高频微波子宫内膜去除术后宫腔影像随访观察

Hysteroscopic appearance of the endometrial cavity after microwave endometrial ablation

目的:随访微波子宫内膜去除术(MEA)后宫腔影像改变情况;评价MEA宫腔镜检查的意义。方法:在2000～2008年349例行MEA手术患者中术后随机抽取53例进行宫腔镜检查,观察患者MEA术后宫腔内膜的破坏、宫腔粘连的形成及组织愈合的情况;同时随访患者术后月经改变情况,探讨术后宫腔形态的变化与患者术后月经情况的联系。随访时间为术后1个月至术后8年。结果:共53例MEA术后患者行宫腔镜检查。术后3个月内宫腔内主要为坏死脱落的内膜组织及退变的平滑肌,患者月经改变为不规则点滴出血;术后半年,宫腔内可见肉芽组织形成及纤维化改变,患者表现为规律的少量月经或闭经;术后1年以上,宫腔内主要为瘢痕组织覆盖,而患者月经改变主要为闭经;术后2年以上,宫腔镜检查可见不同形态的宫腔粘连。共28例(52.8%)发生术后宫腔粘连,其中1例表现为宫颈管粘连,12例(22.6%)发生宫底部位灶性粘连,11例(20.7%)形成管状宫腔,双侧宫角均封闭,4例(7.5%)宫腔完全粘连、闭锁。此28例患者中,22例月经表现为闭经,4例表现为不规则的点滴出血,2例出现月经减少。结论:微波子宫内膜去除术后宫腔形态改变差异十分显著,患者术后月经改变与术后宫腔形态改变密切相关。术后行宫腔镜检查有助于对MEA术后各种阴道出血进行鉴别。

Objective：To assess the appearance of the endometrial cavity after microwave endometrial ablation.Methods：From 2000 to 2008,349 consecutive women who had undergone microwave endometrial ablation and who were followed up from 1 months to 8 years,were randomized invited to undergo outpatient hysteroscopy for assessment of the uterine cavity according to the postablation time.The presence of residual endometrium and intrauterine adhesions was noted and their locations recorded.The menstrual patterns of the women at the time of assessment were also recorded.We sought to evaluate the possible correlation between the hysteroscopic findings and the menstrual outcome.Results：53 women agreed and underwent outpatient diagnostic hysteroscopy.The median age at the time of endometrial ablation was 43.1years （range,33 to 53years）.Second-look hysteroscopy at 3 months or less after ablation were always exhibited varied necrosis in the endometrium and superficial myometrium,destroyed endometrium and the debris were seen in the uterus.Most of them developed minimal spotting during the menstrual cycles. Granulomatous reaction and fibrosis were present after 6 months postablation,fibrotic cavity could also be seen,the menstrual patterns of these women were regular reduction or cessation of menstrual flow. Post-hysteroscopy at 1 year after ablation showed fibrotic cavity,varied myofibrous scars could be seen. Most of the patients developed amenorrhea. All kinds of intrauterine adhesions were observed at second-look hysteroscopy after 2 years or more postablation. Postablation intrauterine adhesions were found in 28 women （52.8%）; 1 had cervical adhesion（1.9%）;12 had focal adhesions in the fundal area（22.6%）;11 patients（20.7%） formed narrowed uterus which liked a bucket ,whose endometrial cavity appeared totally scarred with bilateral stenotic ostia; 4（7.5%） had complete obliteration of the cavity. Of these 28 women,22 had amenorrhea ,4 had spotting during menstruation and 2 had hypomenorrhea.Conclusion：The hysteroscopic appearance of the uterine cavity after microwave endometrial ablation varies considerably. Menstrual outcome is associated with postablation appearance. Post-hysteroscopic ablative reaction should be recognized and distinguished from other causes of vaginal bleeding after microwave endometrial ablation.