What is the best course of action for a patient experiencing new onset intermittent pelvic pain and abnormal menstrual bleeding while on combination oral contraception?

Immediate Management of New Onset Pelvic Pain and Abnormal Bleeding on Combined Oral Contraceptives

This patient requires a pelvic examination and pelvic ultrasound within the next week, not symptomatic management alone, because new onset pelvic pain with abnormal bleeding after years without symptoms warrants evaluation for underlying pathology such as fibroids, endometriosis, ovarian cysts, or other structural abnormalities before attributing symptoms solely to contraceptive-related bleeding irregularities. 1, 2

Critical Assessment Gap

The current plan has a significant deficiency:

• No pelvic examination was performed, which is essential for evaluating new onset pelvic pain and abnormal bleeding 1
• Underlying pathology must be excluded before attributing symptoms to contraceptive side effects, including sexually transmitted infections, pregnancy complications, thyroid disorders, endometrial polyps, fibroids, endometriosis, or ovarian cysts 1, 2
• The CDC explicitly recommends considering underlying health conditions when bleeding irregularities occur with contraceptive use 1

Appropriate Diagnostic Workup

Immediate Actions (Within 1 Week)

• Perform pelvic examination to assess for cervical pathology, adnexal masses, uterine enlargement, and pelvic tenderness 1
• Order transvaginal ultrasound, which is the preferred imaging modality for structural gynecological disease including fibroids, endometriosis, and ovarian cysts 2
• Obtain STI testing (gonorrhea and chlamydia) as purulent cervicitis or infection can cause pelvic pain and bleeding 1
• Consider thyroid function tests as thyroid disorders can cause menstrual irregularities 1

Laboratory Evaluation

• Complete blood count if bleeding is heavy with clots to assess for anemia 3
• Pregnancy test was appropriately performed and negative 1

Symptomatic Management While Awaiting Evaluation

NSAIDs for Pain and Bleeding Control

• Ibuprofen 400-800 mg every 6-8 hours for 5-7 days is appropriate for both pain control and reduction of menstrual bleeding 1, 4
• NSAIDs reduce prostaglandin production, which addresses both dysmenorrhea and heavy bleeding 5, 4
• This can be initiated immediately while diagnostic workup proceeds 1

Contraceptive Management

• Continue current combined oral contraceptive as planned, since discontinuation without evaluation could worsen symptoms 1
• Do not modify the contraceptive regimen until underlying pathology is excluded 1

Red Flags Requiring Urgent Evaluation

The patient should seek emergency care if any of the following develop:

• Severe or worsening pelvic pain
• Heavy bleeding (soaking through a pad per hour for 2+ hours)
• Fever or signs of infection
• Syncope or severe dizziness
• Acute abdominal pain 1

Follow-Up Algorithm

If Evaluation Reveals No Structural Pathology

• Reassurance and continued observation if bleeding irregularities are mild 1
• Consider NSAIDs for 5-7 days during symptomatic periods 1
• If bleeding persists beyond 3-6 months and is unacceptable to the patient, consider alternative contraceptive methods 1

If Structural Pathology Is Identified

• Fibroids: Medical management with tranexamic acid, NSAIDs, or hormonal therapy; surgical options if symptoms are severe 2, 3
• Endometriosis: NSAIDs as first-line, followed by continuous oral contraceptives or surgical management 2, 5, 6
• Ovarian cysts: Expectant management for simple cysts; further evaluation for complex masses 2

Common Pitfalls to Avoid

• Do not attribute new onset symptoms to contraceptive side effects without excluding pathology, especially in a patient with years of symptom-free contraceptive use 1, 2
• Do not delay pelvic examination and imaging when the patient presents with new onset pelvic pain and abnormal bleeding 1
• Do not assume bleeding irregularities are benign without proper evaluation, as this can delay diagnosis of significant conditions like endometriosis or fibroids 2, 3
• Bleeding irregularities from contraceptives typically occur in the first 3-6 months of use, not after years of stable use 1