阴道用雌二醇预防中重度宫腔粘连术后复发的效果研究

发布时间：2018-01-05 01:34

本文关键词：阴道用雌二醇预防中重度宫腔粘连术后复发的效果研究　出处：《中山大学》2015年硕士论文　论文类型：学位论文

【摘要】：研究背景宫腔粘连(intrauterine adhesions,IUA),又叫Asherman综合征,是因子宫内膜基底层损伤性后病理性修复所形成的宫腔或宫颈局部或全部粘连,从而影响患者月经及生育功能的一种常见临床疾病,多由宫腔操作及子宫内膜感染等引起,临床可表现为月经量减少、闭经、周期性腹痛、不孕、习惯性流产等。宫腔镜检查是IUA诊断的金标准,超声及子宫输卵管造影等可辅助诊断。根据美国生育协会1988年制定评分标准,结合患者月经及粘连情况可将IUA分为轻、中至重度粘连,可提示预后和指导治疗。宫腔镜下粘连分离术(transcervical resection of adhesions,TCRA)是目前治疗宫腔粘连的基本方法,如何减少复发和改善预后是难点。目前,临床上常用的辅助措施包括宫腔放置物理屏障及生物胶体,口服大剂量雌激素和生物移植等。中、重度宫腔粘连术后复发率为20.0%~78.9%,治疗效果仍不能令人满意。阴道用雌二醇在辅助生育技术中显示出较口服途径更好的促进子宫内膜增生的作用效果。本研究拟在TCRA联合宫腔放置球囊子宫支架治疗中、重度IUA的基础上,通过比较术后分别予口服及阴道用17β-雌二醇的人工周期预防IUA术后复发粘连的效果,从而探讨阴道用17β-雌二醇在预防中重度宫腔粘连分离术后复发的应用价值。研究目的1.比较TCRA术两种雌激素治疗方法预防中、重度IUA复发的效果,探讨阴道用雌二醇的有效性及安全性。2.两种用药途径相应血清雌二醇(E2)水平及治疗过程中子宫内膜厚度的情况。3.中、重度IUA患者治疗后血清雌激二醇水平与子宫内膜厚度、疗效的关系。研究对象与方法收集我院2014年03月01日~2014年12月31日宫腔镜下确诊为中、重度宫腔粘连患者共50例,将患者随机分成研究组及对照组。所有患者均予行B超引导下TCRA术成功重建宫腔形态,术中予生物胶体冲洗宫腔,在抗炎治疗的同时放置球囊子宫支架7天后取出。术后,研究组给予17β-雌二醇1mg/天阴道给药的方案行人工周期治疗,对照组予17β-雌二醇8mg/天口服给药的方案行人工周期;两组患者用药3周,第三周均加地屈孕酮10mg BID口服,停药1周,共治疗3个人工周期。定期随访月经时间与经量、血清雌二醇水平、子宫内膜情况及用药不良反应。治疗结束后复查肝肾功能及凝血等评估药物副反应情况,必要时予对症处理。复查宫腔镜评估宫腔形态恢复情况,若有粘连复发,予钝性分离,粘连严重无法分离者则予入院二次手术治疗。收集相关临床资料,进行统计分析。结果1.研究组与对照组月经量改善率(68.0%和80.0%)、宫腔恢复正常率(64.0%和72.0%)、宫腔改善率(100.0%和96.0%)、二次手术率(12.0%和8.0%)、妊娠率(均为26.7%)以及术后AFS评分差值(中位数均为8.0分)比较均无统计学差异(P0.05)。2.研究组平均血清E2水平为(742.30±435.58)pg/ml,对照组患者为(253.28±131.31)pg/ml,差异具有统计学意义(P0.001);每个人工周期内研究组平均子宫内膜厚度在均高于对照组,但差异无统计学意义(P0.05)。3.患者血清E2水平与子宫内膜增长厚度及AFS评分差值的相关性均无统计学意义(P0.05),按血清E2不同水平[500pg/ml、(500~999)pg/ml和≥1000pg/ml]将患者分三组,比较第三个人工周期平均内膜厚度、子宫内膜增长厚度及AFS评分差值,各组之间差异无统计学意义(P0.05)。4.研究组与对照组不良反应率分别为28.0%和32.0%,差异无统计学意义(P0.05),常见症状有外阴阴道酵母菌性阴道炎(12.0%和20.0%)、消化道不适(8.0%和0.0%)和乳房胀痛(0.0%和4.0%),仅阴道炎需要药物治疗,其余症状均可自行缓解。两组患者肝肾及凝血功能、血脂在术前、术后与术后变化值无统计学差异(P0.05)。阴道雌二醇治疗对凝血、血脂及肝肾功能不造成明显不良影响。结论1.阴道和口服雌激素在预防中、重度宫腔粘连术后复发的疗效及不良反应结果相当,阴道用药更为经济、方便。2.跟口服雌激素相比,阴道用药血清E2水平更高,早期子宫内膜增长更快,但两种用药治疗3个周期后达到的子宫内膜厚度相当。3.当血清E2高于500pg/ml水平后,增加E2水平并不能进一步增加子宫内膜厚度及提高疗效。
[Abstract]:The research background of intrauterine adhesions (intrauterine adhesions, IUA), also called Asherman syndrome, is the basal layer of the endometrium pathological injury after repair of uterine cervical or partial or total adhesion, thus affecting a common clinical disease, menstruation and reproductive function of patients, caused by uterine cavity operation and uterine infection, clinical manifestations of oligomenorrhea, amenorrhea, periodic abdominal pain, infertility, habitual abortion. Hysteroscopy is the gold standard for the diagnosis of IUA, ultrasound and hysterosalpingography can assist the diagnosis. According to the American Fertility Association in 1988 to develop a standard for evaluation, combined with menstruation and adhesion can be IUA is divided into light, moderate to severe adhesion, prognosis and guiding the treatment. Hysteroscopic adhesiotomy (transcervical resection of adhesions, TCRA) is a basic method for treatment of intrauterine adhesions at present, how to reduce the complex And improve the prognosis is difficult. At present, the common clinical auxiliary measures including uterine cavity placed a physical barrier and Biocolloid, high-dose oral estrogen and biological transplantation. In severe intrauterine adhesions after operation, the recurrence rate was 20.0%~78.9%, the treatment effect is still not satisfactory. The vaginal estradiol in assisted reproductive technology display the oral route to better promote endometrial hyperplasia effect. This study was placed uterine stent in TCRA combined with uterine cavity in the treatment of severe IUA, based on the comparison after operation were given oral and vaginal artificial cycle 17 estradiol to prevent recurrence after IUA adhesion effect, so as to explore the vagina with 17 beta estradiol in the prevention of severe intrauterine adhesions after relapse prevention application. Objective: 1. TCRA comparison of two kinds of estrogen therapy, the effect of severe IUA recurrence, discussion The vagina with the efficacy and safety of.2. estradiol two ways of using the corresponding serum estradiol (E2) level and endometrial thickness in the treatment of.3. in severe IUA patients, serum estrogen estrogen level and endometrial thickness, curative effect. The relationship between the research objects and methods in our hospital from 2014 03 month 01 December 31st ~2014 hysteroscopy diagnosed in severe intrauterine adhesions in patients with a total of 50 cases, the patients were randomly divided into study group and control group. All patients were treated by ultrasound guided TCRA surgery successful reconstruction of uterine cavity shape, intraoperative to Biocolloid flushing the uterine cavity, and uterine balloon placement stents in anti-inflammatory therapy take out after 7 days. After the operation, the study group was given 17 estradiol 1mg/ days vaginal delivery scheme for artificial cycle therapy, control group was treated with 17 beta estradiol 8mg/ day oral administration scheme for artificial cycle; two groups of patients after treatment for 3 weeks, third Week plus dydrogestrone 10mg BID orally, stopping for 1 weeks, were treated with 3 artificial cycle. Regular follow-up time and the amount of menstruation, serum estradiol level, endometrium and adverse drug reaction. After the treatment of the adverse drug reaction of liver and kidney function and coagulation evaluation, if necessary, symptomatic treatment review assessment. Hysteroscopy uterine cavity shape recovery, if adhesion recurrence, to blunt separation, severe adhesion can not be separated is to two times to the hospital surgery. Collect clinical data for statistical analysis. Results of the 1. study group and control group menstrual improvement rate (68% and 80%), to restore normal uterine cavity the rate (64% and 72%), intrauterine improvement rate (100% and 96%), the two operation rate (12% and 8%), the pregnancy rate (26.7%) and postoperative AFS score (median of 8) were no statistically significant difference (P0.05) of.2. group mean serum E2 The flat is (742.30 + 435.58) pg/ml, the control group was (253.28 + 131.31) pg/ml, the difference was statistically significant (P0.001); the mean endometrial thickness in the study group were higher than the control group of each artificial cycle, but the difference was not statistically significant (P0.05) correlation between.3. and serum E2 level in patients with endometrial thickness and growth AFS scores were not statistically significant (P0.05, [500pg/ml) according to the different levels of serum E2, pg/ml and 1000pg/ml] (500~999) were divided into three groups, compared third artificial cycle average endometrial thickness, endometrial thickness and growth AFS score difference, no statistically significant difference between groups (P0.05) of.4. group and control the adverse reaction rates were 28% and 32%, the difference was not statistically significant (P0.05), common symptoms of vulvovaginal yeast vaginitis (12% and 20%), gastrointestinal discomfort (8% and 0%) and breast pain (0% and 4 %), only vaginitis need drug treatment, the symptom relieved by itself. Two groups of liver and kidney and blood coagulation function of patients with blood lipid in preoperative, postoperative and postoperative changes of value had no significant difference (P0.05). The vaginal estradiol treatment on blood coagulation, blood lipid and renal function did not cause significant adverse effects. Conclusion 1. vaginal and oral estrogen in the prevention of severe intrauterine adhesions postoperative recurrence of curative effect and adverse reaction results, vaginal medication is more economical and convenient.2. compared with oral estrogen vaginal medication serum E2 levels higher, early endometrial growth faster, but to two kinds of medication after 3 cycles of treatment of endometrial thickness is.3. when the serum E2 level was higher than that of 500pg/ml, increased E2 levels did not further increase the endometrial thickness and improve the curative effect.

【学位授予单位】：中山大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R713.4

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