Urine tests are a mandatory procedure in order to find out general condition body and the presence of any diseases. One of the indicators of this analysis is the epithelium.
It is a cellular layer lining the skin surfaces, mucous membranes internal organs and systems. The epithelium has its own characteristic features and structure.
Every person has these cells in their urine; they enter through the urethra. Sharp increase This indicator can become a signal about the presence of any infection in the body. By itself, this element carries virtually no information, but in combination with other indicators, it can become a signal about inflammatory processes occurring in the body. We will look at what this means below.
Classification
In addition to the quantity, within general analysis urine, the type of epithelium that is excreted along with the urine is also determined. In this biological fluid Microscopy reveals three types of epithelial cells.
- Flat epithelium– lines the urethra – their number increases with inflammation of the urethra (urethritis).
- Transitional epithelium– covers mainly the walls of the bladder, as well as the ureters and ducts prostate gland, renal pelvis. Just like squamous epithelial cells, this type shaped elements found in urine analysis in single quantities. A sharp increase in the amount of this type of epithelium indicates cystitis, pyelonephritis, prostatitis, urolithiasis. In addition to diseases, several other factors can affect the number of these cells in the urine.
- Renal epithelium– lines the tubules of the kidneys – in the urine healthy person should not be detected at all. The presence of the presented type of epithelial cells for children under 1 month of age is allowed in quantities from 1 to 10 pieces. The detection of renal cells in human urine indicates damage to the renal parenchyma.).
Determining epithelial cells in urine requires special accuracy from the laboratory technician - after all, even if the number is normal at first glance, it is necessary to correctly determine the type of cells - the diagnosis and assessment of the severity of the person’s condition depends on this.
Normal epithelium in urine
In women and men, epithelial cells are always found in the analysis. They get there by sloughing off the mucous membrane urinary tract. Depending on the origin, transitional vtc ( bladder), squamous (lower urinary tract) and renal (kidney) epithelium. Increase in epithelial cells in urinary sediment talks about inflammatory diseases and poisoning with salts of heavy metals.
Normal epithelium in urine:
- in children 0-1/ Negative;
- in men and women 0-1-2-3 in the field of view.
The amount of epithelium found in the urine determines whether there is pathology in the body. An indicator of no more than 3 units means that the person is completely healthy. If there are more epithelial cells, then inflammation of the urethra is preliminarily diagnosed, which is quite often observed in men.
The disease is caused by viruses and bacteria. In women, such a number of epithelial cells does not always mean the presence of the disease. The analysis is often repeated: it may be that the patient did not collect the urine correctly.
How to get tested correctly?
Often, squamous epithelial cells are detected in urine as a result of improper preparation to take the analysis.
- You need to transfer the container with urine to the laboratory within 1-2 hours after urination.
- During menstruation, it is better to refrain from taking the test.
- Urine collection is carried out only in a clean (preferably sterilized) container, sufficient quantity urine – 100 ml.
The basic rule that must be followed is to carry out hygiene procedures for the external genitalia before collecting urine.
Causes of increased squamous epithelium in urine
If squamous epithelial cells are found in the urine above normal levels, this means the presence of an inflammatory process. Here are the diseases that are diagnosed in adults if the analysis indicates high rates:
- Nephropathy medicinal nature . Structural and functional changes kidneys developing during pharmacological therapy.
- Nephropathy (kidney disease in which their functioning is impaired) is of a dismetabolic nature. Disease associated with structural and functional disorders kidneys, developing against the background of metabolic disorders accompanied by crystalluria.
- - inflammation of the bladder caused by a urinary infection.
- Other urethritis of various etiologies, for example, (in men).
If the value is increased in women, this does not always mean the presence of a serious disease (one of the above), while for men it is alarm signal for his health.
Renal epithelium in urine: causes
If an increased concentration of renal epithelium is found in the urine, then this fact indicates ongoing kidney diseases in the body, for example, damage to the renal parenchyma, because the renal epithelium forms the surface of the tubules in the kidneys. The cause of inflammation is intoxication, infections, circulatory failure, glomerulonephritis.
If a patient has undergone a kidney transplant, and three days later the test result shows the presence of the renal variety, and its content is 15 or higher in the field of view, then this fact indicates the possibility of allograft rejection.
