What is the best course of action for a female patient with abnormal vaginal bleeding and discharge, dysuria, and a history of recent unprotected sexual intercourse with new partners, who is currently taking sertraline (Zoloft) for anxiety and depression, and has an intrauterine device (IUD) inserted three months ago?

Management of Abnormal Vaginal Bleeding and Discharge with Recent Unprotected Intercourse and IUD

The comprehensive STI screening and vaginal infection workup already ordered is appropriate, and the patient should be scheduled for an in-person examination with speculum and bimanual assessment to evaluate IUD placement, cervical pathology, and pelvic inflammatory disease, particularly given the high-risk sexual exposure and inability to perform physical examination via telehealth. 1

Immediate Next Steps

In-Person Examination Required

• Schedule urgent face-to-face visit for speculum examination and bimanual pelvic assessment to evaluate for cervical motion tenderness, adnexal tenderness, and lower abdominal tenderness, which are minimum criteria for diagnosing pelvic inflammatory disease (PID) in sexually active patients at risk for STDs. 1, 2
• Verify IUD string presence and proper placement during speculum examination, as the CDC recommends checking for IUD displacement in patients with persistent vaginal bleeding. 3
• Assess for purulent cervicitis, cervical abnormalities, and vaginal discharge characteristics during examination. 1, 2

STI Screening Already Appropriately Ordered

• The comprehensive panel including chlamydia/gonorrhea NAAT via self-collected vaginal swab, HIV, syphilis, and hepatitis B serology meets guideline recommendations for patients with unprotected intercourse with new partners. 4, 5
• Self-collected vaginal swabs are the specimen of choice for chlamydia and gonorrhea screening, with sensitivity >96% and identifying more infected patients than first-catch urine. 5

Management Based on IUD and Bleeding Pattern

IUD-Related Bleeding Assessment

• The 3-month history of continuous bleeding post-IUD insertion falls within the expected 3-6 month adjustment period, where unscheduled spotting or light bleeding is common with levonorgestrel IUDs, with approximately 50% of users experiencing amenorrhea or oligomenorrhea by 2 years. 3
• However, persistent bleeding at 3 months warrants evaluation for underlying gynecological problems including IUD displacement, STIs, pregnancy, and pathologic uterine conditions. 3

Critical Differential Diagnoses to Exclude

Pelvic Inflammatory Disease (High Priority)

• Given unprotected intercourse with two new partners and vaginal discharge with odor, empiric PID treatment should be initiated if examination reveals uterine, adnexal, or cervical motion tenderness, even before culture results return. 1
• N. gonorrhoeae and C. trachomatis are implicated in many PID cases, and immediate antibiotic administration is directly linked to prevention of long-term sequelae. 1
• The IUD does not need to be removed for PID treatment, as international studies demonstrate STIs and PID can be treated with the IUD in place as long as the patient improves with treatment. 1

Post-Coital Trauma vs. Infection

• The temporal relationship between rough intercourse 1-2 weeks ago and symptom onset suggests possible cervical or vaginal trauma, but concurrent STI risk necessitates full evaluation. 2

Dysuria Management

Hold Nitrofurantoin Pending Results

• Do not initiate the previously prescribed nitrofurantoin until urine culture results confirm bacterial UTI, as dysuria in this context may represent urethral irritation from STI (particularly chlamydia or gonorrhea) rather than true cystitis. 1
• The European Association of Urology guidelines note that in patients with typical UTI symptoms, urine culture is recommended when diagnosis is unclear or symptoms are atypical. 1
• Improvement with Ural (urinary alkalinizer) suggests symptom relief rather than infection eradication.

Treatment Algorithm Based on Results

If STI Testing Positive

• Chlamydia/Gonorrhea: Treat per CDC guidelines with appropriate antibiotics; treat partners with sexual contact within 60 days of symptom onset. 1, 6
• Mucopurulent cervicitis: If documented inflammation present after excluding chlamydia and gonorrhea, consider treatment for Ureaplasma urealyticum with doxycycline 100 mg orally twice daily for 7 days. 6
• IUD can remain in place during treatment unless patient has current purulent cervicitis or fails to improve with appropriate antibiotics. 1

If Vaginal Swab Shows BV or Candidiasis

• Treat identified organism per standard protocols. 7
• Avoid empiric antifungal treatment without confirmed diagnosis, as inappropriate treatment is associated with increased return visits within 90 days and contributes to antifungal resistance. 7, 8

If All Testing Negative

• Reassure regarding expected IUD bleeding patterns and counsel that bleeding typically decreases with continued use, as patient education improves method continuation. 3
• If bleeding remains unacceptable to patient after 6 months total (3 more months), counsel on alternative contraceptive methods. 3
• Consider cervical pathology evaluation if post-coital bleeding persists despite negative infectious workup. 2

Critical Safety Netting

• Immediate in-person evaluation needed if: heavy bleeding, fever >38.3°C, worsening pelvic pain, or inability to locate IUD strings. 1, 3
• If PID diagnosed and patient does not show substantial improvement within 72 hours of oral antibiotics, hospitalization with parenteral therapy is required. 1
• Partner notification and treatment is mandatory if STI diagnosed, with evaluation of partners who had sexual contact within 60 days before symptom onset. 1, 6

Sertraline Interaction Considerations

• No significant drug interactions exist between sertraline and standard STI treatments (azithromycin, doxycycline, cephalosporins) or IUD continuation. 1