CC BY
17
UDK 618.14-007.61-072.1-036.8-053.84
IMPROVING THE EFFICIENCY OF HYSTEROSCOPIC TREATMENT OF ENDOMETRIAL HYPERPLASTIC PROCESSES IN PREMENOPAUSE
The endometrial hyperplastic processes (EHP) shared from 15% to 50% in the structure of gynecological diseases. EHP is the main form of hyperproliferative processes in the uterine mucosa in pre-menopausal period. The first stage of this pathology treatment is the dissection of the abnormal endometrium with further morphological examination. Electrosurgical hysteroresectoscopy represent the most modern method of operative treatment in EHP patients. The effectiveness of this procedure is 60-98%. The purpose of this study was to increase the EHP treatment effectiveness in the pre-menopausal period. 122 women with EHP (age 45-54) were involved in this randomized controlled trial. The participants were randomized into two groups: the group I included 44 patients with ablation of the endometrium and subsequent therapy with gonadotropin-releasing hormone agonist (GnRH) for 3 months; and the group II 78 women with endometrial ablation without concomitant drug therapy. The studied groups were comparable in terms of obstetric-gynecological, reproductive and somatic anamnesis, the complaint spectrum, and the basic and accompanying diagnoses. A follow-up analysis after treatment revealed EHP recurrences in 5 (11.4%) women of group I and 28 (35.9%) of group II, p <0.003; among them the recurrences of endometrial polyps - in 4 (9.1%) and 19 (24.4%), p <0.04; recurrences of endometrial hyperplasia in 1 (2.3%) and 11 (14.1%), p <0.03, respectively. The therapy with GnRH agonists after endometrial ablation in premenopausal women allows to increase the therapy efficiency 3 times (from 35.9% to 11.4%) and should be recommended as an obligatory component of therapy, especially among patients with recurrent disease.
Keywords: endometrial hyperplastic processes, pre-menopause, endometrial ablation.
The endometrial hyperplastic processes (EHP) shared from 15% to 50% in the structure of gynecological diseases [7]. EHP is the main form of hyperproliferative processes of the uterine mucosa, and detected in 20% of premenopausal women visited the gynecological departments for disorders of the menstrual cycle [9].
According the protocol approved by Order MoH #676 at 31.12.2004 the first-line therapy of EHP patients is dissection of abnormal endometrium with further morphological study. The tactics of subsequent treatment depends on the type of endometrial pathology. Traditional treatment tactics of patients with hyperplasia of the uterine body mucosa includes the hormonal therapy for 3 months with subsequent control. The absence of clinical and/or morphological effects of conservative treatment is an indication for surgical intervention. In past the basic method of surgical treatment in premenopausal EHP patients was a hysterectomy. With the advent of minimally invasive endosurgical methods of EHP treatment in premenopausal period the hysteroscopic electrosurgical destruction of the endometrium was widespread (also known as "endometrial ablation"). The hysteroresectoscopy is the most up-to-date method of EHP surgery [5]. After introduction the hysteroresectoscopy into clinical practice the rate of radical surgery for uterine bleeding decreased by 30-40%. [2]
The endometrial ablation is the most optimal procedure due its relative simplicity, safety and efficacy. The advantages of this procedure in comparison with hysterectomy are: decreased operation time, reduced postoperative complications, and hospitalization/rehabilitation periods. The effectiveness of this intervention is 60-98% as various authors reported [10]. Such significant difference in rates can be explained by features of efficiency assessment for this procedure. So, if we consider the end-points in terms of symptom relief and absence of reoperations, Fischer F. et al. demonstrated that endometrial ablation efficacy reached 90.2% in group of patients with high risk of recurrences and 95.7% in group with low risk [6].
The effectiveness of ablation in terms of sustained amenorrhea rates also was evaluated by other authors. Sustained amenorrhea was achieved approximately in 50 to 70% of operated patients, whereas hypomenorrhoea - in 80-90% of patients [8]. The preserve of menstrual function after endometrial ablation was explained by the regeneration of endometrium even after electrical destruction of tissue [1]. This phenomenon is called "syndrome tube angles", as the growth of the endometrium occurs from the interstitial region of the fallopian tubes, and should be taken into account due the possibility of malignant transformation of these endometrial areas. Ulankina O.G. demonstrated that within 1.5 years endometrial growth in orifices of fallopian tubes occurs in 10% of endometrial ablation cases. The minimal efficiency of endometrial ablation was in the late reproductive age patients (39.9%), and this population often requires the repeated electrical destruction of endometrium. Using two-stage endometrial hysteroresectoscopic electric destruction allowed the author to obtain the positive results in 97.7% of cases [5].
