A Review on Clinical Studies of Abdominal Acupuncture Treatment for Endometriosis

대한한방부인과학회지pISSN1229-4292/eISSN2508-3619JKoreanObstetGynecol.VOL.33NO.4:023-035(2020)https://doi.org/10.15204/jkobgy.2020.33.4.023 23 자궁내막증환자의복부침치료효과에대한임상연구고찰1부산대학교 한의학전문대학원 한의학과, 2부산대학교 한방병원 한방부인과방승원1, 윤영진2 ABSTRACTAReviewonClinicalStudiesofAbdominalAcupunctureTreatmentforEndometriosisSeung-WonBang1,Young-JinYoon21SchoolofKoreanMedicine,PusanNationalUniversity2Dept.ofKoreanMedicineObstetricsandGynecology,KoreanMedicineHospital,PusanNationalUniversityObjectives:ThepurposeofthisstudyistoconfirmtheeffectivenessandsafetyofacupunctureforEndometriosis.Soprovidingaclinicalbasisforabdominalacupuncturetreatmenthelpingtodevelopclinicalpracticeguideline.Methods:ClinicalstudiesapplyingacupunctureonEndometriosisweresearchedthroughPubmed,ChinaAcademicjournal(CAJ),KoreanstudiesInformationServiceSystem(KISS),ResearchInformationSharingService(RISS),OrientalMedicineAdvancedSearchingIntegratedSystem(OASIS).Interventionsandresultsoftheselectedclinicalstudieswereanalyzed.Results:8Clinicalstudieswerefinallyincludedaccordingtoinclusionandexclusioncriteria.Thosewererandomizedcontrolledstudies.AllofthosestudiesweresearchedinChinaAcademicjournal(CAJ)inChinese.InterventionsofcontrolgroupweremadewithsimpleacupunctureandoraladministrationofDanazolorherbalmedicine.OutcomemeasurementsincludedTreateffect,Reliefinrelatedsymptoms,andCA-125.Allstudiesreportedstatisticallysignificantresultsonabdominalacupunctureandtherewerenoseriousadverseeffects.Conclusions:Thisstudysuggestedabdominalacupuncturehasstatisticallysignificanttreateffect.Thusthistreathelpsimprovequalityoflifeforpatients.Howevertheresultsshouldbetakencautiouslyasmoreclinicalstudiesareneeded.KeyWords:Endometriosis,AbdominalAcupuncture,CA-125 2) Correspondingauthor(Young-JinYoon):PusanNationalUniversityKoreanMedicineHospitalObstetricsandGynecologyDepartment,Keumo-ro20,Yangsan-si,Gyeongsangnam-do,KoreaTel:055-360-5588Fax:055-360-5736E-mail:[email protected] 자궁내막증환자의복부침치료효과에대한임상연구고찰 24 Ⅰ.