Post Coital Bleeding - Case Discussion

History
An 18-year-old woman is referred with postcoital bleeding. It has occurred on approximately seven occasions over the preceding 6 weeks. Generally it has been a small amount of bright red blood noticed a few hours after intercourse and lasting up to 2 days. There is no associated pain.
Her last menstrual period started 3 weeks ago and she bleeds for 4 days every 28 days. Her periods were previously quite heavy but are now lighter since she started the combined oral contraceptive pill (COCP) 6 months ago. There is no history of an abnormal discharge or offensive odour and she has no dyspareunia.
She has had three sexual partners and has been with her current partner for 10 months. She has never been diagnosed with any sexually transmitted infection and has never had a smear test. She had an appendectomy at the age of 7 years and was diagnosed with epilepsy in childhood but has been off all medication for 8 years.

Examination
The abdomen is soft and non-tender. Speculum examination reveals a florid reddened area symmetrically surrounding the external cervical os with contact bleeding. The uterus is normal sized, anteverted and non-tender. There is no cervical excitation and the adnexae are unremarkable.

Questions
• What is the differential diagnosis?
• What further investigations would you perform for this woman?
• If your investigations are negative what is the likely diagnosis and how would you manage the woman?

Case Discussion:

Postcoital bleeding in a young woman is common and normally benign. In this specific case the examination findings are consistent only with cervical ectropion, malignancy or infection.

Differential diagnoses of postcoital bleeding in a young woman
• Cervical ectropion
• Chlamydia or other sexually transmitted infection (STI)
• Cervical malignancy
• Complication of the COCP
• Endocervical polyp

Investigations
- A Sexually transmitted infections screen should be performed:
• endocervical swab for chlamydia
• endocervical swab for gonorrhoea
• high vaginal swab for trichomonas (and candida, not a STI, but possibly a cause of irregular bleeding from vaginitis).
- A cervical smear should also be taken to exclude cervical intraepithelial neoplasia or malignancy prior to treatment.

Management
Assuming the swabs and smear are negative then the diagnosis is of cervical ectropion. This is particularly common around the time of puberty, in women using the COCP, and in pregnancy. It is not of clinical significance and is generally an incidental finding but warrants treatment if it causes embarrassing and troublesome bleeding (or discharge in some cases).

There are three options for treatment:
1 stop the COCP and use alternative contraception
2 cold coagulation of the cervix
3 diathermy ablation of the ectocervix.

Points To Remember: 
• Cervical ectropion is very common and usually incidental and asymptomatic.
• It occurs particularly in pregnancy and with use of the COCP.
• Postcoital bleeding should always be investigated to exclude significant pathology.