Лечение девочек с задержкой полового развития
Лечение при ЗПР должно быть направлено на устранение фонового заболевания, явившегося причиной отсутствия или позднего появления признаков полового созревания. Независимо от характера заболевания можно назначить заместительную гормональную терапию эстрогенами, а в дальнейшем терапию эстроген-гестагенными препаратами в циклическом режиме. При жела-
нии иметь детей пациентке с гонадотропным ги-погонадизмом, обусловленным поражением гипоталамо-гипофизарной системы, для индуцирования овуляции назначают инъекции ХГ в комбинации с менопаузальным гонадотропином (МГ). При гипоталамическом гипогонадизме может быть назначена также пульсирующая терапия гонадотропином в цирхоральном режиме (Claman u. Seibel, 1990; Filicori et al, 1994; Gindoff и. Jewelewicz, 1985).
У девушек, как правило, вначале проводят заместительную эстрогенную терапию. Ее назначают с костного возраста 11—12 лет конъютированными эстрогенными препаратами, начиная с дозы 0,3 мг/сут (в качестве альтернативы можно назначить эстрадиола валерат в дозе 0,2 мг/сут) в течение 6 мес. В течение следующих 6 мес дозу конъ-югированных эстрогенов можно повысить до 0,6 мг/сут (дозу эстрадиола валерата — до 0,5 мг/сут). При проведении терапии в циклическом режиме эстрогены назначают с 1-го по 25-й день, а геста-гены — с 14-го по 25-й. Из гестагенов обычно используют дидрогестерон (10 мг/сут), медроксип-рогестерона ацетат (2,5—5 мг/сут) или хлормади-нона ацетат (2 мг/сут). На второй год терапии дозу конъюгированных эстрогенов можно повысить до 0,9—1,25 мг/сут (эстрадиола валерата до 1—1,5 мг/сут). На третий год лечения дозу эстрогенов доводят до конечной, а именно: конъюгированных эстрогенов до 1,25 мг/сут, эстрадиола валерата до 2 мг/сут (Stolecke, 1998). При сочетанной гипоталамо-гипофизарной недостаточности заместительную эстроген-гестагенную терапию комбинируют с назначением других гормонов: гидрокортизона, L-тироксина и гормона роста.
4.5. Заключение
Несмотря на прогресс, достигнутый в диагностике и лечении преждевременного полового развития у девочек и гипогонадизма у девушек, мы еще далеки от возможности ранней диагностики этих состояний и восстановления нарушенных физиологических механизмов у этих пациенток.
Препараты — антагонисты гонадолиберина замедленного действия представляют собой класс веществ, которые благодаря отсутствию у них стимулирующего эффекта гонадолиберина, обычно проявляющегося в начале терапии этим гормоном, могут заменить агонисты гонадолиберина в лечении девочек с преждевременным поло-
вым развитием. В ближайшие годы мы надеемся оптимизировать временные особенности схемы терапии (завершение лечения агонистами гона-долиберина), а также усовершенствовать методы дифференциальной диагностики гипогонадотроп-ного гипогонадизма и конституциональной ЗПР.
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