1、Individualized treatment for uterine myoma子宫肌瘤的个性化治疗原则 子宫平滑肌瘤是最常见的妇科良性肿瘤，发病率占育龄期妇女20%-40%。Background Uterine myomas are the most common benign uterine tumors,present in 20%40%of women at reproductive age.Hysterectomy has been the most common treatment modality for symptomatic fibroids in the past.Ba
2、ckground过去，子宫切除的有症状的子宫肌瘤的最主要治疗方式。Based on data from 1990 to 1997,the presence of uterine fibroids formed the main indication for hysterectomy in the United States.资料显示，从1990年至1997年，子宫肌瘤在美国是子宫切除术的主要适应症。Despite the frequency with which fibroids are diagnosed and treated,there remains considerable unce
3、rtainty and controversy among clinicians and women regarding the best way to manage them.Myomectomy,the removal of fibroids surgically without hysterectomy,is the second most common surgical procedure for this condition.子宫肌瘤剔除术，即只切除肌瘤而保留子宫的手术，是子宫肌瘤第二主要的手术治疗方式 关于子宫肌瘤的最佳治疗方式，临床医生及患者仍存在相当的争议。Background
4、factors affecting the choice of therapeutic approachage（年龄）parity（产次）childbearing aspirations（生育要求）extent and severity of symptoms（症状的程度）size,number and location of myomas(大小、数目、位置)associated medical conditions（相关适应症）the risk of malignancy（恶性的风险）proximity to menopause（距绝经的时间）the desire for uterine p
5、reservation（保子宫的愿望）Hence,the treatment should be individualized.Background（影响治疗方式的因素）因此，应当采取个性化的治疗。Treatment1.Expectant management（期待治疗）Asymptomatic women with leiomyoma of the uterus of lessthan 12 weeks size,especially those approaching menopause.小于12周大小的无症状子宫肌瘤患者，特别是接近绝经期。follow-up every 36 month
6、s Treatmentcarriy outa detailed history clinical examination to notethe uterine size rate of growth of the tumor2.Medical therapy（药物治疗）Treatment2.1 Antifibrinolytics（抗纤维蛋白溶解药）Tranexamic acid（氨甲环酸）Fist-line nonhormonal therapy for heavy bleeding associated with uterine fibroids and dysfunctional uter
7、ine bleeding.作为一线非激素药物，用于治疗子宫肌瘤及功能失调性子宫出血所致的大量出血。Prolonged treatment may theoretically increase the risk of deep vein thrombosis Treatment长期应用可能会增加患深静脉血栓的风险 Treatment2.2 Nonsteroidal anti-inflammatory drugs(NSAIDs)(非类固醇抗炎药)antagonists of prostaglandins 前列腺素抑制剂reduce dysmenorrhea and heavy menstrual
8、losses Stimulate uterine contractility resulting in paineg.Aspirin,ibuprofen,and naproxen如：阿司匹林，布洛芬，萘普生缓解痛经，减少经量 Treatmentlong-term use gastric ulcers（胃溃疡）gastrointestinal bleeding（胃肠道出血）gastrointestinal adverse effects（胃肠道副反应）anemia（by inhibiting the cyclooxygenase-1 enzyme）（长期应用）贫血（通过抑制环加氧酶-1）Trea
9、tment2.3 Oral contraceptive pills（口服避孕药）However,as myomas are estrogen dependent,they may exhibit an increase in size with combined pills.control menorrhagia and dysmenorrhea（控制月经过多及痛经）For some women,the benefits of hormonal contraception outweigh the risk of this adverse affect.由于肌瘤是雌激素依赖性的，该药可能导致肌
10、瘤增大对于某些女性来说，激素避孕的益处超过了其副作用 Treatment2.4 Danazol（达那唑）creates a high androgen and low estrogen environment resulting in the wasting of endometrium and shrinkage of fibroids.Has been reported to be an effective therapy to shrink fibroids and control their symptoms.造成高雄激素、低雌激素环境导致子宫内膜和肌瘤萎缩已证实是一种缩小肌瘤、控制症
11、状的有效治疗方式 Treatmentside effectsacne（粉刺）hirsutism（多毛症）weight gain（体重增加）irritability（易激惹）musculoskeletal pain（肌肉骨骼痛）hot flushes（热潮红）breast atrophy（乳房萎缩）However,there is no reliable evidence from randomized controlled trials(RCTs)regarding the benefits and/or harms of use of this drug for treating uteri
12、ne myomas副作用 然而，并无来自随机对照实验的可靠证据表明该药治疗子宫肌瘤的益处或危害。Treatment2.5 Gonadotropin-releasing hormone analogs(GnRHa)(促性腺激素释放激素类似物)achieve hypoestrogenism conservative therapy for myomasan adjunct to myomectomyhysterectomy become technically easier and quicker after eliminate the need for surgery for perimenop