Thus, based on the literature data, further research is required for the methods to increase efficiency of endometrial ablation in premenopausal women.
The purpose of this study was the increasing of the EHP treatment efficiency in the pre-menopausal period.
Materials and methods. A randomized controlled study involved 122 women with EHP (aged 45-54). They were randomized into two groups: the group I included 44 patients with ablation of the endometrium and subsequent therapy with gonadotropin-releasing hormone agonist (GnRH) for 3 months; and the group II - 78 women with endometrial ablation without concomitant drug therapy.
The anamnesis of disease, the results of general clinical and hysteroscopic examination, as well as long-term results of EHP treatment were studied.
Data processing was performed using the methods of variation statistics, Mann-Whitney rank test, c2-test and Fisher's exact test.
Results and discussion. The age of the group I participants averaged 47.8 ± 0.37 (47.5, 46-49) years (underneath in the brackets after median values the median and I-III quartiles are stated) and was compared with the group II - 47.7 ± 0.27 (47; 45.8-49.3) years, p> 0.05.
Table 1
Index Group I, n = 44 Group II, n = 78 Overall, n = 122
Age of menarche before 12 years 5 (11,4) 6 (7,7) 11 (9,0)
Age of menarche over 14 years 8 (18,2) 10 (12,8) 18 (14,8)
Heavy menstrual bleeding 26 (59,1) 48 (61,5) 74 (60,7)
Painful periods 20 (45,5) 29 (37,2) 49 (40,2)
Menstrual irregularities 24 (54,5) 36 (46,2) 60 (49,2)
Urogenital infections 13 (29,5) 22 (28,2) 35 (28,7)
Endometrial hyperplasia 7 (15,9) 15 (19,2) 22 (18,0)
Endometrial polyp 19 (43,2) 38 (48,7) 57 (46,7)
Cervical polyp 4 (9,1) 2 (2,6) 6 (4,9)
Hysteromyoma 15 (34,1) 39 (50,0) 54 (44,3)
Endometriosis 5 (11,4) 11 (14,1) 16 (13,1)
Chronic endometritis 4 (9,1) 2 (2,6) 6 (4,9)
Two-sided chronic adnexitis 14 (31,8) 27 (34,6) 41 (33,6)
Cervical ectopy 26 (59,1) 38 (48,7) 64 (52,5)
Cervical dysplasia 4 (9,1) 7 (9) 11 (9,0)
Ovarian cyst 6 (13,6) 14 (17,9) 20 (16,4)
Diagnostic curettage 21 (47,7) 39 (50,0) 60 (49,2)
Laparotomy 6 (13,6) 9 (11,5) 15 (12,3)
Hysteroscopy 2 (4,5) 2 (2,6) 4 (3,3)
Laparoscopy 2 (4,5) 4 (5,1) 6 (4,9)
Genital operative procedures, in general 24 (54,5) 45 (57,7) 69 (56,6)
Infertility, including: 3 (6,8) 4 (5,1) 7 (5,7)
Primary 2 (4,5) 2 (2,6) 4 (3,3)
Secondary 1 (2,3) 2 (2,6) 3 (2,5)
Childbirth 40 (90,9) 71 (91,0) 111 (91,0)
Artificial abortion 33 (75,0) 58 (74,4) 91 (74,6)
Spontaneous abortion 5 (11,4) 8 (10,3) 13 (10,7)
Ectopic pregnancy 2 (4,5) 8 (10,3) 10 (8,2)
Breast pathology 7 (15,9) 11 (14,1) 18 (14,8)
Pathology of the digestive system, 13 (29,5) 31 (39,7) 44 (36,1)
including: liver diseases 12 (27,3) 23 (29,5) 35 (28,7)
Tonsillitis 6 (13,6) 12 (15,4) 18 (14,8)
Cardiopathy 5 (11,4) 7 (9,0) 12 (9,8)
Essential hypertension 5 (11,4) 8 (10,3) 13 (10,7)
Obesity 13 (29,5) 16 (20,5) 29 (23,8)
Pathology of the thyroid gland 9 (20,5) 18 (23,1) 27 (22,1)
Nephropathy 4 (9,1) 5 (6,4) 9 (7,4)
Allergic reactions 7 (15,9) 16 (20,5) 23 (18,9)
Iron-deficiency anemia 7 (15,9) 15 (19,2) 22 (18,0)
Varicose veins 5 (11,4) 2 (2,6) 7 (5,7)
Vegetative-vascular dystonia 7 (15,9) 15 (19,2) 22 (18)
Extragenital operative procedures 21 (47,7) 31 (39,7) 52 (42,6)
Extragenital pathology in general 37 (84,1) 61 (78,2) 98 (80,3)
Note. No significant differences between the groups were found (we used %2-test and Fisher's exact test).
