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Abstract: The patient was a 48-year-old woman who went from having vigorous ovarian function to having declining ovarian function, experiencing symptoms such as insomnia and depression, as well as reduced work capacity, irritability and emotional instability, which greatly reduced the quality of life. Therefore, she came to the hospital and after medication + psychological adjustment, combined with daily diet and habit adjustment, the patient’s clinical symptoms disappeared and she is now working well and in a calm mood.
Basic information】Female, 48 years old
Disease Type】Menopause
Hospital】Guangzhou Huadu District People’s Hospital
Time of consultation】June 2017
Treatment plan】Medication (estradiol valerate tablets/estradiol cyproterone tablets, menopause tablets, menopause health) + psychological adjustment
Treatment period】After outpatient treatment, 5 months of medication
Effectiveness of treatment】remission of menopausal symptoms
I. Initial consultation
A 48-year-old woman came to the clinic with insomnia and dreaminess, hot flashes and excessive sweating, especially at night, and depression for six months. The patient reported that she had her first menstrual period at the age of 14, and her menstrual cycle usually lasted 28-30 days, with a clean period of 4-5 days and normal menstrual flow. The patient denied a history of hyperthyroidism and a history of psychiatric disorders. She had a normal weight and no fever since she became ill. The abdomen was flat and soft, no masses were palpable, the vagina was patent, the vaginal folds did not disappear, there was not much vaginal discharge, the cervix was smooth, the uterus was anteriorly normal in size, and no abnormalities were palpable in the bilateral adnexal areas. Laboratory tests for prolactin and testosterone were slightly elevated, mainly due to diet and exercise, as they had returned to normal after half a month of rechecking, and combined with all the tests, the diagnosis was menopause.
(Laboratory test report sheet)
II. Treatment history
From the analysis of my clinical symptoms and laboratory test results, other organic lesions were excluded and the patient had menopausal symptoms due to decreased ovarian function. Therefore, the following treatment was carried out.
1. Psychological adjustment: First of all, we explained to the patient that she has entered the perimenopause, which is also known as menopause, due to the decline of ovarian function, and that her performance varies due to individual differences. At the same time, tell the patient that menopause is a physiological stage that women must go through, so she should treat it correctly. The patient’s family members should be accompanied, comforted, cared for, and treated with consideration. Participate in more social activities, turn to read more positive books, divert attention and regulate their emotions.
2. Medication: Ask the patient for detailed medical history, no tendency to thrombosis, no estrogen-dependent tumors, so take oral estradiol valerate tablets/estradiol cyproterone tablets in a combination package for treatment for 3 menstrual cycles. After the symptoms were relieved, oral Estradiol tablets were administered for a total of 1 month. After the symptoms were relieved, oral treatment with Estradiol was administered for one month according to the patient’s condition, and the patient was informed that once the above symptoms appeared, he could continue to take Estradiol and stop the medication after the symptoms were relieved.
III. Treatment effect
After a total of 5 months of dietary adjustment, improvement of living condition and medication, clinical symptoms gradually disappeared with estradiol valerate tablets/estradiol cyproterone combination package, and menstruation was normal during the treatment period, occasionally there should be hot flashes, but basically it did not affect normal life and work. At present, she is in good working condition, emotionally calm, and can get along well with her family and colleagues. By the end of the treatment, there are no more painful and negative emotions such as life is worse than death, and she is full of expectation and confidence in life and work.
IV. Notes
The length and severity of menopause varies from person to person, but I was very happy to see the patient’s symptoms gradually relieved. Patients are advised to pay attention to dietary regimen and are advised to drink more soy milk, eat more onions, black beans and other foods containing phytoestrogens in their daily life in order to replenish estrogen and relieve clinical symptoms, and to get more sunlight to prevent osteoporosis. In addition, proper physical exercise is needed. Family companionship is equally important for menopausal patients. If patients experience depression, they must be comforted in a timely manner and accompanied by family members, go on trips to improve their mood and reduce the possibility of serious consequences.
V. Personal insight
Although menopause is a time in a woman’s life when she must go through it, menopausal symptoms vary due to individual differences. Severe menopausal symptoms combined with depression may lead to suicidal tendencies, so it is important to pay attention to menopause and improve menopausal symptoms. The patient was very distressed for six months.