What is the best course of action for a 34-year-old female patient with post-coital bleeding, who had an abortion 6 months ago?

Post-Coital Bleeding in a 34-Year-Old Woman 6 Months Post-Abortion

The most important immediate action is to perform a speculum examination with cervical inspection and obtain cervical cytology (Pap smear) to rule out cervical cancer, as post-coital bleeding can be the presenting symptom of cervical malignancy, even though most cases are benign. 1

Initial Evaluation Priorities

The evaluation must focus on identifying the source of bleeding through direct visualization:

• Perform speculum examination to inspect the cervix for visible lesions, polyps, ectropion, or friability 1
• Obtain cervical cytology if not up-to-date, as cervical cancer is the most serious cause of post-coital bleeding despite being uncommon 1, 2
• Test for cervicitis by screening for gonorrhea and chlamydia, particularly given her age under 35 years 3
• Assess for cervical polyps, which are a common benign cause requiring simple removal 1

Understanding the Clinical Context

The abortion 6 months ago is not directly related to her current post-coital bleeding, as this timeframe is well beyond the immediate post-procedure period where complications would manifest 4. The prevalence of post-coital bleeding ranges from 0.7% to 9.0% in menstruating women, with most causes being benign 1.

Differential Diagnosis by Likelihood

Most common benign causes:

• Cervicitis (infectious or inflammatory) 1
• Cervical ectropion 1
• Cervical polyps 1
• Vaginal trauma from intercourse 5

Serious cause requiring exclusion:

• Cervical cancer or pre-cancerous lesions 1, 2

Management Algorithm

If cervical lesion is visible on examination:

• Refer immediately to gynecology for colposcopy and biopsy 2
• Do not delay diagnosis and treatment if cancer is suspected 2

If cervicitis is identified:

• Treat appropriately with antibiotics for gonorrhea/chlamydia 3
• Reexamine after treatment completion

If cervical polyp is found:

• Remove polyp and send for histopathology 1

If no obvious cause is identified:

• Ensure cervical cytology is obtained 1
• Consider transvaginal ultrasound to evaluate endometrial thickness if bleeding persists 4
• Follow up in 2-4 weeks to reassess 1

Critical Pitfalls to Avoid

• Do not assume the bleeding is related to her previous abortion given the 6-month interval 4
• Do not defer cervical cancer screening in women with post-coital bleeding, even if young 2
• Do not miss infectious cervicitis, which is common in this age group and easily treatable 3
• Do not overlook the need for direct cervical visualization—history alone is insufficient 2