Transitional epithelium in urine: causes
Transitional epithelium lines the renal pelvis, ureters, bladder, large channels prostate gland and upper section urethra. Transitional epithelial cells are found in single numbers in the urine of healthy people.
An increase in the number of transitional epithelial cells can be observed with cystitis, pyelonephritis, kidney stone disease. The norms of the transitional epithelium do not have divisions in accordance with age and gender. Maximum quantity for a healthy person this is no more than 3 cells in the urine.
Almost every woman knows that squamous epithelium in a smear is a very important indicator with which the doctor can determine the condition of the mucous layer of the genital organs.
Cytology analysis provides reliable information about hormonal background, and also about the presence or absence of a pathological process in genitourinary system.
Very often, patients ask the question of whether squamous epithelial cells should be present in the smear and how many of them there should be, after receiving the result of the cytology test.
Some women are scared when they see the presence of epithelial cells in the results. There's really no need to worry.
The flat epithelium in a smear does not pose any danger, of course, if this indicator is normal.
The presence of squamous epithelial cells is physiologically justified. This cover protects all fabric surfaces. There are flat and columnar epithelium.
Depending on the load that the tissue experiences, the integumentary cells have different structure. For example, the skin is covered with multilayered epithelium, which tends to keratinize.
The inner surface of the vagina and the outer part of the cervix are also lined with several layers of cells.
Simply put, squamous epithelium is a covering that forms the mucous layer of internal organs (vagina, cervix and others).
The epithelial layer consists of superficial, basal and intermediate cells. Every six to seven days (as it matures) the young layer changes its cellular form and sizes.
Obsolete particles are peeled off and replaced with new ones, so squamous epithelium should be present in smears of healthy women.
Due to the formation of new cells, the thickness of the mucous membrane increases. It should be noted that squamous epithelium consists of elements with small nuclei and abundant cytoplasm.
Gynecologist attaches great value analysis results. When deciphering, the doctor analyzes the condition of the genital organs and draws conclusions about the presence or absence of hormonal imbalance.
An insufficient number or a significant increase in the cells that form the mucous layer indicates diseases of the body that can lead to the formation of tumors.
The presence of epithelial particles in the smear may indicate vaginitis, urethritis, a lack or excess of certain hormones. Only an analysis will tell you whether such cells are dangerous or not.
The epithelial cover contains cells that make up the intermediate layer. The thickness of the squamous epithelium is one hundred fifty to two hundred microns.
In addition, the smear may contain cylindrical epithelial cells that line the internal os and partially the cervical canal.
The covering provides the necessary amount of mucus to lubricate the cervix. The indicator of cylindrical epithelial cells should also correspond to the norm.
Why is a smear necessary?
Most women pay their visit to the gynecologist with some constraint, modesty or even hostility.
Avoiding troubles for women in terms of health is quite simple.
It is enough to regularly take a cytology test, the results of which can provide answers to many questions. A smear can tell about the presence of not only bacteria, fungi or leukocytes.
The result of the smear analysis will help determine the number of epithelial cells and promptly identify inflammatory (sometimes even cancerous or precancerous) processes in a woman.
The gynecologist definitely recommends taking a cytology test (PAP test) at least once a year. When planning a pregnancy, this analysis is inevitable.
It is very important to get the result of a smear for pregnant women who did not have time to take it in the process of planning a future child.
During pregnancy, the flat epithelium that lines the vagina is capable of retaining harmful microorganisms.
By detecting an increased number of epithelial cells in time, the doctor will help avoid the development of a severe inflammatory process in expectant mother. Lack of estrogen in a pregnant woman can be easily diagnosed by low rate level of squamous epithelium.
Experts prescribe this analysis to women who want to have intrauterine device, if you suspect the presence of genital herpes, in cases of infertility or disorders menstrual cycle.
In patients suffering from overweight(for obesity), there may be disorders associated with gynecology, and the doctor also often recommends a smear test.
The best time to conduct the study is the fourth or fifth day of the cycle. Before taking the test, a woman should abstain from sexual intercourse for at least two or three days, avoid the use of ointments, lubricants, and douching.
You need to stop going to the toilet two to three hours before visiting the gynecologist. Before this, you first need to do a hygienic wash.
A smear is taken from women during a gynecological examination using a special small disposable brush. The material is carefully taken from the surface of the cervix.
