今日の臨床サポート

過多月経

著者: 綾部琢哉 帝京大学医学部付属病院 産婦人科

監修: 小林裕明 鹿児島大学大学院医歯学総合研究科生殖病態生理学

著者校正/監修レビュー済:2020/12/03
参考ガイドライン:
  1. 日本産科婦人科学会/日本産婦人科医会:産婦人科診療ガイドライン 婦人科外来編2020
患者向け説明資料

概要・推奨   

  1. 器質的疾患のない過多月経にはエストロゲン・プロゲスチン配合薬を投与する(推奨度2)
  1. 器質的疾患のない過多月経にはレボノルゲストレル徐放型子宮内システムが有効である(推奨度2)
  1. 器質的疾患のない過多月経には線溶活性亢進を抑制する薬剤が有効である(推奨度2)
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
綾部琢哉 : 特に申告事項無し[2021年]
監修:小林裕明 : 講演料(中外製薬株式会社,アストラゼネカ株式会社),奨学(奨励)寄付など(中外製薬株式会社)[2021年]

改訂のポイント:
  1. 産婦人科診療ガイドライン 婦人科外来編2020では、生殖年齢女性の過多月経を異常子宮出血(AUB)のなかにまとめて病態を分類するFIGOの体系を紹介している。鑑別に漏れがないように各病態の頭文字をとってPALM-COEINとして工夫されているが、本質的に変わるものではないため、これを参考にして本稿の確認を行った。 

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 子宮内膜機能層は卵胞が産生するエストロゲンにより増殖し、黄体が産生するプロゲステロンにより分化して分泌期になる。受精卵が着床しヒト絨毛性ゴナドトロピン(hCG)を分泌すると、このhCGが黄体に作用してその寿命を延長させ、エストロゲンとプロゲステロンの分泌が維持され、子宮内膜は剝離しないで保たれる。
  1. 受精卵の着床がないと黄体はおよそ2週間で寿命を終え退縮する。その結果エストロゲンとプロゲステロンの分泌も消退し、増殖、分化した子宮内膜は剝離、排出される。このときの出血が月経である。
  1. 内膜剝離面の断裂した血管は子宮筋層の収縮により圧迫止血される。この止血効果は子宮内腔が凸面だと有効に作用しにくい。
  1. 子宮内腔が広い、子宮内腔が凸面に変形している、などの場合、剝離される子宮内膜量も増え、過多月経を来し得る(器質的過多月経)。
  1. 子宮内膜が厚い、生殖系内分泌機能のめりはりがない、血液が凝固しにくい、などの場合にも過多月経を来し得る(機能的過多月経)。
 
過多月経の原因

過多月経を来し得る病態を、その機序から整理して示した。

出典

img1:  著者提供
 
 
 
  1. 過多月経は本人の煩わしさのほかに、背景疾患がある場合(器質的過多月経)にはその対応も考慮する。
  1. 過多月経により鉄欠乏性貧血を来す場合には、本人は煩わしくなくても、貧血の治療は必要である。
  1. 鉄欠乏性貧血があったら、過多月経以外の原因を鑑別する必要がある。ほかに原因のない鉄欠乏性貧血では患者に自覚がなくても過多月経を考慮する。
  1. 患者が過多月経といっても、医学的には病的な不正出血が多量にみられている場合がある。
問診・診察のポイント  
  1. 月経血量の正常値は1回の月経あたり20140mlとされている。日本産科婦人科学会の定義では140ml以上を過多月経と呼ぶが、月経量を実際に測定して過多月経と診断することは困難である。
  1. 過多月経を症状により判断するうえで有用な問診内容として、パッド使用量や交換の頻度、凝血塊排出の有無、を尋ねる。ただし、凝血塊の排出とパッドの交換頻度なども必ずしも出血量を反映しない。臨床的に利用可能な客観的指標は鉄欠乏性貧血の有無である。

今なら12か月分の料金で14ヶ月利用できます(個人契約、期間限定キャンペーン)