서론자궁내막증은자궁내막조직이자궁이외의조직에서증식하는것을말하며월경통,하복부통증,골반통,월경과다,복부종괴,불임,성교통등다양한임상증상을나타낸다.아직정확한병인은알려져있지않으나월경역류로인한자궁내막조직및월경혈의골반내로의유입에의한자궁내막조직의자궁외착상,유전적요인,환경적요인,면역학적인요인등이있다1).자궁내막증에대한위험인자로는가족력,만성골반통,월경역류를증가시키는심한월경통,짧은월경주기,월경기간이8일이상,30대이상의가임연령층,비만등을들수있다2,3).자궁내막증의유병률은대체로가임기여성에서10%정도로예측되며점점증가되는추세이다.하지만증상이비특이적이고육안소견및병리학적진단이이루어지지않은경우가많아정확한유병률은알기어렵다4).현재자궁내막증에대한일반적양방치료는통증,자궁내막종의크기에따라골반경수술방법,자궁적출술방법,수술후재발방지를위한약물치료등이다.약물치료는호르몬제제를통해낮은혈중에스트로겐농도를만드는것인데가장많이사용되고있는것은성선자극호르몬분비호르몬효능제(GnRHagonisit,GnRH:Gonadotropin-releasinghormone)이다.GnRH제제는여성체내시상하부에있는GnRH수용체를down-regulation시켜내분비시스템을억제함으로써에스트로겐의존성자궁내막증의병변을 위축시켜자궁내막증을치료한다5).그러나GnRHagonist를비롯한호르몬제제의사용은저에스트로겐혈증에따른안면홍조,질위축등의폐경기증상과골소실의발생등다양한부작용이발생할수있다6).그래서최근한의진료를활용하여더안전하고효과적인중재를개발하기위한연구가다수이루어지는추세이다.한약을비롯한한의학적접근으로GnRHagonist투약시저에스트로겐부작용을호전시키거나,수술후의자궁내막증재발을억제하는보고가잇따르고있다7,8).이에대한대안으로한의학적치료가대두되고있으며한의학에서는자궁내막증의병인을瘀血로보고있다.氣虛,血寒,血熱,氣滯,外傷,出血은瘀血을형성하는대표적인요인이며氣滯血瘀,氣虛血瘀,寒凝血瘀,熱鬱血瘀등으로변증하여치료한다.기존한의학의자궁내막증에대한치료는약물치료와침구치료가대표적이며약물치료는변증에따라氣滯血瘀에血府逐瘀湯,腎虛血瘀에大營煎加味,寒凝瘀阻에少腹逐瘀湯,熱鬱瘀阻에小柴胡湯合桂枝湯등을사용한다.침구치료는기본적으로關元,足三里,百會,子宮,提托,陰陵泉,三陰交등을중심으로中極-關元,子宮-提托,陰陵泉-三陰交등에電針을부가한다25).국내에서는자궁내막증에관련하여한약을중재로한연구가다수이고침만을중재한연구는찾아보기어렵다.2017년중국에서발표된자궁내막증침치료의효과에관한연구19)이후자궁내막증의침치료에관해관심이증대되었으며그중에서도복부침치료에관한임상적근거는부족한상황이다. JKoreanObstetGynecolVol.33No.4November2020 25 복부침치료와관련하여최근복침(腹鍼)요법을자궁내막증치료에활용하는연구가게재되고있다.복침(腹鍼)요법은중국베이징薄氏腹針醫學硏究院의薄智云교수가20여년의임상연구를거쳐1992년학계에발표하면서알려졌으며복부의혈자리에자침을하면장부기능의평형을조절할수있으며더나아가전신질환을치료할수있다고말한다24).이에저자는복침(腹鍼)요법을포함10,14,15)하여자궁내막증의복부침치료의효과에대해국내외임상연구들을정리하고유효성과안전성을평가하여임상적근거를마련하기위해서본연구를진행하게되었다.Ⅱ.대상및방법1.선정기준자궁내막증의침치료효과만보기위해서약물과병행한치료는제외하였고침치료중에서도복부에자침한연구만대상으로하였다.치료군은복부침치료를중재로하여뜸을병행한경우는神闕(CV8)과같은자침하기어려운부위에자극을주기위해뜸을활용한것이었다.대조군은양약혹은한약을이용한약물치료를시행하였거나변증없이기본혈에단순자침한경우들이포함되었다.선정기준으로는모든연구에서치료군과대조군을명확히한경우만포함하였다.평가지표는임상치료효과,통증지표,CA-125등제한을두지않았다.논문형식은학술지에게재된논문에서 임상연구로한정했다.