What are the potential causes and treatment options for post coital (after sexual intercourse) bleeding in a female of reproductive age?

Post-Coital Bleeding: Evaluation and Management

All women presenting with post-coital bleeding should be tested for Chlamydia trachomatis and undergo speculum examination to assess for visible cervical lesions, with urgent referral if malignancy is suspected on examination. 1

Initial Clinical Assessment

History and Physical Examination

• Confirm the bleeding source is truly post-coital and not from the sexual partner, as partner bleeding can be mistaken for the patient's own bleeding 2
• Assess cervical appearance during speculum examination for ulcerating or fungating lesions that suggest malignancy 1
• Document associated symptoms including intermenstrual bleeding, post-menopausal bleeding, menstrual abnormalities (present in 39% of cases), and dyspareunia (present in 13% of cases) 3
• Evaluate for trauma, particularly in nulliparous women, as 89.7% of post-coital trauma cases occur in this population 4

Immediate Testing

• Test for Chlamydia trachomatis in all women with post-coital bleeding and treat if positive 1
• Do not perform unscheduled Pap smears outside the routine screening program, as this is not recommended 1

Risk Stratification

Low-Risk Features

• Age under 40 years: The probability of cervical cancer in women aged 20-24 with post-coital bleeding is 1 in 44,000, increasing to 1 in 2,400 for women aged 45-54 1
• Multiparity: Multiparous women have significantly lower risk (OR 0.39,95% CI 0.22-0.88) compared to nulliparous women 5
• Normal recent cervical cytology within the past year 5

High-Risk Features Requiring Urgent Referral

• Visible cervical lesion on examination (ulcerating or fungating appearance) warrants immediate referral for biopsy 1
• Abnormal Pap smear within the past year increases risk 3.3-fold (95% CI 1.31-8.35) 5
• Nulliparity is an independent risk factor for dysplasia 5
• Age over 40 years increases cancer probability 1

Diagnostic Workup

Colposcopy Indications

• Refer for colposcopy if abnormal cervical cytology is present, especially in nulliparous women 5
• Consider colposcopy even with normal cytology in persistent or recurrent post-coital bleeding, as the positive predictive value for koilocytosis/CIN 1 or higher is 15.6% 5
• Colposcopy findings in women with post-coital bleeding reveal pathology in approximately 48.9% of cases undergoing directed biopsy 5

Expected Findings

The most common etiologies identified at colposcopy include:

• Cervicitis (33.8% of biopsied cases) 5
• Koilocytosis/CIN 1/condyloma (30.3%) 5
• Cervical polyps (12.4%) 5
• Cervical ectropion (25% in general PCB population) 3
• CIN 2/3 or cancer (1.5% combined) 5

Treatment Based on Etiology

Infectious Causes

• Treat Chlamydia with appropriate antibiotics if testing is positive 1
• Manage cervicitis based on identified organism 5

Benign Structural Lesions

• Remove cervical polyps if identified, as they account for 20% of cases 3
• Consider endometrial polyp evaluation with hysteroscopy if bleeding persists despite normal cervical examination, as endometrial polyps can contribute to post-coital bleeding 3
• Cervical ectropion may be managed expectantly or with cryotherapy/thermal ablation if symptomatic 3

Dysplasia/Malignancy

• Refer to gynecologic oncology for CIN 2/3 or invasive cancer 1
• Multidisciplinary team management is essential for confirmed cervical cancer 1

Special Considerations

Natural History Without Identifiable Cause

• Reassurance is appropriate when examination, Chlamydia testing, and age-appropriate cervical cancer screening are normal 2
• The incidence of cervical cancer is low (0.5%) even among women presenting with post-coital bleeding who undergo colposcopy 5

Common Pitfalls to Avoid

• Do not rely solely on cervical cytology to exclude significant pathology, as CIN may not always be asymptomatic 3
• Do not dismiss post-coital bleeding in younger women, though cancer risk is lower, dysplasia can still occur 5
• Do not perform unscheduled Pap smears as they are not recommended and may delay appropriate evaluation 1
• Do not assume all bleeding is benign in nulliparous women, as they have higher risk for dysplasia 5