GnRHa联合反加疗法治疗保守性手术后中重度子宫内膜异位症的临床分析

Clinical analysis of GnRHa combined with add-back therapy in treatment of advanced endometrosis after conservative surgery

目的比较中重度子宫内膜异位症患者保守性手术后辅助促性腺激素释放激素激动剂(gonadotrop in-re-leasing homone agonists,GnRHa)治疗中,联合结合型雌激素(CEE)和安宫黄体酮(MPA)反加疗法与否对治疗效果及副反应的影响,分析应用GnRHa联合反加治疗的必要性和时机。方法 将63例保守性手术后中重度子宫内膜异位症(en-dometriosis,EMT)患者随机分为2组:反加组(31例)术后皮下注射诺雷德,每4周1次,连续3次,于用药第2个月起加用倍美力0.625mg/d+安宫黄体酮4mg/d,连续2个月;单药组(32例)术后单用诺雷德治疗,比较两组治疗前后症状、体征、性激素水平、CA125、副反应、复发率和不孕患者的妊娠率。结果反加组、单药组临床疗效总有效率为93.55%、93.75%,复发率分别为9.68%、9.38%,两组复发都发生在停药后1～2年,两组临床疗效总有效率、复发率及复发间隔无统计学差异(P>0.05);两组患者在GnRHa治疗后1个月,FSH、LH、E2水平与治疗前比较均显著下降,E2降至绝经期水平,单药组比反加组下降更明显(P<0.05),停药后3个月均与用药前比较差异无显著性差异(P>0.05);两组血清学指标CA125阳性率均明显下降;反加组13例不孕患者中妊娠率为53.85%,单药组15例不孕患者中妊娠率则为53.33%,两组比较无显著性差异(P>0.05)。潮热等副反应发生率,单药组为87.50%,反加组仅25.00%,都在用药后1～2个月出现。结论 GnRHa联合反加疗法治疗保守性手术后中重度子宫内膜异位症可以缓解GnRHa的副反应,不影响疗效及复发,是治疗内异症较理想的方案,建议GnRHa用药后1月反向添加。

Objective To study the necessity and the time of GnRHa combined with add-back therapy by evaluating the efficacy and side-effect of GnRHa alone and in combination with hormond add-back therapy in treatment of advanced endometrosis after conservative surgery. Methods 63 cases of advanced endometrosis patients after conservative surgery were randomly divided into 2 groups： add-back group（n=31）which were treated with GnRHa 3.6mg by hypodemic injection of 3 dose, each given 4 weeks apart. CEE（0.625mg/d） and MPA（4mg/d） were used as add-back therapy from 2 to 3 courses of treatment. GnRHa alone group（n=32） were only treated with GnRHa after conservative surgery, compared with the symptoms and signs, serum reprodutive hormone level and CA125 in the two groups before and after treatment, recorded the side effects in treatment and recurrence, following pregnancy rate in infertility patients after treatment in both groups. Results The clinical total effective rate was 93.55% in add-back group and that was 93.75% in GnRHa alone group. The recurrent rates in the add-back group and GnRHa alone group were 9.68% ang 9.38%,respectively. The recurrences in both groups were occurred in 1~2 years after treatment. There were no significant differences between two groups in clinical total effective rates, recurrence rates and recurrence interal （P0.05）. Serum FSH, LH, E2 levels in both groups were suppressed by GnRHa within the first month, E2 levels fell into postmenopausal range, suppression of E2 level in GnRHa alone group was more significantly than that in add-back group（P0.05）. There were no difference in the levels of FSH, LH, E2 between before treatment and 3 months after treatment in both groups（P0.05）. Both positive rates of serum CA125 dropped obviously. There were no significant differences between two groups in pregnancy rates in the infertility patients after treatments, that in add-back group was 53.85%,that in GnRHa alone group was 53.33%. Hypoestrogenic side effects such as hot flush were more common in GnRHa alone group（87.50%） than that in add-back group（25.00%）, they both occurred in 1~2 months after treatments. Conclusion GnRHa combined with add-back therapy is an effective therapy in the treatment of advanced endometrosis after conservative surgery, it can relieve the side effect of GnRHa and has no effect on treatment results and recurrence, it is an ideal regimen for endometriosis, add-back therapy should be star from the second course of treatment.