The procedure is painless, but at the time of taking the scraping, slightly unpleasant sensations may occur.
After the doctor takes the material for analysis, some women may experience slight spotting. This is a normal phenomenon, the patient should not be afraid of this.
Normal squamous epithelium in a smear
The microbial composition of the smear is determined by specialists in laboratory conditions. With the help of special reagents, the epithelium in the scraping is painted in different colors, with the help of which you can designate and evaluate the composition of the material taken for analysis.
The results of the smear are usually known within one day. When all particles of squamous epithelium have correct form and size, the analysis is considered normal. There must be no atypical cells.
If particles with pathology are detected, the doctor should prescribe additional research reasons for their appearance.
As a result of the analysis, a woman may see the abbreviation “Ep”, which means epithelium. In a smear, the normal number of squamous epithelial particles is about fifteen pieces.
A deviation in any direction indicates that some local pathologies are developing in the woman’s body that threaten her health. If the result of the presence of squamous epithelium is overestimated, then the patient may have inflammatory processes.
Woman childbearing age With increased deviation from normal in a smear may suffer from infertility. Often, an increase in the amount of squamous epithelium indicates the presence of vaginitis.
Patients often visit a gynecologist with complaints of itching in the vaginal area, the presence of abundant unpleasant discharge, sometimes with a characteristic odor.
In such cases, the doctor prescribes appropriate antibacterial drugs. To avoid re-infection, it is recommended that the sexual partner of the sick patient also undergo examination.
A situation in which the amount of squamous epithelium in a scraping is significantly higher than normal may be a sign that a woman has gardnerella, trichomonas, gonococcus and other pathogens.
One of the reasons for the presence in a smear in large quantities epithelial cells may contain estrogens.
Excessive saturation of the body with hormones of this group can lead to termination of pregnancy.
An underestimated amount of squamous epithelium in a smear is also an alarming symptom, since it indicates thinning of the vaginal mucous membranes.
Experts attribute the decrease in the indicator to estrogen deficiency in the patient. Women, as a rule, notice practically complete absence discharge.
During sex, an insufficient amount of lubrication is produced, which makes sexual intercourse much more difficult. A small number of epithelial cells usually alerts doctors.
There is an assumption that a woman with this result has a tendency to develop cancerous tumors.
Timely diagnosis of deviations from the norm will help to avoid the further development of a large number of diseases in women. Do not neglect visiting a gynecologist.
At the slightest discomfort, a woman should try to visit a doctor as soon as possible and take a cytology test.
It should be noted that after proper treatment, the squamous epithelium in the scraping often takes on normal values.
When visiting a gynecologist, it is always necessary to take a smear for flora. It can be used to determine the condition of the vaginal mucosa and the presence of infections. Only a doctor can decipher a smear correctly, knowledgeable all indicators. The epithelium in the smear may indicate the presence of an inflammatory process, which may be associated with various reasons.
Indications for testing
There are certain reasons, requiring analysis of a smear from the vagina or urethra to determine the presence of infections or inflammations in the reproductive system:
- pain localized in the lower abdomen;
- taking antibiotics for a long time;
- the presence of suspicious vaginal discharge that causes discomfort;
- sensation of itching and burning in the genital area;
- pregnancy planning;
- carrying out preventive examination.
Subject to availability unpleasant symptoms You should immediately visit a doctor and take a smear and test for the presence of sexually transmitted infections. What epithelium means in a smear depends on the characteristics of its cells and their structure and quantity.
Rules for preparing for analysis
To get reliable result, necessary:
- two days before the smear test, avoid sexual contact;
- do not use vaginal contraceptives(including condoms, ointments, lubricants and creams) and suppositories;
- stop douching two days before the test;
- do not conduct examinations during menstruation, since menstrual blood significantly distorts the results of the analysis and may show that the epithelium in the smear is increased, the most the right option there will be a smear test in the first days after the end of menstruation;
- should not be used the day before intimate hygiene, carrying out hygienic procedures for the genitals is simply necessary warm water without using any detergents;
- You cannot go to the toilet two hours before taking the test.
Proper preparation for taking a smear will allow you to most accurately determine the number of cells in it and assess the health of the reproductive system. The epithelium in the smear indicates the condition of the vaginal and cervical mucosa. If the norm changes, one can conclude that there is inflammation or atrophy of the epithelial layer.
