What should be done for postcoital bleeding?

Management of Postcoital Bleeding

All women with postcoital bleeding require a speculum examination to directly visualize the cervix, and those under 25 years or with new/multiple partners should receive presumptive STI treatment immediately. 1

Immediate Assessment and Risk Stratification

High-Risk Features Requiring Urgent Action

• Visible ulcerating or fungating cervical lesion on examination mandates urgent referral for suspected malignancy 1
• Hemodynamic instability (hypotension, tachycardia) requires immediate resuscitation and surgical evaluation for vaginal laceration 2
• Significant ongoing bleeding (requiring blood transfusion) necessitates prompt surgical repair 2

Patient Risk Categories

• Women under 25 years or those with new/multiple partners are at higher risk for STI-related cervicitis 1
• Cancer probability ranges from 1 in 44,000 (ages 20-24) to 1 in 2,400 (ages 45-54) 1
• First-time intercourse or new partner increases risk of vaginal trauma (50% of surgical cases) 2, 3

Diagnostic Algorithm

Step 1: Mandatory Speculum Examination

Every patient requires direct visualization of the cervix and vagina—this is non-negotiable 1. The examination should assess for:

• Cervicitis (mucopurulent discharge, friability, erythema) 1
• Cervical lesions (polyps, ectropion, frank malignancy) 1
• Vaginal trauma (lacerations at fornix, mid-vagina, or hymenal ring) 2, 3

Step 2: Laboratory Testing

• NAAT testing for Chlamydia trachomatis and Neisseria gonorrhoeae on cervical or urine specimens 1
• Wet mount to assess for >10 WBCs per high-power field (suggests cervicitis) and evaluate for trichomoniasis or bacterial vaginosis 1
• Do NOT perform unscheduled Pap smears—they are not recommended for postcoital bleeding evaluation and delay appropriate management 1

Step 3: Imaging When Indicated

If speculum examination is normal but bleeding persists with irregular menstrual cycles:

• Transvaginal ultrasound is the preferred initial imaging to assess endometrium and exclude structural pathology 4
• Endometrial biopsy indicated when ultrasound shows endometrial thickness ≥4-5mm or risk factors for endometrial cancer exist 4

Treatment Protocol

For High-Risk Patients (Age <25, New/Multiple Partners)

Presumptive STI treatment is indicated even before test results return 1:

• Azithromycin 1 g orally single dose OR Doxycycline 100 mg orally twice daily for 7 days 1
• Partner treatment is essential to prevent reinfection 1

For Vaginal Trauma Requiring Intervention

• Median time from bleeding onset to admission in surgical cases is 12 hours (range 2-24 hours) 2
• Surgical repair typically involves hemostatic suturing at the laceration site 2, 3
• Sexual abstinence for at least 2 weeks post-repair 3
• Psychosexual assessment and support should be offered to patient and partner 2

For Normal Examination with Persistent Bleeding

• Refer to gynecology for further evaluation including possible saline infusion sonohysterography or hysteroscopy 1, 4
• Consider endometrial sampling if risk factors for endometrial pathology exist 4

Critical Pitfalls to Avoid

1. Do not miss frank cervical cancer by failing to perform speculum examination—all women require direct visualization 1
2. Do not perform unscheduled PAP smears as part of postcoital bleeding evaluation—they delay appropriate management 1
3. Do not delay referral when malignancy is suspected based on examination findings 1
4. Do not withhold presumptive STI treatment in high-risk women while awaiting test results 1
5. Do not dismiss significant trauma—vaginal lacerations can cause life-threatening hemorrhage requiring blood transfusion 2

Special Considerations

Postmenopausal Women

• 15% of vaginal trauma cases requiring surgery occur in postmenopausal women 2
• Lower threshold for endometrial evaluation given increased cancer risk 4

Contraceptive Use

• 65% of women with vaginal trauma requiring surgery used no contraception 2
• Consider counseling on barrier methods to reduce STI risk 1

Natural History

Most postcoital bleeding from benign causes (cervicitis, polyps) resolves with appropriate treatment 5. However, tissue diagnosis is mandated if symptoms persist despite negative initial evaluation 4.