促性腺激素释放激素拮抗剂与激动剂治疗子宫内膜异位症：随机对照试验的系统评价和荟萃分析。
完整摘要 · 中文译文
背景：子宫内膜异位症是一种需要个体化长期激素管理的慢性雌激素依赖性炎症性疾病。促性腺激素释放激素激动剂（GnRH-a）可有效抑制卵巢功能，但可能引起低雌激素相关不良反应，而口服促性腺激素释放激素拮抗剂（GnRH-ant）可提供快速、可逆的抑制，且激素波动较小。然而，二者相对疗效和安全性仍不明确。 方法：我们开展了一项系统评价和荟萃分析，纳入比较GnRH-ant与以亮丙瑞林为基础的GnRH-a治疗子宫内膜异位症的随机对照试验，评估症状缓解、盆腔体征、骨密度（BMD）、生活质量和激素结局。 结果：共纳入五项随机对照试验。与GnRH-ant相比，GnRH-a在痛经（标准化均数差（SMD）= 0.69，95% CI：0.48-0.91）、非月经性盆腔痛（NMPP）（SMD = 0.33，95% CI：0.16-0.50）、总体盆腔痛（OPP）（SMD = 0.25，95% CI：0.13-0.38）和性交痛（SMD = 0.14，95% CI：0.02-0.26）方面带来更大改善。GnRH-a还与盆腔压痛、道格拉斯窝硬结评分、峰值疼痛严重程度、镇痛药需求量和月经失血量方面更好的结局相关。亚组分析提示，治疗12周后GnRH-a的镇痛获益更为明显。相比之下，GnRH-ant导致BMD下降显著更少（SMD = 0.64，95% CI：0.39-0.89），在24周时骨保护作用更强。在大多数生活质量 生活质量领域。 结论：基于亮丙瑞林的GnRH-a（促性腺激素释放激素激动剂）提供更优的症状控制，而GnRH-ant（促性腺激素释放激素拮抗剂）对骨密度（BMD）的下降影响较小且卵巢抑制可逆，但应考虑各拮抗剂之间的差异。治疗选择应根据症状严重程度、骨骼健康和生育目标进行个体化。有必要开展长期头对头试验。 系统评价注册：https://www.crd.york.ac.uk/PROSPERO/view/CRD420261289010，注册号CRD420261289010。
完整摘要 · 英文原文
BACKGROUND: Endometriosis is a chronic estrogen-dependent inflammatory disease requiring individualized long-term hormonal management. Gonadotropin-releasing hormone agonists (GnRH-a) effectively suppress ovarian function but may induce hypoestrogenic adverse effects, whereas oral gonadotropin-releasing hormone antagonists (GnRH-ant) offer rapid, reversible suppression with reduced hormonal fluctuation. However, their comparative efficacy and safety remain unclear. METHODS: We performed a systematic review and meta-analysis of randomized controlled trials comparing GnRH-ant with leuprolide-based GnRH-a for the treatment of endometriosis, assessing symptom relief, pelvic signs, bone mineral density (BMD), quality of life, and hormonal outcomes. RESULTS: Five randomized controlled trials were included. Compared with GnRH-ant, GnRH-a yielded greater improvements in dysmenorrhea (standardized mean difference (SMD) = 0.69, 95% CI: 0.48-0.91), nonmenstrual pelvic pain (NMPP) (SMD = 0.33, 95% CI: 0.16-0.50), overall pelvic pain (OPP) (SMD = 0.25, 95% CI: 0.13-0.38), and dyspareunia (SMD = 0.14, 95% CI: 0.02-0.26). GnRH-a was also associated with better outcomes in pelvic tenderness, Douglas pouch induration scores, peak pain severity, analgesic requirements, and menstrual blood loss. Subgroup analysis suggested a more pronounced analgesic benefit of GnRH-a after 12 weeks of treatment. In contrast, GnRH-ant resulted in significantly less BMD reduction (SMD = 0.64, 95% CI: 0.39-0.89), a stronger bone-sparing effect at 24 weeks. No significant differences were observed in most quality-of-life domains. CONCLUSIONS: Leuprolide-based GnRH-a provides superior symptom control, whereas GnRH-ant offers less decline in BMD and reversible ovarian suppression, but differences among individual antagonists should be considered. Treatment selection should be individualized based on symptom severity, bone health, and fertility goals. Long-term head-to-head trials are warranted. SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/PROSPERO/view/CRD420261289010, identifier CRD420261289010.