최근임상연구동향을반영하기위해2010년이후진행된연구만포함하였으며2020년3월,8월2차례검색으로확인된연구만선정하였다.제외기준으로는Casereport,review의관찰연구,질적연구,동물을대상으로한연구,세포실험연구등의invitro연구,대조군이명확하지않은연구,침치료뿐만아니라여러가지중재방법이혼합된연구는제외하였고복부침치료의효과를규명하기위해복부외의혈위를사용한침치료연구도제외하였다.2.검색방법국외데이터베이스로Pubmed,ChinaAcademicjournal(CAJ),국내데이터베이스로한국학술정보(KISS),학술연구정보서비스(RISS),한의학술논문통합검색시스템(OASIS)을이용하였다.각데이터베이스자료제공일로부터1차검색은2020년3월2일까지시행된연구,2차검색은2020년8월10일까지시행된연구를대상으로하였다.검색식은Pubmed의경우(Endometriosis)AND(acupunctureORelectroacupuncture)로입력하였고연구종류를임상연구(ClinicalTrial)또는무작위대조군임상연구(RandomizedControlledTrial)로제한하였다.CAJ의경우주제와편명은(子宮内膜異位症and針)OR(子宮内膜異位症and電針),전문을대상으로(隨機and對照組)의검색을입력하였다.국내데이터베이스의경우자궁내막증,침,전침등의검색어를사용하였다. 자궁내막증환자의복부침치료효과에대한임상연구고찰 26 Ⅲ.결과1.연구선정Pubmed에서22편,ChinaAcademicjournal(CAJ)에서54편,한국학술정보(KISS),학술연구정보서비스(RISS),한의학술논문통합검색시스템(OASIS)에서1편으로총77편의연구가검색되었고중복연구3편을제외하였다.제목과초록을검토하여Pubmed에서임상연구가아닌3편을 제외하고ChinaAcademicjournal(CAJ)에서임상연구가아닌5편을제외하고학술지논문이아닌2편을제외하고복부침치료와관련없는연구를제외하여18편의연구를1차선별하였다.이후18편의연구에서한약과침구를병용중재한연구는제외하고침구치료단독으로중재한논문만선정하여최종적으로8편의연구가선정되었다(Fig.1). Fig.1.Flowchart.2.선정된연구의일반적인특징최종적으로선정된8편의연구들은Pubmed,CAJ에서검색된것이었으며2010년부터2018년사이에발표된연구였다.8편모두무작위대조군임상연구로진행되었으며중국에서연구가시행되었고중국어또는영어로작성되었다.8편의임상연구에서총569명의피험자가참여하였다. JKoreanObstetGynecolVol.33No.4November2020 27 Firstauthor(year)StudydesignPatientdemographicsSamplesizeAge(Meanage±SD*)Zhang9)(2018)RCT†ChinaTG‡42CG§41TG18-50(37±9)CG20-48(36±8)Xiang10)(2016)RCTChinaTG50CG47NotreportedZhu11)(2010)RCTChinaTG30CG3015-46(34)Lin12)(2010)RCTChinaTG30CG2617-41(29.6)Chen13)(2010)RCTChinaTG35CG2617-41(29.6)Sun14)(2012)RCTChinaTG32CG30TG26-42(33.15±3.12)CG22-44(34.54±3.71)Cai15)(2015)RCTChinaTG40CG4022-48(33.4±5.7)Chen16)(2011)RCTChinaTG35CG3518-50(38)SD*:standarddeviation,RCT†:randomizedcontrolledtrial,TG‡:treatmentgroup,CG§:controlgroup Table1.GeneralCharacteristicsofIncludedStudies 3.중재방법8편의연구모두복부에자침하는것을중재로하였으며1편9)의연구에서만복부와함께八髎穴에뜸치료를병행하였다.3편10,11,14)의연구에서는변증에따라서복부에뜸치료를병행하기도하였다.8편의연구모두대조군이존재하였으며2편13,16)은양약인Danazol을대조군으로중재하였으며4편9,11,12,15)은한약을대조군으로중재하여각각加味没竭片(血竭,沒藥,生蒲黃,五靈脂,三稜,莪朮)9),活血化瘀藥物(丹蔘,赤芍,三稜,莪朮,枳殼,香附子)11),桂枝茯苓캡슐12),田七痛經캡슐15)로중재하였다.