子宫内膜息肉的手术治疗及术后复发的预防

目的探讨子宫内膜息肉的宫腔镜手术治疗及术后应用孕激素预防复发的效果。方法选择北京大学深圳医院2001年8月至2007年8月行宫腔镜诊治的子宫内膜息肉86例患者,术后分为激素治疗组和观察组,激素治疗组术后给予安宫黄体酮周期性治疗3个月,观察子宫内膜息肉复发及妊娠情况。结果 86例患者中,宫腔镜检查多发性子宫内膜息肉56例,单发性子宫内膜息肉32例;激素治疗组术后2年,复发率为2.3%,观察组复发率为13.9%,两组比较,差异有统计学意义(P0.05)。32例有生育要求的患者中,术后2年23例自然妊娠,妊娠率为71.9%,但激素治疗组妊娠率(70.6%,12/17)和观察组(73.3%,11/15)比较,差异无统计学意义(P0.05)。结论子宫内膜息肉患者行宫腔镜诊断及治疗效果明确,术后应用孕激素治疗可能有助于预防子宫内膜息肉的复发。     

High prevalence of endometrial polyps in endometriosis-associated infertility

In a retrospective study, examination of 431 infertile women (158 cases with endometriosis and 273 without endometriosis) showed a significantly increased frequency of endometrial polyps in patients with endometriotic infertility and no significant differences among different stages and locations of endometriosis. Hysteroscopic polypectomy and removal of endometriotic foci significantly increased the chances of achieving a pregnancy compared with those without polyps.     

绝经后子宫内膜息肉合并子宫内膜不典型增生及子宫内膜癌高危因素分析

目的分析绝经后妇女子宫内膜息肉(endometrial polyps,EMPs)发生恶变的相关危险因素。方法回顾性分析2001年4月至2009年12月北京大学人民医院妇产科收治的489例经宫腔镜病理确诊为EMPs的患者,依据病理类型分为良性组(471例)和非典型增生/恶性组(18例),比较两组患者的临床特征和子宫内膜息肉恶变的相关危险因素。结果绝经后子宫内膜息肉患者中,子宫内膜息肉合并不典型增生者11例(2.20%,11/489),子宫内膜息肉合并子宫内膜癌者7例(1.43%,7/489)。单因素分析的各临床因素中,绝经≥10年(OR=15.60,95%CI:2.05～118.57)和绝经后出血(OR=4.08,95%CI:1.31～12.70)是与子宫内膜癌前病变或子宫内膜癌相关的危险因素(P<0.05),而高血压、糖尿病、肥胖和子宫内膜息肉病史等因素比较,差异无统计学意义(P>0.05)。结论绝经后子宫内膜息肉发生癌前病变和子宫内膜癌风险增加,绝经≥10年和有绝经后出血症状是发生癌前病变和癌的危险因素。     

子宫腔息肉对不孕患者内膜白血病抑制因子的影响

目的:探讨子宫内膜息肉(EP)对不孕症着床期内膜白血病抑制因子(LIF)转录和表达的影响,初探其对内膜容受性的影响。方法:冻融胚胎移植(FET)前宫腔镜检查的继发不孕患者35例,其中术前彩色超声显示EP者为A组(n=25),未显示EP者为B组(n=10)。于黄体中期行宫腔镜检查EP数目、大小、位置等,并摘除息肉、刮取息肉周围子宫内膜及正常子宫腔内膜,免疫组织化学方法检测LIF,RT-PCR检测LIF m RNA转录水平。结果:患者一般情况及黄体中期雌、孕激素水平组间无统计学差异(P0.05);A组LIF m RNA转录水平及蛋白表达水平略高于B组,但差异无统计学意义(P0.05)。结论:EP对内膜LIF的转录及表达无明显不利影响。     

宫腔镜和超声波对子宫内膜息肉诊断价值的比较

目的：探讨宫腔镜与超声波在诊断子宫内膜息肉上的价值,为子宫内膜息肉的诊断提供参考依据。方法：调查2004年12月至2010年12月在广州某医院进行妇科检查的患者1338例,患者均进行超声、宫腔镜及诊刮后送病理检查,以病理检查作为金标准,超声波和宫腔镜的诊断结果与之进行比较。结果：病理诊断子宫内膜息肉428例,超声诊断子宫内膜息肉的灵敏度、特异度、正确指数分别为61．21％、91．87％、0．53;宫腔镜诊断子宫内膜息肉的灵敏度、特异度、正确指数分别为95．33％、99．23％、0．95,两种检验方法比较差异有统计学意义（P〈0．01）。超声波与宫腔镜联合检查和超声检查诊断子宫内膜息肉的比较中,超声波的检出率为61．45％,超声波与宫腔镜联合检出率为99．30％,两种检验方法比较差异有统计学意义（P〈0．01）。结论：超声波是一种无创伤、操作简单的检查方法,可作为子宫内膜息肉的筛查手段,但漏诊率偏高。宫腔镜诊断的符合率高,准确且直观,但操作较繁杂。超声波与宫腔镜联合检查可弥补各自的缺陷,是诊断子宫内膜息肉的较好的方法。     