11月30日(火)までにお申込みいただくと、
通常12ヵ月の使用期間が2ヶ月延長となり、14ヵ月ご利用いただけるようになります。

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文献 

著者: Anne Lethaby, Martha Hickey, Ray Garry, Josien Penninx
雑誌名: Cochrane Database Syst Rev. 2009 Oct 7;(4):CD001501. doi: 10.1002/14651858.CD001501.pub3. Epub 2009 Oct 7.
Abstract/Text BACKGROUND: Heavy menstrual bleeding (HMB) is a significant health problem in premenopausal women; it can reduce their quality of life and cause anaemia. First-line therapy has traditionally been medical therapy but this is frequently ineffective. On the other hand, hysterectomy is obviously 100% effective in stopping bleeding but is more costly and can cause severe complications. Endometrial ablation is less invasive and preserves the uterus, although long-term studies have found that the costs of ablative surgery approach the cost of hysterectomy due to the requirement for repeat procedures. A large number of techniques have been developed to 'ablate' (remove) the lining of the endometrium. The gold standard techniques (laser, transcervical resection of the endometrium and rollerball) require visualisation of the uterus with a hysteroscope and, although safe, require skilled surgeons. A number of newer techniques have recently been developed, most of which are less time consuming. However, hysteroscopy may still be required as part of the ablative techniques and some of them must be considered to be still under development, requiring refinement and investigation.
OBJECTIVES: To compare the efficacy, safety and acceptability of methods used to destroy the endometrium to reduce HMB in premenopausal women.
SEARCH STRATEGY: We searched MEDLINE, EMBASE, CINAHL, PsycInfo, the Cochrane Central Register of Controlled Trials and the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials (from inception to August 2009). We also searched trial registers and other sources of unpublished or grey literature, reference lists of retrieved studies, experts in the field and made contact with pharmaceutical companies that manufactured ablation devices.
SELECTION CRITERIA: Randomised controlled trials comparing different endometrial ablation techniques in women with a complaint of heavy menstrual bleeding without uterine pathology. The outcomes included reduction of heavy menstrual bleeding, improvement in quality of life, operative outcomes, satisfaction with the outcome, complications and need for further surgery or hysterectomy.
DATA COLLECTION AND ANALYSIS: The two review authors independently selected trials for inclusion, assessed trials for quality and extracted data. Attempts were made to contact authors for clarification of data in some trials. Adverse events were only assessed if they were separately measured in the included trials.
MAIN RESULTS: In the comparison of the newer 'blind' techniques (second generation) with the gold standard hysteroscopic ablative techniques (first generation), there was no evidence of overall differences in the improvement in HMB or patient satisfaction.Surgery was an average of 15 minutes shorter (weighted mean difference (WMD) 14.9, 95% CI 10.1 to 19.7), local anaesthesia was more likely to be employed (odds ratio (OR) 6.4, 95% CI 3.0 to 13.7) and equipment failure was more likely (OR 4.6, 95% CI 1.5 to 14.0) with second-generation ablation. Women undergoing newer ablative procedures were less likely to have fluid overload, uterine perforation, cervical lacerations and hematometra than women undergoing the more traditional type of ablation and resection techniques (OR 0.17, 95% CI 0.04 to 0.77; OR 0.32, 95% CI 0.1 to 1.0; OR 0.22, 95% CI 0.08 to 0.6 and OR 0.31, 95% CI 0.11 to 0.85, respectively). However, women were more likely to have nausea and vomiting and uterine cramping (OR 2.4, 95% CI 1.6 to 3.9 and OR 1.8, 95% CI 1.1 to 2.8, respectively).
AUTHORS' CONCLUSIONS: Endometrial ablation techniques offer a less invasive surgical alternative to hysterectomy. The rapid development of a number of new methods of endometrial destruction has made systematic comparisons between methods and with the 'gold standard' first generation techniques difficult. Most of the newer techniques are technically easier than hysteroscopy-based methods to perform but technical difficulties with new equipment need to be ironed out. Overall, the existing evidence suggests that success rates and complication profiles of newer techniques of ablation compare favourably with hysteroscopic techniques.

