青少年子宫内膜异位宜早期积极治疗

纽约(EGMN)——圣路易斯大学子宫内膜异位中心主任Patrick Yeung Jr.博士在美国子宫内膜异位基金会(EFA)年会上报告，针对接受腹腔镜异常腹膜区域完全切除术的少女的首个研究显示，术后随访5年无1例复发。这一结果与本次年会的主题不谋而合：早期诊断和完全切除是“最好的预防”。

这项观察性研究共纳入20例症状疑似子宫内膜异位的年轻女性，年龄12~19岁，均接受腹腔镜异常腹膜区域完全切除术。最常见的可疑症状包括中至重度慢性盆腔痛、痛经和排便困难。也有患者报告膀胱疼痛、运动时疼痛和肠绞痛。65%的受试者报告生活质量为“极差”或“差”。多数受试者曾接受激素(82.4%)或手术(76.5%)治疗(Fertil. Steril. 2011;95:1909-12)。

在手术中，组织学分析证实17例(85%)为子宫内膜异位。采用改良美国生殖医学会(ASRM)分期标准(Fertil. Steril. 1997;67:817-21)，29.5%为Ⅰ期，64.7%为Ⅱ期，5.9%为Ⅲ期。

术后报告疼痛症状的患者比例明显下降，报告痛经者从术前的82.4%减少至术后的41.2%，报告排便困难者从76.5%减少至17.6%，报告运动时疼痛者从70.6%减少至5.8%，报告肠绞痛者从58.8%减少至5.8%，报告膀胱疼痛者从52.9%减少至11.8%(P值均＜0.05)。生活质量评分也显著改善(P＜0.05)。

经过最多达66个月的随访(平均随访23.1个月)，17例患者中有8例(47%)因难治性复发性疼痛而再次接受腹腔镜治疗，但其中无1例获得子宫内膜异位的大体或组织学诊断。半数患者有盆腔黏连。

该研究中有1/3的患者术后服用了激素抑制药物，但外科医生并未推荐这一治疗。观察到的子宫内膜异位零复发率并不依赖于术后激素抑制治疗。

Yeung博士支持“看见和治疗”腹腔镜。他同意美国妇产科学会(ACOG)的观点，即子宫内膜异位的诊断不应当依据患者对经验性治疗(例如亮丙瑞林)的反应，而应当看到病灶并通过组织学方法确认(Obstet. Gynecol. 2010;116:223-36)。

Yeung博士注意到，年轻的子宫内膜异位患者常有更不典型，例如红色或白色病灶和清晰的丘疹，因此有必要采用兼具放大和照明功能的腹腔镜。“对于年轻患者，你必须近距离观察，找到并切除所有的病灶，不论是典型病灶还是不典型病灶。”他选用了无触点二氧化碳激光作为切除工具。

会上有数位患者描述了诊治子宫内膜异位的曲折经历，并抱怨她们的症状——包括重度月经相关性盆腔痛——常被认为“正常”。Yeung博士指出，从出现症状到得出子宫内膜异位外科诊断的平均间隔时间长达近12年(Hum. Reprod. 1996:11;878-80)。

一些人相信存在“肉眼不可见的子宫内膜异位”，因此患者总是会再来就诊。但Yeung博士强调，这一观点是来自25年前发表的一篇文章，而当时医生还在依靠开放手术中肉眼发现病灶而作出子宫内膜异位的诊断(Fertil. Steril. 1986:46;522-4)。他引用子宫内膜异位专家David B. Redwine博士的话说，医生越能近距离观察病灶、越熟悉子宫内膜异位的典型和不典型表现，“肉眼不可见病灶”的发生率就越趋近于零(Gynecol. Obstet. Invest. 2003;63-7)。

疼痛只是子宫内膜异位的一个方面，因此切除病灶的收益也不能完全用疼痛缓解来衡量。Yeung博士指出，切除病灶还可预防疾病进展(可能包括子宫内膜癌形成和解剖学畸变)，而且还能改善未来的生育力(Fertil. Steril. 2011;95:1909-12)。

在对子宫内膜异位高危患者进行筛查时，Yeung博士会问她们若干重要问题，例如“你是否曾因为盆腔疼痛或痛经而停课或向单位请假？”如果患者有症状，那么当她回答“是”的时候往往会显出兴奋的表情，“你就知道这些症状不同寻常了”。

Yeung博士报告称无相关利益冲突。

爱思唯尔  版权所有

BY AMY ROTHMAN SCHONFELD
Elsevier Global Medical News
Breaking News

NEW YORK (EGMN) – In the first prospective study of endometriosis in teenagers undergoing complete laparoscopic excision of all areas of abnormal peritoneum, no recurrence was found during up to 5 years of follow-up, according to Dr. Patrick Yeung Jr., director of the center for endometriosis at St. Louis University.

