The frequency of significant pathology in women attending a general gynaecological service for postcoital bleeding

Postcoital bleeding: a review on etiology, diagnosis, and management

Postcoital bleeding refers to spotting or bleeding that occurs after intercourse and is not related to menstruation. The prevalence of postcoital bleeding ranges from 0.7 to 9.0 percent of menstruating women. There are multiple etiologies for this common complaint in which most are benign such as cervicitis or cervical polyps. However, the most serious cause of postcoital bleeding is cervical cancer. There are currently no recommendations from governing bodies such as the American College of Obstetricians and Gynecologists on evaluating and treating women with postcoital bleeding. The purpose of this paper is to discuss the common causes of postcoital bleeding, the etiologies of postcoital bleeding, and the likelihood that malignancy is the underlying cause. After an extensive literature review, we compiled a paper illustrating the key concepts a practitioner should know when it comes to postcoital bleeding. Finally, this review will conclude with treatment options for women who are found to have an identifiable source for their bleeding and a discussion on the natural history of postcoital bleeding in women who are found to have no identifiable etiology on evaluation.

Postcoital bleeding: a study of the current practice amongst consultants in the United Kingdom

OBJECTIVES

To measure the variations amongst consultant gynaecologists all over the UK in managing women with postcoital bleeding (PCB).

STUDY DESIGN

A questionnaire was sent to 1020 consultant gynaecologists in the UK, using the database of The Royal College of Obstetricians and Gynaecologists, enquiring about their opinions and the details of practice.

RESULTS

Six hundred and fourteen (60%) replies were received. Three hundred and thirty-seven (59.8%) of the respondents agree that PCB is a significant clinical issue that requires developing national guidelines for management, 452 (80.1%) do not have local guidelines in their departments, 336 (59.6%) agree with The Department of Health guidelines for referral. Two hundred and eighty-one (49.8%) respondents see women in gynaecology clinic, 94 (16.7%) in colposcopy clinic, while 163 (28.9%) see them in either clinics depending on the workload. Only 275 (48.8%) respondents repeat the cervical smear for those with negative smear history who are still within the national screening interval. Chlamydia testing is performed by 450 (79.8%) respondents, whereas 68 (12.1%) consider investigating the endometrium in selected cases.

CONCLUSION

The results highlight the wide variations in managing women with PCB. Given the well-reported association with serious pathology, it may be prudent to standardise the management in the UK based on the best available evidence.

Prevalence of pathology in women attending colposcopy for postcoital bleeding with negative cytology

OBJECTIVE

To determine the frequency of cervical pathology and the incidence of cervical neoplasia in women presenting with PCB at the colposcopy clinic with negative cytology.

DESIGN

A retrospective study.

SETTING

A district general hospital.

POPULATION

Eighty-seven women with postcoital bleeding and negative cytology were seen in the colposcopy unit during 1 January 2003 to 31 December 2005.

METHODS

Women were identified from computer records and details were extracted from the case notes.

MAIN OUTCOME MEASURE

Histopathological diagnosis.

RESULTS

Six women (6.9%) had cervical intraepithelial neoplasia. There were no cases of invasive cancer. Thus in our study 6.9% women with postcoital bleeding had abnormal histology even though they had normal smears. Other identifiable causes were cervical polyp (12.5%), ectopy (33.6%) and Chlamydia (2.3%). No pathology was found in 50% of women.

CONCLUSION

Women with postcoital bleeding even with normal smears appear to be at much greater risk of cervical neoplasia than the general population. Unfortunately there is no general consensus for management of these patients. Hence further research is needed to standardise the management of women with PCB. Patients should be reassured that in vast majority of cases no serious pathology is detected.

How significant is a cervical smear showing glandular dyskaryosis?

OBJECTIVE

To evaluate the incidence, outcome and predictive value of cytology showing glandular dyskaryosis.

PARTICIPANTS

Fifty-seven women with a smear diagnosis of glandular dyskaryosis registered between January 1997 and December 2001.

SETTING

Colposcopy and cytopathology units in a large district general hospital.

RESULTS

Sixty smears in 57 women showing glandular dyskaryosis were identified from a cohort of 135,120 smears, giving an incidence of 0.05%. Hospital records were available for 50 women. Final diagnosis included 13 cases of cervical glandular intraepithelial neoplasia (CGIN), 4 microinvasive cervical adenocarcinomas, 2 undifferentiated tumours, 1 microinvasive squamous carcinoma, 21 cases of CIN and 13 cases of endometrial pathology (8 endometrial cancers). Twelve women had coexistent squamous and glandular disease. Forty-five out of 50 women had significant pathology (positive predictive value 90%). Colposcopy was seen to be of limited value in assessment of smears showing glandular dyskaryosis. Only 1 out of 13 glandular lesions was diagnosed by colposcopy.

CONCLUSION

Smears showing glandular dyskaryosis are associated with significant pathology in 90% of cases and malignancy in 32% of cases. Hence, women with a smear showing glandular dyskaryosis should be referred urgently to a colposcopy clinic and flagged up as suspected cancer. Glandular dyskaryosis should be included in the national referral criteria for suspected gynaecological cancer.