Reproductive system of a woman in different age. Periods of a woman's life associated with reproductive function. The human reproductive system

The health of a nation is determined by the health of people of childbearing age, their ability to reproduce offspring. Having signs of a crisis, the difficult demographic situation in modern Russia is an acute problem (Message Federal Assembly President of the Russian Federation, 2006), which requires the development of effective programs to support motherhood, childhood, and families. Socio-political transformations in Russia, which began in the last quarter of the last century, caused the deformation of many cultural and spiritual values, which also affected reproduction: a decrease in reproductive health indicators, a transformation of family lifestyle, negative trends in the health status of different age groups, in different ways. manifested in various regions of the country (Khamoshina M.B., 2006; Grigorieva E.E., 2007). The implementation of the national project "Health" and the Concept of Reproductive Health of the Russian Federation will significantly change the situation, achieving not only a quantitative increase in children born, but also optimizing the health of living and future populations.

The study of the functioning of the reproductive system at different age periods of women's lives, the influence of climatic, geographical, agroecological factors on them, as well as the study of changes in the functioning of the reproductive system occurring under their influence, is a very urgent task, which involves considering in aggregate all age periods of a woman's life - from the antenatal period before menopause.

WHO adopted the Global Strategy on Reproductive Health in 2004 with a focus on professional activity and occupational health (Izmerov N.F., 2005; Starodubov V.I., 2005; Sivochalova O.V., 2005), declaring, in addition to the state of the environment and lifestyle, an essential adverse effect harmful factors of production on the reproductive function of women.

In connection with the peculiarities of the implementation of the reproductive function, the protection of the reproductive health of a woman in the Russian Federation, suffering from the adverse effects of environmental and production factors, is of particular importance (Sharapova O.V., 2003; 2006). The proportion of adolescents who have a number of combined disorders of somatic and reproductive health is increasing (Kulakov V.I., Uvarova E.V., 2005; Prilepskaya V.N., 2003; Podzolkova N.M., Glazkova O.L., 2004 ; Radzinsky V.E., 2004, 2006).

In the last 10 years, the gynecological morbidity of girls and adolescent girls has significantly increased and the age of patients has decreased, this is especially noticeable in the increase in the frequency of menstrual disorders and neuroendocrine syndromes (Serov V.N., 1978, 2004; Uvarova E.V., Kulakov V.I. ., 2005; Radzinsky V.E., 2006): by 2007, the number of "menstrual disorders" in girls increased by 31.5% and in adolescents by 56.4%. The predicted deterioration in the reproductive health of women of childbearing age in this regard determines not only the medical, but also the socio-economic urgency of the problem of optimizing the reproductive health of women.

The lack of a strategy for managing a woman from her intrauterine development to old age leads to an incorrect interpretation of the existing age-related problems of reproduction; the cause-and-effect relationships of the formation of somatic, reproductive health and quality of life in the pubertal, reproductive and menopausal periods have not been determined.

Correction of the revealed violations, based on the determination of the relationship between the body systems responsible for its reproductive function, made it possible to reimagine the pathogenesis of diseases and disorders of the reproductive system, improve its condition in different age periods, and reduce reproductive losses.

The purpose of the study: to develop and implement a set of milestone medical and recreational activities to improve and maintain reproductive health in different age periods of a woman's life in the current environmental and socio-economic conditions of southern Russia.

Research objectives:

1. to study the indicators of reproduction, reproductive and somatic health of the population of the Krasnodar Territory, depending on the agro-ecological and climate-geographic impact, psychological factors in the family and at work, and the quality of medical care.

2. to establish the features of hormonal and immune homeostasis in different age periods, depending on environmental influences up to puberty and in combination with production - in the reproductive and menopausal periods of life.

3. define age features occurrence and development of gynecological diseases and disorders, their relationship with extragenital diseases.

4. to substantiate the concept of reproductive health formation in the specific environmental and socio-economic conditions of the Krasnodar Territory, taking into account the different agro-ecological load, the state of somatic and psychological health.

5. to develop an algorithm for improving the health of patients with reproductive health disorders based on the studies and evaluate its effectiveness.