나머지2편10,14)은단순복침기본혈위만자침하여대조군중재하였다.치료빈도는월경전1주일부터치료를시작한연구가6편으로가장많았고나머지2편8,9)은월경전5일전치료를 시작하였다.치료기간은8편연구모두3개월월경주기를하나의치료기간으로하였다.유침시간은20분또는30분으로유사하였다.치료혈위는引氣歸元(中脘(CV12)下脘(CV10)氣海(CV6)關元(CV4))이8편모든연구에서사용되었으며그다음은外陵(ST26)이Zhu11)의연구를제외한7편의연구에서사용되었으며그외4편9,14-6)의연구에서水道(ST28),中極(CV3),氣旁,下風濕點을사용하였으며3편9,10,14)의연구에서氣穴(KI13)이사용되었다.2편10,11)의연구에서大橫(SP15)을사용하였고2편10,11)의뜸을병용한연구에서神闕(CV8)에쑥뜸을사용하였다(Table2).그외大赫(KI12)이1편10)에서사용되었다(Table3).Zhang9)와Cai15)연구에서는자침방향에대한언급이없었으며나머지6편 자궁내막증환자의복부침치료효과에대한임상연구고찰 28 의연구에서는양측에자침하였다.Zhu11)의연구에서만0.22×30mmor0.22×40mm로침의크기에대한언급이있었으며그외다른연구에서는침의크기에대한언급은없었고모든연구에서침의자입깊이에대한언급이없었다(Table2).Firstauthor(year)TypeFrequencyDurationAcupointSideSizeofacupunctureneedlesZhang(2018)Acupunture,moxibustion1weekbeforemenstruationfor30minutes3-monthmenstrualcycleCV12,CV10,CV6,CV4,ST28,ST26,KI13,氣旁NotreportedNotreportedXiang(2016)Acupunture5daysbeforemenstruationfor20minutes3-monthmenstrualcycleCV12,CV10,CV6,CV4,CV3,ST28,ST26,KI13,KI12,SP15,氣旁,灸CV8BothNotreportedZhu(2010)Acupunture,moxibustion5daysbeforemenstruationfor30minutes3-monthmenstrualcycleCV12,CV10,CV6,CV4,SP15,腹四關,下風濕點,灸CV8Both0.22×30mmor0.22×40mmLin(2010)Acupunture1weekbeforemenstruationfor30minutes3-monthmenstrualcycleCV12,CV10,CV6,CV4,ST26,下風濕點BothNotreportedChen(2010)Acupunture1weekbeforemenstruationfor30minutes3-monthmenstrualcycleCV12,CV10,CV6,CV4,ST26,下風濕點BothNotreportedSun(2012)Acupunture,moxibustion3times1weekbeforemenstruationfor20minutes3-monthmenstrualcycleCV12,CV10,CV6,CV4,CV3,ST28,ST26,KI13,氣旁BothNotreportedCai(2015)Acupunture3times1weekbeforemenstruationfor20minutes3-monthmenstrualcycleCV12,CV10,CV6,CV4,CV3,ST28,ST26,氣旁NotreportedNotreportedChen(2011)Acupunture1weekbeforemenstruationfor30minutes3-monthmenstrualcycleCV12,CV10,CV6,CV4,CV3,ST26,下風濕點BothNotreported Table2.CharacteristicsofAcupunctureIntervention FrequencyAcupoints8CV12(中脘),CV10(下脘),CV6(氣海),CV4(關元)7ST26(外陵)4ST28(水道),CV3(中極),氣旁,下風濕點3KI13(氣穴)2SP15(大橫),灸CV8(神闕)1KI12(大赫) Table3.FrequencyofAcupointsUsedintheStudies4.