Management of Post-Coital Bleeding with Known Cervical Polyp
This patient requires urgent speculum examination to visualize the cervix and polyp, followed by polypectomy with histopathological examination, and concurrent cervical cytology with colposcopy regardless of recent normal cytology, as post-coital bleeding carries a 2.3% risk of high-grade dysplasia or cancer even with negative screening. 1, 2
Immediate Evaluation Required
Perform speculum examination immediately to:
- Rule out frank cervical cancer (present in 0.6% of post-coital bleeding cases) 2
- Visualize and assess the cervical polyp identified 6 months ago 3
- Evaluate for cervical ectopy, cervicitis, or other visible pathology 4, 1
Critical point: Three of four cervical cancers in post-coital bleeding patients were clinically evident on speculum examination 2
Polyp Management
Remove the cervical polyp via hysteroscopic polypectomy rather than simple avulsion because:
- Simple twisting or blind removal often leaves residual fragments in the cervical canal 3
- Hysteroscopy determines the exact origin of the polyp pedicle (cervical versus endometrial) 3
- Up to 25% of patients with cervical polyps have coexisting endometrial polyps requiring cavity evaluation 3
- All removed polyps require histopathological examination to exclude malignancy 3, 4
Concurrent Cervical Cancer Screening
Perform cervical cytology and colposcopy regardless of recent screening history because:
- 74% of women with CIN diagnosed at colposcopy for post-coital bleeding had negative cytology within the previous 36 months 1
- 10.6% of post-coital bleeding patients have high-grade CIN (CIN II/III) 1
- 1.7% have high-grade dysplasia and 0.6% have cervical cancer 2
Colposcopy protocol:
- Perform colposcopy with directed biopsies of any acetowhite lesions or abnormal vascular patterns 5
- Include endocervical curettage (ECC) if no lesions are visible or if colposcopy is unsatisfactory 5, 6
- Consider HPV DNA testing as part of the evaluation, particularly in women ≥30 years 5, 6
Management Based on Findings
If colposcopy reveals CIN II or III:
- Treat with LEEP, cryotherapy, cold knife conization, or laser ablation 7
- LEEP is preferred for outpatient management with less bleeding and shorter procedure time 8
- Cold knife conization is preferred if microinvasive cancer is suspected due to superior specimen quality 8
If colposcopy reveals CIN I:
- Follow-up without treatment is preferred: repeat cytology at 6 and 12 months OR HPV testing at 12 months 7
- Refer back to colposcopy if repeat cytology shows ≥ASC-US or HPV is positive 7
- Treatment with ablative or excisional methods is acceptable if patient/provider prefer 7
If colposcopy is normal but polyp is present:
- Proceed with polypectomy as planned 3
- Resume routine screening after polyp removal and negative follow-up cytology 4
Risk Stratification Factors
Higher risk patients requiring more aggressive evaluation:
- Current smokers (significantly higher risk of HPV atypia and CIN I) 2
- Advancing age (significant risk factor for cervical cancer) 2
- Women ≥30 years with persistent symptoms 2
Common Pitfalls to Avoid
- Never assume the polyp is the sole cause of bleeding without excluding dysplasia or cancer - 19% of post-coital bleeding patients have CIN despite visible benign pathology 1
- Never rely on recent negative cytology alone - 74% of CIN cases had negative smears within 36 months 1
- Never perform simple polyp avulsion without histopathology - this leaves residual fragments and misses concurrent pathology 3
- Never skip endometrial cavity evaluation in women with abnormal bleeding - 25% have coexisting endometrial polyps 3
Follow-Up Protocol
After polyp removal and negative colposcopy: