RU2571291C1 - Diagnostic technique for early stages of external genital endometriosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: female's blood serum is examined to measure sex hormone binding globulin (SHBG) and apolipoprotein A-IV to be related thereafter; if the derived relation falls within the range of 1.9-2.3, stage I external genital endometriosis is diagnosed, whereas the relation ranged within 2.4-2.7 shows stage II external genital endometriosis.

EFFECT: method enables increasing the diagnostic accuracy and specificity in the early stages of external genital endometriosis.

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Description

The invention relates to medicine, namely to gynecology, and will find wide application for the objective diagnosis of the early stages of external genital endometriosis.

External genital endometriosis is one of the most common diseases of women of reproductive age, often suffering from infertility (Ischenko A.I., Kudrina E.A. Endometriosis: diagnosis and treatment. - M .: GEOTAR-MED, 2002. - 104 p .; Adamyan L.V., Kulakov V.I., Andreeva E.N. Endometrioses: A Guide for Doctors. - M .: Medicine, 2006. - 416 p .; Linde V.A., Tatarova N.A. Endometrioses. - M .: GEOTAR-Medicine, 2010 .-- 192 p.). The disease firmly holds the second place in the structure of gynecological pathology, and in recent years its frequency continues to increase. However, despite many years of research, the pathogenesis of endometriosis has not been fully established, which complicates its timely evidence-based diagnosis necessary to increase the effectiveness of treatment (Seli E., Berkkanoglu M., Arici A. Pathogenesis of endometriosis. Obstet Gynecol Clin North Am. 2003 ; 30 (1): 41-61.).

The diagnostic capabilities of external genital endometriosis are largely determined by the severity and stage of the disease. Especially difficult and at the same time extremely important is the diagnosis of its early stages. This is confirmed by the fact that almost 90% of women with endometriosis, until a true diagnosis is made from 1 year to 7 years, are observed with a diagnosis of chronic salpingoophoritis (Bespalova Zh.V., Volkov NI, Kulakov V.I. Early diagnosis of genital endometriosis in women with infertility. Journal of Obstetrics and Women's Diseases, 2004. - No. 2. P.11-15). The diagnosis of endometriosis with confidence can only be made on the basis of an invasive instrumental examination (laparoscopy or laparotomy), followed by histological examination of biopsy specimens. However, in these cases, the frequency of histological confirmation of the diagnosis ranges from 70 to 85% and the early stages of endometriosis are often not clinically diagnosed (Baskakov V.P., Tsvelev Yu.V., Kira E.F. Endometrioid disease. - St. Petersburg: Publishing House LLC NL. ”2002. - 452 p.).

Among the methods for diagnosing external genital endometriosis known in the medical and patent literature, the following can be noted.

RF patent No. 2164687 (03/27/2001) proposes a method for diagnosing external genital endometriosis by examining peripheral blood, characterized in that the blood determines the spontaneous HCT activity of neutrophils after their incubation with PAMG-2 and when its rates are 24% or more, the external is diagnosed genital endometriosis.

The disadvantages of this method include: the absence of indications of the staged process, the calculation of the diagnostic indicator is carried out using light microscopy, which is a very subjective assessment method; use in the reaction of PAMG-2, which does not have a certificate and is not one of the chemicals included in the "Register of new medical devices authorized for use by the Ministry of Health of the Russian Federation."

A known method for diagnosing the severity of external genital endometriosis (RF patent No. 22199548, 12/20/2003) by spectrophotometric determination of the level of medium-weight molecules in a peritoneal fluid and at a wavelength of 280 nm and extinction indices in the range of 0.100-0.210 e.p. diagnoses external genital endometriosis Stage I; 0.211-0.310 e.p. - external genital endometriosis of the II stage; 0.311-0.526 e.o.s. - external genital endometriosis of the III stage; 0.527-0.726 e.o.s. - external genital endometriosis of the IV stage. The disadvantage of this method is its invasiveness (taking peritoneal fluid); nonspecificity (a change in the level of medium-weight molecules as a marker of endogenous intoxication occurs in various pathological and even functional states of the body). (Encyclopedia of clinical laboratory tests. Edited by N. Titsa. - M.: Publishing House "Labinform", - 1997. - 960 p.); insufficient sensitivity (measurement of the determined products in relative optical density values, and not in absolute units, reduces the accuracy of the method).

