LỢI ÍCH CỦA THUỐC TRÁNH THAI NỘI TIẾT

DANH MỤC CHIA SẼ
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  Hành trình tìm kiếm biện pháp tránh thai của con người đã trải qua hàng thế kỷ. Từ thời rất xa xưa, các đôi uyên ương chưa có điều kiện sanh con đã thử nghiệm nhiều biện pháp để không phải mang thai ngoài ý muốn. Từ cách dùng bọt bể ngâm trong nước giấm đến cách sử dụng dầu ô liu hay bao cao su làm bằng ruột cừu… với nhiều mức độ thành công khác nhau. Đến năm 1960, Cơ quan Quản lý Thuốc và Dược Phẩm Hoa Kỳ (FDA) đã đồng ý cho giới thiệu lần đầu tiên trên thị trường viên thuốc tránh thai dành cho nữ giới – một phương pháp đáng tin cậy giúp họ tự do thỏa mãn cuộc sống tình dục mà không sợ mang thai ngoài muốn. Đây là một trong những sự kiện quan trọng nhất của thập niên vì đã ảnh hưởng đến cuộc sống, sức khỏe sinh sản và sức khỏe tình dục của một nửa thế giới được gọi là phái đẹp của nhân loại.

  Việc chỉ cần uống một viên thuốc nhỏ mỗi ngày và không bị có thai ngoài ý muốn khiến nhiều phụ nữ rất quan tâm. Thực tế, tại Việt Nam, tỉ lệ sử dụng thuốc ngừa thai chứa hormone khoảng 10%-15% tùy giai đoạn, trong đó nhiều trường hợp sử dụng biện pháp này nhằm tận dụng các tác dụng có lợi khác ngoài tác dụng ngừa thai. Bài viết nhằm đề cập đến một số tác dụng có lợi của thuốc tránh thai nội tiết bên cạnh lợi ích ngừa thai của thuốc.

  Bảng sau đây liệt kê ngắn gọn các tác dụng đó như sau

– Điều hòa chu kì kinh nguyệt, điều trị rong kinh, thống kinh.

– Điều trị hội chứng tiền mãn kinh.

– Giảm nguy cơ ung thư nội mạc tử cung, ung thư buồng trứng.

– Điều trị mụn hay rậm lông.

– Cải thiện mật độ xương.

– Điều trị xuất huyết do u xơ tử cung

– Điều trị đau vùng chậu do lạc nội mạc tử cung

  Thực tế, có rất ít bệnh nhân có thể biết được các lợi ích này của thuốc ngừa thai do đó rất cần sự tư vấn của các Bác sĩ Sản Phụ khoa. Hiện nay có 2 loại thuốc ngừa thai nội tiết dạng uống thường gặp là thuốc ngừa thai kết hợp gồm 01 loại progestin và 01 loại estrogen (COCs) và thuốc ngừa thai chỉ chứa Progestin (POPs). Trong đó, Progestin là thành phần không thể thiếu, đóng vai trò chủ chốt cho tác dụng tránh thai của thuốc này. Thành phần Estrogen cũng có tác dụng ngừa thai thứ cấp nhưng quan trọng hơn là giúp ổn định nội mạc tử cung và thiết lập nên một chu kì kinh nguyệt như tự nhiên của người phụ nữ. Tuy nhiên việc sử dụng liều cao nồng độ estrogen sẽ dẫn đến tình trạng tăng đông, thuyên tắc mạch do huyết khối đặc biệt ở những phụ nữ có nguy cơ xơ vữa mạch máu hay tiền sử đột quị, hút thuốc lá, tăng huyết áp… Khi đó, họ sẽ được khuyến cáo sử dụng POPs nhưng sẽ gặp một số tác dụng không mong muốn trong việc hành kinh do thiếu thành phấn nội tiết estrogen.

  Qua gần 60 năm phát triển, hiện nay các thuốc ngừa thai nội tiết phát triển theo hướng giảm dần nồng độ estrogen, duy trì khoảng từ 20μg – 35μg, vừa để đảm bảo hiều quả ngừa thai vừa giảm thấp nhất nguy cơ thuyên tắc mạch. Các loại Progestin mới cũng được nghiên cứu nhằm làm giảm tính cường Androgen của thuốc và có tính hoạt tính mạch hơn để có kết hợp với estrogen liều thấp hơn nữa.

