腹腔镜保守性手术联合药物治疗中、重度子宫内膜异位症及地诺孕素治疗复发性子宫内膜异位症性盆腔痛的疗效分析

摘要

Objective To investigate the curative effect oflaparoscopic conservative surgery combined with commonly used drugs in treatment of moderate and severe endometriosis (EMS),and the curative effect and security of dienogest in the treatment of recurrent endometriosis-associated pelvic pain (EAPP).Methods Totally 432 patients who had a laparoscopic conservative surgery in the treatment of EMS from January 2007 to January 2014 were analyzed retrospectively and follow-up visited.These patients were divided into 4 groups by different postoperative drugs:group A (laparoscopic conservative surgery alone),group B [laparoscopic conservative surgery combined with gonadotropin releasing hormone agonist (GnRH-a)],group C [laparoscopic conservative surgery combined with levonorgestrel releasing intrauterine system (IUS-LNG)] and group D (laparoscopic conservative surgery combined with gestrinone).Fifteen patients with recurrent EAPP used dienogest 2 mg daily for 6-13 cycles.The remission of EAPP in each group,the postoperative pregnancy rate/time of infertile EMS patients,and the recurrence rate/time of EMS were analyzed.The curative effect and security of dienogest in the treatment of EAPP was assessed.Results 1) The visual analogue score (VAS) of EAPP patients were improved significantly after treatment in each group,patients in group B and group C improved more.2) The recurrence rate and recurrence time of EMS showed no statistical difference among four groups.3) The pregnancy rate of infertile patients was 40.0％ in group A,65.21％ in group B and 50.0％ in group D;group B improved more.4) The VAS scores of EAPP recurrence patients after treatment with dienogest showed statistical difference with before.Conclusions 1) Laparoscopic conservative surgery alone or laparoscopic conservative surgery combined with drug both could relieve EAPP and improve pregnancy rate.2) Laparoscopic conservative surgery combined with GnRH-a or IUS-LNG could relieve EAPP more significantly.Laparoscopic conservative surgery combined with GnRH-a could improve the pregnancy rate,and do not prolong postoperative pregnancy time.3) There were no statistical differences of the recurrence rate and postoperative recurrence time of EMS between laparoscopic conservative surgery alone and laparoscopic conservative surgery combined with drug.4) Dienogest was expected to be an ideal drug in treatment of EAPP recurrence.%目的 探讨腹腔镜保守性手术联合常用药物对中、重度子宫内膜异位症(EMS)的治疗效果,以及新型药物地诺孕素对复发性子宫内膜异位症性盆腔痛(EAPP)的有效性及安全性.方法 对2007年1月一2014年1月行腹腔镜保守性手术治疗EMS的432例患者进行回顾性分析与随访,按照术后联合应用不同药物分为A组(单纯行腹腔镜保守性手术组)、B组(术后联合应用GnRH-a类药物组),C组[术后联合应用左炔诺孕酮宫内缓释系统(IUS-LNG)组],D组(术后联合应用孕三烯酮组).14名EAPP复发患者每日口服地诺孕素2 mg治疗6～13个周期.分析各组患者EAPP的缓解情况、EMS合并不孕患者的妊娠率与妊娠时间、EMS的复发率与复发时间;评估EAPP复发患者应用地诺孕素治疗的有效性及安全性.结果 ①4组EAPP患者治疗前后的中位视觉模拟评分(VAS)均得到明显改善;B组、C组患者的改善更为明显.②4组患者EMS术后复发率与复发时间比较无统计学差异.③A组、B组、D组合并不孕患者的术后妊娠率分别为40.00％、65.21％、50.00％;B组患者术后妊娠率更高.④应用地诺孕素治疗复发性EAPP的患者用药前后的VAS评分有统计学差异.结论 ①单纯行腹腔镜保守性手术与手术后联合应用药物均能改善EAPP,提高妊娠率.②联合应用GnRH-a类药物与IUS-LNG后EAPP改善更明显,联合应用GnRH-a类药物还可提高妊娠率,且不延长术后妊娠时间.③联合药物治疗后复发率与平均复发时间较单纯行腹腔镜保守性手术相比并未降低.④地诺孕素有望成为复发性EAPP理想的治疗药物.