针灸治疗痛经的取穴规律研究及痛经的流行病学调查

【作者】 陈旭；

【导师】 解秸萍；

【作者基本信息】 北京中医药大学 ， 针灸推拿学， 2008， 硕士

【摘要】 痛经是妇科最常见的症状之一,是指行经前后或月经期出现下腹疼痛、坠胀,伴腰酸或其他不适,程度严重影响生活和工作质量者。大量流行病学调查发现,女性痛经的发生率较高,并且很多患者强忍疼痛,并不及时检查治疗。痛经不但影响正常工作、生活,还可能掩盖病情,延误恶性妇科疾病的治疗,甚至对生育和生命造成威胁。目前治疗痛经常用的西药主要有非甾类抗炎药、避孕药等,这些药物副作用较多。而中成药的服用又有个体差异,效果不很理想。针灸治疗痛经,疗效确切、操作简便、价格低廉、无毒副作用,易于被广大患者接受。电针方法可以较客观地控制刺激量,便于定量分析。然而,目前针灸临床治疗痛经选穴庞杂、规范的穴位研究较少,给临床治疗痛经的选穴带来一定的难度。如何选择最有效的穴位成为目前针灸界重要课题之一。本课题以探讨针灸治疗胞宫相关疾病及痛经的穴位特异性、观察高校女生痛经发生率及证型分布等的情况为目的,从文献综述、文献研究和痛经流行病学调查三方面,分析针灸治疗胞宫相关疾病及痛经的取穴规律、目前高校女生中痛经高发原因及证型分布特点等,以期为临床治疗痛经选择最有效穴位提供依据,并为治疗痛经的大样本临床试验的开展提供病源及相关信息。另外,本课题还进行了电针三阴交穴治疗原发性痛经疗效的初步临床观察,通过对小样本预试验结果趋势的分析,以期为临床正式试验选择非相关穴作对照提供一定参考。本文分为文献综述、文献研究、痛经流行病学调查及附篇四部分。第一部分文献综述部分文献综述共分两部分:一、中医对胞宫的认识以及中西医对痛经及其病因病理的认识中医认为胞宫功能与脏腑、经络、气血功能的正常密切相关。中医认为造成痛经的病机主要为肾气亏损、气血虚弱、气滞血瘀、寒凝血瘀、湿热蕴结,导致冲任气血亏虚或气血不畅,“不荣则痛”或“不通则痛”造成痛经。现代医学将痛经分为原发性痛经和继发性痛经两类。原发性痛经机理主要与内分泌因素、神经与神经递质、钙镁离子、遗传因素、免疫因素、环境、情绪等因素相关。继发性痛经可由子宫内膜异位症、子宫腺肌病、慢性盆腔炎、妇科肿瘤、宫颈口粘连狭窄等疾病引起。二、三阴交穴的古代应用和现代研究探讨了该穴的命名、功用、主治及临床应用现状。三阴交穴位在小腿内侧,内踝尖上3寸,胫骨内侧缘后际,为足三阴经之交会穴,功能健脾、疏肝、补肾。现代医学对该穴的形态学结构进行了深入的研究,认为三阴交穴是一个多层次的立体结构,进一步增加了对该穴的认识。三阴交主治范围广泛,古代文献中涉及脾胃病症、痛症、妇产科病症、肾膀胱病症、肺病症、心脑病症及其他病症,现代临床研究中涉及生殖、泌尿、消化、免疫、内分泌系统及疼痛等,动物实验中涉及生殖、消化、免疫等方面。第二部分文献研究部分针灸治疗胞宫相关疾病及痛经的穴位特异性研究文献研究部分共分两部分:一、针灸治疗胞宫相关疾病的穴位特异性研究古代文献研究中,查阅了清末以前的42部主要的中医针灸著作。通过统计发现,与胞宫相关穴位共104个,使用最多的为三阴交,其次为中极、气海、关元等穴。与胞宫相关经穴所在经脉,涉及十二条正经及任督二脉,最多的为任脉、肾经,其次为脾经、膀胱经、胃经等经脉。现代文献研究中,在CNKI数据库检索了1979年-2007年的294篇针灸治疗胞宫相关疾病的文献。通过统计发现,与胞宫相关穴位共73个,使用最多的为三阴交,其次为关元、中极、足三里、气海、次髎等穴。与胞宫相关经穴所在经脉,涉及除小肠经外的十一条正经及任督二脉,最多的为脾经其次为任脉、膀胱经、胃经、肝经等经脉。古今文献汇总统计,初步得出针灸治疗胞宫相关疾病的取穴规律:三阴交为临床常用的主穴之一;按部位取穴治疗胞宫相关疾病以下腹部(任脉穴居多)及腰骶部穴位(膀胱经穴居多)最常用;膝下以肝、肾、脾经穴位为主。二、针灸治疗痛经的穴位特异性研究查阅古代中医针灸专著25部,统计发现,治疗痛经穴位共38个,使用最多的为三阴交,其次为阴交、水道、四满、内庭、关元等穴。治疗痛经穴位所在经脉,涉及胃经、任脉、肾经、膀胱经、脾经、大肠经、胆经、肝经、心包经,其中最多的为胃经,其次为任脉、肾经、膀胱经、脾经等经脉,督脉、心经、三焦经、小肠经、肺经未涉及。检索1992年至2007年间针灸治疗痛经的现代文献185篇,统计发现,治疗痛经穴位共47个,使用最多的为三阴交,其次为关元、中极、气海、足三里、次髎等穴。治疗痛经穴位所在经脉,涉及任督二脉及脾经、肾经、肝经、膀胱经、胃经、心经、大肠经、心包经、胆经,其中最多的为脾经,其次为任脉、膀胱经、胃经、肝经、肾经等经脉,而肺经、小肠经、三焦经未涉及。古今文献汇总统计,初步得出针灸治疗痛经的取穴规律:三阴交穴为临床常用的主穴之一,按部位取穴以下腹部(任脉穴居多)及膝下穴位(肝、肾、脾经穴位为主)最常用。第三部分痛经流行病学调查高校女生月经及痛经情况调查问卷目的:为了解女大学生月经、痛经及伴随症状的发生情况。方法:自制并发放流行病学调查问卷1000份,收回973份,回收率为97.3%。结果:女大学生的初潮年龄主要在12~15岁,占调查总人数的86.20%,平均初潮年龄为13.28±1.36岁;493例患者有痛经,占总人数的50.67%;经期伴随症状发生率较高;痛经辨证分型中,寒湿凝滞型和气滞血瘀型两型所占比例较大;不同年级女生痛经发生率不同。讨论:①女生平均月经初潮年龄较以往呈现提前趋势,与物质生活水平提高有关;②本科二至四年级学生课业繁重、就业压力大、起居饮食不规律,容易导致痛经发生;③女生贪凉饮冷、精神紧张、情绪异常等情况多有发生,可以导致寒湿凝滞或气滞血瘀,均可引起痛经。第四部分附篇电针三阴交穴治疗原发性痛经疗效的初步临床观察目的:通过电针三阴交穴与非相关穴治疗原发性痛经疗效的比较,初步观察三阴交治疗的临床疗效。方法:选择6例原发性痛经患者,以数字随机法分为2组(三阴交和悬钟组),每组3例,根据随机方案及与试验相适应的盲法对患者进行电针治疗。电针频率为2/100 HZ,强度以患者耐受为度,留针30分钟。于痛经开始的第一天、VAS疼痛评分≥40mm时开始治疗,每日1次,连续治疗3天。结果:1. VAS量表分值统计:三阴交组与悬钟组VAS分值:在第一次针刺5min、10min、30min及针刺结束后30min,三阴交组与悬钟组的VAS分值从前后差值比的均值比较发现:各时间点三阴交组止痛疗效相对优于悬钟组。2.RSS量表分值统计:第1次治疗后三阴交组与悬钟组RSS-COX2差值比(治疗前-治疗后/治疗前)无差异。但从均值的大小趋势来看,第1次治疗后,悬钟组差值均值略高于三阴交组;而第2次治疗后,三阴交组差值均值较高于悬钟组。讨论:本试验为小型预试验,因为样本量小,无法做统计学处理,因而,试验结果仅初步反映穴位效应的趋势,为课题的正式试验选择非相关穴做对照提供参考。从疗效评价指标(VAS和RSS-COX2)的变化趋势上分析,电针三阴交对原发性痛经的止痛疗效相对优于悬钟,但仍需进一步扩大样本量研究。更多还原

