Complex of clinical symptoms in reproductive­aged women with aplasia of the vagina and uterus

Congenital aplasia of the vagina and uterus most commonly occurs in patients with Mayer–Rokitansky– Küster–Hauser syndrome (Müllerian agenesis) and testicular feminization syndrome (androgen insensitivity syndrome) [1–4]. Aplasia of the vagina and uterus can also occur in combined malformations of the urinary system and gastrointestinal tract (cloacal malformations and anorectal abnormalities) [5], in malformation syndromes, such as oculo-auriculo-vertebral spectrum, Al-Awadi–Raas Rothschild syndrome, Klippel–Feil abnormalities, and others [6, 7].

Women with Mayer–Rokitansky–Küster–Hauser syndrome have a female karyotype and ovaries that can function normally and provide properly developed phenotypic features, but the uterus and the upper two-thirds of the vagina are completely absent, or there are uterine rudiments. This type occurs with a frequency of 1 case per 5000–10 000 newborn girls. The etiology of the Mayer–Rokitansky–Kuster–Hauser syndrome is still unknown and most authors consider it as an embryonic disorder [8, 9].

In the future, the patient can undergo conservative treatment or surgical correction of the malformation depending on the patient’s age, complaints, and form of genital malformation, as well as the patient’s psychosomatic status and desire [10, 11]. A great number of patients will be able to achieve motherhood owing to the available uterine transplantation performed as a treatment for infertility in patients with aplasia of the uterus and vagina or in vitro fertilization (IVF) in the surrogacy program. All these techniques will require prenatal diagnosis, including preimplantation genetic testing [1,12].

Mayer–Rokitansky–Küster–Hauser syndrome may have two different forms: type 1 is characterized by complete aplasia of the vagina and uterus (64%) and type 2 which is atypical refers to the presence of functioning uterine rudiments (24%) and pathology of the fallopian tubes and ovaries in combination with multiple malformations of other organs and systems. Therefore, the assessment of the phenotypic complex of these patients is of scientific and clinical interest [13]. Defects of the urinary and cardiovascular systems as MURCS disorders can reach the incidence of 12% [14]. K. Rall and co-authors (2015) considered that patients with Mayer–Rokitansky–Küster–Hauser syndrome also have disorders of mesodermal tissue development [13]. Thus, the issue of increased stigmatization in women with genital defects is especially interesting from a scientific point of view.

More and more attention has been paid recently to the stigmas of dysembryogenesis and their role in the diagnosis of connective tissue dysplasia syndrome. However, the opinions of researchers differ in determining dysplastic phenotypes and the scope of the stigmatization threshold [15–17]. Given that patients with Mayer–Rokitansky–Küster–Hauser syndrome have a higher threshold of stigmatization compared to patients without genital malformation, the assessment of the correlation between a high threshold of stigmatization and the presence of connective tissue dysplasia syndrome in women is of clinical and scientific interest.

Taking into account all the above, the aim of the study was to describe the complex of clinical symptoms in reproductive-aged patients with aplasia of the vagina and uterus on the basis of retrospective and prospective analysis and to study the correlations of a high threshold of stigmatization with the phenotypic features of connective tissue dysplasia.

Materials and Methods

The study included 406 patients with aplasia of the vagina and uterus who were admitted to the Department of Operative Gynecology, Academician V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russia. The women had surgical correction of genital malformation in the period from 1995 to 2016. Patients with aplasia of the uterus and vagina were divided into two groups. Subgroup I included 364 patients with aplasia of the vagina and uterus with karyotype 46, XX; subgroup II consisted of 42 patients with aplasia of the uterus and vagina, and functioning rudiments (karyotype 46, XX). The control group consisted of 47 patients without genital malformations who were admitted to the the Department of Operative Gynecology for surgical treatment of other gynecological pathology. The average age of patients in the main group was 25 (7.6) years, and in the control group it was 31.6 (9) years.

