A 24-year-old woman comes to the office for evaluation of abnormal vaginal bleeding. The patient has a history of heavy, regular menstrual periods for which a progestin-releasing intrauterine device (IUD) was placed 2 years ago. After IUD insertion, the patient became amenorrheic. However, for the last month, she has had light vaginal spotting with wiping. The patient also recently developed intermittent pelvic pain that has now become constant and unrelieved with ibuprofen. She has no chronic medical conditions and does not use tobacco, alcohol, or illicit drugs. Family history is unremarkable. On bimanual pelvic examination, there is uterine and bilateral adnexal tenderness. The IUD strings are palpable at the cervix. Urine pregnancy test is negative. Which of the following is the most likely cause of this patient's symptoms?

Question

A 24-year-old woman comes to the office for evaluation of abnormal vaginal bleeding.  The patient has a history of heavy, regular menstrual periods for which a progestin-releasing intrauterine device (IUD) was placed 2 years ago.  After IUD insertion, the patient became amenorrheic.  However, for the last month, she has had light vaginal spotting with wiping.  The patient also recently developed intermittent pelvic pain that has now become constant and unrelieved with ibuprofen.  She has no chronic medical conditions and does not use tobacco, alcohol, or illicit drugs.  Family history is unremarkable.  On bimanual pelvic examination, there is uterine and bilateral adnexal tenderness.  The IUD strings are palpable at the cervix.  Urine pregnancy test is negative.  Which of the following is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

11ec25c8_da05_742e_bc81_0de9239c65c3_MD0003_00 After insertion of a progestin-releasing intrauterine device (IUD), patients may experience 3-6 months of irregular bleeding due to gradual endometrial thinning (ie, progestin-induced atrophy), often followed by amenorrhea (Choice E). Those with stable amenorrhea who develop new-onset abnormal vaginal bleeding, such as this patient, require further evaluation. In this patient with a change in bleeding pattern and new-onset pelvic pain, the most likely diagnosis is pelvic inflammatory disease (PID), a polymicrobial infection of the upper genital tract. Risk factors include age <25, multiple sexual partners, and inconsistent barrier protection use. PID is typically a complication of Neisseria gonorrhoeae or Chlamydia trachomatis cervicitis; symptomatic patients initially have abnormal vaginal bleeding (eg, with wiping, postcoital) due to an inflamed, friable cervix. Cervical inflammation can eventually compromise the endocervical barrier, thereby allowing polymicrobial vaginal flora (eg, anaerobes) to ascend the upper genital tract (eg, uterus, fallopian tubes). Patients may initially have intermittent pain; however, as infection and inflammation spread throughout the peritoneal cavity, constant pelvic pain (eg, uterine, bilateral adnexal tenderness) develops. friable cervix PID is diagnosed clinically; patients are prescribed broad-spectrum antibiotic therapy (ie, cephalosporin plus doxycycline) to prevent complications (eg, infertility, chronic pelvic pain). In patients with an IUD in situ, removal is not required because it increases the risk of unintended pregnancy and does not affect treatment outcomes. (Choice A) Adenomyosis, endometrial glands within the myometrium, typically presents with heavy vaginal bleeding and severe dysmenorrhea rather than light vaginal spotting and constant pelvic pain. Adenomyosis (Choice B) Endocervical polyps are benign, vascular, hyperplastic growths that can cause vaginal spotting (eg, postcoital bleeding); however, they do not cause pelvic pain. Endocervical polyps (Choice C) Endometriosis is a common cause of pelvic pain in women of reproductive age due to the abnormal implantation of endometrial glands and stroma outside the uterus. However, patients typically have months to years of pain that worsens with menses; abnormal vaginal bleeding is uncommon. Endometriosis Educational objective: Pelvic inflammatory disease can present with pelvic pain and abnormal vaginal bleeding (eg, with wiping, postcoital) due to an inflamed, friable cervix (ie, cervicitis). References: Pelvic inflammatory disease. (http://www.ncbi.nlm.nih.gov/pubmed/22534388) Retention of intrauterine devices in women who acquire pelvic inflammatory disease: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/23040135) U.S. selected practice recommendations for contraceptive use, 2016. (http://www.ncbi.nlm.nih.gov/pubmed/27467319)

A 24-Year-Old Woman Comes to the Office for Evaluation of Abnormal