Postcoital Bleeding Notes

Postcoital Bleeding: Differentials

  • Postcoital bleeding is a key indicator of cervical cancer.
  • Differentials include:
    • Cervical ectropion
    • Cervical polyps
    • Sexually Transmitted Infections (STIs)
    • Pelvic Inflammatory Disease (PID)
    • Uterine fibroids
    • Endometrial polyps
    • Endometrial hyperplasia and malignancy
    • Hormonal contraception
    • Intrauterine device (IUD)
    • Endometriosis
    • Atrophic vaginitis
    • Vulvar skin conditions (lichen sclerosus, lichen planus)

Etiology

  • Cervical Causes: Cancer, ectropion, polyps, cervicitis
  • Cancers: Endometrial cancer, uterine, endometrial polyps, fibroids
  • Infections: Pelvic inflammatory disease, STIs
  • Atrophic Vaginitis
  • Lactational/Menopausal Causes
  • Traumatic Causes: Violent sex, secondary to delivery
  • Dermatological Conditions: Dermatitis, lichen planus, lichen sclerosus
  • IUD and Contraception

History Taking

  • Open-Ended Questions:

    • Explore the patient's concerns
    • Timing of bleeding episodes (number, duration, progression)
    • Characteristics of bleeding (color - bright, dark; contents - clots, discharge, tissue)
    • Volume of blood (number of pads used, saturation level)
    • Odor
    • Impact on patient's life

  • Five P's:

    • Period History:
      • Last menstrual period (LMP)
      • Heavy/excessive bleeding
      • Excessive pain during period
      • Intermenstrual bleeding/pain
    • Partner History:
      • Sexual activity
      • Bleeding only after sex
      • Painful sex
      • Relationship stability
      • Multiple partners
      • Safe sex practices (condom use)
      • History of STIs
    • Pills:
      • Contraception use, especially IUD
    • Pregnancy:
      • Recent delivery: complications, deep cuts, breastfeeding
    • Cervical Screening Test:
      • Up-to-date
      • HPV vaccination

  • Differential Diagnosis-Specific Questions:

    • Cervical Cancer:
      • Abnormal vaginal discharge
      • Unusual vaginal discharge
      • Loss of weight/appetite
      • Lumps
      • Low back pain
    • PID/STI:
      • Fever
      • Vaginal discharge
      • Abdominal pain
    • Atrophic Vaginitis:
      • Vaginal dryness
    • Dermatological Issues:
      • Rashes
      • Redness on private parts
      • Ulcers
      • Itchiness
    • Traumatic Causes:
      • Relationship with partner
      • History of violent sex

  • Other Relevant History:

    • Smoking, alcohol, drugs
    • Medications, allergies
    • Past medical history
    • Family history

Examination and Diagnosis

  • Patient presented with postcoital bleeding.
  • Cervical screening test was done five years ago
  • Diagnosis: Cervical ectropion (inner layer of cervix has rolled out and expanded)
  • Red ring observed at the cervix during examination confirms ectropion.

Differentials Considered

  • Cervical cancer
  • Polyps (cervical, endometrial)
  • Endometrial cancer
  • Fibroids
  • Infections (PID, STIs)
  • Dermatological conditions (contact dermatitis, lichen planus, lichen sclerosus)
  • Traumatic causes (sexual violence)
  • Atrophic vaginitis