Parameters for weight and height did not differ from the population norm. The height of patients in subgroups I and II was 167.3 (6.7) cm and 164 (6.3) cm, respectively, and it was 166 (6) cm in the control group. The median of weight of patients in the groups was 56 kg in group I, 58 kg in group II, and 58 kg in the control group.

No differences in hereditary disorders were found in the groups. In the main group, hereditary diseases were detected in 109 (26.8%) patients, and in the control group they were revealed in 15 (31.9%) cases. Oncological diseases in relatives of the patients in the main group with aplasia of the vagina and uterus were detected in 46 (11.3%) cases, and there were 4 patients (8.6%) in the control group whose relatives had cancer. Endocrinopathy in relatives of the patients in the main group did not exceed 2% (8 patients), and its rate was 8.6% (4 patients) in the control group.

Allergies were noted in the history of 82 (20.1%) women in the main group, while in the control group this indicator did not exceed 5 (10.6%). The analysis of groups showed that the greatest number of complaints about a tendency to allergic reactions was detected in subgroup II (aplasia of the vagina and uterus with functioning uterine rudiments), namely in 12 (28.5%) patients, while in subgroup I it was noted in 70 (19.2%) patients.

All patients complained of amenorrhea and inability to be sexually active. Complaints of cyclic lower abdominal pain were mainly reported by patients of subgroup II (with functioning uterine rudiments), 23 (54.7%) cases. In subgroup I, only 40 (10.9%) patients presented with such complaints; this could be suggestive of the receptor sensitivity of uterine rudiment tissues, different pain thresholds, stage of rudiment development, and, apparently, the endocrine profile that changes with age in some patients.

The bimanual examination of patients in subgroup I revealed only 11 (3%) patients with the formed vagina, while in subgroup II (in patients with functioning uterine rudiments) this indicator reached 21.4% (9 patients), whichcouldsuggestadequateestrogenization in these patients resulting in tissue elasticity.

In order to clarify the diagnosis and the nature of concomitant pathology in patients with aplasia of the vagina and uterus, different diagnostic methods were used: taking a medical history, physical examination, genetic (karyotyping), pelvic and kidney ultrasound, magnetic resonance imaging (to exclude complex abnormalities or malformation syndromes), excretory urography (to specify the condition of the urinary system and functional activity of the kidneys). Aplasia of the vagina and uterus was diagnosed by examination, karyotyping and ultrasound in 346 women (85.2%).

The patients were generally admitted to the Center with the diagnosis for surgical correction, therefore they did not need any special research methods. When necessary, differential diagnosis of the underlying disease, which caused aplasia of the vagina and uterus, was performed in rare cases at the Center. For example, aplasia of the vagina and uterus was diagnosed only in 20 (4.9%) patients using a combination of ultrasound and MRI, and only in 21(5.2%) patients with MRI. Aplasia of the vagina and uterus was diagnosed during the previous operation in 45 (11%) patients, including 10% of cases diagnosed during laparoscopy.

All the material removed during surgical treatment was examined histologically. Immunohistochemical study of the myometrium, glands and stroma of the endometrium of uterine rudiments was carried out in 8 patients and compared with 3 samples of the myometrium and endometrium of the uterus which were removed due to concomitant gynecological pathology. This study was performed to determine the structure of the connective tissue in patients with aplasia of the vagina and uterus and ones with functioning uterine rudiments.

In the immunohistochemical study of 11 tissue samples, sections 4 microns thick were applied to highly adhesive glasses and dried at 37°C for 18 hours. After removing paraffin from the sections, they were rehydrated in a battery of spirits 95, 80 and 70, incubating them in each solution for 2 minutes. Antigenic activity was restored in Dako PT Link at 97°C for 20 minutes in a 10 mm citrate buffer with a pH of 6.0. The cooled glasses were placed in wet chambers (to prevent the sections from drying out) and incubated for 15 minutes in a 3% solution of hydrogen peroxide to block endogenous peroxidase. The reaction with primary antibodies was carried out for 30 minutes at room temperature. The study used murine monoclonal antibodies to MMP2 [clone 6E3F8], 1:200 (ab86607, Abcam, UK) and rabbit antibodies to MMP9 [clone EP1254], 1:200 (ab76003, Abcam, UK), as well as rabbit polyclonal antibodies to TIMP-1, 1:50 (NeoMarkers, USA), Fibronectin, 1:50 (Dako, Denmark), Laminin alpha-1, 1:50 (Santa Cruz Biotechnology, USA), Collagen I alpha-1, 1:500 (Genetex, USA) and Collagen III alpha-1, 1:1000 (GeneTex, USA).

