Evaluation of Postcoital Bleeding and Breast Enlargement
This patient requires urgent gynecologic evaluation with pelvic examination and pregnancy testing, as postcoital bleeding combined with breast enlargement strongly suggests pregnancy until proven otherwise, and cervical pathology must be excluded. 1
Immediate Diagnostic Priorities
Rule Out Pregnancy First
- Pregnancy is the most critical diagnosis to establish or exclude, as postcoital bleeding can indicate complications including ectopic pregnancy, which carries significant mortality risk 1
- Breast enlargement is a cardinal sign of pregnancy due to hormonal changes 1
- Any abnormal bleeding in reproductive-age women should be considered pregnancy-related until proven otherwise 2
Assess for Cervical Pathology
- Postcoital bleeding most commonly originates from cervical sources including cervicitis, cervical polyps, or cervical malignancy 1
- Direct visualization via speculum examination is essential to identify bleeding sources, assess for cervical lesions, polyps, or signs of malignancy 1
- Digital pelvic examination should be performed cautiously if pregnancy is confirmed, as certain pregnancy complications require imaging first 1
Differential Diagnosis Framework
If Pregnancy is Confirmed
- Cervical changes during pregnancy can cause physiologic postcoital bleeding, particularly in second and third trimesters 1
- Breast enlargement would be expected as a normal pregnancy change 1
- Complications requiring urgent evaluation include threatened abortion, ectopic pregnancy, or placental abnormalities 1, 2
If Pregnancy is Excluded
Cervical Causes (Most Common for Postcoital Bleeding):
- Cervical polyps - benign growths that bleed easily with contact 1
- Cervicitis - infectious or inflammatory cervical disease 1
- Cervical ectropion - exposed columnar epithelium that bleeds with trauma 1
- Cervical dysplasia or malignancy - must be excluded in all cases 2
Hormonal Causes (Explaining Both Symptoms):
- Hormonal contraceptive use, particularly progestin-only methods, can cause irregular bleeding and breast changes 3, 4, 5
- Ovulatory dysfunction or polycystic ovary syndrome can cause both irregular bleeding and hormonal breast changes 6
Other Uterine/Vaginal Causes:
- Vaginal lacerations from trauma during intercourse 1
- Endometrial polyps or submucous fibroids (though these typically cause intermenstrual bleeding rather than specifically postcoital) 6, 2
- Vaginal atrophy (less likely in reproductive age without other risk factors) 1
Recommended Diagnostic Workup
Initial Evaluation
- Urine or serum pregnancy test - mandatory first step 1, 2
- Speculum examination to visualize cervix and vagina, identify bleeding source, assess for polyps or lesions 1
- Bimanual pelvic examination to assess uterine size (pregnancy vs. fibroids), adnexal masses, cervical motion tenderness 1
- Cervical cytology (Pap smear) if not up to date, to screen for dysplasia or malignancy 1
Additional Testing Based on Initial Findings
- STI screening (gonorrhea, chlamydia) particularly if cervicitis suspected or patient has risk factors 1
- Transvaginal ultrasound if pelvic examination reveals masses, if pregnancy confirmed to assess viability and location, or if structural abnormality suspected 1, 6
- Endometrial sampling generally not indicated for isolated postcoital bleeding in reproductive age unless other risk factors present 6
Critical Clinical Pitfalls
Common Diagnostic Errors
- Failing to test for pregnancy is the most dangerous oversight, as ectopic pregnancy can be life-threatening 1, 2
- Attributing postcoital bleeding solely to hormonal contraception without performing speculum examination to exclude cervical pathology 3, 4
- Assuming benign cause without direct visualization - cervical cancer can present with postcoital bleeding even in younger women 2
Medication History Considerations
- Progestin-only contraceptives (pills, Nexplanon, DMPA) commonly cause irregular bleeding but should not cause specifically postcoital bleeding 3, 4, 5
- Anticoagulant use increases bleeding risk and should be documented 3
- Combined oral contraceptives can cause breast tenderness and enlargement 5
Management Approach
If Pregnancy Confirmed
- Refer to obstetrics for prenatal care if intrauterine pregnancy confirmed 1
- Urgent obstetric evaluation if ectopic pregnancy suspected or bleeding heavy 1
- Counsel that light postcoital bleeding can be normal in pregnancy but requires monitoring 1
If Cervical Pathology Identified
- Cervical polyps: removal via polypectomy with histologic examination 1
- Cervicitis: treat underlying infection per STI guidelines 1
- Cervical dysplasia: colposcopy and management per cervical cancer screening guidelines 1