35 year female with post coital bleeding. Next step is?
Clinical examination and pap smear Postcoital bleeding is defined as bleeding occurring during or immediately after sexual intercourse at a time distinct from menstruation. Post coital bleeding has many causes, the most serious of which is cervical cancer. The main aim of investigating women with post coital bleeding is to exclude serious cervical pathology, paicularly Pathologies associated with postcoital bleeding * Cancer 3.8% * Intraepithelial neoplasia 17.2% * Infection (chlamydia and other S.T.D.) 5.7% * Other 23.9% * No pathology 49.4% cervical cancer. Management:? History Initial history taking is almost the most impoant pa of the consultation since risk, factors can be identified and the need .for any paicular careful, follow up determined The history should include woman's age, nature, frequency and clinical association of the bleeding, past history of bleeding, hormonal therapy and contraceptive history. It is impoant to ask about cigarette smoking previous abnormal smears,' sexual activity. Clinical examination Clinical examination is usually done to rule out the presence of cervical polyps and ectropion which are impoant cause of post coital bleeding. Investigations Triple swabs "High vaginal swab, Endocerl swab and chlamydial swab" are useful investigations in women with PCB to exclude chlamydia and other STDs. Cervical smear This should be done only if a cervical smear is due or if the last smear was repoed to be abnormal over a period of three months or more. Colposcopy This is indicated if the cervix is clinically suspicious of cancer, if the smear shows cervical dyskaryosis or if symptoms are suggestive of cancer. Women over the age of 40 presenting with PCB should be referred ,for gynaecological examination and onward referral .for colposcopy. Endometrial investigations These should be done in cases of persistent postcoital bleeding or repeated episodes of PCB especially when associated with spontaneous bleeding or intermenstrual bleeding and when the smear and colposcopy results are repoed to be normal. Out patient hysteroscopy plus directed biopsy would be the preferred investigation.
Pap smear with clinical examination
Visual examination with lugo L iodine
Visual examination with acetic acid
Colposcopy directed biopsy