Smear technique
A smear for cytology is taken using a special spatula, which is included in the standard gynecological kit intended for inspection. It is necessary to take the analysis at the site of transformation (where the squamous epithelium turns into columnar epithelium); after taking the material, it is distributed over a glass slide.
The transformation zone is located in the area of the external pharynx, but in some cases (depending on hormonal balance and age) can change its position. Taking a smear from the area of transitional epithelium is necessary to accurately determine the presence of malignant cells. Since they appear from the lower layers, taking a smear from the location of the surface epithelium, it will be possible to diagnose cancer only at the last stage.
That's why it's very important role plays the epithelium in the smear. The norm in women ranges from 3-15 units in the field of view. If their number is higher, additional examinations need to be carried out to detect a malignant tumor.
What is squamous epithelium and its significance in a smear
The squamous epithelium is the mucous membrane of the vagina. Depending on the phase of the menstrual cycle, cells may undergo minor changes. The surface epithelium is divided into keratinizing and non-keratinizing, the ratio of cells changes in different phases, therefore, it is necessary to take this fact into account in order to determine whether the obtained indicators are normal.
Epithelium in a smear is normal only if its number does not exceed 15 units in the field of view. Exceeding the norm indicates the presence of inflammation, or recently past infection. When the structure of cells changes, suspicions arise about the development of a benign or malignant tumor.
The value of columnar epithelium in a smear
The epithelium in the smear, which has a cylindrical shape, is functional, as it ensures the secretion of mucus on the cervix. Normally, the cylindrical epithelium in a smear is represented by groups of cells that have a honeycomb-like or linear structure.
In addition, goblet-shaped cells can be found, their difference is in the cytoplasm stretched with mucus. In some cases, such cells may contain secretion granules. A common pathology, ectopia, is a displacement of the columnar epithelium and its replacement of flat surface epithelium.
Further diagnostic measures
If epithelium is found in the smear, the norm of which is violated, the doctor can diagnose vaginitis. Except high concentration in the analysis of epithelial cells, the woman should have an uncomfortable discharge that has bad smell, there is itching and pain in the vagina, and redness of the vulva is also observed.
Vaginitis is treated with antibiotics, which are combined with antifungal or other drugs, depending on the type of pathogen.
Treatment of non-infectious vaginitis
If the epithelium in the flora smear is increased, and no infections were found, we can conclude that a non-infectious pathogen is present. These may be hygiene products containing chemicals, causing irritation of the mucous membrane, contraceptives, with hypersensitivity vagina to spermicides.
In these cases, it is enough to stop using the products, and after some time the concentration of epithelium in the smear will itself restore to normal indicators. To speed up the effect, you can use suppositories or tablets that normalize the vaginal microflora and allow normal cells to recover faster.
Epithelium in a smear in men
A high content of epithelial cells in the smear can be observed not only in women, but also in men. The most common disease accompanied by an increased amount of epithelium is urethritis. In men, urethritis is accompanied by pain and burning when urinating, a feeling of discomfort and swelling in the genital area and groin, and the appearance of discharge from the penis or blood in the urine and semen.
Female urethritis is accompanied by chills, pain in the lower abdomen, frequent urges to urination, burning and pain, as well as the presence of atypical vaginal discharge.
Urethritis can be caused by:
- cytomegalovirus;
- herpes simplex virus;
- chlamydia;
- gonococci.
If any virus or bacteria is detected, additional examinations and effective treatment are required.
Atypical epithelial cells in a smear
In some cases, atypical epithelium may be detected in the smear. What does it mean? An altered structure of squamous epithelial cells lining the vagina and cervix may indicate the development of cancerous tumors or dysplasia.
Cervical dysplasia causes cancer in only one percent of women. In other cases, with regular monitoring and treatment, it goes away within a few years. If the disease continues to develop and there is a danger of developing cancer cells, the doctor may recommend a hyperectomy - removal of the uterus and cervix.
Most often, this procedure is performed on women who have reached menopause or women who no longer plan to give birth.
Methods for eliminating atypical cells
If there is a large amount of atypical epithelium, radical methods aimed at destroying cells may be required. After this, the number of cells is normalized, and the epithelium in the smear is restored. The norm for women is recovery period is individual, so after surgical interventions After some time, you need to visit a gynecologist and take a smear test again.