The Dako REAL EnVision system (Dako, Denmark) was used as secondary antibodies. To visualize the sites of binding antibodies to antigens, the reaction of oxidation of the substrate 3,3-diaminobenzidine (DAB) with horseradish peroxidase in the presence of hydrogen peroxide was used to form a water-insoluble brown end product. To make the immunohistochemical reactions properly, positive and negative controls were used. Samples of the studied sections were taken as negative controls, they were subjected to the standard procedure of immunohistochemical reaction, but primary antibodies were not added. Positive controls for each antibody were selected according to the manufacturer’s specifications. After immunohistochemical reactions, the sections were stained with hematoxylin and placed in a synthetic medium «Shandon mount TM» (USA). Thus, the characteristics of connective tissue structures were evaluated based on the condition of the extracellular matrix and cellular elements. Immunohistochemical maturity of connective tissue was assessed using the ratio of various types of collagen, fibronectin, and laminin, as well as the balance between degrading enzymes and their inhibitors (matrix prothenases MMP2 and MMP9 and their inhibitor TIMP1). The results of immunohistochemical reactions were evaluated using a semi-quantitative method in points according to a generally accepted method.

Results

The analysis of concomitant pathology in 406 patients of the main group with aplasia of the vagina and uterus showed that this malformation is often accompanied by malformations of the kidneys and urinary system, which were revealed in 163 (40.1%) cases.

Thus, aplasia of one kidney was detected in 46 (11.3%) patients, duplication of the pyelocalyceal system on one side was in 17 (4.2%) patients, nephroptosis or pelvic dystopia of one or both kidneys was detected in 58 (14.2%) women, ureteral abnormality, bladder exstrophy, was detected in 2 (0.4%) patients. Such characteristics of the kidney structure as hypermobile kidney, hydronephrotic transformation of the kidney, hypoplasia of one kidney, non-functioning kidney, kidney cyst, and rotated kidney were found in 13 (3.2%) patients with aplasia of the vagina and uterus and were not found in the control group. Thus, malformations and characteristics of the urinary system development were identified as follows: their incidence was 135 (37.1%) cases in subgroup I, and 24 (57.1%) cases in subgroup II. These malformations were not detected in the control group.

Diseases of the urinary system (pyelonephritis, urolithiasis, glomerulonephritis, cystitis) were detected in 77 (18.9%) patients in the main group, while in the control group they were detected only in 4 (8.5%) patients, which could be explained by urodynamic disorders.

When analyzing the incidence in the main group, it was found that the highest incidence of diseases of the urinary system was in subgroup II, namely in 19 (45.2%) women, while it did not exceed 53 (14.6%) patients in subgroup I.

Disorders of the musculoskeletal system were detected in 65 (17.9%) patients with aplasia of the vagina and uterus: 58 (15.9%) and 7 (16.7%) in subgroups I and II, respectively. In the control group, the incidence of diseases of the musculoskeletal system did not exceed 3 (6.4%) cases.

Such malformations as abnormal development of the cervical spine, congenital torticollis, dysplasia of the cervical spine, fusion of the vertebrae of the cervical spine and the absence of spinal discs were found in 6 (1.5%) patients of the main group with aplasia of the vagina and uterus and they were not detected in the control group. Such congenital abnormalities as Klippel-Feil syndrome (congenital malformation of the cervical and upper thoracic vertebrae), Scheuermann disease (progressive spinal kyphosis) were detected in 13 (3.2%) patients of the main group with aplasia of the vagina and uterus.