The mean age of menarche in the group I was 13.4 ± 0.22 (13, 13-14) and in the group II - 13.2 ± 0.14 (13, 12-14) years, p> 0.05. In this groups the average duration of menses was 5,6 ± 0,20 (5; 5-7) and 5,5 ± 0,23 (5; 4-7) days, respectively, p> 0.05; the length of the menstrual cycle 29,9 ± 1,14 (28; 27-30) and 27,8 ± 0,32 (28; 26-30) days, p> 0.05. These groups were also compared in the terms of distribution of early and late menarche, heavy and painful menstrual bleeding (Table. 1). At the same time, it should be noted that practically every second examined patient had complaints of menstrual irregularities, especially heavy menstrual bleeding, which according to the literature is the cardinal clinical symptom of endometrial hyperplastic processes [6].
Analysis of the gynecological anamnesis for examined patients revealed no significant differences between the groups (p> 0,05). However, more than half of them had EHP in the past (18% of all examined - endometrial hyperplasia and 46.7% - endometrial polyps), and as a result 56.6% of this women has surgery on the uterus, that is, EHP at the time of examination can be considered as a relapse of a disease, and as indication on the unfavorable prognosis of therapy.
The average number of genital diseases in the group I differed little from the group II: 2.2 ± 0.18 (2, 1-3) vs. 2.5 ± 0.13 (2, 2-3), p> 0.05.
Table 2
Frequency distribution of the complaints and diagnoses among patients with EHP in studied _groups, n (%)___
Index I group, n = 44 II group, n = 78 Overall, n = 122
Complaints
Hyperpolymenorrhea 20 (45,5) 34 (43,6) 54 (44,3)
Spotting between periods 10 (22,7) 15 (19,2) 25 (20,5)
Pain in the lower abdomen 6 (13,6) 10 (12,8) 16 (13,1)
Endometrial polyp by ultrasound 14 (31,8) 27 (34,6) 41 (33,6)
Endometrial hyperplasia by ultrasound 2 (4,5) 6 (7,7) 8 (6,6)
Submucous hysteromyoma by ultrasound 4 (9,1) 5 (6,4) 9 (7,4)
Menstrual irregularities 3 (6,8) 4 (5,1) 7 (5,7)
Other 3 (6,8) 2 (2,6) 5 (4,1)
Diagnosis
Endometrial polyp 32 (72,7) 53 (67,9) 85 (69,7)
Endometrial hyperplasia 22 (50,0) 40 (51,3) 62 (50,8)
Simple endometrial hyperplasia with atypia 1 (2,3) 2 (2,6) 3 (2,5)
Combined EHP 10 (22,7) 15 (19,2) 25 (20,5)
Chronic endometritis 7 (15,9) 15 (19,2) 22 (18,0)
Endometriosis, including: 9 (20,5) 18 (23,1) 27 (22,1)
• Adenomyosis 6 (13,6) 13 (16,7) 19 (15,6)
Hysteromyoma, including: 20 (45,5) 37 (47,4) 57 (46,7)
• Submucous 6 (13,6) 10 (12,8) 16 (13,1)
Anomaly of uterus development 1 (2,3) 3 (3,8) 4 (3,3)
Scar on uterus 4 (9,1) 4 (5,1) 8 (6,6)
Cervical pathology 6 (13,6) 10 (12,8) 16 (13,1)
Cervical polyp 2 (4,5) 3 (3,8) 5 (4,1)
Bleeding 4 (9,1) 4 (5,1) 8 (6,6)
Ovarian cyst 10 (22,7) 12 (15,4) 22 (18,0)
Note. No significant differences between the groups were found (we used c2-test and Fisher's exact test).
