Case Report Highlights Rare Association: Progesterone-Only Contraceptive may Induce Ischemic Colitis

In the case study published in ACG Case Reports Journal, the researchers have reported a unique case of biopsy-confirmed ischemic colitis (IC) in a previously healthy 30-year-old woman who presented with abdominal pain and bloody diarrhea two months after initiation of progesterone-only oral contraceptive.

The case report underscores the importance of vigilance in recognizing and managing adverse effects of commonly used medications.

The case concerns a 30-year-old white woman with no significant medical history presented to the emergency department with a 3-week history of worsening crampy abdominal pain, bloody diarrhea, and nausea. She denied any history of alcohol usage or smoking. Her vital signs on admission were stable. Abdominal examination was positive for normal bowel sounds and diffuse tenderness to palpation but was negative for guarding or rigidity. Her only medication was progesterone-only contraceptives for the past two months.

She responded to conservative management with antiemetics, and intravenous fluids, and was asked to discontinue progesterone-only contraceptive pill on discharge. Her symptoms improved over 2 weeks after discharge while off of her progesterone-only contraceptive. On a 3-month outpatient visit, she denies any recurrence of symptoms.

Progesterone is a hormone crucial for maintaining pregnancy and is known to exert vasoconstrictive effects on blood vessels, which can compromise blood flow to various organs, including the colon. While such an association had been documented previously in a handful of case reports and small-scale studies, the present case provided further evidence to support this intriguing link.

Ischemic colitis occurs with a temporary lack of adequate blood supply to the intestines, specifically in vulnerable areas such as the sigmoid colon and splenic flexure, which lack sufficient collateral blood vessels. Although primarily seen in older individuals with atherosclerotic risk factors, IC can also be triggered by hormonal contraceptives in young women. Although estrogen-containing oral contraceptives are known to increase thromboembolic risk, the impact of progesterone is not well understood.

In conclusion, the case is the first biopsy-proven case of IC resulting from a progesterone-only contraceptive pill. Despite the widespread progesterone-only contraceptive use, IC occurrence within this patient population remains unrecognized.

Although potential patient-related variables may contribute to disease onset in the absence of a known hypercoagulable state, the precise cause remains elusive.

"There is a need for further studies to better comprehend the impact of progesterone on coagulation, particularly concerning the mesenteric vasculature," the researchers wrote.

Reference:

Rajamanuri, Medha MD1; Garg, Meher AS2; Siddiqui, Harris MD1; Pannala, Sreeram MD3. Progesterone-Only Contraceptive-Induced Ischemic Colitis. ACG Case Reports Journal 11(4):p e01313, April 2024. | DOI: 10.14309/crj.0000000000001313