Gyn - Postcoital Bleeding

Question 1

45yo, presented with post-coital bleeding. Normal menstruation. On physical examination, normal size uterus, adnexa.
Pap smear was done 10 years ago.

Diagnosis and initial management?

Answer 1

Initial management
• History
• Onset, duration, progression,
• Severity: amount (clots), frequency, persistence (precipitating factors)
• IMB, dyspareunia
• Complications: anaemic symptoms, ADL affected
• Ddx:
• Benign: structural lesions at cervix, vagina
• Use of IUCD
• Malignancy: Ca cervix
• Medical: coagulation disorders, anticoagulant
• UTI, PR bleed
• Risk factors:
• Immunocompromised
• SHx: Smoking, substance abuse, high risk sex worker
• HPV infection
• Sexual history
• Abd + speculum + PV: look for uterine tenderness and mass, adnexal tenderness and mass, cervical excitation,
abnormal lesions and discharge, any contact bleeding
• Ix: CBC for anemia and infection, iron profile, triple swab, MSU, LRFT
• Pap smear first if no suspicious lesion

Question 2

What further Ix?

Answer 2

Low power magnification 2x to 25x illuminated binocular microscope
• Does not require GA
• Indications: abnormal pap smear results, suspicious lesions, for both diagnosis and treatment
• Examine with green filter easier view of vessels
• Examine with acetic acid identify squamo-columnar junction, look for acetowhite patches,
punctations, mosaic vascular pattern, ulcerations
• Examine with Lugol’s iodine extent of lesion, abnormal epithelium yellow and normal brown

Question 3

Colposcopy is negative. What is the next step?

Answer 3

What treatment for negative colposcopy and post-coital bleeding?

a. Repeat Pap smear in 6months, HPV co-test
b. Conservative mx iron supplement if anemia, transamine if heavy bleeding

Question 4

PS LSIL, Colpo normal, woman finds the symptoms annoying, Mx?

Answer 4

Cryotherapy

ii. HPV Testing: triage test in ASCUS to determine need for colpo, not necessary for LSIL