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

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。     

左炔诺孕酮宫内缓释系统用于子宫内膜异位症保守性手术后复发的治疗

目的 探讨左炔诺孕酮宫内缓释系统(LNG-IUS)用于子宫内膜异位症(内异症)患者保守性手术或保守性手术联合药物巩固治疗后复发者治疗的效果.方法 选择因内异症复发而就诊的患者23例,于月经周期第5～7天宫内放置LNG-IUS.所有患者均无生育要求且不愿再次手术.于放置LNG-IUS后3、6、12、24、36个月随访,观察放置LNG-IUS前后患者疼痛视觉模拟(VAS)评分、血清CA125水平、卵巢内异症囊肿体积的变化以及月经情况、体质量等指标.结果 (1)VAS评分:放置LNG-IUS后12个月,痛经、慢性盆腔痛或性交痛缓解最为明显,VAS评分由放置LNG-IUS前的(5.9±2.3)、(4.3±2.0)分下降为(1.0±0.7)、(1.4±1.1)分,分别比较,差异均有统计学意义(P＜0.01).(2)囊肿体积:11例患者复发表现为卵巢内异症囊肿,放置LNG-IUS后6个月,卵巢内异症囊肿体积由放置前的(11.4±6.1)cm3下降至(5.5±3.4)cm3,两者比较,差异也有统计学意义(P＜0.01);放置12个月时,2例卵巢内异症囊肿消失,放置24个月时,共9例卵巢内异症囊肿消失.(3)血清CA125:从放置LNG-IUS后6个月时开始,CA125水平显著下降,由放置前的(65.5±19.6)kU/L降至放置6个月时的(42.1±13.6)kU/L,差异有统计学意义(P＜0.01),放置后12个月时,CA125水平仍继续下降,此后趋于平稳.(4)其他:放置LNG-IUS后6个月内,阴道不规则出血或点滴出血是常见现象,随着放置时间延长,情况明显缓解.少数患者出现体质量增加的情况.结论 内异症保守性手术或手术联合药物巩固治疗后复发的患者,应用LNG-IUS可有效地缓解疼痛症状,降低血清CA125水平,缩小卵巢内异症囊肿体积,是一种有效、安全、持续时间长、全身副作用少、依从性高的治疗方法.

Abstract：

Objective To evaluate the efficiency of levonorgestrel-releasing intrauterine system (LNG-IUS) in the treatment of recurrent endometriosis after conservative surgery or conservative surgery combined with medical treatment. Methods Twenty-three patients with recurrent endometriosis after conservative surgery or conservative surgery combined with medical treatment were treated by LNG-IUS. All patients rejected further operation and had no desire of fertility. The visual analogue scale (VAS) scores of pain, menstrual model, weight and serum CA125 level and the volume of ovarian endometriotic cysts before and after 3, 6, 12, 24 and 36 months of treatment were recorded and compared. Results ( 1 ) VAS score:after 12 months of using LNG-IUS, dysmenorrheal, chronic pelvic pain or dyspareunia were relieved significantly. VAS score were dropped from 5.9 ± 2. 3,4. 3 ± 2.0 to 1.0 ± 0. 7,1.4 ± 1. 1 ( P ＜ 0. 01 ). ( 2 )Volum of cysts :after 6 months of using LNG-IUS, the volume of recurrent ovarian endometriotic cysts in 11 patients were reduced from ( 11.4 ± 6. 1 ) em3 to ( 5. 5 ± 3.4 ) em3 significantly ( P ＜ 0. 01 ). At 12 months of follow-up, it suggested that 2 patients' ovarian endometriotic cysts disappeared. At 24 months follow-up,9 patients ovarian endometriotic cysts disappeared ( 3 ) CA125: serum CA125 decreased from ( 65.5 ± 19. 6 )kU/L to (42. 1 ± 13.6) kU/L at 6 months after treatment remarkably (P ＜ 0. 01 ). Continued to decrease after 12 months and then become steady. Irregular bleeding and spotting was the main side effects, weight gain was also observed in few patients. Conclusions LNG-IUS could be used in treatment of recurrent endometriosis after conservative surgery or conservative surgery combined with medical treatment effectively. It could relieve pain, reduce the level of CA125 and decrease the size of ovarian endometriotic cysts. LNG-IUS seems to be an effective, safe, and long term treatment for endometriosis with fewer side effects and better compliance.     

