What is the management for a 22-year-old female with regular menstrual cycles presenting with one episode of intermenstrual bleeding and a positive Chlamydia (sexually transmitted infection) test result?

Management of Chlamydia-Positive 22-Year-Old Female with Intermenstrual Bleeding

Treat the chlamydia infection immediately with either azithromycin 1 g orally as a single dose or doxycycline 100 mg orally twice daily for 7 days, ensure all sexual partners from the past 60 days are treated, and instruct strict sexual abstinence for 7 days after treatment completion. 1

Immediate Antibiotic Treatment

First-line treatment options are equally effective:

• Azithromycin 1 g orally as a single dose (97% cure rate) 2, 3

  • Preferred for this 22-year-old patient due to single-dose directly observed therapy, eliminating compliance concerns 2, 3
  • More cost-effective in young adults with potentially erratic follow-up behavior 1

• Doxycycline 100 mg orally twice daily for 7 days (98% cure rate) 2, 3

  • Lower cost alternative with extensive clinical experience 1, 3
  • Requires 7-day compliance, which may be challenging in this age group 1

Alternative regimens (only if first-line options cannot be used): 1, 2

• Erythromycin base 500 mg orally four times daily for 7 days
• Ofloxacin 300 mg orally twice daily for 7 days
• Levofloxin 500 mg orally once daily for 7 days

Critical Management of Intermenstrual Bleeding

The single episode of intermenstrual bleeding is likely related to cervicitis from chlamydia infection. 1

• Chlamydial cervicitis commonly presents with intermenstrual bleeding, cervical friability, or mucopurulent discharge 1, 4
• Treatment of the chlamydia infection will typically resolve the bleeding if cervicitis is the cause 1
• Important caveat: Some women with apparently uncomplicated cervical infection already have subclinical pelvic inflammatory disease (PID), which increases risk for ectopic pregnancy and infertility 1

Mandatory Sexual Partner Management

All sexual partners from the preceding 60 days must be evaluated, tested, and empirically treated. 1, 2, 3

• Partners should receive the same treatment regimen as the index patient 1
• If last sexual contact was >60 days before diagnosis, still treat the most recent partner 2, 3
• Critical pitfall to avoid: Failing to treat partners leads to reinfection in up to 20% of cases 2
• Consider expedited partner therapy if partners are unlikely to seek care 5

Sexual Abstinence Requirements

Patient must abstain from all sexual intercourse for 7 days after initiating treatment AND until all sex partners have completed treatment. 1, 2, 3

• This applies to both single-dose azithromycin and 7-day doxycycline regimens 1
• Resuming intercourse before partner treatment is complete is a major cause of reinfection 2, 5

Additional STI Testing

Test for co-infections at the initial visit: 2

• Gonorrhea testing (high co-infection rate with chlamydia) 1
• Syphilis serology 2
• HIV testing 2

Follow-Up Strategy

Test-of-cure is NOT recommended if she receives azithromycin or doxycycline and is asymptomatic, as cure rates are 97-98%. 1, 2, 3

However, retest at 3 months post-treatment is mandatory: 1, 2, 3, 5

• High reinfection rates (up to 39% in young women) make 3-month retesting critical 2, 5
• Repeat infections carry elevated risk for PID and complications compared to initial infection 2, 5
• Retest at 3 months regardless of whether partners were reportedly treated 2, 5

Return for reevaluation if: 1

• Intermenstrual bleeding persists after treatment completion
• Any new symptoms develop
• Lower abdominal pain occurs (concern for PID)

Common Clinical Pitfalls to Avoid

• Do not wait for test results to treat in this 22-year-old with positive chlamydia—treat immediately 1
• Do not test too early after treatment (wait at least 3 weeks to avoid false-positives from dead organisms) 1, 2
• Do not assume treatment failure if reinfection occurs—84-92% of recurrent infections are reinfections from untreated partners, not antibiotic resistance 5
• Do not allow sexual activity before 7 days post-treatment—both patient and all partners must complete treatment first 2, 3, 5
• Do not forget the 3-month retest—this is when reinfection risk is highest and PID complications can develop 2, 5

Addressing the Intermenstrual Bleeding Specifically

If bleeding persists after chlamydia treatment is completed: 1

• Reassess vaginal flora for bacterial vaginosis 1
• Consider other causes of intermenstrual bleeding (hormonal contraception effects, cervical pathology, pregnancy-related causes)
• Refer to gynecology if persistent cervicitis continues despite appropriate treatment and partner management 1