What is the best approach to manage a 38-year-old female patient with Hashimoto's (autoimmune thyroiditis) who presents with spotting for two months and requests a sexually transmitted disease (STD) panel, with a history of using Depo-Provera (medroxyprogesterone acetate)?

Management of a 38-Year-Old Female with Hashimoto's Thyroiditis, Spotting, and STD Panel Request

For a 38-year-old female with Hashimoto's thyroiditis who presents with two months of spotting and requests an STD panel, the most appropriate approach is to offer a long-acting reversible contraceptive (LARC) such as an IUD while conducting a thorough evaluation for the spotting and performing the requested STD testing.

Initial Assessment

Evaluation of Spotting

• Duration: Two months of spotting requires investigation
• Possible causes:
  • Hormonal fluctuations related to discontinuation of Depo-Provera
  • Thyroid dysfunction from Hashimoto's thyroiditis
  • Structural abnormalities (fibroids, polyps)
  • Infection (including STDs)
  • Malignancy

Thyroid Status Assessment

• Laboratory evaluation:
  • TSH, Free T4
  • Anti-thyroid peroxidase (TPO) antibodies
  • Anti-thyroglobulin antibodies
• Clinical evaluation: Check for symptoms of hypothyroidism or hyperthyroidism

Management Plan

1. STD Testing

• Perform comprehensive STD panel as requested
  • Testing for gonorrhea and chlamydia
  • Syphilis serology
  • HIV testing with appropriate counseling 1

2. Contraceptive Management

• Recommend highly effective contraception:

  • IUD (copper or levonorgestrel) as first-line option due to:
    • Lowest failure rates (<1% per year)
    • No interaction with thyroid condition
    • May help manage abnormal bleeding 1
  • Alternative: Progestin implant if IUD not desired

• Avoid estrogen-containing contraceptives if:

  • Patient has moderate to severe Hashimoto's disease
  • Patient has cardiovascular risk factors
  • Patient is a smoker over age 35 1

3. Management of Hashimoto's Thyroiditis

• If hypothyroid: Initiate or adjust levothyroxine therapy (typically 1.4-1.8 mcg/kg/day) 2
• If euthyroid: Consider prophylactic levothyroxine treatment, which has shown benefits in reducing antibody levels and preventing progression to hypothyroidism 3
• Monitor thyroid function: Regular TSH testing every 6-12 months 2

4. Evaluation of Abnormal Bleeding

• Physical examination:
  • Pelvic examination
  • Pap smear if due
• Laboratory studies:
  • Complete blood count to assess for anemia
  • Pregnancy test
• Imaging:
  • Transvaginal ultrasound to evaluate endometrial thickness and rule out structural causes
• Consider endometrial biopsy if:
  • Age >35 with persistent abnormal bleeding
  • Risk factors for endometrial hyperplasia/cancer

Special Considerations

Post-Depo Bleeding

• Irregular bleeding is common after discontinuation of Depo-Provera
• May take 9-12 months for normal menstrual cycles to resume
• Consider short-term management with NSAIDs for 5-7 days during bleeding episodes 4

Hashimoto's and Reproductive Health

• Hashimoto's thyroiditis is associated with:
  • Increased risk of recurrent miscarriages (2-4 fold)
  • Increased risk of preterm birth 2, 5
• Important: Levothyroxine treatment has not been shown to reduce the risk of subfertility and miscarriage in euthyroid women with thyroid autoantibodies 5

Follow-up Plan

• Review STD test results within 1-2 weeks
• Follow up in 4-6 weeks to:
  • Assess bleeding pattern
  • Review thyroid function tests
  • Discuss contraceptive satisfaction if initiated
• Schedule regular thyroid monitoring every 6-12 months

Pitfalls to Avoid

• Don't assume spotting is solely due to Depo discontinuation - thorough evaluation is needed
• Don't miss thyroid dysfunction - both hypo- and hyperthyroidism can cause menstrual irregularities
• Don't delay STD testing - prompt diagnosis and treatment are essential
• Don't overlook the need for effective contraception - unplanned pregnancy in a woman with uncontrolled Hashimoto's can have adverse outcomes