MINISTRY OF HEALTHCARE OF UKRAINE

BOGOMOLETS NATIONAL MEDICAL UNIVERSITY

Department of Obstetrics and Gynecology No. 3

METHODOLOGICAL RECOMMENDATIONS
ON DISCIPLINE “OBSTETRICS AND GYNECOLOGY”
for the students of IV, V, VI courses
of Medical Faculty

Methodological recommendations
were discussed and approved at the
educational and methodological
meeting of the Department of
Obstetrics and Gynecology No. 3.
Minute No. 1 from 31.08.2022 year.

Head of the Department of Obstetrics

and Gynecology No. 3,
MD, professor V.O. Beniuk

Kyiv, 2022

1
Author’s Stuff:
Head of the Department of Obstetrics and Gynecology No. 3, MD, Professor V.O.
Beniuk
Professor, MD Dyndar O.A.
Professor, MD Ginzburg V.G.
Professor, MD Goncharenko V.M.
Professor, MD Ivaniuta S.O.
Associate Professor, MD Manzhula L.V.
Associate Professor, PhD Beniuk S.V.
Associate Professor, PhD Drupp Yu.G.
Associate Professor, PhD Hychka N.M.
Associate Professor, PhD Kovaliuk T.V.
Associate Professor, PhD Lastovetska L.D.
Associate Professor, PhD Maidannyk I.V.
Associate Professor, PhD Nykoniuk T.R.
Associate Professor, PhD Vygivska L.M
Associate Professor, PhD Usevych I.A.
Assistant, PhD Chebotarova A.S.
Assistant Fursa-Sovhyra T.M.
Assistant, PhD Kurochka V.V.
Assistant, PhD Oleshko V.F.
Assistant, PhD Puchko M.S.
Assistant, PhD Shcherba O.A.
Assistant, PhD Zabudskyi O.V.

Background and precancerous diseases of female genital organs.

2
I. Scientific and methodological justification of the topic
Knowledge of precancerous conditions, methods of early diagnosis of cervical,
uterine and ovarian cancer, methods of their treatment are necessary for a doctor of
any specialty in his practical work.
The risk of precancerous diseases of the endometrium and their transition to cancer
increases in cases when existing disorders of ovulation, fat metabolism,
carbohydrates and hyperplastic processes of the endometrium are combined in one
patient. 
II. Training and educational purposes
To know:
- precancerous conditions of the cervix, their diagnosis and treatment;
- to get acquainted with the classification, clinic, methods of diagnosis of
common precancerous conditions of the uterus, methods of their differential
diagnosis, treatment.
- prevention of possible complications and rehabilitation, with the clinic,
methods of diagnosis and treatment of cervical, uterine and ovarian diseases.
- the role of preventive examinations in timely diagnosis and features of
dispensary follow-up of patients with ovarian tumors;
- possible complications and their prevention, including surgical methods of
treatment, their necessary volume in each case.
Be able to:
- examine a patient with precancerous conditions;
- based on anamnesis, clinic, differential diagnosis, to make the correct
diagnosis;
- -after diagnosis, pathogenetic treatment is prescribed;
- select from the anamnesis the data characteristic of the patient's ovarian
tumor, analyze them,
- to make a diagnosis after an objective examination of the patient;

3
 - to make an individual plan of additional examination of a patient with
precancerous diseases of the cervix for differential diagnosis and to evaluate
the data of instrumental and clinical laboratory examination;
- to develop an individual treatment plan for a specific patient;
- to justify the necessary amount of surgical intervention in various variants of
precancerous conditions.
III. Basic knowledge
Anatomy:
- - the size of the non-pregnant uterus and its location in the pelvis;
- - ligamentous apparatus of the uterus;
- - blood supply to the uterus and appendages.
Histology:
- structure of the uterine wall;
- histological structure of the endometrium
- morphological and histological structure of the ovaries.
Normal physiology:
- female sex hormones, the places of their production, the effect on the
endometrium depending on the phase of the menstrual cycle.
Pathological physiology:
• Definition of the term "tumor", signs of tumor growth, the difference between a
malignant tumor and a benign one.

IV. The content of the training material

Precancerous diseases of female genital organs
Precancerous diseases are diseases with a long (chronic) course of the dystrophic
process and benign tumors that tend to malignancy. Morphologically, precancerous
processes include foci of proliferation (without invasion, atypical epithelial
proliferation, cell atypia).
Individual precancerous conditions:
- vulva,
4
- cervix,
- uterus body, ovaries.
1. 1. Precancerous conditions of the vulva
Leukoplakia is manifested by the proliferation of multilayered squamous
epithelium, a violation of its differentiation and maturation.
Histologically: dermatosis, hyperkeratosis, dysplasia.
Clinically - dry plaques of whitish or yellowish color, which can be both localized
and widespread, itchy and burning. Precancerous conditions - vulva.
Vulva kraurosis is the disappearance of subcutaneous fat of the labia majora,
atrophy of the sebaceous and sweat glands occurs. The skin becomes thinner,
becomes dry, easily vulnerable, the tissues shrink, the entrance to the vagina
narrows sharply.
Morphologically - atrophy of the reticular layer of the skin, the death of elastic
fibers, hyalinization of connective tissue.
It is clinically manifested by itching, burning, which leads to skin injury and
causes secondary vulvitis.
Vulvar cancer against the background of these diseases occurs in 20-50% of cases.
Condyloma of the vulva (papillomavirus infection).Sexually transmitted.
Condylomas are neoplasm covered with a multilayer epithelium containing a
connective tissue stroma with vessels. Located in the area of the labia majora and
labia minora, multiple.
Leukoplakia and vulva kraurosis are chronic neurodystrophic lesions of the
vulva, accompanied by chronic inflammatory processes. Most often, these diseases
develop during menopause and menopause. Etiology: dysfunction of the nervous
system (symmetry of the lesion), sex glands (hormonal deficiency), as well as age-
related atrophic processes in the genitals. Histologically, leukoplakia is based on
the processes of hyperkeratosis with lymphohistiocytic infiltration of subepithelial
tissue. With kraurosis, atrophic changes of the integumentary epithelium with
sclerosis and hyalinosis of the subepithelial tissue prevail.

