(Disclaimer: This article is for scientific purposes only, and the information in the following content has been processed to protect patient privacy)
Abstract: A 42-year-old female patient with a history of irregular menstruation, 5-6 days/30-40 days, with moderate menstrual flow accompanied by dysmenorrhea. She reported 2 episodes of intermenstrual bleeding with dark red blood clots accompanied by lower abdominal distension within the last year, but did not seek medical examination. During a health checkup, an ultrasound examination revealed abnormal echogenicity in the uterine cavity and recommended a review, so she came to our hospital. She was diagnosed with abnormal uterine bleeding, and was discharged from the hospital after recovering from surgery and oral medication.
Basic information】Female, 42 years old
Type of disease】Abnormal uterine bleeding
Hospital】Hunan Provincial Maternal and Child Health Hospital
Date of consultation】May 2022
Treatment plan】Surgical treatment (hysteroscopic endometrial polypectomy, segmental scraping) + oral medication (cefixime capsule)
Treatment period】Inpatient treatment for 3 days, review after 1 month
Treatment effect] Abnormal uterine bleeding was corrected, and the postoperative recovery was good.
I. Initial consultation
At the first visit, the patient was pale, thin and anemic. The patient reported that she had irregular menstruation in the past, 5-6 days/30-40 days, with moderate menstrual flow accompanied by dysmenorrhea. In the last year, she had 2 episodes of intermenstrual bleeding with dark red blood clots and lower abdominal distension, but did not seek medical examination in time. During a recent health checkup, an ultrasound examination suggested abnormal echogenicity of the uterine cavity and recommended a review, so she came to our hospital. After communication with the patient, a vaginal ultrasound examination was performed, suggesting an endometrial thickness of 1.3 cm and a slightly hyperechoic cluster of 1.2×0.7×0.9 cm in the uterine cavity, which was clearly identified as abnormal uterine bleeding caused by endometrial polyp.
II. Treatment history
Pre-operative tests such as routine blood count, coagulation set, liver and kidney function, electrocardiogram, and routine leucorrhea were prescribed for the patient, and the results showed no significant abnormal values. The hysteroscope was used to enter the vagina and the uterus. During the operation, the cervical canal was seen to be regular in shape, a little tissue was scraped out, and the uterine cavity was normal in shape and size. Postoperatively, bilateral horn of the uterus and the opening of the fallopian tubes were visible. Cefixime capsules were given orally regularly for 3 days after surgery to prevent postoperative infection.
III. Treatment results
The patient was clearly conscious after surgery, and her gait was stable and without directional deviation when she was walking with the support of her family, suggesting that the operation was successful. The patient recovered well after taking antibiotics for 3 days, and was advised to stop the medication and take progesterone therapy for 3-6 months after half cycle of menstruation to prevent the recurrence of polyps. One month after discharge, the patient reported no fever, abdominal pain and other uncomfortable symptoms, abnormal uterine bleeding did not reappear, and no abnormal echogenicity was seen in the ultrasound examination.
IV. Precautions
The patient’s abnormal uterine bleeding symptoms returned to normal after surgical treatment combined with drug therapy. I am sincerely happy for the patient and suggest the following daily attention.
1.After discharge from the hospital, it is recommended to take progestin therapy for 3-6 months in the second half of the cycle to prevent the recurrence of polyps, pay attention to menstruation and follow up abnormalities.
2, pay attention to rest, strengthen nutrition, moderately increase the intake of high-protein food and iron-rich food, such as milk, eggs, pig’s blood, etc. Avoid eating spicy and stimulating food to avoid local irritation and inflammation.
3, pay attention to keep the vulva clean, you can use water to rinse, but avoid using irritating lotion, and prohibit sexual intercourse and tub bath for 1 month.
4, daily attention should be paid to abdominal warmth, to avoid cold stimulation of the body, which is not conducive to the health of the body.
V. Personal insight
The patient had been showing excessive menstrual flow in the early stage, but did not pay attention to it, and only after the physical examination suggested abnormalities did she seek medical attention. We hereby call on all women to seek medical attention in a timely manner if abnormalities in menstrual volume, color and cycle occur, as early treatment can shorten the treatment time and improve the prognosis if the disease exists.