13、ausal women造成低雌激素环境保守治疗子宫肌瘤切除术辅助治疗围绝经期妇女避免手术子宫切除变得容易、迅速 Treatmentadverse effectsmenopausal symptoms(更年期症状）osteoporosis（骨质疏松症）pelvic pain（盆腔痛）a hormonal add-backprolong the therapeutic effects of GnRHa.improve the reducetion of bone mineral content副作用激素反向添加延长GnRHa的治疗效果改善骨密度的减少 Treatmenttibolone（替勃龙）r
14、aloxifene（雷诺昔芬）progestogens alone（单纯孕激素）estrogens alonea combination of estrogens and progestogensSome add-back regimes（单纯雌激素）雌孕激素联合 Treatment3.Uterine artery embolization(UAE)（子宫动脉栓塞）This procedure,first described for management of myomas in 1995,attempts to limit growth by limiting the blood suppl
15、y.该方法于1995年首次被用于子宫肌瘤的治疗，通过抑制肌瘤血供来抑制其生长 Be recommended for large symptomatic myomas in women who do not wish or are poor candidates for major surgery.对于肌瘤较大，有症状，又不愿或不适合进行手术的妇女，推荐采用该方法。TreatmentCompared with hysterectomymerits（优点）demerits（缺点）a short hospital stay（住院时间短）improvement in quality of life（改
16、善生活质量）much fewer serious adverse effects（副作用少）more minor complications（小并发症多）unscheduled hospital visits（不定期随访）higher readmission rates（再入院率高）Treatmentmay be consideredabnormal uterine bleeding that is unresponsive to conservative managementa high degree of suspicion of pelvic malignancygrowth of my
17、oma after menopausedistortion of endometrial cavity or tubal obstruction in infertile women those with recurrent pregnancy losses,pain,or pressure symptoms interfering with quality of lifeanemia secondary to chronic uterine blood loss4.Surgical management（手术治疗）may be considered in patients（可适用于以下患者）
18、large myomas（大肌瘤）a distorted endometrial cavity(子宫腔扭曲)unexplained in vitro fertilization failures（不明原因的体外受精失败）may interfere with oocyte retrieval （可能影响卵的拾取）before gonadotrophin（促性激素应用之前）Treatment4.1 Abdominal myomectomy（经腹子宫肌瘤切除术）Treatmentwith menstrual irregularities（月经失调）with risk of endometrial p
19、atholog（子宫内膜病变高危因素）particularly if aged more than 35 years （特别是超过35岁）require endometrial histologic evaluation before myomectomy（子宫肌瘤切除前应行内膜组织学检查）A thorough preoperative evaluation is advisable prior to myomectomy.全面的术前评估是必要的 Treatment The procedure can be carried out by laparoscopy（腹腔镜）or laparotom
20、y（剖腹手术）.laparoscopic myomectomyless hemoglobin dropreduced operative blood loss more patients fully recuperated at day 15diminished operative paindiminished operative pain Superficial subserous or pedunculated myomas are best suited for laparoscopic removal.表浅的浆膜下肌瘤或带蒂的肌瘤非常适合腹腔镜切除 TreatmentThe patie
21、nt was a 21-year-old nulliparous woman presenting witha lump in the abdomen and infertility.A clinical intraoperative photograph taken during myomectomy of an anterior isthmic fibroid and a normal-sized body of the uterus.Treatment The quality of uterine repair would influence the risk of uterine ru
22、pture during a subsequent pregnancy event.子宫的恢复情况将影响以后妊娠时子宫破裂的风险 Hemorrhage and adhesion formation continue to be other areas of concern after myomectomy.出血和粘连形成也是肌瘤切除术后值得关注的问题 For those who desire conception,a delay of 46 months before attempting pregnancy is recommended after myomectomy to allow f
23、or myometrial healing.对希望妊娠的患者，建议子宫肌瘤切除术后休息4-6个月再妊娠，以利于子宫肌层的恢复。Treatment4.2 Hysteroscopic myomectomy（宫腔镜子宫肌瘤切除术）Indication（适应症）abnormal bleeding（异常出血）history of pregnancy loss（流产史）Infertility（不孕）pain（疼痛）suspicion of endometrial malignancy（怀疑内膜恶变）inability to distend the cavity（无法膨胀宫腔）tumor extension
