本文關鍵詞：陰道用雌二醇預防中重度宮腔粘連術后復發(fā)的效果研究　出處：《中山大學》2015年碩士論文　論文類型：學位論文

  更多相關文章： 宮腔粘連 Asherman綜合征 雌二醇 宮腔粘連松解術

【摘要】：研究背景宮腔粘連(intrauterine adhesions,IUA),又叫Asherman綜合征,是因子宮內(nèi)膜基底層損傷性后病理性修復所形成的宮腔或?qū)m頸局部或全部粘連,從而影響患者月經(jīng)及生育功能的一種常見臨床疾病,多由宮腔操作及子宮內(nèi)膜感染等引起,臨床可表現(xiàn)為月經(jīng)量減少、閉經(jīng)、周期性腹痛、不孕、習慣性流產(chǎn)等。宮腔鏡檢查是IUA診斷的金標準,超聲及子宮輸卵管造影等可輔助診斷。根據(jù)美國生育協(xié)會1988年制定評分標準,結(jié)合患者月經(jīng)及粘連情況可將IUA分為輕、中至重度粘連,可提示預后和指導治療。宮腔鏡下粘連分離術(transcervical resection of adhesions,TCRA)是目前治療宮腔粘連的基本方法,如何減少復發(fā)和改善預后是難點。目前,臨床上常用的輔助措施包括宮腔放置物理屏障及生物膠體,口服大劑量雌激素和生物移植等。中、重度宮腔粘連術后復發(fā)率為20.0%~78.9%,治療效果仍不能令人滿意。陰道用雌二醇在輔助生育技術中顯示出較口服途徑更好的促進子宮內(nèi)膜增生的作用效果。本研究擬在TCRA聯(lián)合宮腔放置球囊子宮支架治療中、重度IUA的基礎上,通過比較術后分別予口服及陰道用17β-雌二醇的人工周期預防IUA術后復發(fā)粘連的效果,從而探討陰道用17β-雌二醇在預防中重度宮腔粘連分離術后復發(fā)的應用價值。研究目的1.比較TCRA術兩種雌激素治療方法預防中、重度IUA復發(fā)的效果,探討陰道用雌二醇的有效性及安全性。2.兩種用藥途徑相應血清雌二醇(E2)水平及治療過程中子宮內(nèi)膜厚度的情況。3.中、重度IUA患者治療后血清雌激二醇水平與子宮內(nèi)膜厚度、療效的關系。研究對象與方法收集我院2014年03月01日~2014年12月31日宮腔鏡下確診為中、重度宮腔粘連患者共50例,將患者隨機分成研究組及對照組。所有患者均予行B超引導下TCRA術成功重建宮腔形態(tài),術中予生物膠體沖洗宮腔,在抗炎治療的同時放置球囊子宮支架7天后取出。術后,研究組給予17β-雌二醇1mg/天陰道給藥的方案行人工周期治療,對照組予17β-雌二醇8mg/天口服給藥的方案行人工周期;兩組患者用藥3周,第三周均加地屈孕酮10mg BID口服,停藥1周,共治療3個人工周期。定期隨訪月經(jīng)時間與經(jīng)量、血清雌二醇水平、子宮內(nèi)膜情況及用藥不良反應。治療結(jié)束后復查肝腎功能及凝血等評估藥物副反應情況,必要時予對癥處理。復查宮腔鏡評估宮腔形態(tài)恢復情況,若有粘連復發(fā),予鈍性分離,粘連嚴重無法分離者則予入院二次手術治療。收集相關臨床資料,進行統(tǒng)計分析。結(jié)果1.研究組與對照組月經(jīng)量改善率(68.0%和80.0%)、宮腔恢復正常率(64.0%和72.0%)、宮腔改善率(100.0%和96.0%)、二次手術率(12.0%和8.0%)、妊娠率(均為26.7%)以及術后AFS評分差值(中位數(shù)均為8.0分)比較均無統(tǒng)計學差異(P0.05)。2.研究組平均血清E2水平為(742.30±435.58)pg/ml,對照組患者為(253.28±131.31)pg/ml,差異具有統(tǒng)計學意義(P0.001);每個人工周期內(nèi)研究組平均子宮內(nèi)膜厚度在均高于對照組,但差異無統(tǒng)計學意義(P0.05)。3.患者血清E2水平與子宮內(nèi)膜增長厚度及AFS評分差值的相關性均無統(tǒng)計學意義(P0.05),按血清E2不同水平[500pg/ml、(500~999)pg/ml和≥1000pg/ml]將患者分三組,比較第三個人工周期平均內(nèi)膜厚度、子宮內(nèi)膜增長厚度及AFS評分差值,各組之間差異無統(tǒng)計學意義(P0.05)。4.研究組與對照組不良反應率分別為28.0%和32.0%,差異無統(tǒng)計學意義(P0.05),常見癥狀有外陰陰道酵母菌性陰道炎(12.0%和20.0%)、消化道不適(8.0%和0.0%)和乳房脹痛(0.0%和4.0%),僅陰道炎需要藥物治療,其余癥狀均可自行緩解。兩組患者肝腎及凝血功能、血脂在術前、術后與術后變化值無統(tǒng)計學差異(P0.05)。陰道雌二醇治療對凝血、血脂及肝腎功能不造成明顯不良影響。結(jié)論1.陰道和口服雌激素在預防中、重度宮腔粘連術后復發(fā)的療效及不良反應結(jié)果相當,陰道用藥更為經(jīng)濟、方便。2.跟口服雌激素相比,陰道用藥血清E2水平更高,早期子宮內(nèi)膜增長更快,但兩種用藥治療3個周期后達到的子宮內(nèi)膜厚度相當。3.當血清E2高于500pg/ml水平后,增加E2水平并不能進一步增加子宮內(nèi)膜厚度及提高療效。
[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.

【學位授予單位】：中山大學
【學位級別】：碩士
【學位授予年份】：2015
【分類號】：R713.4

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