因骨盆腔疼痛而進行子宮切除術者僅20%發現子宮內膜異位症


  根據線上發表於5月4日、6月版婦產科期刊的一篇研究,進行良性子宮切除術治療慢性骨盆腔疼痛的婦女,在手術時確認有子宮內膜異位症的比率不到四分之一。
  
  即使有子宮內膜異位症的術前診斷,超過4成婦女在進行子宮切除術時發現並無沾黏。
  
  另外,手術時有子宮內膜異位症者,同時進行卵巢切除術的可能性達2倍,不過,只有22.4%具有病理資料證明卵巢子宮內膜異位。
  
  安娜堡密西根大學婦女醫院婦產科醫師Erika L. Mowers醫師等人在9,622名婦女的回溯研究中寫道,進行重大摘除手術治療慢性骨盆腔疼痛的婦女中,發現子宮內膜異位症的比率低,這在病患諮詢時相當重要。研究對象是在2013年1月至2014年7月間,參加「Michigan Surgical Quality Collaborative」研究,進行腹腔鏡或開腹子宮切除術治療良性、非癌性、非產科適應症。他們研究發現,進行手術的術前適應症包括慢性骨盆腔疼痛、疑似子宮內膜異位,或兩者兼而有之。
  
  約有15%至17%的育齡婦女患有子宮內膜異位症,是這類婦女慢性骨盆腔疼痛的最常見原因之一,有10%至32%的子宮切除術是為了治療慢性骨盆腔疼痛,5%至19%是為了治療子宮內膜異位症。Mowers醫師等人寫道,儘管每年都進行為數不少的子宮切除術,我們並不知道在子宮切除術過程中確定多少比率的子宮內膜異位症。
  
  因為注意到,子宮切除術治療慢性骨盆腔疼痛並未能一致地降低子宮內膜異位症患者的復發疼痛風險,作者們形容這些研究對象的高卵巢切除術比率為令人關注的,因為保留卵巢具有已知的健康益處。
  
  進行分析的9,622名良性子宮切除術案例中,15.2% (n = 1465)的患者在手術時有子宮內膜異位症;子宮內膜異位症發病率因不同適應症而異,慢性骨盆腔疼痛者有21.4% (806/3768)、術前適應症為子宮內膜異位症者有57.2% (705/1232)、兩個適應症皆有者,則是有58.0% (484/835)呈現視覺上或病理上的植入證據。
  
  最常見的沾黏部位是子宮、輸卵管、卵巢、骨盆;涉及膀胱、輸尿管、腸道,或者是骨盆或網膜外的植入,則是比較不常見。
  
  研究者指出,手術確認疾病者比較可能有中度與嚴重沾黏,她們同時進行卵巢切除術的機率是2.03倍(95%信賴區間1.71 - 2.40)。整體而言,慢性骨盆腔疼痛婦女有47.4% (n = 773)在進行卵巢切除術時發現有子宮內膜異位症,至於有慢性骨盆腔疼痛但無子宮內膜異位症證據者,則是有33.3% (n = 2867)(P < .001)。
  
  有趣的是,既非術前疼痛、也不是子宮內膜異位症適應症的5,457名婦女中,意外發現子宮內膜異位症的比率有8.0%(n = 434)。
  
  在術前適應症為慢性骨盆腔疼痛的3,786名患者中,比較常發生沾黏的是那些較年輕者(<45歲)、白人、較弱勢、身體質量指數較低、以及那些沒有使用止痛劑、荷爾蒙治療或黃體素子宮內避孕器進行事先處理者,子宮較大的婦女比較不會有子宮內膜異位症。
  
  Mowers醫師等人寫道,需探討進行子宮切除術婦女之子宮內膜異位症風險因素的進一步特徵,以能最優化地進行手術規劃和病患諮商,因為涉及子宮內膜異位的子宮切除術,往往更具有技術上的挑戰。
  
  同時具有子宮異常出血或子宮肌瘤等術前適應症者,有子宮內膜異位症的可能性較低,飲酒或抽菸和子宮內膜異位症無關。
  
  研究結果與其他研究如Howard在1993年的報告一致,該篇報告發現慢性骨盆腔疼痛患者的子宮內膜異位症盛行率為28%,密西根大學分析的差異在於它是藉由術中觀察。
  
  Mowers醫師和共同作者寫道,需後續研究以確認慢性骨盆腔疼痛婦女的子宮內膜異位症術前風險因素,是否與子宮切除術後持續性疼痛有關,以及這些是否會影響患者的滿意度。
  
  資料來源: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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