The state of the endometrium in women of reproductive age against the background of combined hyperproliferative diseases of the uterus. Dubchak A., Shevchuk O., Kornatskaya A., Zadorozhnaya T., Dubenko O. State Institution «Institute of pediatrics, obstetrics and gynecology named after acad. O.M. Lukyanova NAMS of Ukraine» (Ukraine, Kyiv) The level of infertility in our country for 2021 reached 20%, i.e., approximately one in five out of 15 million couples in Ukraine cannot conceive a child in the traditional way. These are very significant and alarming indicators. We have a demographic crisis, negative population growth. The share of the uterine factor of infertility in an isolated or combined version accounts for 24–62%. Purpose of the study. To study the state of the endometrium in women of reproductive age against the background of combined hyperproliferative diseases of the uterus (HPDU). Patients. We examined 75 women of reproductive age with a combination of HPDU: adenomyosis and polyps of the uterine cavity and/or endometrial hyperplasia; adenomyosis and uterine leiomyoma; adenomyosis, uterine leiomyoma and endometrial polyps and/or endometrial hyperplasia (main group) and 47 patients without HPDU (comparison group). In the main group, 18 (24%) patients had a combination of adenomyosis and uterine leiomyoma, (1 subgroup), 25 (33.3%) women - with a combination of adenomyosis of the uterus and endometrial polyps and / or endometrial hyperplasia (2 subgroup), 17 ( 22.7%) - with a combination of uterine leiomyoma and endometrial polyps and / or endometrial hyperplasia, (subgroup 3), 15 (20%) women with a combination of uterine adenomyosis, uterine leiomyoma and endometrial polyps and / or endometrial hyperplasia, (subgroup 4). Ultrasonographic and Doppler examinations were performed using an Acuson X 300 device (Siemens, Germany) with a transvaginal probe with a scanning frequency of 9–4 Hz and a Verso device (Siemens, Germany). On days 21-24 of a 28-day menstrual cycle, hysteroscopy was performed using Karl Storz equipment (Germany) or Pipell endometrial biopsy. Hysteroscopy or Pipell biopsy of the endometrium was performed according to strict clinical indications, the main of which was the suspicion of pathology of the endometrium of the uterus or cervical canal according to ultrasound, hysterosalpingography, and menstrual irregularities. Thus, a certain “layer” of patients of reproductive age was examined, who were in the department of rehabilitation of the reproductive function of women of the SE “IPOG named after academician E.M. Lukyanova of the National Academy of Medical Sciences of Ukraine”. A morphological and immunohistochemical (IHC) study of biopsy specimens was carried out (the proliferation factor was studied - the Ki-67 protein, progesterone receptors (RR), estrogen receptors (RE). The intensity of IHC reactions to the Ki-67 protein was estimated as a percentage (number of stained nuclei per 100 cells) Immunohistochemical study was carried out using an Olimpus BX51 microscope (Japan). Main results. In 35 (46.7%) of the examined women of the main group, endometrial polyps were detected, in 28 (37.3%) patients - hyperplasia of the basal layer of the endometrium, in 16 (21.3%) - focal simple endometrial hyperplasia and in 9 (12%) ) women - endometrial atrophy. Almost 30% of the examined had a combined pathology of the endometrium. In 38 (50.7%) patients, chronic endometritis was found, confirmed by the presence of plasma cells, inflammatory infiltrates in the surface layer of the endometrium, and stromal fibrosis. In 8 (10.7%) women, plasma cells, inflammatory infiltrates and sclerosis of the spiral arteries were detected. Ki-67-positive cells in women of the main group were located mainly in the basal layer of the endometrium, localized in the cell nuclei and stained brown (fig. 1). Fig.1. Examined with combined hyperplastic diseases of the uterus. IHC reaction. Ki67 is a proliferative marker in the stroma and epithelium of the endometrial glands. Van Gieson staining. Magnification × 200. In women of the main group, the expression of Ki-67 in the cells of the glandular and integumentary epithelium was higher than the data of the comparison group (p<0.001), and there was also a tendency to increase the expression of Ki-67 in the cells of the endometrial stroma (table 1), (fig. 2) . Table 1 - Expression of the proliferation marker in the endometrium, % Group of surveyed women Indicator Кі–67 in the main group control group (27,5±2,6) * 6,5±1,5 12,8±1,3 9,4±1,4 epithelium Кі–67 in the stroma Note: * - significant difference relative to the control group (p<0.05); Fig. 2. Examined women with hyperproliferative diseases of the uterus. Expression of Ki-67 in the nuclei of stromal cells and glandular epithelium. Van Gieson staining. Magnification × 200. Type IV collagen was concentrated in the basement membranes of glandular structures and vessels, including newly formed capillary type vessels, which improved their visualization and made it possible to estimate their density per 10 fields of view (fig. 3). Fig. 3. Examined with HPDU. Expression of type IV collagen in basement membranes of glands and vessels. Van Gieson staining. Magnification × 200. IHC reactions with antibodies to steroid receptors: estrogen receptor (RE) (type a) and progesterone receptor (RP) (type A and B) were performed to assess the functional potential of the endometrium. A high expression of steroid receptors for estrogens (fig. 4) was noted in the nuclei of cells of the glandular epithelium in the examined women of the main group compared with the control. Fig.4. Examined women with HPDU. Expression of RE in the nuclei of the epithelium and stroma. IHC reaction with monoclonal antibodies. Magnification × 400. In quantitative terms, the expression of estrogen receptors was detected on average in a larger number of cells than the expression of progesterone receptors. The ratio of steroid receptors RP/RE in the epithelium of women in the main group was 0.96 and significantly differed from the values of the control group - 1.18. Thus, the presence of changes in the ratio of receptors to sex steroids indicates dysfunctional disorders of tissue reception in HPDU. Findings. Our data on the diversity of endometrial pathology in women with a combination of HPDU, which indicate a change in proliferative activity, regulation of the cell cycle and provide a basis for a more accurate choice of treatment tactics for each particular patient.
