大型弥漫型子宫腺肌病保守性手术及药物治疗综合管理疗效分析

摘要

目的 探讨保守性手术联合促性腺激素释放激素激动剂(GnRH-a)与左炔诺孕酮宫内缓释系统(LNG-IUS)治疗(下称综合治疗)大型弥漫型子宫腺肌病(LDAM)综合管理疗效.方法 对2009年3月至2011年9月在复旦大学附属妇产科医院就诊的14例LDAM患者给予综合治疗.LDAM指超声提示子宫长径、前后径、横径中有一单径超过95 mm,或者提示有一单径线达到85～95 mm,而且同时提示子宫内另含较集中的腺肌病病灶≥2个,每个病灶直径均大于35 mm.所有患者用戈舍瑞林3.6 mg腹部皮下注射3个月后行保守性手术,术后延续使用GnRH-a 3个月,相当于第6支GnRH-a注射后28d放置LNG-IUS,并继续随访48个月,观察其疗效、月经模式及副反应.GnRH-a注射期间同时口服中药坤泰胶囊及钙尔奇D片,以减少低雌激素症状与骨量丢失.于GnRH-a治疗前后、放置LNG-IUS后第1年内每3个月和第2、3年每6个月以及第4年末分别随访1次,观察其疗效、月经模式及副反应.结果 综合治疗后的12例完成随访,与治疗前相比,子宫平均体积从治疗前410.6 cm3下降到166.3 cm3,内膜厚从8.3mm下降到6.2 mm,视觉模拟评分法(VAS)评分从8.6分下降到2.9分,血红蛋白从75.0 g/L上升到142.1g/L,血清CA125从78.9kU/L下降到27.1 kU/L.其月经模式趋向规则、经量减少并走向月经稀发.其中有2例于放置宫内节育器后第6年已同时实施了取出LNG-IUS并置入新的LNG-IUS术.另有1例放置宫内节育器后18个月脱落,1例放置宫内节育器后36个月取器后自然妊娠.放置宫内节育器期间主要副反应表现为脱落、卵巢囊肿、体重增加、痤疮、乳房胀痛等.结论 经腹保守性手术联合GnRH-a与LNG-IUS治疗LDAM是有效、可行的长期综合管理措施.%Objective To investigate the effect of comprehensive management for large diffuse adenomyosis (LDAM)by using conservative surgery combined with GnRH-a and levonorgestrel-releasing intrauterine system (LNG-IUS).Methods Fourteen patients with LDAM were treated by using comprehensive treatment with abdominal conservative surgery combined with GnRH-a and LNG-IUS at the Affiliated Obstetrics and Gynecology Hospital of Fudan University between March 2009 and September 2011.Subcutaneous injection of 3.6-mg goserelin was performed in all patients for 3 months,and then conservative surgery was performed.Then,the GnRH-a treatment was continued for 3 months;with follow-up of 48 months.During the GnRH-a injection,the traditional Chinese medicine Kuntai capsule and Caltech D tablets were given to reduce symptoms of low estrogen level and bone loss.The treatment effects,menstrual pattern,and side effects were observed for 48 months.Before and after the GnRHa treatment,every 3 months in the first year,every 6 months in the second and third year,and at the end of the fourth year after placement of Mirena,the curative effect,menstrual pattern,and side effects were observed.Results After long-term comprehensive management 12 cases finished the follow-up,the uterine volume was significantly reduced (from 410.6 cm3 to 166.3 cm3),the endometrial thickness was significantly thinner (from 8.3 mm to 6.2mm),dysmenorrhea scores were reduced (from 8.6 to 2.9),and hemoglobin level increased significantly (from 75.0 g/L to 142.1 g/L),and serum CA125 level decreased significantly(from 78.9 kU/L to 27.1 kU/L).The menstrual pattern characterized by irregular vaginal bleeding was improved and tended to be regular.Menstrual quantity decreased and tended to be oligomenorrhea or amenorrhea.In two patients,the implanted LNG-IUS was replaced with a new one after 6 years.One patient had ring off after 18 months,and another patient had the LNG-IUS removed after 36 months and was impregnated naturally.The main side effects were expulsion of LNG-IUS,ovarian cysts,weight gain,acne,and breast tenderness.Conclusion Long-term comprehensive management for large diffuse adenomyosis by using conservative surgery combined with GnRH-a and LNG-IUS is effective and feasible.