【Abstract】 Dysmenorrhea is one of the most common gynecologic complains. Symptoms of dysmenorrhea include pelvic pain with nauses, diarrhea, fatigue and lower back sore that usually occur just before or during menstruation and give much impact on patients’life quality. Abundance of epidemiologic surveys show that the incidence of dysmenorrhea is relatively high. However, majority of women with dysmenorrhea just bear the pain and do not seek medical advice. In fact, the pain can not only affect normal work, but also conceal illnesses and delay the diagnosis and treatment of serious gynecologic diseases, and even threaten to pregnancy and life. Nonsteroidal anti-inf lammatory drugs (NSAIDs) and oral contraceptive pills are common therapy for dysmenorrhea in western medicine, but have many side-effects. Since the differentiation of each dysmenorrhea person, Chinese herbal medicine doesn’t work very well.Acupuncture and moxibustion has many advantages on treating dysmenorrhea, such as reliable curative effect, easy management, low price, no toxic side-effects, and could be accepted by many people.And the measures of stimulations are controlled objectively and are easily quantitatively analyzed by electric-acupuncture. However, since the numerous and jumbled acupoints treating dysmenorrhea in clinic and less of standard researches on acupoints, it is hard to select acupoints to treat dysmenorrhea. Therefore, how to choose the most effective acupoints are important task in acupuncture fiuld.The aim of this task is to discuss the specificity of acupoints on treating uterus related diseases and dysmenorrhea by acupuncture and moxibustion, investigate the occurring rate and distributing of different patterns of dysmenorrhea. From literature reviews, literature researches and epidemiology of dysmenorrhea, this subject analyses the rule of choosing acupoints on treating uterus related diseases and dysmenorrhea by acupuncture and moxibustion and the reasons and characteristics of patterns’distributing of dysmenorrhea, in order to provide evidences to choosing acupoints in clinic and patients source and other information for large sample size clinical trial on dysmenorrhea.In addition, this subject exploringly observed the effects on primary dysmenorrhea by electric-acupuncturing Sanyinjiao by analyzing the trend of results of the small sample size trial in order to offer some references on selecting“no-related acupoints”for formal clinical trials.This thesis displays four sections: literature reviews, literature researches, epidemiology research of dysmenorrhea and postscript.First Section: literature ReviewsThere are two reviews. First review: The cognitions on pathogenesis of dysmenorrhea and diseases related to uterus by TCM and western medicine.The fuctions of the uterus according to Chinese medicine are tightly related with bowels and viscera, meridians and collatrals, qi and blood. Deficiency of kidney qi, deficiency of qi and blood, stagnation of qi and blood, cold stagnation, heat dampess could lead to deficiency or stagnation of qi and blood of Ren and Du meridians and cause dysmenorrhea.In western medicine, dysmenorrhea is divided into two types: primary and secondary. Primary dysmenorrhea is related to such factors as incretion, nerve and nerve transmitter, Calcium ion, magnesium ion, inheritance, immunity, environment, emotion, etc. Secondary dysmenorrhea can be caused by endometriosis, adenomyosis, chronic pelvic inflammatory disease, gynecological tumour, conglutination and straitness of uterine neck. Second review: Ancient usages and modern researches on SanyinjiaoThis review discussed the naming, location, functions and clinical use of Sanyinjiao from both ancient and modern literatures. The acupoint is located on the medial side of the shank, 3 cun directly above the tip of the medial malleolus, on the posterior border of the medial aspect of the tibia. It is the crossing point of there yin Meridians of