What is the appropriate treatment for a 36-year-old female with an irritated cervix, raw-appearing tissue, and trace bleeding/spotting after sampling?

Management of Irritated Cervix with Raw-Appearing Tissue and Post-Sampling Bleeding

Immediate Clinical Assessment

The most critical first step is to perform or ensure completion of cervical cancer screening with appropriate cytology and biopsy of any grossly visible or suspicious lesion, as cervical cytology can be falsely negative even when invasive cancer is present. 1

Essential Diagnostic Steps

• Perform direct visualization and biopsy of the raw-appearing tissue immediately, as any grossly visible or suspicious cervical lesion requires biopsy regardless of cytology results 1
• Obtain cervical cytology if not already done, reported using the Bethesda System 1
• Consider colposcopy for detailed evaluation of the cervical transformation zone, particularly given the visible abnormality 1
• Test for sexually transmitted infections (Chlamydia trachomatis and Neisseria gonorrhoeae), as cervicitis is a common cause of cervical irritation and bleeding 1, 2

Critical Differential Diagnoses to Exclude

The raw-appearing cervix with contact bleeding raises several important diagnostic considerations:

• Cervical cancer or precancerous lesions (CIN 2/3) - must be excluded first given the visible abnormality 1
• Cervicitis - most commonly from sexually transmitted infections, but can occur with bacterial vaginosis even without chlamydia or gonorrhea (15% of women with BV develop cervicitis) 2
• Cervical ectropion - benign condition causing friable, raw-appearing tissue that bleeds easily 3
• Cervical polyps - common benign cause of postcoital or contact bleeding 3
• Less common: tuberculosis (in endemic areas), endometriosis, or granulomatous inflammation 4, 5

Management Based on Findings

If Biopsy Shows No Malignancy or High-Grade Dysplasia

• Treat identified infections with appropriate antimicrobials if STI testing is positive 1
• For cervicitis without identified pathogen, consider empiric treatment for common causes, though note that "normal flora" like Group B Streptococcus can occasionally cause chronic cervicitis 6
• Absence of H2O2-producing Lactobacillus species increases risk of cervicitis and may warrant treatment of bacterial vaginosis if present 2

If Biopsy Shows CIN 2 or CIN 3

• Proceed with definitive treatment: LEEP, cryotherapy, cold knife conization, or laser ablation 1
• Cold knife conization is preferred if microinvasive cancer is suspected, as LEEP cautery artifact may compromise pathologic evaluation 1

If Biopsy Shows Invasive Cancer

• Immediate referral for staging and treatment per cervical cancer guidelines 1
• Workup includes CBC, liver and renal function tests, chest radiograph, and imaging (CT, MRI, or PET/CT) as indicated 1

Common Pitfalls to Avoid

• Never delay biopsy of a visible cervical lesion while waiting for cytology results, as cytology can be falsely negative in the presence of invasive cancer 1
• Do not assume the bleeding is simply from sampling trauma without tissue diagnosis 3
• Do not treat empirically for cervicitis without obtaining appropriate cultures and STI testing 1
• Ensure proper follow-up protocols are in place, as many patients are lost to follow-up after abnormal findings 1
• Document all findings, test results, and follow-up plans clearly in the medical record 1

Age-Specific Considerations

At age 36, this patient:

• Should receive standard adult cervical cancer screening protocols (not adolescent protocols) 7
• Has lower likelihood of spontaneous regression if high-grade lesions are present compared to younger women 7
• Requires colposcopy for any squamous lesions beyond ASC-US if found on cytology 1

Follow-Up Strategy

• If infectious cervicitis is treated, repeat examination in 2-4 weeks to ensure resolution of the raw-appearing tissue 1
• If cytology shows abnormalities, follow age-appropriate management algorithms for ASC-US, LSIL, or higher-grade lesions 7, 8
• Establish clear documentation and tracking system to ensure patient completes all recommended follow-up 1