Correction of functional disorders of the state of the reproductive system taking into account the function of the thyroid gland in different age periods.
Kharkiv National Medical University Department of Obstetrics, Gynecology and Pediatric Gynecology.
Authors: I.A. Tuchkina‚ E.V. Blagovishchenskyi, O.V. Piontkovska‚ L.A. Vyhovska‚ T.V. Rubinska
The formation and development of the reproductive function (RF) in puberty, its restoration in women of childbearing age, ensuring the normal course of the climacteric period do not lose their relevance, since the urgent problems of modern obstetrics and gynecology include ensuring the normal functioning of the reproductive system in various periods of a woman's life. This is due to the high frequency of obstetric and gynecological pathology, which has remained high in recent decades and has no tendency to decrease [1].
The reproductive system (RS) of a woman is a set of interconnected structural elements: the hypothalamus, pituitary gland, ovaries, target organs and other endocrine glands that ensure the implementation of the generative function. The most important part of the neuroendocrine system, which significantly affects RF, is the thyroid gland (TSH) [2].
The close connection of the hypothalamic-pituitary-ovarian and hypothalamic-pituitary-thyroid systems is carried out due to the presence of common central regulation mechanisms. The function of the reproductive and thyroid systems is regulated by the tropic hormones of the anterior lobe of the pituitary gland (luteinizing hormone - LH, follicle-stimulating hormone - FSH, prolactin PRL, thyroid-stimulating hormone - TSH), which in turn are under the control of the hypothalamus. Thyrotropin-releasing hormone (TRH, thyroliberin) of the hypothalamus is a stimulator not only of TSH, but also of PRL of the pituitary gland, therefore, dysfunction of the pituitary-thyroid system leads to changes not only of gonadotropins, but also of PRL.
Thyroid pathology can be the cause of reproductive disorders (SDR), such as premature or late puberty, menstrual disorders (NMF), - amenorrhea (AM), dysfunctional bleeding (DMK), including pubertal (PMK) and climacteric, anovulation , infertility, galactorrhea, miscarriage, pathology of the fetus and newborn [Z]. In turn, the state of the reproductive system significantly affects the function of the thyroid gland. This is confirmed by a change in thyroid function during pregnancy and lactation in patients with benign tumors and hyperplastic processes of the female genital organs [4,5]. Currently, it has been proven that estrogens have a pronounced stimulating effect on the thyroid gland, increase the sensitivity of pituitary thyrotrophs to tyroliberin. Therefore, increased production of estrogens can lead to an increase in the activity of thyrotrophs, which leads to an increase in the activity of the thyroid gland [3, b, 7]. On the contrary, in conditions of prolonged hypoestrogeny, the sensitivity of thyrotrophs to tyroliberin decreases, which can be considered as one of the possible mechanisms for the development of secondary hypothyroidism in patients with hypoestrogenic conditions (NPR and NMF in puberty, hypogonadotropic amenorrhea, resistant ovary syndrome, exhaustion syndrome, and surgical menopause) [8 , 9, 10].
Experimental work conducted in recent decades has provided evidence of the presence of receptors for thyroid-stimulating hormone (TSH) and triiodothyronine (T3) in the ovary and thus the direct influence of thyroid dysfunction on steroidogenesis and oocyte maturation [11]. At the cellular level, thyroid hormones act unidirectionally with FSH, exerting a direct stimulating effect on the functions of granulosa cells, including their morphological differentiation; stimulate the secretion of progesterone and estradiol by the corpus luteum; affect the ability of oocytes to fertilize, the quality and viability of embryos [12, 13]. Thus, MS dysfunction may be a consequence of inadequate functioning of thyroid hormones at the level of the ovaries.
Adequate functioning of the thyroid gland depends on a balanced intake of essential micronutrients (vitamins, trace elements, minerals, fatty acids and essential amino acids). One of the typical examples of micronutrient deficiency is iodine deficiency, which manifests itself in a wide range of disorders, from the deficiency of thyroid hormones in the fetus and child, which leads to an irreversible decrease in mental development, up to cretinism, hearing pathology, visual memory, speech, speech. , which are expressed in an increase in the number of miscarriages and stillbirths.
Research conducted in our country under the leadership of the Ministry of Health showed that there is a moderate iodine deficiency in almost all of its territory, and a third of the population of Ukraine lives in goitre-endemic regions. Over the past 5 years in the country, the number of children with pathology caused by iodine deficiency has increased 3.5 times, and in adult women, thyroid dysfunction is the most common condition in endocrinology. It should be taken into account that dietary correction and prevention of thyroid disorders during puberty, in the active reproductive and climacteric age of a woman may not meet the needs of micronutrients, therefore, medication correction and prevention is necessary, which would fully compensate for the high needs of the female body. . In connection with the above, the aim of the work was to improve the comprehensive treatment and prevention of disorders of endocrine-dependent gynecological pathology, taking into account the state of the thyroid gland in different age periods.