The following methods are usually used to treat dysplasia:
- Laser therapy is the most modern and effective way. In addition to removing the atypical area, you can also examine its depth and act on all layers of tissue. This procedure It is very painful and traumatic, so bleeding may begin after a few days.
- Diathermy - cauterization, is the effect of electricity on an atypical area. Is the fastest and simple method. After cauterization, scars may remain on the cervix, which in some cases cause the development of infertility.
- Cryothermy is the effect of ultra-low temperatures on the damaged area. The method is effective only on initial stages dysplasia. With the development of cancer cells or the occurrence of atypical processes in the cells of the basal layer, it does not produce any results.
All these procedures are aimed at destroying atypical cells under the influence of temperature or a laser beam. In place of the destroyed cells, squamous and cylindrical epithelial cells appear, which are normal for the cervix and vagina.
The epithelium in the smear, the norm of which has been restored after such procedures, will not carry the risk of developing cancer. If the effectiveness medical procedures didn't bring it, s high probability you will have to perform a hyperectomy (removal of the uterus and cervix).
Ella asks:
What does the presence of epithelium in a vaginal smear indicate?
Normally, squamous epithelial cells gradually peel off from the surface of the mucous membrane of the vagina and cervical canal. After all, epithelial cells and skin are constantly renewed, while the “old” ones peel off and die. Such desquamated epithelial cells can be detected in a vaginal smear in quantities from 3 to 15 pieces in one field of view. Therefore, simply the presence of a normal number of epithelial cells in a smear indicates the normal course of renewal processes of the mucous membrane of the genital organs. That is, when normal quantity epithelium in the woman’s smear, everything is fine with the vaginal mucosa.
If there are no epithelial cells in the smear, then this indirectly indicates a hormonal imbalance in the woman’s body, in which there is a lack of estrogen and an excess of androgens (male sex hormones). Except hormonal imbalance, the reason for the absence of epithelial cells in the smear may be atrophy of the vaginal mucosa.
If there is an increased number of epithelial cells in the smear, then this indicates an active process of renewal of the vaginal mucosa, which is indirect sign inflammatory process. Inflammation can be caused by the following diseases:
- Sexually transmitted infections (for example, genital herpes, syphilis, gonorrhea, mycoplasmosis, ureaplasmosis, trichomoniasis, chlamydia, etc.);
- Colpitis (vaginitis) – inflammation of the vaginal mucosa;
- Vulvovaginitis – inflammation of the mucous membrane of the vagina and vestibule of the vagina;
- Cervicitis – inflammation of the mucous membrane of the cervical canal;
- Urethritis - inflammation of the mucous membrane of the urethra;
- Endometritis – inflammation of the mucous membrane of the uterine cavity;
- Bacterial vaginosis (gardnerellosis) – vaginal dysbiosis;
Find out more on this topic:
- Blood test for antibodies - detection of infectious diseases (measles, hepatitis, Helicobacter, tuberculosis, lamblia, treponema, etc.). Blood test for the presence of Rh antibodies during pregnancy.
- Blood test for antibodies - types (ELISA, RIA, immunoblotting, serological methods), norm, interpretation of results. Where can I get a blood test for antibodies? Research price.
- Fundus examination - how the examination is performed, results (normal and pathological), price. Fundus examination in pregnant women, children, newborns. Where can I get tested?
- Fundus examination – what does it show, what eye structures can be examined, which doctor prescribes? Types of fundus examination: ophthalmoscopy, biomicroscopy (with a Goldmann lens, with a fundus lens, at a slit lamp).
- Glucose tolerance test - what does it show and what is it needed for? Preparation and implementation, standards and interpretation of results. Glucose tolerance test during pregnancy. Where can you buy glucose? Research price.
- Ultrasound of the stomach and esophagus - interpretation of results, indicators, norm. What does ultrasound show for various diseases of the stomach and esophagus? Where can I get an ultrasound of the stomach and esophagus? Research price.
For preventive purposes, to clarify the diagnosis gynecological diseases The doctor orders a cytology test. Flat epithelium in a smear - important indicator condition of the mucous layer of the genital organs. This analysis is also necessary to determine the presence of a pathological process in the genitourinary system in men.