6. develop and implement a system of organizational, treatment and diagnostic measures aimed at improving the state of the reproductive system of girls, adolescent girls, women of the reproductive and menopausal periods, taking into account antenatal development, childhood and puberty, born and living in adverse conditions of agroecological impact and climatic and geographical influence of the habitat of the south of the Russian Federation.

Scientific novelty of the research.

Multifactorial mathematical analysis the influence of climatic, geographical and agroecological factors on the formation and functioning of the reproductive system, gynecological morbidity, which contributed to the clarification of the reasons for the low reproduction of the population of the Krasnodar Territory. The ideas about the pathogenesis of disorders in the reproductive system and the characteristics of gynecological diseases in different age periods of a woman's life have been expanded.

The concept of formation of reproductive health in different age periods of women's life is substantiated, taking into account the agro-ecological load, psychological health, immunological and hormonal characteristics of the body.

For the first time, a reliable relationship between the state of the reproductive system and immunological, hormonal features homeostasis depending on the presence of extragenital diseases, including metabolic disorders.

A comprehensive program for the rehabilitation of patients with disorders in the reproductive system has been developed and implemented by testing medical and diagnostic measures based on new approaches to the pathogenesis of the formation of reproductive disorders.

The practical significance of the work.

Based on the analysis, developed and implemented in Krasnodar Territory evidence-based system of measures to improve the reproductive health and reproductive potential of adolescents, women of the reproductive period for the present and future realization of their childbearing function, improve the state of somatic and gynecological health, the quality of life of women in the menopausal period.

Developed, tested and implemented on the territory of the region and the city of Krasnodar "Method for determining hormonal status disorders in women" (invention No. 2225009 dated February 27, 2004) and "Method of hormonal contraception" (invention No. 2222331 dated January 27, 2004), allowed to increase the use of COCs in the region by 69.7% and reduce the number of abortions by 63.4%, which is ahead of the rate of decline in the number of abortions in the Russian Federation by 34.8%.

An algorithm for clinical and laboratory examination of women at various ages has been developed and put into practice, including a survey methodology using specially designed questionnaires, the determination of hormonal, cytochemical and immunological parameters, which has made it possible to develop and implement a comprehensive method for the treatment of reproductive health disorders, which is based on the proposed by us complex of metabolic therapy (decision on granting a patent for the invention 2006 113715/14(014907) dated 04/21/2006).

A center for pediatric and adolescent gynecology, schools for women of the late reproductive and perimenopausal age have been created, which, along with a gynecologist, provide for the positions of a psychologist, andrologist, geneticist, dermatovenereologist, urologist and infectious disease specialist.

Implementation preventive measures and treatment and diagnostic algorithms for improving the health of women in different age periods, outside and during pregnancy, led to a decrease in perinatal mortality by

5.3%, the stillbirth rate - by 10.6%, the maternal mortality rate has stabilized (13.1/100 thousand births).

Basic provisions for defense.

1. Reproduction of the population of the Krasnodar Territory at the end of the 20th - beginning of the 21st century is characterized by a decrease in the birth rate and an increase in mortality, negative rates of natural population growth exceeding those in most territories of the Russian Federation, an earlier onset of depopulation processes than in the country ("Russian cross" - since 1990 of the year).

2. In addition to the deterioration of socio-economic living conditions, demographic indicators may be affected by reproductive health indicators that have deteriorated by the end of the 20th century (1999-2000): an increase in gynecological morbidity by 12.7% compared to 1990, menstruation disorders by 75.5%, an increase in the number of infertility in marriage by 16.9%, the incidence of absolute male infertility by 15%, diseases of the kidneys and urinary tract by 13.7%, neoplasms by 35.8%, malignant diseases of women by 17.6 %, including the mammary gland by 31.5%, the cervix and body of the uterus by 12.7%, and the ovaries by 15.2%. The frequency of diseases of the circulatory system increased by 50.7%, and diseases of the blood and blood-forming organs - by 63%, including anemia - by 80.5%, diseases of the digestive system - by 45.2%, diseases endocrine system- by 64.3%, including diabetes by 15.3%, which may be the result of the ongoing agro-ecological load on the habitat, which is 4.5-5.0 times higher than the national average, while the level of oil products content is 1.5-2.5 times higher in 15 districts and cities of the region .