5
Clinic: often accompanied by concomitant diseases (diabetic vulvitis, etc.), against
which the disease develops imperceptibly with the appearance of itching of the
vulva. The skin and mucous membranes become pale and shiny with leukoplakia.
Then small, rarely multiple whitish spots (plaques) appear, which somewhat
protrude above the surface of the tissues, similar in color and density to asbestos.
Plaques that merge form a solid field, similar to crumpled parchment paper.
With kraurosis, the clitoris and labia minora atrophy, the vulva wrinkles due to the
fusion of the skin with the underlying tissue, the entrance to the vagina narrows
sharply, the skin and mucous membranes acquire a pearly whitish-gray hue, lose
elasticity (a pronounced parchment symptom), the skin becomes dry, smooth, the
vessels are highlighted. Inguinal lymph nodes are enlarged, painful.
Treatment is complex, it is necessary to start with the treatment of concomitant
diseases. Psychotherapy, hypnotherapy, sleeping pills, tranquilizers, bromide
preparations, valerian. Hormone therapy (androgens, can be combined with small
doses of estrogens), biogenic stimulants, corticosteroids. Within the limits of the
effectiveness of these measures - vulva formation, X-ray therapy or surgical
treatment (vulvectomy).
Dysplasia of the vulva.
Morphologically, this is atypical for a multilayered flat epithelium of the vulva
with a violation of the layers, without involving the surface layer in the process or
its penetration through the basement membrane.
Preinvasive vulvar cancer is a pathology of the integumentary epithelium of the
skin and the mucous membrane of the vulva, along the entire thickness of which
there are morphological signs of cancer, loss of layers and polarity, but there is no
invasion through the basement membrane into the stroma.
There are two varieties:
Bowen's disease - morphologically reveals a picture of hyperkeratosis with
parakeratosis and acanthosis against the background of cr in situ.
Clinically - the presence of flat or raised spots with flat edges and some tissue
infiltration.
6
Paget's disease is characterized by the presence of large fresh cells in the
epidermis with changes in the skin and mucous membranes of the cr type in situ.
Clinically, this is manifested by single bright red, sharply limited eczema-like
spots that have a granular surface with infiltration of the skin. In 50% of cases, it
leads to the development of invasive cancer.
Research methods: clinical, histological, additional: cytological, radioisotope.
Precancerous and background conditions of the cervix
Cervical pathology is detected in 10-15% of cases. Cervical cancer is the most
common pathology and accounts for 12% of all malignant neoplasms in women.
Precancer and background states of the cervix
Cervical cancer is a visual form of its pathology, so today a screening program
(cytological) has spread (to identify precancerous conditions of the cervix). Using
the cytological method of examination, precancerous changes are detected on the
visually unchanged cervix. According to the decision of the WHO expert group,
dysplasia should be considered as a precancerous cervix. Today, pathological
changes in the cervix are usually divided into background, precancerous and tumor
processes.
Clinical and morphological classification of pathological processes of the
cervix
1. Background processes: pseudoerosion, leukoplakia, polyps, flat
condylomas.
2. Precancerous processes - dysplasia can be mild, moderate, severe.
3. Preinvasive cancer (Ca in situ, intraepithelial cancer).
4. Microinvasive cancer.
5. Invasive cancer: squamous keratinizing, squamous non-keratinizing,
adenocarcinoma, dimorphic glandular-squamous, low--differentiated.

The main clinical symptoms: leucorrhoea, blood, pain.

I. The first symptom that the patient and the doctor should pay attention to is a
change in the usual type of leucorrhoea, often liquid (a signal symptom). The

7
 appearance of pain in a child, girls and women of any age, especially menopausal
and elderly, always requires special attention and careful examination by a doctor.
leucorrhoea with an admixture of blood (sulfurous leucorrhoea), the color of meat
slops, with an unpleasant odor indicate a disorder and infection of the tumor and
sharply increase the suspicion of cancer.

II. The second important initial symptom is contact bleeding - small blood spots
on underwear, rarely - like real bleeding. They occur during sexual intercourse,
douching, vaginal examination, the introduction of mirrors, and sometimes during
defecation. There are also bleeding during the intermenstrual period.

III. The pain is initially unstable, aching in nature, often occurs at night, and later
progresses both during the day and at night, which greatly affects the general
condition of the patient.

Classification

Clinical and morphological classification of diseases of the cervix (International

Classification of Diseases - X (1992).

Cipher

Cervical Conditions

XIV.Diseases of the genitourinary system (N00-N99)

N 72 Inflammatory cervical disease cervicitis, endocervicitis, endocervicitis with

erosion or ectropion, or without them

N 74.0 Tuberculosis infection of the cervix uteri

N 80.8 Other endometriosis (includes the cervix)

N 84.1 Cervical polyp

N 86 Erosion and ectropion of the cervix. Decubital (trophic) ulcer of the cervix.
Excluded their conjugation with cervicitis.

N 87 Dysplasia of the cervix. Excluded carcinoma in situ of the cervix (D06)

N 87.0 Slightly expressed cervical dysplasia. Cervical intraepithelial neoplasia of

8
 the I degree

N 87.1 Moderate dysplasia of the cervix. Cervical intraepithelial neoplasia of grade

II

N 87.2 Severe cervical dysplasia, not elsewhere classified

Sharply expressed dysplasia of BSU

Excluded Cervical intraepithelial neoplasia of III degree with or without

mention of pronounced dysplasia (D06)

N87.9 Cervical dysplasia, unspecified

N88 Other non-inflammatory disorders of the cervix.

Excluded: inflammatory diseases of the cervix (№72), cervical polyp (№

84.1)

N88.0 Cervical leukoplakia

N88.1 Old cervical rupture

Cervical spikes

The present obstetrical trauma is excluded (071.3)

N88.2 Cervical stricture and stenosis

Exclusion complication of labor (065.5)

N 88.3 Insufficiency of the cervix. Examination and care for (presumed) ischemic-
cervical insufficiency outside of pregnancy

N 88.4 Hypertrophic lengthening of the cervix

N 88.8 Other specified inflammatory diseases of the cervix. Excluded: current injury
(071.3)

N 88.9 Non-inflammatory disease of the cervix, unspecified

International classification of colposcopic terms (A)

9
Adopted at the VII World Congress on the pathology of the cervix and colposcopy
(Rome, 1990).

I. Normal colposcopic signs.

1. Squamous multilayered epithelium.

2. Cylindrical epithelium.

3. Normal zone of transformation.

II. Abnormal colposcopic signs

A. Within the transformation zone.

1. Acetyl white epithelium:

a) flat;

b) micro-papillary or micro-fibrillation.

2. Punctuation.

3. Mosaic.

4. Keratosis (leukoplakia).

5. Iodine-negative epithelium.

6. Atypical vessels.

B. Outside the transformation zone (ectocervix, vagina).

1. Acetyl white epithelium:

a) flat;

b) micropopulations or micro-fricatives.

2. Punctuation.

3. Mosaic.

4. Leukoplakia.

5. Iodine-negative epithelium.

6. Atypical vessels.
10
III. Suspicion of invasive cancer in colposcopy.

IV. Unsatisfactory colposcopy.

1. Limit of multilayered planar epithelium is NOT visualized.

2. Severe inflammation or atrophy.

3. Cervix is NOT visualized.

V. Mixed symptoms.

1. Acetic-non-white micropapillary surface.

2. Exophytic condyloma.

3. Inflammation.

4. Atrophy.

5. Ulcer.

6. Others.

Colposcopic classification of pathological processes of the cervix. (C)

(Kohanevich EV, 1997)

I. Benign (background) pathological processes.

1. ectopia of the cylindrical epithelium:

a) dyshormonal;

b) posttraumatic.

