BQYTE .

CONG HOA xA HOI. cnu NGHiA .

VIET NAM
DQc lip - TV do - Hfnh phuc
S6: 5306/QD-BYT Ha Nf}i, ngay O1-thangA~nam 2019

QVYETDJNH
V~ vi~c ban hanh tai li~u chuyen mfm
"HU'o-ng d~n chAn doan va di~u tr! IfCDQi mfc tir cung"

.
BO TRUONG BO Y TE .
Can cir Luat Kham benh, chua benh nam 2009;

Can cir Nghi dinh s6 75/2017/ND-CP ngay 20 thang 6 nam 2017 cua Chinh phu
quy dinh clnrc nang, nhiem vu, quyen han va co c~u t6 chirc cua BQ Y t@;

Xet dS nghi cua Cue tnrong Cue Quan Iy kham, chua benh,

QUYETDJNH:

Di~u 1. Ban hanh kern theo Quyet dinh nay tai lieu chuyen mon "Hu6ng d~n
chan doan va diSu tri lac nQi mac til cung".

Di~u 2. Tai lieu chuyen mon "Hu6ng d~n ch~n doan va diSu tri lac nQi mac til
cung" bao gam ban gi~y va ban di~n til (app) diroc ap dung tai cac co kham benh, sa
chua benh trong ca nuac.

Di~u 3. Quy@tdinh nay co hi~u h.rc kS tiI ngay kY, ban hanh.
Di~u 4. Cac ong, ba: Chanh Van phong BQ, Chanh thanh tra BQ, T6ng Cvc
truang, Cvc truang va Vv truang cac T6ng cvc, Cvc, Vv thuQc BQ Y t@,Giam d6c
Sa Y t@cac tinh, thanh ph6 tn.rc thuQc trung uang, Giam d6c cac B~nh vi~n tn.rc
thuQc BQ Y t@,Thu truang Y t@cac nganh chiu trach nhi~m thi hanh Quy@tdinh
nay.!.

Noi nhpn:
- NhuDiSu 4;
- BQ truang (d€ bao cao);
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- LUll: VT, KCB, PC.

Nguy~n TrU'O'ng SO'n

Chứng thư: Bộ Y tế
Ngày ký: 09/12/2019 11:14:30
Hệ thống VOffice Bộ Y Tế
 BQYTE

HuONG nAN CHAN DoAN vA DIEU TRI•

LAC
•
NOI
•
MAC
•
TU CUNG
(Ban hanh kernthea Quyet dinh s6 5306/QD-BYTngay 07 thdng 11 ndm 2019)

