经阴道彩超在子宫腺肌病诊断中的应用

目的探讨经阴道彩色多普勒超声技术(TVCDS)在子宫腺肌病诊断及鉴别诊断中的价值。方法对67例患者进行术前经腹部和经阴道彩色多普勒检查结果与术后病理进行对照分析。结果 67例术前经阴道彩色多普勒超声诊断子宫腺肌病与术后比较符合率(89.55%)明显高于经腹部彩超检查的符合率(50.75%)。结论经阴道彩色多普勒超声诊断子宫腺肌病,较经腹部检查有明显优势。可以根据超声图像及血流分布、频谱等特点为临床及时提供较准确的依据,并提供与子宫肌瘤的鉴别要点,为临床医生选择治疗方案提供帮助。     

子宫内膜异位症和（或）子宫腺肌症与面部色素斑发生的关系

目的 研究子宫内膜异位症（简称内异症）和（或）子宫腺肌症（腺肌症）不孕与患者面部色素斑发生的关系,初步探讨内异症和（或）腺肌症表型特征及可能机制。方法 选择150例内异症和（或）腺肌症相关不孕患者及200例非内异症或腺肌症不孕患者作为研究对象,分别设为内异症和（或）腺肌症组和对照组。分析两组患者年龄、体质量指数(BMI)、血清基础雌二醇(E2)水平及面部色素斑发生情况（阳性率）;比较内异症和（或）腺肌症组内面部色素斑阳性与阴性者的血清基础E2、癌抗原125(CA125)水平和抗子宫内膜抗体(AEmAb)阳性率。结果 内异症和（或）腺肌症组患者面部色素斑阳性率明显高于对照组（47.33% vs 19.00%）(P<0.05）; 内异症和（或）腺肌症组各年龄段患者面部色素斑阳性率均显著高于对照组（P<0.05）;两组患者年龄、BMI、血清基础E2水平比较差异均无统计学意义（P>0.05）。内异症和（或）腺肌症组中面部色素斑阳性者与阴性者比较,血清基础E2和CA125水平以及AEmAb阳性率略有升高,但差异均无统计学意义（P>0.05）。结论 内异症和（或）腺肌症与患者面部色素斑产生有一定关系,但是否独立于体内基础雌激素并反映内异症和（或）腺肌症的病情程度,尚有待于进一步探讨。     

Factors influencing the ablative efficiency of high intensity focused ultrasound (HIFU) treatment for adenomyosis: A retrospective study

Objectives The aim of this study was to investigate factors affecting ablative efficiency of high intensity focused ultrasound (HIFU) for adenomyosis. Materials and methods In all, 245 patients with adenomyosis who underwent ultrasound guided HIFU (USgHIFU) were retrospectively reviewed. All patients underwent dynamic contrast-enhanced magnetic resonance imaging (MRI) before and after HIFU treatment. The non-perfused volume (NPV) ratio, energy efficiency factor (EEF) and greyscale change were set as dependent variables, while the factors possibly affecting ablation efficiency were set as independent variables. These variables were used to build multiple regression models. Results A total of 245 patients with adenomyosis successfully completed HIFU treatment. Enhancement type on T1 weighted image (WI), abdominal wall thickness, volume of adenomyotic lesion, the number of hyperintense points, location of the uterus, and location of adenomyosis all had a linear relationship with the NPV ratio. Distance from skin to the adenomyotic lesion’s ventral side, enhancement type on T1WI, volume of adenomyotic lesion, abdominal wall thickness, and signal intensity on T2WI all had a linear relationship with EEF. Location of the uterus and abdominal wall thickness also both had a linear relationship with greyscale change. Conclusion The enhancement type on T1WI, signal intensity on T2WI, volume of adenomyosis, location of the uterus and adenomyosis, number of hyperintense points, abdominal wall thickness, and distance from the skin to the adenomyotic lesion’s ventral side can all be used as predictors of HIFU for adenomyosis.     