Long-term follow-up after conservative surgery for rectovaginal endometriosis

OBJECTIVE: The purpose of this study was to evaluate long-term results in patients who received conservative surgical treatment for rectovaginal endometriosis. STUDY DESIGN: We analyzed the follow-up data for 83 women who underwent surgery for rectovaginal endometriosis. The inclusion criteria were age 20 to 42 years, moderate-to-severe pain symptoms, conservative treatment with retention of the uterus, and at least 1 ovary; the follow-up period was > or =12 months. Kaplan-Meier analysis and Cox regression were used to calculate recurrence rates. RESULTS: The cumulative rates of pain recurrence, clinical or sonographic recurrence, and new treatment were 28%, 34%, and 27%, respectively. The younger patients had the higher risk of recurrence. Pregnancy had protective effects against the recurrence of symptoms and a need for a new treatment. Patients who underwent bowel resection had fewer recurrences. CONCLUSION: Segmental resection and anastomosis of the bowel, when necessary, improves the outcome without affecting chances of conception. Higher recurrence rates in younger patients seems to justify a more radical treatment in this group of women.     

Long-term follow-up and recurrence rate after mesorectum-sparing bowel resection among women with rectovaginal endometriosis

Objective

To demonstrate the quality of a combined vaginal–abdominal surgical approach to rectovaginal endometriosis by analyzing long-term outcome and recurrence rates.

Methods

In a prospective cohort study in Berlin, Germany, women with endometriosis of the rectovaginal septum were enrolled between September 2004 and December 2012. Bowel infiltration was verified intraoperatively and treated by a nerve-sparing, mesentery-preserving vaginal–abdominal operative approach. Operative results were evaluated by assessing short- and long-term complications and recurrence rates.

Results

During the study period, 110 women underwent surgery. For 71 (64.5%) patients, bowel infiltration was confirmed intraoperatively. Overall, 15% of the patients had peri- or postoperative complications. No long-term complications occurred. After a median follow-up of 64 months, no recurrence in the rectovaginal septum was observed among the study patients. The recurrence of pelvic endometriosis was 15%.

Conclusion

The surgical nerve-sparing approach to rectovaginal endometriosis was confirmed to facilitate precise diagnosis and treatment with minimal morbidity and a long-term complication rate of 0%.     

Effects of the levonorgestrel-releasing intrauterine system on urinary symptoms in patients with adenomyosis

Objectives

We hypothesized that treatment of adenomyosis with the levonorgestrel-releasing intrauterine system (LNG-IUS) can concurrently improve urinary incontinence along with irritative and obstructive symptoms and thus positively affect the patients’ quality of life.

Study design

Sixty-five patients suffering from heavy prolonged menstrual bleeding (menorrhagia) with dysmenorrhea diagnosed with uterine adenomyosis by ultrasound were enrolled in this study. LNG-IUS was inserted in the outpatient department for the treatment of the uterine adenomyosis. The patients filled out two validated questionnaires, the Urogenital Distress Inventory (UDI-6) and the Incontinence Impact Questionnaire (IIQ-7), before and 6 months after the insertion of the LNG-IUS. The before and after scores were compared using the non-parametric Mann–Whitney U test.

Results

The mean (±SD) age of the patients was 44.5 ± 6.5 years. Both UDI and IIQ scores were significantly lower at 6 months after treatment with the LNG-IUS (P < 0.0001). UDI scores revealed improvement rates of 14.3%, 35.7%, and 22.7% for urinary incontinence, irritative symptoms, and obstructive symptoms, respectively. Moreover, improvements in irritative and obstructive symptoms were significantly correlated with improvements in menorrhagia and dysmenorrhea (P < 0.04). IIQ scores demonstrated improvement rates of 18.9%, 14.6%, 19.7%, and 18.5% for physical activity, travel, social relations, and emotional health, respectively.

