What is the most appropriate initial step for an elderly woman presenting with post coital (after sexual intercourse) bleeding?

Management of Post-Coital Bleeding in an Elderly Woman

The most appropriate initial step is a speculum examination to visualize the cervix, NOT a Pap smear or endometrial sampling as the first action. If the cervix appears normal on examination, then proceed with cervical assessment (colposcopy referral), not endometrial sampling, as the cervix is the most likely source in post-coital bleeding.

Clinical Context and Risk Assessment

Post-coital bleeding in an elderly (postmenopausal) woman carries significant risk for cervical pathology:

• Cervical cancer is the primary concern with post-coital bleeding, though the absolute risk remains relatively low (1 in 2,400 for women aged 45-54) 1
• Invasive cervical cancer occurs in approximately 0.6-4% of women presenting with post-coital bleeding 2, 3
• Cervical intraepithelial neoplasia (CIN) is found in 17% of women with post-coital bleeding 2
• Advancing age is a significant risk factor for cervical cancer in women with post-coital bleeding 3

Algorithmic Approach

Step 1: Urgent Speculum Examination (FIRST)

• All women with post-coital bleeding require urgent speculum examination to rule out frank cervical cancer 3
• If malignancy is suspected on examination (visible ulcerating or fungating lesion), refer urgently for further investigation 1
• Eight of 10 cervical cancers in women with post-coital bleeding were clinically apparent on examination 2

Step 2: If Cervix Appears Normal

• Refer for colposcopy, as 30% of women with significant cervical pathology (including CIN and cancer) had normal or inflammatory cervical smears 2
• Unscheduled Pap smears are NOT recommended outside the screening programme 1
• A normal-appearing cervix does NOT exclude cervical cancer—two cancers were visible only with colposcopy in one series 2

Step 3: Consider Chlamydia Testing

• Test for Chlamydia trachomatis and treat if appropriate, as this is a common benign cause 1

Why NOT Endometrial Sampling First?

Endometrial pathology is NOT the typical cause of post-coital bleeding—the trauma of intercourse affects the cervix, not the endometrium. However, there are specific scenarios where endometrial assessment becomes relevant:

• If the patient has additional symptoms of postmenopausal bleeding (not just post-coital), then endometrial assessment is indicated 4, 5
• If benign endometrial cells are found on Pap smear in a postmenopausal woman, endometrial assessment is required regardless of symptoms 4
• The two endometrial cancers found in post-coital bleeding series likely had concurrent postmenopausal bleeding 2

Why NOT Pap Smear as Initial Step?

• Four women with cervical cancer had normal smears before referral for post-coital bleeding evaluation 2
• Pap smears have significant false-negative rates for detecting cervical pathology in symptomatic women 2
• Guidelines explicitly state unscheduled smears are not recommended outside screening programmes 1
• Direct visualization with colposcopy is superior to cytology for evaluating symptomatic post-coital bleeding 2, 3

Critical Pitfalls to Avoid

• Never rely on a normal Pap smear to exclude serious pathology in a woman with post-coital bleeding—19 of 63 women (30%) with significant pathology had normal or inflammatory smears 2
• Never dismiss post-coital bleeding as benign without visualization—while 49% have no identifiable cause, the risk of malignancy is substantially higher than in the general population 2
• Never delay colposcopy referral in postmenopausal women with post-coital bleeding, as advancing age increases cancer risk 3

Answer to the Question

Neither A (Pap smear) nor B (Endometrial sample) is the most appropriate FIRST step. The correct initial approach is speculum examination to visualize the cervix, followed by colposcopy referral if the cervix appears normal 1, 2, 3. If forced to choose between the two options given, Pap smear (A) is closer to appropriate as it at least evaluates the cervix (the likely source), whereas endometrial sampling addresses the wrong anatomical site for post-coital bleeding. However, both are suboptimal compared to direct visualization and colposcopy.