宫腔镜下子宫内膜息肉的临床诊断与治疗（附42例报告）

目的 探讨子宫内膜息肉的官腔镜下的临床诊疗。方法 因异常子宫出血行官腔镜检185例，其中子宫内膜息肉42例，占22．7％，其中多发性子宫内膜息肉21例，单发11例，息肉样增生12例，合并宫颈息肉10例。其中电切8例，余行诊刮处理。结果 病理组织学诊断：子宫内膜息肉24．例，肌瘤1例，增生期5例，分泌期10例，增生期过长11例，息肉鳞状化生3例。结论 应当重视官腔镜对子宫内膜息肉的诊断和治疗。     

不孕症合并子宫内膜非典型增生患者助孕治疗的临床分析

目的探讨不孕症合并子宫内膜非典型增生患者经保守治疗后助孕治疗的疗效和安全性。方法回顾性分析8例不孕症合并子宫内膜非典型增生患者，经孕激素或促性腺激素释放激素激动剂（GnRHa）治疗子宫内膜非典型增生缓解后，采用助孕治疗，观察助孕治疗的疗效及其对子宫内膜的影响。结果经孕激素或GnRHa治疗后，8例患者子宫内膜非典型增生全部缓解。共进行单纯促排卵治疗7个周期，促排卵联合人工授精2个周期，体外受精-胚胎移植（IVF—ET）7个周期，冻融胚胎移植2个周期。单纯促排卵周期均未妊娠，人工授精1个周期双胎妊娠；7个IVF—ET周期中，胚胎移植6个周期，3个周期获得临床妊娠；冻融胚胎移植1个周期获得临床妊娠。现足月分娩6活婴。1例未妊娠患者在促排卵后4个月发现子宫内膜癌变。结论不孕症合并子宫内膜非典型增生的患者经孕激素或GnRHa治疗缓解后，及时助孕治疗能提高妊娠率，但需严密观察，注意子宫内膜癌发生的可能。     

子宫内膜息肉213例分析

目的　通过对 2 1 3例子宫内膜息肉的回顾性分析 ,探讨子宫内膜息肉的病因、诊断及处理。方法　回顾性分析 1 993年 1月～ 2 0 0 1年 1 2月我院通过手术病理诊断的 2 1 3例子宫内膜息肉病历。结果　患者平均年龄 4 9 1岁 (2 6～ 82岁 )。 3例 (1 4 % )有激素替代的历史 ;1 0例 (4 7% )为乳腺癌术后服用三苯氧胺。 5 6例绝经后患者中 ,2 4例 (4 2 9% )绝经后出血 ;32例 (5 7 1 % )无症状 ,仅通过超声或手术后发现。 1 5 7例未绝经患者中 ,5 7例 (36 3% )有不规则出血症状 ;5 3例 (33 8% )周期正常 ,但经量增多 ;4 7例 (2 9 9% )月经正常。经超声诊断率为 6 5 3% (1 30 1 99) ,刮宫诊断率为 30 0 % (1 8 6 0 )。病理报告 1 6 5例 (77 5 % )合并正常内膜 ;2 4例 (1 1 3% )合并存在子宫内膜单纯增生 ;6例 (2 8% )合并存在子宫内膜复合增生 ;3例 (1 4 % )并子宫内膜非典型增生 ;2例 (0 9% )合并子宫内膜癌 ;1例 (0 5 % )合并低度恶性子宫内膜间质肉瘤。结论　子宫内膜息肉是一种常见的宫腔内良性病变 ,常表现为异常出血 ,也可无症状 ,常与子宫内膜的增生或子宫内膜癌前病变合并存在。妇科阴道超声作为无创性检查 ,可提示内膜息肉的存在 ,宫腔镜是诊断内膜息肉的金标准。处理首选宫腔镜下内膜息肉     

控制性超促排卵刺激中子宫内膜息肉对体外受精-胚胎移植妊娠结局的影响

目的:探讨在控制性超促排卵(controlled ovarian hyperstimulation,COH)刺激过程中新诊断的子宫内膜息肉(endometrial polyp,EP)对体外受精/卵胞质内单精子显微注射-胚胎移植(IVF/ICSI-ET)新鲜周期妊娠结局的影响。方法:选择行IVF/ICSI-ET新鲜周期的3 003例患者的3 003个周期进行回顾性分析。IVF/ICSI-ET术前行相关检查诊断宫腔形态正常,根据在COH过程中是否新发现EP将其分为研究组(新发现息肉,n=60)和对照组(未发现息肉,n=2 943)。观察患者妊娠结局。结果:患者的临床妊娠率、自然流产率、继续妊娠率组间比较,差异均无统计学意义(P0.05)。研究组和对照组生化妊娠率(20.0%vs 9.8%)、异位妊娠率(3.3%vs 0.1%),差异有统计学意义(P=0.035,P0.000 1)。结论:在COH刺激过程中新诊断的与生化妊娠和异位妊娠的发生相关,但不影响IVF-ET新鲜周期的最终临床妊娠率、继续妊娠率以及早期流产率的发生。     