Conclusions

LNG-IUS used for treating menorrhagia and dysmenorrhea improved urinary incontinence along with irritative and obstructive symptoms in patients with adenomyosis.     

Use of a levonorgestrel-releasing intrauterine device in the treatment of rectovaginal endometriosis

OBJECTIVE: To evaluate the effectiveness of a levonorgestrel-releasing IUD as therapy for endometriosis of the rectovaginal septum. DESIGN: Prospective therapeutic non-randomized, self-controlled clinical trial analyzing changes in pain symptoms and size of lesions induced by the levonorgestrel-releasing IUD over 12 months. SETTING: Tertiary referral center for treatment of deep endometriosis. PATIENT(S): Eleven symptomatic patients with rectovaginal endometriosis. INTERVENTION(S): A levonorgestrel-releasing IUD was inserted and maintained for 12 months. MAIN OUTCOME MEASURE(S): Severity of dysmenorrhea, pelvic pain, and deep dyspareunia were assessed before insertion of the IUD and throughout treatment. The size of rectovaginal endometriotic lesions were evaluated by using transrectal and transvaginal ultrasonography. RESULT(S): Dysmenorrhea, pelvic pain, and deep dyspareunia greatly improved and the size of the endometriotic lesions was significantly reduced by treatment. CONCLUSION(S): Insertion of a levonorgestrel-releasing IUD alleviates pain and reduces the size of lesions in patients with endometriosis of the rectovaginal septum.     

Sonovaginography is a new technique for assessing rectovaginal endometriosis

OBJECTIVE: To evaluate the efficacy of a new technique, the sonovaginography, for the assessment of rectovaginal endometriosis. DESIGN: Prospective study. SETTING: University hospital. PATIENT(S): Forty-six women were scheduled for laparotomic or laparoscopic surgery because of rectovaginal endometriosis suspected on the basis of patient history and/or clinical examination. INTERVENTION(S): Before surgery, all the women underwent transvaginal ultrasonography and then sonovaginography. The latter is based on transvaginal ultrasonography combined with the introduction of saline solution to the vagina that creates an acoustic window between the transvaginal probe and the surrounding structures of the vagina. Ultrasound findings were compared with the results of surgical exploration and histological examination. MAIN OUTCOME MEASURE(S): We assessed the accuracy of transvaginal ultrasonography and of sonovaginography for the detection and the location and extension assessment of rectovaginal endometriotic lesions, as well as compared patient compliance between the procedures. RESULT(S): Sonovaginography diagnosed rectovaginal endometriosis more accurately than did transvaginal ultrasonography, with a sensitivity and specificity of 90.6% and 85.7%, respectively, whereas the transvaginal ultrasonography has shown a sensitivity and specificity of 43.7% and 50%, respectively. Patient discomfort did not differ significantly between the procedures. CONCLUSION(S): Sonovaginography is a reliable and simple method for the assessment of rectovaginal endometriosis and provides information on location, extension, and infiltration of the lesions, which are important factors in selecting the kind of surgery.     

Hepatocellular adenoma and focal nodular hyperplasia after long-term use of danazol for endometriosis: a case report

Danazol, an inhibitor of pituitary gonadotropin with weak androgenic effect, is currently being used for the treatment of endometriosis. In contrast to other C17 alkylated anabolic steroids, it has been rarely associated with the occurrence of primary liver tumors. We present the case of a patient with endometriosis in whom a hepatocellular adenoma was discovered after 14 years of treatment with danazol for endometriosis. The patient showed no clinical signs of a liver tumor and it was only detected by ultrasonography and magnetic resonance imaging (MRI). When long-term danazol therapy is required, regular ultrasonography for monitoring and early tumor detection is recommended.     