There is a method for diagnosing the stage of external genital endometriosis (RF patent No. 2242002, 10.12.2004) by examining blood serum, characterized in that the content of ά2-macroglobulin is determined and at its level from 600.0 mg / dl and higher, stage 1 is diagnosed, with the value from 599.0 to 480.0 mg / dl - stage II endometriosis, from 479.0 to 360.0 mg / dl - stage III endometriosis and from 359.0 mg / dl - stage IV endometriosis. The disadvantages of this method are low specificity, since a change in the content of α2-macroglobulin in blood serum can be a reflection of inflammatory processes not only in reproductive tissues, but also in any other organ (liver, pancreas, gastrointestinal tract) (Encyclopedia of clinical laboratory tests. Edited by N. Titsa, Moscow: Labinform Publishing House, - 1997. - 960 pp., Ivanova OM, Value of α2-macroglobulin in the pathogenesis of coronary heart disease. - Bulletin of new medical technologies. - 2008. - No. 4. - S. 109-112; Zorina V.N . and others. The role of alpha-2-macroglobulin in the pathogenesis of rheumatoid arthritis and systemic lupus erythematosus. - Bulletin of Siberian medicine. - 2010. - No. 5. - S. 39-44). The sensitivity and reliability of the method are not indicated.

There is also a drawback to the method of early diagnosis of external genital endometriosis in women by examining an endometrial biopsy (RF patent No. 2247391, February 27, 2005), characterized in that the cathepsin D activity is determined in a tissue sample and at its value of 0.1 Units. farm.act / h and less diagnose external genital endometriosis. The method is invasive (taking ZAG endometrium), characterized by limited information content (using one enzyme only from the group of acidic lysosomal endopeptidases without taking into account neutral exopeptidases), insufficient accuracy and specificity. Extremely low relative values of the reaction products (tenths and hundredths of a unit) indicate a weak sensitivity of the method.

A known method for the diagnosis of external genital endometriosis in women with infertility (RF patent No. 2291439, 01/10/2007) by examining peripheral venous blood, characterized in that the blood determines the relative number of CD16 + monocytes in a monocytic gate and with values of this indicator equal to or less than 45 %, external genital endometriosis is diagnosed. This method, as well as the previous one, is characterized by the absence of an indication of the staged process, which reduces its diagnostic value. In addition, the method has limited capabilities and is recommended for use only in infertility.

A known method for the diagnosis of genital endometriosis (RF patent No. 2363000, July 27, 2009), including the study of blood serum and peritoneal fluid, characterized in that in the obtained samples the enzyme-linked immunosorbent method determines the content of vascular endothelial growth factor (VEGF) and if the ratio of the content of VEGF in serum to the content of VEGF in the peritoneal fluid exceeds a value of 4.35, diagnosed with external genital endometriosis.

The disadvantages of the method include its invasiveness (study of peritoneal fluid), as well as insufficient specificity, since angiogenic VEGF plays a very important role not only in local processes of angiogenesis in the endometrium, but also at the systemic level in a woman’s body (Manukhina E.I., Gevorkyan M. .A., Manukhin IB, Studenaya LB Clinical significance of vascular endothelial growth factor in patients with polycystic ovary syndrome. - Attending physician. - 2011. - No. 3 - P. 55-57; Costa N., Paramanathan S., Mac Donald D., Wierzbicki AS, Hampson G. Factors regulating circulating vascular endothelial growth factor (VEGF): association with bone mineral density (BMD) in post-menopausal osteoporosis. - Cytokine. - 2009. - Vol. 46, N 3. - P. 376-381; Thielemann A., Baszczuk A., Kopczynski Z., Kopczynski P., Grodecka-Gazdecka S. Clinical usefulness of assessing VEGF and soluble receptors sVEGFR-1 and sVEGFR-2 in women with breast cancer. Ann Agric Environ Med. 2013. - Vol. 20, N 2. - P . 293-297).