2. Benign area of transformation (zone of benign metaplasia):

a) the middle zone of transformation;

b) the final transformation zone.

3. Inflammation of the cervix

a) exocervicitis;

b) endocervicitis.

4. Real erosion.
11
5. Benign polypoid formations.

6. Endometriosis of the cervix.

II. Precancerous conditions of the cervix.

1. Simple leukoplakia.

2. Dysplasia fields:

a) multilayer squamous epithelium;

b) metaplastic prismatic epithelium.

3. Papillary zone of dysplasia:

a) multilayer squamous epithelium;

b) metaplastic prismatic epithelium.

4. Pre-tumescent transformation zone.

5. Condyloma.

6. Precancerous polyps.

III. Preclinical cancer of the cervix.

1. Proliferating leukoplakia.

2. The fields of atypical epithelium.

3. Papillary zone of atypical epithelium.

4. A zone of atypical transformation.

5. Zone of atypical vascularization.

IV. Clinically expressed cancer.

1. Exophytic form.

2. Endophytic form.

3. The mixed form.

Cytological classification of dysplasia by Richart (1968) (C)

"Cervical intraepithelial neoplasia" (CIN) is distributed:

12
CIN I - mild dysplasia

CIN II - moderate dysplasia

CIN III - severe dysplasia and preinvasive cancer

Histological classification of background diseases, precancerous conditions

and cervical cancer (Yakovleva IA, Kukutė B., 1979) (C)

background processes precancerous processes cancer

A. Hyperplastic, A. Dysplasia that occurs on the A. Pre-clinical forms:

associated with unchanged neck or on the site 1. Cancer in situ.
hormonal imbalance of background processes: mild
2. Cancer in situ with
1. Endocervicitis: or severe
the onset of invasion.
- Simple; B. Leukoplakia with atypical
3. Microcirculation.
cells.
- Proliferating; Clinical forms:
B. Erythroplasty.
- Healing. - squamous cell;
G. Adenomatosis.
2. Polyps: - keratinizing;
- Simple; - not keratinizing cancer;
- Proliferating; - adenocarcinoma of
- Epidermal. different degrees of

3. Papillomas. maturity;

4. Simple leukoplakia. - clear cell carcinoma

(meso-neural)
5. Endometriosis.
- glandular squamous
B. Inflammatory:
cell carcinoma;
- true erosion;
- adenoid cystic cancer;
cervicitis.
- undifferentiated
B. Posttraumatic:
cancer.
- ectropion;

13
- scarring changes;

- cervico-vaginal
fistulas.
 
International Classification of Colposcopic Terms (IFCPC, Rio de Janeiro,
2011)
General provisions:
1. Adequate / inadequate picture (with an indication of the cause: an objective
evaluation of CM is difficult due to inflammation, bleeding, scarring, etc.).
2. The boundary between the multilayered planar and cylindrical epithelium (it is
visualized completely, partially, it is not visualized).
3. The zone of transformations I, II, III type.
I. I. Normal colposcopic pictures:
1. Multicharge flat epithelium (mature, atrophic).
2. Cylindrical epithelium (ectopia).
3. Metaplastic epithelium (pseudo-cysts, open glands - crypts).
4. Deciduosis (during pregnancy).
I I I. Anomalous colposcopic patterns:
1. General principles: a) localization of the lesion (within or outside the CMM
according to the dial) b) the size of the lesion site (as a percentage of endocervix).
2. Degree I (weak lesion): a) thin epithelium with uneven fuzzy contours, gentle
mosaic; gentle punctuation.
3. Degree I I (pronounced lesion): a) dense epithelium with distinct contours b)
rapid whitening; c) Aceto-white tight rim around the open glands (crypt), coarse
mosaic; rough punctuation; within the lesion, the contours of a denser section; a
sign crests.
4. Nonspecific signs: a) leukoplakia; b) erosion; c) filled with Lugol's solution
(Schiller's test): iodine-positive; iodine is negative.

14
5. Suspicion of invasion: atypical vessels. Additional signs: "brittle" vessels,
uneven surface, exophytic lesions, areas of necrosis and ulcers.
I V. Other colposcopic patterns:
1. Congenital BT.
2. Stenosis. Condylomas.
3. Congenital anomalies.
4. Polyps.
5. Consequences of previous treatment.
6. Inflammation.
7. Endometriosis. 
 
Diagnostics.
In modern oncogynecology, the concept of a two-stage examination system has
been put forward:
At the 1st stage - primary detection (screening),
At the 2nd stage, in-depth diagnostics methods are conducted in case of suspected
cancer of the reproductive system.
Collecting anamnesis, you need to identify:
1. The presence of a prolonged inflammatory process of the genitals.
2. Erosion of the cervix, which does not heal for a long time or gives relapses for
several months, and sometimes years, despite treatment.
3. An indication of an old cervical injury.
4. The presence of pain.
5. Contact and acyclic bleeding.
6. Diagnosis of the early stage of cervical cancer is possible with a thorough
examination of the patient and the use of additional research methods.
During the examination, it is necessary to apply special research methods, of
particular importance among which are cytology and colposcopy, hysteroscopy.
The patient is carried out:
1. Study with the help of vaginal mirrors.
15
The main method of studying the vaginal part of the cervix is colposcopy -
examination of the vaginal part of the cervix with a special optical device, gives a
multiple increase. Colposcopy is distinguished: simple and extended
2. Additional methods (specialized department, gynecological hospital), which
include: Colpomicroscopy, cervicosсopy, chromoscopy, fluorescent
colpocervicoscopy, studies with radioactive phosphorus, determination of sexual
chromatin, etc. For screening of diagnosis of cervical cancer, the most common
cytological screening.
3. Colpocytology. For cytological examination, swabs are taken from suspicious
areas of the vaginal cervix or the transformation zone (external cervix) of the
cervical canal and the anterolateral part of the cervix. Smears are taken with a
cotton swab, applied to a slide, dried and painted manually according to a certain
procedure (for a Papanicolaou test or hematoxylin eosin). Examination of smears
under a microscope allows you to identify atypical cancer cells.
For many years, work has been carried out in the direction of increasing the
sensitivity and specificity of the PAP test (Pap smear). The main disadvantage of
the traditional PAP test is false negative conclusions due to:
1. Loss of cellular material (up to 80%) when taken and applied to glass
2. The impossibility of thin and uniform application of cellular material on glass
due to mucus, inflammatory elements and destroyed cells
3. Non-compliance with the rules of fixing the material on the glass (drying of the
cells significantly reduces the diagnostic information of micro-preparations)
4. Incomplete staining of cellular material associated with its layering (thick
smear)
As a result, we have a sample of cells that does not allow us to reliably estimate the
cytological preparation giving false-negative results.
Liquid cytology is a technique, the essence of which is the transfer of cellular
material into a special liquid medium that ensures the preservation of cells. In the
USA and European countries, in particular in Germany, liquid cytology is
recognized as the most informative way to obtain biological material and is
16
recommended as the "gold standard" for the diagnosis of intraepithelial neoplasia
of the mucous membrane of the cervical canal and the vaginal part of the cervix.
Cellular material is collected with special brushes. In a conventional Рap test, it is
evenly distributed in a thin layer over a specially treated non-greased slide is
immediately treated with a fixing mixture until the smear dries, and sent to the
laboratory, where the glass is evaluated under a microscope. In liquid cytology, the
material is placed in a special stabilizing solution, which ensures its safety, and
sent to the laboratory, where the cells are automatically separated from blood and
mucus impurities. Then a representative sample of cells is placed on a slide with a
monolayer and painted with a special paint, which improves the quality of
diagnostics.
The results of the cytological study are classified according to the Papanicolau
system;
1) absence of atypical cells;
2) atypical cells without signs of malignancy;
3) suspicion of cancer;
4) some signs of cancer;
5) cancer.
Classification of Bethesda
Cytological classification of Bethesda is based on the term SIL (Squamous
Intraepithelial Lesion) - squamous intraepithelial lesion. This classification is now
used to treat cytological smears of the cervix. At the same time, three types of
drugs are of clinical importance: normal smears, without cytological changes;
"Incomprehensible" smears that do not have definite meaning, in other words - do
not allow the researcher to accurately answer the question about the nature of the
lesion, but at the same time are not the norm (ASC -US, Atypical squamous cells
of undetermined significance), and low-grade precursors LSIL) and high (HSIL)
degree.
The terminology system Bethesda, 2001 (Terminology Bethesda System)

