins at 11 or 14 days. The endometrium of the late stage of the phase is significantly different from what it is like at the early stage. The glands acquire a tortuous shape, cell nuclei at different levels. There is one epitheal layer, but it is multirowed. Vacuoles with glycogen mature in the cells. The vascular network is tortuous. Cell nuclei become rounded and larger. The connective tissue is engorged.

Secretion phases

Secretion is also divided into three stages:

1. Early - from 15 to 18 days of the cycle.
2. The average is 20-23 days of the cycle, at this time secretion is most active.
3. Late – from 24 to 27 days, when secretion subsides.

The secretory phase is replaced by the menstrual phase. It is also divided into two periods:

1. Desquamation - from day 28 to day 2 of a new cycle, if the egg is not fertilized.
2. Recovery - from 3 to 4 days, until the active layer is completely rejected, and until the start of a new proliferation process.

After passing through all stages, the cycle repeats again. This happens before pregnancy, menopause, if there are no pathologies.

How to diagnose

Diagnostics will help determine signs of proliferation of a pathological type. There are several ways to diagnose proliferation:

1. Visual inspection.
2. Colposcopic examination.
3. Cytological analysis.

To avoid serious diseases, it is necessary to regularly visit a gynecologist. The pathology can be seen during a routine gynecological examination. Other methods can more accurately determine the cause of abnormal proliferation.

Diseases associated with proliferation

The endometrium actively grows in the proliferation phase, cell division occurs under hormonal influence. During this period, pathologies may appear due to rapid cell growth. Tumors may appear, tissues will begin to grow, etc. Diseases can appear if something goes wrong during the cyclic phases of proliferation. In the secretory phase, the development of membrane pathologies is practically excluded. Most often, during cell division, hyperplasia of the uterine mucosa develops, which in some cases can lead to infertility and cancer of the reproductive organ.

The disease provokes a hormonal imbalance that occurs during the period of active cell division. As a result, its duration increases, there are more cells, and the mucous membrane becomes much thicker than normal. Treatment of such diseases must be timely. Most often, medication and physiotherapeutic treatment are used. In serious cases, surgical intervention is resorted to.

Why does the proliferation process slow down?

Inhibition of endometrial proliferation processes or failure of the second stage of the menstrual cycle is distinguished by the fact that cell division stops or occurs much more slowly than usual. These are the main symptoms of impending menopause, ovarian deactivation and cessation of ovulation. This is a normal phenomenon, typical before menopause. But, if inhibition occurs in a young woman, then this is a sign of hormonal instability. This pathological phenomenon must be treated, it leads to premature cessation of the menstrual cycle and the inability to become pregnant.

There are 3 types of gonadotropin secretion: tonic, cyclic and episodic, or pulsating. Tonic, or basal, secretion of gonadotropins is regulated by negative feedback, and cyclic secretion by a positive feedback mechanism involving estrogen. Pulsatile secretion is caused by the activity of the hypothalamus and the release of gonadoliberins.

The development of the follicle in the first half of the cycle is carried out due to the tonic secretion of FSH and LH.

FSH leads to the synthesis of estrogens in a certain follicle, which, by increasing the number of receptors for FSH, contribute to its accumulation (by binding to its receptors), further maturation of the follicle and increased secretion of estradiol. An increase in estradiol secretion leads to inhibition of FSH formation. Other follicles undergo atresia at this time. The concentration of estradiol in the blood reaches a maximum in the preovulatory period, which leads to the release of large amounts of GnRH and a subsequent peak in the release of LH and FSH. Preovulatory increases in LH and FSH stimulate rupture of Graafian vesicle and ovulation.

LH is the main regulator of steroid synthesis in the ovaries. LH receptors are localized on luteal cells. It activates enzymes involved in the biosynthesis of progesterone. Under the influence of LH, the amount of cholesterol necessary for the synthesis of hormones increases in the ovaries. Thus, in the corpus luteum, under the influence of LH, the processes of steroidogenesis at the site of conversion of cholesterol to pregnanolone are enhanced.

An increase in the level of LH and FSH leads to inhibition of their synthesis and release, and an increased concentration of GnRH in the hypothalamus inhibits its synthesis and release into the pituitary portal system. Adrenaline and norepinephrine stimulate the release of GnRH. Cholecystokinin, gastrin, neurotensin, opioids and somatostatin inhibit the release of GnRH.

Roleprolactin - growth of mammary glands and regulation of lactation. This is done by stimulating the synthesis of lactalbumin, fats and carbohydrates in milk. Prolactin also regulates the formation of the corpus luteum and its production of progesterone, affects water-salt metabolism, retaining water and sodium in the body, enhances the effects of aldosterone and vasopressin, and increases the formation of fat from carbohydrates.

Oxytocin selectively acts on the smooth muscles of the uterus, causing its contractions during childbirth. Under the influence of high concentrations of estrogen, the sensitivity of receptors to oxytocin sharply increases, which explains the increase in contractile activity of the uterus before childbirth. The participation of oxytocin in the process of lactation is to enhance the contraction of myoepithelial cells of the mammary glands, due to which milk secretion increases. An increase in the secretion of oxytocin, in turn, occurs under the influence of impulses from the receptors of the cervix, as well as mechanoreceptors of the nipples of the mammary gland during breastfeeding.

1. Menstrual cycle (ovarian and uterine).

The ovarian cycle consists of two phases- follicular and luteal, which are separated by ovulation and menstruation.The duration of the ovarian (menstrual) cycle normally varies from 21 to 35 days.

INfollicular phase under the influence of FSH, the growth and development of one or more primordial follicles is stimulated, as well as the differentiation and proliferation of granulosa cells. FSH also stimulates the processes of growth and development of primary follicles, the production of estrogens by follicular epithelial cells. Estradiol, in turn, increases the sensitivity of granulosa cells to the action of FSH. Along with estrogens, small amounts of progesterone are secreted. Of the many follicles that begin to grow, only 1 will reach final maturity, less often 2-3. The preovulatory release of gonadotropins determines the process of ovulation itself. The volume of the follicle increases rapidly in parallel with the thinning of the follicle wall. The significant increase in estrogen levels observed within 2-3 days before ovulation is due to the death of a large number of mature follicles with the release of follicular fluid. High concentrations of estrogen inhibit the secretion of FSH by the pituitary gland through a negative feedback mechanism. The ovulatory surge of LH and, to a lesser extent, FSH is associated with the existence of a positive feedback mechanism of ultra-high concentrations of estrogen and LH levels, as well as with a sharp drop in estradiol levels during the 24 hours preceding ovulation.

Ovulation of the egg occurs only in the presence of LH or human chorionic gonadotropin. Moreover, FSH and LH act as synergists during follicle development, and at this time the theca cells actively secrete estrogens.

After ovulation, there is a sharp decrease in the levels of LH and FSH in the blood serum. From the 12th day of the second phase of the cycle, a 2-3-day increase in the level of FSH in the blood is observed, which initiates the maturation of a new follicle, while the concentration of LH throughout the second phase of the cycle tends to decrease.

The cavity of the ovulated follicle collapses, and its walls gather into folds. Due to rupture of blood vessels at the time of ovulation, hemorrhage occurs in the cavity of the postovulatory follicle. A connective tissue scar appears in the center of the future corpus luteum - stigma

The ovulatory surge of LH and the subsequent maintenance of high levels of the hormone for 5-7 days activates the process of proliferation and glandular metamorphosis of granular zone cells with the formation of luteal cells, i.e. comes luteal phase ovarian cycle.

The epithelial cells of the granular layer of the follicle multiply intensively and, accumulating lipochromes, turn into luteal cells; the membrane itself is abundantly vascularized. The vascularization stage is characterized by the rapid proliferation of epithelial granulosa cells and intensive ingrowth of capillaries between them. The vessels penetrate into the cavity of the postovulatory follicle from the side thecae internae into the luteal tissue in a radial direction. Each cell of the corpus luteum is richly supplied with capillaries. Connective tissue and blood vessels, reaching the central cavity, fill it with blood, envelop the latter, limiting it from the layer of luteal cells. The corpus luteum has one of the highest levels of blood flow in the human body. The formation of this unique network of blood vessels ends within 3-4 days after ovulation and coincides with the period of peak function of the corpus luteum (BagavandossP., 1991).

Angiogenesis consists of three phases: fragmentation of the existing basement membrane, migration of endothelial cells and their proliferation in response to a mitogenic stimulus. Angiogenic activity is controlled by major growth factors: fibroblast growth factor (FGF), epidermal growth factor (EGF), platelet-derived growth factor (PLGF), insulin-like growth factor-1 (IGF-1), as well as cytokines such as necrotic factor tumor (TNF) and interleukins (IL-1; IL-6) (BagavandossP., 1991).

From this moment on, the corpus luteum begins to produce significant amounts of progesterone. Progesterone temporarily inactivates the positive feedback mechanism, and the secretion of gonadotropins is controlled only by the negative influence of estradiol. This leads to a decrease in the level of gonadotropins in the middle of the corpus luteum phase to minimum values ​​(EricksonG.F., 2000).

Progesterone, synthesized by the cells of the corpus luteum, inhibits the growth and development of new follicles, and also participates in the preparation of the endometrium for the implantation of a fertilized egg, reduces the excitability of the myometrium, suppresses the effect of estrogens on the endometrium in the secretory phase of the cycle, stimulates the development of decidual tissue and the growth of alveoli in the mammary glands. The plateau of serum progesterone concentration corresponds to the plateau of rectal (basal) temperature (37.2-37.5 ° C), which underlies one of the methods for diagnosing ovulation that has occurred and is a criterion for assessing the usefulness of the luteal phase. The basis for the increase in basal temperature there is a decrease in peripheral blood flow under the influence of progesterone, which reduces heat loss. An increase in its content in the blood coincides with an increase in basal body temperature, which is an indicator of ovulation.

Progesterone, being an antagonist of estrogen, limits their proliferative effect in the endometrium, myometrium and vaginal epithelium, causing stimulation of the secretion of glycogen-containing secretion by the endometrial glands, reducing the stroma of the submucosal layer, i.e. causes characteristic changes in the endometrium necessary for implantation of a fertilized egg. Progesterone reduces the tone of the uterine muscles and causes them to relax. In addition, progesterone causes proliferation and development of the mammary glands and during pregnancy helps to suppress the ovulation process. if fertilization does not occur, then after 10-12 days regression of the menstrual corpus luteum occurs, but if the fertilized egg has penetrated into the endometrium and the resulting blastula begins to synthesize hCG, then the corpus luteum becomes corpus luteum of pregnancy.

Granulosa cells of the corpus luteum secrete the polypeptide hormone relaxin, which takes an important part during childbirth, causing relaxation of the pelvic ligaments and relaxation of the cervix, and also increases glycogen synthesis and water retention in the myometrium, while reducing its contractility.

If fertilization of the egg does not occur, the corpus luteum enters the stage of reverse development, which is accompanied by menstruation. Luteal cells undergo dystrophic changes, decrease in size, and pyknosis of the nuclei is observed. Connective tissue, growing between the disintegrating luteal cells, replaces them, and the corpus luteum gradually turns into a hyaline formation - the white body.

Period of regression of the corpus luteum characterized by a pronounced decrease in the levels of progesterone, estradiol and inhibin A. A decrease in the levels of inhibin A and estradiol, as well as an increase in the frequency of impulses of Gn-RH secretion ensure the predominance of FSH secretion over LH. In response to an increase in FSH levels, a pool of antral follicles is finally formed, from which the dominant follicle will subsequently be selected. Prostaglandin F 2 a, oxytocin, cytokines, prolactin and 0 2 radicals have a luteolytic effect, which may be the basis for the development of corpus luteum failure in the presence of an inflammatory process in the appendages. Menstruation occurs against the background of regression of the corpus luteum. By the end of it, the levels of estrogen and progesterone reach their minimum. Against this background, the tonic center of the hypothalamus and pituitary gland is activated and the secretion of predominantly FSH, which activates the growth of follicles, increases. An increase in the level of estradiol leads to stimulation of proliferative processes in the basal layer of the endometrium, which ensures adequate regeneration of the endometrium.

Cyclic changes in the endometrium touch its surface layer, consisting of compact epithelial cells, and the intermediate one, which are rejected during menstruation.

