Case 1: Abdominal Distention, Bloating, and an Intrauterine Device in a 19-year-old Girl

Presentation

A 19-year-old woman with a history of abnormal uterine bleeding requiring blood transfusion presents for care in an adolescent medicine clinic for 2 weeks of generalized abdominal pain. She reports loose stools at onset and constipation at the time of the visit. Her menses are regular and typically light; however, the previous month’s cycle was uncharacteristically heavy and prolonged. She reports vaginal intercourse with 5 male partners in the past year and consistent condom use. She has never had a sexually transmitted infection (STI). She had a 52-mg levonorgestrel-containing intrauterine device (LNG-IUD) placed under sedation approximately 1 year earlier for contraception and treatment of abnormal uterine bleeding.

On physical examination she is comfortable and her vital signs are normal. Abdominal examination reveals distention and diffuse tenderness. Genital examination reveals a copious gray-white vaginal discharge. The cervix, adnexa, and uterus are nontender. Microscopy of the discharge demonstrates the presence of white blood cells and positive amine odor (“whiff”) test results without clue cells. The clinician orders a urine pregnancy test (which is negative) and urine nucleic acid amplification testing for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis, in addition to blood cell counts, liver function tests, amylase level, and lipase level. During her visit to the clinic, the patient receives a clinical diagnosis of bacterial vaginosis and starts a 7-day course of metronidazole, and the clinician orders an outpatient abdominal sonogram.

Testing for chlamydia is reported as positive 2 days after the index visit. The clinician notifies the patient of her test results. The patient starts a …