(Disclaimer: This article is for general use only, and the information in the following content has been processed to protect patient privacy)
Abstract: A 42-year-old patient, Sister Li, had dysmenorrhea for many years and had not been treated systematically because her symptoms were not severe. In the last 3 years, her dysmenorrhea worsened with increased menstrual flow, so she came to the hospital for consultation. After examination of vaginal 3D uterine adnexal ultrasound, the results suggested thickened light spots and enhanced echogenicity of the uterine muscle wall, and adenomyosis was considered as a possibility.
Basic information】Female, 42 years old
Disease Type】Uterine adenomyosis, uterine fibroids
Hospital】Guangxi Zhuang Autonomous Region Jiangbin Hospital
Date of consultation】June 2021
Treatment Plan】Medication (Pregnant Trienone Capsules)
Treatment Period】7 months of outpatient treatment
Results】The condition was controlled, the menstrual flow returned to normal, no dysmenorrhea, and the treatment was effective.
I. Initial consultation
Patient Li had one spontaneous miscarriage and one normal delivery in the past. The patient reported that she had dysmenorrhea since she was in her 20s, and her symptoms were not serious at that time. In the last 3 years, she had abdominal pain during menstruation, mainly in the lower abdomen, and her menstrual flow was slightly increased. In the last 2 months, her symptoms were more pronounced than before, so she came to the hospital for outpatient consultation. adenomyosis and uterine fibroids, and was given outpatient treatment.
II. Treatment history
We explained to the patient that she was diagnosed with adenomyosis and uterine fibroids based on her medical history and ultrasound examination results, and that the treatment options were pharmacological and surgical, and that she still had fertility requirements, and that her uterus was only slightly enlarged and had not been treated systematically before, so she could try pharmacological treatment first and then consider surgical treatment if the treatment was not effective. The patient was then advised to start treatment with progesterone capsules on the first day of menstruation and thereafter to take the drug weekly, which has the therapeutic effect of causing atrophy and degeneration of the endometriotic lesions.
III. Therapeutic effect
Patients took progesterone capsules continuously for a total of 6 months in the outpatient clinic, and menstruation stopped during the medication period. However, because of the side effects of progesterone capsules, the patient was closely observed during the medication period. At present, the patient only experienced stomach discomfort, fatigue, seborrheic dermatitis and other discomforts, and the blood routine and liver and kidney functions were normal on recheck. After 1 month of discontinuation, the patient’s menstruation returned to normal, with normal menstrual volume and no obvious dysmenorrhea, indicating that the drug treatment is effective.
IV. Precautions
The patient had normal menstruation and was very happy for her. The following points should also be noted.
1. The use of medication for adenomyosis can relieve the symptoms for a period of time, but there is a risk of recurrence of symptoms after stopping the medication. The patient has a childbearing requirement and is already 42 years old, it is recommended that she should get pregnant as soon as possible after stopping the medication, if the condition worsens after childbirth, surgery can be considered to remove the uterus for more definite results.
2, usually pay attention to a light diet, pay attention to a balanced diet, eat more fruits and vegetables, and eat less spicy and stimulating and cold food.
3. Long-term discomfort such as increased menstruation and dysmenorrhea will have a negative impact on the patient’s body and mind, so it is recommended that the patient face the disease correctly and follow the doctor’s instructions for active treatment.
V. Personal insight
The onset of adenomyosis is due to the gradual invasion of endometrial glands into the myometrium, which is greatly related to abortion, pregnancy, endometritis and other diseases that damage the basal layer of the endometrium, so young women should reduce the occurrence of abortion and uterine infection to prevent the disease. The treatment of adenomyosis is mainly based on the patient’s age, fertility requirements, the severity of the disease and other factors, such as the patient’s fertility requirements, the disease is relatively mild, so you can choose drug therapy to control the disease, so that early conception.