左炔诺孕酮宫内缓释系统在卵巢子宫内膜异位囊肿术后应用的评价

目的:探讨卵巢子宫内膜异位囊肿保守性手术后宫腔放置左炔诺孕酮宫内缓释系统(LNG-IUS)的临床价值。方法:选择2006年1月~2008年4月在我院施行卵巢子宫内膜异位囊肿剥除术患者90例,分为A、B、C 3组,A组31例(LNG-IUS组),B组30例(孕三烯酮组),C组29例(未用药组)。观察比较术前VAS3分者治疗后VAS的评分变化,治疗6个月A、B两组FSH、LH和E2水平,治疗1年A、B两组患者对治疗效果满意度并愿继续接受治疗的情况以及治疗费用等。结果:A组治疗3个月和6个月VAS与术前比较有显著差异(P0.01);与B组的差异无统计学意义(P=0.611,P=0.462);治疗1年A组与B组平均VAS评分无显著差异(P=0.623),A组与C组的差异有统计意义(P0.05)。术后6个月A组E2平均水平正常为85.41±25.73 pmol/L;B组E2明显降低为53.80±16.64 pmol/L,与治疗前的差异有统计学意义(P0.05)。治疗1年愿意继续治疗的A组占87%明显高于B组的47%,差异有统计学意义(P0.01);而治疗费用两组无显著差异。结论:LNG-IUS治疗卵巢子宫内膜异位囊肿引起的疼痛有一定的作用,对卵巢功能影响较小,有较好的依从性,可作为卵巢子宫内膜异位囊肿保守手术后的辅助治疗方法。     

Comparison of a levonorgestrel-releasing intrauterine device versus expectant management after conservative surgery for symptomatic endometriosis: a pilot study

OBJECTIVE: To determine whether the frequency and severity of dysmenorrhea are reduced in women with symptomatic endometriosis in whom a levonorgestrel-releasing intrauterine device (Lng-IUD) is inserted after operative laparoscopy compared with those treated with surgery only. DESIGN: Open-label, parallel-group, randomized, controlled trial. SETTING: A tertiary care and referral center for patients with endometriosis. PATIENTS(S): Parous women with moderate or severe dysmenorrhea undergoing first-line operative laparoscopy for symptomatic endometriosis. INTERVENTION(S): Randomization to immediate Lng-IUD insertion or expectant management after laparoscopic treatment of endometriotic lesions.Proportions of women with recurrence of moderate or severe dysmenorrhea in the two study groups 1 year after surgery and overall degree of satisfaction with treatment.Moderate or severe dysmenorrhea recurred in 2 of 20 (10%) subjects in the postoperative Lng-IUD group and 9/20 (45%) in the surgery-only group. Thus, a medicated device inserted postoperatively will prevent the recurrence of moderate or severe dysmenorrhea in one out of three patients 1 year after surgery. A total of 15/20 (75%) women in the Lng-IUD group and 10/20 (50%) in the expectant management group were satisfied or very satisfied with the treatment received. CONCLUSION(S): Insertion of an Lng-IUD after laparoscopic surgery for symptomatic endometriosis significantly reduced the medium-term risk of recurrence of moderate or severe dysmenorrhea.     

Lidocaine gel vs lidocaine spray in reducing pain during insertion of the intrauterine contraceptive device

Objectives: The aim of this study was to compare the pain-relieving effect of intracervical lidocaine gel with that of lidocaine spray or no local anaesthesia in decreasing pain during insertion of the intrauterine contraceptive device (IUCD).

Methods: In a prospective multicentre non-randomised comparative study design, 420 women were divided into three groups of 140 and fitted with the same type of IUCD. Group 1 received cervical lidocaine gel, group 2 received cervical lidocaine spray and group 3 received no topical anaesthesia. A visual analogue scale was used to measure the degree of pain experienced.

Results: There were no significant differences between the three groups with regard to baseline characteristics such as age and number of deliveries. Significantly less pain was felt during cervical traction in women using a local anaesthetic. However, there were no significant differences in pain due to IUCD insertion.

Conclusions: Application of a local anaesthetic decreased the pain resulting from cervical traction but not that resulting from IUCD insertion.     