치료효과및안전성1)임상치료효과8편의연구중6편9-13,16)의연구에서임상치료효과에대한평가를진행하였다.Sun14)와Cai15)의연구를제외한모든연구에서복부침치료전후의임상치료효과를비교하여복부침치료효과의개선지표로삼았으며각각‘완쾌,효과적,유효,무효’의단계로나누어효과를비 JKoreanObstetGynecolVol.33No.4November2020 29 교하였다.임상치료효과를연구한총6편9-13,16)의연구중Zhang9)의연구를제외한모든논문에서총유효율이90%이상이었으며Zhang9)의연구에서도단기치료효과는90%이상의총유효율을보였다.모든논문의임상치료효과의통계학적의의는p<0.05로유의하게효과가있음을알수있었다(Table4).2)월경통증변화8개의연구중5편9-11,14,15)의연구에서통증과관련된평가를진행하였다.Zhang9),Xiang10),Zhu11),Sun14)의연구에서치료전후월경통변화에대하여평가하였으며4개연구모두치료후에월경통이감소한것을볼수있었다.통계학적의의는Zhang9),Xiang10)연구에서p<0.01,Zhu11),Sun14)연구에서p<0.05로유의하게나타났으며Sun14)의연구를제외한다른연구에서는통증감소효과가대조군과의차이가뚜렷하게나타났다.Zhang9)의연구에서는진통(鎭痛)시간에대한평가를진행하였으며대조군에비해관찰군이진통발생시간이짧았고진통유지시간이길다는것을확인할수있었다(p<0.05).치료전후VAS를비교한연구는Xiang10),Cai15)의연구에서진행되었으며두연구모두치료전과비교하여치료후VAS값이감소하였고통계학적의의는각각Xiang10)에서p<0.0001,Cai15)에서p<0.05를보여유의하게나타났다.또두연구모두대조군과비교하여관찰군에서VAS (visualanalogscale)감소효과가컸다.Cai15)의연구에서는현재통증강도(PresentPainIntensity,PPI)와통증점수(PainRatingIndex,PRI)변화를평가했으며치료전과비교해치료후PPI값이감소하였고대조군과비교해서감소변화는작은편이었다.통계학적의의는p<0.05로PPI,PRI모두유의하게변화가있음을알수있었다(Table4).3)CA-1258개의연구중에4개9,10,14,15)의연구에서혈청CA-125의변화를평가하였다.Zhang9),Xiang10),Sun14),Cai15)의연구에서모두치료후혈청CA-125값이유의하게감소하였음을알수있었고(p<0.05)Zhang9),Xiang10)연구에서는대조군과비교하여도현저히감소폭이컸지만통계학적의의는Zhang9)연구에서p<0.05로유의하게나타난데비해Xiang10)연구에서는p=0.6415로유의한변화는아니었다(Table4).4)안전성8편의연구중4편9,10,12,13)의연구에서부작용에대해언급을하였다.4편11,14-6)의연구에서는부작용보고가없었으며2편9,10)의연구에서는부작용언급이있었으나모두대조군에서발생한부작용으로개인적원인,통증등으로중도탈락하였다.관찰군에서는부작용이발생하지않았다.그외2편12,13)의연구에서는모든과정에서부작용이발생하지않았다(Table4). 자궁내막증환자의복부침치료효과에대한임상연구고찰 30 Firstauthor(year)InterventionOutcomemeasurementResultAdverseeffectZhang(2018)Acupunture,moxibustion1.Treateffect2.Reliefinrelatedsymptoms3.Painrelieftime4.CA-1251.TG*>CG†(p<0.05)2.TG<CG(pCG(pCG(p<0.05)NosevereeventsXiang(2016)Acupunture1.Reliefinrelatedsymptoms2.VAS‡3.Treateffect4.CA-1251.TG<CG(p<0.0001)2.TG<CG(pCG(p=0.0273)4