摘要
目的观察促性腺激素释放激素激动剂(GnRHa)和左炔诺孕酮宫内节育系统(LNG-IUS)分级治疗方案对于子宫不同程度增大的子宫肌腺症的疗效。方法选取2010年1月-2013年12月于复旦大学附属妇产科医院诊断为子宫肌腺症的92例患者,将其分入轻度增大LNG-IUS组(11例)、轻度增大联合治疗组(20例)、中度增大联合治疗组(39例)、重度增大联合治疗组(13例)和单纯GnRHa治疗组(9例),分别于治疗前(T0),注射GnRHa后1(T1)、2(T2)、3(T3)、6个月(T4),以及放置LNG-IUS后1(t1)、3(t2)、6(t3)、12(t4)、24(t5)、36个月(t6)时随访1次,对比治疗前后患者的子宫体积、血清CA125水平、痛经和月经情况,并记录患者LNG-IUS脱落和续用情况,观察不同治疗方案的疗效。结果轻度增大LNG-IUS组患者在t3至t5时间点的子宫体积,轻度增大联合治疗组患者在T1(即t1)、T2、T3(即t2)和t3至t5时间点的子宫体积,中度增大联合治疗组患者在T1至T3、t1至t4时间点的子宫体积,重度增大联合治疗组患者在T1至T4、t1至t3时间点的子宫体积均显著小于同组T0时间点(P值均<0.05)。轻度增大LNG-IUS组患者在t2至t6时间点的疼痛视觉模拟评分(VAS评分),轻度和中度增大联合治疗组患者在t1至t6时间点的疼痛VAS评分,重度增大联合治疗组患者在t1至t4时间点的疼痛VAS评分均显著低于同组T0时间点(P值均<0.05);轻度和中度增大联合治疗组抑制痛经的时间持续≥3年,重度增大联合治疗组抑制痛经的时间持续<2年;轻度增大联合治疗组患者在t1、t2时间点的疼痛VAS评分显著低于轻度增大LNG-IUS组同时间点(P值均<0.05)。轻度增大LNGIUS组和轻度增大联合治疗组患者在t2、t3时间点的CA125水平,中度增大联合治疗组患者在T3、t2、t3时间点的CA125水平,重度增大联合治疗组患者在T3、T4、t2、t3时间点的CA125水平均显著低于同组T0时间点(P值均<0.05)。轻度增大LNG-IUS组患者在t3时间点的CA125水平显著低于同组t2时间点(P<0.05),中度增大联合治疗组患者在t2时间点的CA125水平显著低于同组T3时间点(P<0.05)。轻度、中度和重度增大联合治疗组患者在t2时间点的CA125水平均显著低于轻度增大LNG-IUS组同时间点(P值均<0.05),轻度增大联合治疗组患者在t3时间点的CA125水平显著低于重度增大联合治疗组同时间点(P<0.05)。在随访期间,83例放置LNG-IUS的患者中,发生环脱落5例,其中轻度增大LNG-IUS组1例,中度增大联合治疗组2例,重度增大联合治疗组2例;发生环位下移6例,其中轻度增大LNG-IUS组1例,轻度增大联合治疗组1例,中度增大联合治疗组2例,重度增大联合治疗组2例。更改治疗方案15例,其中轻度增大LNG-IUS组1例,中度增大联合治疗组4例,重度增大联合治疗组10例。结论对于子宫增大不明显、症状不严重的肌腺症患者,可单用LNG-IUS治疗;对于子宫中度增大的肌腺症患者,可采用先注射GnRHa 3针预处理后放置LNG-IUS的联合治疗方案;对于子宫增大严重的肌腺症患者,GnRHa联合LNG-IUS治疗方案的总体疗效和满意度较低,可行保守性手术后再联合GnRHa和LNG-IUS治疗。
Objective To evaluate the clinical outcomes of classified conservative treatment for adenomyosis using levonorgestrel-releasing intrauterine system （LNG-IUS） combined with gonadotropin-releasing hormone agonist （GnRHa）. Methods A total of 92 patients diagnosed as adenomyosis between January 2010 andDecember 2013 were treated by using LNG-IUS or LNG-IUS combined with GnRHa. Of them, 11 patients with mildly enlarged uterus （group A） underwent solo LNG-IUS, other 20 patients with mildly enlarged uterus （group B） received LNG-IUS combined with GnRHa, 39 with moderately enlarged uterus （group C） and 13 with severely enlarged uterus （group D） also received combined treatment, and other 9 with severely enlarged uterus were treated only by GnRHa （group E）. Follow-up was taken at the following time points~ pretreatment （To）, 1 month （T1）, 3 months （T3） and 6 months （T4） after injection of GnRHa, 1 month （tl）, 3 months （t2）, 6 months （t3）, 12 months （t4）, 24 months （t5） and 36 months （t6） after placing LNG-IUS. During follow-up, the size of uterus and serum 0A125 were measured, and dysmenorrheal, menstrual cycles, and continuous use of LNG-IUS were recorded. Results Compared with that at To, uterus in group A at t3to t5, in group B at T1 （tl） ,T2, T3 （t2）, and t3 to t5, in group C at T1 to T3, and t1 to t4, in group D at T1 to T4, and tlto t3 were significantly decreased Call P〈 0.05）. Compared with that at To, visual analogue scale （VAS） score in group A at t2to t6, in group B and C at t1 to t6, in group D at t1 to t4 were also significantly decreased Call P〈0.05）. Dysmenorrhea were inhibited at least 3 years in group A, B and C, while less than 2 years in group D. VAS score in group B were significantly less than those in group A at tt and t2 （both P〈0.05）. Compared with that at To, serum level of CA125 in group A and B at t2 and t3, in group C at T3, t2 and t3, in group D at T3, t4, t2 and T3 were significantly decreased Call P〈0.05）. Serum level of 0A125 in group A at t3 was significantly lower than that at t2 （P〈0.05）. Serum CA125 level in group C at t2 was significantly lower than that at T3（P〈0.05）. Serum CA125 level in group B, C and D at t2 were significantly lower than those in group A Call P〈0.05）. Serum CA125 level in group B at t3 was significantly lower than that in group D （P〈0.05）. During follow-up, LNG-IUS fell off in 5 patients Cone in group A, two in group C and another two in group D） and moved down in 6 patients （one in group A, another one in group B, two in group C and another two in group D）. Treatment plan was changed in 15 patients Cone in group A, four in group C and 10 in group D）. Conclusion LNG-IUS refers to the adenomyosis patients with normal or mildly enlarged uterus and mild symptoms. For those with moderately enlarged uterus, GnRHa can be used at first for 3 months and then LNG- iUS is placed. For those with severely enlarged uterus, the over-all effect of GnRHa combined LNG-IUS treatment is not satisfying, so patients should be suggested to undergo conservative surgical treatment followed by GnRHa and LNG-IUS.
出处
《上海医学》
CAS
CSCD
北大核心
2015年第3期239-244,共6页
Shanghai Medical Journal