A novel technique using magnetic resonance imaging jelly for evaluation of rectovaginal endometriosis

OBJECTIVE: To evaluate the usefulness of the magnetic resonance imaging (MRI) jelly method as a preoperative diagnostic means for patients with rectovaginal endometriosis. DESIGN: Prospective study. SETTING: University hospital. PATIENT(S): Thirty one patients with suspected rectovaginal endometriosis based on clinical symptoms and the results of preoperative pelvic, rectal, and ultrasonographic examinations, who were scheduled to undergo laparoscopic surgery. INTERVENTION(S): Before surgery, jelly for ultrasonography was injected into the vagina and rectum for MRI. The MRI findings were compared with findings obtained through laparoscopic surgery and histopathologic examination of the removed tissues. MAIN OUTCOME MEASURE(S): The complete cul-de-sac obliteration and deep lesion confirmed at the time of the laparoscopic surgery were evaluated by the MRI jelly method. RESULT(S): For detecting the presence of complete obliteration of the cul-de-sac, the accuracy of the diagnosis of rectovaginal endometriosis attained using the MRI jelly method was sensitivity 90.9% and specificity 77.8%. For the presence of a deep lesion, the sensitivity was 94.1% and specificity 100%. CONCLUSION(S): The condition of the cul-de-sac could be imaged clearly via the MRI jelly method. Not only rectovaginal endometriosis presenting with deep lesions, but also complete cul-de-sac obliteration alone could be diagnosed preoperatively at a high rate.     

Factors affecting the spontaneous expulsion of the levonorgestrel-releasing intrauterine system

Objective

To estimate the incidence of, and identify risk factors for, spontaneous expulsion of the levonorgestrel-releasing intrauterine system (LNG-IUS).

Methods

Pre-insertion characteristics for 481 women who received the LNG-IUS at a single institution in the Republic of Korea between 2003 and 2011 were analyzed retrospectively. The median duration of follow-up was 13.4 months. Kaplan–Meier plots were constructed to estimate the time to occurrence of spontaneous expulsion in multiple subgroups.

Results

The overall crude incidence of spontaneous LNG-IUS expulsion was 9.6%. The cumulative incidence was 7.9%, 9.1%, and 9.6% at 1, 2, and 3 years, respectively. It was significantly higher in women with adenomyosis (9.1%, 10.6%, and 11.1%) or uterine leiomyoma (14.5%, 15.8%, and 15.8%) than in those with a normal uterus (3.6%, 4.1%, and 4.6%) (P = 0.008). Women with heavy menstrual bleeding (11.0%, 12.7%, and 13.4%), dysmenorrhea (8.1%, 9.0%, and 10.0%), or pre-insertion receipt of gonadotropin-releasing hormone agonists (13.3%, 16.0%, and 17.3%) also had higher cumulative incidences than those without these conditions (P < 0.05). Most (84.5%) women with a spontaneous expulsion chose to discontinue the device.

Conclusion

Clinicians need to be aware of the risk factors for spontaneous LNG-IUS expulsion because this can lead to a discontinuation of its use.     

Sublingual misoprostol prior to insertion of a T380A intrauterine device in women with no previous vaginal delivery

Abstract

Objective To investigate whether sublingual misoprostol administered one hour before intrauterine device (IUD) insertion reduces failed insertions, insertion-related complications and pain in parous women delivered only by elective caesarean section (CS).

Methods Single-blind randomised controlled trial conducted in Ismailia, Egypt, between July 2010 and December 2011. Women who had never delivered otherwise than by elective CS and desirous of using an IUD were randomly allocated to receive sublingually 400 μg misoprostol and 100 mg diclofenac (misoprostol group) or 100 mg diclofenac alone (control group) one hour before IUD insertion. Outcome measures were failed insertion, ease of insertion judged by the investigators, insertion-related complications, and patients’ satisfaction.

Results In all, 255 women (130 and 125 in the study and control groups, respectively) had an IUD inserted. Seven insertions failed: five in the control group, and two in the study group. Ease of insertion and patients’ satisfaction were comparable in both groups. Abdominal pain and nausea were the commonest side effects reported in the misoprostol group.

Conclusion Sublingual administration of misoprostol one hour before IUD insertion in parous women with no previous vaginal delivery does not facilitate the procedure and may cause undesirable side effects. This approach is not recommended as a standard treatment.