.TG>CG(p=0.6415)NosevereeventsZhu(2010)Acupunture,moxibustion1.Treateffect2.Comparisonofmenstrualpain1.TG>CG(p<0.05)2.TG<CG(pCG(pCG(p<0.05)NoSun(2012)Acupunture,moxibustion1.Comparisonofmenstrualpain2.CA-1251.TG<CG(p<0.05)2.Reducted(p<0.05)NotreportedCai(2015)Acupunture1.VAS2.Presentpainintensity(PPI)3.CA-1251.TG<CG(p<0.05)2.TG<CG(pCG(pCG(p<0.05)NotreportedTG*:treatmentgroup,CG†:controlgroup,VAS‡:visualanalogscale Table4.InterventionandResultsofIncludedStudies Ⅳ.고찰자궁내막증을경험하는여성들은불안,무기력,두려움,우울증등과부정적감정,스트레스를증가시키며삶의질이감소된다.가장왕성한성적활동을가진시기에15~20%의높은유병률을보이기때문에불임가능성이높아지고우울증이증가하여사회적으로여러문제를야기한다17).자궁내막증의치료는신체적,정신적영향을이해하여치료해야하며불임등의문제는사회적문제와도연관되므로적극적치료의필요성이대두된다18). 자궁내막증은염증성반응과여러가지병태생리학적인변화를유발하는부인과영역의만성질환이다5).자궁내막증을치료하기위한양방의학의수술치료방법이나호르몬요법,약물요법은부작용을수반하게되고특히GnRHagonist를비롯한호르몬제제의사용은저에스트로겐혈증에따른안면홍조,질위축,골다공증등각종부작용을야기한다6).따라서이러한부작용을발생시키지않으면서자궁내막증을치료할수있는치료법으로한의학의침술은그대안이될수있다.기존한의학의자궁내막증에대한치료는약물치료와침구치료가대표적이며 JKoreanObstetGynecolVol.33No.4November2020 31 약물치료는변증에따라血府逐瘀湯,大營煎加味,少腹逐瘀湯,小柴胡湯合桂枝湯등을사용하고침구치료는기본적으로關元,足三里,百會,子宮,提托,陰陵泉,三陰交등을중심으로中極-關元,子宮-提托,陰陵泉-三陰交등에電針을부가한다.자궁내막증은한의학에서癥瘕의범주로볼수있는데癥瘕의병기는일반적으로氣滯,濕痰,瘀血등의범주로설명되어진다25).그중한의학에서보는자궁내막증은瘀血을기본으로하고있다20).역대문헌에서는≪素問⋅調經論≫“寒氣客於子門,子門閉塞,氣不得通,惡血當瀉不瀉,衄以留止,日以益大,將如懷子,月事不以時下,皆生瘀於子,可導以下”,張仲景≪金匱要略⋅婦人姙娠病脈證幷治≫“婦人宿有癥病經斷未及三月而得漏下不止胎動在臍上者爲癥痼害”,孫思邈≪千金要方⋅求子第一篇≫“月水去留,前後交亘,瘀血留滯”,王肯堂≪證治準繩≫“婦人飮食其居,一失其宜,皆能使血瘀滯不行,故百病由汚血者多”,李梴≪醫學入門≫“女子癥瘕疝氣發則腹痛逆氣上衝乃胞中傷損瘀血結成久則堅硬如石塞於子門大如懷胎月事不下乃先感寒氣而後血壅不流所致”등에서瘀血과婦人病에관련된瘀血證을설명하고있다21).복부자침은자궁외에서성장하는자궁내막증의癥瘕를근처經絡經穴을자극함으로써氣의순환을돕고불균형을조절함으로써瘀血을제거하는것으로사료된다.자궁내막증의한의학적치료법에관한연구는한약을중재로치료효과를관찰하거나한약과침술의병행하여효과를관찰하는임상연구가주를이루었다.2017년중국에서자궁내막증의침치료효과에 관한문헌고찰연구19)가발표된이후침치료에관한관심이높아졌고이번연구는이를심화연구하여복부침치료의경우더특이적으로어떠한효과를보이는지관찰하는데의의가있다.5개의데이터베이스를통해검색된연구중선정,배제기준을거쳐최종적으로8편의연구가선정되었다.중재방법은8편의연구모두복부에자침을시행하였고팔료혈에뜸을병행한연구9)도있었다.변증에따라뜸을병행한3편의연구10,11,14)를포함하면침과뜸을같이사용한연구는4편의연구9-11,14)가있었고뜸으로인한효과가복부침치료효과에어떠한영향을주었는지는제시되어있지않아향후연구에서고려해야하는사항이다.대조군으로는한약군9,11,12,15),양약군13,16),단순복침10,14)이사용되었고한약군이4편연구로가장많았다.