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Abstract: This patient was diagnosed with uterine fibroids after a mass in the lower abdomen was found during a check-up 3 years ago. Because the fibroids were small and there were no obvious discomfort symptoms at that time, no attention was paid to them and no treatment was performed. Later, after menopause, menstruation reappeared with heavy volume, blood clots and abdominal pain and back pain, so she came to our hospital and was clearly diagnosed with uterine fibroids. After surgical treatment, as well as postoperative anti-inflammatory, fluid and blood replenishment treatment, the patient’s related symptoms disappeared and the treatment effect was better.
Basic information】Female, 50 years old
Disease Type】Uterine fibroids
Hospital】Jinan Hospital of Integrative Medicine
Date of consultation】February 2022
Treatment plan】Surgical treatment (hysterectomy, bilateral salpingo-oophorectomy) + intravenous infusion (Ornidazole injection, Ceftriaxone sodium for injection, compound amino acid injection (18AA), sodium lactate ringer injection, tranexamic acid injection)
[Treatment period] Hospitalization 7 days, regular follow-up
【Treatment effect】Good results after surgery, related symptoms disappeared
I. Initial consultation
The patient, Ms. Wang, is a 50-year-old woman who reported that she had regular menstruation, her menarche was 17 years old, her periods were usually 4 days, her cycles were 26 days, her menstrual flow was moderate, and she had no dysmenorrhea. 3 years ago, she was diagnosed with uterine fibroids after a checkup at a local hospital, but the fibroids were small and there was no other discomfort, so she did not undergo treatment. In February 2022, after six months of menopause, she had two menstrual periods with heavy menstrual flow and blood clots, as well as abdominal pain, back pain and other uncomfortable symptoms. The patient underwent gynecological ultrasound examination, and the results indicated uterine fibroids and cervical cysts, and was admitted to the hospital with “uterine fibroids with cervical cysts”.
II. Treatment history
The patient was admitted to the hospital and underwent routine blood and urine tests, blood group, coagulation system, biochemical complete set, viral complete set, electrocardiogram, chest X-ray, liver, biliary, pancreatic, spleen, kidney and cardiac ultrasound, etc., and the surgical evaluation was based on the results. After discussion with the patient and her family, the decision was made to perform a transabdominal hysterectomy with bilateral salpingo-oophorectomy. Postoperatively, cardiac monitoring, oxygen, continuous catheterization, and acupressure were given to help venting, and pneumatic compression was applied to prevent venous thrombosis in both lower extremities, and ornidazole injection and ceftriaxone sodium for injection were given as an IV to prevent infection. Drug changes were performed.
III. Treatment results
The patient had a smooth surgical procedure, good anesthesia, stable respiratory and blood pressure, intraoperative bleeding of about 50 ml, postoperative anti-inflammatory and rehydration treatment, and the effect was good. On the 7th day of hospitalization, the patient recovered well, her vital signs were stable, there was no vaginal bleeding, no fluid flow, no abdominal pain, no back pain, and she reported that her incision pain was mild.
IV. Notes
We are glad that after a series of treatment, the patient recovered well and was discharged successfully. However, since the patient was not completely cured at the time of discharge, the following points still need to be noted after discharge.
1, daily should be based on more rest, do not work too hard, do not do heavy physical labor, to ensure sufficient sleep, which is conducive to postoperative recovery.
2, daily should increase nutrition appropriately, eat more light, nutritious high-protein food, such as fresh vegetables, fruits, eggs, meat, milk, etc., avoid eating spicy and stimulating, cold and blood-activating food.
3, postoperative body resistance and immunity decline, so after discharge from the hospital to pay attention to personal hygiene, careful care of abdominal wounds to avoid wound infection, while using warm boiled water to wash the vulva every night.
4. Patients are prohibited from having sex and taking a tub bath for 2 months after surgery. After 2 months, they should go to the gynecological clinic for follow-up examinations, abdominal ultrasound examinations to assess the recovery of the pelvis after surgery, and gynecological examinations to see the recovery of the vaginal stump, and if there is any discomfort, they should consult the doctor at any time.
V. Personal insight
Uterine fibroid is a very common disease in modern gynecology. It is a benign tumor, and most of the time when the fibroid is very small, patients have no discomfort symptoms, so they ignore the examination and treatment. Once the patient neglects the examination, the fibroids, if malignant, will grow faster, accompanied by some uncomfortable symptoms, such as abnormal vaginal bleeding, heavy menstruation, or pressure symptoms, such as pressure on the bladder and rectum, causing irregularities in urination and defecation, and in women of childbearing age, also affecting their fertility.
This patient did not take the fibroids seriously when they were first discovered, and they were not treated, which led to their gradual development and eventually forced surgery for treatment. By the time the fibroids were discovered, they had grown larger, making treatment more difficult. This shows that regular gynecological checkups are important for the early detection, early diagnosis, and early treatment of gynecological diseases.