【作者】 刘京芳；

【导师】 杜惠兰；

【作者基本信息】 河北医科大学 ， 中西医结合临床， 2007， 硕士

【摘要】 目的:子宫内膜异位症(以下简称“内异症”)是妇科疑难病之一,多发于育龄期妇女。内异症的发病机制有多种学说,被大多数人认可的为Sampson提出的经血逆流学说。进入腹腔的内膜在异位的生长首先是内膜细胞的黏附。近来,细胞黏附分子的黏附作用日益引起人们的重视。目前西医治疗主要采用药物及手术的方法,但存在停药后易复发、副作用大、价格昂贵等问题。本研究的目的是通过临床观察及动物实验,观察补肾温阳化瘀法治疗内异症的疗效,并从细胞黏附分子方面探讨其作用机制。方法:1临床研究:选自2005年10月～2006年12月在石家庄市四院就诊,符合内异症诊断标准、纳入标准、排除标准及中医辨证标准的内异症患者30例,服用补肾温阳化瘀中药者,连续服用3个月经周期,观察期间不得服用与本病症有关的其他中西医药物,于治疗前后空腹采集肘静脉血3ml,离心取上清液,置于-70℃冰箱保存待测;行手术治疗者30例,术中抽取腹腔液3～4毫升;对照组血清来自无心、脑、肝、肾、血液病及内分泌疾病的自愿受试者30名,空腹采集肘静脉血3ml,离心吸取上清液,置于-70℃冰箱保存待测;对照组腹腔液来自同期因子宫肌瘤行手术治疗的患者30例,术中抽取腹腔液3～4毫升30例。全部患者均知情同意,并除外心脑肝肾疾病,治疗前3个月无激素类药物治疗史,月经规律,各组年龄比较分布均衡,无统计学差异,具有可比性。观察项目:(1)参照中国中西医结合学会妇产科专业委员会第三届学术会议修订的标准拟定疗效判定标准,根据标准统计治愈率;(2)检测治疗前后血清及腹腔液中细胞黏附分子(sICAM-1,sVCAM-1)的含量变化及血清内分泌激素(E2,P)、CA125的水平的改变。2动物实验:选用动情周期正常的健康清洁级SD雌性大鼠60只,体重200±50克。60只大鼠随机选取10只做为正常对照组;其他50只根据Jones方法复制内异症大鼠模型。制模4周后选择造模成功的大鼠,随机数字表方法分为中药低剂量组、中药高剂量组、丹那唑组、模型组4组,每组10只。低、高剂量组分别按15.41克、61.76克/千克(分别相当于临床成人剂量的5倍、20倍)给予补肾温阳化瘀中药灌胃,每日一次,连用4周;丹那唑组按25毫克/日,给予丹那唑水溶液灌胃,连用4周;模型组及对照组给予同体积的蒸馏水。末次给药后,禁食8小时,选择动情期的大鼠断头处死,无菌操作剖腹测量各组异位灶的体积大小;取出各组在、异位内膜组织,吸去血液,于4%多聚甲醛溶液中固定,常规石蜡包埋,5μm厚连续切片,进行免疫组织化学染色,测定内膜组织中细胞间黏附分子-1(ICAM-1)、核转录因子-κB(NF-κB)的表达。结果:1临床研究表明,中药组经补肾温阳化瘀法治疗3疗程后,临床治愈7例(23.33%),显效9例(30.00%),有效6例(20.00%),无效8例(26.67%),总有效22例,总有效率为73.33%。中药组治疗前与正常对照组血清P含量比较无统计学意义(P>0.05),中药组治疗前与正常对照组血清E2含量相比较升高,有显著性差异(P<0.01)。中药组治疗后血清P与治疗前比较显著升高,有统计学意义(P<0.01),E2与治疗前比较显著降低,有统计学意义(P<0.01)。血清中sICAM-1、sVCAM-1中药组治疗前与正常对照组比较显著升高,有统计学意义(P<0.05,P<0.01),治疗前后均有显著性差异(均P<0.01);腹腔液中sICAM-1、sVCAM-1中药组与正常对照组比较均含量升高,有显著性差异(P<0.01,P<0.05)。血清CA125中药组治疗前与正常对照组比较显著升高(P<0.01),治疗前后有显著性差异(P<0.01)。2动物实验结果表明:治疗4周后,中药高剂量组与模型组比较,异位灶的体积明显减小,差异有显著性(P<0.01),治疗后与治疗前比较异位灶体积明显减小,差异有显著性(P<0.01);中药低剂量组与模型组比较无统计学差异;丹那唑组与模型组比较,异位灶的体积也有所减小,差异有显著性(P<0.01)。组织学观察:中药高剂量治疗组异位内膜组织腺体数目少,腺腔小,腺上皮细胞呈柱状,而模型组异位内膜组织,腺体数目较多。ICAM-1蛋白阳性染色定位于腺上皮细胞浆内。模型组ICAM-1表达增多,与对照组比较有显著性差异(P<0.01),高、低剂量组与丹那唑组ICAM-1表达均低于模型组(均P<0.01),高剂量组与对照组比较无显著性差异(P>0.05)。NF-κB蛋白阳性染色定位于腺上皮胞质内。正常大鼠NF-κB表达较少。模型组NF-κB多表达于胞质,与对照组比较显著升高(P<0.05),高剂量组和丹那唑组NF-κB的表达与模型组比较均降低,差异有统计学意义(P<0.01,P<0.01),低剂量组NF-κB的表达与模型组比较无统计学差异(P>0.05)。在位内膜组织NF-κB活性与ICAM-1表达呈正相关(r=0.698,P<0.05)。结论:1补肾温阳化瘀法治疗内异症不仅可缩小病灶,松解盆腔粘连,减轻盆腔瘀血,缓解疼痛,而且能够调节患者卵巢功能,具有用药副反应小的特点,不失为临床治疗内异症的有效方法之一。2内异症患者体内sICAM-1、sVCAM-1含量有不同程度的升高,我们认为其可能干扰内异症患者体内的免疫环境,有利于异位内膜的黏附,在内异症发病中起到关键作用。3内异症模型大鼠内膜内NF-κB的活性增强,与ICAM-1的蛋白表达呈正相关,提示ICAM-1的黏附作用增强可能与NF-κB的表达增强有关。补肾温阳化瘀法通过调节内膜中NF-κB的活性来调节细胞黏附分子的表达,从而达到治疗内异症的效果。更多还原

【Abstract】 Objective: Endometriosis(for short“EM”) is one of a complex diease in gynecology, it happens to most of the women who are in child-bearing period. The pathogeny and episodic mechanism of endometriosis is not clear completely heretofore. There are many thoerys about the episodic mechanism of endometriosis. Most scholar approbated the thoery of Sampson.The growth of endometrium which flowed into celiac inside must depend on adhering of endometrium issue. People were cognizant of the importance of the function of Cellular adhersion molecules. At present, druggery therapies and surgery are used for treatment of endometriosis. But there are some problems: the rate of recurrence after surgery is high; And after the pseudomenopause