The prototype of the claimed invention selected a method for the diagnosis of external genital endometriosis (RF patent No. 2211454, 08/27/2003) in women by examining biological material, characterized in that the concentration of interferon-γ is determined in a sample of peripheral venous blood serum and when its content is 1000 pcg / ml or less, external genital endometriosis is diagnosed.

This method, like the previous ones, has several disadvantages:

- the inability to determine the stage of the disease;

- insufficient specificity of the method, since the content of interferon-γ in the blood varies depending on many endogenous and exogenous factors: stress, the presence of autoimmune diseases, viral infections, immunodeficiency states and even periodontal inflammation, which occurs in so many people (Recent advances in Clinical Immunology. Edited by R.A. Thompson, M .: Medicine, 1983. - 199 p .; Ershov F.I. The interferon system in norm and pathology. - M .: Medicine, 1996. - 240 p.) ;

- insufficiently high accuracy (77%).

These disadvantages are proposed to eliminate in the present method.

The objective of the invention is to develop a highly informative method that allows you to diagnose the early stages of external genital endometriosis.

The problem is solved as follows: in the blood serum of a woman, the content of sex hormone-binding globulin (SHBG) and apolipoprotein A-IV are determined, their ratio is calculated, and when it is in the range of 1.9-2.3, stage I of external genital endometriosis is diagnosed, and with a value of 2.4-2.7 - II stage of external genital endometriosis.

The technical result obtained during the use of the invention consists in increasing the accuracy and specificity of the method for diagnosing the early stages of external genital endometriosis, which will allow timely appropriate appropriate pathogenetic therapy.

The novelty of the proposed method lies in the fact that for the first time it is proposed to diagnose the early stages of external genital endometriosis by a single determination in the blood serum of a woman of the content of SHBG and apolipoprotein A-IV. In a complex chain of disorders leading to the development of endometriosis, changes in the expression of proteins that are modulators of many biological processes in endometrial cells and endometrioid heteropathy cells can be important.

A significant role in maintaining the functional state of the endometrium is played by proteins associated with the regulation of the action of sex steroids necessary to ensure almost all metabolic processes in the uterus. They participate in the modification of proliferation, angiogenesis, stimulation of the secretion of many growth factors, etc. These proteins include SHBG, the main function of which is the transport of steroid hormones (estrogens and androgens) and the regulation of their bioavailability for target tissues (Hammond GL Diverse roles for sex hormone-binding globulin in reproduction. Biol Reprod. 2011; 85 (3): 431-441.). The role of SHBG as an activator of the adenylate cyclase system, a mediator in the realization of hormonal effects, is also known. (Kahn S.M., Hryb D.J., Nakhia A.M. et al. Sex hormone-binding globulin is synthesized in target cells. J Endocrinol. 2002; 175 (1): 113-120.). A change in SHBG production can lead to an imbalance between free and bound estrogens, and its hypersecretion protects estrogens from catabolism and increases their accessibility to endometrial cells, including those located outside the uterine cavity, which contributes to the development of endometriosis (Misao R., Hori M., Ichigo S. et al. Levels of sex hormone-binding globulin (SHBG) and corticosteroid-binding globulin (CBG) messenger ribonucleic acid (mRNAs) in ovarian endometriosis. Reprod Nutr Dev. 1995; 35 (2): 155-165.) .

On the other hand, in these processes, an important role is played by proteins associated with maintaining a certain level of the starting components for the synthesis of steroid hormones, in particular cholesterol. The production and transport of the latter are affected by enzymes involved in the metabolism of lipoproteins. A powerful activator of the enzyme lecithin cholesterol acyltransferase is apolipoprotein A-IV, an increase in the level of which promotes the development of hypercholesterolemia (Spaulding HL, Delvin E., Lambert M. et al. Apo A-IV: an update on regulation and physiologic functions. Biochim Biophys Acta. 2003; 1631 (2): 177-187.).

The simultaneous determination of two of the above proteins in the blood serum increases the accuracy and specificity of the method and makes it possible to more objectively judge the creation of conditions for the formation of hyperestrogenia, which plays a key role in the development of endometriosis.