PMID 19821278  Cochrane Database Syst Rev. 2009 Oct 7;(4):CD001501. do・・・
著者: A M Propst, R F Liberman, B L Harlow, E S Ginsburg
雑誌名: Obstet Gynecol. 2000 Oct;96(4):517-20.
Abstract/Text OBJECTIVE: To determine the frequency of operative complications and whether they can be predicted by specific patient characteristics or type of hysteroscopic procedure.
METHODS: We collected demographic and medical history information on 925 women who had hysteroscopies from 1995 through 1996. We compared differences in rates of operative complications of specific hysteroscopic procedures. Operative complications were defined as uterine perforation, excessive glycine absorption (1 L or more), hyponatremia, hemorrhage (500 mL or more), bowel or bladder injury, inability to dilate the cervix, and procedure-related hospital admissions.
RESULTS: Operative complications occurred in 25 (2.7%) of 925 hysteroscopies. Excessive fluid absorption was the most frequent complication. Hysteroscopic myomectomy and resection of uterine septum were associated with greater odds of complications (odds ratio [OR] 7.4, 95% confidence interval [CI] 3.3, 16.6 and OR 4.0, 95% CI 0.9, 19.6, respectively). Hysteroscopic polypectomy and endometrial ablation were associated with lower odds of complications (OR 0.1, 95% CI 0.0, 0.7 and OR 0.4, 95% CI 0.1, 3.3, respectively). Hysteroscopies done by reproductive endocrinologists and preoperative GnRH agonist therapy were associated with 4-7 times higher odds for operative complications.
CONCLUSION: Complications during hysteroscopic surgery are rare. Among hysteroscopic procedures, myomectomies and resections of uterine septa have significantly higher rates of complications, especially excessive fluid absorption. Meticulous fluid management might limit the number of serious complications of these higher-risk procedures.

PMID 11004351  Obstet Gynecol. 2000 Oct;96(4):517-20.
著者: Andra H James, Peter A Kouides, Rezan Abdul-Kadir, Jennifer E Dietrich, Mans Edlund, Augusto B Federici, Susan Halimeh, Pieter Willem Kamphuisen, Christine A Lee, Oscar Martínez-Perez, Claire McLintock, Flora Peyvandi, Claire Philipp, Jeffrey Wilkinson, Rochelle Winikoff
雑誌名: Eur J Obstet Gynecol Reprod Biol. 2011 Oct;158(2):124-34. doi: 10.1016/j.ejogrb.2011.04.025. Epub 2011 Jun 1.
Abstract/Text Acute menorrhagia is a common gynecological disorder. Prevalence is high among women with inherited bleeding disorders and recent guidance for optimal management is lacking. Following a comprehensive review of the literature, an international expert panel in obstetrics, gynecology and hematology reached consensus on recommendations regarding the management of acute menorrhagia in women without a diagnosed bleeding disorder, as well as in patients with von Willebrand disease, platelet function disorders and other rare hemostatic disorders. The causes and predictors of acute menorrhagia are discussed and special consideration is given for the treatment of women on anticoagulation therapy. This review and accompanying recommendations will provide guidance for healthcare practitioners in the emergency management of acute menorrhagia.

Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.
PMID 21632169  Eur J Obstet Gynecol Reprod Biol. 2011 Oct;158(2):124-3・・・
著者: Jan Endrikat, Heather Shapiro, Eeva Lukkari-Lax, Michael Kunz, Werner Schmidt, Michel Fortier
雑誌名: J Obstet Gynaecol Can. 2009 Apr;31(4):340-7.
Abstract/Text OBJECTIVES: To evaluate the efficacy of a levonorgestrel-releasing intrauterine system (LNG-IUS) compared with a combined oral contraceptive containing 1 mg norethindrone acetate and 20 mg ethinyl estradiol (OC1/20) in reducing menstrual blood loss (MBL) in women with idiopathic menorrhagia.
METHODS: A prospective, randomized, open-label study was conducted in nine centres in Canada. Healthy women over 30 years of age suffering from idiopathic menorrhagia were treated either with LNG-IUS (n = 20) or with OC1/20 (n = 19) over 12 months. The primary endpoint was the change in MBL from baseline to 12 months. Secondary endpoints included treatment success (defined as a MBL score < 100 after 12 months), hemoglobin levels, and the menorrhagia severity score.
RESULTS: In both treatment groups, MBL decreased significantly from baseline to 12 months (P < 0.001). For the primary endpoint, the MBL score decreased significantly more in the LNG-IUS group (median from 228 to 13, mean percent change-83%) compared to the OC1/20 group (median from 290 to 72; mean percent change-68%) (P = 0.002) after 12 months. In the LNG-IUS group, 80% of subjects had treatment success compared with 36.8 % in the OC1/20 group (P < 0.009). Both treatments increased hemoglobin concentrations significantly between baseline and 12 months. The menorrhagia severity score was consistently lower in the LNG-IUS group at all study time points and was significantly lower (P = 0.045) at six months. Both treatments were well tolerated.
CONCLUSION: Both the LNG-IUS and the combined oral contraceptive effectively decreased menstrual blood loss in women with idiopathic menorrhagia. The overall clinical benefit was more pronounced with LNG-IUS than with OC1/20.