3. Gynecological morbidity, which has undergone significant changes in all age groups, is characterized by: the growth of childhood gynecological diseases due to an increase in inflammatory diseases evenly in all age groups (0-14 years old by 8.7%, 15-17 years old by 27.9%, 18-45 years old by 48.5%); increase in benign ovarian tumors with age. 0-9 years only in those born to mothers with a long-term threat of miscarriage, who received various, including hormonal, drugs; Premature adrenarche in girls aged 6-8 years is highly correlated with the treatment of mothers with glucocorticoids during pregnancy. In general, girls and adolescent girls of the region are characterized by an increase in the age of menarche from 13.6 ± 1.2 years to 14.8 ± 1.5 years with a significant increase in the number of menstrual irregularities not only in the puberty, but also in the reproductive periods: 15-17 years -36% (ZPR - 15%, LPR - 21%); 18-35 years - 40%: amenorrhea - 5.7%, oligomenorrhea - 30-35%, dysmenorrhea - 23%, premenstrual tension syndrome - 17%, luteal phase insufficiency - 14%. A significant increase in diseases of inflammatory origin, uterine fibroids, adenomyosis and their combination in the late reproductive period (36-45 years) with a decrease in menstrual irregularities may be the result of improper reproductive behavior.

4. Differences in the frequency of gynecological morbidity are due to living in areas with different intensity of use of agrochemical fertilizers. Gynecological morbidity with a significant predominance of inflammatory and endocrine-determined diseases is higher in areas where the pesticide load is higher (2.0-2.5 MPC).

5. Psychological aspects of reproductive health, differentiated at different age periods of a woman's life, highly correlate with the presence of gynecological diseases and disorders: in prepuberty and puberty, low self-esteem and guilt prevailed due to delayed sexual development, late formation of secondary sexual characteristics, cosmetic defects, earlier pubarche, then in the reproductive period there is more often a feeling of guilt due to infertility in marriage, miscarriage, including the habitual one, not self-accusation prevails, but the search for reasons from the outside. After the birth of a child, these phenomena disappear, replaced by a sense of superiority over the remaining infertile "peers. A sharp deterioration in the psychological status in the menopausal period is associated with both an increase in extragenital diseases and menopausal disorders. Women who had psychological problems in pubertal and reproductive periods, almost 100% are prone to depression in menopause. .

6. Hormonal homeostasis is characterized by different from the normative secretion of prolactin in all age groups: in the prepubertal and pubertal periods, prolactin exceeds the national average by 5.7±0.3%; at the same time, in obese girls and girls it is significantly higher than with normal body weight, and in reproductive age its content is higher than the norm by 9.3 ± 0.1%, with obesity - by 13.2 ± 0.1%. In the menopausal period, prolactin levels decrease more rapidly than in the Russian Federation, at 49.2±0.3 years its level is lower by 42%, and at 55.1±0.7 years - by 61%.

7. Indicators of immune homeostasis are highly correlated with menstrual irregularities and body weight. With an increase in body weight in all age groups, a significant increase in leptin was found, most pronounced up to 18 years (3.7 times). When the menstrual cycle is disturbed, leptin decreases: its level significantly decreases in the reproductive age by 1.7 times, in the menopausal age - by 2.4 times, which correlates with the quantitative depression of the cellular link of immunity increasing with age. With increased weight in reproductive age significantly (p<0,05) повышается число МС-клеток, а в возрасте старше 46 лет происходит отмена количественных дефектов клеточного иммунитета. При нарушениях менструального цикла с возрастом снижается содержание интерлейкина-4 и увеличивается концентрация интерлейкина-1(3, а при повышении массы тела - увеличение концентрации интерлейкина-4 и тенденция к снижению интерлейкина-1Р

8. Gynecological diseases and disorders occur the earlier, the less weight girls are born. The low birth weight of daughters of mothers treated for a long time during pregnancies is noted in 72% of cases, in 78.8% it is combined with chronic and/or acute hypoxia. Immune status disorders, frequent and prolonged diseases in childhood are associated with inflammatory diseases of the genitals (12%), menstrual cycle disorders (17%), oligo- and dysmenorrhea (27%), premenstrual syndrome (19%), uterine bleeding during puberty (3%). In reproductive age, the onset of inflammatory diseases occurred at 20-24 years (70%), mainly as a result of induced abortion, IPPGT associated with frequent changes of sexual partners. In the late reproductive and menopausal periods, abnormal uterine bleeding (40-44 years), endometrial hyperplasia (47 years), uterine fibroids (40 years), endometriosis (38-42 years) and their combination (41-44 years) predominate. The combination of genital and extragenital diseases in all age groups was 1:22.5: on average, there were 2.9 diseases per woman in the reproductive period, 3.1 in the late reproductive period, and 3.9 diseases in the menopausal period.