24、 deep into the myometrium（肌瘤深入子宫肌层）Contraindications（禁忌症）TreatmentCategory T:O all pedunculated submucus myomasCategory T:I less than 50%penetration into the myometriumCategory T:II greater than 50%penetration into the myometriumClassification of submucous myomasCategory T:O and T:Ican be removed hy
25、steroscopicallyby a surgeon with modest previous experiencereserved for highly skilledhysteroscopic surgeons Treatmenta hysteroscopic view of a submucus myoma arising from the uterine fundus.4.3 Vaginal myomectomy（经阴道子宫肌瘤切除术）Treatment Large myomas arising from the uterine body may fill the vagina an
26、d result in intermenstrual bleeding,unhealthy discharge,or urinary retention.来源于宫体的大肌瘤可能填满阴道，导致月经间期出血，不洁分泌物或尿潴留。Most of these can be enucleated per vaginum and the stalk ligated.大部分这类肌瘤可经阴道剜出，并将瘤蒂结扎。Treatment an intraoperative clinical photograph of partial(right-sided)inversion of uterine fundus ca
27、used by a large stalked myoma arising from the fundus.来源于宫底的带蒂大肌瘤导致部分（右侧）子宫底的内翻 TreatmentHysterectomyWhen childbearing considerations have been fulfilledthere is reasonable likelihood of malignancythe most common major gynecological surgical procedure33.5%are done for myomas4.4 Hysterectomy（子宫切除）Tre
28、atmentHysterectomyeliminates the needfor progestational agentsa high degree of patient satisfactionenables the woman to takeunopposed estrogen therapy Treatment A clinical photograph of leiomyosarcoma arising in a leiomyomatous uterus as seen at hysterectomy.子宫切除术中所见子宫平滑肌肉瘤 Treatment a nondescent va
29、ginal hysterectomy of a myomatous uterus in progress.正在进行的阴式子宫切除术 Treatment An intraoperative photograph of a false broad ligament myoma taken at hysterectomy.子宫切除术时见一假性阔韧带肌瘤 Treatment An intraoperative clinical photograph of enucleation of a true broad ligament myoma.子宫切除术中见一真性阔韧带肌瘤 Treatment A nor
30、mal sized uterine body sitting atop a large posterior cervical myoma after hysterectomy.一正常大小子宫位于一个大的宫颈后肌瘤的上方 Treatment5.High Intensity Focused Ultrasound(HIFU)High Intensity Focused Ultrasound(HIFU)is a highly precise medical procedure that applies high-intensity focused sonic energy to locally hea
31、t and destroy diseased or damaged tissue through ablation.Treatmentthe basis of thistreatment modalityThe rise in temperature of the tissue the resultant protein denaturation irreversible cell damage Treatment The method uses multiple exposures of high intensity focused ultrasound energy on the targ
32、et fibroid to raise the tissue temperature to levels high enough to destroy it.Symptomatic women who are desiring a noninvasive therapeutic outpatient option for myoma are suitable candidates for this modality.患有子宫肌瘤的有症状的妇女，希望进行无创治疗的，可选择这种治疗方式。这种方法将高强度超声能量聚焦于靶肌瘤，使组织温度升高到足以破坏它的程度。The efficacy of HIFU
33、 surgery correlates with signal intensity of T2-weighted magnetic resonance images.Those with low signal intensity on pretreatment images are more likely to shrink than those with high signal intensity.Treatment HIFU治疗的效果与核磁共振T2加权像中肌瘤的信号强度有关，低信号的肌瘤比高信号的容易萎缩。Small myoma size,intramural location,fewer
34、 number,and T2 hypodensity are important predictors of treatment success.小肌瘤，壁间肌瘤，数量少，T2低信号的肌瘤容易得到满意的治疗效果 Asymptomatic myomas Conclusionreassurance and careful follow upsymptomatic myomasmedical therapy tried as a first-line of treatment surgical treatment reserved for appropriate indicationsmyomectomyperformed when subsequent childbearing is a considerationUterine artery embolizationan effective standard alternative for large symptomatic myomas(poor surgical risks or wish to avoid major surgery)HIFUan effective and safe alternative modality of conservative treatment of uterine myomas