As is known, there is a distinction between phase I - the proliferation phase (early stage - 5-7 days, middle - 8-10 days, late - 10-14 days) and phase II, the secretion phase (early - 15-18 days , first signs of secretory transformations; average - 19-23 days, most pronounced secretion; late - 24-26 days, beginning regression, regression with ischemia - 26-27 days), phase III, phase of bleeding or menstruation ( desquamation - 28-2 days and regeneration - 3-4 days).

Normal the proliferation phase lasts 14 days . The changes in the endometrium that occur during this phase are caused by the action of an increasing amount of estrogens secreted by the growing and maturing follicle (Khmelnitsky O.K., 2000).

In the early stage of the proliferation phase(5-7th day of the cycle) the endometrium is thin, there is no division of the functional layer into zones, its surface is lined with flattened cylindrical epithelium, having a cubic shape. Glandular crypts are in the form of straight or slightly convoluted tubes with a narrow lumen; in cross sections they have a round or oval shape. The epithelium of the glandular crypts is prismatic, the nuclei are oval, located at the base, are well stained, the apical edge of the epithelial cells in the light microscope appears smooth and clearly defined.

In the middle stage of the proliferation phase alkaline phosphatase activity increases in the endometrium. Phenomena of edema and loosening are observed in the stroma. The cytoplasm of stromal cells becomes more distinguishable, their nuclei are revealed quite clearly, and the number of mitoses increases compared to the early stage. The stromal vessels are still sporadic, with thin walls.

In the late stage of the proliferation phase(11-14th day of the cycle) some thickening of the functional layer is noted, but division into zones is still absent. The surface of the endometrium is lined with tall columnar epithelium. The glandular structures acquire a more convoluted, corkscrew shape and are more closely adjacent to each other than in previous stages. The epithelium of glandular crypts is high cylindrical. Its apical edges appear smooth and clear under light microscopy. Electron microscopy reveals microvilli, which are dense cytoplasmic processes covered with a plasma membrane. By increasing in size, they create additional area for the distribution of enzymes. It is at this stage that the activity of alkaline phosphatase reaches its maximum (Topchieva O.I. et al., 1978).

At the end of the proliferation phase light optical examination reveals small subnuclear vacuoles in which small glycogen granules are detected. At this stage, glycogen is formed in connection with the preovulatory secretion of gestagens in the follicle that has reached maturity. The spiral arteries of the stroma, which grow from the basal layer to the middle stage of the proliferation phase, are not yet very tortuous, therefore in histological sections only one or two vessels with thin walls cut across are found (Topchieva O.I. et al., 1978; Zheleznov B. I., 1979).

Thus, estrogens, simultaneously with the proliferation of epithelial cells, stimulate the development of the cell’s secretory apparatus during the proliferation phase, preparing it for further full function in the secretion phase. This explains the sequence of events that has a deep biological meaning. This is why without prior exposure to estrogen on the endometrium, progesterone has virtually no effect. Today it has been revealed that progesterone receptors, which provide sensitivity to this hormone, are activated by the previous action of estrogens.

The secretion phase lasts 14 days, directly related to the hormonal activity of the corpus luteum and the corresponding secretion of progesterone. A shortening or prolongation of the secretion phase by more than two days in women of reproductive age should be considered a pathological condition, since such cycles, as a rule, turn out to be anovulatory. Fluctuations in the secretory phase from 9 to 16 days can occur at the beginning or end of the reproductive period, i.e. with the formation or extinction of the utero-ovarian cycle.

In the diagnosis of the 1st week of the secretory phase, changes in the epithelium are of particular importance, allowing us to talk about ovulation that has occurred. Characteristic changes in the epithelium during the first week are associated with the increasing function of the corpus luteum. In the 2nd week, the day of past ovulation can be most accurately determined by the state of the stromal cells. Changes in the 2nd week in the stroma are associated with the highest function of the corpus luteum and its subsequent regression and decrease in progesterone concentration.

During the early stage of the secretion phase(on the 15-18th day of the cycle) the thickness of the endometrium increases noticeably compared to the proliferation phase. The most characteristic sign of the onset of the secretion phase - its early stage - is the appearance of subnuclear vacuoles in the epithelium of the glands. In a conventional light-optical study, the manifestation of secretion in the form of subnuclear vacuoles is usually observed on the 16th day of the cycle, which indicates that ovulation has occurred and the pronounced hormonal function of the menstrual corpus luteum. By the 17th day of the cycle (3rd day after ovulation), glycogen granules are contained in most glands and are located at the same level in the basal regions of the cells under the nucleus. As a result of this, the nuclei located above the vacuoles are also arranged in a row, at the same level. Then, on the 18th day (4th day after ovulation), glycogen granules move to the apical parts of the cells, as if bypassing the nucleus. As a result of this, the nuclei again seem to descend down to the base of the cell. Often by this time, the nuclei in different cells are at different levels. Their shape also changes - they become more rounded, mitoses disappear. The cytoplasm of the cells becomes basophilic, and acidic mucopolysaccharides are detected in their apical part.

The presence of subnuclear vacuoles is a sign of accomplished ovulation. However, we must remember that they are clearly visible under light microscopy 36-48 hours after ovulation. It should be borne in mind that subnuclear vacuoles can also be observed in other situations characterized by the action of progesterone. At the same time, however, they will not be detected in the same way in all glands, and their shape and size will be different. Thus, subnuclear vacuoles are often found in individual glands in the tissue of “mixed” hypoplastic and hyperplastic endometrium.

Along with subnuclear vacuolization, the early stage of the secretion phase is characterized by a change in the configuration of the glandular crypts: they are tortuous, expanded, uniform and regularly located in the loose, somewhat edematous stroma, which indicates the action of progesterone on stromal elements. Spiral arteries in the early stage of the secretion phase acquire a more tortuous appearance, but the “tangles” characteristic of subsequent stages of secretion are not yet observed.

In the middle stage of the secretion phase(19-23rd day of the cycle) the most pronounced secretory transformations are observed in the endometrium, which occur as a result of the highest concentration of corpus luteum hormones. The functional layer is thickened. It clearly shows a division into spongy (spongy) or deep and compact or superficial layers. In the compact layer, the glandular crypts are less tortuous, stromal cells predominate, the epithelium lining the surface of the compact layer is tall, prismatic, and non-secreting. The corkscrew-shaped glandular crypts are quite closely adjacent to each other, their lumens are increasingly expanding, especially by the 21-22nd day of the cycle (that is, by the 7-8th day after ovulation) and become more folded. The process of glycogen release by apocrine secretion into the lumen of the glands ends by the 22nd day of the cycle (8th day after ovulation), which leads to the formation of large, stretched glands filled with fine granules that are clearly visible when stained for glycogen.

In the stroma, during the middle stage of the secretion phase, a decidual-like reaction occurs, noted mainly around the vessels. Then the decidual reaction from the island type acquires a diffuse character, especially in the superficial parts of the compact layer. Connective tissue cells become large, round or polygonal in shape, resembling the appearance of an end pavement; on the 8th day after ovulation, glycogen is found in them.

The most accurate indicator of the middle stage of the secretion phase, indicating a high concentration of progesterone, are changes in the spiral arteries, which in the middle stage of secretion are sharply tortuous and form “tangles”. They are found not only in the spongy, but also in the most superficial parts of the compact layer, since from the 9th day after ovulation the stromal edema decreases, then by the 23rd day of the cycle the tangles of spiral arteries are already most clearly expressed. The presence of developed spiral vessels in the functional layer of the endometrium is considered one of the most reliable signs that determine the full effect of progesterone. The weak development of “tangles” of spiral vessels in the endometrium of the secretory phase is regarded as a manifestation of insufficient function of the corpus luteum and insufficient preparedness of the endometrium for implantation.

As indicated by O.I. Topchieva et al. (1978), the structure of the endometrium of the secretory phase of the middle stage on the 22-23rd day of the cycle can be observed with prolonged and increased hormonal function of the menstrual corpus luteum, i.e. with persistence of the corpus luteum (in such cases, the juiciness and decidual-like transformation of the stroma, as well as the secretory function of the glands, are especially pronounced), or in the early stages of pregnancy during the first days after implantation - with intrauterine pregnancy outside the implantation zone; as well as evenly in all parts of the mucous membrane of the uterine body with progressive ectopic pregnancy.

Late stage of the secretion phase(24-27th day of the cycle) occurs if fertilization of the egg has not occurred and pregnancy has not occurred. In this case, on the 24th day of the cycle (10th day after ovulation), the trophism of the endometrium, due to the onset of regression of the corpus luteum and, accordingly, a decrease in the concentration of progesterone, is disrupted, and a number of dystrophic processes develop in it, i.e. Regressive changes occur in the endometrium.

With conventional light-optical microscopy, 3-4 days before the expected menstruation (on the 24-25th day of the cycle), a decrease in the juiciness of the endometrium is noted due to loss of fluid, and wrinkling of the stroma of the functional layer is observed. Due to the wrinkling of the endometrial stroma, the glands become even more folded, are closely located to each other and acquire a sawtooth shape on longitudinal sections, and a star-shaped outline on transverse sections. Along with the glands in which the secretory function has already ceased, there is always a certain number of glands with a structure corresponding to the earlier stages of the secretory phase. The epithelium of glandular crypts is characterized by uneven coloring of the nuclei, some of which are pyknotic; small drops of lipids appear in the cytoplasm.

During this period, in the stroma, predecidual cells come closer to each other and are detected not only in the form of islands around tangles of spiral vessels, but also diffusely throughout the compact layer. Among the predecidual cells, small cells with dark nuclei are found - endometrial granular cells, which, as shown by electron microscopic studies, are transformed from connective tissue cells, i.e. larger predecidual cells, which are located predominantly in a compact layer. In this case, the cells are depleted of glycogen, their nuclei become pyknotic.

On the 26-27th day of the cycle, expansion of capillaries and hemorrhages in the superficial layers can be detected in the stroma. This is because as the cycle progresses, the spiral arterioles lengthen faster than the thickness of the endometrium increases, so that the vessels adapt to the endometrium by increasing tortuosity. During the premenstrual period, coiling becomes so pronounced that it slows blood flow and causes stasis and thrombosis. This point, along with a number of other biochemical processes, explains endometrial necrosis and dystrophic changes in blood vessels that lead to menstrual bleeding. Shortly before the onset of menstruation, vasodilation is replaced by spasm, which is explained by the action of various types of toxic products of protein breakdown or other biologically active substances against the background of a drop in progesterone levels.

Bleeding phase, menstruation(28-4th day of the cycle), characterized by a combination of desquamation and regeneration processes.

Uterus

- a hollow, pear-shaped smooth muscle organ, flattened in the anteroposterior direction. The uterus is divided into the body, isthmus and cervix. The upper convex part of the body is called the fundus of the uterus. The uterine cavity has the shape of a triangle, in the upper corners of which the openings of the fallopian tubes open. Below, the uterine cavity, narrowing, passes into the isthmus and ends with the internal os.

Cervix

- This is the narrow cylindrical lower part of the uterus. It distinguishes between the vaginal part, which protrudes into the vagina below the vaults, and the supravaginal upper part, located above the vaults. Inside the cervix there is a narrow cervical (cervical) canal 1–1.5 cm long, the upper section of which ends with the internal os, and the lower section with the external os. The cervical canal contains a mucus plug that prevents the penetration of microorganisms from the vagina into the uterus. The length of the uterus in an adult woman is on average 7–9 cm, the thickness of the walls is 1–2 cm. The weight of the non-pregnant uterus is 50–100 g. The walls of the uterus consist of three layers. The inner layer is the mucous membrane (endometrium) with many glands, covered with ciliated epithelium. There are two layers in the mucous membrane: the layer adjacent to the muscular layer (basal), and the superficial layer - functional, which undergoes cyclic changes. Most of the uterine wall is made up of the middle layer - muscle (myometrium). The muscular layer is formed by smooth muscle fibers that make up the outer and inner longitudinal and middle circular layers. The outer serous (perimetric) layer is the peritoneum covering the uterus. The uterus is located in the pelvic cavity between the bladder and rectum at the same distance from the walls of the pelvis. The body of the uterus is inclined anteriorly, towards the symphysis (uterine anteversion), has an obtuse angle relative to the cervix (uterine anteversion), and is open anteriorly. The cervix is ​​facing posteriorly, the external os is adjacent to the posterior fornix of the vagina.