9. The concept of RH formation in specific climatic, geographical, ecological and socio-economic conditions of the Kuban provides for the interdependence of ante- and intranatal factors, low birth weight as an integral indicator of intrauterine distress, high infectious index, aggravated heredity, high allergization, extragenital and gynecological morbidity in all age periods of life women and the possibility of correcting predicted and detected disorders using the developed algorithm of diagnostic and treatment measures.

10. The algorithm for improving the reproductive system is based on the optimization of the required medical examination of girls and women of childbearing age with the necessary volume of laboratory diagnostic methods in high-risk groups of reproductive health disorders and the traditional treatment of identified and prevention of predicted diseases. This makes it possible to reduce gynecological morbidity at the age of up to 18 years by 29%, at the age of early reproduction by 49.9%, in the late reproductive period by 35% and in the menopausal period by 27.6%.

11. The developed and implemented system of organizational and treatment and diagnostic measures makes it possible to generally improve reproductive health in various age groups: in 2004-2006, maternal mortality was consistently 2 times lower than the national average, perinatal mortality was reduced by 1.3 times, the stillbirth rate was reduced by 10 .6%, infant mortality from congenital anomalies decreased by 1.1 times, the number of infertile marriages decreased by 19.6%, the birth rate increased by 3.7%, the number of abortions decreased by 9.9%, the number of women using effective methods increased contraception by 69.7%.

Approbation of research results and publication.

The main provisions of the dissertation were reported at the Russian Scientific Forum "Maternal and Child Health Protection" (Moscow, 2005), the Republican Scientific Forums "Mother and Child" (2005, 2006), the Kuban Congresses of Obstetricians and Gynecologists (2002, 2003, 2004), the international conference "Immunology of reproduction: theoretical and clinical aspects" (2007), International conference "Therapeutic aspects of modern hormonal contraception" (2002), congresses of obstetricians and gynecologists of the North Caucasus (1994, 1998) and European congresses on contraception (Prague, 1998; Ljubljana, 2000 ; Istanbul, 2006),

The results of the study are presented in 41 publications, including 11 publications in journals recommended by the Higher Attestation Commission of the Russian Federation; methodological manual for doctors "Algorithm for prescribing hormonal contraceptives" (Regional Department of Health), monograph "Reproductive health of residents of the Krasnodar Territory: ways to improve it" (2007).

Implementation of the research results.

The results are implemented in the work of: the Department of Health of the Krasnodar Territory (department of assistance to mothers and children), Regional Clinical Hospital No. 1; Regional Perinatal Center, Regional Family Planning Center, City Multidisciplinary Hospital No. 2 of Krasnodar, as well as in antenatal clinics, obstetric and gynecological hospitals in Krasnodar and the Krasnodar Territory. The developed complex is used in the work of endocrinologists, neurologists dealing with reproductive health problems. The obtained data are used in the educational process at the Department of FPC and teaching staff of KSMU for training obstetrician-gynecologists, general practitioners, clinical interns and residents, as well as at the Department of Obstetrics, Gynecology and Perinatology of KSMU.

A short-term training program on topical issues of reproductive medicine was developed, tested and introduced into the educational process of the departments of obstetrics and gynecology of KSMU, including issues of a systematic approach, management of patients with disorders in different age periods, as well as infertility and miscarriage.

The structure and scope of the dissertation.

The dissertation consists of an introduction, an analytical review of the literature, a description of the program, research materials and methods, four chapters of the materials of our own research, justification and evaluation of the effectiveness of the measures taken, a discussion of the results,

1. Reproduction of the population of the Krasnodar Territory at the end of the 20th and beginning of the 21st century has unidirectional trends with the country as a whole, significantly differing in the earlier onset of depopulation processes (the “Russian cross” is implemented in 1990) and significantly higher rates of natural population decline, which is determined by climatic and geographical features region, exorbitant agrochemical load in most of the territory of the region, the consumption of food and water containing toxicants.

