What should be done for a patient who notices a small blood stain after sexual intercourse (coitus)?

Post-Coital Bleeding: Evaluation and Management

Women presenting with post-coital bleeding should undergo speculum examination with cervical inspection, testing for Chlamydia trachomatis, and cervical cytology (or HPV co-testing if available), with urgent referral to colposcopy reserved for those with visible cervical lesions suspicious for malignancy or abnormal screening results. 1, 2

Initial Assessment

History and Physical Examination

• Document the bleeding pattern carefully: confirm the bleeding is truly post-coital and not from the partner, as this distinction is vital 1
• Assess cervical cancer risk factors: age, smoking status, sexual history, and time since last cervical screening 1, 2
• Perform speculum examination to visualize the cervix and identify visible lesions, cervicitis, polyps, or ectropion 1, 2
• If a visible ulcerating or fungating cervical lesion is present, refer urgently for suspected malignancy without delay 1

Laboratory Testing

• Test for Chlamydia trachomatis in all women with post-coital bleeding, as genital chlamydia infection is a common non-specific cause 1
• Obtain cervical cytology if the patient is due for screening or has not had recent testing 1, 2
• HPV co-testing (HPV DNA plus cytology) provides superior risk stratification when available 3

Risk Stratification and Triage

Low-Risk Patients (Can Avoid Immediate Colposcopy)

• Women with negative HPV co-test (negative for oncogenic HPV and negative cytology) have extremely low risk of high-grade dysplasia or cancer (0% in recent cohorts) and do not require colposcopy unless clinically indicated 3
• Multiparous women have lower risk of significant pathology (OR 0.39) compared to nulliparous women 4
• Treat identified infections (Chlamydia) and reassess after treatment completion 1

High-Risk Patients (Require Colposcopy)

• Nulliparous women with abnormal PAP smear have significantly elevated risk (OR 3.3) and should undergo colposcopy 4
• Any woman with abnormal cytology or positive HPV testing requires colposcopy referral 1, 4
• Recurrent post-coital bleeding despite negative initial evaluation warrants colposcopy, though the absolute risk remains low (0.08% cancer, 1.8% high-grade dysplasia in cytology-negative patients) 4, 3
• Women with visible cervical abnormalities on examination require urgent referral 1

Management Based on Findings

Benign Cervical Pathology

• Cervicitis: treat underlying infection and reassess 2
• Cervical polyps: can be removed in office setting 2
• Cervical ectropion: may require cryotherapy or observation 2

When No Cause is Identified

• Reassure the patient that most post-coital bleeding is benign and self-limited 1, 2
• Ensure cervical screening is up to date per guidelines 1
• Advise return if bleeding persists or worsens 2

Critical Pitfalls to Avoid

• Do not perform unscheduled cervical cytology outside the screening program in low-risk women with normal examination, as this has poor yield 1
• Do not miss cervical cancer in older women: the probability of cervical cancer with post-coital bleeding increases with age (1 in 2,400 for women aged 45-54 versus 1 in 44,000 for women aged 20-24) 1
• Do not assume all bleeding is benign: while most causes are benign (cervicitis, polyps, ectropion), cervical cancer remains the most serious etiology requiring exclusion 2
• Do not delay referral when malignancy is suspected clinically, even if cytology is pending 1
• Recognize that negative cytology alone does not exclude high-grade disease: 2% of women with initially negative cytology had possible high-grade lesions on repeat testing at colposcopy 3