Hit NQi 2019

~ ~1
 . .
Muc Iuc

1. D~I CUON"G 4
2. YEU TO NGUY Co 4
/.. tru
2 ..1 C au au vaa kiIn h nguy~t
. .,.. p h:=:
rue glal " .4
2.2. Moi truong ·····
..························
4
2.3. Ch~ dQ an 4
3. CHAN DoAN 5
3.1. Lam sang 5
3.1.1. Trieu chung co nang 5
3.1.2. Trieu chung thuc thd 5
3.2. C~n lam sang 6
····..···································
3.2.1. Sieu am 6
3.2.2. Cong huong tir (MRJ) · 6
3.2.3. Dau an sinh h9C 6
3.2.4. Cdc kfJ thudt khdc h6 tro chdn doan LNMTC sdu, LNMTC bang quang,
nieu quan, true trang
.",? ,
.6
3.3. Ph an loai th~ lam sang LNMTC 6
3.3.1. LNMTC a phuc mac 6
3.3.2. LNMTC buong trtmg 6
3.3.3. LNMTC sdu 6
3.3.4. Benh tuyen co tit cung ·····..· 7
3.3.5. LNMTC tai cac vi tri khac ····.·· 7
3.4. Phfin dQ LNMTC (theo ASRM da hi~u chinh) 7
3.5. ChAn doan phan loai theo ICD (International Classification of Diseases). 7
3.6. ChAn doan phan bi~t 7
··································
4. DIEU TR:J 7
4.1. Nguyen t~c va muc tieu di~u tr] 7
4.1.1. Nguyen tac iliJu tri 7
4.1.2. M1!-ctieu tliJu tri ······································7
4.2. Di~u tr] LNMTC va dau 8
4.2.1. DiJu tri noi khoa giam dau buac 1 ···············8
4.2.2. ou« tri noi khoa giam dau buoc 2 9
4.2.3. ou« tri phdu thudt giam dau ·· ········ 9
2
4.3. Di~u tr] LNMTC va hi~m mUQn- va sinh l1
.... t':"ac va rn'{tctieu
4.3..1 N guyen leu di . ...·····················································11
~ trl····
uleu
4.3.2. DiJu tri phdu thudt trong LNMTC va va sinh ll
4.3.3. DiJu tri noi tidt sau phdu thudt cho LNMTC va hidrn muon - va sinh .. 12
4.3.4. ou« tri hiem muon - va sinh kern LNMTC bang phuang phdp bam tinh
trung vaa buong tir cung (lUI) 12
4.3.5. DiJu tri hidrn muon - va sinh kern LNMTC bangphuongphap h6 tro
sinh san (ART) 12
4.3.6. Phdu thudt diJu tri LNMTC truoc khi thuc hien ART 12
4.4. Di~u tr] LNMTC khac (thanh bung, tAng sinh mfin ) 13
PHV LVC 01 · ; 14
. .
PHU LUC 02 15
. .
PHU LUC 03 16
. THAM KHAo
TAl LIEU 21

3
 HUONG nAN CHAN DoAN vA DIEU TRI..LAC NOI
. MAC
. TU CUNG
(Ban hanh kern thea Quyit dinh s6 5306/QD-BYT ngay 07 thong 11 ndm 2019)

l.D~I CUONG
- Lac nQi mac tu cung (LNMTC) la benh ly phu khoa man tinh, phirc tap, dS tai
phat, trong do co SlJhien dien cua rna giong rna tuyen a nQi mac nr cung va rna
d~m my hanh nam ngoai buong tu cung. SlJ hien dien rna lac ch6 nay thuc dAy
SlJhinh thanh cac phan irng viem man tinh va la benh li phu thuoc estrogen.
a
- Benh LNMTC bao g6m cac the: LNMTC phuc mac, LNMTC buong tnrng, a
LNMTC sau, benh tuyen co tir cung (hay con goi LNMTC vao co tu cung); cac
thS LNMTC thirong di kern voi nhau tren cung mot benh nhan,
_ Tful suat mac benh khong duoc biSt chinh xac, uoc tinh khoang 10% phu ncr dQ
tu6i sinh san bi LNMTC. Trong s6 BN LNMTC co khoang 40 - 82% phu nfl bi
dau vling ch~u m~n tinh, 500/0 ph\! nu LNMTC bi anh huang gay hiSm mUQnva
a
sinh, 17- 48% la cac kh6i LNMTC bu6ng trung.
- Lam sang co thS khong co tri~u chUng, nhung LNMTC thuOng hay xuat hi~n
trong b~nh canh dau vung ch~u, hiSm mUQn,ho~c kSt hQ'Pca hai. ChAn doan chu
ySu dlJa vao hoi b~nh su, kham lam sang va chAn doan hinh anh. B~nh doi hoi
mQt kS ho~ch diSu tri dai h~ vai m\!c tieu t6i uu hoa diSu tri nQi khoa tranh l~p
di l~p l~i cac can thi~p ngo~i khoa.
_ M~c du co rat nhiSu n6 llJc trong nghien cUu vS LNMTC, cac bac SI lam sang
hi~n t~i v~n dang d6i di~n vai khong it kho khan trong chAn doan va xu tri, vi v~y
mQt tai li~u huang d~n vS chAn doan va diSu tri LNMTC la cful thiSt.
2. YEU TO NGUY co
2.1. cau true giai phiu va kinh nguy~t
Nhom ph\! nu sau co thS co nguy cO'cao bi LNMTC:
_ Ph\! nu chua sinh de, chu kY kinh ngAn, hanh kinh dai ngay, cUOngkinh, d~y thi
sam
- TiSn su gia dinh co nguai bi LNMTC
- TAcnghen dUOngthoat mau kinh
2.2. Moi trtfO'ng
Lien quan giua LNMTC va SlJphO'inhiSm vai cac chat hoa hQc d~n dSn biSn d6i
cac nQi tist t6 da duQ'cghi nh~n, nhung cO'chS chua biSt roo
2.3. Ch~ de}an
Thuc u6ng co c6n, caffeine, chat beo, thit do, thu6c la... co thS la nguy cO'cao
LNMTC

