子宫内膜异位症疼痛的治疗

北大医院周应芳20090716美国内异症经验治疗规范目前法国内异症治疗规范中国内异症诊治规范拟诊EM病史、症状、检查不孕LAP+HYS年龄＜35YI～II期年龄≥35YIII～IV期不孕≥3Y指导或IUI/COH妊娠无效直接IVF-ET或GnRHa3mon后IVFIVFIVFIVF痛经非甾体镇痛剂OCs×3～6mon周期或连续有效无效LAP或手术GnRH-a/add-back无效观察盆腔包块影像学检查囊肿＜5cm且不除外功能性无变化或变大缩小或消失观察囊肿＞5cm或提示巧囊和其他肿瘤深部结节----单极电凝----单极汽化剥除囊壁（strippingtechnique）

直接剥除法（immediatestripping）一般囊肿环切剥除法（circularexcisionandsubsequentstripping）大囊肿年龄较大者分离粘连打开囊腔找到囊壁完整剥除妥善止血剥除囊壁（直接剥除法）SmallECOSmallECO(Type-1)只剥巧囊是不够的！内异症与盆腔疼痛深部浸润型内异症

（deeplyinfiltratingendometriosis，DIE）

DIE的诊断辅助诊断DIE的诊断DIE的治疗DIE-USL直肠游离方法肠道内异症的处理细节泌尿系内异症的处理细节UreterEMRVEMUreterEM-Sample1UreterEMDIE-RVEMUreterEM-Sample2UreterEM-Sample2UreterEM-Sample3UreterEM-Sample-3LUNADIE的腹腔镜治疗否则出现大的并发症可能在所难免RectalPerforation二.内异症的药物治疗常用药物内美通或孕三烯酮（gestrinone）GnRH-a类避孕药（OC）孕激素达那唑（danazol）二.痛经的药物治疗非甾体抗炎药（NSAIDS）性激素类药物一线用药方案口服避孕药观察3个月，若有效，可继续使用二线用药方案孕激素﹑雄激素衍生物以及GnRH-a其他:中医中药环氧合酶抑制剂-临床应用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环氧合酶抑制剂

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

一线用药--避孕药短效避孕药1～2片/d，以闭经为准，连服6～9个月疗效和假孕疗法相似副作用轻

一线用药--避孕药一线用药--避孕药

Long-cycletreatmentwithoclong-cycleregimenswithcontinuousadministrationofOCsfor3or6monthsfollowedbyahormone-freeintervalof7daysmayreducethefrequencyofmenstruationsandcycle-dependentcomplaints

Thedatasuggestthattherateoftreatment-relatedsidee