Dawood M Y
Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Medical School at Houston.
Acta Obstet Gynecol Scand Suppl. 1994;159:22-34.
The non-surgical treatment of endometriosis involves hormone therapy that either affects the lesions directly, or indirectly inhibits endometrial proliferation and induces atrophy through estrogen deprivation, or through a combination of these effects. The medications used to treat endometriosis are progestins (e.g. norethindrone, medroxyprogesterone acetate), oral contraceptives (e.g. estrogen-progesterone acetate), androgens and their derivatives (e.g. danazol, gestrinone), and gonadotropin-releasing hormone (GnRH) agonists (e.g. buserelin, leuprolide acetate, nafarelin, goserelin, tryptorelin). Agents such as GnRH agonists that produce sustained and prolonged hypoestrogenemia, similar to the postmenopausal hypogonadal state, can have a significant negative impact on trabecular bone mass. Evidence from the use of oral contraceptives and medroxyprogesterone acetate indicated that they had no apparent adverse effect on bone mass. Initial studies with dual-photon absorptiometry were unable to detect any appreciable bone loss with GnRH agonists. Later studies, however, have invariably found significant bone loss as early as 3 months after the start of treatment. Quantitated computerized tomography always shows significant trabecular bone loss of the vertebrae and hip with GnRH agonists. Depot preparations appear to produce more marked loss than daily intranasal sprays. Recovery of bone loss may take 6-12 months after the end of therapy, with considerable individual variations. In contrast, treatment of endometriosis with danazol produces bone gain. If endometriosis has to be treated with bone-depleting agents, prevention or attenuation of bone loss using combined therapy with progestins, etidronate or calcitonin together with GnRH agonists should be considered; however, further studies are necessary to define the efficacy of such combined therapy. Smoking and excessive caffeine intake should be avoided. The risk of bone loss should be considered when choosing the appropriate management of endometriosis, the selection of patients, repeat therapies for recurrent endometriosis, and the formulation of such therapies, in order to minimize or overcome it.
子宫内膜异位症的非手术治疗包括激素疗法，该疗法要么直接作用于病灶，要么通过雌激素剥夺间接抑制子宫内膜增殖并诱导萎缩，或通过这些作用的组合来实现。用于治疗子宫内膜异位症的药物有孕激素（如炔诺酮、醋酸甲羟孕酮）、口服避孕药（如醋酸雌二醇 - 醋酸孕酮）、雄激素及其衍生物（如达那唑、孕三烯酮）以及促性腺激素释放激素（GnRH）激动剂（如布舍瑞林、醋酸亮丙瑞林、那法瑞林、戈舍瑞林、曲普瑞林）。像GnRH激动剂这类会产生持续且长期低雌激素血症的药物，类似于绝经后性腺功能减退状态，会对小梁骨量产生显著负面影响。使用口服避孕药和醋酸甲羟孕酮的证据表明，它们对骨量没有明显不良影响。早期使用双能光子吸收法的研究未能检测到GnRH激动剂导致的任何明显骨质流失。然而，后来的研究总是发现，早在治疗开始3个月后就出现了显著的骨质流失。定量计算机断层扫描始终显示，使用GnRH激动剂时，椎骨和髋部的小梁骨有明显流失。长效制剂似乎比每日鼻内喷雾剂导致的流失更明显。治疗结束后，骨质流失的恢复可能需要6 - 12个月，个体差异较大。相比之下，用达那唑治疗子宫内膜异位症会使骨量增加。如果必须使用导致骨质流失的药物来治疗子宫内膜异位症，应考虑使用孕激素、依替膦酸或降钙素与GnRH激动剂联合治疗来预防或减轻骨质流失；然而，需要进一步研究来确定这种联合治疗的疗效。应避免吸烟和过量摄入咖啡因。在选择子宫内膜异位症的合适治疗方法、患者选择、复发性子宫内膜异位症的重复治疗以及这些治疗方法的制定时，应考虑骨质流失的风险，以便将其降至最低或加以克服。
