因骨盆腔疼痛而进行子宫切除术者仅20%发现子宫内膜异位症


  根据在线发表于5月4日、6月版妇产科期刊的一篇研究,进行良性子宫切除术治疗慢性骨盆腔疼痛的妇女,在手术时确认有子宫内膜异位症的比率不到四分之一。
  
  即使有子宫内膜异位症的术前诊断,超过4成妇女在进行子宫切除术时发现并无沾黏。
  
  另外,手术时有子宫内膜异位症者,同时进行卵巢切除术的可能性达2倍,不过,只有22.4%具有病理资料证明卵巢子宫内膜异位。
  
  安娜堡密西根大学妇女医院妇产科医师Erika L. Mowers医师等人在9,622名妇女的回溯研究中写道,进行重大摘除手术治疗慢性骨盆腔疼痛的妇女中,发现子宫内膜异位症的比率低,这在病患咨询时相当重要。研究对象是在2013年1月至2014年7月间,参加「Michigan Surgical Quality Collaborative」研究,进行腹腔镜或开腹子宫切除术治疗良性、非癌性、非产科适应症。他们研究发现,进行手术的术前适应症包括慢性骨盆腔疼痛、疑似子宫内膜异位,或两者兼而有之。
  
  约有15%至17%的育龄妇女患有子宫内膜异位症,是这类妇女慢性骨盆腔疼痛的最常见原因之一,有10%至32%的子宫切除术是为了治疗慢性骨盆腔疼痛,5%至19%是为了治疗子宫内膜异位症。Mowers医师等人写道,尽管每年都进行为数不少的子宫切除术,我们并不知道在子宫切除术过程中确定多少比率的子宫内膜异位症。
  
  因为注意到,子宫切除术治疗慢性骨盆腔疼痛并未能一致地降低子宫内膜异位症患者的复发疼痛风险,作者们形容这些研究对象的高卵巢切除术比率为令人关注的,因为保留卵巢具有已知的健康益处。
  
  进行分析的9,622名良性子宫切除术案例中,15.2% (n = 1465)的患者在手术时有子宫内膜异位症;子宫内膜异位症发病率因不同适应症而异,慢性骨盆腔疼痛者有21.4% (806/3768)、术前适应症为子宫内膜异位症者有57.2% (705/1232)、两个适应症皆有者,则是有58.0% (484/835)呈现视觉上或病理上的植入证据。
  
  最常见的沾黏部位是子宫、输卵管、卵巢、骨盆;涉及膀胱、输尿管、肠道,或者是骨盆或网膜外的植入,则是比较不常见。
  
  研究者指出,手术确认疾病者比较可能有中度与严重沾黏,她们同时进行卵巢切除术的机率是2.03倍(95%信赖区间1.71 - 2.40)。整体而言,慢性骨盆腔疼痛妇女有47.4% (n = 773)在进行卵巢切除术时发现有子宫内膜异位症,至于有慢性骨盆腔疼痛但无子宫内膜异位症证据者,则是有33.3% (n = 2867)(P < .001)。
  
  有趣的是,既非术前疼痛、也不是子宫内膜异位症适应症的5,457名妇女中,意外发现子宫内膜异位症的比率有8.0%(n = 434)。
  
  在术前适应症为慢性骨盆腔疼痛的3,786名患者中,比较常发生沾黏的是那些较年轻者(<45岁)、白人、较弱势、身体质量指数较低、以及那些没有使用止痛剂、荷尔蒙治疗或黄体素子宫内避孕器进行事先处理者,子宫较大的妇女比较不会有子宫内膜异位症。
  
  Mowers医师等人写道,需探讨进行子宫切除术妇女之子宫内膜异位症风险因素的进一步特征,以能最优化地进行手术规划和病患谘商,因为涉及子宫内膜异位的子宫切除术,往往更具有技术上的挑战。
  
  同时具有子宫异常出血或子宫肌瘤等术前适应症者,有子宫内膜异位症的可能性较低,饮酒或抽菸和子宫内膜异位症无关。
  
  研究结果与其它研究如Howard在1993年的报告一致,该篇报告发现慢性骨盆腔疼痛患者的子宫内膜异位症盛行率为28%,密西根大学分析的差异在于它是藉由术中观察。
  
  Mowers医师和共同作者写道,需后续研究以确认慢性骨盆腔疼痛妇女的子宫内膜异位症术前风险因素,是否与子宫切除术后持续性疼痛有关,以及这些是否会影响患者的满意度。
  
  资料来源:http://www.24drs.com/
  
  Native link:Just 20% of Hysterectomies for Pelvic Pain Find Endometriosis

Just 20% of Hysterectomies for Pelvic Pain Find Endometriosis

By Diana Swift
Medscape Medical News

Fewer than one in four women having benign hysterectomy for chronic pelvic pain had confirmed endometriosis at time of surgery, according to a study published online May 4 and in the June issue of Obstetrics & Gynecology.