therapy and spurious pregnancy therapy also have the problems of recurrence and ill effect; So it is an important topic that explore the episodic mechanism and effective therapy of endometriosis.In order to explore the episodic mechanism of endometriosis and provide an effective therapy,we invest therapeutic effect of endometriosis by treatment of Bushen Wenyang Huayu principle (BSWYHY, Tonifying Kidney,Warming Yang and Removing Blood Stasis).Methods:1 Clincical observation:Thirty patients who fitted the diagnostic standard, included standard, excluded standard and traditional Chinese medicine standard in differentiation of symptoms and signs of EM coming from the fourth hospital of city Shijiazhuang during October 2005 to Decemberr 2006 were collected.Thirty cases with endometriosis were treated by the tonifying kidney warming yang removing blood stasis method for three menstrual cycles.During the observed course ,the patients did not take any other herb or western drug. we collected three milliliter blood in ulnar vein and centrifuge for serum in pretherapy amd postreatment. The serum would be conserved in refrigerator below zero 70 centidegree for measurement. The other 30 cases with peritoneal fluid were collected while operating, diagnosis was confirmed by pathological examination. 30 voluntary subjects were selected as serum control group eliminating disease in heart, kidney or endocrine system etc. While 30 cases with peritoneal fluid were collected as normal endometrium and peritoneal fluid control group,diagnosis was confirmed by pathological examination.Detected the contents of sICAM-1、sVCAM-1、E2、P、CA125 in serum and peritoneal fluid by means of radio immunoassay or enzyme linked immunosorbent assay. Since the control group cases had no significant difference with the patients in age, they were comparable.The amelioration of the symptoms and physical signs were determined.we can measure the changes of Serum hormones and Cellular adhersion molecules to discuss the episodic mechanism of endometriosis.2 Experimental research: 60 depuratory and healthy SD females rats with normal estrous cycle(4-5days),200±50g in body weight,50 rats were used methord JONES to duplicate the model of endometriosis.After 4 weeks,chose the rats that duplicate model triumphantly and divided them into 4 groups stochasticly:low-dose group ,high-dose group,Danazol group,model group.There were 10 rats in each group.Control group were raised by routine feed.Those rats of low dose and high dose groups were administrated in dose of 15.41g/kg、61.76g/kg separately,once per day for 4 weeks.The rats of Danazol group were in dose of 25mg once daily.Model group were given the same voluminal distilled water.Fasting eight hours after last administration ,sacrificed the rats by decapitation during anestrum. Disseced and got rats endometrium quickly,slighlty wiped with filter paper.Fixed endometrium in 4% Polyoxymethylene,paraffin embedded ,slice in 5μm.Detected the expression of ICAM-1 and NF-κB in endometrium tissue by means of immunohistochemistry.Results:1 Clincical observation: Thirty cases with endometriosis treated