대조군으로단순복침을사용한연구는변증에따라관찰군에서자침부위를가감하는방식으로연구를진행하였으며이를포함해변증,증형에따라환자군을나눈연구는4편9,10,14,15)이였다.환자를변증,증형에따라나눈연구에서2편10,14)의연구에서만증형별로치료전후효과를비교관찰하여증형구분에따른차이를관찰하였으며나머지2편9,15)의연구에서는증형에따른구분을시행하지않아환자모두동일한자침효과로보기는어려웠다.치료결과8편중6편9-13,16)의연구에서임상치료효과를관찰하였고Zhang9)의연구에서치료군이대조군보다치료효과가좋았으며(p<0.05),Xiang10)연구(p=0.0273),Zhu11)연구(p<0.05),Lin12)의연구(p<0.05),Chen13)의연구(p<0.05),Chen16)의연구 자궁내막증환자의복부침치료효과에대한임상연구고찰 32 (p<0.05)로모두치료군이대조군보다통계적으로유의한임상치료효과를얻었다.Zhang9)의연구중단기치료효과를포함해6편모두총유효율이90%이상으로통계학적으로유의한결과를보여자궁내막증의치료에복부침치료를고려해야하는근거를마련하였다.치료전후월경통증변화를관찰한4편의연구9-11,14)중3편의연구9-11)에서뚜렷하게치료군에서대조군보다월경통의유의한감소를보였다.Zhang9)연구에서통증경감(p<0.01),통증시간감소(p<0.05)의결과와Xiang10)연구에서통증경감(p<0.0001),VAS감소(p<0.0001)와Zhu11)연구에서월경통비교감소(p<0.05)의결과를보였다.Sun14)의연구에서는치료군과대조군의효과차이가적었는데통증증상적분법수치변화가치료군에서치료전10.66±3.212에서치료후8.065±2.446로,대조군에서치료전10.22±4.311에서치료후8.121±2.024로치료군과대조군의차이가적었다(p<0.05).이러한결과는Sun14)연구가다른연구들과달리대조군중재에서복침기본혈위를동일하게하였고변증유형에따라자침부위를가감하는형태로치료군을중재하였기때문으로생각된다.또한VAS,PPI,PRI등을관찰한연구에서도대조군에비해치료군에서유의한통증감소효과(p<0.05)를보이며복부침치료의통증감소효과를관찰할수있었다.통증치료가여성환자의삶의질과도연관18)되어있다는점을고려할때자궁내막증의복부침치료를월경통증에우선적으로활용할수있을것이다.CA-125은난소암,자궁내막암등에서 증가하는당단백으로종양표지자이다.CA-125는암이외에도자궁내막증에서도증가하는데이를지표로한4편9,10,14,15)의연구중3편9,14,15)에서치료전후모두통계학적으로유의한감소를보였다(p<0.05).그러나Xiang10)연구에서는대조군과비교할때치료군에서유의한감소를보이지않았다(p=0.6415).이는CA-125의농도가자궁내막증의3,4기진단과치료에는유용하게사용될수있으나1기와2기자궁내막증의경우진단의정확도가떨어져단독적인사용보다는다른진단,치료법과함께보조적인사용이유용하기때문으로생각된다22).가장많이치료에사용된경혈은中脘(CV12),下脘(CV10),氣海(CV6),關元(CV4)으로8편의연구중8편모두에서사용되었다.그다음은外陵(ST26)7편,水道(ST28),中極(CV3),氣旁,下風濕點4편등순이었다.주로임맥(任脈)의혈이주로사용되었으며족양명위경(胃經)의혈도많이쓰였음을알수있다.임맥(任脈)은족삼음경(足三陰經)과음유맥(陰維脈),충맥(衝脈)등과交會하며온몸의음경(陰經)을조절하는경맥(經脈)으로少腹에서비뇨생식계와관련이된다.족양명위경(胃經)도비뇨생식계부위를지나고승읍혈(承泣穴)에서임맥(任脈)과도연계된다.복부부위의자침은자율신경인교감신경과부교감신경의활성정도를변화시켜인체의생리적변화를가져오는데23)이를통해비뇨생식계에어떤영향을주는지는향후연구가필요하다.부작용에대해서언급한연구는4편9,10,12,13)으로2편9,10)에서는대조군에서발생한부작용이었고나머지2편12,13)은치료군,대 JKoreanObstetGynecolVol.33No.4November2020 33 조군모두부작용이발견되지않았다고하였다.복부자침으로인한부작용은경미하거나거의없을것으로사료되어양방치료의부작용6)과비교할때복부침치료를적극적으로활용할수있는근거가될수있다.