左炔诺孕酮宫内缓释系统用于防治子宫内膜异位症和子宫腺肌病的临床观察

Effects of levonorgestrel-releasing intrauterine system on pain and recurrence associated with endometriosis and adenomyosis

目的观察左炔诺孕酮宫内缓释系统(LNG-IUS)用于治疗子宫内膜异位症(EM)及子宫腺肌病(AM)相关疼痛和防止复发的疗效。方法EM患者21例,AM患者12例,于保守性手术后即刻,或单纯疼痛复发后放置LNG-IUS,EM患者中有4例在放置前注射促性腺激素释放激素激动剂(GnRHa),AM患者中有5例放置前注射GnRHa。以放置LNG-IUS前后自身对照,比较疼痛视觉模拟评分(VAS)、血清生殖激素和CA125水平,随诊记录阴道出血等副反应的发生情况;放置前注射GnRHa者与单纯放置者比较出血模式的差异。结果疼痛复发后单纯放置LNG-IUS的5例EM患者,VAS评分由放置前的(8·09±0·21)降至(1·64±1·12)分,两者比较,差异有统计学意义(P=0·042);5例单纯放置LNG-IUS的AM患者,VAS评分由(8·41±1·59)降至(3·99±3·87)分,两者比较,差异无统计学意义(P=0·068)。所有患者于随访期限内,仅2例患者分别出现疼痛或病灶复发,其余患者无疼痛或病灶的复发。放置LNG-IUS后有30例患者完成了初次随诊,初次随诊时间平均为5个月,月平均出血天数18·6d,以不规则点滴出血为主;放置LNG-IUS前是否加用GnRHa的患者月平均出血天数分别为(19±6)和(18±6)d,两者比较,差异无统计学意义(P=0·089)。随诊满1年时,22例患者转为每月规律性阴道出血,月平均出血天数8d。结论LNG-IUS能有效控制EM和AM相关疼痛并延缓复发,不规则和(或)点滴阴道出血是最显著的副反应,放置前注射GnRHa对出血的改善效果欠佳。

Objective To observe the effects of levonorgestrel-releasing intrauterine system （ LNG- IUS） in treatment of pain associated with endometriosis （ EM ） and adenomyosis （ AM ） , and in prevention of disease recurrence. Methods Thirty-three cases of moderate to severe EM or AM patients received insertion of LNG-IUS immediately after conservative operation, or after recurrence of simple pain, and were self controlled respectively before and after insertion of LNG-IUS. The visual analogue scale （VAS） was compared, and the change of the lesion and the uterine size, as well as the serum steroid and CA125 were observed. The side-effects, such as bleeding pattern were recorded. The bleeding period was compared between the cases injected with or without gonadotropin-releasing hormone agonist （GnRHa） before insertion of LNG-IUS. Results Baseline and follow-up VASs of EM were 8. 09 ± 0. 21 and 1.64 ± 1.12 （P = 0. 042）, of AM were 8.41 ± 1.59 and 3.99 ± 3.87 （P = 0. 068 ）, respectively. During nearly 2 years＇ follow-up, moderate dysmenorrhea recurred in only 1 case who was hyper-estrogenism at that time. Generally, irregular bleeding and spotting period were longer in this LNG-IUS treated group than those reported in literatures in which LNG-IUS was used for contraception. Persistent prolonged spotting was seen in most of the patients during 1 year follow-up. Average bleeding days in one month during the first 6 months after insertion of LNG-IUS were both around 18 days, whether using GnRHa or not. Conclusions LNG-IUS greatly reduces pain associated with EM and AM, and delays disease recurrence. Irregular bleeding and spotting is the main side effects. Administration of GnRHa in advance does not improve the bleeding symptoms.