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Abstract: The patient has been menopausal for 4 years and has had excessive and yellowish colored banding for the past 3 years, during which she was examined and treated for 1 week and her symptoms were slightly relieved. Recently, the symptoms reappeared and she developed abdominal pain, so she came to our outpatient clinic. Based on the examination results, she was initially diagnosed with chronic endometritis and was recommended to be hospitalized for hysteroscopy and symptomatic treatment with anti-inflammatory drugs. After diagnostic hysteroscopy, she was sent for pathological diagnosis suggesting endometritis, and was discharged after 1 week of anti-inflammatory treatment.
Basic information】Female, 55 years old
Disease Type】Chronic endometritis
Hospital】Jinan Hospital of Integrative Medicine
Date of consultation】March 2022
Treatment plan】Surgical treatment (hysteroscopy, curettage) + medication (Ornidazole sodium chloride injection, levofloxacin injection, tranexamic acid sodium chloride injection, gynecological Qianjin tablets)
[Treatment period] 7 days
【Treatment effect】7 days after treatment, the symptoms are relieved, the treatment effect is good
I. Initial consultation
The patient reported that she was 51 years old and menopausal, with no obvious discomfort and not much discharge. In the past 3 years, she had symptoms of increased leucorrhea and yellowish color, and her underwear was often moist, and after treatment with antibiotics orally and locally, her symptoms were slightly relieved, but after stopping the medication, her symptoms often recurred. Now the above symptoms appeared again, accompanied by vague pain in the abdomen, and the patient came to our gynecology clinic for systematic examination and treatment. Gynecological ultrasound was performed in the clinic, and the results indicated fluid in the uterine cavity. Combining the symptoms, medical history and examination results, the preliminary diagnosis was endometritis, and further hysteroscopic examination and anti-inflammatory treatment were recommended for hospitalization.
II. Treatment history
After admission, the patient was given routine blood and urine tests, blood group, coagulation system, complete biochemical and viral tests, electrocardiogram, chest X-ray, etc. The results showed no significant abnormalities and no contraindications to surgery. Before the operation, antibiotic drugs ornidazole sodium chloride injection and levofloxacin injection were given intravenously to control inflammation. During the operation, fluid was found in the uterine cavity and the endometrium was congested and edematous, so diagnostic scraping was performed and the scraped tissue was sent for pathological diagnosis. After the operation, the patient was given sodium ornidazole chloride injection and levofloxacin injection as an anti-inflammatory drip, tranexamic acid sodium chloride injection as a drip to prevent postoperative bleeding, and oral gynecological Qianjin tablets to treat endometritis.
III. Treatment effect
After surgical treatment, the patient’s lesions were eliminated and her body gradually recovered. After 7 days of hospitalization, the patient’s vital signs were stable, vaginal discharge was normal, no odor or color abnormality, no abdominal pain or lumbago, etc. The patient felt that she was in good health and recovered well, and requested to be discharged from the hospital. Considering that the patient met the discharge criteria, she was discharged from the hospital. Because the patient’s treatment plan was correctly selected and the patient’s compliance was good, the treatment effect was good.
IV. Notes
1. We are glad that the patient was cured after treatment and the discomfort disappeared. Pay attention to personal hygiene on weekdays, try to wear cotton underwear, change and wash them regularly, it is recommended to scald them with boiling water and put them in the sun, pay attention to the underwear to be washed separately from other people’s.
2, try to reduce the number of abortion scraping and uterine operation, reasonable contraception, avoid risky sex, pay attention to hygiene after surgery, timely anti-inflammatory, post-operative should not be too early intercourse.
3, the diet is light, rich in nutrition, less spicy and stimulating food, prohibit alcohol, so as not to aggravate the discomfort.
4. Once abdominal pain, fever and other uncomfortable symptoms appear, consult a doctor at any time to avoid delaying the disease.
V. Personal insight
Chronic endometritis is a common and frequent gynecological disease, and belongs to a kind of pelvic inflammatory disease. Women who have vaginitis that is recurrent for a long time and cannot be cured, or who have frequent uterine operations are prone to suffer from chronic endometritis if they do not pay attention to hygiene, and in this case, the patient’s illness may be caused by the IUD removal surgery. Female patients with symptoms such as increased vaginal discharge, odor, menstrual cycle disorder, irregular vaginal bleeding, abdominal pain, back pain and amenorrhea should be examined and treated promptly.