17
Atypical glandular cells AGC

Atypical glandular cells, favor AGC, favor

neoplastic neoplastic

Atypical squamous cells ASC

Atypical squamous cells ASC-US

undertermined significance

Atypical squamous cells can not ASC-H

exclude HSIL

Cervical intraepithelial neoplasia CIN 1, 2, 3

grade 1, 2 or 3

Carcinoma in situ CIS

High grade squamous HSIL

intraepitelial lesion

Low grade squamous LSIL

intraepitelial lesion

Not otherwise specified NOS

Squamous intraepitelial lesion SIL

 

4. According to the order of the Ministry of Health of Ukraine No. 503 of

28.12.2002 "On improving outpatient obstetric and gynecological care in Ukraine":
Women aged 18 and those who live sexually, then at a younger age, one time a
year pass cytological screening.

5. Vaginal and rectal examination. In a bimanual study of a patient with cervical

cancer, an increase in the density of the cervix is observed, limiting its mobility.

Comparison of colposcopic, cytological and histological signs of benign and

precancerous processes of the cervix

18
I. Benign (background) pathological processes

colposcopic features cytological signs histological signs

Ectopy of the cylindrical Unchanged cylindrical Simple endocervicosis
epithelium epithelium

Benign middle zone of Metaplastic epithelium Proliferating

transformation (zone of endocervicosis
benign metaplasia)

Benign terminal terminal Multilayered scawmoid Stationary endocervicosis

area (benign metaplasia epithelium
zone) Ov. Nabothi

Inflammatory processes of Epithelium of all layers Layers of squamous or

the cervix (exo, with dystrophic changes, cylindrical epithelium,
endocervicitis) leukocytes small cell infiltration of
connective tissue

True erosion Cells of different layers of Connective tissue without

squamous epithelium epithelium

Benign polypoid Proliferation of glandular Glandular or epidermis

formations epithelium with an polyp
insignificant increase in the
number of nuclei

Endometriosis of the cervix Weak proliferation of Endometriosis of the

glandular epithelium cervix

II. Precancerous conditions of the cervix

Simple leukoplakia Nuclear-free surface cells Signs of keratinous
with hyperkeratosis epithelium keratinization

Dysplasia fields of Groups of multilayer Foci of dysplastic

19
multilayer squamous squamous epithelium with multilayer squamous
epithelium dyskaryosis (CIN I-III) epithelium in the form of
"columns", which deepen
into the connective tissue

Dysplasia fields of Groups of metaplastic Foci of dysplasic

metaplastic prismatic epithelium with metaplastic epithelium in
epithelium dyskaryosis (CIN I-III) the form of "columns",
which deepen into the
connective tissue

Papillary zone of dysplasia Groups of multilayer Foci of dysplasic

of multilayer squamous squamous epithelium with metaplastic epithelium
epithelium dyskaryosis (CIN I-III) with proliferation of
connective tissue papillae

Papillary zone of dysplasia Groups of metaplastic Foci of dysplasic

of metaplastic prismatic epithelium with metaplastic epithelium
epithelium dyskaryosis (CIN I-III) with proliferation of
connective tissue papillae

Precancerous Proliferation of glandular Proliferation of glandular

transformation zone epithelium with dysplastic epithelium by
dyskaryosis (CIN I-III) glands

Condyloma Squamous epithelium of

various layers with
koylocytic atypia (CIN I)

Precancerous polyps Proliferation of glandular The pronounced

or squamous epithelium proliferation of connective
with dyskaryosis (CIN I- tissue papillae, the
III) proliferation of the spastic
20
 epithelium with hyper-
dyskaryosis

 
 

Treatment of patients develops in three main directions and includes 3 stages:

l) complex radiotherapy;

2) combined treatment (radiotherapy and surgical treatment)

3) only surgical treatment.

Patients with decompensation of the cardiovascular system, anemia, with weight

loss need primarily in appropriate treatment: regimen, diet, cardiotonic drugs,
blood transfusion, iron preparations (no more than 10 days).

In the treatment of background and precancerous processes on the cervix,

medications, chemical coagulation, diathermoexcision, diathermoconidation,
plastic surgery on the cervix, diathermocoagulation, cryodestruction, laser therapy
are used. Surgical treatment as an independent method of treating patients with
cervical cancer should be used in the treatment of patients with early forms of
cervical cancer

In case of preinvasive cancer: an operation is performed - conization of the cervix

by electrosurgical method (LООP). As a result of such a small operation, a clinical
cure occurs in 99% of patients.

Anti-inflammatory therapy.

Targeted antibacterial, antifungal, antiviral and antiseptic therapy is prescribed

until the vaginal biocenosis normalizes.

Correction of the vaginal microflora is carried out with biological preparations

from live bifido- (Bifiform, biosporin) and lactobacilli (yogurt, linex, Vagilak).

Correction is prescribed in three courses of 7-8 days with intervals of 10-12 days
between them, taking into account the degree of dysbiotic disorders.
21
Hormonal therapy.

In case of detection of ectopia of a dishormonal nature, the use of oral

contraceptives is indicated. Hormonal contraception is carried out for 3-6 months.
With concomitant hormone-dependent gynecological diseases (endometriosis,
uterine leiomyoma), treatment is carried out in accordance with nosological forms.

With papillomavirus infection, interferon preparations are used.