Fallopian tubes

start from the corners of the uterus, go to the sides to the side walls of the pelvis. They are 10–12 cm long and 0.5 cm thick.

The walls of the tubes consist of three layers: the inner - mucous, covered with single-layer ciliated epithelium, the cilia of which flicker towards the uterus, the middle - muscular and the outer - serous. The tube is divided into an interstitial part, passing through the thickness of the uterine wall, an isthmic part, the most narrowed middle part, and an ampullary part, an expanded part of the tube ending in a funnel. The edges of the funnel have the appearance of fimbriae - fimbriae.

Ovaries

are paired almond-shaped glands, measuring 3.5–4, 1–1.5 cm, weighing 6–8 g. They are located on both sides of the uterus, behind the broad ligaments, attached to their posterior leaves. The ovary is covered with a layer of epithelium, under which the tunica albuginea is located; the cortex is located deeper, in which there are numerous primary follicles at different stages of development, the corpus luteum. Inside the ovary there is a medulla consisting of connective tissue with numerous vessels and nerves. During puberty, the ovaries undergo a monthly rhythmic process of maturation and release of mature eggs capable of fertilization into the abdominal cavity. This process is aimed at implementing the reproductive function. The endocrine function of the ovaries is manifested in the production of sex hormones, under the influence of which during puberty the development of secondary sexual characteristics and genital organs occurs. These hormones are involved in cyclical processes that prepare a woman’s body for pregnancy.

Ligamentous apparatus of the genital organs and pelvic tissue

The suspensory apparatus of the uterus consists of ligaments, which include paired round, wide, infundibulopelvic and proper ovarian ligaments. The round ligaments arise from the angles of the uterus, anterior to the fallopian tubes, pass through the inguinal canal, and attach in the area of ​​the symphysis pubis, pulling the fundus of the uterus forward (anteversion). The broad ligaments extend in the form of double sheets of peritoneum from the ribs of the uterus to the lateral walls of the pelvis. The fallopian tubes pass through the upper parts of these ligaments, and the ovaries are attached to the posterior layers. The infundibulopelvic ligaments, being a continuation of the broad ligaments, run from the funnel of the tube to the wall of the pelvis. The ovarian ligaments extend from the fundus of the uterus posteriorly and below the origin of the fallopian tubes they are attached to the ovaries. The anchoring apparatus includes the uterosacral, main, uterovesical and vesico-pubic ligaments. The uterosacral ligaments extend from the posterior surface of the uterus in the area of ​​transition of the body to the cervix, cover the rectum on both sides and are attached to the anterior surface of the sacrum. These ligaments pull the cervix posteriorly. The main ligaments go from the lower part of the uterus to the lateral walls of the pelvis, the uterovesical ligaments - from the lower part of the uterus anteriorly, to the bladder and further to the symphysis, like the vesico-pubic. The space from the lateral sections of the uterus to the walls of the pelvis is occupied by periuterine parametric tissue (parametrium), in which vessels and nerves pass.

Physiology of the female reproductive system

The female reproductive system has four specific functions: menstrual, reproductive, reproductive and secretory.

Menstrual cycle are rhythmically repeating complex changes in the reproductive system and throughout a woman’s body that prepare her for pregnancy. The duration of one menstrual cycle is counted from the first day of the last menstruation to the first day of the next menstruation. On average it is 28 days, less often 21–22 or 30–35 days. The normal duration of menstruation is 3–5 days, blood loss is 50–150 ml. Menstrual blood is dark in color and does not clot. Changes during the menstrual cycle are most pronounced in the organs of the reproductive system, especially in the ovaries (ovarian cycle) and the lining of the uterus (uterine cycle). An important role in the regulation of the menstrual cycle belongs to the hypothalamic-pituitary system. Under the influence of releasing factors of the hypothalamus, the anterior lobe of the pituitary gland produces gonadotropic hormones that stimulate the function of the gonads: follicle-stimulating hormone (FSH), luteinizing hormone (LH) and luteotropic hormone (LTG). FSH promotes the maturation of follicles in the ovaries and the production of follicular (estrogenic) hormone. LH stimulates the development of the corpus luteum, and LTG stimulates the production of the corpus luteum hormone (progesterone) and the secretion of the mammary glands. In the first half of the menstrual cycle, the production of FSH predominates, in the second half - LH and LTG. Under the influence of these hormones, cyclic changes occur in the ovaries.

Ovarian cycle.

This cycle consists of 3 phases:

1) follicle development – ​​follicular phase;

2) rupture of a mature follicle – ovulation phase;

3) development of the corpus luteum - luteal (progesterone) phase.

In the follicular phase of the ovarian cycle, the follicle grows and matures, which corresponds to the first half of the menstrual cycle. Changes occur in all components of the follicle: enlargement, maturation and division of the egg, rounding and proliferation of follicular epithelial cells, which turns into the granular shell of the follicle, differentiation of the connective tissue membrane into outer and inner. Follicular fluid accumulates in the thickness of the granular membrane, which pushes the follicular epithelial cells on one side towards the egg, and on the other towards the wall of the follicle. The follicular epithelium surrounding the egg is called radiant crown. As the follicle matures, it produces estrogenic hormones that have a complex effect on the genitals and the entire woman’s body. During puberty, they cause the growth and development of the genital organs, the appearance of secondary sexual characteristics, and during puberty - an increase in the tone and excitability of the uterus, proliferation of cells of the uterine mucosa. Promote the development and function of the mammary glands, awaken sexual feelings.

Ovulation is the process of rupture of a mature follicle and the release from its cavity of a mature egg, covered on the outside with a shiny shell and surrounded by cells of the corona radiata. The egg enters the abdominal cavity and then into the fallopian tube, in the ampullary section of which fertilization occurs. If fertilization does not occur, then after 12–24 hours the egg begins to deteriorate. Ovulation occurs in the middle of the menstrual cycle. Therefore, this time is the most favorable for conception.

The developmental phase of the corpus luteum (luteal) occupies the second half of the menstrual cycle. In place of the ruptured follicle after ovulation, a corpus luteum is formed, producing progesterone. Under its influence, secretory transformations of the endometrium occur, necessary for implantation and development of the fertilized egg. Progesterone reduces the excitability and contractility of the uterus, thereby helping to maintain pregnancy, stimulates the development of mammary gland parenchyma and prepares them for milk secretion. In the absence of fertilization, at the end of the luteal phase, the corpus luteum reverses, the production of progesterone stops, and the maturation of a new follicle begins in the ovary. If fertilization has occurred and pregnancy has occurred, the corpus luteum continues to grow and function during the first months of pregnancy and is called corpus luteum of pregnancy.

Uterine cycle.

This cycle comes down to changes in the uterine mucosa and has the same duration as the ovarian cycle. It distinguishes two phases - proliferation and secretion, followed by rejection of the functional layer of the endometrium. The first phase of the uterine cycle begins after the endometrial shedding (desquamation) during menstruation ends. In the proliferation stage, epithelization of the wound surface of the uterine mucosa occurs due to the epithelium of the glands of the basal layer. The functional layer of the uterine mucosa sharply thickens, the endometrial glands acquire a tortuous shape, and their lumen expands. The endometrial proliferation phase coincides with the follicular phase of the ovarian cycle. The secretion phase occupies the second half of the menstrual cycle, coinciding with the development phase of the corpus luteum. Under the influence of the corpus luteum hormone progesterone, the functional layer of the uterine mucosa loosens even more, thickens and is clearly divided into two zones: spongy (spongy), bordering the basal layer, and more superficial, compact. Glycogen, phosphorus, calcium and other substances are deposited in the mucous membrane, creating favorable conditions for the development of the embryo if fertilization has occurred. In the absence of pregnancy, at the end of the menstrual cycle, the corpus luteum in the ovary dies, the level of sex hormones decreases sharply, and the functional layer of the endometrium, which has reached the secretion phase, is rejected and menstruation occurs.

Under the influence of ovarian hormones, changes occur in the uterine mucosa. If fertilization does not occur, the corpus luteum dies and the uterine lining is rejected, and menstruation begins. Rejection of the functional layer is called desquamation phase. After rejection of the functional layer in the uterine cavity, a wound surface is formed, which within 3-5 days is epithelialized due to the epithelial cells of the basal layer of the endometrium.

The process of epithelization of the wound surface of the uterus is called regeneration phase. The regeneration phase normally lasts 3-5 days. From the moment of complete epithelization of the wound surface, menstruation ends.

Subsequently, under the influence of estrogen hormones, until the middle of the menstrual cycle, that is, from the 1st to the 14th day of a 28-day menstrual cycle, the functional layer grows. In functional growth, glands are formed, but they do not function. This phase of the uterine cycle is called proliferation phase.

In the 2nd half of the menstrual cycle, from the 15th to the 28th day, under the influence of gestagen hormones, the glands of the functional layer of the endometrium begin to function. The secretion of these glands serves as a nutrient medium for the fertilized egg at the time of its implantation (that is, grafting) and is called Royal jelly. If fertilization does not occur, the menstrual cycle repeats again.

Male reproductive system.

The male external genitalia and internal genitalia are distinguished. The external genitalia include the penis and scrotum. The internal genital organs include: testicles, vas deferens, prostate gland and seminal vesicles. The male reproductive system is connected to the urinary system, and the urethra is also the vas deferens.

Anatomy of the external genitalia.

Penis. The penis is divided into: root, body and head. The length of the penis is 5-8 cm; in a state of arousal (erection), the length of the penis is 12-15 cm. The body of the penis consists of 2 cavernous bodies and 1 spongy body, which ends in the glans. The urethra runs through the corpus spongiosum and normally opens at the glans penis. The cavernous bodies have a large number of lacunae (cavities), which fill with blood during sexual arousal. The outside of the penis is covered with skin that is easily displaced; excess skin covers the head of the penis and is called foreskin. Along the back surface in the area of ​​the head, the skin is attached in the form of a longitudinal fold and is called bridle. The foreskin produces a secretion called smegma. Smegma has carcinogenic properties.

Scrotum – a musculocutaneous organ in the cavity of which the testicles, epididymis and the initial section of the spermatic cord are located. The skin of the scrotum is pigmented, covered with sparse hair, contains a significant number of sweat and sebaceous glands, the secretion of which has a specific odor, and is richly innervated. The main function of the scrotum is to create optimal conditions for the functioning of the testicles, maintaining a constant temperature at 34 - 34.5 degrees C (thermostat function).

The endometrium consists of two layers: functional and basal. The functional layer changes its structure under the influence of sex hormones and, if pregnancy does not occur, is rejected during menstruation.

Proliferative phase

The beginning of the menstrual cycle is considered to be the 1st day of menstruation. At the end of menstruation, the thickness of the endometrium is 1-2 mm. The endometrium consists almost exclusively of the basal layer. The glands are narrow, straight and short, lined with low columnar epithelium, the cytoplasm of the stromal cells is almost the same.

As estradiol levels increase, a functional layer is formed: the endometrium prepares for embryo implantation. The glands lengthen and become convoluted. The number of mitoses increases. As they proliferate, the height of the epithelial cells increases, and the epithelium itself changes from single-row to multi-row by the time of ovulation. The stroma is swollen and loosened, with increased cell nuclei and cytoplasmic volume. The vessels are moderately tortuous.

Secretory phase

Normally, ovulation occurs on the 14th day of the menstrual cycle. The secretory phase is characterized by high levels of estrogen and progesterone. However, after ovulation, the number of estrogen receptors in endometrial cells decreases. Endometrial proliferation is gradually inhibited, DNA synthesis decreases, and the number of mitoses decreases. Thus, progesterone has a predominant effect on the endometrium in the secretory phase.

Glycogen-containing vacuoles appear in the endometrial glands, which are detected using the PAS reaction. On the 16th day of the cycle, these vacuoles are quite large, present in all cells and located under the nuclei. On the 17th day, the nuclei, pushed aside by vacuoles, are located in the central part of the cell. On the 18th day, vacuoles appear in the apical part, and nuclei in the basal part of the cells, glycogen begins to be released into the lumen of the glands by apocrine secretion. The best conditions for implantation are created on the 6th-7th day after ovulation, i.e. on the 20-21st day of the cycle, when the secretory activity of the glands is maximum.