PMID 19497153  J Obstet Gynaecol Can. 2009 Apr;31(4):340-7.
著者: Janesh Gupta, Joe Kai, Lee Middleton, Helen Pattison, Richard Gray, Jane Daniels, ECLIPSE Trial Collaborative Group
雑誌名: N Engl J Med. 2013 Jan 10;368(2):128-37. doi: 10.1056/NEJMoa1204724.
Abstract/Text BACKGROUND: Menorrhagia is a common problem, yet evidence to inform decisions about therapy is limited. In a pragmatic, multicenter, randomized trial, we compared the levonorgestrel-releasing intrauterine system (levonorgestrel-IUS) with usual medical treatment in women with menorrhagia who presented to their primary care providers.
METHODS: We randomly assigned 571 women with menorrhagia to treatment with levonorgestrel-IUS or usual medical treatment (tranexamic acid, mefenamic acid, combined estrogen-progestogen, or progesterone alone). The primary outcome was the patient-reported score on the Menorrhagia Multi-Attribute Scale (MMAS) (ranging from 0 to 100, with lower scores indicating greater severity), assessed over a 2-year period. Secondary outcomes included general quality-of-life and sexual-activity scores and surgical intervention.
RESULTS: MMAS scores improved from baseline to 6 months in both the levonorgestrel-IUS group and the usual-treatment group (mean increase, 32.7 and 21.4 points, respectively; P<0.001 for both comparisons). The improvements were maintained over a 2-year period but were significantly greater in the levonorgestrel-IUS group than in the usual-treatment group (mean between-group difference, 13.4 points; 95% confidence interval, 9.9 to 16.9; P<0.001). Improvements in all MMAS domains (practical difficulties, social life, family life, work and daily routine, psychological well-being, and physical health) were significantly greater in the levonorgestrel-IUS group than in the usual-treatment group, and this was also true for seven of the eight quality-of-life domains. At 2 years, more of the women were still using the levonorgestrel-IUS than were undergoing the usual medical treatment (64% vs. 38%, P<0.001). There were no significant between-group differences in the rates of surgical intervention or sexual-activity scores. There were no significant differences in serious adverse events between groups.
CONCLUSIONS: In women with menorrhagia who presented to primary care providers, the levonorgestrel-IUS was more effective than usual medical treatment in reducing the effect of heavy menstrual bleeding on quality of life. (Funded by the National Institute of Health Research Health Technology Assessment Programme; ECLIPSE Controlled-Trials.com number, ISRCTN86566246.).

