子宮內(nèi)膜異位癥疼痛的治療

北大醫(yī)院周應(yīng)芳20090716美國內(nèi)異癥經(jīng)驗治療規(guī)范目前法國內(nèi)異癥治療規(guī)范中國內(nèi)異癥診治規(guī)范擬診EM病史、癥狀、檢查不孕LAP+HYS年齡＜35YI～I(xiàn)I期年齡≥35YIII～I(xiàn)V期不孕≥3Y指導(dǎo)或IUI/COH妊娠無效直接IVF-ET或GnRHa3mon后IVFIVFIVFIVF痛經(jīng)非甾體鎮(zhèn)痛劑OCs×3～6mon周期或連續(xù)有效無效LAP或手術(shù)GnRH-a/add-back無效觀察盆腔包塊影像學(xué)檢查囊腫＜5cm且不除外功能性無變化或變大縮小或消失觀察囊腫＞5cm或提示巧囊和其他腫瘤深部結(jié)節(jié)----單極電凝----單極汽化剝除囊壁（strippingtechnique）

直接剝除法（immediatestripping）一般囊腫環(huán)切剝除法（circularexcisionandsubsequentstripping）大囊腫年齡較大者分離粘連打開囊腔找到囊壁完整剝除妥善止血剝除囊壁（直接剝除法）SmallECOSmallECO(Type-1)只剝巧囊是不夠的！內(nèi)異癥與盆腔疼痛深部浸潤型內(nèi)異癥

（deeplyinfiltratingendometriosis，DIE）

DIE的診斷輔助診斷DIE的診斷DIE的治療DIE-USL直腸游離方法腸道內(nèi)異癥的處理細(xì)節(jié)泌尿系內(nèi)異癥的處理細(xì)節(jié)UreterEMRVEMUreterEM-Sample1UreterEMDIE-RVEMUreterEM-Sample2UreterEM-Sample2UreterEM-Sample3UreterEM-Sample-3LUNADIE的腹腔鏡治療否則出現(xiàn)大的并發(fā)癥可能在所難免RectalPerforation二.內(nèi)異癥的藥物治療常用藥物內(nèi)美通或孕三烯酮（gestrinone）GnRH-a類避孕藥（OC）孕激素達(dá)那唑（danazol）二.痛經(jīng)的藥物治療非甾體抗炎藥（NSAIDS）性激素類藥物一線用藥方案口服避孕藥觀察3個月，若有效，可繼續(xù)使用二線用藥方案孕激素﹑雄激素衍生物以及GnRH-a其他:中醫(yī)中藥環(huán)氧合酶抑制劑-臨床應(yīng)用STUDYDESIGNafterconservativesurgeryforsymptomaticendometriosis(StageIandII)(n=28).Rofecoxib25mgperday(n=16)orplacebo(n=12)wasgivenfor6months.RESULTSAsignificantimprovementofbothpelvicpainanddyspareuniawasobservedaftera6monthspersistingsincetheendofthetreatment(P<0.0001).Theefficacyofrofecoxibwashigherthanplaceboandnorecurrenceoccurred,whileintheplacebo-treatmenta16%(2/12)occurred.Nosignificantsideeffectshavebeenfoundwiththeuseofrofecoxib.CONCLUSIONSRofecoxibwaseffective,safeandlowcosttherapyandmightbealsoproposedinearlystageofendometriosis.CobellisL,EuropeanJournalofObstetrics,Gynecology,&ReproductiveBiology.116(1):100-2,2004Italy環(huán)氧合酶抑制劑

COX-2specificinhibitorAnimalresearchsRegressionofendometrialexplantsinratstreatedwiththecyclooxygenase-2inhibitorrofecoxib.DoganE,Fertility&Sterility.82Suppl3,2004TurkeyCyclooxygenase-2selectiveinhibitorpreventsimplantationofeutopicendometriumtoectopicsitesinrats.MatsuzakiS.Fertility&Sterility.2004FranceNSAIDSdifferentiallysuppressendometriosis

inamurinemodelFemaleC57BL/6mice,implantationofautologousendometriumSeveralNSAIDsorthevehicle-matchedcontrolfor4weeks,thelesionburden

controls 5.7mmcelecoxib 1.3mmindomethacin 1.4mmnaproxen 2.7mmsulindac 3.1mmrofecoxib 3.4mmibuprofen 4.1mmaspirin 5.9mm

Fertil-Steril.2005,83(1):171-81

一線用藥--避孕藥短效避孕藥1～2片/d，以閉經(jīng)為準(zhǔn)，連服6～9個月療效和假孕療法相似副作用輕

一線用藥--避孕藥一線用藥--避孕藥

Long-cycletreatmentwithoclong-cycleregimenswithcontinuousadministrationofOCsfor3or6monthsfollowedbyahormone-freeintervalof7daysmayreducethefrequencyofmenstruationsandcycle-dependentcomplaints

Thedatasuggestthattherateoftreatment-relatedsidee