On the 21st day of the cycle, the decidual reaction of the endometrial stroma begins. The spiral arteries are sharply tortuous; later, due to a decrease in stromal edema, they are clearly visible. First, decidual cells appear, which gradually form clusters. On the 24th day of the cycle, these accumulations form perivascular eosinophilic couplings. On the 25th day, islands of decidual cells are formed. By the 26th day of the cycle, the decidual reaction becomes maximum. About two days before menstruation, the number of neutrophils that migrate there from the blood sharply increases in the endometrial stroma. Neutrophilic infiltration is replaced by necrosis of the functional layer of the endometrium.

The main way to neutralize ammonia.

4.Coenzyme: concept, classification, examples.

Answer:

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2) Ovarian cycle:

1- follicular phase: follicular development, estrogen secretion and ovulation

2-luteal phase: the corpus luteum functions, progesterone is secreted

3-phase of involution of the corpus luteum: the secretion of estrogen and progesterone stops

follicular phase: FSH causes the maturation of follicles and the formation of estrogens. The release of estrogen into the bloodstream inhibits the secretion of FSH and stimulates the formation of LH, which ensures ovulation and progesterone production, the transition to the next phase.

luteal phase: The corpus luteum is formed, which produces progesterone, which, entering the blood, inhibits the secretion of LH and stimulates the release of prolactin. Prolactin supports progesterone production and stimulates the development of mammary glands. If the egg is not fertilized or implanted, the transition to phase 3 begins. If fertilized, then pregnancy occurs.

involution phase of the corpus luteum: the corpus luteum undergoes reverse development, progesterone production progressively decreases. Low levels of estrogen and progesterone in the blood lead to the fact that the production of folliberin and FSH is reactivated, and, consequently, the follicular phase begins.

The phases of the ovarian cycle correspond to certain changes in the uterus caused by sex hormones - the uterine phases.

Uterine cycle:

1- proliferative phase: estrogens released during the maturation of the follicle act on the endometrium, causing proliferation of the uterine epithelium and increased contractile activity of the myometrium.

2- secretory phase: the endometrium, prepared by estrogen, under the influence of progesterone, secretes mucus, this is necessary for implantation of the egg;

3rd menstrual phase: progesterone production continues, which inhibits LH production. A decrease in LH causes mucosal rejection and bleeding.

3) Ammonia is neutralized in the following ways:

a) reductive amination (insignificant, although it provides the formation of some amino acids)

b) the formation of amides of aspartic and glutamic acid - asparagine and glutamine. This process occurs in the nervous, muscle tissue and kidneys; catalysts are asparagine synthetase and glutamine synthetase.

c) the formation of ammonium salts occurs in the kidney tissue, where ammonia is delivered in the form of asparagine and glutamine. Here they are hydrolyzed to form aspartate and glutomate, and ammonia is released. Ammonia is neutralized by the formation of ammonium salts, which are eliminated in the urine.

d) the synthesis of urea - the main way of neutralizing and removing ammonia - is carried out in the liver. It occurs in several reactions:

1 – synthesis of carbamoyl phosphate; enzyme – carbamoylphosphosynthetase.

2 - carbamoyl phosphate interacts with ornithine, forming citrulline; catalyst – ornithine carbamoyl phosphate transferase.

3 – citrulline interacts with aspartate, forming arginine succinate.

4 – arginine succinate is broken down into fumarate and arginine.

5 – arginine, under the action of arginase, is hydrolytically broken down into urea and ornithine.

Urea is a harmless compound, its synthesis occurs in the liver, dysfunction of which leads to a slowdown in the process, a decrease in the urea content in the blood and a decrease in excretion in the urine.

4) Coenzymes – These are substances necessary for some enzymes to be active. They directly participate in the chemical reaction catalyzed by the enzyme.

Classification:

a) inorganic (metal ions, some anions)

b) organic

Metal ions – calcium, magnesium, potassium, zinc, iron ions. They are involved in: stabilization of tertiary or quaternary structure, substrate binding or catalysis.

There are coenzymes nucleotide nature, tetrapyrrole coenzymes and coenzymes - derivatives of vitamins.

Coenzymes – nucleotides – as part of transferases they participate in the transfer of phosphate, pyrophosphate, adenylate, and in the transformation of sugars.

Tetrapyrrole coenzymes identical to heme in hemoglobin; participate in electron transport as part of cytochromes and peroxidase.

Coenzymes – vitamins participate in a variety of chemical metabolic reactions. For example, the coenzyme form of vitamin B1 (thiamine), thiamine diphosphate, catalyzes the decarboxylation reaction.

Every month, a woman’s body undergoes changes associated with hormonal cyclic fluctuations. One of the manifestations of such changes is menstrual bleeding. But this is only the visible part of a complex mechanism aimed at maintaining a woman’s reproductive function. It is very important that the mucous layer of the uterus - the endometrium - has a normal thickness throughout the entire cycle. What thickness of the endometrium before, during and after menstruation is considered normal?

What happens in the female body every month?

The normal menstrual cycle consists of three phases: proliferation, secretion, desquamation (menstruation). During each of them, changes occur in the ovaries and endometrium, caused by fluctuations in hormones (estrogen, progesterone, pituitary hormones). Therefore, on different days of the cycle, as well as during menstruation, the thickness of the endometrial layer changes.

For example, the thickness of the endometrium before menstruation is much greater than in the first days after it. The usual duration of the menstrual cycle is 28 days, during which time the uterine lining should completely recover.

Changes in the endometrium in the proliferation phase

The proliferation phase consists of early, middle and late stages. At the early stage of the proliferation phase, immediately after menstruation, the endometrium should be no more than 2-3 mm. During this period, at the beginning of the menstrual cycle, endometrial regeneration begins thanks to the cells of the basal layer. Visually, the uterine mucosa at this stage is thin, pale pink, with isolated small hemorrhages.

The middle stage begins on the 4th day of the menstrual cycle. There is a gradual increase in the thickness of the endometrium; on the 7th day after menstruation it is 6-7 mm. The duration of this period is up to 5 days.

At a late stage, the normal thickness of the endometrium is 8-9 mm. This stage lasts three days. At this stage, the uterine mucosa loses its uniform structure. It becomes folded, and areas of thickening of certain zones are observed. For example, the endometrium is somewhat denser and thicker in the fundus and on the posterior wall of the uterus, and slightly thinner on its anterior surface. This is due to the preparation of the mucous membrane for implantation of the fertilized egg.

This video provides detailed information about the course of menstruation:

What changes in the endometrium occur during the secretion phase?

This phase is also divided into early, middle and late stages. It begins 2-4 days after ovulation. Does this phenomenon affect the thickness of the endometrium? At the early stage of secretion, the endometrium has a thickness of at least 10 and maximum 13 mm. The changes are associated primarily with increased production of progesterone by the corpus luteum of the ovary. The mucous membrane increases even more significantly than in the proliferation phase, by 3-5 mm, becomes swollen, and acquires a yellowish tint. Its structure becomes homogeneous and does not change until the onset of menstruation.

The middle stage lasts from the 18th to the 24th day of the menstrual cycle and is characterized by the most pronounced secretory changes in the mucous membrane. At this point, the normal thickness of the endometrium is a maximum of 15 mm in diameter. The inner layer of the uterus becomes as dense as possible. When performing an ultrasound during this period, you can notice an echo-negative strip at the border of the myometrium and endometrium - the so-called rejection zone. This zone reaches its maximum before menstruation. Visually, the endometrium is swollen and, due to folding, can acquire a polypoid appearance.

What changes occur in the late stage of secretion? Its duration is from 3 to 4 days, it precedes menstrual bleeding, and usually occurs on the 25th day of the monthly cycle. If a woman is not pregnant, then involution of the corpus luteum occurs. Due to the reduced production of progesterone, pronounced trophic disorders occur in the endometrium. When performing an ultrasound during this period, the heterogeneity of the endometrium is clearly visible, with areas of dark spots and areas of vascular disorders. This picture is caused by vascular reactions occurring in the endometrium, leading to thrombosis, hemorrhage, and necrosis of mucosal areas. The rejection zone on ultrasound becomes even more distinct, its thickness is 2-4 mm. On the eve of menstruation, capillaries in the layers of the endometrium become even more dilated and spirally convoluted.

Their tortuosity becomes so pronounced that it leads to thrombosis and subsequent necrosis of mucosal areas. These changes are called "anatomical" menstruation. Immediately before menstruation, the thickness of the endometrium reaches 18 mm.

What happens during the desquamation phase?

During this period, the functional layer of the endometrium is rejected. This process begins on the 28-29th day of the menstrual cycle. The duration of this period is 5-6 days. There may be deviations from the norm for one or two days. The functional layer looks like areas of necrotic tissue; during menstruation, the endometrium is completely rejected in 1-2 days.

With various diseases of the uterus, delayed rejection of areas of the mucous membrane can be observed, this affects the intensity of menstruation and its duration. Sometimes during menstruation there is very heavy bleeding.

If the bleeding intensifies, you should consult a gynecologist. This should be especially remembered during the first menstruation after a miscarriage, as this may mean that particles of the fertilized egg remain in the uterus.

Additional information about menstruation is provided in the video:

Does menstruation always start on time?

Sometimes there are situations when the onset of menstruation occurs untimely. If pregnancy is excluded, then this phenomenon is called delayed menstruation. The main reason causing this condition is hormonal imbalance in the body. Some experts consider the norm to be late in a healthy woman up to 2 times a year. They can be quite common for teenage girls who have not yet established their menstrual cycle.

Factors that may lead to this condition:

1. Chronic stress. It can provoke disruption of the production of pituitary hormones.
2. Excess body weight or, conversely, sudden weight loss. Women who suddenly lose weight may experience a loss of menstruation.
3. Insufficient intake of vitamins and nutrients from food. This can happen when you are addicted to weight loss diets.
4. Significant physical activity. They can lead to a decrease in the production of sex hormones.
5. Gynecological diseases. Inflammatory diseases in the ovaries lead to disruption of hormone production.
6. Diseases of the endocrine organs. For example, menstrual irregularities often occur with thyroid pathology.
7. Operations on the uterus. Often a delay in menstruation occurs after an abortion.
8. After spontaneous abortion. In some cases, curettage of the uterine cavity is additionally performed. After a miscarriage, the endometrium does not have time to recover, and the onset of menstruation occurs later.
9. Taking hormonal contraceptives. After their cancellation, menstruation may occur later than 28 days.

The average delay is most often up to 7 days. If your period is delayed by more than 14 days, you must be tested again to determine if you are pregnant.

If there are no periods for a long time, 6 months or more, they talk about amenorrhea. This phenomenon occurs in women during menopause, rarely after an abortion, when the basal layer of the endometrium was damaged. In any case, if the normal menstrual cycle is disrupted, you should consult a gynecologist. This will allow timely detection of the disease and begin its treatment.

Article outline

The endometrium is the inner mucous membrane of the uterus, penetrated by a thin and dense network of blood vessels. It supplies the reproductive organ with blood. The proliferative endometrium is a mucous membrane that is in the process of rapid cell division before the start of a new menstrual cycle.

The structure of the endometrium

The endometrium has two layers. Basal and functional. The basal layer remains virtually unchanged. It promotes the regeneration of the functional surface during the menstrual cycle. It consists of cells that are as adjacent to each other as possible, equipped with a thin but dense vascular network. up to one and a half centimeters. Unlike the basal layer, the functional layer is constantly changing. Because during menstruation, labor, surgery, diagnosis, it is damaged. There are several cyclic stages of the functional endometrium:

1. Proliferative
2. Menstrual
3. Secretory
4. Presecretory

The stages are normal, successively replacing each other, according to the period passing in the woman’s body.

What is the normal structure?