章勤辨治子宫腺肌病痛经经验

介绍章勤教授治疗子宫腺肌病痛经的经验。认为其病机以脾肾亏虚为本,水瘀互结为标,治疗以温补脾肾、水瘀同治为法。并遵循月经周期的规律,分期而治,配合中药制剂保留灌肠,同时注重情志因素对于本病的影响。并举验案1则。     

基于数据挖掘的赵瑞华治疗子宫腺肌病痛经用药规律研究

[目的] 挖掘赵瑞华教授治疗子宫腺肌病痛经的经验。[方法] 筛选2016年1月至2021年6月就诊于中国中医科学院广安门医院赵瑞华教授门诊，且治疗有效的子宫腺肌病痛经患者的处方数据，应用频次分析、关联规则分析、聚类分析等数据挖掘方法，对符合纳入标准的处方数据进行挖掘，包括一般资料、中药频次、性味功效、药物组合、核心处方等内容。[结果] 共纳入子宫腺肌病痛经患者122例，802个诊次处方，患者平均年龄(38.30±0.51)岁。患者痛经平均病程(78.15±8.42)月，明显高于患者诊断子宫腺肌病的平均病程(32.55±3.23)月，差异有统计学意义(P<0.01)。使用频率大于50%的药物有茯苓、桂枝、鸡内金、白芍、薏苡仁、炒白术、三七粉、生甘草、党参、胡芦巴、生姜、丹参、姜黄和醋柴胡。温性药、平性药，辛、甘、苦味药物使用频次较高，药物归经主要涉及到脾经、肝经、肺经、胃经和肾经。常用的药物组合为桂枝-白芍、鸡内金-薏苡仁、茯苓-炒白术等。药物聚类分析显示，高频使用的中药主要聚为3类，结合数据挖掘及专家访谈结果，最终总结出赵瑞华教授治疗子宫腺肌病痛经的核心处方。[结论] 赵瑞华教授治疗子宫腺肌病痛经组方精简、用药平和，处方用药充分体现了其重视阳气、重视脾胃、疏肝理气、活血化瘀的学术思想，临床疗效显著，可供参考。     

Guideline No. 437: Diagnosis and Management of Adenomyosis

ObjectiveTo describe the current evidence-based diagnosis and management of adenomyosis.Target PopulationAll patients with a uterus of reproductive age.OptionsDiagnostic options include transvaginal sonography and magnetic resonance imaging. Treatment options should be tailored to symptoms (heavy menstrual bleeding, pain, and/or infertility) and include medical options (non-steroidal anti-inflammatory drugs, tranexamic acid, combined oral contraceptives, levonorgestrel intrauterine system, dienogest, other progestins, gonadotropin-releasing analogues), interventional options (uterine artery embolization), and surgical options (endometrial ablation, excision of adenomyosis, hysterectomy).OutcomesOutcomes of interest include reduction in heavy menstrual bleeding, reduction in pelvic pain (dysmenorrhea, dyspareunia, chronic pelvic pain), and improvement in reproductive outcomes (fertility, miscarriage, adverse pregnancy outcomes).Benefits, Harms, and CostsThis guideline will benefit patients with gynaecological complaints that may be caused by adenomyosis, especially those patients who wish to preserve their fertility, by presenting diagnostic methods and management options. It will also benefit practitioners by improving their knowledge of various options.EvidenceDatabases searched were MEDLINE Reviews, MEDLINE ALL, Cochrane, PubMed, EMBASE. The initial search was completed in 2021 and updated with relevant articles in 2022. Search terms included adenomyosis, adenomyoses, endometritis (used/indexed as adenomyosis before 2012), (endometrium AND myometrium) uterine adenomyosis/es, symptom/s/matic adenomyosis] AND [diagnosis, symptoms, treatment, guideline, outcome, management, imaging, sonography, pathogenesis, fertility, infertility, therapy, histology, ultrasound, review, meta-analysis, evaluation]. Articles included randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Articles in all languages were searched and reviewed.Validation MethodsThe authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Table A1 for definitions and Table A2 for interpretations of strong and conditional [weak] recommendations).Intended AudienceObstetrician-gynaecologists, radiologists, family physicians, emergency physicians, midwives, registered nurses, nurse practitioners, medical students, residents, and fellows.Tweetable AbstractAdenomyosis is common in reproductive-aged women. There are diagnostic and management options that preserve fertility available.SUMMARY STATEMENTS

