【作者】 张霞；

【导师】 王惠兰； 陈素芹；

【作者基本信息】 河北医科大学 ， 妇产科学， 2003， 硕士

【摘要】 目的:评价微波子宫内膜去除术（MEA）治疗异常子宫出血的疗效及疗效的影响因素、安全性。方法:前瞻性、观察性临床研究。选择绝经前后、无生育要求、药物治疗失败的异常子宫出血患者87例，排除宫腔结构异常和内膜恶性肿瘤及癌前病变。术前一日晚行宫颈插管，放入宫颈扩张棒扩张宫口直径达9mm。术前15分钟静脉注射冬眠Ⅲ号半量，刮宫内膜薄化后行MEA，在MEA前后行宫腔镜检查。2例直径＞1cm的内膜息肉先行电切，再行MEA。术后部分病人服用妇康片（2.5~3.75）mg，(1.5~2.5)月抑制子宫内膜生长。术后1月、3月、6月、12月门诊复查询问月经周期、经量、经期、痛经及经前期症状、下腹痛等情况，妇科检查，部分病人同时行阴道超声和/或宫腔镜检查,术后3月复查血常规。绝经前妇女治疗的满意度评价根据患者月经减少到正常或更少而且对治疗满意，绝经后治疗满意为无阴道出血。结果:1.临床资料：患者年龄(32~73)岁，平均(45.2±8.0)岁，功血23例，子宫肌瘤25例（肌壁内和／或浆膜下23例、粘膜下2例）、子宫内膜息肉30例、子宫粘膜下腺肌瘤１例，严重内科疾病合并子宫出血23例：肾衰8例、血小板减少性紫癜4例、再障6例、脑梗塞5例，还有伴肾移植术后1例，肺结节病1例，高血压、糖尿病<WP=4>9例，绝经后患者均为子宫内膜息肉。贫血57例，月经明显增多4月~12年，平均（2.4±3.2）年。重度贫血5例，中度贫血36例，轻度贫血16例。平均宫腔深度（9.2±1.1）（7~11.5）cm，平均手术时间(285.5±74.6)（119~430）秒。1例术中疼痛不能耐受加笑气吸入。大部分病人术后腹痛轻微，仅3例术后用凯扶兰止痛。术后阴道排黄红色液体持续（0~40多）天。2.术后阴道出血的变化：治疗后平均随访(13±4) （6~24）个月。约有56%的病人在术后1个月左右阴道出血时间为(1~50多)天不等，量多少不定，此后部分病人出现闭经或少量月经，治疗后服用妇康片能明显减少出血。绝经前81例，1例术后3月死于尿毒症，80例随访到术后半年以上，闭经48例（60%），点滴月经22例（27.5%），少量月经8例（10%），少量不规则阴道出血2例(2.5%)，治疗满意率为97.5%，2例术后月经量明显减少，但不规则少量阴道出血时间长对治疗效果不满意，其中1例回顾其治疗时资料发现在MEA后宫腔镜下可见前后壁内膜稍红，内膜去除不充分可能是不规则阴道出血的原因。30例随访到术后1年以上，闭经16例（53.3%）、点滴月经8例（26.7%），少量月经6例（20%），满意率100%。术后半年平均经期由术前(15.4±9.3)天降至(1.7±3.6)天，P＜0.01，差异有显著性意义。术后随访2年以内月经状况变化很小，疗效稳定。绝经后6例治疗后均无出血，满意率100%。3.贫血症状的改变：57例合并贫血，术前平均血红蛋白为(85±22) (34~119)g.l-1，术后3个月升至(116±18) (60~138)g.l-1，P＜0.01，差异有显著性意义。4.围月经期症状变化：痛<WP=5>经改善有效率72.7％（16/22），经前期症状改善率85.3％。5.疗效的影响因素：52.5%（42/80）术前后服妇康片，术后闭经率83.3%，术后服药28.8%(23/80)例，闭经率87%，服药与未服药两组的术后闭经率差异有显著性意义，P＜0.01。6.并发症：无术中并发症，术后7例子宫内膜炎抗炎，2例宫腔积血，5例术前无痛经术后出现周期性下腹痛不伴宫腔积血，无进一步外科手术者。7.术后宫腔镜下表现：术后宫腔镜检查显示宫腔挛缩呈管状，宫腔内可见白色纤维素样物及肉芽组织，无宫腔闭塞性粘连,2例宫颈内口瘢痕挛缩狭窄，平均宫腔深度较术前减少1.5cm。结论:1.本研究证实用刮宫薄化内膜代替药物内膜预处理不仅疗效好、省钱，还能使MEA用于急诊出血及有用药、手术、麻醉禁忌的严重内科合并症患者, 能替代子宫切除及宫腔镜下子宫内膜电切术。充分完整的破坏子宫内膜全层是治疗成功的关键。2.MEA治疗1月可能有不规则阴道出血，与宫腔内创面坏死组织脱落有关，6个月以后月经状况变化很小，随访到术后2年，疗效稳定。术前后用妇康片可减少术后早期阴道出血，提高术后闭经率。术后6个月的月经状况可评价MEA的疗效，远期疗效有待进一步观察。3.因为MEA是盲操作，术前充分扩张宫颈，治疗前后即行宫腔镜检查，不仅提高疗效，而且减少术中并发症，提高了治疗的安全性。避免宫颈管的烧灼能防止术后宫腔积血。大的子宫内膜息肉宫腔镜下电切与MEA合用能提高疗效。4.MEA创伤小，手术时间短，静脉镇静下病人可耐受手术。更多还原