PMID 23301731  N Engl J Med. 2013 Jan 10;368(2):128-37. doi: 10.1056/N・・・
著者: A Lethaby, C Farquhar, I Cooke
雑誌名: Cochrane Database Syst Rev. 2000;(4):CD000249. doi: 10.1002/14651858.CD000249.
Abstract/Text BACKGROUND: Heavy menstrual bleeding (HMB) is an important cause of ill health in women. Medical therapy, with the avoidance of possibly unnecessary surgery, is an attractive treatment option. A wide variety of medications are available to reduce heavy menstrual bleeding but there is considerable variation in practice and uncertainty about the most appropriate therapy. Plasminogen activators are a group of enzymes that cause fibrinolysis (the dissolution of clots). An increase in the levels of plasminogen activators has been found in the endometrium of women with heavy menstrual bleeding compared to those with normal menstrual loss. Plasminogen activator inhibitors (antifibrinolytic agents) have therefore been promoted as a treatment for heavy menstrual bleeding. There has been a reluctance to prescribe tranexamic acid due to possible side effects of the drugs such as an increased risk of thrombogenic disease (deep venous thrombosis). Long term studies in Sweden, however, have shown that the rate of incidence of thrombosis in women treated with tranexamic acid is comparable with the spontaneous frequency of thrombosis in women.
OBJECTIVES: To determine the effectiveness of antifibrinolytics in achieving a reduction in heavy menstrual bleeding.
SEARCH STRATEGY: All studies which might describe randomised controlled trials of antifibrinolytic therapy for the treatment of heavy menstrual bleeding were obtained by electronic searches of MEDLINE 1966-1997, EMBASE 1980-1997 and the Cochrane Library. Companies producing antifibrinolytics and experts within the field were contacted for reference lists and information on unpublished trials.
SELECTION CRITERIA: Randomised controlled trials in women of reproductive age treated with antifibrinolytic agents versus placebo, no treatment or any other medical (non-surgical) therapy for regular heavy menstrual bleeding within either the primary, family planning or specialist clinic settings. Women with post menopausal bleeding, intermenstrual bleeding, iatrogenic or pathological causes of heavy menstrual bleeding were excluded.
DATA COLLECTION AND ANALYSIS: Fifteen eligible trials were assessed by three reviewers and eight of these did not meet with the inclusion criteria. Of the seven remaining trials, four of these could be included within the meta-analysis. The remaining three trials had a crossover design and despite contacting the authors and appropriate companies, we were unable to extract the results in a format suitable to include these within the meta-analysis. However the results are included within the text of the review for discussion.
MAIN RESULTS: Antifibrinolytic therapy compared to placebo showed a significant reduction in mean blood loss (WMD -94.0 [-151.4, -36.5]) and significant change in mean reduction of blood loss (WMD -110.2 [-146.5, -73.8]). This objective improvement was not mirrored by a patient perceived improvement in monthly menstrual blood loss (RR 2.5 [0.9, 7.3]) in the one study which recorded this outcome (~~ Edlund 1995~~). Antifibrinolytic agents were compared to only three other medical (non-surgical) therapies: mefenamic acid, norethisterone administered in the luteal phase and ethamsylate. In all instances, there was a significant reduction in mean blood loss (WMD -73.0 [-123.4, -22.6], WMD -111.0 [-178.5, -43.5] and (WMD -100 [-143.9, -56.1] respectively) and a strong, although non-significant trend in favour of tranexamic acid in the participants' perception of an improvement in menstrual blood loss. There were no significant differences in the frequency of reported side effects with tranexamic acid when compared to oral luteal phase progestogens (RR 0.4 [0.1, 1.2]) or withdrawal from treatment because of adverse events when compared with NSAIDs and ethamsylate when these treatments were used for heavy menstrual bleeding. Change in the quality of life measures, flooding and leakage and sex life, were significantly improved in the tranexamic acid group when compared to the oral progestagen group. These findings are based in most cases on only one trial.
REVIEWER'S CONCLUSIONS: Antifibrinolytic therapy causes a greater reduction in objective measurements of heavy menstrual bleeding when compared to placebo or other medical therapies (NSAIDS, oral luteal phase progestagens and ethamsylate). This treatment is not associated with an increase in side effects compared to placebo, NSAIDS, oral luteal phase progestagens or ethamsylate. Flooding and leakage and sex life is significantly improved after tranexamic acid therapy when compared with oral luteal progestogens but no other measures of quality of life were assessed. No study has used resource cost as an outcome. There are no data available within randomised controlled trials which record the frequency of thromboembolic events.

