左炔诺孕酮宫内缓释系统不同应用方法治疗子宫腺肌病疗效观察

Effect of different application methods of levonorgestrel intrauterine sustained-release system in the treatment of adenomyosis

目的探讨左炔诺孕酮宫内缓释系统(LNG-IUS)不同应用方法治疗子宫腺肌病的临床效果。方法采用随机抽样方法选择2014年12月至2017年12月在遵义医学院附属妇女儿童医院、遵义医学院附属医院、遵义市第一人民医院、遵义市播州区妇幼保健院进行诊治的300例子宫腺肌病患者为研究对象,根据腺肌瘤最大直径或子宫肌壁最大厚度将患者分为轻度组(腺肌瘤最大直径或肌壁最大厚度<30 mm)、中度组(腺肌瘤最大直径或肌壁最大厚度30～40 mm)和重度组(腺肌瘤最大直径或肌壁最大厚度> 40 mm),每组100例。轻度组患者于月经期第2～5天给予子宫内放置LNG-IUS;中度组患者于月经期第2～5天给予子宫内放置LNG-IUS,并每间隔28 d皮下注射亮丙瑞林3. 75 mg,共3次,或月经干净后给予高强度聚焦超声(HIFU)治疗;重度组患者于非经期给予肌壁大部切除-子宫重建术(MURU)治疗,并在术中给予子宫内放置LNG-IUS。比较3组患者治疗前及治疗后3个月的痛经程度、月经量评分、血清卵巢癌相关抗原(CA125)水平、子宫体积及治疗后3个月的不良反应。结果治疗前3组患者痛经程度、月经量评分、血清CA125水平比较差异均无统计学意义(F=0. 253、0. 562、0. 327,P> 0. 05),3组患者子宫体积比较差异有统计学意义(F=80. 042,P <0. 05)。治疗后3个月,3组患者痛经程度、月经量评分、血清CA125水平、子宫体积比较差异均无统计学意义(F=0. 242、0. 672、0. 672、0. 584,P> 0. 05)。3组患者治疗后3个月痛经程度、月经量评分、血清CA125水平及子宫体积均显著低于治疗前(P <0. 05)。治疗后3个月,轻度组、中度组、重度组患者不良反应发生率分别为16. 0%(16/100)、19. 0%(19/100)、18. 0%(18/100),3组患者不良反应发生率比较差异无统计学意义(χ~2=1. 488,P> 0. 05)。结论根据腺肌瘤最大直径或肌壁最大厚度选择LNG-IUS单独或联合促性腺激素释入激素抑制剂、HIFU、MURU治疗子宫腺肌病可以保留患者子宫并取得比较好的治疗效果。

Objective To investigate the clinical effect of different application methods of levonorgestrel intrauterine sustained-release system (LNG-IUS) in the treatment of adenomyosis.Methods A total of 300 patients with adenomyosis in the Maternal and Children Hospital Affiliated to Zunyi Medical University,the Affiliated Hospital of Zunyi Medical University,the First People's Hospital of Zunyi City and the Maternal and Children Hospital of Bozhou district of Zunyi City from December 2014 to December 2017 were selected as subjects.The patients were divided into mild group (the maximum thickness of myometrium or maximum thickness of uterine muscular wall <30 mm),moderate group (the maximum thickness of myometrium or maximum thickness of uterine muscular wall was 30-40 mm) and severe group (the maximum thickness of myometrium or maximum thickness of uterine muscular wall >40 mm) according to the maximum diameter of adenomyoma or maximum thickness of uterine muscular wall,100 cases in each group.The patients in the mild group were treated with LNG-IUS intrauterine placement on the 2^nd to 3^rd day of menstruation.The patients in the moderate group were treated with LNG-IUS intrauterine placement on the 4^th to 10^th day of menstruation,and leuprorelin 3.75 mg by subcutaneous injection every 28 days for three times,or high intensity focused ultrasound (HIFU) after menstruation.The patients in the severe group were treated with major uterine wall resection and reconstruction of the uterus (MURU) during non-menstrual period,and the LNG-IUS was placed in uterus during operation.The degree of dysmenorrhea,menstrual volume score,the level of serum carbohydrate antigen 125 (CA125) and uterine volume of patients in the three groups were observed before and three months after operation;and the adverse reaction was observed at three months after treatment.Results There was no significant difference in the degree of dysmenorrhea,menstrual volume score and the level of serum CA125 among the three groups before treatment (F=0.253,0.562,0.327;P>0.05).There was significant difference in uterine volume among the three groups (F=80.042,P<0.05).Three months after treatment,there was no significant difference in the degree of dysmenorrhea,menstrual volume score,serum CA125 level and uterine volume among the three groups (F=0.242,0.672,0.672,0.584;P>0.05).The degree of dysmenorrhea,menstrual volume score,serum CA125 level and uterine volume of the patients at three months after treatment were significantly lower than those before treatment in the three group(P<0.05).Three months after treatment,the incidence of adverse reactions in the mild group,moderate group and severe group was 16.0%(16/100),19.0%(19/100) and 18.0%(18/100),respectively.There was no significant difference in the incidence of adverse reactions among the three groups (χ^2=1.488,P>0.05).Conclusion LNG-IUS alone or in combination with gonadotropin-releasing hormone antagonist,HIFU and MURU in the treatment of adenomyosis can reserve the uterus according to the maximum diameter of adenomyoma,and achieve better therapeutic effect.