Chemical coagulation.

The main conditions of treatment:

- the presence of post-traumatic ectopia without deformity of the cervix,

- absence of cytological, colposcopic signs of dysplasia,

- a small prevalence of the process (from one to two thirds of the cervix),

- Absence of pregnancy.

The affected area is treated with a cotton swab with Solkovagin solution twice with
an interval of 1-2 minutes.

The results of therapy are evaluated 4 weeks after the application of the drug. If the
effect of the application is insufficient, repeat 2-3 times with an interval of 4
weeks.

Electrocoagulation.
The procedure is performed on an outpatient basis. Local anesthesia.
Electrocoagulation is carried out before the formation of a white scab in the first
phase of the menstrual cycle, after which it is recommended to refrain from sexual
relations for a month. To improve the recovery process, candles with methyluracil
are prescribed during this period.

Indications:

- benign background processes without pronounced deformation and hypertrophy

of the cervix.

Contraindications:
22
- Acute and subacute inflammatory processes of the female genital organs;

- Exacerbation of chronic inflammation;

- Active genital tuberculosis;

- Acyclic bloody discharge from the genital tract

- Benign background processes in combination with severe deformities and

hypertrophy of the cervix, especially in people over 40 years of age.

The first control examination (colposcopy, cytological examination, bacterioscopy)

is performed after the next menstruation. The second follow-up inspection is
performed 3 months after coagulation.

Recovery is established according to colposcopy, cytology and normalization of

the vaginal flora.

The duration of the medical examination is 3 months after complete clinical

recovery.

 ELECTROEXCISION.

Paracervical anesthesia 1-2% with lidocaine solution.

Indications:

1) a combination of benign and (or) precancerous processes on the cervix with its
hypertrophy and deformation;

2) the presence of dysplasia in patients who had previously undergone destruction

of the cervix, which caused the displacement of the transformation zone into the
cervical canal, or this displacement is due to the age of the patient (after 40 years);

3) with relapses of dysplasia after electrocoagulation, cryodestruction of laser

vaporization;

4) with intracervical localization of dysplasia;

5) with severe dysplasia.

Contraindications:

23
- inflammatory processes of the female genital organs;

- the presence of lesions of the cervix, which pass to the vaginal vault and vaginal
walls

- large post-traumatic deformation of the cervix, which moves to the vaginal vault;

- severe somatic diseases.

Cryodestruction.

Indications:

- benign and precancerous pathological processes.

Contraindications:

- inflammatory diseases of female genital organs;

- tumors of female genitalia with suspicion of malignancy.

- severe somatic diseases in the stage of decompensation.

Laser vaporization.
Laser vaporization is a method of exposure to pathological tissue with a laser
beam.
The advantages of this method are:
• the effect is strictly dosed in depth and area - it is impossible to make a mistake
and damage neighboring, healthy areas.;
• conducted under the supervision of colposcopy
• minimized risk of bleeding
• conducted on an outpatient basis
• laser coagulation does not leave scarring and narrowing of the cervical canal
- this allows it to be used for women who do not give birth.
Contraindications:
• acute inflammatory diseases;
• severe dysplasia (CIN III c.) and cervical cancer;
• polyps of the upper third of the cervical canal
• tumors of the female genital organs with suspected malignancy,
24
• severe somatic diseases in the decompensation stage
Indications:
- benign and precancerous pathological processes with localization on the vaginal
part of the cervix.
Today, erbium and neodymium lasers are used. The wavelength is 2,940 nm. It
should be noted that it is 10 times more effective than CO2 Lazarus, since the
radiation penetrates to a smaller depth (about 1 microns), causes rapid evaporation,
without thermal burns, that is, "cold" lazarus.

Argon-plasma coagulation of tissues is a method of monopolar high-frequency

surgery, in which the energy of a high-frequency current is transmitted to the tissue
in a non-contact way using ionized inert argon gas, resulting in the formation of an
argon-plasma torch between the electrode and the tissue.

When the torch acts on the tissue, it localizes and coagulates to a depth. The
advantages of the APC method are the absence of electrode contact with tissues,
eliminating microbial contamination, the ability to control the depth and area of
coagulation, and the absence of damage to the underlying connective tissue

When using argon-plasma coagulation for the treatment of pathological processes

of the cervix, healing occurs in a short time, rough scars are not formed, which
makes it possible to apply this method to women who have not given birth.

The level of radical treatment is determined by the severity of dysplasia.

Hysterectomy.
Indications:
CIN III with localization in the cervical canal;
- technical impossibility of carrying out electroexcision in connection with
anatomical features;
- combination with uterine fibroids or ovarian tumors;
- relapse after cryotherapy or laser therapy.
When the process spreads to the vaginal vaults, extirpation of the uterus with the
upper third of the vagina is shown.
25
Clinical observation after treatment of benign processes is carried out for 2
months, while sexual intercourse and topical use of methyluracil candles are
recommended. After treatment of dysplasia, follow-up lasts up to 2 years.
The issue of removing the ovaries is resolved during surgery in case of detection of
their pathological changes and with the consent of the patient.
Prevention. Due to the establishment of the role of HPV in the mechanism of
development of precancer tumors, a specific primary prevention of cervical cancer
has become possible: vaccination. To date, two vaccines have been developed -
Cervarix (Belgium) and Gardasil (USA). Cervarix is divalent, that is, it is effective
against HPV types 16 and 18; Gardasil is quadrivalent (against types 16, 18, 31
and 45). Vaccination is carried out in 3 stages and includes 3 injections with an
interval of 1 to 6 months. Effectively, this method can be used in girls who do not
lead a sexual life.
Background and precancerous processes of the endometrium

Hyperplasia of the endometrium is a benign pathology of the uterine mucosa,

which is characterized by the progression of clinical and morphological
manifestations from simple and complex hyperplasia to atypical precancerous
conditions of the endometrium and develops against the background of absolute or
relative hyperestrogenism.