PMID 11034679  Cochrane Database Syst Rev. 2000;(4):CD000249. doi: 10.・・・
著者: A Lethaby, C Augood, K Duckitt, C Farquhar
雑誌名: Cochrane Database Syst Rev. 2007 Oct 17;(4):CD000400. doi: 10.1002/14651858.CD000400.pub2. Epub 2007 Oct 17.
Abstract/Text BACKGROUND: Heavy menstrual bleeding (HMB) is an important cause of ill health in premenopausal women. Although surgery is often used as a treatment, a range of medical therapies are also available. Nonsteroidal anti-inflammatory drugs reduce prostaglandin levels which are elevated in women with excessive menstrual bleeding and also may have a beneficial effect on dysmenorrhoea.
OBJECTIVES: The primary objective of this review was to investigate the effectiveness of non-steroidal anti-inflammatory drugs (NSAIDs) in achieving a reduction in menstrual blood loss in women of reproductive years HMB.
SEARCH STRATEGY: We searched the Cochrane Menstrual Disorders & Subfertility Group trials register (searched April 2007), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1, 2007), MEDLINE (1966 to April 2007), EMBASE (1985 to April 2007), CINAHL (1982 to April 2007), Current Contents (1993 to April 2007) and reference lists of articles. We also contacted manufacturers and researchers in the field.
SELECTION CRITERIA: The inclusion criteria were randomised comparisons of individual NSAIDs with either each other, placebo or other medical treatments in women with regular heavy periods measured either objectively or subjectively and with no pathological or iatrogenic (treatment induced) causes for their heavy menstrual blood loss.
DATA COLLECTION AND ANALYSIS: Seventeen RCTs were identified that fulfilled the inclusion criteria for this review and data were extracted independently. Odds ratios for dichotomous outcomes and weighted mean differences for continuous outcomes were estimated from the data of nine trials. The results of the remaining seven crossover trials with data unsuitable for pooling and one trial with skewed data were described in the Other Data section.
MAIN RESULTS: As a group, NSAIDs were more effective than placebo at reducing heavy menstrual bleeding but less effective than either tranexamic acid, danazol or the levonorgestrel releasing intrauterine system (LNG IUS). Treatment with danazol caused a shorter duration of menstruation and more adverse events than NSAIDs but this did not appear to affect the acceptability of treatment. There were no statistically significant differences between NSAIDs and the other treatments (oral luteal progestogen, ethamsylate, an older progesterone releasing intra-uterine system (Progestasert), oral contraceptive pill (OCC)) but most studies were underpowered. There was no evidence of a difference between the individual NSAIDs (naproxen and mefenamic acid) in reducing HMB.
AUTHORS' CONCLUSIONS: NSAIDs reduce HMB when compared with placebo but are less effective than either tranexamic acid, danazol or LNG IUS. However, adverse events are more severe with danazol therapy. In the limited number of small studies suitable for evaluation, no significant difference in efficacy was demonstrated between NSAIDs and other medical treatments such as oral luteal progestogen, ethamsylate, OCC or another type of IUS, Progestasert.

PMID 17943741  Cochrane Database Syst Rev. 2007 Oct 17;(4):CD000400. d・・・
著者: M A Guven, T Bese, F Demirkiran
雑誌名: Int J Gynecol Cancer. 2004 Jan-Feb;14(1):57-63.
Abstract/Text BACKGROUND: The aim of the study was to compare the accuracy of hydrosonography with that of transvaginal ultrasonography in detection of intracavitary pathologies in patients with history of abnormal uterine bleeding.
STUDY DESIGN: Prospective, randomized, and unblinded study.
MATERIAL AND METHODS: A total of 197 women (n = 130 premenopausal and n = 67 postmenopausal) aged between 23 and 71 years (mean age 45.7 +/- 8.9) presenting with a history of abnormal uterine bleeding were included into the study. Hydrosonography was carried out by experienced gynecologists, on the same setting in an outpatient clinic immediately after the performance of transvaginal sonography. The finally obtained surgical-pathologic findings were compared with the results obtained from transvaginal sonography and hydrosonography. Sensitivity, specificity, positive, and negative predictive values were calculated for each procedure.
RESULTS: The surgical-pathologic examination confirmed normal physiologic endometrium in 50 (48%) of 104 women who were said to have normal endometrium on transvaginal sonography. Seventy (75%) of 93 women diagnosed of intracavitary pathologies on transvaginal sonography were confirmed by surgical-pathologic findings. The sensitivity, specificity, positive predictive value, and negative predictive value of transvaginal sonography in the detection of intracavitary pathology were 56, 68, 75, and 48%, respectively. Surgical-pathologic results revealed intracavitary pathologies in 23 (30%) of 76 women who were said to have normal endometrium on hydrosonography. Among 121 women diagnosed of intracavitary pathologies on hydrosonography, 101 (81%) women were confirmed after histological evaluation of the surgical specimens. The sensitivity, specificity, positive predictive value, and negative predictive value of hydrosonography in the detection of intracavitary pathology were 81, 73, 83, and 70%, respectively. Sensitivity and negative predictive value were significantly higher with hydrosonography. There were five cases of endometrial malignancy in which one of the case of malignancy was on polyp and two cases of endometrial hyperplasia with atypia which were not stated on sonographic results.
CONCLUSION: Hydrosonography is more accurate than transvaginal ultrasography in the detection of intracavitary pathologies in women with abnormal uterine bleeding.