2. The deterioration of RD is due to the constantly increasing gynecological morbidity in all age periods of life: the total figures are 12.4% up to 18 years, 45.8% are at the age of 18-45 years, over 45 years - 41.8%.

3. The "peak" of gynecological morbidity at the age of 0-18 years falls on the age of 15.4±1.2 years, 18-45 years - 35.2±1.1 years, over 45 years - 49.7±0.8 years.

4. The somatic health of the female population is characterized by a significant excess of statistical indicators for the Russian Federation: diseases of the cardiovascular system - by 4.7%;, respiratory diseases - by 11.3%, diseases of the gastrointestinal tract - by 17.6%, endocrine pathology - by 5.9%, diseases of the mammary glands by 3.7%.

5. Infertile marriage, the frequency of which increases from 13.7% in 2000 to 17.9% in 2006, is an integral indicator of reproductive distress in the region, due not only to socio-economic, agroecological, climatic and geographical impact on the habitat, but also psychological changes in personality, family, society, most pronounced in girls with gynecological diseases and disorders and in women in barren marriages.

6. Gynecological morbidity in girls and adolescent girls is highly directly correlated with frequent and prolonged treatment of the threat of miscarriage in their mothers, mainly with preparations of corpus luteum hormones (low weight - 3.9%, macrosomia - 12.9%, adrenarche 24.2% ). The influence of chronic hypoxia during pregnancy and/or acute hypoxia during childbirth on the development of MS, in particular ZPR, should be considered proven. The same contingents are characterized by a decrease in the immune status, an increase in infectious (ARVI, chickenpox, scarlet fever) and somatic morbidity of allergic and endocrine origin.

7. Endocrine-determined diseases, tending to increase, in women of reproductive age reached values ​​comparable to inflammatory diseases: 29.4% and 32.1%. Dominant in the structure of gynecological morbidity are fibroids, adenomyosis, their combination, MC disorders, abnormal uterine bleeding with corresponding age peaks. The predominance of inflammatory diseases in the age group of 20-24 years is associated with the abortion of the first pregnancy, frequent change of sexual partners and high prevalence of SIS.

8. The peculiarities of the menopausal period in Kuban women should be considered its earlier onset (47.6±1.5 years), manifested by psychological (37.8±2.6 years), vegetative-vascular (38.5±3.4 years) and urogenital (41 .7 ± 2.4 years) disorders. Significantly more frequent somatic morbidity (2-2.5 per 1 woman), on average, 1 woman accounts for 3.1 diseases in the reproductive and 3.9 in the menopausal periods.

9. Features of hormonal homeostasis of all women with endocrine-related diseases of the genital organs are changes in prolactin excretion: increased up to 45 years (pubertal and reproductive) and reduced in the menopausal period. In all age periods, the level of prolactin excretion correlates with the excretion of cortisol, testosterone, 17-OP. Significant differences in the interaction of these hormones in women with and without obesity (p<0,05).

10. Hormonal effects are metabolically realized through leptin and cytokines, especially altered in obesity in the reproductive and perimenopausal periods: leptin increases 3.7 times, interleukins - 1.7-2.1 times.

11. Disturbed relationships of endocrine-metabolic regulation of homeostasis are transformed into severe immune deficiency (the level of interleukins decreases by 7.9%, lymphocytes - by 5.1%, leukocytes - by 1.2%, the content of immunocompetent lymphocytes changes in almost all gynecological diseases, which, perhaps, explains the high incidence of chickenpox in women with MC disorders in the reproductive period of life.

12. The concept of RH formation in the specific environmental, climatic and geographical conditions of the Kuban is based on the idea of ​​the interdependence of the causal determinants of heredity identified by this study, the drug load on the body of the mother of the future girl, leading to an increase in gynecological morbidity in childhood and adolescence, combined with it somatic and infectious diseases of immunocompromised children and adolescents, an almost twofold excess of the total incidence in reproductive age and one and a half times in menopausal. In combination with the agrochemical load, increased insolation, the harmful effects of industrial production, a decrease in material well-being in families and psychological changes in attitudes towards reproduction in society, the problem of the reproductive health of women in the Krasnodar Territory can be considered as an interdisciplinary multifactorial problem that requires urgent measures by government authorities, changes in organizational fundamentals of medical care for women of all age groups, social interaction of educational, humanitarian and religious organizations.