4
3. CHAN DoAN
LNMTC thuong duoc chsn doan muon. Viec cham chS trong chAn doan co thS d~n
dSn nhfmg h~ qua bftt 19i cho diSu trio
sa d6 Quy trinh lam sang ch~n doan va diSu tri LNMTC trong Phu luc 01 ban hanh
kern theo.
3.1. Lam sang
3.1.1. Trieu chtmg co nang
• Trieu clnrng lien quan phu khoa: dau bung khi hanh kinh, co thS dau khong lien
quan ky kinh, dau khong co tinh chu ky, dau sau khi giao hop, hoac dau khu tru
theo ky kinh tai thanh bung quanh SyO m6 lfty thai, hoac dau tai vung telng sinh
mon sau sinh duong am dao .... , xu§.thuyet til cung b§.t thtrong (trong benh tuyen
cootil cung), cham hoac khong co thai.
• Trieu clnrng khong lien quan phu khoa: phu nu trong dQ tu6i sinh de co di dai
ti~n (celu) dau, di tieu dau, tiSu ra mau, chay mau tl1JCtrang .... xay ra theo chu ky
a
kinh. Cac kh5i lac tuyen NMTC buong tnrng co kich thuoc 100 co thS gay chen
ep tl1JCtrang hay bang quang gay cac trieu chirng do chen ep nhu tiSu kho tiSu
l~t nh~t, tao bon ....
Hai nhom tri~u chUng nay co thS xu§.thi~n dan thueln ho~c di kern vai nhau.
3.1.2. Tri¢u chUng thlfc thd
Celnkham thanh bVng, am hQ, am d~o, telng sinh mon/ kham tl1Jc trang, nh§.tla khi
co tri~u chUng ggi y tren. Cac d§.uhi~u th\fc thS (ggi y LNMTC va vi tri LNMTC):
_ LNMTC sau: vach am d~o tn.rc trang, 2 day ch&ng tu cung cung nS cUng khi
kham bkg tay co kSt hqp kham tn,rc trang; ho~c nhin thfty cac n5t xanh tim trong
vung cung d6 sau khi kham b&ng rna vit ho~c d~t van am d~o, sa ch~m co thS
dau.
_ LNMTC vao bu6ng trUng: kham am d~o hay tl1JCtrang thfty co kh5i c~nh til cung
a
mQt ho~c 2 ben, kern di dQng.
_ B~nh tuySn cootu cung: kham phVkhoa th§.ytu cung co kich thuac 100, day khong
dSu nhu kh5i celu(nSu la LNMTC thS Ian toa), co thS kern di dQng.
_ MQt s5 vi tri LNMTC khac: sa dugc kh5i cUng ch~c ggi y LNMTC, cuang va
dau theo kY kinh, n&mt~i thanh bVng quanh vung SyO m6 l§.ythai, ho~c vung tfing
sinh mon ...
_ Th\fc tiSn kham lam sang co thS khong ghi nh?n gi b§.tthuOng du co tri~u chUng
coonang ggi y LNMTC.