PMID 14764030  Int J Gynecol Cancer. 2004 Jan-Feb;14(1):57-63.
著者: Sangchai Preutthipan, Yongyoth Herabutya
雑誌名: Fertil Steril. 2005 Mar;83(3):705-9. doi: 10.1016/j.fertnstert.2004.08.031.
Abstract/Text OBJECTIVE: To ascertain the therapeutic efficacy and safety of hysteroscopic polypectomy in 240 premenopausal and postmenopausal patients.
DESIGN: Retrospective study.
SETTING: Tertiary university hospital.
PATIENT(S): Two hundred forty patients with intrauterine endometrial polyps, who mostly suffered from abnormal uterine bleeding and infertility.
INTERVENTION(S): Hysteroscopic polypectomy using various instruments including microscissors, grasping forceps, or electrosurgery either with a monopolar probe or a resectoscope.
MAIN OUTCOME MEASURE(S): Operating time, amount of glycine absorption, complications, resumption of normal menstruation, cumulative pregnancy rate, and recurrent rate of polyps after hysteroscopic surgery.
RESULT(S): Resectoscopic polypectomy needed more operating time, had more glycine absorption and complications, but less recurrence than other hysteroscopic techniques. The resectoscope had a 0% recurrence rate and that grasping forceps had a 15% recurrence rate. A total of 21 (8.7%) complications occurred, but no major complications were noted. After long-term follow-up of 9 years and 2 months, those with abnormal uterine bleeding resumed normal menstruation in 93.1% and those with infertility had a cumulative pregnancy rate of 42.3%. There was no statistical difference in reproductive outcome between patients having polyps < or = 2.5 cm and >2.5 cm.
CONCLUSION(S): We found hysteroscopic polypectomy to be effective, safe, minimally invasive procedure with low rate and mild complications. Restoration of reproductive ability did not depend on the size of the removed lesion. Resectoscopic surgery is more preferable to prevent recurrence of polyps.

PMID 15749501  Fertil Steril. 2005 Mar;83(3):705-9. doi: 10.1016/j.fer・・・
著者: Tirso Pérez-Medina, José Bajo-Arenas, Francisco Salazar, Teresa Redondo, Luis Sanfrutos, Pilar Alvarez, Virginia Engels
雑誌名: Hum Reprod. 2005 Jun;20(6):1632-5. doi: 10.1093/humrep/deh822. Epub 2005 Mar 10.
Abstract/Text BACKGROUND: It was our intention to determine whether hysteroscopic polypectomy before intrauterine insemination (IUI) achieved better pregnancy outcomes than no intervention.
METHODS: A total of 215 infertile women from the infertility unit of a university tertiary hospital with ultrasonographically diagnosed endometrial polyps (EP) undergoing IUI were randomly allocated to one of two pretreatment groups using an opaque envelope technique with assignment determined by a random number table. Hysteroscopic polypectomy was performed in the study group. Diagnostic hysteroscopy and polyp biopsy was performed in the control group.
RESULTS: Total pregnancy rates and time for success in both groups after four IUI cycles were compared by means of contingency tables and life-table analysis. A total of 93 pregnancies occurred, 64 in the study group and 29 in the control group. Women in the study group had a better possibility of becoming pregnant after polypectomy, with a relative risk of 2.1 (95% confidence interval 1.5-2.9). Pregnancies in the study group were obtained before the first IUI in 65% of cases.
CONCLUSIONS: These data suggest that hysteroscopic polypectomy before IUI is an effective measure.

