Sowter M C, Singla A A, Lethaby A
5 Wellington Terrace, Clifton, Bristol, UK, BS8 4LE.
Cochrane Database Syst Rev. 2000(2):CD001124. doi: 10.1002/14651858.CD001124.
Menorrhagia is one of the most common reasons for pre-menopausal women to be referred to a gynaecologist. Although medical therapy is generally the first approach, many will eventually require or request a hysterectomy. Hysterectomy is associated with a significant in-patient hospital stay and a period of convalescence that makes it an unattractive and unnecessarily invasive option for many women. Hysteroscopic endometrial ablation or resection offers a day-case surgical alternative to hysterectomy for these women. It is also a cheaper procedure than hysterectomy. Complete endometrial removal or destruction is one of the most important determinants of treatment success. Therefore surgery will be most effective if undertaken when endometrial thickness is less than 4mm, in the immediate post-menstrual phase, however there are often difficulties in reliably arranging surgery for this time. The other option is the use of hormonal agents which induce endometrial thinning or atrophy prior to surgery. The most commonly evaluated agents have been goserelin (a GnRH analogue) and danazol. Progestogens and other GnRH analogues have also been studied although less data are available. It has been suggested that the use of these agents, particularly GnRH analogues, will reduce operating time, improve the intra-uterine operating environment, and reduce distension medium absorption (this is the fluid used to distend the uterine cavity during surgery).
To investigate the effectiveness of gonadotrophin-releasing hormone (GnRH) analogues, danazol, and progestogens, when used for endometrial thinning prior to hysteroscopic surgery for menorrhagia, in improving the intra-uterine operating environment and treatment outcome after surgery.
The Menstrual Disorders and Subfertility Group search strategy (see Review Group details) was used to identify randomised trials that had compared the use of these drugs with either each other, or placebo, or no pre-operative treatment.
Trials were included if they compared the effects of these agents with each other, or with placebo or no treatment on relevant intra-operative and post-operative treatment outcomes. Only randomised studies were included in this review.
Eight studies met the inclusion criteria for this review. Four studies compared goserelin (a GnRH analogue) with no treatment or placebo. Three studies compared goserelin with danazol. One study compared progestogens, danazol and triptorelin (a GnRH analogue) with no treatment. Data was extracted independently by two reviewers. A third reviewer checked data extraction for accuracy and wrote to authors where relevant data was missing or unclear. Intra-operative parameters included endometrial thickness, duration of surgery, ease of surgery, distension medium absorption and complication rate. Post-operative outcomes compared were the proportion of women with amenorrhoea, post-operative menstrual loss and dysmenorrhoea, and the need for further surgery. Data on side-effects were also recorded.
When compared with no treatment GnRH analogues are associated with a shorter duration of surgery, greater ease of surgery and a higher rate of post-operative amenorrhoea. Post-operative dysmenorrhoea also appears to be reduced. The use of GnRH analogues has no effect on intra-operative complication rates and patient satisfaction with this surgery is high irrespective of the use of any pre-operative endometrial thinning agent. GnRH analogues produce more consistent endometrial atrophy than danazol. For other intra-operative and post-operative outcomes any differences are minimal. Both GnRH analogues and danazol produce side-effects in a significant proportion of women, though few studies have reported these in detail. Little randomised data is available to assess the effectiveness of progestogens as endometrial thinning agents and the effect of any thinning agent
月经过多是绝经前女性转诊至妇科医生处的最常见原因之一。尽管药物治疗通常是首选方法，但许多患者最终还是需要或要求进行子宫切除术。子宫切除术与较长的住院时间和一段恢复期相关，这使其对许多女性来说是一个缺乏吸引力且侵入性不必要的选择。宫腔镜子宫内膜消融或切除术为这些女性提供了一种日间手术替代子宫切除术的方法。它也是一种比子宫切除术更便宜的手术。完全去除或破坏子宫内膜是治疗成功的最重要决定因素之一。因此，如果在月经刚结束阶段子宫内膜厚度小于4mm时进行手术，手术将最为有效，然而，在这个时间可靠地安排手术往往存在困难。另一种选择是在手术前使用激素药物使子宫内膜变薄或萎缩。最常评估的药物是戈舍瑞林（一种促性腺激素释放激素类似物）和达那唑。孕激素和其他促性腺激素释放激素类似物也已被研究，尽管可用数据较少。有人认为，使用这些药物，特别是促性腺激素释放激素类似物，将减少手术时间，改善子宫内手术环境，并减少膨胀介质吸收（这是手术期间用于扩张子宫腔的液体）。
研究促性腺激素释放激素（GnRH）类似物、达那唑和孕激素在宫腔镜手术治疗月经过多前用于使子宫内膜变薄时，对改善子宫内手术环境和术后治疗效果的有效性。
采用月经紊乱与生育力低下组的检索策略（见综述组详细信息）来识别比较这些药物彼此之间、与安慰剂或无术前治疗的随机试验。
如果试验比较了这些药物彼此之间、与安慰剂或无治疗对相关术中及术后治疗结果的影响，则纳入试验。本综述仅纳入随机研究。
八项研究符合本综述的纳入标准。四项研究比较了戈舍瑞林（一种促性腺激素释放激素类似物）与无治疗或安慰剂。三项研究比较了戈舍瑞林与达那唑。一项研究比较了孕激素、达那唑和曲普瑞林（一种促性腺激素释放激素类似物）与无治疗。数据由两名综述员独立提取。第三名综述员检查数据提取的准确性，并在相关数据缺失或不清楚时写信给作者。术中参数包括子宫内膜厚度、手术持续时间、手术难易程度、膨胀介质吸收和并发症发生率。比较的术后结果是闭经女性的比例、术后月经失血和痛经情况以及进一步手术的必要性。还记录了副作用数据。
与无治疗相比，GnRH类似物与较短的手术持续时间、更高的手术难易程度和更高的术后闭经率相关。术后痛经似乎也有所减轻。GnRH类似物的使用对术中并发症发生率没有影响，并且无论是否使用任何术前子宫内膜变薄药物，患者对该手术的满意度都很高。GnRH类似物比达那唑产生更一致的子宫内膜萎缩。对于其他术中及术后结果，任何差异都很小。GnRH类似物和达那唑在相当比例的女性中都会产生副作用，尽管很少有研究详细报道这些副作用。几乎没有随机数据可用于评估孕激素作为子宫内膜变薄药物的有效性以及任何变薄药物 的效果。
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