Initial Evaluation of Post-Coital Bleeding in Young Women

Introduction to Appropriate Testing

A speculum examination is mandatory and must be performed first to assess for cervicitis, cervical lesions, polyps, ectropion, and vaginal trauma, as recommended by clinical guidelines 1
The American College of Obstetricians and Gynecologists implies that direct visualization can identify frank cervical cancer, which requires urgent referral, and missing this by relying on cytology alone is a critical error 1

Young women (under 25 years) or those with new/multiple partners are at higher risk for sexually transmitted infections causing cervicitis, which is the most common cause of post-coital bleeding in this age group, according to the Centers for Disease Control and Prevention 1
Laboratory evaluation should include NAAT testing for Chlamydia trachomatis and Neisseria gonorrhoeae on cervical or urine specimens, as recommended by the National Institute of Allergy and Infectious Diseases 1

Presumptive treatment for cervicitis is indicated for high-risk women (age <25, new/multiple partners) with Azithromycin 1 g orally single dose OR Doxycycline 100 mg orally twice daily for 7 days, as recommended by the American College of Obstetricians and Gynecologists 1
Refer to gynecology/colposcopy if examination is normal but bleeding persists, or if cervical lesions are identified, according to the American Society for Colposcopy and Cervical Pathology 1

Endometrial biopsy is indicated for women aged 35 years or older with post-coital bleeding, or those with risk factors for endometrial cancer (obesity, unopposed estrogen, PCOS, tamoxifen, anovulation, HNPCC), as recommended by the National Comprehensive Cancer Network 2