PMID 15760959  Hum Reprod. 2005 Jun;20(6):1632-5. doi: 10.1093/humrep/・・・
著者: Ioannis Stamatellos, Aristotelis Apostolides, Panagiotis Stamatopoulos, John Bontis
雑誌名: Arch Gynecol Obstet. 2008 May;277(5):395-9. doi: 10.1007/s00404-007-0460-z. Epub 2007 Sep 13.
Abstract/Text OBJECTIVE: To assess the reproductive benefits of hysteroscopic polypectomy in previous infertile women depending on the size or number of the polyps.
DESIGN AND METHODS: In this retrospective study, from February 2000 to September 2005, totally 83 selected women were included with: a) diagnoses of primary or secondary infertility, endometrial polyp/polyps and abnormal uterine bleeding. Endometrial polyps were diagnosed by transvaginal ultrasound followed by diagnostic hysteroscopy, to confirm diagnosis, and hysteroscopic polypectomy. All 83 subjects who consisted the study group, met inclusion criteria: age under 35 years, at least 12 months of infertility, from 3 to 8 months menstrual disorders (intermenstrual bleeding or spotting, menometrorrhagia or menorrhagia) and from 3 to 18 months of follow-up with attempts to conceive after hysteroscopic polypectomy. The endometrial polyp/polyps appeared to be the only reason to explain their infertility after infertility workup of the couples. There was a comparison of fertility rates after hysteroscopic polypectomy between patients having endometrial polyp < or = 1 cm and patients with bigger or multiple polyps.
RESULTS: Of the 83 subjects, all were found to have endometrial polyps in diagnostic hysteroscopy, confirmed at histologic examination after hysteroscopic polypectomy. Among patients of the study group, there were no significant differences in age, type or length of infertility, or follow-up period after the procedure. The mean size of the endometrial polyps was 1.9 +/- 1.4.cm. Thirty-one patients had endometrial polyp < or = 1 cm and 52 patients had bigger or multiple endometrial polyps. Following polypectomy, menstrual pattern was normalized in 91.6% of patients. Spontaneous pregnancy and delivery at term rates, in the total population of the study, increased after the procedure and were 61.4% and 54.2% respectively. There was no statistical difference in fertility rates between patients having polyps < or = 1 cm and patients having >1 cm polyps or multiple polyps. Spontaneous abortion rate in the first trimester of pregnancy was 6% of the total number of patients and there was no statistical difference between patients with small or bigger/multiple polyps. Type of infertility did not affect fertility rates after hysteroscopic polypectomy. Complication rate after hysteroscopic polypectomy was as low as 2.4%, while recurrence rate of the procedure reached 4.9% of patients.
CONCLUSION: Hysteroscopic polypectomy of endometrial polyps appeared to improve fertility and increase pregnancy rates in previous infertile women with no other reason to explain their infertility, irrespective of the size or number of the polyps. Type of infertility of patients seems not to affect fertility rates after hysteroscopic polypectomy. Menstrual pattern was normalized in the majority of patients after hysteroscopic polypectomy. In addition, hysteroscopic polypectomy is a safe procedure with low complication rate.

PMID 17851673  Arch Gynecol Obstet. 2008 May;277(5):395-9. doi: 10.100・・・
著者: Atsushi Yanaihara, Takeshi Yorimitsu, Hiroshi Motoyama, Shinji Iwasaki, Toshihiro Kawamura
雑誌名: Fertil Steril. 2008 Jul;90(1):180-2. doi: 10.1016/j.fertnstert.2007.05.072. Epub 2007 Sep 24.
Abstract/Text OBJECTIVE: To assess endometrial polyp location and abnormal endometrial findings and their impact on pregnancy rate.
DESIGN: Retrospective study.
SETTING: Reproductive clinic in Kanagawa, Japan.
PATIENT(S): A retrospective study was conducted on 230 infertility patients who had an endometrial polyp, as suspected on the basis of ultrasound and as diagnosed by hysteroscopy.
INTERVENTION(S): Polyps were excised by either polypectomy or curettage. All samples were examined for pathology. The endometrial cavity was subdivided into five area categories: uterotubal junction, anterior uterine wall, posterior uterine wall, lateral uterine wall, and multiple. The patients received < or =6 months of follow-up; pregnancy rates were compared between the five subdivisions.
MAIN OUTCOME MEASURE(S): Pregnancy rates.
RESULT(S): The incidence of endometrial polyps was as follows, by location: uterotubal junction, 8.0%; posterior uterine wall, 32.0%; anterior uterine wall, 15.4%; lateral uterine wall, 9.2%; and multiple, 35.4%. The pregnancy rate after surgery was as follows, by location: uterotubal junction, 57.4%; posterior uterine wall, 28.5%; anterior uterine wall, 14.8%; lateral uterine wall, 18.8%; and multiple, 40.3%. Endometrial hyperplasia was found in 6.9% of the cases. The pregnancy rate after surgery at the uterotubal junction was significantly higher than that of other locations.
CONCLUSION(S): Endometrial polyps are commonly found on the posterior wall of the uterus; however, excision of polyps that were located at the uterotubal junction significantly improved the pregnancy rate. Endometrial polyps should be categorized by both size and location.

PMID 17889854  Fertil Steril. 2008 Jul;90(1):180-2. doi: 10.1016/j.fer・・・

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