  Classification according to ICD-10:

N84 Polyp of the female genital organ

N84.0 Polyp body of the uterus

endometrial polyp

N85 Other non-inflammatory lesions of the uterus, with the exception of the cervix

N85.0 Endometrial glandular hyperplasia:

cystic, glandular-cystic, polypoid

N85.1 endometrial adenomatous hyperplasia

Hyperplasia of the endometrium is atypical (adenomatous)

26
Classification of hyper proliferative processes of the endometrium (developed
by the Subcommittee on the body of the uterus of the International Society of
Gynecology Pathologists and approved by WHO, 1994):
- simple non-atypical endometrial hyperplasia
- complex non-atypical endometrial hyperplasia
- simple atypical endometrial hyperplasia
- complex atypical endometrial hyperplasia
adenocarcinoma.
Symptoms
• The endometrium has increased in volume
• Structurally different from the normal endometrium (the glands and stroma are
active, the glands are uneven, some are cystically dilated).
• There is a balance between the proliferation of glands and stroma
• Blood vessels in the stroma are evenly distributed
• * Absence of nuclear atypia

Symptoms of cell atypia

• Cellular dyspolarity
• Incorrect stratification
• Anisocytosis
• Hyperchromatism of nuclei• Increasing the number of cores
• Expansion of vacuoles
• Cytoplasmic eosinophilia
Simple (see Symptoms of simple atypical) + atypia cells
Complex (adenomatous) (see Signs of complex non-atypical) + atypia of cells:
* Atypical (with cellular atypia)
• More pronounced proliferation of glands
• Glands of structurally irregular shape
• * The balance between the proliferation of glands and stroma is disturbed
• Absence of atypia of the nuclei
27
Atypical (without cellular atypia)
Complex (adenomatous)
Simple

Clinico-morphological classification of hyperproliferative processes of the

endometrium [V. Bohman, 1985]:

1. Background processes: glandular hyperplasia, endometrial polyps.

2. Precancerous diseases: atypical hyperplasia.

3. Endometrial cancer

In the terminology of WHO (1994), in unlike to the Bohman classification (1985)

and ICD-10, the term "endometrial polyposis" is not distinguished, since it is
recommended to interpret it as the result of productive chronic endometritis, which
requires additional examination and adequate etiopathogenetic anti-inflammatory
therapy, as well as hormone therapy in these cases are determined by the features
of morphofunctional structure background endometrium.

  According to the WHO classification (2004):

- a simple atypical endometrial hyperplasia is characterized by an increase in the

number of both glandular and stromal elements is characteristic, with a slight
overweight of the former;

- the main sign of complex non-atypical hyperplasia of the endometrium is the

presence of glands widespread or focal. The glands are tightly adjacent to each
other with the loss of stroma between them. Another important feature of this type
of hyperplasia is the increased structural complexity of the glands with numerous
lateral and intraocular epithelial protrusions in the lumen of the glands and stroma.
Usually, there is a more pronounced multiplicity of epithelium in the glands than in
the case of simple hyperplasia.

The glands are tightly adjacent to each other with the loss of stroma between them.
Another important feature of this type of hyperplasia is the increased structural
complexity of the glands with numerous lateral and intraocular epithelial
28
protrusions in the lumen of the glands and stroma. There is usually a more
pronounced multiplicity of epithelium in the glands than in the case of simple
hyperplasia.

- simple atypical glandular hyperplasia of the endometrium differs from simple

and combined non-atypical hyperplasia by the presence of atypia of glandular
cells, manifested by a loss of polarity of the location and an unusual configuration
of nuclei, which often acquire a rounded shape. The nuclei of cells with this form
of hyperplasia are polymorphic, and large nucleoli are often isolated in them. This
variant of atypical hyperplasia is quite rare;

- complex atypical endometrial hyperplasia is characterized by pronounced

proliferation of the epithelial component in combination with tissue and cellular
atypia without invasion of glandular structures into the basal membrane. The
glands lose their regularity for a normal endometrium, they are very diverse in
shape and size. The epithelium lining the glands consists of large cells with
polymorphic, rounded or elongated nuclei with disturbed polarity and several rows
of their arrangement.

Examination of women with hyperproliferative endometrial processes in the

presence of clinical indications includes:

1. Bacteriological and bacterioscopy examination.

2. Hormonal examination of the pituitary-gonadal system.

3. Examination of the thyroid gland function.

4. Perform a glucose tolerance test

When interpreting histological conclusions, it is extremely important to use unified

methods of evaluation of the endometrium by clinicians and histologists using a
unified classification of its pathological conditions and evaluation of their
functional category (see Table 1).

Table1. - Functional categories of different types of hyperproliferative

endometrial processes (GLMutter et al., 2000)
29
WHO nomenclature functional category treatment
(1994)

Simple non-atypical Effect of relative or absolute Hormone therapy

hyperplasia hyperestrogenism

Complex non- atypical

Hyperplasia

Simple atypical Precancer Hormonal or surgical

hyperplasia treatment

Complex atypical
hyperplasia

Adenocarcinoma Cancer It is based on the

stage

 
Clinic
Clinical manifestations of hyperproliferative processes of the endometrium are
uterine bleeding by the type of metro- or menorrhagia, however, in 10-30% of
cases, an asymptomatic course of the disease is noted.
Diagnostics
Basic diagnostic tasks:
1. Identification of the hyperplastic process and clinical interpretation of the results
of histological examination of the endometrium.
2. Establishment of hormonal dependence of the hyperplastic process and
assessment of the features of hormonal imbalance in a particular patient.
The main method of screening and monitoring the condition of the endometrium is
ultrasound examination using a transvaginal sensor. Ultrasonography:
- endometrial thickness
- its structure;
30
- relief of the uterine cavity;
- the presence of concomitant pathology of the myometrium;
- Anatomical features of the uterine appendages
In peri- and postmenopausal patients, it is advisable to calculate the endometrial to
uterine ratio (EMF) - the ratio of the thickness of the endometrium to the anterior-
posterior size of the uterus, which allows for a faster rate of endometrial involution
compared to the myometrium.
Ultrasonic signs of various types of pathology of the endometrium are given in
Table 2.
Table 2.
Types of
pathology of Ultrasound signs

the
structure inclusion soundproof external cavity
endometrium
conductivity circuit relief

M-echo

simple heterogeneous small increased equal not

hyperplasia (+) numerous changed
echopositive

complex heterogeneous small slightly equal not

hyperplasia (++) numerous increased changed
(adenomatous) echo-
negative

polyps heterogeneous different medium or rounded deformed

(+++) densities and sharply formations of
sizes increased different
diameters

atypical heterogeneous small increased mostly unmodified

31
hyperplasia (+++) echopositive uneven, or
or echo sometimes deformed
negative there is no
division with
a
myometrium

The diagnosis of endometrial hyperplasia can be established only as a result of

histological examination.
Ultrasonic indications for taking material for the morphological study of the
endometrium
In the perimenopause and reproductive period:
An increase in the thickness of the endometrium of more than 16mm or ultrasound
signs of endometrial structure disorders
- The EMC exceeds 0.33.
In post-menopause:
Increase in endometrial thickness by more than 5 mm;
- The EMC is more than 0.15.
The main method of obtaining endometrial samples for histological examination is
diagnostic curettage of the uterine cavity, which, in
there are no contraindications, it is carried out 7 days before menstruation, its
diagnostic capabilities are significantly increased when using hysteroscopy.
The use of a hysteroscopy allows
- visualize pathological changes in the endometrium and determine their features
and localization;
- to control the quality of diagnostic curettage in order to remove possible
remnants of hyper proliferative endometrial sites or polyps with minimal injury to
healthy tissues.

