围绝经期异常子宫出血不同治疗方案研究

Research on Different Treatment Schemes for Abnormal Uterine Bleeding in Perimenopause

摘要: 目的：系统比较口服地屈孕酮、左炔诺孕酮宫内缓释系统(LNG-IUS)及促性腺激素释放激素激动剂(GnRH-a)治疗围绝经期排卵障碍性异常子宫出血(AUB-O)的临床疗效、安全性和对患者生活质量的影响。方法：选取2023年12月至2024年12月于安徽医科大学附属滁州医院妇产科就诊的180例AUB-O患者，所有患者均行宫腔镜手术，按随机数字表法分为三组，每组各60例，分别接受口服地屈孕酮、LNG-IUS置入或GnRH-a治疗。术后1、3、6个月随访，记录子宫出血缓解情况、复发率、血红蛋白水平、月经量(PBAC评分)、子宫内膜厚度及更年期症状改良Kupperman评分。结果：三组患者治疗后子宫出血程度、血红蛋白水平、月经量及子宫内膜厚度均较治疗前显著改善(P < 0.05)。术后3个月及6个月，GnRH-a组Kupperman评分[分别为(24.5 ± 3.8)分和(26.3 ± 4.2)分]显著高于地屈孕酮组[分别为(12.1 ± 2.8)分和(10.2 ± 2.5)分]和LNG-IUS组[分别为(20.1 ± 3.1)分和(19.8 ± 3.0)分] (P < 0.01)。术后6个月，地屈孕酮组PBAC评分[(69.42 ± 11.24)分]高于LNG-IUS组[(69.77 ± 13.18)分] (P < 0.01)，与GnRH-a组[(83.11 ± 10.35)分]无显著差异；地屈孕酮组与LNG-IUS组子宫内膜厚度[分别为(4.76 ± 1.55) mm和(4.83 ± 1.62) mm]均薄于GnRH-a组[(6.16 ± 1.54) mm] (P < 0.01)，但组间比较无显著差异。术后6个月，地屈孕酮组累积复发5例(8.33%)，LNG-IUS组和GnRH-a组均为9例(15.00%)，地屈孕酮组复发率显著低于其余两组(P < 0.05)。结论：口服地屈孕酮、LNG-IUS和GnRH-a治疗围绝经期AUB-O均有效。在本研究的6个月观察期内，地屈孕酮在改善更年期症状及降低复发率方面显示出优势。

Abstract: Objective: To systematically compare the clinical efficacy, safety, and impact on quality of life of oral dydrogesterone, levonorgestrel-releasing intrauterine system (LNG-IUS), and gonadotropin-releasing hormone agonist (GnRH-a) in the treatment of perimenopausal abnormal uterine bleeding due to ovulatory dysfunction (AUB-O). Methods: A total of 180 patients with AUB-O treated at the Department of Obstetrics and Gynecology, Chuzhou Hospital affiliated to Anhui Medical University, from December 2023 to December 2024, were selected. All patients underwent hysteroscopic surgery and were randomly divided into three groups (60 cases each) receiving oral dydrogesterone, LNG-IUS insertion, or GnRH-a treatment. Follow-ups were conducted at 1, 3, and 6 months postoperatively to record uterine bleeding remission, recurrence rate, hemoglobin levels, menstrual blood loss (PBAC score), endometrial thickness, and modified Kupperman score for menopausal symptoms. Results: After treatment, all three groups showed significant improvements in uterine bleeding severity, hemoglobin levels, menstrual blood loss, and endometrial thickness compared to pre-treatment levels (P < 0.05). At 3 and 6 months postoperatively, the Kupperman scores of the GnRH-a group [(24.5 ± 3.8) points and (26.3 ± 4.2) points, respectively] were significantly higher than those of the dydrogesterone group [(12.1 ± 2.8) points and (10.2 ± 2.5) points, respectively] and the LNG-IUS group [(20.1 ± 3.1) points and (19.8 ± 3.0) points, respectively] (P < 0.01). At 6 months postoperatively, the PBAC score of the dydrogesterone group [(69.42 ± 11.24) points] was higher than that of the LNG-IUS group [(69.77 ± 13.18) points] (P < 0.01), but not significantly different from the GnRH-a group [(83.11 ± 10.35) points]. The endometrial thickness of both the dydrogesterone group [(4.76 ± 1.55) mm] and the LNG-IUS group [(4.83 ± 1.62) mm] was thinner than that of the GnRH-a group [(6.16 ± 1.54) mm] (P < 0.01), with no significant difference between the two groups. At 6 months postoperatively, the cumulative recurrence rate was 5 cases (8.33%) in the dydrogesterone group, compared to 9 cases (15.00%) each in the LNG-IUS and GnRH-a groups, indicating a significantly lower recurrence rate in the dydrogesterone group (P < 0.05). Conclusion: Oral dydrogesterone, LNG-IUS and GnRH-a are all effective in treating perimenopausal AUB-O. During the 6-month observation period of this study, dydrogesterone demonstrated advantages in improving menopausal symptoms and reducing recurrence rates.