What is squamous epithelium
When reading the smear, the doctor analyzes the condition of the patient’s internal genital organs and determines the presence of hormonal imbalance. Female vagina And urethra The inside is lined with a mucous membrane, which consists of cellular material - squamous epithelium. The epithelial layer of the vagina contains three types of cells:
- Superficial;
- Basal;
- Intermediate.
Every five to seven days, surface cells are renewed: old ones are shed, and new ones are formed in their place. In case of disruption of production female hormones There is a failure in the renewal mode of the surface epithelium: new cells are formed, but old ones remain, resulting in thickening of the mucous membrane.
In what cases does a doctor prescribe a study of cellular material?
Cytological examination is carried out annually for the purpose of preventive examination, even in the absence of pathological symptoms. Main indications for the study:
- Long-term treatment of inflammatory processes in the body with antibiotics;
- Pain in the pelvis;
- Beli with foul odor;
- Itching, redness on the genitals.
The doctor prescribes cytological smear mandatory for girls of childbearing age before planning conception. This allows you to find and treat existing pathologies before pregnancy begins.
How to prepare for the examination
Inadequate preparation for the study can affect the final result of the analysis. To correctly decipher the presence of squamous epithelium in a smear, it is recommended:
- Do not make love for forty-eight hours;
- Stop using it two days before contraception;
- On the eve of the study, perform hygiene procedures without using soap.
Cytological analysis is not performed during menstruation. The reliability of the analysis will increase if the smear is taken within a week after the end of your period. On the day of collection of the test, before visiting the doctor, it is not recommended to urinate for one and a half hours.
How does the smear procedure work?
Before prescribing the test, the gynecologist notifies the patient about the upcoming procedure in advance to prepare the woman for the study. On next appointment The doctor takes a smear from the mucous membranes of the cervix, urethra and vagina: special tool Scraping is done from those places that, according to the doctor, have undergone pathological changes.
The collected material is placed on a glass slide and sent to the laboratory. Test results can usually be obtained within a week or a little earlier.
Analysis of a smear for cytology in some cases may contain unreliable information about the condition of the epithelial layer of the vagina or urethra. Factors that can change clinical picture tests for squamous epithelium are quite numerous. This includes the use of hormonal therapy for the treatment of diseases, the period after ovulation, and the onset of menopause.
Normal squamous epithelium in a smear and deviations from this norm
U healthy woman the smear reveals from three to fifteen units of squamous epithelium. Subject to availability pathological processes squamous epithelial cells in the smear can be found in significantly larger or, conversely, smaller numbers.
An excess number of epithelial cells indicates the presence of leukoplakia, a disease in which the production of certain hormones is reduced. Leukoplakia - serious illness, which can lead to infertility and the appearance of tumors.
This pathology is characterized by increased exfoliation of keratinized epithelial cells. The disease is caused by:
- Imbalance in work endocrine system;
- Reduced immunity;
- Respiratory diseases more than twice a year;
- Chronic infectious diseases genitals;
- Often - piercing in the intimate area.
An increase in squamous epithelium in the analysis can also indicate vaginitis - an inflammatory process of an infectious nature.
Signs of vaginitis:
- Foul-smelling discharge;
- Itching in the vulva area;
- Burning in the vagina;
- Pain during intimacy.
If a woman has a smear in addition to increased amount epithelial cells, key cells are present, and infectious vaginitis caused by Gardnerella is suspected. If a pathology is detected, the doctor prescribes antibacterial therapy to the patient and her sexual partner.
A decrease in the number of squamous epithelial cells is also alarming symptom, which can occur with estrogen deficiency. An imbalance often occurs in women after forty years, when the production of female hormones decreases. This decrease leads to thinning of the mucous membranes, and the process of renewal of epithelial cells slows down significantly. At the same time, the environment inside the vagina becomes not acidic, but neutral and even alkaline. This leads to growth pathogenic flora, which was previously held back by unsuitable conditions.
The vaginal walls become dehydrated and inflammatory processes appear. The following symptoms are characteristic of epithelial cell atrophy:
- Complete absence of discharge;
- Vaginal dryness during sex, making sexual intercourse difficult;
- Bleeding from the walls of the vagina;
- Frequent urination.
Atrophic changes are a reason to regularly see a gynecologist. They may precede various pathologies, including very serious ones. The doctor prescribes how symptomatic treatment(for example, the use of lubricants during sexual intercourse), and general - hormonal therapy.
(23 Votes)