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Abstract: A 36-year-old female patient was found to have an abnormal gynecologic ultrasound examination that showed abnormal echogenic clusters in the uterine cavity because she attended a company physical examination 1 month ago. Her previous menstruation was regular and slightly heavy, and she came to our hospital for a review to clarify the diagnosis because she was more aware of medical care. After prescribing gynecologic ultrasound, the patient decided to undergo surgery combined with drug treatment. Postoperative pathology showed no malignant changes and the patient’s general condition was good, and she was discharged without any other discomfort.
Basic information】Female, 36 years old
Disease Type】Endometrial polyp
Hospital】Hunan Provincial Maternal and Child Health Hospital
Date of consultation】June 2022
Treatment plan】Surgical treatment (hysteroscopic endometrial polyp electrosurgery) + oral medication (Anguish pill, Cefdinir tablets)
Treatment period】Hospitalization for 5 days, review after 1 month
Treatment effect】Polyp removed, stable condition
I. Initial consultation
At the first visit, the patient was in good spirits, with a steady pace and a healthy physical appearance. The patient reported that her gynecological ultrasound examination revealed abnormal echogenic clusters in the uterine cavity and that her menstruation was regular but slightly heavy. She had previously undergone hysteroscopy and endometrial biopsy, which clearly diagnosed multiple polyps with a number greater than 6. After obtaining the patient’s consent, a repeat ultrasound examination showed a thick endometrium with multiple slightly strong echogenic spots of varying sizes, up to 5×4 cm. After talking to the patient about her condition, she agreed to undergo hysteroscopic endometrial polyp electrosurgery and was admitted to the hospital.
II. Treatment history
After admission, the patient signed a consent form for surgery after routine blood and liver and kidney function tests were performed to rule out any contraindication to surgery. Under general anesthesia, the hysteroscope was used to enter the uterus vaginally, and the cervical shape was regular. The endometrium was thick and uneven, with hyperplasia in the anterior and posterior walls of the uterus as well as in the lateral walls, which appeared pink and coral-like. More polyps were seen in both corners of the uterus, about 0.3-0.6 cm in diameter, with no obvious adhesions. The bleeding was about 2 ml, and the procedure was relatively smooth. After the operation, the patient was treated with cefdinir tablets for anti-infection and Angiostasis pills for hemostasis.
III. Treatment results
The patient regained consciousness 10 minutes after surgery and reported no dizziness, headache and other discomfort after questioning, so she was sent to the ward for recuperation. Three days after the operation, the patient was clinically monitored for no fever, abdominal pain and other infectious symptoms, good mental status, normal appetite and bowel movements, and was informed that the pathological results did not show any malignant lesions. The patient was discharged in good general condition. One month after the operation, the patient returned to the hospital for a follow-up examination. The patient had a good mental state, normal appetite and no other special discomfort, and a repeat ultrasound examination indicated a good treatment effect.
IV. Precautions
Since the patient had a strong sense of medical care and high degree of cooperation with treatment, and the pathological examination showed no malignant changes, I was sincerely happy for the patient and advised him to pay attention to the following matters on a daily basis.
1, after discharge from the hospital to comply with medical advice to take drugs on time, do not increase or decrease the amount of drugs or replace new drugs.
2.After surgery, it is recommended to take oral contraceptives for 3-6 months to prevent the recurrence of polyps.
3, daily should pay attention to rest, strengthen nutrition, moderate increase the intake of high-protein food, such as milk, eggs, etc..
4.Prohibit sexual intercourse and bathing for 1 month, and pay attention to keep the vulva clean.
5.After discharge, if there are abnormal symptoms such as abnormal vaginal bleeding, abdominal pain, fever, etc., seek medical attention promptly.
V. Personal insight
Most endometrial polyps are caused by high estrogen levels or inflammatory factors, and are characterized by abnormal uterine bleeding, in addition to the abnormal menstrual manifestations of the patients in this case, such as excessive menstruation, shortened menstrual cycle and prolonged menstrual period. Once the above symptoms appear in daily life, you should go to the hospital as soon as possible, and early treatment after clear diagnosis of the disease can inhibit the development of the disease and avoid adverse consequences.