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Abstract: The patient in this case is a 39-year-old female patient. The patient reported persistent abnormal menstruation, feeling hot flashes, easy sweating, irritability, poor sleep and decreased libido in the past two months, and came to the hospital untreated. After blood tests, the initial diagnosis was ovarian insufficiency and secondary infertility. Through medication, the patient’s condition has been controlled, her menstruation has returned to normal and all indicators are improving.
Basic information】Female, 39 years old
Type of disease】Ovarian insufficiency, secondary infertility
Hospital】Jiangbin Hospital of Guangxi Zhuang Autonomous Region
Date of consultation】February 2022
Treatment plan】Oral medication (estradiol valerate tablets, progesterone capsules, calcium gluconate oral solution, vitamin D drops)
Treatment period】3 months of outpatient treatment
Effectiveness】The condition was controlled, menstruation returned to normal, and all indicators are improving
I. Initial consultation
One day in February 2022, I was sitting in the outpatient clinic, and the patient was a middle-aged woman who reported that she was preparing for her second child and had not been pregnant for one year. In the past two months, she has been feeling hot flashes, sweating easily, irritable, sleep deprivation, and loss of libido, which has not been treated. The patient was on her third day of menstruation and had only a small amount of brown blood.
The preliminary diagnosis was ovarian insufficiency with secondary infertility, in which ovarian insufficiency is a manifestation of decreased ovarian reserve function.
II. Treatment history
We explained to the patient that her failure to conceive for one year and her menstrual abnormalities in the last six months were both caused by the decrease in ovarian reserve function. The patient agreed to cooperate actively with the treatment. After completing the outpatient examination of thyroid function, electrocardiogram, coagulation function and bone densitometry, the result of bone densitometry was low, but other examination results did not show any significant abnormality, and then she was given hormone supplementation medication, including natural estrogen estradiol valerate tablets and progesterone capsules, as well as calcium supplementation calcium gluconate oral solution and vitamin D drops oral treatment.
III. Treatment effect
After 3 months of regular medication treatment, the patient’s sex hormone levels were rechecked, and the results showed that folliculopoietin decreased to 16 mIU/ml, serum anti-müllerian hormone was 1.32 ng/ml, and ultrasound indicated a number of 6 sinus follicles in both ovaries. The patient indicated that her menstrual flow was regular during the medication period, and her menstrual flow increased compared with the previous period, and her symptoms such as hot flashes and sweating, irritability and irritability, as well as her sleeping condition improved.
IV. Notes
I am sincerely happy for the patient’s gradual improvement in this case. Since the patient is an outpatient and lacks the supervision of medical staff, it is necessary to remind the patient that he should always pay attention to the changes of his condition, continue the hormone supplementation treatment, and come to the outpatient clinic every 3 months to review the liver function, hormone level and ultrasound to understand his condition and treatment response.
In daily life, it is recommended to eat a light and highly nutritious diet, to eat more calcium-rich foods, to develop good living habits, to avoid staying up late and straining, to exercise regularly, and to ensure personal hygiene.
If you have the need to prepare for pregnancy, it is recommended that after a period of treatment, you should consult an infertility clinic for standardized treatment under the guidance of a doctor.
V. Personal insight
Women with unexplained menstrual abnormalities that cannot be relieved after general treatment should not assume that they are just ordinary menstrual problems, but should pay attention to them and should go to the hospital as early as possible to check whether there is a problem of decreased ovarian reserve function.
In this case, after the patient found the abnormal symptoms, she was treated according to the instructions and the treatment effect was good, thus regularizing the menstrual flow, prolonging the menstrual flow, restoring the ovarian function and helping to increase the chance of ovulation, and subsequently, with good results in the regulation, natural conception is still possible.