Congenital malformations of the hands or feet (bilateral radial club hand, ankylosis of the elbow, radial club hand, shortening of both forearms, impaired sensitivity of the hands, etc.) were detected in 4 (0.9%) patients.

Scoliosis and joint hypermobility did not exceed 19 (4.7%) and 11 (2.7%) cases in the main group, respectively. Rheumatoid arthritis and osteochondrosis of the lumbar spine in the patients with aplasia of the vagina and uterus did not exceed 4 (0.9%) and 9 (2.2%), respectively. In the comparison group these disorders were found in 3 (6.4%) women.

The most common diseases of the gastrointestinal tract in patients of the main group were chronic gastritis and gastroduodenitis which occurred in 36 (8.9%) cases, cholecystitis and biliary dyskinesia – 31 (7.6%) patients, liver cyst and gallbladder inflection – 7 (1.7%) women. Diffuse changes in the pancreas, splenomegaly, spleen calcifications, gastroesophagoreflux disease, benign hyperbilirubinemia were noted in 2.2% (9 women), gastric or duodenal ulcers were in 3 (0.7%) patients, and chronic colitis was in 3 (0.7%) patients.

The analysis of the groups showed that gastrointestinal pathology prevailed in subgroup II (in patients with functioning uterine rudiments), namely 9 (21.4%) women, while 61 (16.7%) women in subgroup I had this disease. This pathogenesis can be due to the long-term use of pharmaceutical drugs in the treatment of pain symptoms in patients with functioning rudiments, as well as possible dysregulation pathology.

Eye disorders were detected in 36 (8.8%) patients in the main group and in 3 (6.4%) patients in the control group. In the main group, among eye disorders there were myopia in 26 (6.4%) patients, astigmatism in 2 (0.5%) patients, strabismus in 1 woman, hypermetropia in 4 (1%) cases. The maximum incidence of eye diseases was detected in group II, in 10 (23.8%) patients, and in group I they were found in 26 (7.1%) patients.

Heart malformations, such as atrial septal defect, ventricular and atrial septal defect, and mitral valve defect were detected in 41 (10.1%) patients of the main group (control group in 8.6% women): in subgroup I in 34 (9.3%) patients and in subgroup II in 7 (16.7%) patients.

Mitral valve prolapse was detected in 30 (7.4%) patients with aplasia of the vagina and uterus: in subgroup I – in 27 (7.4%) women, in subgroup II – in 3 (7.1%) women. In the control group, the incidence of pathology was 8.5% ( in 4 patients).

Varicose veins of the lower extremities were found in 13 (3.2%) patients with aplasia of the vagina and uterus, neurocirculatory dystonia – in 36 (8.9%) women. In the control group, it was found in 1 (2.1%) and 3 (6.4%) patients, respectively.

Surgical treatment for inguinal or umbilical hernia in the previous history was performed in 21 (5.2%) women of the main group: 18 (4.9%) and 3 (7.1%) patients in subgroups I and II, respectively. In the control group, it was not detected.

General operations such as appendectomy, in rare cases cholecystectomy, sphincteroplasty, ureterosigmoanastomosis were performed previously and were noted in the history of 97 (23.9%) patients in the main group: 84 (23.1%) and 13 (30.9%) patients in subgroups I and II, respectively. In the control group, the frequency of surgical interventions for this pathology did not exceed 9 (19.1%) patients.

Concomitant gynecological pathology was detected in 56 (13.8%) women of the main group including 14.2% in subgroup I and 32.4% in subgroup II. Uterine rudimentary fibroids were detected in 23 (5.7%) patients, external genital endometriosis was revealed in 10 (2.5%) patients, and rudimentary adenomyosis was detected in 7 (16.2%) cases (the results were confirmed histologically).

Surgical treatment of the primary disease was performed in 361 (88.9%) patients out of 406 patients in the main group. Nine patients underwent a course of colpoelongation, taking into account the mobility and extensibility of tissues in this area and the presence of the lower third of the vagina.