Transvaginal ultrasound and diagnostic hysteroscopy as a predictor of endometrial polyps: risk factors for premalignancy and malignancy

The aim of this study is to assess accuracy of transvaginal ultrasound (TVUS) and diagnostic hysteroscopy in diagnosing endometrial polyps and to determine premalignancy and malignancy rates in asymptomatic women. The study was designed to retrospectively analyze 438 women who underwent operative hysteroscopy in a day-care unit when endometrial polyp was suspected after TVUS and diagnostic hysteroscopy. Multivariate logistic regression modeling showed effects of age, previous breast cancer with tamoxifen treatment, and menopause with or without bleeding on pathologic results. The results indicate that positive predictive value of TVUS with diagnostic hysteroscopy was 79.9%. Premalignancy or malignancy occurred in 3.2% and was significantly related to menopause with abnormal bleeding (P < 0.001), which carried a 20-fold higher risk of pathology than any other group. Age was also a risk factor. It was concluded that TVUS with diagnostic hysteroscopy reliably evaluates endometrial polyps. The low incidence of endometrial tumors in asymptomatic (especially premenopausal) women suggests that their operative evaluation may not be cost effective. Larger studies are needed to support this tentative conclusion.     

Aromatase and cyclooxygenase-2 expression in endometrial polyps during the menstrual cycle

Objectives.?To study the changes in aromatase, Ki-67 and cyclooxygenase-2 (COX-2) expression during the menstrual cycle in both endometrial polyps and normal endometria.

Patients and methods.?Paraffin-embedded tissue samples from 118 premenopausal patients were submitted to immunohistochemistry for measurement of aromatase, COX-2 and Ki-67 expression. Fifty cases of endometrial polyps and 68 cases of disease-free endometrium were included.

Results.?The presence of aromatase expression was significantly higher in endometrial polyps than in disease-free endometria. On the other hand, changes in COX-2 and Ki-67 expression followed a similar pattern during the menstrual cycle in both groups, expression peaking during the proliferative phase and falling during the late luteal phase.

Conclusion.?A significantly higher proportion of endometrial polyps express aromatase compared with disease-free endometrium; however, no correlation was found between aromatase expression and changes in either Ki-67 or COX-2 expression during the menstrual cycle.     

Prognostic significance of hysteroscopic imaging in endometrioid endometrial adenocarcinoma

OBJECTIVE: The aim of this study was to relate hysteroscopic features of endometrioid endometrial adenocarcinoma to stage, grade and overall survival. METHODS: Sixty women with endometrioid adenocarcinoma underwent laparotomy and staging according to current FIGO classification. Before surgery hysteroscopy was performed in all patients to establish the morphology of neoplasia, the extent of endometrial lining involvement, and endocervical spreading. These hysteroscopic parameters were related to overall survival, surgical stage, and grade of disease. RESULTS: First-stage carcinomas were found in 50 patients, second-stage in 4, third-stage in 3, and fourth-stage in 3 patients. Well-differentiated tumors were detected in 32, moderately differentiated in 21, and poorly differentiated in 7 patients. The cumulative 48-month probability of survival was 86.6%. The morphology of adenocarcinomas was unrelated to both their stage and their grade; no relationship to survival was found. The extent of carcinomatous spread within the endometrial cavity was significantly related to stage, grade, and survival. Endometrial lining involvement of less than 50% was associated with 100% survival, 97.1% of first-stage diseases, and 96.6% of low-grade carcinomas. These percentages dropped to 73.1, 65.3 (Fisher's exact test, P = 0.001), and 76.9% (Fisher's exact test, P = 0.035), respectively, when tumoral growth involved more than half of the endometrium. Hysteroscopy detected all carcinomas metastasizing to the cervix; in 8 patients we overdiagnosed endocervical spreading, although histology was negative. From these figures, hysteroscopy showed a sensitivity and specificity in predicting cervical spread of 100 and 87.3%, respectively. CONCLUSIONS: The extent of endometrial lining involvement in patients with endometrioid carcinoma provides preoperative information on the risk of extrauterine spread. We confirm the high accuracy of hysteroscopy in excluding cervical spread.     

子宫内膜息肉的手术治疗

宫腔镜下子宫内膜息肉切除术是子宫内膜息肉诊治的“金标准”。近年来出现一系列宫腔镜下子宫内膜息肉切除术的新技术,能在提高手术效率的同时改善患者的就诊体验,实现“即诊即治”,使子宫内膜息肉的门诊诊疗成为趋势。在临床开展相应手术时,术者应根据实际情况选择合适的治疗方式以达到最优的治疗效果。文章介绍了子宫内膜息肉手术的适应证,简述常用手术系统及手术技巧,并分析了门诊宫腔镜进行子宫内膜息肉切除的注意事项。