5
- Tang kha nang co thai.
- CM thien chAt hrong s6ng.
_ Xac dinh nguoi benh can phfiu thuat, va Iva chon thai diem phil hQP nhAt.
- Co k@hoach diBu tri va theo doi sau phfiu thuat,
4.2. Di~n tr] LNMTC va dan
SO'd6 Quy trinh lam sang diBu tri dau do LNMTC trong Phu luc 03 diroc ban hanh
kern theo.
• Dau bung kinh, dau vung chau man tinh n@uco dap irng giam dau diroc voi cac
thuoc giam dau khang viem khong - steroids (NSAIDs), vien tranh thai k@thQP
(COCs), hoac nQi ti@tprogestins rna khong can bang chirng mo hoc xac nhan
LNMTC, thi cac diBu tri nay diroc xem Ia vira la chAn doan vira la diBu tri
LNMTC. Ngoai ra nQi soi 6 bung la mot kY thuat co tinh chat xam IAn.Chinh vi
cac ly do nhu vay thirc hien nQi soi 6 bung dS chan doan tnroc khi diBu tri dau
bung kinh, dau vung chau man khong phai la buac thuang qui.
• can lo~i tm cac nguyen nhan gay dau vilng ch~u khac truac khi b~t dau diBu tri
theo kinh nghi~m.
4.2.1. Di~u trt n¢i khoa giam aau bUGe1
a) Giam aau nh6m khang viem kh6ng - steroid (NSAIDs)
Hi~u qua trong diBu tri th6ng kinh nguyen phat, la nhom thu6c co thS chQn h;radau
tien diBu tri dau do LNMTC. Thu6c co ch6ng chi dinh cho nguai co tiBn sir loet d~
day ta trang, b~nh ly tim m~ch ....
b) Thu6e vien tranh thai kit h(lp
_ Hi~u qua giam dau bVng kinh, giam giao hQP dau, giiim dau vilng ch~u m~n tinh
va co tac dVng ngira thai. Co thS xem xet ke dan thu6c vien tranh thai k@thQP
u6ng theo chu kY ho~c lien tvc, va khong u6ng qua 3 thang n@ukhong giam dau.
_ NQi ti@ttranh thai k@thQP co hi~u qua giam dau bvng kinh, giao hQP dau nhung
it hi~u qua giam dau trong LNMTC sau.
e) Progestin, khang progestin, danazol
_ La mQt trong cac Iva chQn giam dau do LNMTC, tuy d~c diSm tUng nguai b~nh
co thS Iva chQn cac thu6c thuQc nhom progestin khac nhau (dienogest,
norethisterone acetate, ho~c khang progestin (gestrinone).
_ LlJa chQn progestin va khang progestin can luu y thu6c co tac dVng phv it nhAt,
nhAt la cac tac dVng phv khong h6i phvc (huy@tkh6i, nam hoa ... )
_ Dvng cv tu cung co nQi ti@tlevonorgestrel (LNG-IUS) lam giam cuang kinh,
giam dau, chi dinh trong b~nh tuy@ncO'tu cung co tri~u chUng.