On average, every patient of the group I had 3.8 ± 0.39 (4; 2-5) pregnancies; 2.3 ± 0.36 (2; 0.253) medical abortions and 1.4 ± 0.11 (1; 1-2) births; group II - 3.6 ± 0.33 (3, 2-4) pregnancies, p> 0.05; 2.0 ± 0.28 (1; 0-2) abortions, p> 0.05 and 1.5 ± 0.10 (1; 1-2) births, p> 0.05. Of all features of the reproductive history, it should be noted that almost all patients had labors in the past, and most of them had artificial termination of pregnancy, which may be one of the etiological mechanisms of EHP development [6].
The incidence of somatic and somatoform disorders in the group I had no statistically significant differences from those in the group II (tab. 4). The average number of extragenital diseases in the group I reached 2.3 ± 0.26 (2, 1-3), and in the group II 2.2 ± 0.19 (2; 1-4), p> 0, 05. The distributions of patient complaints in the study groups were presented with a comparable frequency (Table. 2). The most common complaints were profuse menstrual bleedings (44.3% of all patients) and the spotting between periods (20.5%), and this corresponds to the literature data about complaint spectrum at EHP [2, 5]. All patients underwent hysteroscopy. The range of hysteroscopy protocol conclusions in the group I did not differ significantly from those in the group II. Among EHP dominated endometrial polyps (69.7%) and endometrial hyperplasia without atypia (50.8%). The comorbidity profile in EHP patients was characterized by the presence of chronic endometritis (18.0%), endometriosis (22.1%) and uterine fibroids (46.7%). These diseases are reported by the majority of authors as the main causes of abnormal uterine bleeding [2, 4]. The investigation of long-term treatment results revealed the EHP relapses in 5 (11.4%) women of the group I and in 28 (35.9%) of the group II, p <0.003: including relapses of endometrial polyps - in 4 (9.1%) and 19 (24.4%), p <0.04; relapses of endometrial hyperplasia in 1 (2.3%) and 11 (14.1%), p <0.03, respectively. Two patients of the group II experienced relapses of both polyp and endometrial hyperplasia.
1. The advantages of endometrial ablation in comparison with a hysterectomy are: decreased operation time, reduced postoperative complications, and hospitalization/rehabilitation periods.
2. According to the literature the endometrial ablation has minimal efficiency in patients in late reproductive age, and requires a further search of methods for increasing efficiency in premenopausal women.
3. This randomized controlled study of 122 women (aged 45-54 years) with endometrial hyperplasia has shown that administration of gonadotropin-releasing hormone agonists after endometrial ablation in premenopausal patients was accompanied by 3-fold lowering of disease recurrences in comparison with patients with endometrial ablation without additional medication.
4. Using gonadotropin-releasing hormone agonists after endometrial ablation in premenopausal patients allowed to increase therapy efficacy and can be recommended as a mandatory component of therapy, especially in patients with recurrent disease.
Prospects of further studies. Further research is planned to develop a differential tactics for women with endometrial hyperplasia in late reproductive age and to evaluate effectiveness of this tactics.
1. Bahvalova AA. Risk regeneratsii slizistoy obolochki tela matki posle ablatsii endometriya u bolnyih s retsidiviruyuschimi giperplasticheskimi protsessami v endometrii. Vestn. Ros. assots. Akusherov-ginekologov. 2000. 1: 95-9.
2. ovk IB, Gorban NE, Borisyuk OYu. Giperplaziya endometriya (Klinicheskaya lektsiya). Zdorove zhenschinyi. 2016. 5, 111: 10-8.
3.Korniienko SM. Histeroskopiia v diahnostytsi ta likuvanni vnutryshnomatkovoi patolohii u zhinok piznoho reproduktyvnoho ta premenopauzalnoho viku. Pediatriia, akusherstvo ta hinekolohiia. 2011. 73, 4:219-22.
4.Tatarchuk TF, Kalugina LV, TutchenkoTN. Giperplasticheskie protsessyi endometriya: Chto novogo?. Reproduktivna endokrinologlya. 2015. 5, 25: 7-13.
5.Ulankina OG. Klinicheskoe znachenie sostoyaniya interstitsialnogo otdela matochnoy trubyi dlya gisterorezektoskopicheskoy ablyatsii endometriya. Ginekologiya. 2002. 4, 3. http://old.consilium-medicum.com/media/gynecology/02_03/100.shtml.
6.Fischer F, Klapdor R, Gruessner S et al. Radiofrequency endometrial ablation for the treatment of heavy menstrual bleeding among women at high surgical risk. Int J Gynaecol Obstet. 2015.131, 2: 123-8.
