What are the next steps for a patient experiencing post-coital bleeding?

Management of Post-Coital Bleeding

For patients experiencing post-coital bleeding, a thorough clinical evaluation including pelvic examination, cervical cytology, and testing for sexually transmitted infections is essential as the first step in management, with urgent referral for colposcopy if malignancy is suspected on examination.

Initial Assessment

• Post-coital bleeding is a common gynecological symptom with prevalence ranging from 0.7% to 9.0% of menstruating women 1
• The probability of cervical cancer in women with post-coital bleeding varies by age:
  • Age 45-54: 1 in 2,400
  • Age 20-24: 1 in 44,000 2
• Test for Chlamydia trachomatis and other sexually transmitted infections, as these are common causes 2
• Perform a complete physical examination including speculum examination to visualize the cervix 2

Urgent Referral Criteria

• If malignancy is suspected on examination (visible ulcerating or fungating lesion), refer urgently for further investigation 2
• Unscheduled cervical smears outside the regular screening program are not recommended 2

Diagnostic Algorithm

1. Speculum examination:

   • Essential first step to rule out frank cervical cancer 3
   • Assess for cervical polyps, cervicitis, or other visible causes 1

2. Cervical cytology:

   • Review recent cervical screening results
   • Note that 30% of women with significant pathology may have normal or inflammatory cervical smears 4

3. Colposcopy referral:

   • Consider referral even with normal cytology as post-coital bleeding increases risk of cervical intraepithelial neoplasia and cancer 4
   • Approximately 2% of women with post-coital bleeding and normal cytology may have cervical precancer or cancer detected at colposcopy 3

Common Etiologies

• Benign causes (most common):

  • Cervicitis
  • Cervical polyps
  • Cervical ectropion
  • Vaginal trauma 1, 4

• Significant pathology:

  • Cervical intraepithelial neoplasia (CIN): found in approximately 17% of cases 4
  • Invasive cancer: found in approximately 4% of cases referred for evaluation 4
  • Endometrial cancer: rare but possible cause 4

Risk Factors for Significant Pathology

• Current smoking significantly increases risk of HPV atypia (p=0.015) and CIN1 (p=0.003) 3
• Advanced age is a significant risk factor for cervical cancer (p=0.037) 3

Management Based on Findings

• If cervical cancer is diagnosed:

  • Refer to multidisciplinary team for optimal management 2
  • Perform magnetic resonance imaging for staging (except for FIGO stage IV) 2

• If benign cause identified:

  • Treat the underlying cause (e.g., antibiotics for cervicitis, removal of polyps) 1
  • Follow-up to ensure resolution of symptoms 5

• If no cause identified (occurs in ~49% of cases):

  • Consider follow-up examination in 4-6 weeks 4
  • Reassurance may be appropriate as most cases without identified etiology are benign 4

Special Considerations

• Patients with persistent post-coital bleeding despite normal initial evaluation should be considered for repeat assessment 5
• Sexual trauma should be considered in the differential diagnosis, particularly in cases with significant bleeding requiring surgical intervention 6