  Năm 2010, Hiệp hội sản phụ khoa Hoa Kì đã đưa ra các khuyến cáo lâm sàng khi tận dụng lợi ích của thuốc tránh thai nội tiết trong điều trị một số bệnh lý liên quan đến sản phụ khoa như sau

  1. Điều trị thống kinh

  Thống kinh là tình trạng đau bụng nhiều trong giai đoạn hành kinh do các Prostaglandin được bài tiết ra bên trong cơ tử cung gây nên sự co thắt cơ tử cung. Thống kinh là dạng rối loạn kinh nguyệt thường gặp nhất, thường thấy ở phụ nữ bị lạc tuyến trong cơ tử cung (Adenomyosis). COCs được chứng minh có thể giảm sản xuất các Prostaglandin và giảm thống kinh ở 70-80% phụ nữ. Các nghiên cứ RCT nhỏ và các dữ liệu khảo sát đã cho thấy sự giảm rõ rệt biểu hiện thống kinh ở người phụ nữ sử dụng COCs.

  Que cấy tránh thai Implanon cũng giảm biểu hiện thống kinh ở đa số người dùng, từ mức ban đầu 59% xuống còn 21% sau điều trị, 81% trong số ban đầu tỏ ra hài lòng về sự cải thiện thống kinh. Các thông tin về khả năng điều trị thống kinh của dụng cụ tử cung chứa Levonorgestrel còn hạn chế do cơ chế của dụng cụ này thường làm giảm hay mất kinh.

  Các dữ liệu về khả năng giảm thống kinh ở phụ nữ lạc nội mạc tử cung vùng chậu còn hạn chế. Sử dụng COCs liên tục có thể có lợi do tác dụng không ra kinh. Các kho chứa trong mô phóng thích chậm Medroxy Progesterone Acetate (DMPA), que cấy Implanon và dụng cụ tử cung chứa Levonorgestrel cho thấy hiệu quả giảm đau trong lạc nội mạc tử cung.

  2. Điều hòa chu kì kinh nguyệt

  Các rối loạn kinh nguyệt bao gồm thiếu kinh, vô kinh, cường kinh, thống kinh, kinh mau hay kinh thưa, rong kinh… là tình trạng rất hay gặp. Nó có thể tác động tới sinh hoạt hằng ngày và làm giảm chất lượng cuộc sống của người phụ nữ.

  COCs có thể điều hòa chu kì kinh nguyệt bất thường bằng cách bổ sung các hormone nội tiết thay thế để tạo ra chu kì kinh nguyệt giống như tự nhiên. Trong đa số các thử nghiệm lâm sàng, ra đốm máu li ti là biểu hiện thường gặp trong 3-6 tháng đầu sử dụng COCs nên phụ nữ sử dụng COCs để điều hòa chu kì cần đươc tư vấn về vấn đề này. Ngoài ra còn có các biểu hiện như đau vùng chậu, nhức đầu, đau căng vú hay phù vào những khoảng thời gian không có hormone.

  Viên tránh thai chỉ chứa Progestin sẽ ức chế rụng trứng ở 50% bệnh nhân, số còn lại này sẽ hành kinh bình thường. DMPA và dụng cụ tử cung chứa Levonorgestrel ban đầu sẽ tăng tỉ lệ xuất huyết bất thường nhưng càng về sau sẽ giảm lượng máu kinh do phần lớn phụ nữ sử dụng biện pháp này trở nên vô kinh.

  Khi phụ nữ không muốn hành kinh hay muốn kinh thưa hơn, có thể sử dụng DMPA hay dụng cụ tử cung chứa Levonorgestrel. DMPA hay que cấy tránh thai Implanon không phải là sự lựa chọn lý tưởng cho những trường hợp gây vô kinh tạm thời bởi sự ra máu bất thường trong giai đoạn sớm sau khi sử dụng. Hầu hết người sử dụng DMPA hay dụng cụ tử cung chứa Levonorgestrel sẽ bị mất kinh.

