A 24-year-old woman comes to the office due to spotting after vaginal intercourse. She also has some yellow vaginal discharge and dysuria but no pelvic pain or cramping. The patient has taken combination oral contraceptives for the past 3 years and has had no menses for the past year. Her mother was diagnosed with cervical cancer at age 47. BMI is 35 kg/m². Vital signs are normal. On examination, the abdomen is soft and nontender. Speculum examination reveals purulent discharge from the cervical os, and the cervix is friable. On bimanual examination, there is no cervical motion tenderness, and the adnexa are nontender bilaterally. Urine pregnancy testing is negative. Microscopy of the discharge shows abundant neutrophils. If left untreated, this patient's condition could lead to which of the following complications?

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11ec160b_37f4_2131_9249_edc2c0a357d9_MD0001_00 Acute cervicitis classically presents with purulent cervical discharge and a friable cervix that bleeds easily with contact (ie, postcoital bleeding). Microscopy showing inflammation (eg, neutrophils) without a visible pathogen is classic for cervicitis due to Chlamydia trachomatis or Neisseria gonorrhoeae, which are often identified by nucleic acid amplification testing. Left untreated, cervicitis can compromise the endocervical barrier, allowing polymicrobial vaginal flora to ascend into the normally sterile uterus and fallopian tubes. In contrast to cervicitis, infection involving the upper genital tract (ie, pelvic inflammatory disease [PID]) can cause fever, abdominal pain, and cervical motion/uterine/adnexal tenderness due to increased bacterial load and spread. When the infection extends to the fallopian tube, it creates an inflammatory exudate (ie, salpingitis) that causes the tubal walls to adhere. With prolonged infection, the exudate may be replaced by scar tissue, causing permanent tubal scarring and obstruction that impedes the fertilization and/or implantation of future pregnancies. Therefore, common complications of PID include tubal factor infertility and ectopic pregnancy. (Choice A) Primary ovarian insufficiency is the accelerated depletion of oocytes and loss of both ovarian follicular development and estrogen production in women age <40. Risk factors include genetic disorders (eg, Turner syndrome) and chemoradiation. (Choice B) Cervical cancer can occur in patients with chronic human papillomavirus infection (eg, types 16 and 18). (Choice C) Patients with cervical insufficiency cannot maintain a closed cervix as pregnancy progresses (ie, as the load on the cervix increases); therefore, second-trimester pregnancy loss occurs. Risk factors include prior cervix surgery or inherited collagen disorders (eg, Ehler-Danlos syndrome). (Choice D) Increased unopposed estrogen stimulation can lead to endometrial hyperplasia. Obesity is a risk factor due to increased androgen-to-estrogen conversion. (Choice E) Recurrent urinary tract infections typically occur when enteric bacteria colonizing the periurethral area ascend the urethra. Certain sexual behaviors (eg, frequent intercourse, spermicide use) promote periurethral colonization. Educational objective: Neisseria gonorrhoeae and Chlamydia trachomatis can cause acute cervicitis (eg, purulent cervical discharge, friable cervix). Untreated, cervicitis can progress to pelvic inflammatory disease and long-term complications such as tubal factor infertility and ectopic pregnancy. __________ References: Sexually transmitted diseases and infertility. (http://www.ncbi.nlm.nih.gov/pubmed/28007229)

A 24-Year-Old Woman Comes to the Office Due to Spotting