The condition of the endometrium in the uterus depends on the phase of the menstrual cycle. When the time of proliferation comes to an end, the main layer reaches 20 mm, and is practically immune to the influence of hormones. When the cycle just begins, the endometrium is smooth and pinkish in color. With focal areas of the active layer of the endometrium that has not separated, remaining from the previous menstruation. Over the next seven days, a gradual thickening of the proliferative endometrial membrane occurs due to active cell division. There are fewer vessels, they hide behind the grooves that appear due to heterogeneous thickening of the endometrium. The thickest mucous membrane is on the posterior uterine wall, at the bottom. On the contrary, the “baby place” and the anterior uterine wall change minimally. The mucous layer is about 1.2 centimeters. When the menstrual cycle ends, normally the active covering of the endometrium is completely shed, but as a rule, only part of the layer is shed in some areas.

Forms of deviation from the norm

Violations of the normal thickness of the endometrium occur either due to natural causes or are pathological. For example, in the first seven days after fertilization, the thickness of the endometrial covering changes - the baby's place becomes thicker. In pathology, thickening of the endometrium occurs during abnormal cell division. As a result, an extra mucous layer appears.

What is endometrial proliferation

Proliferation is a phase of rapid cell division in tissues that does not exceed standard values. During this process, the mucous membrane is regenerated and grows. The new cells are not of an atypical type; normal tissue forms on them. Proliferation is a process characteristic not only of the endometrium. Some other tissues also undergo the process of proliferation.

Causes of proliferation

The reason for the appearance of the endometrium is of a proliferative type, due to the active rejection of the active layer of the uterine mucosa. After this, it becomes very thin. And it should be regenerated before the next menstruation. The active layer is renewed during proliferation. Sometimes, it has pathological causes. For example, the proliferation process occurs with endometrial hyperplasia. (if hyperplasia is not treated, it prevents you from getting pregnant). With hyperplasia, active cell division occurs and the active layer of the uterine mucosa thickens.

Phases of endometrial proliferation

Endometrial proliferation is an increase in the cellular layer through active division, during which organic tissues grow. At the same time, the mucous layer in the uterus thickens during normal cell division. The process lasts up to 14 days, it is activated by the female hormone - estrogen, synthesized during the maturation of the follicle. Proliferation consists of three stages:

• early
• average
• late

Each stage lasts a certain period of time, and manifests itself differently on the mucous layer of the uterus.

Early

The early stage of endometrial proliferation lasts from five to seven days. During this period, the endometrial cover is covered with a cylindrical cell epithelial layer. The glands are dense, straight, thin, round or oval in diameter. The epitheal glandular layer is located low, the cell nuclei at the base are oval, painted in a bright red hue. Connecting cells (stroma) are spindle-shaped, their nuclei are large in diameter. The blood vessels are almost straight.

Average

The average stage of proliferation occurs on the eighth – tenth day of the cycle. The epithelium is lined with tall prismatic epithelial cells. At this time, the glands bend a little, the nuclei turn pale, become larger, and are located at different levels. The number of cells formed through indirect division increases. The connective tissue swells and becomes loose.

Late

The late stage of proliferation begins at 11 or 14 days. The endometrium of the late stage of the phase is significantly different from what it is like at the early stage. The glands acquire a tortuous shape, cell nuclei at different levels. There is one epitheal layer, but it is multirowed. Vacuoles with glycogen mature in the cells. The vascular network is tortuous. Cell nuclei become rounded and larger. The connective tissue is engorged.

Secretion phases

Secretion is also divided into three stages:

1. Early - from 15 to 18 days of the cycle.
2. The average is 20-23 days of the cycle, at this time secretion is most active.
3. Late – from 24 to 27 days, when secretion subsides.

The secretory phase is replaced by the menstrual phase. It is also divided into two periods:

1. Desquamation - from day 28 to day 2 of a new cycle, if the egg is not fertilized.
2. Recovery - from 3 to 4 days, until the active layer is completely rejected, and until the start of a new proliferation process.

After passing through all stages, the cycle repeats again. This happens before pregnancy, menopause, if there are no pathologies.

How to diagnose

Diagnostics will help determine signs of proliferation of a pathological type. There are several ways to diagnose proliferation:

1. Visual inspection.
2. Colposcopic examination.
3. Cytological analysis.

To avoid serious diseases, it is necessary to regularly visit a gynecologist. The pathology can be seen during a routine gynecological examination. Other methods can more accurately determine the cause of abnormal proliferation.

Diseases associated with proliferation

The endometrium actively grows in the proliferation phase, cell division occurs under hormonal influence. During this period, pathologies may appear due to rapid cell growth. Tumors may appear, tissues will begin to grow, etc. Diseases can appear if something goes wrong during the cyclic phases of proliferation. In the secretory phase, the development of membrane pathologies is practically excluded. Most often, during cell division, hyperplasia of the uterine mucosa develops, which in some cases can lead to infertility and cancer of the reproductive organ.

The disease provokes a hormonal imbalance that occurs during the period of active cell division. As a result, its duration increases, there are more cells, and the mucous membrane becomes much thicker than normal. Treatment of such diseases must be timely. Most often, medication and physiotherapeutic treatment are used. In serious cases, surgical intervention is resorted to.

Why does the proliferation process slow down?

Inhibition of endometrial proliferation processes or failure of the second stage of the menstrual cycle is distinguished by the fact that cell division stops or occurs much more slowly than usual. These are the main symptoms of impending menopause, ovarian deactivation and cessation of ovulation. This is a normal phenomenon, typical before menopause. But, if inhibition occurs in a young woman, then this is a sign of hormonal instability. This pathological phenomenon must be treated, it leads to premature cessation of the menstrual cycle and the inability to become pregnant.

The mucous membrane of the uterus lining its cavity. The most important property of the endometrium is its ability to undergo cyclic changes under the influence of changing hormonal levels, which is manifested in a woman by the presence of a menstrual cycle.

The endometrium is the mucosal layer lining the uterine cavity. That is, it is the mucous membrane of a woman’s internal hollow organ, intended for the development of an embryo. The endometrium consists of stroma, glands and integumentary epithelium, and has 2 main layers: basal and functional.

• The structures of the basal layer are the basis for the regeneration of the endometrium after menstruation. The layer is located on the myometrium and is characterized by a dense stroma, which is filled with numerous vessels.
• The functional thick layer is not permanent. He is constantly exposed to hormonal levels.

Genetics, as well as molecular biology and clinical immunology, are constantly evolving. Today, it is these sciences that have been able to significantly expand the understanding of cellular regulation and intercellular interaction. It was possible to establish that proliferative cellular activity is affected not only by hormones, but also by a variety of active compounds, including cytokines (peptides and a whole group of hormone-like proteins) and arachidonic acid, or rather its metabolites.

Endometrium in adults

A woman's menstrual cycle lasts approximately 24-32 days. In the first phase, under the influence of estrogen hormones, proliferation (growth) of the glands occurs. The secretion phase begins under the influence of progesterone (after the follicle ruptures and the egg is released).

While the epithelium is being rebuilt under the influence of hormones, changes are also observed in the stroma. Leukocyte infiltration can be seen here, the spiral arteries are slightly enlarged.

Changes in the endometrium that occur during the menstrual cycle should normally have a clear sequence. Moreover, each phase should have an early, middle and late stage.

If changes in the structures of the endometrium during the cycle do not occur in a clear sequence, then dysmenorrhea most often develops and bleeding appears. The consequence of such disorders can be, at a minimum, infertility.

Disturbances in the hormonal background can be caused by disturbances in the functioning of the central nervous system, pathologies of the ovaries, adrenal glands, pituitary gland and/or hypothalamus.

Endometrium during pregnancy

Throughout her life, a woman’s hormones actively influence the cellular receptors of the uterine mucosa. During the period of time when any hormonal shift occurs, the growth of the endometrium also changes, which often leads to the development of diseases. All kinds of proliferative disorders arise mainly under the influence of hormones produced by the adrenal glands and ovaries.

Pregnancy and the endometrium are closely related, because even the attachment of a fertilized reproductive cell is possible only to the mature walls of the uterus. Before implantation of the fertilized egg, a decidua formed from stromal cells appears in the uterus. It is this shell that creates favorable conditions for the life of the embryo.

Before implantation, the secretory phase predominates in the endometrium. Stromal cells are filled with biologically active substances, including lipids, salts, glycogen, trace elements and enzymes.

During implantation, which takes approximately two days, hemodynamic changes are observed, and significant changes are observed in the endometrium (glands and stroma). In the place where the fertilized egg is attached, blood vessels dilate and sinusoids appear.

Changes in the endometrium and maturation of the fertilized egg must occur simultaneously, otherwise the pregnancy may be terminated.

Diseases of the uterine mucosa are common. In addition, pathologies of this kind are diagnosed in both children and adults; they can be practically asymptomatic, easily treatable, or, for example, on the contrary, provoke extremely unpleasant health consequences.

If we consider the most common diseases of the endometrium, then we should immediately note various hyperplastic processes. It is these disorders that predominantly occur against the background of hormonal imbalance, often before menopause. The clinical picture of such disorders is bleeding, the uterus most often enlarges, and the mucous layer thickens.

Changes in endometrial structures, the appearance of formations - all this may indicate a serious malfunction, which is important to eliminate as soon as possible in order to prevent the development of complications.

Transformation of the endometrium is certainly a complex biological process that affects almost the entire neurohumoral system. Hyperplastic processes (HPE) are focal or diffuse tissue proliferation, which affects the stromal and most often glandular components of the mucous membrane. Metabolic and endocrine disruptions also play a significant role in the pathogenesis of HPE. Thus, it is worth highlighting dysfunctions of the thyroid gland, immune system, fat metabolism, etc. That is why the majority of women with obvious hyperplastic processes of the endometrium are diagnosed with a certain degree of obesity, diabetes mellitus and some other diseases.

Not only hormonal imbalances can provoke the development of endometrial hyperplastic processes. Immunity plays a role in this matter, as do inflammatory and infectious changes affecting the mucous membrane, and even problems with tissue reception.

As for symptoms, endometrial hyperplastic processes can manifest as bleeding and pain in the lower abdomen, although often the problem has no obvious signs. Mostly hyperplastic processes in the uterine mucosa are accompanied by a lack of ovulation, which gives rise to such a sign of pathology as infertility.

Endometrial hyperplasia

In the medical field, endometrial hyperplasia is changes in the structures and/or pathological growth of glands. These are also violations that may include:

• improper distribution of glands;
• structural deformation;
• growth of endometrial glands;
• there is no division into layers (namely, the spongy and compact parts are taken into account).

Endometrial hyperplasia mainly affects the functional layer; the basal part of the uterine mucosa is affected in rare cases. The main signs of the problem are an increased number of glands and their expansion. With hyperplasia, the ratio of glandular and stromal components increases. And all this happens against the background of the absence of cell atypia.

According to statistics, a simple form of endometrial hyperplasia degenerates into cancer only in 1-2% of cases. A complex form is several times more likely.

Polyps of the mucous layer of the uterine cavity

Most endometrial hyperplastic processes are polyps, which are diagnosed in 25% of cases. Such benign formations appear at any age, but are mainly of concern in the period before or after menopause.

Taking into account the structure of the endometrial polyp, several types of formations can be distinguished:

• glandular polyp (can be basal or functional);
• glandular-fibrous;
• fibrous;
• adenomatous formation.

Glandular polyps are diagnosed mainly in women of reproductive age. Glandular-fibrous - before menopause, and fibrous most often in the postmenopausal period.

At the age of 16-45 years, polyps can appear both against the background of endometrial hyperplasia and on normal mucosa. But after menopause, benign formations (polyps) are most often single; they can reach enormous sizes, protrude from the cervix and even disguise themselves as neoplasms of the cervical canal.

Endometrial polyps appear mainly against the background of hormonal imbalance, which involves progesterone and estrogens. Doctors note the fact that polyps in women of reproductive age can develop after various surgical interventions on the uterus. The appearance of polyps is also associated with inflammatory diseases of the internal genital organs.

Clinical manifestations indicating a polyp in the uterus are varied, but most often a woman experiences disruptions in her menstrual cycle. The pain symptom is rarely bothersome. Such a sign can appear only in some cases, for example, with necrotic changes in the formation. Endometrial polyps are diagnosed using ultrasound and hysteroscopy. Surgery is used to treat polyps. Polyps are treated primarily by a gynecologist, although consultations with an endocrinologist, venereologist and some other specialized specialists are possible.

Endometrial cancer and precancer are two different concepts and it is important to be able to distinguish between them. Only a competent attending physician can determine the type of endometrial disorders, based on the results of diagnostic procedures and some other factors.

