POSTCOITAL AND INTERMENSTRUAL BLEEDING
A 28-year-old woman presents with intermenstrual and postcoital bleeding. She has been taking the combined oral contraceptive pill (COCP) for 4 years and has had regular light periods throughout that time. She has been with the same partner since she was 20 years and has had no previous episodes of bleeding. The bleeding is light and fresh, occurring immediately after intercourse. At other times it occurs spontaneously at unpredictable times. It varies in intensity but is never heavy. There is no associated pain.
She had a normal smear test at the age of 25 years. She has never had any sexually trans- mitted infections, has never been pregnant and there is no relevant previous gynaeco- logical history.
Medically she is well and takes no medication.
The abdomen is non-tender with no palpable masses. The external genitalia appear nor- mal. On speculum examination the vagina appears normal as does the cervix. However, protruding through the external cervical os is a pink fleshy tumour which is freely mobile when touched with a cotton swab.
· What are the usual differential diagnoses for irregular bleeding in women taking the COCP who have normal examination findings?
· What is the likely diagnosis in this case?
· How would you further manage this patient?
In this case the examination shows an endocervical polyp. This is generally a benign lesion that extends through the cervical canal from the endometrial cavity, on a long thin pedicle. It may be asymptomatic and found incidentally at the time of a routine smear test. Alternatively it may give rise to symptoms of intermenstrual or postcoital bleeding as in this woman.
The management is simple by avulsion in the outpatient clinic under speculum examin- ation. The polyp is grasped with polyp forceps and twisted repeatedly until it detaches from its base. It does not matter if the whole stalk does not detach with the polyp, as any rem- nant generally necroses and disappears. The polyp should always be sent for histological examination although malignancy is extremely rare.
In older women or those in whom the history suggests another possible pathology, then ultrasound should be arranged to assess the endometrial cavity more thoroughly. This is not necessary in this case.
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