Workup of Postcoital Bleeding
The workup for postcoital bleeding should begin with a speculum examination to visualize the cervix and rule out visible malignancy, followed by testing for Chlamydia trachomatis, with urgent referral required only if an ulcerating or fungating cervical lesion is present. 1
Initial Clinical Assessment
The evaluation should focus on identifying serious pathology while recognizing that most cases are benign:
- Perform a speculum examination to directly visualize the cervix and vagina, looking specifically for ulcerating or fungating lesions, cervical ectopy, polyps, or signs of trauma 1, 2
- If a visible suspicious lesion is present, urgent referral for further investigation is mandatory rather than proceeding with routine workup 1
- Document the appearance of the cervix, vaginal walls, and any bleeding source 2
Essential Laboratory Testing
- Test for Chlamydia trachomatis in all patients with postcoital bleeding, as genital chlamydia infection is a common treatable cause 1
- Pregnancy test should be performed to exclude pregnancy-related bleeding 3
- Unscheduled cervical cytology (Pap smear) is NOT recommended outside the regular screening program for evaluation of postcoital bleeding 1
Additional Considerations Based on Clinical Context
Evaluate for other gynecological conditions that may present with postcoital bleeding:
- Cervical polyps or fibroids - may require ultrasound if suspected on examination 1, 4
- Cervicitis - often associated with sexually transmitted infections 2
- Cervical ectopy - a common benign finding, particularly in younger women 4
- Thyroid disorders - consider TSH if other menstrual irregularities are present 1
Risk Stratification for Cervical Cancer
The probability of cervical cancer varies significantly by age:
This low overall risk supports a conservative initial approach in the absence of visible lesions, though vigilance remains essential.
Treatment Algorithm
If Chlamydia is positive: Treat with appropriate antibiotics 1
If a specific gynecological problem is identified (polyps, ectopy, cervicitis): Treat the condition or refer for specialized care 1
If no cause is identified and bleeding persists:
- Consider NSAIDs for 5-7 days as short-term treatment 1
- Consider low-dose combined oral contraceptives if medically eligible 1
- Reassess periodically, and if bleeding continues despite treatment, further investigation may be warranted 1
Critical Pitfalls to Avoid
- Do not perform unscheduled Pap smears as part of the postcoital bleeding workup - this is not recommended and delays appropriate management 1
- Do not miss visible cervical lesions - any ulcerating or fungating lesion requires urgent referral regardless of other findings 1
- Do not forget Chlamydia testing - this is a common and treatable cause that is frequently overlooked 1, 4
- Do not initiate hormonal treatment if malignancy is suspected based on examination findings 1