Foot. It can invigorating spleen, releasing liver-qi and reinforcing kidney. Modern medicine discovered that the morphological structure of Sanyinjiao is multihierarchical and tridimensional. This acupoint can treat large range of diseases. Antient literature involved diseases of spleen, stomach, gynecology, kidney, bladder, lung, heart, brain, etc. Modern clinical and experimental researches involved disease of reproductive, urinary, digestic, immune and endocrine systems and pain. Second Section: literature researches Specificity of acupoints by treating diseases related to uterus and dysmenorrhea with acupuncture and moxibustionThere are two researches.First research: Specificity of acupoints by treating diseases related to uterus with acupuncture and moxibustion42 ancient literatures before Qing Dynasty which are about acupuncture treating diseases related to uterus, were refered. There are 104 points are related to uterus diseases according to the statistic. In these points, SanYinJiao used most, and then Zhongji, Qihai, Guanyuan, etc. The meridians which 104 points belong to are 12 meridians, Ren Meridian and Du Meridian. The most used is Ren Meridian and Kidney Meridian, then Spleen Meridian, Bladder Meridian, Stomach Meridan, etc.294 modern literatures from 1979 to 2007 on CNKI database, which are about acupuncture treating diseases related to uterus, were refered. There are 73 points are related to uterus diseases. In these points, SanYinJiao used most, and then Guanyuan, Zhongji, Zusanli, Qihai, Ciliao, etc.The meridians which 73 points belong to involve 11 meridians (except Small Interstine Meridian), Ren Meridian and Du Meridian. The most used is Spleen Meridian, the Ren Meridian, Bladder Meridian, Stomach Meridan, Liver Meridian, etc.Ancient and modern literatures were collected and rules of selecting points of treating uterus related diseases are preliminarily concluded: Sanyinjiao is the main point in clinic; points on lower abdomen (which mostly belong to Ren Meridian) and points on lower lumb (which mostly belong to Bladder Meridian) are often used; the often used points below knee are generally belong to three Yin Meridans of Foot.Second research: Specificity of acupoints by treating dysmenorrhea with acupuncture and moxibustion.25 ancient literatures which are about acupuncture treating dysmenorrhea, were refered. There are 38 points are related to dysmenorrhea according to statistic. In these points, Sanyinjiao is the most used one, then Yinjiao, Shuidao, Siman, Neiting, Guanyuan, etc. The meridians which 38 points belong to involve Stomach Meridian, Ren Meridian, Kidney Meridian, Bladder Meridian, Spleen Meridian, Large Intestine Meridian, Gallbladder Meridian, Liver Meridian, Pericardium Meridian, and Stomach Meridian is the most used one. Du Meridian, Heart Meridian, Three Burners Meridian, Small Intestine Meridian, Lung Meridian are not involved.185 modern literatures from 1992 to 2007 on CNKI database, which are about acupuncture treating dysmenorrhea, were refered. There are 47 points are related to dysmenorrhea. In these points, SanYinJiao is the most used one, then GuanYuan, Zhongji, Qihai, Zusanli, Ciliao, etc. The meridians which 47 points belong to involve Ren Meridian, Du Meridian, Spleen Meridian, Kidney Meridian, Liver Meridian, Bladder Meridian, Stomach Meridian, Heart Meridian, Large Intestine Meridian, Pericardium Meridian, Gallbladder Meridian, and Spleen Meridian is the most