科研之友
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摘要
Endometriosis is a chronic disease affecting up to 10% of women in the general population and up to 40% in subfertile women. The most common symptom is pain, which can recur even after treatment. Fertility problems are common among women of reproductive age with this disease. There is no cure. The main goal of treatment is to relieve pain and improve fertility. The primary aim of this overview was to summarize data on treatments associated with improved outcomes in women with endometriosis. Data were analyzed in studies published from 1979 to 2012 from 140 randomized clinical trials (included in 18 Cochrane systematic reviews). Primary treatment outcomes evaluated were self-reported pain relief for dysmenorrhea and live birth rate. Secondary outcomes examined included clinical improvement or resolution of endometriosis- related pain, recurrence of pain, clinical pregnancy, ongoing pregnancy, miscarriage, and adverse events. The patient population comprised 13,599 women of reproductive age seen at gynecology and fertility clinics worldwide. Pain relief, improved fertility, and adverse reactions were compared for treatment versus placebo or no treatment and one treatment versus another treatment. The quality of evidence for treatment outcomes in all studies ranged from very low to moderate. Pain Relief The levonorgestrel-releasing intrauterine device (LNG-IUD) system reduced the number of painful symptoms compared with usual care. Gonadotropin-releasing hormone analogs (GnRHa) relieved pelvic tenderness compared with placebo and relieved dysmenorrhea compared with no treatment. Laparoscopic surgery (ablation and excision) reduced pain at 6 months compared with diagnostic laparoscopy. Laparoscopic excision of the endometrioma cyst wall decreased recurrence of dysmenorrhea after 2 years more than did ablation. Evidence was very low quality for studies comparing excisional versus ablative surgery, danazol versus placebo, and acupuncture versus Chinese herbal medicine. Fertility Outcomes Prior to in vitro fertilization, clinical pregnancy rates in women with endometriosis were increased by GnRHa compared with no GnRHa. Compared with diagnostic laparoscopy, laparoscopic surgery (ablation and excision) increased live births and ongoing pregnancies. Laparoscopic excision of the endometrioma cyst wall increased clinical pregnancy rates more than did ablation. Adverse Effects Gonadotropin-releasing hormone analog therapy was associated with higher rates of sleep disturbances than placebo. Compared with GnRHa therapy, danazol was associated with higher rates of sleep disturbances, hot flashes, vaginitis, and headaches. Depot progestogens were associated with higher rates of nausea, weight gain, and bleeding compared with other treatments. Limited evidence is available to guide clinical decisions for endometriosis therapy, especially for preventing recurrence. There are insufficient data to demonstrate the superiority of any one treatment for endometriosis. Methodological problems that limit the value of the data include high risk of bias, poor reporting of randomization methods, allocation concealment, small sample sizes, and wide confidence intervals. Direct comparisons of medical and surgical treatments for endometriosis pain are needed as well as randomized trials exploring the role of surgical interventions in women undergoing assisted reproductive techniques.
- 出版日期2015-7
