Treatment of adnexitis based on syndrome differentiation and treatment in traditional Chinese medicine

Grandma Yang is 65 years old. She has been feeling pain in her lower abdomen and a feeling of soreness and heaviness in her lumbar region in recent days. The pain worsens after activities or housework and eases after rest. One weekend, Grandma Yang's daughter-in-law brought her to the hospital for treatment. Gynecological examination revealed a pelvic mass, and B-ultrasound showed an abdominal mass measuring 6.5cm×4.3cm×2.2cm. The tumor marker test was negative, and the diagnosis was: adnexitis, right adnexal inflammatory mass. After one week of antibacterial treatment, the size of the mass did not change, so she was referred to traditional Chinese medicine for treatment. Her tongue was dark red, her tongue coating was thin and greasy, and her pulse was thin and stringy. It was considered to be liver depression, qi stagnation, dampness and heat.

During the follow-up visit one week later, the patient reported that he had loose stools 2 to 3 times a day after taking the medicine, and his back pain and abdominal pain symptoms were slightly relieved. The above prescription was removed from the earthworm, and scorched Atractylodes macrocephala, raw Coix seed, Shixiao Powder, and Bayueza were added. The medicine was decocted in water and taken orally for 7 consecutive doses.

During the third visit one week later, the patient complained of loose stools once, but stools that were formed the rest of the time, abdominal relief, and loss of appetite. The patient was given peach kernel added to the prescription for the follow-up visit, decocted in water, and taken for 14 doses in a row.

After two weeks, the patient complained of occasional backache and abdominal pain, normal bowel movements, and a good diet. Ultrasound reexamination showed a right adnexal mass of 3.0 cm × 1.6 cm × 1.3 cm. The patient was still treated from the perspective of liver depression and qi stagnation, damp-heat, phlegm and blood stasis, and the prescription was adjusted appropriately. The prescription mainly included raw astragalus, red vine, patrinia, raw coix seed, red peony root, cyperus, green peel, lindera, curcuma, peach kernel, processed arisaema, angelica, fennel, and moutan bark. All the medicines were used together, decocted in water, and taken for 28 doses.

After four weeks and five visits, the patient complained of occasional lower abdominal pain, palpitations and shortness of breath on cloudy days, red tongue with thin yellow fur, and reexamination with B-ultrasound, and the inflammatory mass had disappeared. The treatment of chest pain was changed to replenishing qi and nourishing yin, while taking into account the treatment of phlegm and promoting blood circulation to improve the outcome. The Chinese medicine prescription was revised, which mainly included Radix Pseudostellariae, Codonopsis, Salvia miltiorrhiza, Raw Astragalus, Angelica, Semen Persicae, Processed Cyperus, Citrus aurantium, Shixiaosan, Curcuma australis, Cortex Moutan and other drugs. All the drugs were used together, decocted in water, and taken for 14 doses.

Two weeks later, on the sixth visit, the patient's complexion was good, his tongue was pale red with white fur, his diet and bowel movements were normal, and he no longer had abdominal pain or a feeling of heaviness in the lumbar region.