【Abstract】 Objective:To evaluate the efficacy, influencing factors of outcomes and safety of Microwave endometrial ablation (MEA) for abnormal uterine bleeding .Methods: Prospective, observation study. 87 pre-and post-menopausal patients without further fertility and with failed medical for abnormal uterine bleeding were treated with MEA, exclusion criteria included abnormal uterine cavity and (pre) malignant lesions. The cervix dilated to Hegar 9mm with urine tube 12 hours preoperation. Intravenous sedation (Dolantin 50mg and Promethazinun 25mg) was used 15 minutes before operation. Preoperative endometrial thinning agent was thorough uterine curettage. 2 cases of endometrial polyps of greater than 1cm in diameter were performed polypetomy before MEA. Some patients took norethisterone (2.5~3.75)mg for (1.5~2.5) months postoperation. Follow up data at 1 and 3 and 6 and 12 months on menstrual flow, Dysmenorrhoea, premenstrual symptoms and pelvic pain, some patients had a transvaginal scan and/or hysteroscopy. Full blood count were repeated 3 months postoperation. Assessment of satisfaction was based on the reduction of menses to<WP=8>eumenorrhoea or less and satisfaction in premenopausal women, no bleeding in postmenopausal. Results：1.Clinical material:The mean age was (45.2±8.0) years(range 32~73). 23 were dysfunctional uterine bleeding and 25 leiomyoma (23 intramural and subserous, 2 submucosal) and 30 endometrial polyps and 1 uterine submucous adenomyomas, generalized severe disease with uterine bleeding including 8 renal failure, 4 thrombocytopenic purpura and 6 aplastic anemia, 5 brain infarction, 1 postoperative renal transplantation, 1lung sarcoidosis, 9 hypertension and diabetes mellilus, 6 postmenopausal bleeding were endometrial polyps. 57 women were preoperative amemia, The mean duration of preoperative menorrhagia was (2.4±3.2)years(range 4months～12years),5 were severe amemia, 36 moderate, 16 mild. The mean uterine sounding was (9.2±1.1) cm（range 7～11.5）, the mean treatment time was 286.5±74.6 seconds (range 119-430). The inhalation of nitrous oxide premixied with oxygen (50%: 50%) for analgesia only was required in 1 woman (1/87) for pain intraoperation, postoperative pelvic pain was mild and only 3 women(3/87) had severe pain requiring oral analgesia. postoperative vaginal discharge were reported in 0 to more than 40 days. Average follow-up time was 13±4(range 6-24)months. 2.The changes of menstrual blood loss: Approximately 56% patients had vaginal<WP=9>bleeding 1month postoperation in 1 to more than 50 days, from then on some were amenorrhea or hypomenorrhoea, administration of norethisterone could reduce vaginal bleeding significantly. 81 were premenopausal, 1 case died of uremia 3 months postoperation. follow-up of 80 cases was up to 6 months postoperation, overall satisfication was 97.5%(78/80), with 48(60%) amenorrhea, 22(27.5%) spotting, 8(10%) hypomenorrhoea and eumenorroea, and 2(2.5%) irregular bleeding, whom menstrual blood loss was reduced significantly were dissatisfied for irregular bleeding. When reviewed the appearance of hysteroscopy finding the endometrium in antero-posterior wall of cavity was a little red, so incomplete endometrial destruction was probably the cause of irregular bleeding. Follow-up of 30 cases was up to 12 months after operation, satisfication was 100%, with 16(53.3%) amenorrhea,8(26.7%) spotting, 6(20.0%) hypomenorrhoea and eumenorroea. The mean duration of menstrual flow reduced significantly from 15.4±9.3 days/cycle (range 4~30) to 1.7±3.6 days/cycle (range 0~20) 6 months postoperation, P＜0.01. All patients had stable menstrual pattern in 2 years follow-up. 6 postmenopausal patients were amenorrhea postoperation, satisfication rate were 100%. 3. The changes of amemia: The mean haemoglobin rose significantly from 85±22 g.l-1(range 34~119) to 116±18g.l-1 (range 60~138) 3 months postoperation in preoperative amemia women, P＜<WP=10>0.01. 4. The changes of dysmenorrhoea and premenstrual symptoms: Dysmenorrhoea and premenstrual symptoms im更多还原