7. Giuntoli RL, Gerardi MA, Yemelyanova AV. et al. Stage I noninvasive and minimally invasive uterine serous carcinoma: comprehensive staging associated with improved survival. Int. J. Gynecol. Cancer. 2012. 22, 2: 273-9.
8.Glazerman LR. Endometrial ablation as a treatment for heavy menstrual bleeding. Surg Technol Int. 2013. 23: 137-41.
9.Korniyenko S. The peculiarities of the history and condition of the endometrium of premenopausal women. Zdorovie zhenschiny. 2016. 10: 91-3.
10. Moulder JK, Yunker A. Endometrial ablation: considerations and complications. Opin Obstet Gynecol. 2016. 28, 4:261-6. doi: 10.1097/GCO.0000000000000282. PMID: 27253237.
МОЖЛИВОСТ1 П1ДВИЩЕННЯ ЕФЕКТИВНОСТ1
ПСТЕРОСКОПШНОГО Л1КУВАННЯ Г1ПЕРПЛАСТИЧНИХ ПРОЦЕС1В ЕНДОМЕТР1Я В ПРЕМЕНОПАУЗ1 Коршенко С.М. У CTpyKTypi пнеколопчних захворювань на гтерпластичш процеси ендометрiя (ГПЕ) припадае вщ 15% до 50%. ГПЕ основна форма
ВОЗМОЖНОСТИ ПОВЫШЕНИЯ ЭФФЕКТИВНОСТИ ГИСТЕРОСКОПИЧЕСКОГО ЛЕЧЕНИЯ ГИПЕРПЛАСТИЧЕСКИХ ПРОЦЕССОВ ЭНДОМЕТРИЯ В ПРЕМЕНОПАУЗЕ Корниенко С.М. В структуре гинекологических заболеваний на долю гиперпластических процессов эндометрия (ГПЭ) приходится от 15% до 50%. ГПЭ основная форма
гiперпролiферативних процеЫв слизово! оболонки матки, яку виявляють в пременопаузi. Перший етап лкування вказано! патологи - видалення змшеного ендометрiя з подальшим морфологiчним дослщженням. Електрохiрургiчна гiстерорезектоскопiя е найбiльш сучасним методом хiрургiчного лiкування хворих з ГПЕ. Ефективнiсть ще! операцп за даними лтератури становить 60-98%. Метою проведеного дослщження було пiдвищити ефектившсть лiкування ГПЕ в пременопаузальном перюдг У рандомiзованому контрольованому дослiдженнi взяли участь 122 жшки у вщ 45-54 рокiв з ГПЕ. Вони методом випадково! вибiрки були роздшеш на 2 групи: в 1-у групу увшшли 44 пацiентки, яким була проведена аблящя ендометрiя з наступним призначенням на 3 мюящ агошста гонадотропiнрiлiзiнг гормону (ГнРГ); в 11-у - 78 жшок, яким була проведена аблящя ендометрiя без додатково! медикаментозно! терапи. Групи не вiдрiзнялися за акушерсько-гiнекологiчним, репродуктивним та соматичним анамнезом, спектром скарг, основних i супутнiх дiагнозiв. Вивчення вщдалених результатiв лiкування показало, що рецидив ГПЕ був дiагностовааний у 5 (11,4%) жшок I-о! групи i у 28 (35,9%) П-о! групи, р <0,003: в !х числi, рецидив полiпiв ендометрiя - вщповщно у 4 (9,1%) i 19 (24,4%), р <0,04; рецидив гшерплазп ендометрiя - у 1 (2,3%) i 11 (14,1%), р <0,03. Призначення агошспв ГнРГ тсля абляцп ендометрiя у пацiенток в пременопаузi дозволяе пiдвищити ефективнiсть терапй в 3 рази (з 35,9% до 11,4%) i повинно бути рекомендовано в якост обов'язкового компонента терапи, особливо у пацiенток з рецидивом захворювання.
Ключовi слова: гiперпластичнi процеси ендометрiя, пременопауза, аблация ендометрiя
Стаття надшшла 12.04.2017 р.