13. The system of organizational and treatment and diagnostic measures developed on the basis of this concept, based on the priority use of methods for optimizing medical care to improve the condition of the reproductive system of girls, adolescent girls, women of fertile and menopausal ages, using modern technologies for diagnosing and treating reproductive disorders, creating new structural and functional institutions (adolescent health center) with simultaneous treatment of gynecological, andrological, somatic, urological diseases and psychological rehabilitation, identification of risk groups and extended laboratory studies of homeostasis in risk groups of reproductive disorders, including a rational contraceptive policy, made it possible to reduce the rate of maternal mortality, improve perinatal indicators, reduce the incidence of children under 18 years old by 6.8%, 18-45 years old - by 10.2%), 46 years and older - by 4.9%. I I

1. Clinical examination of girls in a children's clinic should be carried out with the participation of a pediatric gynecologist, especially in risk groups for violations of the formation of the reproductive system: children from mothers treated for a long time during pregnancy, with an increased drug load.

2. A prognostic and early diagnostic criterion for the state of the reproductive system is the combined determination of the excretion of prolactin, 17-OP, testosterone. Their abnormal values ​​should provide for an in-depth study of the excretion of leptin, interleukins and the determination of the immune status. First of all, girls who already have metabolic changes in areas with unfavorable agro-ecological conditions and the harmful influence of other production factors are subject to in-depth examination. It is advisable to conduct a continuous staged clinical examination of girls, adolescent girls, women of childbearing age for timely prediction, detection and treatment of disorders of RH and gynecological morbidity.

3. A further reduction in the number of abortions, especially during the first pregnancy, is possible only with the joint participation in the education of adolescents of education workers (secondary schools, vocational schools), health care (territorial antenatal clinics, youth centers), public and religious organizations.

4. Staged clinical examination of women of childbearing age can be effective only with a full comprehensive examination of girls at the age of 18 when she moves from the stage of a children's polyclinic (pediatric gynecologist) to an adult network - a territorial polyclinic and antenatal clinic. Further medical examination, the scope of examination and treatment should be determined by the state of somatic and reproductive health, the presence of harmful environmental factors and the psychological status of patients.

5. Treatment of gynecological diseases, timely carried out by traditional methods, allows to achieve a cure for uterine fibroids - absolute with surgery and up to 60% with conservative methods of treatment, inflammatory diseases of the genitals in 31.4%, MC disorders in groups under 18 years of age in 49.9% , in the reproductive period - in 39.8%>, in the perimenopausal period - in 27.6%.

6. Infertile marriage, diagnosed in a timely manner with proper examination and the use of assisted reproductive technologies, makes it possible to achieve the birth of the desired child in almost 85% of cases, including tubal pregnancy - 32.7%, ovarian - 16.8%, male infertility - 21, 7%, with insemination - in 9.6% and IVF - in 19.2%.

7. An increase in the number and severity of diseases of the reproductive system of menopausal age provides for the timely recovery of women in late reproductive age, in relation to the conditions of the Kuban at 39-43 years old - “peak gynecological morbidity”: tumors of the uterus and ovaries - 39.7 years, endometriosis - 40, 3 years, cervical erosion - 42.3 years.

8. HRT for menopausal disorders, based on the conscious choice of the method by the patient herself, lasting 3-5 years, including in somatically burdened women with individual selection of the drug, taking into account the route of administration, allows leveling the psychological problems of menopause in 70%, urogenital - in 87% , vegetative-vascular - in 80%, metabolic-endocrine - in 17%, there is no significant increase in DMZH and diseases of the circulatory system and gastrointestinal tract. The increase in prolactin that occurred before menopause is leveled by the appointment of dopaminergic phytopreparations.

Staged clinical examination of girls, adolescent girls, women of fertile and menopausal age, taking into account socio-economic, environmental, psychological factors of life, carried out by the joint activities of doctors of various specialties, can reduce the incidence: up to 18 years in general by 49.9%, 18- 35 years old - by 39.9%, 36-45 years old - by 31.6%, 46 years and older - by 27.7%.

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