8
_ Dienogest co hieu qua giam dau nrong duong GnRH voi it tac dung phu do r6i
loan v~ mach, khong anh huong m~t d<)xuong; co the sir dung lau dai (lien tuc
hoac ngitt quang) voi cac dfr li~u lam sang danh gia sau honl Onam theo doi,
_ Norethisterone acetate co the diroc su dung de giam dau trong LNMTC, tuy
nhien dfr li~u lam sang con han chS va kern hieu qua trong mot s6 tnrong hop
dau do LNMTC.
_ Danazol do co nhieu tac dung phu va co cac tac dung phu khong h6i phuc.
Medroxyprogesterone acetate dang tiem co anh huong m~t d<)xuong. Do v~y
khong khuyen cao diSu tri giam dau voi thuoc nhom danazol va
medroxyprogesterone acetate, tnr khi khong con Iva chon nao khac,
4.2.2. Di~u tri noi khoa giam dau buoc 2
a) Progestins
NSu trong buoc 1 chua diroc su dung, thi trong buoc 2 co the chi dinh dienogest
diSu tri, khi nhom NSAID, thuoc vien tranh thai kSt hqp khong co hi~u qua giam
dau.
b) GnRH dfmg Vt7n
_ GnRH d6ng v~ co hi~u qua giam dau do LNMTC, khuy~n cao ph6i hqp vai li~u
phap b6 trq (add - back therapy) de diSu chinh cac tri~u chUng r6i lo~ v~n m~ch
do thiSu h\lt estrogen va giam m~t d<)xuong nSu diSu tri keo dai tren 6 thang.
Chua co dfr li~u vS hi~u qua va tinh an toan khi su d\lllg d6ng v~n GnRH de giam
dau khi su d\lng tren 6 thang. Cfin can nhitc lqi ich va nguy co khi su d\lng keo
dai tren 6 thang.
_ Li~u phap b6 trq (add- back) nen duqc ph6i hqp ngay khi bitt dfiu diSu tri GnRH.
_ Th~n trQng khi chi dinh diSu tri cho ph\l nfr tre va tu6i vi thanh nien vi (y nhUng
d6i tuqng nay chua duqc danh gia hSt m~t d<)xuong t6i da.
_ Cac GnRH d6ng v~n (Goserelin, Triptorelin, Leuprolid ...) dSu co the la m<)ttrong
cac Iva chQn de giam dau do LNMTC.
e) (Ie ehi Aromatase
_ Can nhitc su d\lng thu6c lrC chS aromatase kSt hqp vai thu6c vien tranh thai ph6i
hqp, progestins, GnRH d6ng v~n de giam dau do LNMTC sau, khong dap (rng
diSu tri n<)i- ngo~i khoa
_ Thu6c co nhiSu tac d\lng ph\l, chi nen chi dinh khi t~t ca mQi diSu tri n<)i- ngo~i
khoa th~t b~i.
4.2.3. Di~u trt phdu thut7tgiam aau
a) Chi dtnh di~u trt phdu thu(jt
- Th~t b~i vai t~t ca cac diSu tri n<)ikhoa
_ LNMTC va co b~nh 1;' ho~c tinh tr~ng di kern khac cfin can thi~p ph§.uthu~t.
9
PHVLVC 02

PH AN DO..LAC NOI
. MAC
. Tit CUNG ( THEO ASRM da hieu. chinh)
DQ I(toithieu): 1-5
DQ II (nhe): 6-15
DQ III(trungbinh):16-40
DQ IV (nang): > 40
TongeQng _
,......
u
!II. Lac nQi mac tU cung <1 ern 1-3 ern >3ern
eu , ..........
2 4
,=..t:: , ...........
Nang 1 ......

~ Sau 2 4 16
co Ben Phcii Nang 1 2 4

i
...
, ........ ................

Sau 4 16 \20
co
1 2 4
=
.sO Ben Trai Nang
=
I=Q Sau 4 16 20

Mat cimg do sau Ban phan \ Toan phan

4 40

Dinh <% bern~t %-¥3 bern~t >¥3bern~t

co
i co
Ben Phai Mang mong
Day, chat
1
4
2
8
4
16
.sO= 4
~ = ;
Ben Trai Mang mong ,
1
........
2
Day, eh~t 4 8 16

Ben Phai Mang mong 1 2 4

co , .................... ........... ................

i...
,0 Ben Trai
Day, eh~t
Mang mong
+.
4*
1
8*
2 .............
16
4 . .....

> Day, chat 4* 8* 16

*Neu loavoi t~choan toan, chuyen diem danh gia sang 16.

15
PHl) Ll)C 03
QUY TRINH LAM SANG
flIEU TRI L~C NOI M~C TU CUNG vA DAU
(Ban App va web: Quy trinh Him sang)
(Ban hanh kern thea Quyit dinh sb 5306/QD-BYT ngay 07 thang 11 ndm 2019)

Chan doan LNMTC NSAIDs (9)

Dap frog di~u tr] I Dienogest (10)

eieu tr] nQikhoa glarn
dau bU'cYc1 (8)
N9i ti~t tranh thai (11)
~;

Khong dap frng Dienogest (13)

;;;;i;
Niu truoc do chua sit dung

eieu tr] nQikhoa giam dau LNG-IUS (14)

bU'cYc
2 (12) ".
GnRH d6ng v~n (15)
Khong dap frog
v Lira chon khac (16)
eieu tr] phau thu~t de giam
dau (17)