УДК 616.981.21/.958.7: 616-036.4
гиперпролиферативных процессов слизистой оболочки матки, которую выявляют в пременопаузе. Первый этап лечения данной патологии - удаление измененного эндометрия с дальнейшим морфологическим исследованием. Электрохирургическая гистерорезек-тоскопия представляют собой наиболее современные методы хирургического лечения больных с ГПЭ. Эффективность этой операции составляет 60-98%. Целью проведенного исследования было повышение эффективности лечения ГПЭ в пременопаузальном периоде. В рандомизированном контролируемом исследовании приняли участие 122 женщины в возрасте 45-54 лет с ГПЭ. Они методом случайной выборки были разделены на 2 группы: в 1-ю группу вошли 44 пациентки, которым была произведена аблация эндометрия с последующим назначением на 3 месяца агониста гонадотропинрилизинг гормона (ГнРГ); во 11-ю - 78 женщин, которым была произведена аблация эндометрия без дополнительной медикаментозной терапии. Группы не отличались по акушерско-гинекологическому,
репродуктивному и соматическому анамнезу, спектру жалоб, основных и сопутствующих диагнозов. Изучение отдаленных результатов лечения показало, что рецидив ГПЭ был отмечен у 5 (11,4 %) женщин 1-ой группы и у 28 (35,9 %) 11-ой группы, р<0,003: в их числе, рецидив полипов эндометрия — соответственно у 4 (9,1 %) и 19 (24,4 %), р<0,04; рецидив гиперплазии эндометрия — у 1 (2,3 %) и 11 (14,1 %), р<0,03. Назначение агонистов ГнРГ после аблации эндометрия у пациенток в пременопаузе позволяет повысить эффективность терапии в 3 раза (с 35,9% до 11,4%) и должно быть рекомендовано в качестве обязательного компонента терапии, особенно у пациенток с рецидивом заболевания.
Ключевые слова: гиперпластические процессы эндометрия, пременопауза, аблация эндометрия
Рецензент Корнацька А.Г.
ВИВЧЕННЯ ОСОБЛИВОСТЕЙ 1МУННОГО СТАТУСУ ПАЦ1еНТ1В 13 ПОеДНАНИМ ПЕРЕБ1ГОМ ХРОН1ЧНОГО В1РУСНОГО ГЕПАТИТУ С ТА В1РУСУ 1МУНОДЕФ1ЦИТУ
ЛЮДИНИ
Мета роботи: вивчення основних етдемюлопчних, кйшчних та лабораторних особливостей прояву i переб^у вiрусного гепатиту С та ВШ-шфекцй як мкст-патологп, розробка та обгрунтування алгоритму етдемюлопчно! дiагностики, лжування i профiлактики. ХВГС збiльшуе вiрусне навантаження В1Л, що негативно корелюе з кiлькiстю СД4+ Т-лiмфоцитiв, а значить - зi ступенем iмунодефiциту, що пiдтверджуеться у нашому дослщженш. Проведена антиретровiрусна терапiя демонструвала зниження маркерiв кл^инно! ланки iмунiтету - лiмфоцитiв, СБ3+, СБ3+8+ та СБ3+19+ клiтин та зниження маркерiв гуморально! ланки iмунiтету - Ig А, ^ М та Ig О, а також елеващю СБ3+4+ та СБ16+56+ клiтин i в грут з мононозологiею В1Л, i в грут з коморбiднiстю В1Л+ХВГС. Отримаш результати свiдчать про зменшення шфламаторного процесу i рiвня iмунодефiциту тсля антиретровiрусноl терапи в групах В1Л i В1Л+ХВГС.
Ключов! слова: хрошчний в1русний гепатит С, в1рус ¡мунодефщиту людини, ¡мунний статус.
В1русн1 гепатити з парентеральным шляхом передач! та В1Л-шфекщя в1дносяться до числа найбшьш актуальних проблем сучасно! медицини. Кшьюсть людей, заражених в1русами гепатит1в та В1Л, продовжуе зб1льшуватися. Понад мшьйон людей у св1т1 щороку помирають в1д захворювань, пов'язаних 1з цими шфекщями, або !х насл1дк1в. Залученими в еп1дем1чний процес виявляються люди з р1зних соц1альних { вшових груп населення [3].
З огляду на, що засоби специф1чно1 профшактики В1Л-1нфекцй на сьогодн1шн1й день вщсутш, основне значення мають максимально ранне виявлення 1нф1кованих ос1б, строгий контроль за донорською кров'ю та И препаратами, контроль трансплантапв на наявнють В1Л, робота серед населення ¡з сан1тарно! осв1ти. В даний час саме останнш напрям, як { залучення
