摘要目的：探讨高强度聚焦超声（HIFU）消融技术联合促性腺激素释放激素激动剂（GnRH-a）及左炔诺孕酮宫内缓释系统（LNG-IUS）治疗子宫腺肌病痛经的临床效果。方法回顾性分析2012年4月至2015年12月在中南大学湘雅三医院予HIFU消融治疗的有痛经症状的子宫腺肌病患者477例的临床及随访资料，比较仅行HIFU消融治疗（H组）、HIFU联合GnRH-a治疗（H+G组）、HIFU联合LNG-IUS治疗（H+M组）、HIFU联合GnRH-a及LNG-IUS治疗（H+G+M组）的疗效，并分析HIFU消融治疗子宫腺肌病痛经疗效的影响因素。结果所有患者治疗后总有效率随时间延长而下降，治疗后3个月有效率为89.4%（345/386），12个月为84.0%（221/263），24个月为74.2%（98/132）；总复发率为12.9%（39/303）。4组患者治疗后3个月的有效率分别为：H组83.7%（170/203）、H+M组95.0%（95/100）、H+G组100.0%（43/43）、H+G+M组96.8%（30/31），12个月的有效率分别为：H组79.4%（123/155）、H+M组93.2%（69/74）、H+G组11/12、H+G+M组15/17，24个月的有效率分别为：H组68.0%（51/75）、H+M组96.4%（27/28）、H+G组6/12、H+G+M组15/15，复发率分别为：H组19.0%（29/153）、H+M组3.3%（3/90）、H+G组19.4%（6/31）、H+G+M组4.5%（1/22），以上指标4组间分别比较，差异均有统计学意义（P<0.05）；两两比较，治疗后3个月时H组的有效率显著低于H+M组、H+G组（P=0.003、P=0.005），治疗后12个月时H组显著低于H+M组（P=0.006），治疗后24个月时H组显著低于H+G+M组（P=0.005），且24个月时H+G组显著低于H+G+M组（P=0.001）；同时，H组的复发率显著高于H+M组（P<0.008）。H组患者中，HIFU消融治疗子宫腺肌病痛经疗效与子宫体积有关，子宫体积大者的疗效高于子宫体积小者（P=0.017，OR＝2.739，95%CI为1.200~6.251）；且随患者年龄增加，痛经疗效有增高趋势（P<0.05）。结论联合GnRH-a和（或）LNG-IUS能提高HIFU消融治疗子宫腺肌病痛经的疗效、降低复发率，可根据患者的病情个体化选择HIFU消融治疗后的辅助治疗方案。

abstractsObjective To investigate the clinical effect of dysmenorrhea in patients with adenomyosis treated by high intensity focused ultrasound (HIFU) ablation combined with gonadotropin-releasing hormone agonist (GnRH-a) and levonorgestrel-releasing intrauterine system (LNG-IUS). Methods From April 2012 to December 2015, 477 cases of adenomyosis patients with dysmenorrhea were treated by HIFU in the Third Xiangya Hospital. Among them, some patients were treated with HIFU alone, some of them were treated with HIFU combined with GnRH-a and (or) LNG-IUS, thus were classified as H group, H+G group, H+M group and H+G+M group. The improvements of clinical results were compared among the four groups and the influencing factors of HIFU treatment for adenomyosis were also analyzed. Results During the follow-up&nbsp;period, the overall effective rates of the treatment decreased with time, 3 months 89.4% (345/386), 12 months 84.0%(221/263), 24 months 74.2%(98/132), and the overall recurrence rate was 12.9%(39/303). The significant difference in the curative at 3 months [H group 83.7%(170/203), H+M group 95.0%(95/100), H+G group 100.0%(43/43), H+G+M group 96.8%(30/31)], 12 months [H group 79.4%(123/155), H+M group 93.2%(69/74), H+G group 11/12, H+G+M group 15/17], and 24 months [H group 68.0%(51/75), H+M group 96.4% (27/28), H+G group 6/12, H+G+M group 15/15] after HIFU treatment and recurrence rate [H group 19.0%(29/153), H+M group 3.3%(3/90), H+G group 19.4%(6/31), H+G+M group 4.5%(1/22)] were observed among the four groups (P<0.05). Pairwise comparison further showed that, in 3 months after the treatment, the effect of H group was significantly lower than those of H+M group and H+G group (P=0.003, P=0.005);in 12 months after the treatment, the effect of H group was significantly lower than that of H+M group (P=0.006);while in 24 months after treatment, the effect of H group was significantly lower than that of H+G+M group (P=0.005), and the effect of H+G group was lower than that of H+G+M group (P=0.001); and the recurrence rate of H group was significantly higher than that of H+M group (P<0.008). In patients of group H, the effect of HIFU was related to uterine size, the effect of patients with large uterine volume was significantly higher than that of small volume of uterine of patients (P=0.017, OR=2.739, 95%CI:1.200-6.251); with increasing of age, the improvement of dysmenorrhea had a increasing trend (P<0.05). Conclusions HIFU combined with GnRH-a and (or) LNG-IUS could improve the treatment effect in relief of dysmenorrhea. Based on our results, individual treatment protocol should be selected for different patients.