MATERIALS AND METHODS
The work was carried out at the clinical bases of the department of obstetrics, gynecology and pediatric gynecology of KhNMU (ODKB M91 and maternity hospital M91 in Kharkiv). 93 patients were under supervision. Of them, there are 56 patients aged 14-18 with endocrine-dependent NPR and NMF, 26 women aged 19-45 with NMF and 11 patients aged 48-52 with pathological menopause. Among the examined adolescents, 20 were diagnosed with delayed sexual development (SRD); at 12 - AM; in - 8 - PMK; at 16 – dysmenorrhea (DM). Out of 26 women of reproductive age, 10 had AM, 12 had DM, and 4 had DMK. Climacteric disorders were manifested by hot flushes, vasovegetative disorders in combination with NMF in the form of metrorrhagia in 3 examined and in the form of oligoopsomenorrhoea in 8 women.
All patients underwent a comprehensive clinical and laboratory examination, which included the study of anamnesis, evaluation of genealogical data, karyotype (according to indications), the degree and nature of physical and sexual development, the nature of menstrual function; the gynecological status, the functional state of the ovaries (colpocytology, basal temperature) were studied. X-rays of the skull were studied, bone age was assessed (in teenagers), computer and nuclear magnetic resonance imaging were used as indicated.
Ultrasound of the pelvic organs, internal organs, and mammary gland was performed in real time using a convex sensor on the Sonolier 420 "Simmens" device according to generally accepted methods, and dopplerography was used. Hormonal profile was evaluated: determination of gonadotropic and steroid hormones in blood serum.
The comprehensive assessment of the endocrine system was complemented by the study of the state of the thyroid gland (T3, T4, TSH, AtTPO, ultrasound of the thyroid gland). When evaluating the thyroid gland, its location, contours, echo structure, echo density, presence or absence of nodular pathology, length, width, thickness, volume of the right and left lobes, total volume, thickness of the isthmus were determined. Generally accepted laboratory methods were carried out (clinical blood tests, urine tests, biochemical tests), the somatic health status of the patients was determined, all of them were consulted by related specialists (pediatrician, therapist, neuropathologist, ophthalmologist, endocrinologist). During the examination, oncological processes of MS were excluded.
The control group consisted of 28 adolescent girls, students of secondary schools in the city of Kharkiv, and 20 gynecologically healthy women of reproductive and perimenopausal age.
RESEARCH RESULTS
During a comprehensive examination, it was established that hyperplasia of the thyroid gland was detected in patients in 38-59% of cases, depending on the form of gynecological pathology. Thyroid hypofunction was determined most often in all examined groups (in girls with ZPV AM, DM); in women of reproductive and perimenopausal age with AM, DM. Thyroid hyperfunction - in patients with PMK, DMK and metrorrhagia in perimenopause. During the objective examination, a diffuse non-toxic goiter (DNZ) of O-P, rarely H degree was diagnosed. The nodular form was found in 4 women of reproductive and 2 women of perimenopausal age.
The hormonal profile characterizing the functional state of MS revealed hypogonadotropinemia and hypoestrogenia in ZPR and AM, normo- and hypoestrogenia in PMK, hyperestrogenia in patients with DMD and metrorrhagia in perimenopause. Complex treatment of gynecological disorders in examined patients was carried out taking into account the thyroid status and included therapy of accompanying somatic pathology, general stimulating, general strengthening treatment (biostimulants, methyluracil), physiotherapy (exercise, massage, enteral oxygenation, pel, therapy).
Sedatives, non-hormonal therapy that regulates menstrual function: (verospiron, placenta preparations - for AM, DM), uterotonic, hemostatic, normalizing blood coagulation and anticoagulation, anti-anemic agents (for PMK, DMK and DMK) were used for DM, AM.
The medical complexes included vitamins of group "B", "C", "E", "A", askorutin, the drug Endonorm®, for normalizing the function of the thyroid gland, which is a plant-vitamin-mineral complex for improving the activity of the endocrine system as a whole and the thyroid gland in particular.
