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Postcoital bleeding (query bank)

Published: 07/02/2014

Question

Should women with postcoital bleeding and findings of either normal cervix or cervical ectropion only on speculum examination have a cervical smear performed prior to colposcopy referral?

Answer

The following guidelines on post-coital bleeding (PCB) were identified:

A diagnostic guide for abnormal vaginal bleeding in pre- and peri-menopausal women. Cancer Australia. (2011)

The flow chart says, after taking a history, physical examination and identify risk factors: “Exclude cervical pathology: pap smear and screen for chlamydia. Colposcopy recommended for post-coital bleeding”

NHS Cervical Screening programme. Colposcopy and programme management (2010)

“Women presenting with symptoms of cervical cancer – such as postcoital bleeding (particularly in women over 40 years), intermenstrual bleeding and persistent vaginal discharge – should be referred for gynaecological examination and onward referral for colposcopy if cancer is suspected. Examination should be performed by a gynaecologist experienced in the management of cervical disease (such as a cancer lead gynaecologist). They should be seen urgently, within two weeks of referral.”

Department of Health . Clinical Practice Guidance for the Assessment of Young Women aged 20–24 with Abnormal Vaginal Bleeding (2010)

“If the cervix looks abnormal and suspicious, which will be the case in a very small proportion, the correct action is urgent referral to colposcopy under the ‘two week wait’ rule. If there is a benign lesion, such as cervical polyp, a routine gynaecological referral will suffice. If the cervix looks normal, the recommended action will be a pregnancy test and testing for cervical infection (e.g. Chlamydia, N Gonorrhoea, Herpes), which could be performed in general practice, family planning clinics or GUM clinics.”

NICE. Referral for suspected cancer. (2005)

“The first symptoms of gynaecological cancer may be alterations in the menstrual cycle, intermenstrual bleeding, postcoital bleeding, postmenopausal bleeding or vaginal discharge. For a patient who presents with any of these symptoms, the primary healthcare professional should undertake a full pelvic examination, including speculum examination of the cervix.

In patients found on examination of the cervix to have clinical features that raise the suspicion of cervical cancer, an urgent referral should be made. A cervical smear test is not required before referral, and a previous negative cervical smear result is not a reason to delay referral.”

(Evidence level IV)

More recently, See & Havenga have determined the frequency of pathology in 73 women with PCB and proposed a management pathway which notes that cervical smear should not be performed unless it is due.

Alfhaily & Ewies reviewed the outcome of 137 women with PCB and found the prevalence of CIN was 28.6% of those who underwent colposcopy and 15 women out of 19 (78.9%) who had CIN and adenocarcinoma in situ had negative previous smear history. They review literature concerning smears in women with PCB and recommend that women with PCB for >4 weeks should have smear testing (if the previous one was done >3 months before consultation), triple swabs (chlamydial, endocervical and high vaginal) and colposcopy.

Tehranian et al reviewed data from 123 women with PCB, evaluated by clinical examination, cytology, colposcopy, and histopathology. Cytology had a sensitivity of 50%, specificity of 86.5%, positive predictive value (PPV) of 33.3%, and negative predictive value (NPV) of 92.8%. Cytology missed 7 (50%) of 14 patients with a biopsy-proven abnormality, which included 6 cases of CIN 1 and 1 case of low-grade glandular neoplasia. Colposcopy missed 3 (21.4%) abnormalities: 2 were CIN 1 and 1 was CIN 2. Colposcopy had a sensitivity of 78.6%, and a PPV of 23.4%. The authors concluded that “Because of its higher sensitivity, colposcopy can be recommended for the investigation of persistent PCB, even in the presence of normal cytology.”

(Evidence level III)

References

Search date

February 2014

Classification of evidence levels

  • Ia: Evidence obtained from meta-analysis of randomised controlled trials.
  • Ib: Evidence obtained from at least one randomised controlled trial.
  • IIa: Evidence obtained from at least one well-designed controlled study without randomisation.
  • IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study.
  • III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.
  • IV: Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.

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