"~
;;~
Khong dap (rng
"~ ....
1-

'"'' X~m xet I(ilichan doan,

Tai phat dau tarn them xet nghi~m
Het dau
± HQichan da chuyen khoa

_.... eieu tr] dau man tinh vcYiIi~u phap nQi khoa dijc hi~u

;1 ~. :, ~
Theo d6i/dfeu tr] dlf phong tai phat - Tham kham phV khoa djnh kl (18)

16
 MO PHONG NQI DUNG BAN APP vA WEB
chio amio va ai~u tr] lac oQimac tfr cung

(I)Tri~u clnmg lam sang:

_ Trieu chimg lien quan phu khoa: dau bung khi hanh kinh, co thS dau khong lien
quan ky kinh, dau khong co tinh chu ky, dau sau khi giao hop, hoac dau khu tru
thea ky kinh tai thanh bung quanh seo m6 l~y thai, tai vung tdng sinh mon sau
sinh nga am dao .... , xu~t huyet tir cung b~t thuong (trong benh tuyen co tir cung),
cham hoac khong co thai.
_ Trieu chirng khong lien quan phu khoa: phu nu trong dQ tu6i sinh de co di cdu
dau, di tiSu dau, tiSu ra mau, chay mau tnrc trang ... xay ra thea chu ky kinh. Cac
kh6i lac tuyen nQi mac tir cung van buong tnrng co kich thircc Ian co thS gay
chen ep true trang hay bang quang gay cac trieu clnrng do chen ep nhu ti@ukho
tieu lAtnhAt, di cdu tao bon ....
Hai nhom tri~u chUng nay co thS dan thudn hay di kern v6i nhau.
(2) Sicu am vung ch~u va b1}ng
_ Sieu am nga am d~o (TVS) la Iva chQn ddu tien dS chAn doan LNMTC vling
ch~u; ph\! nu dQc than, chua timg giao hgp co thS duQ'c sieu am qua nga trvc
trang (TRS).
_ Sieu am nga am d~o co thS hfru ich giup chAn doan LNMTC 6 trvc trang ho~c
lo~i trir LNMTC 6 trvc trang.
_ Sieu am giup chAn doan ho~c lo~i tm LNMTC bu6ng trUng.
_ Hinh anh sieu am d~c trung LNMTC van bu6ng trlrng 6 ph\! nu ti@nman kinh:
echo kern d~g kinh rna, co thS co phan thuy thuy, khong ch6i nhu co dong chfly
m?chmau.
_ Sieu am 3 chi@u(3D) chua duQ'cd6ng thu~n su d\!ng dS chAn doan LNMTC vach
trvc trang am d~o.
(3) MRI vung ch~u
Khi sieu am khong danh gia duQ'ch@ttinh ch~t, muc dQ xam l~n cua bu6u v6i cac
co quan xung quanh, ho~c khi cdn danh gia sang thuang LNMTC sau, cdn phan bi~t
gifra b~nh tuy@nco tu cung va nhan xo tu cung .... MRI co thS duQ'cchi dinh them.
(4) Xct nghi~m CAl2S
_ Xet nghi~m CA12S: thuOng tang trong l?c nQi m?c tu cung tuy nhien it co gia tri
vi khong d~c hi~u.
_ MQt s6 cac d~u ~n sinh hQc co ngu6n g6c trong mo nQi m~c tu cung, dich tu cung
hay mau kinh vaJho~c d~u ~n miSn dich trong huy@ttuang, nu6c tiSu ho~c huy@t
thanh it co y nghia trong chAn doan l?c nQi m~c tu cung.
17
(5) ChAn doan lam sang xac djnh LNMTC
Chan doan LNMTC bang nQi soi 6 bung mang tinh xam Ian anh huong dSn du trfr
buong tnrng, nen co thS chAn doan xac dinh LNMTC cho benh nhan dira tren danh
gia lam sang, khong cftn b&ng chirng mo hoc LNMTC.
(6) Phfin lo~i giai doan b~nh LNMTC
Phan dQLNMTC co thS diroc thirc hien khi benh nhan co can thiep phftu thuat. Bang
phan dQLNMTC trong Phu luc s6 02 kern theo.
(7) Thao lu~n vo; ngU'o; b~nh v~ mong muan di~u tr], xay dt}'ng k~ hoach di~u
tr] lau dai vo; ID\lC tieu tAi U'U hoa di@utr] nQi khoa, han ch~ can thi~p ngoal khoa
l~p di l~p lal,
- Nguyen t~c:
+ Ca thS hoa diSu tri hu6ng dSn 1Q'iich ngiroi benh, khong hu6ng dSn muc tieu 10~i
b6 t6n (sang) thuong.
+ T6i uu hoa diSu tri nQi khoa va tranh cac phftu thu~t l~p di l~p l~i.
- M\lc tieu diSu tri
+ Giam dau, giam tiSn triSn va giam tai phat b~nh.
+ Tang kha nang co thai.
+ Cai thi~n chat 1uqng s6ng.
+ Xac dinh nguai b~nh cftn phftu thu~t, va Iva chQn thai diSm phil hQ'Pnhat.
+ Co kS ho~ch diSu tri va theo d5i sau phftu thu~t
(8) Di~u tri nQi khoa giam dau bU'&c1
_ DiSu tri LNMTC khong co tri~u chUng tily thuQc vao muc dQ t6n thuong
LNMTC t~i thai diSm hi~n t~i va mong mu6n cua b~nh nhan.
_ Cftn xem xet dfr li~u tac d\lng ph\l khac nhau cua cac thu6c, d~c bi~t 1atac d\lng
ph\l khong thS h6i ph\lC (vi d\l nhu nguy cO'huySt kh6i va tac d\lng ph\l nam hoa)
dS Iva chQn H~u phap phil hQ'Pnhat vai b~nh nhan.
(9) NSAIDs:
Giam dau nhom khang viem non - steroides (NSAIDs) co hi~u qua trong diSu tri
th6ng kinh nguyen phat, n&mtrong nhom thu6c co thS chQn Iva dftu tien diSu tri dau
do LNMTC. Thu6c co ch6ng chi dinh cho nguai co tiSn sir 10et d~ day ta trang, b~nh
1ytim m~ch ....
(10) Dienogest
_ Dienogest 1a progestins duQ'c chUng minh hi~u qua giam dau trong LNMTC va
duQ'cdanh gia 1a diSu tri d~c hi~u giam dau trong LNMTC bao g6m dau vilng
ch~u, giao hQ'Pdau, dau b\lng kinh ....

