(Disclaimer: This article is for scientific use only, and the information in the following content has been processed to protect patient privacy)
Abstract: The patient presented to the clinic with burning and itching sensation in the vulva. Gynecologic examination showed loss of vaginal folds, congestion of the vaginal mucosa, and a yellowish discharge, and laboratory test results showed leukocytes (++). The patient was diagnosed with atrophic vaginitis based on her symptoms and examination. After treatment with estrogen supplementation and bacterial inhibition, the patient’s burning and itching sensation in the vulva disappeared and the atrophic vaginitis was cured.
Basic information】Female, 63 years old
Type of disease】Atrophic vaginitis
Hospital】Shengjing Hospital of China Medical University
Date of consultation】August 2021
Treatment plan】Oral medication (metronidazole tablets) + vaginal medication (progesterone vaginal pellets, Kangmu gel)
Treatment Period】1 month
Results】The patient’s vulvar itching and burning sensation disappeared and her atrophic vaginitis was cured.
I. Initial consultation
The patient, accompanied by her family, was full of sadness at the time of consultation. She complained that she had been menopausal for 6 years and had vulvar discomfort, burning and itching sensation in recent months. The gynecological examination showed that the patient’s vulva was dry, the vaginal folds had disappeared, the vaginal mucosa was congested, and the discharge was yellowish, and the laboratory results showed leukocytes (++) bacilli (+) in the leucorrhoea.
II. Treatment history
The patient was given progesterone vaginal pills to supplement estrogen and strengthen vaginal resistance, and antibiotic metronidazole tablets to inhibit bacterial growth. After 7 days of treatment, the patient underwent gynecological examination again. The patient’s vaginal mucosa was better congested, and the burning and itching sensation was less than before, and the routine leucorrhoea showed leukocytes (+). After 1 month of medication, the patient returned by phone and the burning and itching sensation disappeared and the atrophic vaginitis was cured.
III. Treatment effect
The patient was full of worries when she visited the clinic because of the burning and itching sensation of vulva caused by atrophic vaginitis. After 7 days of treatment with antibiotics and estrogen supplementation, the patient’s vaginal mucous membrane congestion improved and the burning and itching sensation of vulva was reduced. After continuing the treatment for 1 month, the burning and itching sensation disappeared, the patient was cured of atrophic vaginitis, her mental state was restored, there was no more psychological pressure, and her quality of life increased significantly, so she was given discontinuation of treatment.
IV. Precautions
After medication, the burning and itching sensation in the vulva disappeared and the patient’s mental state returned to the past. Patients should take regular exercise and rest habits and eat light, easily digestible food, not spicy, stimulating food and ensure good nutritional intake.
V. Personal insight
Atrophic vaginitis is usually caused by the decline or absence of ovarian function in postmenopausal women. Postmenopausal women have lower estrogen levels and lower resistance, which can easily lead to inflammation. In this case, the patient had burning and itching vulva due to atrophic vaginitis, but fortunately, after active treatment, the disease was cured and the burning and itching vulva disappeared, obtaining a good treatment effect and the patient’s face showed the old smile. Although the disease was cured, subsequent patients should still pay attention to the cleanliness of the vulva area, change underwear regularly and wash the vulva area frequently to prevent further infection.