Endometrial precancer is adenomatous polyps and hyperplasia with pronounced atypia, in which the cells may have an irregular shape, structure, etc. The following morphological features can be attributed to atypia of the uterine mucosa:

• Blood vessels are unevenly distributed and thrombosis and/or stasis may be present.
• The stroma is edematous.
• The number of glands that are located too close to each other increases. Sometimes the glands have pathological elongated projections.
• With slight atypia, the cytoplasm is basophilic. With obvious atypia - oxyphilic.
• Hyperchromic nuclei, which may have an uneven or even distribution of the chromatin itself.

Without effective medical supervision and timely therapy, endometrial hyperplasia in its simple form degenerates into cancer in 7-9% of cases (subject to the presence of atypia). As for the complex form, the indicators here are not reassuring and they reach 28-30%. But it is important to know that the appearance of precancer is influenced not only by the morphological form of the disease, but also by various concomitant pathologies, for example, those associated with the internal genital organs, the thyroid gland, etc. The risks increase if a woman with endometrial hyperplastic processes suffers from obesity, She was diagnosed with uterine fibroids, polycystic ovary syndrome or, for example, disorders of the hepatobiliary system, diabetes mellitus.

Diagnosis of endometrial pathologies

Hysterosalpingography, as well as transvaginal ultrasound, are considered the most common diagnostic methods prescribed for endometrial pathologies. As for a more in-depth examination, in this case separate curettage and hysteroscopy can be performed. The attending physician can make a diagnosis at any stage of diagnostic studies, but it can be accurately verified only after analyzing the results of a histological examination.

Hysteroscopy is an accurate diagnostic procedure that allows you to fully visually assess the condition of the uterine cavity, its cervical canal and the mouth of the tubes. The manipulation is performed using an optical hysteroscope.

Hysteroscopy for endometrial hyperplasia or other hyperplastic processes of the uterine mucosa is prescribed by the attending physician; the information content of this method is about 70-90%. Hysteroscopy is used to detect pathology, determine its nature, and location. The method is also indispensable for curettage, when diagnostics of this type are prescribed before the procedure and immediately after, to control the quality of its implementation.

It is impossible to independently diagnose problems with the mucous membrane of the uterine cavity, even if the patient has the results of ultrasound or hysteroscopy. Only the attending physician, taking into account the patient’s age, the presence of concomitant chronic diseases and some other factors, will be able to accurately make the correct diagnosis. Under no circumstances should you try to determine the disease yourself, much less treat the disease without consulting a doctor. Alternative medicine is not relevant in this case and can only worsen an already complex health condition.

Transvaginal ultrasound scanning is an absolutely safe non-invasive diagnosis. The modern method makes it possible to almost accurately identify problems associated with the structures of the endometrium, although the information content of the procedure may be influenced by some factors, including the age of the patient, the presence of some concomitant gynecological diseases and the type of hyperplastic processes. Endometrial ultrasound is best performed in the first days after the menstrual cycle. But it is not possible to accurately distinguish glandular type endometrial hyperplasia from atypical endometrial hyperplasia using such a diagnosis.

Endometrium: Normal levels after menopause may vary depending on various factors.

• A median uterine echo of up to 4-5 mm in thickness can be considered normal if a woman’s menopause occurred no more than five years ago.
• If the postmenopausal period began more than five years ago, then a thickness of 4 mm can be considered the norm, but subject to structural homogeneity.

Endometrial polyps in the uterus most often appear on ultrasound as ovoid or almost round inclusions with increased echo density. The information content of diagnostics for polyps is more than 80%. The capabilities of endometrial ultrasound can be increased by contrasting the cavity.

Ultrasounds are performed both in private clinics and in some state-run outpatient clinics. You should take this fact into account and ask your treating specialist about the best options for choosing an institution.

Also, the doctor can individually prescribe additional diagnostic methods if there are doubts regarding the diagnosis.

Endometrial biopsy

Aspirate from the uterine cavity can be examined using cytological and histological analyses. Aspiration biopsy is often used as a control method for hormonal treatment, when the effectiveness of drug therapy is determined using a special procedure. For malignant processes of the uterine mucosa, a biopsy allows you to accurately determine and make a diagnosis. The method helps to avoid curettage, which is performed for diagnosis.

Hyperplastic processes of the endometrium: treatment

In women of all age groups with endometrial pathologies, treatment should be comprehensive. The attending physician will definitely develop an individual program and prescribe therapy, including, possibly, for:

• stopping bleeding;
• full restoration of the menstrual cycle in women of childbearing age;
• achieving subatrophy and atrophy of the uterine mucosa in women over 45 years of age.

Relapse prevention also plays an important role.

Therapy for hyperplastic processes in menstruating women usually consists of hormonal treatment, which is prescribed after diagnosis.

• In the case when a woman of reproductive age is diagnosed with endometrial hyperplasia (without cellular atypia), the following drugs are most often prescribed: combined oral contraceptives in tablets, Norethisterone and/or Dydrogesterone, Medroxyprogesterone, HPC (hydroxyprogesterone capronate).
• If hyperplasia is accompanied by cell atypia, then the following may be prescribed: Danazol, Gestrinone, Buserelin, Diferelin, Goserelin, etc.

It is important to take into account possible infectious causes of the development of hyperplastic processes, because in this case, hormonal medications may be completely ineffective.

If there is a relapse of hyperplastic processes (without obvious atypia) of the uterine mucosa, and hormonal medications do not have the desired therapeutic effect, then under certain conditions the attending physician may prescribe endometrial ablation. This minimally invasive procedure is an alternative to classic endometrial curettage. During its implementation, the mucous membrane is removed or destroyed. But ablation is recommended only for those women over 35 years of age who do not plan to become pregnant again.

If a woman of reproductive age is diagnosed with uterine fibroids or adenomatosis in combination with hyperplastic processes of the uterine mucosa, then this is not a contraindication for ablation. Although doctors believe that the presence of such problems in a woman can negatively affect the results of treatment.

In the event that a patient is diagnosed with an atypical form of endometrial hyperplastic processes, hormonal therapy is ineffective and a relapse occurs, surgical intervention is prescribed. Which operation will be recommended is decided only by the attending physician, taking into account the characteristics of the patient’s health condition, the presence of concomitant chronic diseases and even her age. The operation is prescribed on an individual basis. It could be:

• Intervention on the ovaries (wedge resection) in women with polycystic ovary syndrome.
• Adnexectomy (for ovarian neoplasms that are hormone-producing in nature).
• Hysterectomy.

Modern medicine offers many effective ways to carry out successful operations. But it is impossible to say in absentia which surgical intervention is suitable for a particular patient. Only a competent doctor, taking into account the results of diagnostic studies and the woman’s age, will be able to prescribe truly correct therapy.

Treatment of hyperplastic processes in perimenopause

Premenopause is a stage at which the processes of extinction of ovarian functions already occur and ovulation stops. This period begins approximately after 40-50 years. Its duration is about 15-18 months. At the very beginning of premenopause, the intervals between menstruation increase, their duration and abundance decrease.

If a patient is diagnosed with endometrial hyperplasia, for example, treatment will initially involve hysteroscopy combined with endometrial curettage, which is performed solely for diagnostic purposes. Next, therapy is prescribed taking into account the morphological characteristics of the endometrium and the presence of gynecological diseases. The drug treatment regimen and the list of hormonal medications will also depend on the patient’s desire to maintain her menstrual cycle.

Among the medications, it is worth highlighting Norethisterone, Dydrogesterone, Medroxyprogesterone, Danazol, Gestrinone, Buserelin, Diferelin, Goserelin, etc. They are prescribed depending on the presence or absence of atypia.

During pre- and perimenopause, ablation may be prescribed. Hysteroscopic surgery is performed in cases where there are constant relapses of hyperplasia of the mucous membrane of the uterine cavity (without cellular atypia), and hormonal treatment cannot be prescribed due to any extragenital disease.

Management of postmenopausal patients with endometrial hyperplasia

If a postmenopausal woman experiences bleeding and there is a suspicion of endometrial pathology, a diagnostic separate curettage is prescribed. If the problem appears for the first time, then it is prescribed for hyperplastic processes. If a hormone-producing ovarian mass is detected, surgical removal of the uterus and appendages is recommended. Recurrence of hyperplastic processes in the uterus in women can be the reason for prescribing extirpation of the organ with appendages. If for some reason this operation is contraindicated for a postmenopausal woman, then therapy with gestagens or ablation of the mucous layer is allowed. At this moment, it is very important to monitor the patient’s condition and constantly conduct diagnostic echography. An endometrial biopsy is also prescribed.

During hormone therapy, the attending physician comprehensively recommends antiplatelet agents, hepatoprotectors and anticoagulants in order to significantly reduce the risks of complications.

Targeted polypectomy is a modern and effective method of treating women diagnosed with an endometrial polyp. Complete removal of the formation is allowed only under hysteroscopic control. In addition, such an intervention should involve not only mechanical endoscopic instruments, but also laser technologies, as well as electrosurgical elements.

Doctors recommend excision of the formation electrosurgically in cases where the polyp is determined to be parietal and fibrous. It is also important to note the fact that premenopausal women are recommended to combine polypectomy with ablation of the mucous layer. After the endometrial polyp in the uterus is removed, hormones are prescribed. Moreover, therapy can have a different application regimen, which is tailored to the patient’s age and the morphological characteristics of the distant formation.

Synechiae inside the uterus

Intrauterine adhesions can partially or completely affect the organ cavity. Doctors put forward three main theories regarding the causes of this pathology:

• injuries;
• infections;
• and neurovisceral factors.

The main reason for the appearance of synechiae is mechanical damage to the basal part of the mucous membrane of the uterine cavity. Such injuries are possible during inaccurate curettage, abortion, and childbirth. The appearance of synechiae is often observed in patients after a frozen pregnancy or various surgical interventions on the uterus.

In terms of their symptoms, synechiae inside the uterus are specific. Signs of a problem may include amenorrhea and/or hypomenstrual syndrome.

Such adhesions cause infertility in women; they often prevent the fetus from developing, which is why miscarriage occurs. According to medical experts, even small synechiae in the uterus can negatively affect, for example, IVF.

Synechiae are determined using some diagnostic procedures. In this case, ultrasound, hysteroscopy, and increasingly hysterosalpingography are used.

Synechiae are treated only with dissection. Moreover, the type of operation will always depend on the degree of patency of the uterine cavity and the type of fusion.

If it occurs after such a surgical intervention, then the woman is at risk for complications during pregnancy or delivery.

Over the past few decades, the number of patients suffering from uterine cancer has been constantly increasing, which is likely a consequence of the fact that women are living longer and, accordingly, are going through menopause for a longer period. The age of women affected by endometrial cancer ranges on average from 60 to 62 years.

The disease can develop in two pathogenetic variants - autonomously and as a hormone-dependent disease.

Autonomously developing endometrial cancer is found in less than 30% of cases. It is observed in those women who do not have disturbances in the functioning of the endocrine system. The problem develops along with atrophy of the mucous membrane when a high level of estrogen is not observed in the first period of the menstrual cycle.

It is believed that the occurrence of autonomous endometrial cancer is influenced by depression of the immune system. Depressive immune changes consist of a significant decrease in the number of T-lymphocytes, when their forms sensitive to theophylline are inhibited, as well as a significant increase in the number of lymphocytes whose receptors are blocked.

Typically, the autonomous form of the disease appears in women after 60 years of age. No risk factors have been identified for this type of disease. It is often observed in thin elderly patients, while hyperplastic processes are not previously observed. There is a frequent history of bleeding due to mucosal atrophy. The tumor is poorly differentiated, insensitive to hormonal treatment, metastasis and penetration into the myometrium occurs early.

The hormone-dependent type of the disease can be traced in approximately 70% of morbidity cases. Its pathogenesis is influenced by prolonged hyperestrogenism, which often appears as a consequence:

• anovulation;
• neoplasms in the ovaries;
• excessive peripheral conversion of androgens to estrogens - (observed in diabetes and obesity);
• effects of estrogen (observed during hormone replacement therapy with estrogen and treatment of breast malignancies with tamoxifen, resulting in the formation of metabolites with active estrogens).

