POSTCOITAL AND INTERMENSTRUAL BLEEDING
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.
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
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
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.
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.
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.