Laparoscopic access was used in 339 (83.4%) patients and diagnostic laparoscopy was performed in 9 (2.2%) patients. Perineal access was used for 18 (4.4%) surgical interventions, including combined operations with laparoscopy, and repeated operations for neovaginal stricture in five patients, removal of polyps in the neovaginal area that was formed from the sigmoid colon; two patients underwent subsequent removal of the neovaginal area due to the development of malignant changes. Previous history of operations to remove uterine rudiments in case of colpopoiesis or corrective surgery was noted in 34 (9.4%) women.

The main type of surgical treatment in 72.3% of cases (263 patients) was pelvic peritoneal colpopoiesis with mostly minimally invasive surgery techniques. Colpopoiesis was performed using two patented methods developed in our Center (the first patent for invention No. 2585739 «A new method of peritoneal colpopoiesis operation performed for surgical correction of internal genital malformation, namely aplasia of the vagina and uterus» dated May 25, 2015, and the second patent for invention No. 2587723 «Improved technique of pelvic peritoneal colpopoiesis operation with laparoscopic assistance» dated July 3, 2015).

The following abnormalities were found in patients of subgroups I and II during the operation: hypoplasia or aplasia of the fallopian tubes in 32 (7.9%) women, and congenital absence of appendages on one side in two patients. An elongated ovary with suspected ovotestis was detected in three patients.

Repeated surgery was performed in 37 (10.2%) women of subgroup I: 7 (18.9%) patients with neovaginal stricture, 9 (24.3%) patients with shortening of the previously formed neovaginal area due to the lack of sexual activity and non–compliance with postoperative recommendations for neovaginal care, 4 (10.8%) patients with an attempt to perform colpopoiesis and rectal injury at the local clinic, 2 cases of recurrent polyps in the neovaginal area after sigmovaginopoiesis, 15 (40.5%) women with conservative colpoelongation which was ineffective.

All removed rudiments (42 patients in subgroup II) were examined morphologically. Focal endometrium with functional activity was found in 40.5% (17 samples) of patients: 12 samples showed endometrium in the proliferation phase, and 5 samples showed endometrium in the secretion phase. Focal endometritis without signs of functional activity was detected in 9 (21.4%) samples. No endometrium was found in other samples.

The following pathology of uterine rudiments was also detected: internal endometriosis was revealed in seven (16.7%) cases; five (11.9%) patients had a thin endometrium with inflammatory changes.

There was a study of the myometrium and endometrium of the uterus removed during laparoscopic surgery due to concomitant pathology. The results of histological examination confirmed the presence of functional activity of the endometrium and the phase of functional activity, mainly proliferation (in 62.5% of cases), was determined.

The results of the immunohistochemical study showed that fibronectin was not detected either in the glands, in the endometrial stroma, or in the myometrium in patients with uterine rudiments and in patients of the control group.

MMP2 or gelatinase A was equally detected in the cytoplasm of endometrial gland cells in all patients of the main group and control group, namely, 62.5% and 66.7%, respectively. However, MMP2 expression was more remarkable in the patients with aplasia of the uterus and vagina in the main group than in the control group.

The distribution of MMP2 in the cytoplasmic, apical, and membrane localizations of the endometrial glands was found in 50% of patients with functioning uterine rudiments and was not revealed in patients of the control group. Only the cytoplasmic location of MMP2 was detected in the second half of patients with functioning uterine rudiments and in two patients in the control group. In the endometrial stroma, MMP2 expression was detected only in one patient with uterine rudiments in 5% of cells with a nuclear location.

In the myometrium, MMP2 was found in two patients of the main group, mainly with a cytoplasmic location in 20% and 5% of cells with weak and remarkable expression, and only in one patient of the control group with a cytoplasmic location and moderate expression.

Thus, the location of MMP2 in the cytoplasm, apical region, and membrane was more typical for the endometrial glands of uterine rudiments.

Gelatinase MMP9 was detected in the endometrial glands of rudiments only in 37.5% of cases, and in one case in 60% of cells with a membrane localization and in 5% of cells with a cytoplasmic localization.