• 1.Providers should be aware that adenomyosis has been associated with heavy menstrual bleeding, pelvic pain, infertility, miscarriage, and adverse pregnancy outcomes (moderate).

RECOMMENDATIONS

• 1.Transvaginal sonography should be the first-line modality for imaging of suspected adenomyosis in patients presenting with heavy menstrual bleeding, pelvic pain, infertility, miscarriage, and adverse pregnancy outcomes (strong, high).
• 2.Transvaginal sonography in patients presenting with symptoms suggestive of adenomyosis should be assessed by radiologists for the following: presence of features typical of adenomyosis, location, focal or diffuse disease, cystic or non-cystic disease, uterine layer involvement, extent of disease, and the size of the largest lesion or affected area (strong, high).
• 3.Magnetic resonance imaging should be considered by clinicians if there is inconclusive sonographic evaluation of adenomyosis or suspicion of significant concomitant pelvic pathology (conditional, moderate).
• 4.Oral contraceptives, levonorgestrel-releasing intrauterine system, and dienogest should be used as first-line medical options for pain and heavy menstrual bleeding from adenomyosis (strong, moderate).
• 5.Gonadotropin-releasing hormone (GnRH) agonists can be considered as a second-line agent for management of pain and heavy menstrual bleeding from adenomyosis; add-back hormones should be initiated if GnRH agonists are used longer than 6 months (strong, low).
• 6.Uterine artery embolization is an effective treatment option for heavy bleeding and pain associated with adenomyosis; it can be offered to patients who have completed child-bearing and would like to preserve their uterus (strong, moderate).
• 7.Minimally invasive thermal ablation procedures, such as high-intensity focused ultrasound, radiofrequency ablation, and percutaneous microwave ablation, might be used for the treatment of symptomatic adenomyosis in the future, but more data are needed before they are used outside of a research context (conditional, low).
• 8.Adenomyomectomy is an effective treatment option for symptomatic adenomyosis (strong, moderate).
• 9.Adenomyomectomy can be a challenging surgical procedure, with the potential for significant perioperative morbidity, and should be performed by an experienced surgeon (strong, low).
• 10.Focal adenomyosis may be amenable to surgical excision using minimally invasive routes (laparoscopy, robotic); however, diffuse adenomyosis is best approached using an open technique (conditional, low).
• 11.Given the substantial risk of intraoperative hemorrhage, anemia (hemoglobin <120 g/L) should be corrected before adenomyomectomy (strong, low).
• 12.Patients undergoing adenomyomectomy should be counselled about the uncertain impact of these procedures on fertility and pregnancy. They should be specifically informed about the increased risk of uterine rupture during pregnancy, and the need for pre-labour cesarean delivery (strong, low).
• 13.Total hysterectomy is an effective treatment option for symptomatic adenomyosis and can be offered to women who have completed child-bearing after appropriate counselling regarding risks, benefits, and alternative treatments (strong, low).
• 14.Patients with dysmenorrhea undergoing surgical management of adenomyosis should be counselled to have concurrent excision of any coexisting endometriosis during surgery, for more complete relief of their symptoms (strong, low).
• 15.The impact of adenomyosis on pregnancy outcomes in patients undergoing fertility treatments is uncertain (conditional, low).
• 16.For patients with adenomyosis undergoing in vitro fertilization, gonadotropin-releasing hormone agonist downregulation for a period of 2 to 4 months may be considered before transferring fresh or frozen embryos (weak, low).