본연구는자궁내막증의복부자침의치료효과를관찰하기위해고찰한연구로국내에서는연구된바가없다.따라서중국인을대상으로한연구가주를이루고국외연구를위주로고찰하여국내환자에게적용시해석에주의가필요하다는한계점이있다.또한복침(腹鍼)요법은중국베이징薄氏腹針醫學硏究院의薄智云교수가1992년학계에발표하며알려진것으로복부혈위에특정술기로자침하여질환을치료하는요법인데이와관련된논문10,14,15)에서어떤술기를이용하여복침요법을시행했다는언급이없고변증에따른특정혈위를가감하는언급만있어서술기로인한효과를알수없다는한계점이있다.침치료중재특성상참여자,연구자맹검이어렵고Zhu11)의연구를제외하면자침한침의종류,크기,깊이가서술되어있지않아연구에어떤영향을주었는지알수없다는점,문헌의질에대한평가가이루어지지않았다는점이이번연구의한계점으로지적할수있다.그러나이번연구는복부침치료가임상치료효과,통증감소효과,CA-125감소등자궁내막증치료에있어서긍정적인효과를가져올수있으며부작용이거의없는안전한치료라는근거를확인할수있었다.아직연구수가부족해더많은연구가필요할것으로보이며이번연구가향후자궁내막증의복부침치료 연구에가이드라인을설정해줄수있을것으로보인다.향후자궁내막증의복부침치료와병행한한약또는양약의치료효과,진통소염제와비교하여복부침치료의진통효과정도와삶의질개선정도등다양한방면에서연구가이루어진다면자궁내막증치료에있어서환자들이다양한치료방법을선택할수있을것으로보인다.Ⅴ.결론자궁내막증의복부침치료를시행한8편의임상연구로치료전후에대조군과의차이를비교하여임상치료효과,VAS등을활용한월경통변화,혈청CA-125변화를평가하였으며다음과같은결론을얻었다.1.임상치료효과결과자궁내막증의복부침치료시총유효율이90%이상으로통계학적으로유의한결과를얻었고,치료전후월경통변화를관찰한결과대조군에비해치료군에서진통(鎭痛)시간,VAS,PPI,PRI모두유효한결과를얻었다(p<0.05).2.CA-125의경우복부침치료후4개의연구에서혈청CA-125값이유의하게감소하였으나(p<0.05)Xiang8)연구에서대조군과의차이가p=0.6415로통계적으로유의한결과는아니었다.3.대조군과비교하여치료군에서부작용은관찰되지않았으며가장많이치료에사용된경혈은中脘(CV12),下脘(CV10),氣海(CV6),關元(CV4)으로8편의연구중8편모두에서사 자궁내막증환자의복부침치료효과에대한임상연구고찰 34 용되어자궁내막증의복부침치료에있어기본적인치료혈위였다.4.자궁내막증의복부침치료는월경통을감소시키고임상치료효과를보여주면서환자의삶의질을개선시키고한약,양약,수술치료등과병행치료했을때더효과적으로활용할수있으므로이에대한추가적인연구가필요하다.□Received:Oct04,2020□Revised:Oct19,2020□Accepted:Nov27,2020References1.MoonJB,etal.Clinicalanalysisoftheendometriosis.KoreanJournalofObstetricsandGynecology.2006;49(11):2335-40.2.MahnazA,etal.EvaluationofRiskFactorsAssociatedwithEndometriosisinInfertileWomen.IntJFertilSteril.2016;10(1):11-21.3.RobertHemmings,etal.Evaluationofriskfactorsassociatedwithendometriosis.Fertility&Sterility.2004;81(6):1513-21.4.JungUS.Clinicalchracteristicsofthepatientswithendometriosisconfirmedbyhistopathology.DepartmentofObstetricsandGynecology,GraduateSchool,KoreaUniversity.2005.5.LimYT.CurrentConceptsintheManagementofEndometriosis.KoreanJournalofObstetricsandGynecology.2005;48(3):533-44. 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