Even with a preoperative diagnosis of endometriosis, more than four in 10 of the women had no adhesions at the time of hysterectomy.

However, those with endometriosis at surgery were twice as likely to undergo oophorectomy at the same time, although only 22.4% presented with pathology-documented ovarian endometriomas.

"The low rate at which endometriosis is found among women undergoing major extirpative surgery for chronic pelvic pain is important to consider when counseling patients," write Erika L. Mowers, MD, an obstetrician-gynecologist at the University of Michigan and Women's Hospital in Ann Arbor, and colleagues in a retrospective study of 9622 women. This cohort had laparoscopic or abdominal hysterectomy for benign, noncancer, nonobstetrical indications in the Michigan Surgical Quality Collaborative between January 2013 and July 2014. They were studied by preoperative indications for surgery: chronic pelvic pain, suspected endometriosis, or both.

Some 15% to 17% of reproductive-age women suffer from endometriosis, one of the commonest drivers of chronic pelvic pain in this population, and of the 10% to 32% of hysterectomies performed for chronic pelvic pain, some 5% to 19% are for endometriosis. "Despite the large number of hysterectomies performed each year, we do not know how often endometriosis is identified during hysterectomy," Dr Mowers and colleagues write.

Noting that hysterectomy for chronic pelvic pain has not been shown to consistently lower the risk for recurrent pain even in those with endometriosis, the authors called the high oophorectomy rate in this cohort "concerning given the known health benefits of ovarian retention."

In the 9622 benign hysterectomies available for analysis, 15.2% (n = 1465) of patients had endometriosis at the time of surgery. Endometriosis prevalence varied according to indication: 21.4% (806/3768) of women with an indication of chronic pelvic pain, 57.2% (705/1232) with a preoperative indication of endometriosis, and 58.0% (484/835) with an indication of both showed visual or pathologic evidence of implants.

The most frequent sites of adhesions were the uterus, fallopian tubes, ovaries, or pelvis. Involvement of the bladder, ureter, and bowel, or implants outside of the pelvis or omentum, were less frequent.

The researchers note that those with surgically confirmed disease were more likely to have both moderate and severe adhesions. As well, they had a 2.03 (95% confidence interval, 1.71 - 2.40) greater odds ratio of having concurrent oophorectomy. In total, 47.4% (n = 773) of women with chronic pelvic pain found to have endometriosis underwent oophorectomy at time of surgery vs 33.3% (n = 2867) of those with chronic pelvic pain, but no evidence of endometriosis (P < .001).

Interestingly, unexpected endometriosis in the 5457 women with neither preoperative pain nor an indication of endometriosis was found in 8.0% of the women (n = 434).

In the 3786 patients whose preoperative indication was chronic pelvic pain, adhesions occurred more frequently in those of younger age (<45 years), white race, and lower parity and lower body mass index, as well as in those failing a prior treatment such as analgesics, hormone therapy, or a progesterone intrauterine device. Women with larger uteruses were less likely to have endometriosis.

"Further characterization of risk factors for endometriosis in women undergoing hysterectomy is needed to optimize surgical planning and patient counseling because hysterectomies involving endometriosis are often more technically challenging," Dr Mowers and coauthors write.

Those with a concurrent preoperative indication of abnormal uterine bleeding or fibroids had a lower likelihood of endometriosis. There was no association with alcohol or tobacco use and endometriosis.

Although the findings are consistent with those of other studies such as Howard's 1993 report, which found a 28% endometriosis prevalence in patients with chronic pelvic pain, the Michigan analysis differs by virtue of its restriction to intraoperative observations.

"Further investigations are needed to determine whether the preoperative risk factors for endometriosis in women with chronic pelvic pain are associated with persistent pain after hysterectomy or whether they affect patient satisfaction," Dr Mowers and coauthors write.

The authors have disclosed no relevant financial relationships.

Obstet Gynecol. 2016;127:1045-1053.

    
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