32
- perform intrauterine operations with the use of electro and laser surgery.
Aspiration biopsy of the endometrium is performed using a Pipelle and is
recommended for monitoring the condition of the endometrium during hormone
therapy. Its use at the screening stage is not recommended due to the discrepancy
in the results of histological examination of endometrial samples obtained during
biopsy and curettage in 18-42% of cases.
To assess the potential of the endometrium in relation to malignancy, it is
possible to conduct an immunohistochemical study. In particular, the study of
markers such as PTEN, p53, beta-catechin, Bcl-2, COS-2, p27, p21, MLH-1, -2
and -6, survivin, p16, Ki 67, expression of estrogen and progesterone receptors
(Eralpha, ER-beta, PR).

Stages of treatment of patients with endometrial hyperplasia

Stage I - removal of the altered endometrium with subsequent morphological

examination and determination of further tactics depending on the type of
pathology of the endometrium.

Stage II - hormone therapy aimed at suppressing the endometrium.

The duration of this stage of hormone therapy is 6 months with repeated

histological examination after 3 and 6 months. With histological confirmation of
endometrial hyperplasia, treatment correction is carried out after 3 months on
hormone therapy, and in women with atypical forms of hyperplasia, the treatment
method is coordinated with an oncogynecologist.

Hormonotherapy is performed in the reproductive period, and in peri and

postmenopause - only with non-atypical forms of endometrial hyperplasia.

Groups of drugs used for hormone therapy of endometrial hyperplastic

processes

Gestagens:

-Dydrogesterone (only with non-atypical endometrial hyperplasia in the

reproductive age from 5 to 25 days at a dose of 20-30 mg per day)

33
- Medroxyprogesterone acetate (regimens and doses see table 3)

- Gestonorone caproate (regimens and doses see Table 3)

- 12.5% of 17 Hydroxyprogesterone capronate (regimens and doses see Table 3).

GnRH agonists:
- Dipherylin 3.75 mg once every 28 days, 3-6 months
- Goserelin 3.6 mg subcutaneously once in 28 days
- Buserelin 3.75 mg once every 28 days, 3-6 months;
- Buserelin nasal spray 900 mg per day daily.

Indications for the use of GnRH agonists in women with endometrial

hyperplasia:

- simple atypical EH in peri- and post-menopause;

- recurrent course of a simple atypical EH in the reproductive age after

monotherapy with gestagens;

- atypical complex EH in reproductive age and perimenopause;

- recurrent complex non-atypical EH in reproductive age;

- simple and complex atypical EH in reproductive age;

- in combination with uterine leiomyoma or adenomyosis.

The use of GnRH agonists in combination with gestagens is advisable for 3

months, and if necessary (in the absence of endometrial atrophy in the control
histological study of the endometrium after 3 months of therapy) - up to 6 months.
In case of confirmation of endometrial atrophy after 3 months further appointments
of monotherapy with gestagens for 3 more months are carried out. Agonists in
these cases are used to increase the effectiveness of conservative therapy and
prevent metabolic and psychopathological disorders as a result of prolonged use of
high doses (see Table 3) of prolonged gestagens (Gestonorone caproate,
Medroxyprogesterone, Depo-provera, 17Hydroxyprogesterone capronate).

34
III stage - optimization of the hormonal status in order to prevent the
development of hyperestrogenemia.

In the reproductive age:

- restoration of a two-phase menstrual cycle provided that the reproductive

function is necessary (see protocol for the treatment of anovulatory infertility)

the use of hormonal contraceptives with progestin that have a pronounced

antiproliferative effect on the endometrium (monophasic estrogen-progestin drugs:
ethinylestradiol (0.03 mg) - levonorgestrel (0.15 mg) ethinestradiol (0.03 mg) -
desogestrel (0.15 mg), ethinylestradiol (0.03 mg) - dienogest (2.0 mg))

- local use of gestagens (intrauterine system with levonorgestrel).

In perimenopause - menostasis using GnRH agonists (buserelin- 3 months) in

patients receiving progestogens for 6 months.

At the IV stage - dispensary observation for 5 years after effective hormone

therapy and 6 months after surgical treatment (ultrasound of the pelvic organs 2
times a year. In parallel with hormone therapy according to clinical indications,
correction of exchange-endocrine disorders, normalization of the central and
autonomic nervous systems, correction of the immune status.

If the conservative therapy is ineffective, surgical treatment is indicated. In the

case of atypical forms of GE, especially in women of reproductive age, it is
advisable to use hysteroscopic resection or ablation of the endometrium, and
atypical preference is given to a hysterectomy. However, in the reproductive age
and at any age in the presence of somatic pathology, the use of endometrial
ablation is also possible in atypical forms.

Indications for surgical treatment of patients with hyperplastic endometrial

processes:

In the reproductive age:

- complex atypical EН in the absence of the effect of conservative therapy after 3

months,
35
- simple atypical and complex non-atypical hyperplasia with ineffective therapy
after 6 months.

In the climacteric period:

- complex atypical hyperplasia - when establishing a diagnosis,

- simple atypical and complex non-atypical hyperplasia - in the absence of the

effect of conservative therapy after 3 months.

Table 3. - Schemes and regimens for the use of gestagens in the therapy of
atypical endometrial hyperplasia in women of different age groups
Age, years Drug Dosage and Duratio Performanc Dispensary
method of n, e supervision
administration months monitoring

up to 18 - 12.5% solution of 500 mg Echography not less than a

after 17- intramuscularl 6th at 3, 6, 12 year after the
coordinatio Hydroxyprogesteron y 2 times a months, stable
n of e capronate week biopsy and normalization
therapy histological of the
Depostat 200-400 mg 6th
with onco- examinatio menstrual
(gestonorone intramuscularl
gynecologi n of the cycle
capronate) y once a week
st endometriu
m after 3
months.
Depo-provera 200-400 mg 6th
Separate
(Medroxyprogestero intramuscularl
diagnostic
ne acetate) y once a week
curettage
after 6
months

19-40 years12.5% solution of 500 mg 6th Echography not less than a

36
old 17- intramuscularl at 3, 6, 12 year after the
hydroxyprogesteron y 2 times a months, stable
e capronate week biopsy and normalization
histological of the
Depostat 200-400 mg 6th
examinatio menstrual
(gestonorone intramuscularl
n of the cycle
capronate) y once a week
endometriu
m after 3
months.
Depo-Provera 200-400 mg 6th
Separate
(medroxyprogestero intramuscularl
diagnostic
ne acetate) y once a week
curettage
after 6
months.

41-50 years 12.5% solution of 500 mg 6th Echography at least 1 year

old 17- intramuscularl at 1, 3, 6, of normal
Hydroxyprogesteron y 3 times a 12 months menstrual
e caprolate week Separate cycle or 1
diagnostic year of stable
Depostat 200-400 mg 6th
curettage at postmenopau
(gestonorone intramuscularl
3 and 12 se
capronate) y 2 times a
months.
week
biopsy and
Depo-Provera 400 mg 6th histological
intramuscularl examinatio
(medroxyprogestero
y 2 times a n of the
ne acetate)
week endometriu
m after 12
37
 months.

