What history, physical examination, investigations, differential diagnosis, and management should be performed for a woman presenting with post‑coital bleeding?

Post-Coital Bleeding: History, Physical Examination, Investigations, and Differential Diagnosis

Critical Initial Assessment

All women presenting with post-coital bleeding require urgent speculum examination to exclude visible cervical cancer, which accounts for 0.6-4% of cases and may be clinically apparent in most instances. 1, 2, 3

Essential History Components

• Age and smoking status: Advancing age significantly increases cervical cancer risk (p=0.037), while current smoking increases risk of HPV atypia and CIN1 (p=0.015 and p=0.003 respectively) 3
• Cervical screening history: Document date and result of last cervical cytology, as 30% of women with significant pathology (CIN or cancer) have normal or inflammatory smears 2
• Pattern and duration of bleeding: Distinguish true post-coital bleeding from intermenstrual or postmenopausal bleeding, which may indicate different pathology 1
• Sexual history: Number of partners, contraceptive use, and history of sexually transmitted infections, particularly Chlamydia trachomatis 1
• Associated symptoms: Pelvic pain, vaginal discharge, dyspareunia, or constitutional symptoms suggesting advanced malignancy 4, 5

Physical Examination Priorities

Perform speculum examination immediately to identify:

• Visible cervical lesions: Ulcerating, fungating, or friable masses indicating possible invasive cancer requiring urgent multidisciplinary team referral 1
• Cervical ectopy: The most common benign cause, appearing as red, granular tissue around the external os 4, 2
• Cervical polyps: Present in approximately 5% of cases and typically benign 2
• Hemorrhagic nodules or unusual lesions: Consider rare causes such as cervical endometriosis 6
• Vaginal or vulvar pathology: Exclude non-cervical sources of bleeding 2

Digital rectal examination should be performed if malignancy is suspected to assess parametrial involvement 7

Investigation Algorithm

First-Line Testing

• Test for Chlamydia trachomatis in all women with post-coital bleeding and treat if positive, as genital chlamydia is a common non-specific cause 1
• Cervical cytology should be performed if screening is due, but unscheduled smears outside the screening program are not recommended 1

Colposcopy Indications

Refer for urgent colposcopy (within 2 weeks) if: 1, 5, 2, 3

• Visible cervical abnormality on speculum examination
• Persistent post-coital bleeding despite negative initial examination and chlamydia treatment
• Abnormal cervical cytology
• Age >45 years with new-onset post-coital bleeding
• Current smoker with persistent symptoms

Key evidence: Among women referred to colposcopy for post-coital bleeding with negative cytology, 6.6% had low-grade dysplasia, 1.7% had high-grade dysplasia (CIN2/3), and 0.6% had cervical cancer 3

Advanced Imaging

• MRI pelvis is indicated for women with biopsy-confirmed cervical carcinoma (except FIGO stage IV) to determine optimal management 1
• CT scan should be considered for FIGO stage IV disease or patients unsuitable for MRI 1

Differential Diagnosis by Prevalence

Common Benign Causes (>90% of cases)

1. Cervical ectopy – Most frequent cause; friable columnar epithelium extends onto ectocervix 4, 2
2. Cervicitis – Often associated with Chlamydia or other STIs 1, 4
3. Cervical polyps – Found in 5% of cases; typically benign 2
4. Trauma/mechanical causes – Particularly in context of vigorous intercourse 4
5. No identifiable cause – Occurs in 40-49% of women despite thorough evaluation 2, 3

Premalignant Lesions (6-8% of cases)

• CIN1 (low-grade dysplasia) – 6.6% of women referred to colposcopy 3
• CIN2/3 (high-grade dysplasia) – 1.7% of women referred to colposcopy 3
• Note: CIN may cause post-coital bleeding because fragile abnormal epithelium detaches during intercourse 2

Malignant Causes (0.6-4% of cases)

• Invasive cervical cancer – 4% in general gynecology services, 0.6% in colposcopy referrals with normal-appearing cervix and normal cytology 2, 3
• Endometrial cancer – Rare cause but must be considered, especially in postmenopausal women 2

Rare Causes

• Cervical endometriosis – Presents as hemorrhagic nodules; consider when no ectopy or malignancy visible 6
• Vaginal cancer – Included in 4% cancer rate from general gynecology services 2

Critical Pitfalls to Avoid

• Never attribute post-coital bleeding to hemorrhoids or assume benign cause without speculum examination, as 0.6% of women with normal-appearing cervix and normal cytology have invasive cervical cancer 2
• Do not rely on negative cervical cytology to exclude serious pathology, as 30% of women with significant pathology (CIN or cancer) have normal or inflammatory smears 2
• Avoid delaying colposcopy referral in high-risk patients (age >45, smokers, persistent symptoms), as early detection significantly impacts morbidity and mortality 1, 3
• Do not perform unscheduled cervical smears outside the screening program, as they are not recommended and colposcopy is the appropriate investigation 1

Natural History and Follow-Up

• 49% of women with post-coital bleeding have no identifiable cause after complete evaluation; these women typically have spontaneous resolution of symptoms 2
• Re-evaluation is warranted if bleeding persists beyond 8 weeks despite treatment of identified benign causes 4, 5