We have established diagnostic parameters for the development of early stages of external genital endometriosis by determining the ratio in the blood serum of SHBG / apolipoprotein A-IV, with a value in the range of 1.9-2.3, stage I of external genital endometriosis is diagnosed, and with a value of 2.4-2 , 7 - II stage of external genital endometriosis.

A detailed description of the method and examples of its clinical implementation

The method is as follows. In the blood serum taken from the cubital vein of women with suspected external genital endometriosis (dysmenorrhea, pelvic pain, dyspareunia, infertility, menorrhagia), the content of SHBG (in nmol / L) and apolipoprotein A-IV (in nmol / L) are determined ) by the enzyme immunoassay with the Alkor-Bio (Russia) and Cloud-Clone Corp. (Latvia) kits in accordance with the protocols of the developers on the Sunrise Tecan analyzer (Austria). Calculation of estimated values is carried out according to calibration curves.

The SHBG / apolipoprotein A-IV ratio is calculated, with a value in the range of 1.9-2.3, stage I of external genital endometriosis is diagnosed, and with a value of 2.4-2.7, stage II of external genital endometriosis is diagnosed, which allows differential tactics management of patients with endometriosis.

The performance of the proposed method is confirmed by the following clinical examples.

Example 1

Patient P-ko M.V., 27 years old, was admitted to the hospital of FSBI RNIIAP complaining about the absence of pregnancy for 2 years. From the anamnesis of life it is known that menstruation from 13 years to 3-4 days, after 28 days, painless; married 2 years, spouse 28 years, during 2 years with regular sexual life, pregnancy does not occur; endocrine and male infertility factors are excluded. Given the lack of data for the apparent cause of infertility, a suspicion of chronic bilateral salpingitis, the patient is recommended and a subsequent diagnostic laparoscopy is performed. Before surgical intervention in the blood serum of a woman, the content of SHBG and apolipoprotein A-IV was determined (the concentration of SHBG was 62.17 nmol / L, apolipoprotein A-IV was 34.23 nmol / L) and their ratio was calculated, which amounted to 1.8, that according to the claimed method testified to the absence of external genital endometriosis. During the operation during chromohydrotubation, the indigo carmine solution penetrated the tube and poured into the abdominal cavity in the 2nd minute, the fallopian tubes are edematous, hyperemic. When hysteroscopy revealed chronic endometritis, which is confirmed by histology No. 17191-92: endometrial layers in the proliferation stage, mild signs of chronic endometritis. Diagnosed with Chronic bilateral salpingitis. Chronic endometritis Secondary infertility

Thus, the diagnosis of the claimed method was confirmed.

Example 2

Patient M-ah A.A .;, 18 years old, was admitted to the hospital of the FSBI RNIIAP complaining of pain in the lower abdomen over the past 6 months. Given the data of a bimanual examination - in the area of the left appendages, a tight-elastic formation with a diameter of up to 6 cm is palpable, painful; history data - the left ovarian cyst was first discovered in July 2012, a course of anti-inflammatory and hormonal therapy (no effect) was carried out, a preliminary diagnosis was made: Cyst of the left ovary. It was decided to perform laparoscopy, cystectomy of the left ovary. In the preoperative period, when performing blood tests in a patient, the content of SHBG and apolipoprotein A-IV were studied, which amounted to 67.79 nmol / L and 35.68 nmol / L, respectively. The ratio of these indicators was 1.9, which corresponds to the claimed method of stage I of external genital endometriosis. During the operation, superficial foci of endometriosis up to 0.5 cm in diameter, a cyst of the left ovary with transparent contents and a dense capsule of 6.0 × 5.5 cm were revealed in the posterior uterine space, a biopsy of the foci of endometriosis was performed. In histoanalysis No. 14089-100: in the biopsy specimen of the peritoneum, coarse fibrous tissue with a diffuse arrangement of endometrioid glandular cells. Diagnosed with cyst of the left ovary. External genital endometriosis stage I. Retrocervical endometriosis.

Thus, the diagnosis of the claimed method was confirmed.