For hormone-dependent endometrial cancer, the following risk factors exist:

• infertility and absence of childbirth throughout life;
• late menopause;
• overweight;
• diabetes mellitus;
• hereditary predisposition to a disease with metabolic endocrine pathogenesis - breast, ovarian, uterine, colon cancer;
• neoplasms in the ovaries;
• carrying out estrogen monotherapy in the period after menopause;
• Tamoxifen (an antitumor drug) is used in the treatment of breast cancer.

Cancer classification

Uterine cancer is classified based on how widespread it is. Classification is based on clinical parameters and/or histological results.

The classification of the disease is used before surgery or in the case of inoperable patients. Depending on the stage, endometrial cancer is classified as follows:

• Stage 0 - formation in situ.
• Stage 1 - formation is limited to the body of the uterus.
• 2 - does not extend beyond the boundaries of the uterine body, but directly affects the cervix of the hollow organ.
• 3 - penetrates the pelvis and grows within its boundaries.
• 4 - extends beyond the boundaries of the pelvis and can affect nearby organs.
• 4A - the formation grows in the tissue of the rectum or bladder.

Histological data make it possible to distinguish the following morphological stages of the disease:

• Stage 1A - located directly in the endometrium.
• 1B - tumor penetration into the muscle layer is no more than 1/2 of its thickness.
• 1C - tumor penetration into the muscle layer by more than 1/2 of its thickness.
• 2A - the formation affects the glands of the cervix.
• 2B - formation affects the stroma.
• 3A - the tumor penetrates the serous uterine membrane, metastasis to the ovaries or fallopian tubes is observed.
• 3B - the formation penetrates the vaginal area.
• 3C - metastases to the pelvic and/or para-aortic lymph nodes.
• 4A - the formation affects the mucous membrane of the bladder or intestines.
• 4B - distant metastases appear.

The doctor, based on the above classification and the data obtained after histology, draws up an appropriate treatment plan for patients (in the postoperative period).

In addition, there are 3 degrees of cancer differentiation, which depends on how severe the cellular atypia is. Differentiation happens:

• high;
• moderate;
• low.

Clinical picture of cancer

To a certain extent, the manifestation of the disease is associated with menstruation. In patients with a preserved cycle, endometrial cancer often manifests itself in the form of heavy and prolonged, usually acyclic menstrual bleeding. But in 75% of cases, endometrial cancer begins in the period after menopause and causes bloody discharge, which can be spotty, scanty, or copious. During this period, they appear in 90% of patients, and only 8% of patients do not have any clinical symptoms of the development of a malignant tumor. You should know that in addition to bloody discharge, there may also be purulent vaginal discharge.

Pain occurs quite late, when endometrial cancer penetrates into the pelvis. If the infiltrate compresses the kidneys, pain is most often felt in the lumbar region.

Postmenopausal women are recommended to undergo an ultrasound examination of the pelvic organs, which should be performed annually. For women at risk of endometrial cancer, ultrasound is indicated once every 6 months. This allows pathologies such as cancer and endometrial hyperplasia to be recognized in time and optimal treatment to begin.

A homogeneous endometrium is the norm, and if even small inclusions are detected in its echo structure, the doctor suspects pathology and refers the patient to diagnostic curettage of the mucous membrane under the control of hysteroscopy. Also considered a pathology is an endometrial thickness of more than 4 mm (if postmenopause occurs early, then more than 5 mm).

If there are clear echographic signs of malignant changes in the endometrium, the doctor prescribes a biopsy. Curettage of the mucous part for diagnosis and a hysteroscopy procedure are also often indicated.

If a woman has irregular menstrual cycles, there are signs of pathological changes in the endometrium, and bleeding is observed during the period after menopause, then diagnostic endometrial curettage and hysterocervicoscopy are necessary. In 98% of cases, hysteroscopy performed after menopause is informative, and a thorough histological analysis of scrapings makes it possible to definitively determine the disease.

When the diagnosis is established accurately, the woman is carefully examined to determine what stage the disease is at and to select the optimal therapeutic tactics. In addition to laboratory tests, as well as gynecological examinations, the following is carried out:

• echography of all organs located in the abdominal cavity;
• colonoscopy and cystoscopy, chest x-ray, CT (computed tomography) and other studies, if necessary.

Treatment of patients with endometrial cancer is prescribed based on the stage of the disease and the condition of the woman. Patients who have distant metastasis, the tumor has extensively spread to the cervix, has grown into the bladder and/or rectum, are inoperable. As for those patients who require surgery, for 13% of them surgical treatment is contraindicated, due to the presence of concomitant diseases.

Surgical treatment of the disease involves removal of the uterus along with the appendages. In the first stages of endometrial cancer development, a special operation may be prescribed in which the integrity of the organ is not violated, that is, the uterus is removed through the vagina.

Lymphadenectomy is necessary because metastases that penetrate the lymph nodes do not respond to hormones.

The advisability of lymphadenectomy is dictated by the presence of at least one of the following risk factors:

• spread of the tumor into the muscular layer of the uterus (myometrium) by more than 1/2 of its thickness;
• spread of formation to the isthmus/cervix;
• the tumor extends beyond the boundaries of the uterus;
• the diameter of the formation exceeds 2 cm;
• if cancer with low differentiation, clear cell or papillary cancer, as well as serous or squamous cell type of the disease is diagnosed.

If the pelvic lymph nodes are affected, metastasis to the lumbar lymph nodes is detected in 50-70% of patients.

If a well-differentiated disease is diagnosed in stage 1A, radiation therapy is not required; in all other cases it is indicated, sometimes in combination with hormone therapy, which makes the treatment more effective.

Treatment of the disease in the 2nd stage of its development may include extended removal of the uterus, followed by radiation and hormonal therapy. The doctor independently draws up a treatment regimen that will be most effective for the patient. The treating specialist may first carry out appropriate therapy, and then surgery. In both cases, the result is almost the same, but the first is preferable, since it makes it possible to more accurately determine at what stage the cancer process is.

Treatment of the disease, which is at stages 3 and 4 of its development, is selected only on an individual basis. Usually it begins with surgical intervention, during which the maximum possible reduction of the formation itself is ensured. After the operation, hormonal and radiation therapy (with subsequent correction, if necessary) is prescribed in combination.

Prognosis for oncology

The prognosis for patients suffering from uterine cancer largely depends on the stage of the disease. In addition, the following factors are important:

• woman's age;
• type of tumor from a histological point of view;
• size of education;
• tumor differentiation;
• depth of penetration into the muscle layer (myometrium);
• extension to the cervix;
• presence of metastases, etc.

The prognosis worsens as the patient's age increases (it has been proven that survival rates also depend on age). Primary preventive measures to prevent endometrial cancer are usually aimed at eliminating factors that could potentially lead to the disease, namely:

• weight loss for obesity;
• compensation for diabetes mellitus;
• normalization of reproductive function;
• complete restoration of menstrual function;
• elimination of all causes leading to anovulation;
• correct and timely surgical intervention for feminizing formations.

Preventive measures of the secondary type involve timely diagnosis and optimal treatment of all, including precancerous, pathological processes occurring in the endometrium. In addition to well-chosen treatment and a thorough annual (or once every 6 months) examination with mandatory transvaginal echography, it is necessary to regularly see a leading specialist and monitor your health.

Diagnosis and treatment of endometrial pathologies is the competence of a gynecologist-endocrinologist, especially if problems arise against the background of hormonal imbalance. Also, for example, in case of endometrial cancer, you will need to consult an oncologist or surgeon.

If a woman is bothered by constant or periodic pain in the lower abdomen, bleeding appears regardless of the phase of the menstrual cycle, then it is advisable to immediately seek help from your local gynecologist. If this is not possible, you can initially visit a therapist, who, if necessary, will refer the patient for a consultation with a more specialized specialist.

The hysteroscopic picture of the unchanged endometrium depends on the phase of the menstrual cycle (in the reproductive period) and the duration of menopause (in the postmenopausal period). As is known, the control of the normal menstrual cycle occurs at the level of specialized neurons of the brain, which receive information about the state of the external environment, convert it into neurohormonal signals (norepinephrine), which subsequently enter the neurosecretory cells of the hypothalamus.

In the hypothalamus (at the base of the third ventricle), under the influence of norepinephrine, gonadotropin-releasing factor (GTRF) is synthesized, which ensures the release of hormones of the anterior pituitary gland into the bloodstream - follicle-stimulating hormone (FSH), luteinizing hormone (LH) and lactotropic (prolactin, PRL) hormones. The role of FSH and LH in the regulation of the menstrual cycle is quite clearly defined: FSH stimulates the growth and maturation of follicles, LH stimulates steroidogenesis. Under the influence of FSH and LH, the ovaries produce estrogens and progesterone, which, in turn, cause cyclic transformations in target organs - the uterus, fallopian tubes, vagina, as well as in the mammary glands, skin, hair follicles, bones, adipose tissue.

The secretion of estrogen and progesterone by the ovaries is accompanied by cyclic transformations in both the muscular and mucous membranes of the uterus. In the follicular phase of the cycle, hypertrophy of myometrial cells occurs, and in the luteal phase, their hyperplasia occurs. In the endometrium, the follicular and luteal phases correspond to periods of proliferation and secretion (in the absence of conception, the secretion phase is replaced by a desquamation phase - menstruation). The proliferation phase begins with slow growth of the endometrium. The early proliferative phase (up to 7-8 days of the menstrual cycle) is characterized by the presence of short elongated glands with narrow lumens, lined with columnar epithelium, in the cells of which numerous mitoses are observed.

There is rapid growth of spiral arteries. The middle proliferative phase (up to 10-12 days of the menstrual cycle) is characterized by the appearance of elongated convoluted glands and moderate edema of the stroma. Spiral arteries become tortuous due to their faster growth compared to endometrial cells. In the late phase of proliferation, the glands continue to enlarge, become sharply convoluted, and acquire an oval shape.

In the early phase of secretion (the first 3-4 days after ovulation, until the 17th day of the menstrual cycle), further development of the glands and expansion of their lumen are observed. In epithelial cells, mitoses disappear, and the concentration of lipids and glycogen in the cytoplasm increases. The middle stage of secretion (19-23 days of the menstrual cycle) reflects the transformations characteristic of the heyday of the corpus luteum, i.e. period of maximum gestagenic saturation. The functional layer becomes higher and is clearly divided into deep (spongy) and superficial (compact) layers.

The glands expand, their walls become folded; A secretion appears in the lumen of the glands, containing glycogen and acidic glycosaminoglucuronglycans (mucopolysaccharides). The stroma with the phenomena of a perivascular decidual reaction, in its interstitial substance the amount of acidic glycosaminoglucuronglycans increases. The spiral arteries are sharply tortuous and form “tangles” (the most reliable sign that determines the luteinizing effect).

Late stage of secretion (24-27 days of the menstrual cycle): during this period, processes associated with regression of the corpus luteum and, consequently, a decrease in the concentration of hormones produced by it are observed - the trophism of the endometrium is disrupted, its degenerative changes are formed, morphologically the endometrium regresses, signs of its ischemia appear . At the same time, the juiciness of the tissue decreases, which leads to wrinkling of the stroma of the functional layer. The folding of the walls of the glands intensifies.

On the 26-27th day of the menstrual cycle, lacunar expansion of capillaries and focal hemorrhages into the stroma are observed in the superficial layers of the compact layer; due to the melting of the fibrous structures, areas of separation of the cells of the stroma and the epithelium of the glands appear. This state of the endometrium is called “anatomical menstruation” and immediately precedes clinical menstruation.

In the mechanism of menstrual bleeding, important importance is given to circulatory disorders caused by prolonged spasm of the arteries (stasis, blood clot formation, fragility and permeability of the vascular wall, hemorrhage into the stroma, leukocyte infiltration). The result of these transformations is necrobiosis of the tissue and its melting. Due to the dilation of blood vessels that occurs after a long spasm, a large amount of blood enters the endometrial tissue, which leads to rupture of blood vessels and rejection (desquamation) of necrotic sections of the functional layer of the endometrium, i.e. to menstrual bleeding.

The regeneration phase is quite short and is characterized by the regeneration of the endometrium from the cells of the basal layer. Epithelization of the wound surface occurs from the marginal sections of the glands of the basement membrane, as well as from the unrejected deep sections of the functional layer.

