子宫腺肌病患者的MRI特征与临床症状及治疗效果的关系

Analysis of the relationship between MRI imaging characteristics and clinical symptoms and therapeutic efficacy in adenomyosis patients

目的探讨子宫腺肌病患者的磁共振成像(MRI)特征与临床症状及治疗效果的关系。方法自行设计"子宫腺肌病临床特征调查表", 对459例于2015年9月至2020年9月在北京大学第三医院就诊并行盆腔MRI检查确诊为子宫腺肌病的患者进行回顾性调查研究。收集患者的临床症状及治疗情况;在MRI下确定病灶的位置, 并测量病灶最大厚度、肌层最大厚度、宫腔长度、子宫体积、病灶与内膜及浆膜的最小距离, 以及是否合并卵巢子宫内膜异位囊肿(OMA);分析子宫腺肌病患者MRI特征的差异以及MRI特征与临床症状及治疗效果之间的关系。结果 (1)459例子宫腺肌病患者的年龄为(39.1±6.4)岁, 合并痛经的患者376例(81.9%, 376/459), 合并月经量多者195例(42.5%, 195/459), 合并不孕者145例(31.6%, 145/459)。(2)患者是否合并痛经与宫腔长度、子宫体积、病灶/肌层最大厚度比、是否合并OMA相关(P均<0.001);多因素分析显示, 合并OMA为患者痛经的独立危险因素(OR=0.438, 95%CI为0.226~0.850, P=0.015)。患者是否合并月经量多与年龄、是否合并OMA、宫腔长度、病灶距内膜及浆膜的最小距离、子宫体积、病灶/肌层最大厚度比相关(P均<0.001);多因素分析显示, 病灶/肌层最大厚度比增大是患者月经量多的独立危险因素(OR=774.791, 95%CI为3.500~1.715×105, P=0.016)。患者是否合并不孕与年龄、病灶距内膜及浆膜的最小距离、是否合并OMA相关(P均<0.01);多因素分析显示, 年龄小和子宫体积大是患者不孕的独立危险因素(OR=0.845, 95%CI为0.809~0.882, P<0.001;OR=1.001, 95%CI为1.000~1.002, P=0.009)。(3)51例体外受精-胚胎移植(IVF-ET)患者的成功率为39.2%(20/51), 合并痛经、痛经最重时的视觉模拟评分法评分高及子宫体积大是影响IVF-ET成功率的因素(P均<0.05)。病灶最大厚度越小, 病灶距浆膜距离越近、距内膜距离越远, 子宫体积越小, 病灶/肌层最大厚度比越小的子宫腺肌病患者, 孕激素类药物治疗的疗效越好(P均<0.05)。结论合并OMA增加了子宫腺肌病患者发生痛经的风险;病灶/肌层最大厚度比是月经量多的危险因素;年龄小、子宫体积大可致合并不孕的风险增大;痛经程度重及子宫体积大会影响患者IVF-ET的成功率;病灶小、远离内膜的子宫腺肌病患者, 孕激素类药物治疗的效果相对更好。

Objective To investigate the relationship between magnetic resonance imaging(MRI)imaging characteristics and clinical symptoms and therapeutic efficacy in adenomyosis patients.Methods The clinical characteristics of the adenomyosis questionnaire was self-designed.This was a retrospective study.From September 2015 to September 2020,totally 459 patients were diagnosed with adenomyosis and underwent pelvic MRI examination at Peking University Third Hospital.Clinical characteristics and treatment were collected,MRI was used to determine the lesion location,and to measure the maximum lesion thickness,the maximum myometrium thickness,uterine cavity length,uterine volume,the minimum distance between the lesion and serosa or endometrium,and whether combined with ovarian endometrioma.The difference of MRI imaging characteristics in patients with adenomyosis and its relationship with clinical symptoms and therapeutic efficacy were analyzed.Results(1)Among the 459 patients,the age was(39.1±6.4)years.There were 376 patients(81.9%,376/459)with dysmenorrhea.Whether patients had dysmenorrhea were related to uterine cavity length,uterine volume,ratio of the maximum lesion thickness to the maximum myometrium thickness,and whether patients had ovarian endometrioma(all P<0.001).Multivariate analysis suggested that ovarian endometrioma was the risk factor for dysmenorrhea(OR=0.438,95%CI:0.226-0.850,P=0.015).There were 195 patients(42.5%,195/459)with menorrhagia.Whether patients had menorrhagia were related to age,whether patients had ovarian endometrioma,uterine cavity length,the minimum distance between lesion and endometrium or serosa,uterine volume,ratio of the maximum lesion thickness to the maximum myometrium thickness(all P<0.001).Multivariate analysis suggested that ratio of the maximum lesion thickness to the maximum myometrium thickness was the risk factor for menorrhagia(OR=774.791,95%CI:3.500-1.715×105,P=0.016).There were 145 patients(31.6%,145/459)with infertility.Whether the patients had infertility were related to age,the minimum distance between lesion and endometrium or serosa,and whether patients had ovarian endometrioma(all P<0.01).Multivariate analysis suggested that young and large uterine volume were risk factors for infertility(OR=0.845,95%CI:0.809-0.882,P<0.001;OR=1.001,95%CI:1.000-1.002,P=0.009).(2)The success rate of in vitro fertilization-embryo transfer(IVF-ET)was 39.2%(20/51).Dysmenorrhea,high maximum visual analogue scale score and large uterine volume affected the success rate of IVF-ET(all P<0.05).The smaller the maximum lesion thickness,the smaller the distance between the lesion and serosa,the larger the distance between the lesion and endometrium,the smaller the uterine volume,and the smaller the ratio of the maximum lesion thickness to the maximum myometrium thickness,the better the therapeutic efficacy of progesterones(all P<0.05).Conclusions Concomitant ovarian endometrioma increases the risk of dysmenorrhea in patients with adenomyosis.The ratio of the maximum lesion thickness to the maximum myometrium thickness is an independent risk factor for menorrhagia.Young and large uterine volume may increase the risk of infertility.Severe dysmenorrhea and large uterine volume affect the success rate of IVF-ET.The therapeutic efficacy of progesterones is relatively better when the lesion is small and far away from the endometrium.