Example 3

Patient S-va O.V., 29 years old, was admitted to the hospital of FSBI RNIIAP complaining of the absence of pregnancy for 3 years. From the anamnesis of life it is known that menstruation from 14 years, 6 days, after 30 days, painful, heavy; inflammatory, endocrine and male factors of infertility are excluded; with metrosalpingography - fallopian tubes are passable on both sides, contrast in the abdominal cavity; post-coital test is positive, ovulation test is positive. Spouse 34 years old, normozoospermia. Suspicion of external genital endometriosis, recommended diagnostic laparoscopy. During preoperative preparation in the serum of the cut, the protein content was studied, which amounted to 95.04 nmol / L for SHBG and 39.6 nmol / L for apolipoprotein A-IV. The ratio between them is 2.4, which corresponds to stage II of external genital endometriosis by the present method. During the operation, superficial foci of endometriosis with a diameter of up to 0.5 cm were revealed at the lower poles of both ovaries, in the posterior uterine space and on the sacro-uterine ligaments, in the plica vesicouterina (anterior uterine space) left and right multiple surface foci of endometriosis are also up to 0.5 cm in diameter. Diagnosed with External genital endometriosis stage II. Retrocervical endometriosis.

Thus, the diagnosis of the claimed method was confirmed.

Example 4

Patient Peninsula M.M., 28 years old, was admitted to the hospital of the Federal State Budgetary Institution RNIIAP complaining of a lack of pregnancy for 3 years, pain during sexual intercourse. From the anamnesis of life it is known that menstruation from 12 years, 5 days, after 27 days, painful, moderate; inflammatory, endocrine and male factors of infertility are excluded; In June 2012, metrosalpingography was performed - fallopian tubes are passable from both sides. She is 32 years old, normospermia. Suspicion of external genital endometriosis, recommended diagnostic laparoscopy. Before surgery, the content of SHBG and apolipoprotein A-IV was determined in the blood serum of a woman, which amounted to 118.21 nmol / L and 41.8 nmol / L, respectively. The ratio of these indicators is 2.8, which according to the claimed method indicates a later stage of external genital endometriosis. During the operation, deep foci of endometriosis with a diameter of up to 1.5-2 cm were revealed at the lower pole of the right ovary, in the posterior uterine space and on the sacro-uterine ligaments. Diagnosed with External genital endometriosis stage III. Retrocervical endometriosis.

Thus, the diagnosis of the claimed method was confirmed.

According to the claimed method, we examined 92 women in whom the content of SHBG and apolipoprotein A-IV were determined in the blood serum and the ratio of these proteins was calculated. Of the examined patients, 52, the ratio of SHBG to apolipoprotein A-IV was 1.9-2.7, which indicated the presence of external genital endometriosis of the early stages. Of these, in 21, the studied indicator was 1.9–2.3 and the external genital endometriosis of stage I was histologically confirmed (a truly positive result). Only one woman from this group this diagnosis was not histologically confirmed (false-positive result). In 30 women with a studied ratio of 2.4-2.7, stage II of external genital endometriosis was revealed. There was no false negative result in all women with external genital endometriosis. In 40 women with a ratio of 1.8 or lower, histological analysis did not show the presence of external genital endometriosis in patients.

From the above data it follows that the accuracy and specificity of the method is 98%.

The above confirms the prognostic value of the proposed method.

Thus, the claimed method is more efficient compared to the known and has several advantages:

1. High accuracy - 98%, specificity - 98%.

2. Non-invasiveness.

3. Diagnosis of the early (I and II) stages of external genital endometriosis.

4. Does not require special expensive equipment.

5. The one-time study.

The inventive method allows to diagnose external genital endometriosis in the early stages of the disease and can be recommended for use in gynecological practice.

Claims (1)

A method for the diagnosis of the early stages of external genital endometriosis by a blood test, characterized in that the blood serum of women determines the content of sex hormone-binding globulin and apolipoprotein A-IV, their ratio is calculated, and when it is 1.9-2.3, stage I is diagnosed external genital endometriosis, and with its size 2.4-2.7 - stage II of external genital endometriosis.