These findings support one of the key themes of the annual congress of the Endometriosis Foundation of America, as expressed by cofounder Dr. Tamer Seckin: Early diagnosis and complete excision are “the best prevention.”

In this observational study conducted by Dr. Yeung and his colleagues at an Atlanta-based specialty endometriosis practice, 20 young women aged 12-19 years with symptoms suspicious for endometriosis underwent complete laparoscopic excision of all areas of abnormal peritoneum. The most common suspicious symptoms included moderate to severe chronic pelvic pain, dysmenorrhea, and dyschezia; other symptoms reported were painful bladder, pain with exercise, and intestinal cramping. Quality of life was described as “awful” or “poor” for 65% of the girls. The majority had previous hormonal (82.4%) or surgical (76.5%) treatment (Fertil. Steril. 2011;95:1909-12).

At surgery, histologic analysis confirmed endometriosis in 17 of the 20 (85%) patients. Using the revised American Society for Reproductive Medicine staging criteria (Fertil. Steril. 1997;67:817-21), 29.5% of patients had stage I disease, 64.7% had stage II, and 5.9% had stage III.

After surgery, fewer girls reported pain symptoms such as dysmenorrhea (82.4% before surgery, reduced to 41.2% after surgery), dyschezia (76.5%, reduced to 17.6%), painful exercise (70.6%, reduced to 5.8%), intestinal cramping (58.8%, reduced to 5.8%) and bladder pain (52.9%, reduced to 11.8%) (all P less than .05). Quality of life scores also significantly improved (P less than .05).

During follow-up of up to 66 months (average, 23.1 months), 8 of 17 (47%) patients underwent a subsequent laparoscopy for persistent recurrent pain. None of these patients had endometriosis diagnosed visually or histologically. Half of the girls had pelvic adhesions.

One-third of the girls in the study took postoperative hormonal suppression medication; no recommendations were made about such treatment by the surgeons. The zero recurrence rate of endometriosis observed did not depend on postoperative hormonal suppression. “Postoperative suppression was not specifically recommended because it was felt [that] complete excision was achieved,” said Dr. Yeung.

Dr. Yeung is an advocate of “see and treat” laparoscopy. He echoes the American College of Obstetricians and Gynecologists’ position that that diagnosis of endometriosis cannot be made by determining the response to empiric therapy (such as leuprolide), but rather by seeing the lesions and getting histological confirmation of the diagnosis (Obstet. Gynecol. 2010;116:223-36).

Noting that younger women with endometriosis often have more atypical and subtle findings, such as red or white lesions and clear papules, he emphasized that it is critical to visualize the field well using high-definition optics with laparoscopy that can provide the benefits of both magnification and illumination. “In the younger patient, you have to look closely and systematically with ‘near contact’ laparoscopy to find it all.” (Near contact laparoscopy refers to the camera tip’s being brought close to the tissue being examined to allow for adequate magnification and illumination of all peritoneal surfaces.)

Dr. Yeung uses the noncontact carbon dioxide (CO2)laser as his “cutting tool of choice,” but states that complete excision of all abnormal areas of peritoneum (both typical and atypical) is the most important. “Half the battle is finding it all, especially in younger women, and the other half of the battle is cutting it all out wherever it is found.”

During the meeting, several patients recounted their difficult journeys with endometriosis. A common complaint was that their symptoms – including severe menstrual-related pelvic pain – were considered to be “normal.”

Dr. Yeung confirmed that the average time from symptom onset to surgical diagnosis of endometriosis is nearly 12 years (Hum. Reprod. 1996:11;878-80).

Some believe that “invisible endometriosis” exists, so that endometriosis will always come back. This idea came from an article published 25 years ago when endometriosis was identified with the naked eye at open surgery (Fertil. Steril. 1986:46;522-4). Dr. Yeung cited a graph by Dr. David B. Redwine, an ob.gyn in Bend, Oregon, who specializes in endometriosis, that shows that the more closely one looks at the tissue and the more one knows what endometriosis looks like in all of its forms (typical and atypical or subtle), the rate of “invisible endometriosis approaches zero especially by experienced surgeons” (Gynecol. Obstet. Invest. 2003;63-7).

It is important to note that pain is only one aspect of endometriosis as a disease, and, therefore, the potential benefits of removing of endometriosis cannot be fully described in terms of pain relief or quality of life benefit alone. Eradication of disease may prevent progression of disease (which may include formation of endometriomas and distortion of anatomy), and may have profound benefits on present or future fertility (Fertil. Steril. 2011;95:1909-12), he commented.

To screen for patients at high risk for having endometriosis, Dr. Yeung asks them several important questions, such as “Have you missed school or work due to pelvic pain or painful periods?” When a patient is asked these questions, “if she has any symptoms, her face lights up as she say ‘yes,’ ” said Dr. Yeung. “These symptoms are not normal.”

Dr. Yeung said he had no relevant disclosures.