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_ Dienogest voi liSu 2mg/ngay hieu qua giam dau nrong duong thuoc dang v~n
GnRH nhirng it tac dung phu gay b6c hoa va khong anh huang dSn m~t dQ
khoang xuong khi su dung lau dai.
_ Dienogest co the duoc su dung lau dai (lien tuc hoac ng~t quang) de dat hieu qua
giam dau va giam tai phat lau dai cho benh nhan.
_ Dienogest co the duoc su dung de giam dan tren hra tu6i vi thanh nien bi
LNMTC.
(11) NQiti~t tranh thai
_ Thuoc vien tranh thai kSt hQ'Puong lien tuc; hoac mieng dan estrogen! progestin
co hieu qua giam thong kinh, giam giao hQ'Pdau, giam dau vung chau man tinh
va ngira thai.
_ Co the xem xet ke toa thuoc ngira thai nQi tiSt kSt hQ'Ptheo chu leY hoac lien tuc,
khong dung qua 3 thang nSu khong giam dau. NSu su dung noi tiSt tranh thai
khong giam dau duQ'c cho b~nh nhan, chuyen d6i li~u phap su d\lng Dienogest
co the duQ'Cxem xet.
+ NQi tiSt tranh thai co hi~u qua giam dau b\lllg kinh, giao hQ'Pdau do LNMTC
+ NQi tiSt tranh thai it hi~u qua giam dau trong LNMTC l~c ch6 (Philc m~c,
LNMTC sau).
(12) Di~u tri nQikhoa gHimdau barre 2:
_ Chi dinh trong truOng hQ'PdiSu tri nQi khoa giam dau bu6c 1 khong hi~u qua.

