Vercellini Paolo, Buggio Laura, Somigliana Edgardo
Department of Clinical Sciences and Community Health, Università degli Studi; and Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
Department of Clinical Sciences and Community Health, Università degli Studi; and Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
Fertil Steril. 2017 Dec;108(6):913-930. doi: 10.1016/j.fertnstert.2017.08.038.
Defining whether medical therapy is effective in women with deep rectovaginal endometriosis and in which circumstances it can be considered an alternative to surgery is important for patients and physicians. Numerous observational and some randomized controlled studies demonstrated that different hormonal drugs improved pain and other symptoms in approximately two-thirds of women with deep rectovaginal endometriosis. Because major differences in the effect size of various compounds were not observed, much importance should be given to safety, tolerability, and cost of medications when counseling patients. Progestins seem to offer the best therapeutic balance when long-term treatments are planned. Women should be informed that hormonal drugs control but do not cure endometriosis and that, to avoid surgery, they should be used for years. Medical therapy is not an alternative to surgery in women with hydronephrosis, severe subocclusive bowel symptoms, and in those wishing a natural conception. A progestin should systematically be chosen as a comparator in future randomized trials on novel medications for deep endometriosis. In the meantime, the use of existing drugs should be optimized, and medical and surgical treatments could be viewed as subsequent stages of a stepwise approach. In general, there is no absolute "best" choice, and women must be thoroughly informed of potential benefits, potential harms, and costs of different therapeutic options and allowed to choose what they deem is better for them.
确定药物治疗对深部直肠阴道子宫内膜异位症女性是否有效以及在何种情况下可被视为手术替代方案，对患者和医生而言都很重要。众多观察性研究和一些随机对照研究表明，不同的激素药物可改善约三分之二深部直肠阴道子宫内膜异位症女性的疼痛及其他症状。由于未观察到各种药物在效应大小上存在重大差异，因此在为患者提供咨询时，应高度重视药物的安全性、耐受性和成本。当计划进行长期治疗时，孕激素似乎能提供最佳的治疗平衡。应告知女性，激素药物可控制但无法治愈子宫内膜异位症，且为避免手术，需使用数年。对于患有肾积水、严重的肠梗阻样症状的女性以及希望自然受孕的女性，药物治疗并非手术的替代方案。在未来针对深部子宫内膜异位症新药物的随机试验中，应系统地选择孕激素作为对照。与此同时，应优化现有药物的使用，药物治疗和手术治疗可被视为逐步治疗方法的后续阶段。一般而言，不存在绝对的“最佳”选择，必须让女性充分了解不同治疗方案的潜在益处、潜在危害和成本，并允许她们选择自认为对自己更好的方案。
