What could be causing my abdominal pain after using a hot tub and taking the progesterone-only pill (POP)?

Abdominal Pain After Hot Tub Use and Progesterone-Only Pill: Causes and Management

Your abdominal pain is most likely related to either hot tub folliculitis caused by Pseudomonas aeruginosa or a side effect of the progesterone-only pill (POP). Based on the evidence, these are the two most probable causes requiring different management approaches.

Hot Tub-Related Causes

• Pseudomonas folliculitis ("hot tub folliculitis") is a common infection that appears several hours to days after hot tub exposure, presenting with skin rash and sometimes abdominal symptoms 1
• The infection typically includes maculovesicular rash, fever, and sometimes upper respiratory complaints, with possible adenopathy and breast tenderness 1
• Pseudomonas aeruginosa is the causative organism, which thrives in inadequately chlorinated hot tubs 2, 1
• This condition typically resolves spontaneously without treatment, though symptoms can be uncomfortable 1
• Another hot tub-related condition is Pontiac fever (caused by Legionella pneumophila), which can present with fever, headache, myalgia, and respiratory symptoms 3

Progesterone-Only Pill Related Causes

• Abdominal pain is a known side effect of progesterone-only pills, listed in FDA drug labeling 4
• Specifically, abdominal pain (cramping) occurs in approximately 20% of patients taking progesterone, compared to 13% on placebo 4
• Abdominal distention (bloating) is reported in 8% of patients taking progesterone 4
• Other gastrointestinal side effects that may accompany abdominal pain include nausea (8%), diarrhea (8%), and vomiting 4

Diagnostic Considerations

• If your abdominal pain is accompanied by skin rash, particularly pustular lesions, hot tub folliculitis is more likely 2, 1
• If the pain is accompanied by bloating, nausea, or irregular vaginal bleeding without skin manifestations, POP side effects are more probable 4
• For nonspecific abdominal pain without localization, imaging may be necessary if symptoms persist or worsen 5
• CT scan with IV contrast is the preferred imaging modality for evaluating nonlocalized abdominal pain when the diagnosis remains unclear 5

Management Recommendations

For Hot Tub Folliculitis:

• The condition is typically self-limiting and resolves without specific treatment 1
• Maintain adequate hydration and use over-the-counter pain relievers for symptom management 1
• Avoid further hot tub exposure until symptoms resolve completely 1
• Seek medical attention if you develop high fever, severe pain, or worsening symptoms 2

For POP-Related Symptoms:

• If symptoms are mild and tolerable, continued observation may be appropriate as side effects often diminish over time 4
• Consider discussing alternative contraceptive options with your healthcare provider if symptoms persist 5
• For women with gastrointestinal conditions, progestin-only methods are generally considered safe (Category 1) according to medical eligibility criteria 5
• Levonorgestrel, barrier methods, or other contraceptive options may be considered if symptoms are severe or persistent 5

When to Seek Immediate Medical Attention

• Severe abdominal pain that is worsening or associated with fever 5
• Signs of dehydration from persistent vomiting or diarrhea 5
• Development of jaundice or signs of liver impairment 4
• Sudden onset of chest pain, severe headache, visual changes, or difficulty breathing 4

Prevention

• Ensure hot tubs are properly maintained with adequate chlorination and cleaning 1
• Consider showering immediately after hot tub use to reduce bacterial exposure 1
• For those experiencing gastrointestinal side effects from POP, taking the medication at bedtime may help reduce symptom awareness 4
• Discuss timing of medication with your healthcare provider to optimize tolerability 4

If symptoms persist beyond a few days or worsen significantly, consult with your healthcare provider for further evaluation and management.