| Background and ObjectivesIntrauterine adhesion (intrauterine adhesion, IUA) is a injurious lesion of the basal layer of endometrial, It usually due to uuterine operation or infection. The clinical manifestations are:menstrual flow reducing, amenorrhea, cyclic abdominal pain, infertility, habitual abortion, etc. Hysteroscopy is the gold standard for diagnosis of intrauterine adhesion, Transcervical resection of adhesions (transcervical resection of adhesions, TCRA) is in the direct vision targeted separation of adhesions, and it is the preferred method in intrauterine adhesion separation, so it can prevent creating a new wound than by blind separation. But IUA is easy to relapse after adhesion separation, especially in severe intrauterine adhesion. In clinical treatment, post-operation adhesion prevention is still a problem, and it is also a hot spot in research. At present, the commonly used preventive measures include:place the balloon catheter within the uterine cavity, IUD (intrauterine device, IUD), oral estrogen, and so on. But the results are still unsatisfactory. Foreign literature reported that regular hysteroscopic examination after separation can discover the recurrence of adhesions earlier and separate the adhesions in a timely manner, so can effectively prevent the development of adhesions. In this comprehensive study, on the base of placing balloon catheter in the intrauterine and the IUD, we added high dose of estradiol valerate combined with regularly hysteroscopy review to prevent the recurrent adhesions of moderate or severe intrauterine adhesions after TCRA. By applying above integrate approach, we evaluate the value of hysteroscopy and estradiol valerate in preventing the recurrent adhesions of moderate or severe intrauterine adhesions after TCRA.Materials and MethodsWe collect the clinical data of59patients who were diagnosed moderate or severe intrauterine adhesions by hysteroscopy in our hospital from January2007to June2011. And all of the patients undergo the TCRA surgery successfully. The patients are divided into three groups according to different treatments after TCRA: group A, placing a balloon catheter in intrauterine after the TCRA surgery, injection of normal saline according to uterine size,3-6ml.Routine use of antibiotics3days, then pull out the balloon catheter and place a IUD. Group B, using the same measue with Group A treatment and give estradiol valerate8mg/day×21days after operation, add progesterone capsules200mg/day in the last seven days, for3months. Group C, using group B treatment and add hysteroscopy review monthly. Give blunt dissection if mild membranous adhesions occur; if the muscle or fibrous adhesions occur, immediately take the ring out and undergo TCRA surgery. Patients of group B and C review the liver and kidney function monthly.3months later, all of the patients review hysteroscopy to understand uterine morphological changes, and follow-up the recovery of menses. Review the liver and kidney function regularly for patients of group B and C to understand the circumstances of the adverse drug reaction and timely give symptomatic treatment.Results1The result of patients of group C review hysteroscopy within3months after operationIn the three months after operation, The patients of Group C received hysteroscopy review in the period of the third day to seventh day after the menstrual had gone. The first month after surgery, hysteroscopy showed57.69%(15/26) patients with normal uterine morphology,34.62%(9/26) patients with mild adhesions,7.69%(2/26) patients with moderate adhesion. The second months after surgery, hysteroscopy showed73.08%(19/26) patients with normal uterine morphology, and23.08%(6/26) patients with mild adhesions,3.85%(1/26) patients with moderate adhesion. The third months after surgery, hysteroscopy showed88.46%(23/26) patients with normal uterine morphology, and11.54%(3/26) patients with mild adhesions. There is no severe intrauterine adhesions happened to any patient.2Situation of menstrual of patients of group C within3months after operationWe follow up the patients of Group C in the three months each month of the amount of change. One month after surgery,46.15%(12/26) patients restored normal menstruation, and34.62%(9/26) patients with menstrual flow improved significantly compared with the preoperative,19.23%(5/26) patients with menstrual flow and significant changes in the preoperative. two months after surgery,53.85%(14/26) in patients with menstruation returned to normal,30.77%(8/26) patients with menstrual flow improved significantly compared with the preoperative,15.38%(4/26) patients with menstrual flow and significant changes in the preoperative. Three months after surgery,73.08%(19/26) in patients with menstruation returned to normal,19.23%(5/26) patients with menstrual flow improved significantly compared with the preoperative,7.69%(2/26) patients with menstrual flow and significant changes in the preoperative.3Three months later the three groups of patients with hysteroscopy reviewThree months after, patients of A, B and C groups, underwent hysteroscopic exploration and taking out the ring surgery, group A readhesion rate was46.67%(7/15), in which mild adhesion rate was13.33%(2/15), moderate adhesion rate was26.67%(4/15), severe adhesions rate was6.67%(1/15); group B readhesion rate was 27.78%(5/18), in which mild adhesions rate wasl1.11%(2/18), moderate adhesions rate was16.67%(3/18); Group C readhesion rate was11.54%(3/26), and all were mild adhesions. Visiblely the adhesion rate and the degree of adhesion are:group C <group B<group A. The difference of the three groups was statistically significant (P=0.023).4After three months of operation,the three groups of patients with menstrual recoveryThree months after surgery, follow-up of three groups of patients with menstrual recovery of group A,40.00%(6/15) patients returned to normal,26.67%(4/15) improved significantly compared with the preoperative and33.33%(5/15) no significant change; of group B,44.44%(8/18) patients returned to normal,33.33%(6/18) improved significantly compared with the preoperative,22.22%(4/18) no significant change; of group C,73.08%(19/26) patients return to normal,19.23%(5/26) improved significantly compared with the preoperative,7.69%(2/26) no significant change. The difference of the three groups was statistically significant (P=0.044).5Complications and adverse drug reactionsIn all patients with TCRA surgery no case occurred complications. During the use of estradiol valerate, a small number of patients complained of gastrointestinal discomfort, improved after given symptomatic treatment.All patients with no liver and kidney dysfunction.Conclusions1. For the patients with moderate or severe intrauterine adhesions, after TCRA, being placed IUD and balloon catheter can prevent the recurrent adhesions at a certain extent.2. On the basis of placing IUD and balloon catheter in the intrauterine, if adding high doses of estradiol valerate combining with regular hysteroscopy examination, it can improve the amount of menstruation, and it can find new adhesion, promptly separation can avoid the happening of dense adhesion. So the integrated approach can effectively prevent the recurrent adhesions happening. |
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