It is impractical to expand the indications for hysterectomy in GE without prior

conservative therapy, especially in patients under the age of 49. At the same time,
it is important to emphasize the need to expand the above indications for surgical
treatment, in case of a risk of possible malignant neoplasm, individually for each
specific patient, taking into account the risk factors for endometrial cancer.

Risk factors for endometrial cancer:

- infertility in history

- obesity;

- polycystic ovary;

- diabetes mellitus, mainly of type II;

- insulin resistance;

- a family variant of neoplasia of the breast, ovaries, large intestine and body of the
uterus (Lynch Syndrome Type II).

№Mechanism of action The drug dose

and regimen

anti-stress preparations

1 - anti-stress action 1. Novopassit on 1 table. 2-3

- nootropic effect times / day

- improvement of microcirculation and metabolic 2. Tincture of motherwort for

processes in the central nervous system in order 30-50 drops before meals 3-4
to normalize the regulation in the hypothalamic- times / day
pituitary-ovary system 3. Adaptol according to 1
table. 3 times / day

4. Gidazepam according to 1

38
 table. 3 times / day

5. Valerian tincture

6.Mg B6 for 1-2 tablets. 3

times a day

Vitamins, antioxidants

2. - antioxidant action 1. Vit.B1 to 1.0 in / muscle

- normalization of relationships in the 2. Vit.B2 to 1,0 in / muscle

hypothalamus-pituitary-ovary system 3.Vit. C to 500 mg / day from
- participation in the synthesis of steroid the 1st to the 25th day of the
hormones menstrual cycle

- adaptogenic action 4.Vit. E for 200 mg / day from

the 14th to the 25th day of the
menstrual cycle

5.Vit. A 150000-200000 IU /
day from the 5th to the 25th
day of the menstrual cycle

6. Multivitamins

Venotonics

3. - improvement of microcirculation; 1. Ginkor forte for 1 caps. 2-4

- increased venous tone times / day

- improving the functioning of the drainage 2. Eskuzan 1 tab. 3 times / day

system;

- improvement of tissue hydration

Immunocorrectors, adaptogenes

4. - stimulation of cellular and humoral immunity; 1.Timalin 1.0 ml / muscle

- increase in nonspecific resistance of the number 10

39
 organism; 2. Methyluracil 500 mg 3

- increase of adaptive capabilities of the times / day

organism; 3. Imunoflum according to 1

- anti-inflammatory effect; table. 1 per day

- decrease in the production of growth factors 4. Erbisol 1 amp.

intramuscularly 10 every day

 V. The plan of organization of classes

Organizational time 2 % of study time
Motivation of the topic 3% of study time
Control of the initial level of knowledge 20% of study time
Independent work of the student 35% of study time
Control of the final level of knowledge 20% of study time
Assessment of students ' knowledge 15% of study time
The generalization of the teacher, homework 5% of teaching time

40
 VI. The main stages of classes

A. Preparatory - motivation of the topic, control of the initial level of

basic knowledge by answering each student to a question from this topic,
assignment of tasks for independent work.

B. Main-independent work of students under the supervision of a teacher.

The lesson is held in the study room. Students with a low level of knowledge study
educational literature and textbooks. The rest of the students, divided into groups
of 2-3 people, independently work on the phantom under the supervision of the
teacher, find out the technique of medical/medical abortion. After that, students
with a teacher go to the operating room or to the Department of gynecology
(depending on the presence of appropriate patients), perform a cervical
examination in the mirrors, diagnosis and determination of the term of pregnancy,
determine the method of abortion.

Final - control over learning by solving situational tasks, oral reports of

students on the work done, differential diagnosis, generalization, evaluation of
each student's work, homework.
 
VII. Methodical Support
Location of the lesson:
• Examination room of the gynecological department
• Department of Gynecology
• Operating room of the gynecological department
Equipment:
tables, figures and tools for gynecological examination, operating material.
VIII. Control questions and tasks
1. Give definition to precancerous conditions of the uterus.
2. What precancerous conditions of the cervix do you know? Their diagnosis and
treatment.
3. What are the types of endometrial hyperplasia?
41
4. List the precancerous conditions of the external genitalia.
5. Explain the pathogenetic mechanisms of the development of endometrial
hyperplastic processes.
6. What are the contraindications for using the method of laser vaporization?
7. What are the advantages of the argon-plasma ablation method?
8. What is the essence of fluid cytology?
9. Is there a cervical cancer prevention? If so, how is it used?
10.List the indications for surgical treatment of patients with endometrial
hyperplastic processes.
Reference:

Basic:

1. Intrauterine pathology: the reference book of the doctor of the

"Gynecologist": management / V.О. Beniuk, V.N. Goncharenko, Yu. V.
Kuvita [and others]; Ed. V.O.Beniuk. - Kiev: Library "Health of Ukraine",
2013. - 203 p. : Ill., Tab.
2. Family doctor's Handbook of Obstetrics and gynecology. / Edited by prof.
V. O. Beniuk. - Kyiv: "Doctor-media", 2016.- 622 p.
3. Algorithms in obstetrics and gynecology. The third edition, supplemented,
edited by prof. V.O. Beniuk. K.: "Library "Health of Ukraine". -2014.- 504
p.
4. Algorithms in obstetrics and gynecology: a reference book of a doctor / ed.
V.O. Beniuk; National Medical University. O .O. Bogomolets, Clinical
Hospital "Pheophany". - M.: Health of Ukraine, 2009. - 425 p. : And l., Tab.
5. Ambulatory-polyclinic care in gynecology: a directory of a doctor / ed. V.O.
Beniuk, V. Ya. Golotа, I.A.Useyvich; National Medical University
O.O.Bogomolets. - M.: Health of Ukraine, 2007. - 504 p.: Tab.
6. Unified clinical protocol of primary, secondary (specialized) and tertiary
(highly specialized) medical care Benign and precancerous processes of the
cervix, approved by the order of the Ministry of Health of Ukraine No. 676
42
 of 31.12.2004.
7. 7.Order of the Ministry of health of Ukraine No. 1039 "on approval of the
unified clinical protocol of primary, secondary(specialized),tertiary highly
specialized) medical care' menopausal disorders and other disorders in the
perimenopausal period ' dated 17.06.2022.

Additional literature

1. V.M. Zaporozhan, V.K. Chaika, L.B. Markin and others. Obstetrics and
Gynecology (in 4 volumes): National Textbook: edited by Professor V.M.
Zaporozhan. "Medicine". -2013. – 1032p.
2. Gynecology: a textbook / O.V. Stepankovska, M.O. Shcherbina - type 4,
exp. - K.: "Medicine", 2018. – 432 p. + + 2p. color. includes.
3. Gynecology: a textbook for doctors. Higher education institution of the IV
level of accreditation. Approved by the Ministry of Emergency Situations /
Edited by B.M. Ventskovsky, G.K. Stepankovska, V.P. Lakatosh. - K.,
2012. - 352 p.

43