  3. Điều trị rong kinh

  Cường kinh (60-80ml mỗi chu kì hay hơn) nếu không điều trị sẽ dẫn đến thiếu máu thiếu sắt. Tình trạng này ước tính xảy ra ở 10% phụ nữ trong độ tuổi sinh sản và 30% số phụ nữ phải cần can thiệp. COCs có thể làm giảm lượng máu kinh và được xem như biện pháp hữu hiệu ban đầu để điều trị rong kinh, đặc biệt thích hợp ở những phụ nữ mong muốn có thai bởi vì tác dụng ngừa thai sẽ mất khi ngưng thuốc.

  Lượng máu mất khi hành kinh sẽ giảm 40-50% khi sử dụng COCs theo từng chu kì. Hiệu quả của COCs có thể tăng lên khi sử dung theo cách kéo dài và liên tục. COCs kéo dài và liên tục cũng như các biện pháp ngừa thai chỉ với Progestin giúp giảm tổng số ngày hành kinh và gây vô kinh ở một số phụ nữ. Những thử nghiệm lâm sàng khi sử dụng dụng cụ tử cung chứa Levonorgestrel cho thấy hiệu quả giảm lượng máu mất lên đến 86% sau 3 tháng, 97% sau 12 tháng, tỉ lệ vô kinh từ 20-80%.

  Thử nghiệm lâm sàng so sánh dụng cụ tử cung chứa Levonorgestrel và COCs, kết quả dụng cụ tử cung chứa Levonorgestrel hiệu quả hơn trong điều trị và người phụ nữ cũng hài lòng và sẵn sàng dùng tiếp. Tuy nhiên, họ cũng phải chấp nhận một số các tác dụng phụ như xuất huyết giữa chu kì hay đau căng vú.

  4. Điều trị rậm lông và mụn trứng cá

  Tất cả các COCs đều có khả năng cải thiện tình trạng rậm lông và mụn trứng cá bởi vì chúng đều làm tăng các globulin gắn hormone sinh dục và ức chế sản xuất androgen – hormone cần thiết cho sự hình thành và tồn tại của mụn và sự mọc lông. Một số loại thuốc có hiệu quả trên thị trường như Yasmin ( Drospirenone và ethynyl estradiol), Diane 35 (cyproterone và ethynyl estradiol) hay COCs thế hệ 2 kết hợp Levonorgestrel, COCs thế hệ 3 kết hợp Desogestrel. Các thuốc chỉ chứa Progestin dường như không có hiệu quả trong việc điều trị tình trạng này.

  Tuy nhiên không phải ai cũng có thể sử dụng thuốc tránh thai để cải thiện làn da. Thuốc này được chỉ định cho những trường hợp nữ bị mụn trứng cá mức độ trung bình trở lên và có liên quan đến yếu tố nội tiết. Đối tượng thích hợp nhất là phụ nữ khỏe mạnh, trong độ tuổi sinh đẻ, có nhu cầu ngừa thai, chưa có ý định có thai trong thời gian gần, da nhờn hoặc rậm lông, hói đầu và bị mụn trứng cá.

  5. Giảm nguy cơ ung thư

  Ung thư nội mạc tử cung: Các bằng chứng mạnh mẽ cho thấy rằng sử dụng COCs giúp giảm 50% khả năng K nội mạc tử cung so với người chưa từng sử dụng COCs. Việc dùng hơn 5 năm hay dưới 5 năm đều giúp giảm nguy cơ như nhau, kéo dài đến 20 năm sau và giảm nguy cơ tử vong.

  Ung thư buồng trứng: Nghiên cứu tổng hợp toàn cầu từ 45 nghiên cứu với 23000 trường hợp K buồng trứng và 87000 trường hợp đối chứng cho thấy rằng sử dụng COCs giúp giảm nguy cơ K buồng trứng 27%. Thời gian sử dụng càng dài sẽ giảm nguy cơ càng nhiều, ước tính giảm 20% sau mỗi 5 năm sử dụng. Khả năng phòng ngừa cũng được quan sát thấy ở viên liều thấp. Một vài nghiên cứu còn thấy rằng COCs sử dụng như một hàng rào hóa học bảo vệ ung thư buồng trứng ở phụ nữ có đột biến gen BRCA.

