How Should I Treat Postcoital Bleeding in a Premenopausal Patient?

Anne Moore, RNC, MSN, CNP

Disclosures

September 20, 2001

Question

How do you manage a premenopausal patient who complains of occasional postcoital bleeding? The patient has a normal Pap smear, normal physical exam, and negative cervical cultures. Is a colposcopy warranted for further evaluation?

Jan Dettweiler, APRN

Response from Anne Moore, RNC, MSN, CNP

Postcoital bleeding should be carefully investigated. Persistent postcoital bleeding is more common than intermittent bleeding and is generally associated with a vaginal, cervical, or intrauterine abnormality. This being the case, a careful history and thorough examination are warranted. Often, the diagnosis is one of exclusion.

Common causes of postcoital bleeding include: cervical pathology (dysplasia), sexually transmitted infections (chlamydia or gonorrhea), or cervical polyps. Vaginitis, caused by an infection such as Trichomonas or Candida, can also result in bleeding but the patient would likely be symptomatic, complaining of discharge, itching, or irritation.

A speculum examination facilitating careful visualization and inspection of the vagina and cervix is warranted to assess the patient for vaginitis or cervicitis. A cervical polyp should be readily visible as a red, pedunculated extension of columnar epithelium extruding from the cervical os. These can be easily removed if they are small in size. (Polyps can be easily removed by applying ring forceps, twisting the polyp on its base, and pulling gently. Most cervical polyps are pedunculated and detach easily and painlessly). Normal cervical and vaginal epithelium is light pink, moist, and nonfriable to touch with a cotton swab. Inspection of the vagina, vulva, perineum, and rectum for lesions or signs of trauma should be performed.

Wet preps of vaginal discharge, cervical cultures, and a Pap smear can help make a differential diagnosis by ruling out infection and cervical pathology. A colposcopic examination of the vagina and cervix could ascertain the presence of lesions not readily visible with a routine speculum examination. Generally, however, if the bleeding is significant, visualization should suffice. Use of the colposcope should be individualized to the patient situation and used at the discretion of the practitioner, mindful of the fact that this is often an expensive procedure. If all of the above are normal, the uterus is next on the list for evaluation.

The uterus should be small, mobile, firm, and nontender. A tender uterus may indicate endometritis or adenomyosis. Pain, however, would, more than likely, have been part of the presenting complaint.

If the entire work up is negative, a transvaginal ultrasound or histogram, a test that infuses fluid into the uterus to evaluate contour, should be performed. This will determine the presence of an intrauterine polyp or fibroid that could be causing the bleeding.

Intermittent postcoital bleeding is a diagnostic challenge. More than likely, the diagnosis is one of exclusion. Patients need to understand the differential diagnoses and work up and understand that, occasionally, no clear etiology can be identified. Knowing that the symptom is not part of a larger problem may provide sufficient information to give the patient a measure of comfort with what may continue to be a nuisance.

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