Normally, the uterine cavity has the shape of a triangular slit, in the upper sections of which the mouths of the fallopian tubes open, and its lower section communicates with the cervical canal through an internal opening. It is advisable to evaluate the endoscopic picture of the uterine mucosa during an undisturbed menstrual cycle taking into account the following criteria:
1) the nature of the mucosal surface;
2) the height of the functional layer of the endometrium;
3) the condition of the endometrial tubular glands;
4) structure of mucosal vessels;
5) the condition of the orifices of the fallopian tubes.

During the early phase of proliferation the endometrium is pale pink or yellow-pink, thin (up to 1-2 mm). The excretory ducts of the tubular glands are clearly visualized and evenly distributed. A dense vascular network is identified through the thin mucosa. In some areas, small hemorrhages are visible. The mouths of the fallopian tubes are free, easily identified in the form of oval or slit-like passages, localized in the recesses of the lateral sections of the uterine cavity.

1 - the mouth of the fallopian tube is free, defined as a slit-like passage

IN mid and late proliferation phases the endometrium acquires a folded character (thickened longitudinal and/or transverse folds are visualized) and a bright pink uniform hue. The height of the functional layer of the mucosa increases. The lumen of the tubular glands becomes less noticeable due to the tortuosity of the glands and moderate edema of the stroma (in the preovulatory period the lumen of the glands is not determined). Mucosal vessels can be identified only in the middle phase of proliferation; in the late stage of proliferation, the vascular pattern is lost. The orifices of the fallopian tubes, in comparison with the early phase of proliferation, are less clearly defined.

1 - endocervix; 2 - fundus of the uterus; 3 - the mouth of the fallopian tube; in this phase, the lumen of the glands is less noticeable, but the vessels can be identified

IN early phase of secretion The endometrium is distinguished by a pale pink tone and a velvety surface. The height of the functional layer of the mucosa reaches 4-6 mm. During the heyday of the corpus luteum, the endometrium becomes succulent with multiple folds that have a flat top. The spaces between the folds are defined as narrow gaps. The orifices of the fallopian tubes are often not visualized or barely noticeable due to severe swelling and folding of the mucosa. Naturally, the vascular pattern of the endometrium cannot be detected. On the eve of menstruation, the endometrium acquires a bright, intense shade. In this period, dark purple layers are identified, freely hanging into the uterine cavity - fragments of rejected endometrium.

In this period, dark purple layers are identified, freely hanging into the uterine cavity - fragments of rejected endometrium (1)

IN first day of menstruation a large number of mucous fragments are determined, the color of which varies from pale yellow to dark purple, as well as blood clots and mucus. In areas with complete rejection of the functional layer, numerous pinpoint hemorrhages are visualized against a pale pink background.

In the postmenopausal period, involutive processes progress in the reproductive system of women, caused by a decrease in the regenerative potential of cells. Atrophic processes are observed in all organs of the reproductive system: the ovaries shrink and become sclerotic; the weight of the uterus decreases, its muscular elements are replaced by connective tissue; The vaginal epithelium becomes thinner. In the first years of menopause, the endometrium has a transitional structure, characteristic of the premenopausal period.

Subsequently (as the ovarian function progressively declines), the resting non-functioning endometrium is transformed into an atrophic one. In low atrophic endometrium, the functional layer is indistinguishable from the basal layer. The wrinkled compact stroma, rich in fibers, including collagen, contains small single glands lined with low single-row columnar epithelium. The glands look like straight tubes with a narrow lumen. There are simple and cystic atrophy. Cystically dilated glands are lined with low, single-row columnar epithelium.

Hysteroscopic picture in postmenopause is determined by its duration. In the period corresponding to the transitional mucosa, the latter is characterized by a pale pink color, a weak vascular pattern, single point and scattered hemorrhages. The mouths of the fallopian tubes are free, and near them the surface of the uterine cavity is pale yellow with a dull tint. The atrophic endometrium has a uniform pale or pale yellow color, the functional layer is not identified. The vascular network is often not visualized, although mucosal varicose veins may be observed. The uterine cavity is sharply reduced, the mouths of the fallopian tubes are narrowed.

With induced endometrial atrophy due to the influence of exogenous hormones (the so-called glandular hypoplasia with glandular-stromal dissociation), the surface of the mucosa is uneven (“cobblestone-like”), yellow-brown in color. The height of the functional layer does not exceed 1-2 mm. Deep stromal vessels are visible between the “cobblestones”. The mouths of the fallopian tubes are well visualized, their lumen is narrowed.

The study of the endoscopic anatomy of the endometrium and the walls of the uterine cavity allows not only to evaluate cyclic changes in the mucous membrane of patients examined for infertility, but also to carry out differential diagnosis between normal and pathological transformation of the endometrium. Briefly, the main provisions of this chapter can be presented as follows:

• proliferation phase:

1) the surface of the mucosa is smooth, the color is pale pink;
2) the height of the functional layer of the endometrium is within 2-5 mm;
3) the excretory ducts of the glands are visualized and evenly distributed;
4) the vascular network is dense but thin;
5) the mouths of the fallopian tubes are free;

• secretion phase:

1) the surface of the mucosa is velvety, with numerous folds, the color is pale pink or pale yellow;
2) the height of the functional layer of the endometrium is within 4-8 mm;
3) the excretory ducts of the glands are not identified due to stromal edema;
4) the vascular network is not determined;
5) the mouths of the fallopian tubes are often not visualized or barely noticeable;

• endometrial atrophy:

1) the surface of the mucosa is smooth, the color is pale pink or pale yellow;
2) the height of the functional layer of the endometrium is less than 1 mm;

4) the vascular pattern is weakly expressed or not defined;
5) the mouths of the fallopian tubes are free, but narrowed;

• induced endometrial atrophy:

1) the surface of the mucosa is uneven (“cobblestone-like”), the color is yellow-brown;
2) the height of the functional layer of the endometrium is up to 1-2 mm;
3) the excretory ducts of the glands are not identified;
4) deep stromal vessels are visible between the “cobblestones”;
5) the mouths of the fallopian tubes are free, but narrowed.

A.N. Strizhakov, A.I. Davydov

The main purpose of the endometrium is to create conditions for conception and successful pregnancy. The endometrium of the proliferative type is characterized by a significant proliferation of mucous tissue due to intense cell division. As you know, throughout the entire menstrual cycle, the inner layer lining the uterine cavity undergoes changes. This happens monthly and is a natural process.

The structural structure of the endometrium consists of two main layers - basal and functional. The basal layer is little subject to change, since it is intended to restore the functional layer during the subsequent cycle. Its structure consists of cells tightly pressed against each other, penetrated by multiple blood-supplying vessels. is in the range from 1 to 1.5 cm. The functional layer, on the contrary, changes regularly. This occurs due to damage occurring during menstruation, during childbirth, from surgical interventions during abortion and diagnostic procedures. There are several main phases of the cycle: proliferative, menstrual, secretory and presecretory. These alternations should occur regularly and in accordance with the functions that the female body needs in each specific period.

Normal structure of the endometrium

During different phases of the cycle, the state of the endometrium in the uterus varies. For example, by the end of the proliferation period, the basal mucous layer increases to 2 cm and almost does not respond to hormonal influences. In the initial period of the cycle, the uterine mucosa is pink, smooth, with small areas of an incompletely separated functional layer formed in the previous cycle. Over the next week, a proliferative type occurs, caused by cell division.

Blood vessels are hidden in the folds that arise due to the unevenly thickened layer of the endometrium. The largest layer of mucous membrane in proliferative type endometrium is observed on the posterior wall of the uterus and its bottom, while the anterior wall and part of the child's place below remain almost unchanged. The mucous membrane in this period can reach a thickness of 12 mm. Ideally, by the end of the cycle, the functional layer should be completely rejected, but this usually does not happen and rejection occurs only in the outer areas.

Forms of deviation of the endometrial structure from the norm

Differences in endometrial thickness from normal values ​​occur in two cases - for functional reasons and as a result of pathology. Functional appears in early pregnancy, a week after the process of fertilization of the egg, during which thickening of the child's place occurs.

Pathological causes are due to a violation of the division of regular cells, resulting in the formation of excess tissue, leading to the formation of tumor formations, for example, the resulting endometrial hyperplasia. Hyperplasia is usually classified into several types:

• , with the absence of a clear separation between the functional and basal layers, with an increased number of glands of various shapes;
• in which some of the glands form cysts;
• focal, with the proliferation of epithelial tissue and the formation of polyps;
• , characterized by a changed structure in the structure of the endometrium with a decrease in the number of connective cells.

The focal form of atypical hyperplasia is dangerous and can develop into a cancerous tumor of the uterus. This pathology occurs most often.

Stages of endometrial development

During the menstrual period, most of the endometrium dies, but almost simultaneously with the onset of a new menstruation, its restoration begins through cell division, and after 5 days the structure of the endometrium is considered completely renewed, although it continues to be thin.

The proliferative stage goes through 2 cycles - the early phase and the late one. The endometrium during this period is able to grow and from the beginning of menstruation until ovulation, its layer increases 10 times. During the first stage, the lining inside the uterus is covered with a cylindrical low epithelium with tubular glands. During the second cycle, the proliferative endometrium is covered with a higher layer of epithelium, and the glands in it lengthen and acquire a wavy shape. During the presector stage, the endometrial glands change their shape and increase in size. The structure of the mucous membrane becomes saccular with large glandular cells secreting mucus.

The secretory stage of the endometrium is characterized by dense and smooth surface and basaltic layers that do not show activity.

Important! The stage of the proliferative type of endometrium coincides with the period of formation and

Feature of proliferation

Every month, changes occur in the body, intended for the moment of pregnancy and the period when gestation begins. The period of time between these events is called the menstrual cycle. The hysteroscopic state of the proliferative type of endometrium depends on the day of the cycle, for example, in the initial period it is smooth and quite thin. The late period brings significant changes to the structure of the endometrium; it is thickened, has a bright pinkish color with a white tint. During this period of proliferation, it is recommended to examine the mouths of the fallopian tubes.

Proliferative diseases

During the proliferation of the endometrium, intensive cell division occurs in the uterus. Sometimes disturbances occur in the regulation of this process, as a result of which dividing cells form excess tissue. This condition threatens the development of cancerous tumors in the uterus, disturbances in the structure of the endometrium, endometriosis and many other pathologies. Most often, examination reveals endometrial hyperplasia, which can have 2 forms, such as glandular and atypical.

Forms of hyperplasia

The glandular manifestation of hyperplasia in women occurs at older ages, during and after menopause. With hyperplasia, the endometrium has a thickened structure and polyps formed in the uterine cavity that protrude into it. Epithelial cells in this disease are larger in size than normal cells. With glandular hyperplasia, such formations are grouped or form glandular structures. It is important that this form does not produce further division of the formed cells and, as a rule, rarely takes a malignant direction.

The atypical form refers to precancerous conditions. It does not occur in youth and appears during menopause in older women. Upon examination, it is possible to notice an increase in columnar epithelial cells with large nuclei and small nucleoli. Lighter cells containing lipids are also detected, the number of which is directly related to the prognosis and outcome of the disease. Atypical glandular hyperplasia takes a malignant form in 2-3% of women. In some cases, it may begin to reverse, but this only happens when treated with hormonal drugs.

Therapy for the disease

Occurring without major changes in the structure of the mucosa, it is usually treatable. To do this, a study is carried out using diagnostic curettage, after which the taken samples of mucous tissue are sent to the laboratory for analysis. If an atypical course is diagnosed, a surgical operation is performed with curettage. If it is necessary to preserve reproductive functions and preserve the ability to conceive after curettage, the patient will be forced to take hormonal medications with progestins for a long time. After the disappearance of pathological disorders, a woman most often becomes pregnant.

Proliferation always means intensive growth of cells that, having the same nature, begin to develop simultaneously in one place, that is, they are located locally. In female cyclic functions, proliferation occurs with regularity and throughout life. During menstruation, the endometrium is shed and then restored through cell division. Women who have any abnormalities in reproductive functions or detected pathologies should take into account what phase of proliferation the endometrium is in during an ultrasound examination or when performing diagnostic scrapings from the uterus. Since at different periods of the cycle these indicators can differ significantly from each other.