What is the recommended management for a female patient of reproductive age with a normal vascular examination, an intrauterine device (IUD) in place, normal ovaries, and incidental cholelithiasis, but no evidence of pelvic varices or venous obstruction?

Management of Incidental Cholelithiasis in a Reproductive-Age Female with IUD

The incidental cholelithiasis requires no intervention; the patient should be counseled about potential symptoms and instructed to seek care only if biliary colic develops, while the IUD requires no action given the normal pelvic examination. 1, 2

Cholelithiasis Management

Expectant Management is Standard

• Asymptomatic cholelithiasis follows a benign natural course and should be managed with observation alone (expectant management). 2
• Only 10-25% of asymptomatic gallstones progress to symptomatic disease, and the majority of patients rarely develop complications without first experiencing at least one episode of biliary pain. 2
• Routine cholecystectomy for asymptomatic cholelithiasis is too aggressive and not indicated for most patients. 2

Patient Counseling Requirements

• The patient should be educated to recognize symptoms of biliary colic: right upper quadrant abdominal pain (often elicited by palpation as a positive Murphy's sign), referred pain to the right supraclavicular region or shoulder, nausea, and vomiting. 1
• If symptoms develop, referral to a surgeon and/or gastroenterologist should occur within 2 weeks of initial presentation. 1
• The patient should understand that approximately 15% of the US population has cholelithiasis, with women at higher risk than men, and that pregnancy and increasing parity further increase this risk. 1

When Intervention is Indicated

• Cholecystectomy is recommended only if symptoms become severe and/or recurrent. 1
• For a single symptomatic episode, lifestyle and dietary modifications combined with medication management (such as gallstone dissolution agents) may be considered before surgical intervention. 1

IUD Management

No Action Required

• The IUD is appropriately positioned within the uterus with normal ovaries and no evidence of complications, requiring no intervention. 3
• The absence of pelvic varices, venous obstruction, free fluid, or adenopathy confirms normal pelvic anatomy with the IUD in situ. 3

Contraceptive Continuation

• The patient can continue using the IUD as her contraceptive method without restriction, as it is classified as a long-acting reversible contraception (LARC) method appropriate for women of reproductive age. 3
• All contraceptive methods, including IUDs, are considered U.S. Medical Eligibility Criteria category 1 or 2 (no restriction or advantages generally outweigh risks) for women of reproductive age without specific contraindications. 3

When to Seek Care

• The patient should be instructed to seek prompt medical attention if she experiences heavy bleeding, severe cramping, pelvic pain, abnormal vaginal discharge, or fever, as these may indicate IUD-related complications. 4, 5
• If the IUD strings become non-palpable or if she develops symptoms concerning for malposition, ultrasound evaluation should be performed. 4, 6

Common Pitfalls to Avoid

• Do not perform cholecystectomy for asymptomatic cholelithiasis simply because it was discovered incidentally. The widespread use of abdominal ultrasonography has led to increased diagnosis of asymptomatic gallstones, but this does not justify prophylactic surgery. 2
• Do not remove a properly positioned IUD based solely on the presence of incidental findings unrelated to the device. 3
• Avoid ordering repeat imaging for the cholelithiasis unless symptoms develop, as this adds no clinical value and increases healthcare costs. 1, 2