In the stroma, MMP9 was found in 75% of patients with functioning uterine rudiments, and of these, 50% had a membrane localization and remarkable expression, and 50% had a nuclear localization and remarkable expression; while in the control group, all patients had a nuclear localization of MMP9, in 3% and 5% of cells with remarkable expression, the membrane type of localization was not detected.

MMP9 was found in the myometrium in 62.5% of patients in the group with uterine malformation, including 90% of cases with a nuclear localization and remarkable expression. In the control group, MMP9 was not detected.

Thus, MMP2 and MMP9 were detected much more frequently and with greater expression in patients of the main group than in the control group.

TIMP 1 (tissue inhibitor of metalloproteinase 1) was not detected in samples obtained from women of both groups.

Type I collagen was found in the endometrial stroma of uterine rudiments in 100% of cells with a membrane localization, as well as in 100% of cells in the control group. Type I collagen was also found in the myometrium in all patients of both groups, but in the main group its content in cells varied from 60% to 90%.

Type III collagen was not found in the endometrial glands in either the main group or the control group. It was found in the endometrial stroma in all patients of both groups and it had a membrane localization and remarkable expression. Type III collagen was found in myometrium in all patients of both groups with a remarkable expression and membrane localization.

Abnormal expression of the adhesive glycoprotein laminin in our study was not detected either in the main group or in the control group.

Discussion

The analysis of phenotypic characteristics of 406 patients with aplasia of the uterus and vagina showed that the growth of patients did not differ in subgroups I and II, (167.3 (6.7) cm, and 164 (6.3) cm, respectively) and from the patients of the control group (166 (6) cm). The growth of patients in subgroup II with aplasia of the vagina and uterus and functioning rudiments was closer to the growth indicators of women with normal menstruation in the control group, which may be suggestive of the formation of genital malformation at a later stage of embryogenesis.

The patients of the main group did not have any hereditary abnormalities and did not differ from those of the control group. The patients of the main group had more than twice allergies in their medical history in comparison with the control group, 20.1% vs. 10.6%, respectively, which could indicate a dysregulatory pathology caused by dishormonal changes in the main group.This suggestion is confirmed by the fact that the frequency of allergic reactions increased by more than 1.5 times (28.5%) in patients with partially functioning uterine rudiments in comparison with patients of subgroup I with aplasia of the vagina and uterus (19.2%).

The presence of cyclical menstrual pain in the lower abdomen in 23 (54.7%) patients compared to 40 (10.9%) patients in subgroup I, as well as the frequency of natural colpopoiesis (up to 21.4%) compared to 3% in subgroup I indicated a more adequate endocrine profile in patients of subgroup II compared to subgroup I. These findings indicate the receptor sensitivity of uterine rudiments and their degree of development, adequate estrogenization of such patients, providing tissue elasticity, and the correct motivational component. Our suggestion is confirmed by the presence of functioning uterine rudiments in patients of subgroup II with aplasia of the vagina.

A high incidence of malformations of the urinary system, 123 (30.3%) cases, also evidenced an impairment of embryogenesis. The high incidence of diseases of the urinary system was a consequence of urodynamic disorders and had a functional character, namely, 53 (14.6%) and 19 (45.2%) patients in subgroups I and II, respectively.

The frequency of malformations of the musculoskeletal system (up to 5%) in the main group was suggestive of dysembryogenesis, which was not found in the control group. Given that the frequency of scoliosis and joint hypermobility did not exceed 19 (4.7%) and 11 (2.7%) cases in the main group, respectively, and it did not differ from the number of cases in the control group (3 and 4%), it is impossible to assume that patients with aplasia of the vagina and uterus have connective tissue dysplasia.