used one. Lung Meridian, Small Intestine Meridian and Three Burners Meridian are not involved.Ancient and modern literatures were collected and rules of selecting points of treating uterus related diseases are preliminarily concluded: Sanyinjiao is the main point in clinic; points on lower abdomen (which mostly belong to Ren Meridian) and points below knee (which mostly belong to three Yin Meridans of Foot) are often used.Third Section: Epidemiology research on dysmenorrheaQuestionnaire on menstruation and dysmenorrhea of university girlsObjective: To know the incidence of menstruation and dysmenorrhea of female students in a university. Method: 1,000, self-made questionnaires were conducted to female students from different specialties and grades to investigate their detailed information of menstruation and dysmenorrhea. Statistical analysis was made after they returned the questionnaires. Result: 1,000, questionnaires were provided and 973 were returned. The analysis showed that the age of menarche was mainly around 12 to 15 years old, which accounted for 86.20%. The average age of menarche was 13.28±1.36 years. 50.67% of 973 schoolgirls had painful menstruation. Many students had other premenstrual or menstrual disturbances. Discussion:①The average age of menarche of girls are smaller than before, which could be related to the improvement of life standard;②Because of the heavy burden of study and irregular dietary and habits, many students of grade 2 and 4 have dysmenorrheal;③Drinking cold water、intensity and irregular emotion could lead to block of coldness and dampness or stagnation of qi and blood, then lead to dysmenorrhea.Fourth Section: PostscriptElementary observation of effects on primary dysmenorrhea by electric-acupuncturing SanyinjiaoObjective: elementarily observation of effects of Sanyinjiao by comparison of effects of Sanyinjiao and other acupoints with electric-acupuncture for primary dysmenorrhea.Methods: 6 patients who met the including criteria of primary dysmenorrhea had been assigned into 2 groups with 3 cases in each group. The 2 points were San Yin Jiao and Xuan Zhong. The frequency of electric-acupuncture was 2/100 Hz, and the intensity was bearable. The needles were kept for 30 minutes. This treatment began at the first day of menstrual pain with VAS score more than 40mm, and lasted for 3 days with 1 time per day.Results:1. VAS Scores:VAS scores of Sanyinjiao group and Xuanzhong group: Sanyinjiao group had relatively better analgetic effects than Xuanzhong group on each time point.2. RSS Scores:Sanyinjiao group’s and Xuanzhong group’s ratios of difference (anterior score– latter score / anterior score) of RSS-COX2 score in first day’s treatment had no differences. However, being compared by mean scores, after 1st day’s treatment, Xuanzhong group’s ratio of difference of RSS score was little more than that of Sanyinjiao group; while after 2nd day’s treatment, Sanyinjiao group’s ratio of difference of RSS-COX2 score was more than that of Xuanzhong group.Discussions: Since the sample size was too small to make statistics processing, this pre-trial just provided reference to choosing“no-related acupoint”for formal trial by analyzing the trend of effects of acupoints. Although the analgetic effect of electric-acupuncturing on Sanyinjiao was relatively better than that of Xuanzhong by analyzing the trend of effect evaluation indexes (VAS and RSS-COX2), large spacement trial are needed.更多还原