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Abstract: The patient is a 45-year-old female patient who came to the clinic complaining of vaginal bleeding for more than 1 month, the amount of which was first high and then low. She had irregular menstruation six months ago, and the pathology of scraping before May suggested simple hyperplasia of the endometrium. Through the patient’s medical history and auxiliary examination, Western medicine diagnosed dysfunctional uterine bleeding and hemorrhagic anemia (mild); Chinese medicine diagnosed leakage (spleen and kidney deficiency type), and gave Chinese medicine formula and Western medicine treatment, and the patient’s symptoms were significantly relieved after treatment.
Basic information】Female, 45 years old
Type of disease】Bloody leakage
Hospital】The First Affiliated Hospital of Henan University of Traditional Chinese Medicine
Date of consultation】May 2021
Treatment plan】Oral Chinese medicine (Liu Wei Di Huang Wan plus reduction) + oral Western medicine (ferrous succinate tablets) + oral Chinese medicine (Jian Shen Sheng Blood tablets)
Treatment Period】2 weeks of outpatient treatment
Treatment effect】No vaginal bleeding, good overall recovery
I. Initial consultation
The patient was 45 years old and complained of vaginal bleeding for more than 1 month, the amount of which was more then less. We asked the patient about the symptoms of discomfort: significant lumbar soreness, shortness of breath, cold hands and feet, lack of appetite, insomnia, easy to wake up, dreamy, dry mouth, and thin stools, and observed the patient’s light tongue, thin white fur, and weak pulse. The patient was further examined with pelvic transvaginal ultrasound and blood cell analysis. The pelvic ultrasound showed that the thickness of endometrium was 5 mm, and the hematocrit analysis showed that the hemoglobin was 98 g/L. The menstrual period, volume, color and quality were normal six months ago, but irregular menstruation occurred in the past six months, and the diagnostic scraping suggested that the endometrium was simply hyperplastic. Western medicine diagnosis: dysfunctional uterine bleeding; Traditional Chinese medicine diagnosis: leakage (spleen and kidney deficiency).
II. Treatment history
Spleen deficiency can lead to shortness of breath, body fatigue, and then symptoms such as unheated limbs, cold hands and feet, and loss of appetite; kidney deficiency can easily lead to irregular menstruation and lumbago. The treatment is to tonify the kidneys, strengthen the spleen, and regulate menstruation. The patient was given Six Flavored Dihuang Pill with reduction. She was also given oral ferrous succinate tablets to improve her anemia and was advised to return to the clinic in 1 week. At the follow-up, the patient’s vaginal bleeding stopped, and the original treatment herbal formula was changed from charcoal to salt dulcimer and lateral cypress leaf for another week to consolidate the effect.
III. Treatment effect
After lifestyle adjustment and regular medication treatment, the patient complained that her vaginal bleeding had stopped, her shortness of breath and weakness had been significantly relieved, her stools had been formed, her appetite had improved, her back pain had been reduced, and her sleep quality had been greatly improved.
IV. Precautions
The patient’s body recovered well through the treatment, the patient felt particularly happy, and I was also happy for the patient. In the life afterwards, patients also need to pay more attention to their living habits. Good daily life management is conducive to better treatment effect and alleviation or control of symptoms in order to promote recovery.
1, first of all, you need to pay attention to more bed rest, reduce activities, upper body padded, conducive to the discharge of menstrual blood, keep the pubic area clean, to avoid infection. At the same time, maintain a relaxed mood and happy spirit, and avoid adverse mental stimulation and excessive emotional fluctuations.
2. During the period of menorrhagia, you need to eat more foods with high protein and vitamins, such as meat, beans, milk and eggs, fresh fruits, etc. You also need to take some cinnamon and red dates to nourish the blood and regulate menstruation. Avoid foods with blood-boosting effects, such as motherwort, ginger, brown sugar, etc., which can aggravate the symptoms of menorrhagia and anemia. Also avoid spicy and cold foods.
V. Personal insight
For most women in menopause, their emotions become more sensitive, so that they often have some physical changes with the disease, such as chest pain, menstrual disease and other characteristic manifestations, and the disease of menorrhagia is a possible problem for all, and this disease is usually a serious change in menstrual cycle, period and volume. Some people do not pay enough attention to this disease, and failure to take active treatment may bring great harm to health. Once the leakage occurs, it still needs active treatment, while avoiding anxiety, and this time also requires family members and doctors to work together to create a pleasant treatment experience for the patient. When there are menopausal women in the family, family members should pay more attention to the patient’s emotions, which can directly affect our health.
This patient’s family has been very helpful in helping the patient to have a peaceful state of mind during treatment.