with TCM. Three months treatment successively is a course.The amelioration of the symptoms and physical signs were determined. The number of sufferer which was cure was 22 and the rate of availability was 73.33%.Serum concentration of P were no significant difference between EM women and control group(P>0.05),and the concetration were increased after cure (P<0.01).Serum concentration of E2 in EM women was higher than that in control group(P<0.01),and the concetration were descend after cure (P<0.01).Serum concentration of sICAM-1 and sVCAM-1 in EM women were higher than that in control group(P<0.05, P<0.01), and the concetration were descend after cure (P<0.01,P<0.01). Peritoneal fluid concentation of sICAM-1and sVCAM-1 in EM women were higher than that in control group(P<0.01,P<0.05), Serum concentration of CA125 in EM women was higher than that in control group(P<0.01),and the concetration were descend after cure (P<0.01).2 Animal experiment indicate:After treat 4 weeks,the cubage of implant in high dose and Danazol groups were lower than that in model group,(P<0.01,P<0.01),There were no significant difference between low dose group and model group(P>0.05).Positive expression of ICAM-1 was located mainly in the cellular plasma. In model group,expression of ICAM-1 were located in cellular plasma, and the expression of ICAM-1 was increased(P<0.01). Expression of ICAM-1 in high-dose, low-dose and Danazol groups were lower than that in model group(P<0.01、P<0.01、P<0.01).There were no significant difference between high-dose group and control group(P>0.05) Positive expression of NF-κB were located in the intracytoplasm.In control group,expression of NF-κB was not obviously,mostly located in intracytoplasm,seldom in nucleus.In model group,expression of NF-κB were located in intracytoplasm.Expression of NF-κB in model group were higher than control group(P<0.05). Expression of NF-κB in high-dose and Danazol groups were lower than that in model group(P<0.01、P<0.01). There were no significant difference between low- dose group and model group(P>0.05).There were no significant difference between high-dose group and control group(P>0.05).There were positive correlation between expression of ICAM-1 and activation of NF-ΚB in endometrium tissue.(r=0.698,P<0.05).Conclusions:1 Bushen Wenyang Huayu principle not only can reduce focus ,loosen conglutination, alleviate ache,furthermore,it can adjust the fuction of ovary.The side-effect of Chinese traditional medicine was trifling,it is good among the effective method which treat EM.2 The level of sICAM-1and sVCAM-1 were all increased in EM group. We consider that it influenced immunity surroundings of EM patient, and it can accelerate ectopic adhering. It is very importance of the episodic mechanism of endometriosis.3 The activity of NF-κB in endometrium of model rats of EM were increased, and it showed positive correlation with the expression of ICAM-1,which indicated that strong adhesively of ICAM-1 was relate to the strong expression of NF-κB likelihood. Bushen Wenyang Huayu principle adjust the activity of NF-κB achieve to adjust the expression of CAMs .更多还原