  6. Phòng ngừa loãng xương

  Ở người phụ nữ, estrogen là hormone quan trọng quá trình tạo xương. Estrogen kích thích các tế bào tạo xương và ức chế các tế bào hủy xương, ức chế sự tái hấp thu xương vào máu. BMD ( bone mineral density) là chỉ số thường dụng để đánh giá mật độ xương. Sử dụng COCs cho thấy giúp tăng BMD vào cuối độ tuổi sinh sản, thời gian sử dụng càng lâu càng giúp tăng mật độ xương. Nhưng đối với thanh thiếu niên và phụ nữ trẻ cần tăng lượng canxi hấp thu để tăng cường bảo về xương do nguy cơ mật độ xương giảm khi sử dụng ở lứa tuổi này. Phụ nữ sử dụng DMPA hay que cấy Implanon sẽ làm giảm mật độ xương.

  7. Vai trò trong điều trị nang buồng trứng ?

  Bằng cơ chế ức chế sự rụng trứng, các thuốc ngừa thai nội tiết giúp giảm sự hình thành các nang noãn và nang hoàng thể ghi nhận được trên siêu âm. Các nang này thường phát hiện tình cờ do hiếm khi biểu hiện trên lâm sàng mặc dù có thể dẫn đến nhiều siêu âm kiểm tra theo dõi không cần thiết. Tuy nhiên, nếu đã tồn tại nang cơ năng tại buồng trứng thì việc sử dụng COCs không có ý nghĩa trong điều trị. Một loạt các nghiên cứu RCT đã phủ định quan niệm rằng ức chế FSH sẽ thúc đẩy quá trình phát triển lớn hơn của các nang chức năng. Việc sử dụng COCs cũng không đẩy nhanh quá trình tiêu biến các nang này và không có lợi hơn việc theo dõi tiếp.

  8. Vai trò đối với u xơ tử cung.

  Ảnh hưởng thực sự của COCs lên sự hình thành và phát triển của u xơ tử cung vẫn chưa được biết rõ. Các nghiên cứu bệnh chứng và đoàn hệ đều không cho thấy liên quan đến sự hình thành hay giảm nguy cơ phát triển khối u.

  Các nghiên cứu về khả năng sử dụng COCs đề điều trị u xơ tử cung còn ít. Dùng COCs có thể kiểm soát triệu chứng chảy máu mà không làm tăng kích thước khối u trong khi liệu pháp sử dụng Progestin kết hợp kháng GnRH qua nhiều nghiên cứu cho kết quả trái ngược nhau.

  Dụng cụ tử cung chứa Levonorgestrel được chứng minh có thể giúp giảm một ít kích thước khối u xơ.

   Các khuyến cáo mức độ A của ACOG về sử dụng tránh thai nội tiết:

– COCs không nên sử dụng để điều trị các nang chức năng đang tồn tại của buồng trứng.

– COCs có thể giúp giảm nguy cơ K nội mạc tử cung và K buồng trứng.

– COCs được chứng minh giúp điều hòa kinh nguyệt và giảm lượng máu khi hành kinh, điều trị thống kinh, giảm các triệu chứng tiền kinh nguyệt và cải thiện tình trạng mụn.

– Sử dụng COCs liên tục, DMPA và dụng cụ tử cung chứa Levonorgestrel có thể sử dụng để ức chế kinh nguyệt kéo dài.

  Tóm lại, ngoài tác dụng ngừa thai thì phương pháp tránh thai nội tiết cũng mang đến nhiều lợi ích nên đây là lựa chọn hấp dẫn cho nhiều chị em phụ nữ. Tuy nhiên, nó cũng mang theo một số nguy cơ. Bạn cần tham vấn các Bác sĩ Sản Phụ khoa để có thể kết hợp hài hòa tác dụng ngừa thai và một số lợi ích tuyệt vời khác của thuốc tránh thai.

BS Nguyễn Thị Ngọc Huyền – Khoa Phụ

Tài liệu tham khảo

– ACOG (2010), “Noncontraceptive Uses of Hormonal Contraceptives”, Practice Bulletin, VOL. 115, NO. 1, pp 206-218.
– Internet.

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