The composition of the drug includes:
L-Tyrosine 140 mg
Extra 150 mg of white foxglove roots
Extra three-part series of 70 mg
Extra bare licorice roots 50 mg
Extra kelp sugar 70 mg
Vitamin C 7.5 mg
Vit B15 1 mg
Vit. E 1 mg
Vitamin A 150 mcg
Zinc (oxide) 0.75 mg
Selenium (nitrate) 15 mcg
Iodine with extr. kelp 25 mcg
Phenolic compounds Foxglove regulates the production of thyroid-stimulating hormone (TSH) in the front of the pituitary gland, which regulates thyroid function and returns it to a euthyroid state.
Low tripartite is rich in flavonoids, ascorbic acid, carotene and manganese, which participate in the enzymatic processes of the thyroid gland, regulating its endocrine function and normalizing metabolism, and also have immunomodulatory activity. Licorice root glycoside - glycyrrhizin breaks down in the body to form glycyrrhetinic acid, which is chemically similar to steroid hormones, has an anti-inflammatory effect and regulates water-salt exchange.
Kelp is a source of organic iodine (up to 0.3% of dry weight), which is easily absorbed by the body, normalizing thyroid function. Kelp contains monoiodotyrosine and diiodotyrosine, inactive plant hormones that regulate iodine uptake by the thyroid gland.
Zinc - is part of enzymes, catalyzes energy processes in the cell, strengthens and modulates the regulatory effect on the thyroid gland of white foxglove.
Selenium - supports the immune system, helps prevent oncological processes of the lungs, intestines, mammary and thyroid glands; participates in the synthesis of the "super-antioxidant" coenzyme 0-10.
Vitamins A, C, E, 815 (pangamic acid) activate oxygen exchange in tissue cells, in particular. and thyroid gland, regulate redox processes, normalizing metabolism. L-Tyrosine is an amino acid that is a raw material for the production of thyroid hormones.
Endonorm® in hypothyroid conditions increases the functional activity of the thyroid gland by activating proliferative processes in interfollicular islands and increasing the speed of synthetic processes. The effect of the drug in autoimmune thyroiditis and nodular forms of goiter is due to a mediated effect by reducing the functional load of the thyroid gland and changing the reactivity of the humoral regulation of its function. The pharmacological effect of the use of the drug Endonorm in climacteric syndrome is manifested due to the normalization of the level of gonadotropic hormones (mediated effect on the hypothalamic-pituitary system) and increased functional activity of the adrenal cortex.
The effect of the drug in the complex treatment of hyperplastic diseases of the female reproductive system (mastopathy, endometriosis, endometrial hyperplasia) is due to its pronounced anti-inflammatory properties and gonadotropic activity. The effect of using the drug in the complex treatment of metabolic syndrome is achieved by restoring the function of the thyroid gland and increasing the intensity of metabolic processes in body tissues.
The drug Endonorm® was prescribed to patients with NMF and NPR, 1 capsule 2-3 times a day, depending on the initial functional state of the thyroid gland, every day for 2 months with a break of 10 days after the first month. Echosonographic and hormonal control was carried out before treatment and in dynamics. When evaluating the results of the use of complex treatment with the inclusion of the drug Endonorm, side reactions and complications were not detected. Teenage patients and adult women showed the highest efficiency in the case of ZPV AM, DM.
The patients' memory improved, the ability to make productive contact increased (in the presence of psycho-emotional disorders), positive dynamics of the neurological status, the state of the autonomic nervous system and the psycho-emotional sphere were noted, and the "quality of life" increased. In older women, against the background of treatment, "hot flushes" decreased or completely disappeared, and a general improvement in the state of health was noted.
The developed treatment for the ineffectiveness of non-hormonal therapy included the use of hormonal drugs. The results of the study on the use of complex symptomatic treatment of gynecological patients of various ages with the inclusion of the drug Endonorm showed that the restoration of impaired functions of the reproductive system, taking into account the correction of the thyroid status, was 76-83% (depending on the age and nature of the gynecological pathology). Treatment with the inclusion of hormonal drugs increased the clinical effectiveness to 89-98% (with PMK, DMK, perimenopausal metrorrhagia).
Conclusions
1. Endocrine-dependent gynecological disorders of MS in patients of various ages require complex therapy taking into account thyroid pathology.
2. The use of the drug Endonorm® in the treatment of gynecological patients during puberty increases the clinical effectiveness of complex therapy, which normalizes menstrual function, sexual development, and the functional state of the thyroid gland.
3. The use of the drug Endonorm® in the treatment of gynecological disorders in the reproductive and perimenopausal age contributes to the normalization of the function of MS, reducing the manifestations of the pathological course of the climacteric period.
4. Complex correction of gynecological disorders and disorders of thyroid function with the inclusion of the drug Endonorm® is effective and is not accompanied by side reactions and complications.
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