The signs of embryogenesis are known to correlate with slight cardiac abnormalities [18]. In this study, no slight cardiac abnormalities were detected in patients with aplasia of the vagina and uterus, and the incidence of valvular heart disease did not differ in the main and control groups (10% and 8.6%, respectively). Moreover, the patients of the main group did not have «benign» cardiac arrhythmias (migration of the pacemaker, episodes of lower atrial rhythm, rare episodes of ventricular parasystole), which could indirectly indicate slight heart abnormalities associated with connective tissue dysplasia. Therefore, in this study, it is inappropriate to accept that patients with aplasia of the vagina and uterus have connective tissue dysplasia. The data obtained are consistent with the results of the study by Lalatta F. et al. (2015), who conducted a dysmorphological assessment of 115 patients with Mayer–Rokitansky–Küster–Hauser syndrome and did not reveal any external deviations from the normal indicators, except for a slightly elongated shape of the eyelids [19].

Gastrointestinal pathology can also be described as one having dysregulatory aspects, its frequency in the main group reached 19% (78 patients). Given that there have been no special studies aimed at detecting gastrointestinal malformations, so it is too early to assume that embryogenesis is impaired in the gastrointestinal tract in patients with genital malformations.

Dysregulation status in patients with aplasia of the vagina and uterus was confirmed by a high frequency of allergic reactions (20.2%) (especially in patients with functioning uterine rudiments, namely, 28.5% compared to 19.2% in subgroup I), while in the control group this pathology did not exceed 10.6%.

Dysembryogenesis impairment can also be discussed in terms of the analysis of intraoperative findings, when malformations of the fallopian tubes, ovaries, etc. were often revealed.

In our study, based on the results of histological examination of the functioning uterine rudiments, the proliferation phase was mainly detected (62.5% of cases), the secretion phase was less common. However, some studies indicate that epithelium is low-cubic and does not form glands in uterine rudiments with a cavity [20]. In other studies, the authors note the presence of correct differentiation of tissues in uterine rudiments, and highlight that this differentiation is less significant in patients with concomitant malformations of other organs and systems [21]. In addition, in some studies, the authors noted an impairment of decidualization in the endometrium of uterine rudiments, in comparison with the endometrium isolated when receiving surgical material after hysterectomy on the 9th day of the cycle [22]. However, such studies are rare, and the comparison between the results of histological research involves the development of common criteria for describing rudiments that are currently absent.

As for the analysis of the data obtained in the immunohistochemical study of functioning uterine rudiments, it can be assumed that the patients of the main group showed an increase in the level of matrix metalloproteinases (MMP2 and MMP9), which determine tissue remodeling, angiogenesis, proliferation, migration and differentiation of cells, apoptosis, cleavage of collagen to the level of fibronectin, etc. According to the preliminary studies, it is difficult to assume whether the increased level of MMP is a consequence of cyclic changes in patients with functioning rudiments when blood outflow and microcirculation are impaired, or whether it is a consequence of mesodermal dysmorphopathy. A number of researchers associate the level of tissue differentiation with the severity of concomitant malformations [20], and the level of MMP2 in rudiments in another study was marked at the detection level [21]. Some authors believe that an increase in the expression of MMP2 and MMP9 to varying degrees, accompanied by an impairment of their intercellular cooperation, may be due to the presence of undifferentiated connective tissue dysplasia [23]. Our data do not allow us to draw conclusions about the presence of regularities in the distribution, expression, and accumulation of metalloproteinases in the cells of patients with uterine rudiments and the patients of the control group. However, taking into account the small number of patients of the group, and the fact that the data on the immunohistochemical characteristics of the distribution of markers of connective tissue disorganization were obtained for the first time, we consider that it is possible to conduct further research in this direction.

Conclusion

Patients with aplasia of the uterus and vagina have a higher rate of malformations of other organs and systems than women with gynecological pathologies, and this fact can be suggestive of embryogenesis impairment.

Dysregulation pathology prevails in patients with aplasia of the vagina and uterus in case of functioning rudiments (neurovascular manifestations, dysfunctional diseases of the urinary and digestive systems, etc.).

Functioning uterine rudiments may be subjected the same pathological processes as the normal uterus (fibroids, endometriosis).

It is necessary to perform ultrasound assessment of the urinary organs in all ifant girls due to the fact that malformations in the early neonatal age are difficult to detect and there is a high incidence of malformations of the urinary system, which reaches 50%.

Patients with aplasia of the vagina and uterus must be examined for karyotype.