(13) Dienogest
_ Dienogest la progestins duQ'c chUng minh hi~u qua giam dau trong LNMTC va
duQ'cdanh gia la diSu tri d~c hi~u giam dau trong LNMTC bao gam dau vung
ch~u, giao hQ'Pdau.
_ Dienogest v6i liSu 2mg/ngay hi~u qua giam dau tuong duong thu6c dang v~
GnRH nhung it tac d\lllg ph\l gay b6c hoa va khong anh huang dSn m~t dQ
khoang xuong khi su d\lng lau dai.
_ Dienogest co the duQ'Csu d\lng lau dai (lien t\lc ho~c ng~t quang) de d~t hi~u qua
giam dau va giam tai phat lau dai cho b~nh nhan.
_ Dienogest co the duQ'Csu d\lllg de giam dau tren lua tu6i vi thanh nien bi
LNMTC.
(14) LNG-IUS
D\lng C\ltu cung chua Levonorgestrel co the la mQt Iva chQn giam dau trong l~c nQi
m~ctucung.
(15) GnRH Dang vin
_ GnRH dang v~n co hi~u qua giam dau do LNMTC, khuySn cao ph6i hQ'Pv6i li~u
phap b6 trQ'( add - back therapy) de diSu chinh cac tri~u chUng r6i lo~n v~n m~ch
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 do thieu hut estrogen va giam m~t dQ xirong nSu di@utri keo dai tren 6 thang.
Chua co du lieu d§.ydti v@hieu qua va tinh an toan khi su dung dfmg v~n GnRH
d~ giam dau khi sir dung tren 6 thang.
_ Lieu phap b6 tro (add- back) nen duoc phci hop ngay khi b~t d§.udi@utri GnRH.
_ Than trong khi chi dinh di@utri cho phu nu tre va tu6i vi thanh nien vi cac phu
nu nay chua ducc danh gia hSt m~t dQxuong t6i da.
_ Cac GnRH d6ng v~n (Goserelin, Triptorelin, Leuprolid ....) d@uco th~ la mot trong
cac lua chon d~ giam dau do LNMTC.
(16) L1!a chon khac:
_ Danazol va anti-progestagens (gestrinone), medroxyprogesterone acetat chi sir
dung khi cac lieu phap tren th~t bai,
(17) Di~u tr] ph~u thuit d~ giam dau
_ Chi dinh di@utn phau thu~t khi:
+ Th~t b~i vai t~t ca cac di@utri nQi khoa
+ LNMTC va co b~nh ly ho~c tinh tr~ng di kern khac c§.ncan thi~p phau thu~t
_ Hi~u qua di@utri giam dau la nhu nhau khi m6 rna hay nQi soi 6 b\lng. Tuy nhien
nQi soi uu tien Iga chQn vi la phau thu~t it xam l~n nen b~nh nhan it dau sau m6,
n~m vi~n ng~n ngay, h6i ph\lc nhanh, co tinh thfim my ...
(18)Theo doi/di~u tri d1!phong tai phat - Tham kham phl} khoa dinh ki
_ LNMTC la b~nh ly m~n tinh, b~nh nhan LNMTC nen duqc biSt truac v@nguy
co tai phat b~nh d~ ph6i hqp vai bac si di@utri v@kS ho~ch di@utri lau dai giam
tai phat, tham kham va theo d6i dinh ki.
_ I.>i@utri nh~m ngan ngira tai phat dau hay tai phat LNMTC keo dai tren 6 thang,
la di@utri dg phong c~p 2 sau phau thu~t.
_ Du li~u y van ghi nh~n d~t d\lng C\ltu cung co Levonorgestrel, Dienogest it nh~t
18 -24 thang sau phau thu~t di@utri dau, la mQt trong cac bi~n phap dg phong
c~p 2 tai phat dau do LNMTC.
_ ChQn Iga di@utn (lien t\lC ho~c ng~t quang) tuy thuQc nguy~n vQng nguai b~nh, chi
phi di@utn, kha nang s~n co va tac d\lng ph\l.

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