Case Presentation: A healthy 42-year-old female presented to the emergency room complaining of bright red blood per rectum for one day, associated with a severe lower abdominal pain and tenesmus. Her medications included oral contraceptives which she took for menopausal symptoms. Upon presentation, the patient was afebrile, tachycardic, and normotensive. On exam, the patient had significant tenderness to palpation in the left and right lower quadrants without rebound tenderness or guarding. Except for a leukocytosis of 13,000/L, her labs were within normal limits including lactic acid, stool leukocytes, inflammatory markers, and chemistry. The patient underwent computed tomography (CT) of the abdomen and pelvis which showed diffuse mucosal edema and wall thickening along the distal transverse colon, extending into the descending and sigmoid colon. Of note, the patient was seen a few months prior to this admission with similar complaints and had identical CT findings of colitis at that time. The patient was provided supportive care, completed a course of antibiotics, and had complete resolution of symptoms. In the interim, she underwent an outpatient endoscopy and colonoscopy with biopsies which were negative for inflammatory bowel disease and other etiologies of bloody diarrhea. During the current admission, the patient was started on intravenous hydration and antibiotics. The patient underwent a flexible sigmoidoscopy with biopsies showing changes which were consistent with ischemic colitis.
Discussion: Estrogen-containing oral contraceptive pills (ESOCPs) have been implicated in venous thrombosis with an estimated incidence of 1.6 per 1000 person-years1. However, the vast majority of cases present as lower extremity venous thrombosis or subsequent pulmonary embolism. This report describes a unique case of ischemic colitis in a young female secondary to oral contraceptive use.
Conclusions: Thus far, ischemic colitis secondary to ESOCPs has been described anecdotally. This patient reported taking tablets of combination ethinyl estradiol and drospirenone daily. Further history revealed she had recently been taking increasing doses daily as needed for hot flashes and other menopausal symptoms. In a patient without significant risk factors for atherosclerotic cardiovascular disease or previous history of venous thromboembolism, a detailed and comprehensive medical history becomes imperative in eliciting the etiology of ischemia. This patient’s symptoms resolved with supportive care and cessation of oral contraceptives, which have led to absence of recurrent symptoms. This case uniquely adds to a growing body of literature that supports the risk of thrombosis in the setting of hormone replacement therapy in menopausal women.