Date Published: May 23, 2019
Publisher: Public Library of Science
Author(s): Omer Cohen, Edwardo Schejter, Regina Agizim, Ron Schonman, Gabby Chodick, Ami Fishman, Anat Hershko Klement, Linus Chuang.
Postcoital bleeding (PCB) is a common gynecological symptom that may cause concern among both patients and physicians. Current literature is inconclusive regarding management recommendations.
To identify risk-factors for dysplasia/cancer among patients presenting post-coital bleeding (PCB).
Using large health maintenance organization (HMO) database, all women reporting PCB in 2012–2015 were identified. PCB patient records in a single colposcopy center were reviewed. Age, marital status, ethnicity, gravidity, parity, BMI, smoking, PAP smear result (within 1 year of PCB presentation), colposcopy and biopsy results were recorded. Cases were matched by age and socio-economic enumeration area to controls accessing primary care clinics for routine care.
Yearly incidence of PCB ranged from 400 to 900 per 100,000 women; highest among patients aged 26–30 years. Among the sample of 411 PCB cases with colposcopy, 201 (48.9%) had directed biopsy. Biopsy results included 68 cervicitis (33.8%), 61 koilocytosis/CIN 1/condyloma (30.3%), 44 normal tissue (21.9%), 25 cervical polyp (12.4%), 2 CIN 2/3 (1%) and 1 carcinoma (0.5%). Positive predictive value for koilocytosis/CIN 1 or higher pathology was 15.6% (64/411) and 0.7% for CIN 2 or higher grade pathology (3/411). In conditional logistic regression, multiparty was a protective factor: OR 0.39 (95% CI 0.22–0.88, P = 0.02), while pathological PAP smear was a related risk-factor: OR 3.3 (95% CI 1.31–8.35, P = 0.01). When compared to controls, PCB patients were significantly (P = 0.04) more likely to present CIN 1 or higher grade pathology (OR 1.82, 95% CI 1.02–3.33).
Study results indicate that PCB may require colposcopy, especially for nulliparous women with an abnormal PAP smear.
Postcoital bleeding (PCB) is a common gynecological symptom that may cause concern among both patients and physicians. Its prevalence varies from 0.7%-9% among menstruating women [1–3]. PCB may reflect a benign condition such as infection, but can also indicate the presence of pre-malignant condition or cervical cancer . Colposcopy has been suggested as the appropriate investigative tool for ruling out cervical cancer or other pre-malignant pathology; however, the literature is inconclusive regarding management recommendations. The single systematic review published on this topic recommended against routine colposcopy . There is currently no consensus regarding when PCB requires further investigation and when women can precede with routine gynecological follow-up. One of the main reasons for the lack of consensus is the paucity of data involving the prevalence of PCB in the population and the incidence of cervical cancer among these patients . Other reasons include variations in study design, statistical analysis, and study location [6–8]. Therefore, management of PCB varies among countries .
The study was approved by the Assuta Hospital Ethics Review Board (approval number 25/16). Maccabi Health Services is a nationwide health maintenance organization with 2.1 million insured customers. The study was based on a query of the database identifying all non-pregnant women ages 18–50 recorded as having PCB from January 1, 2012 through December 31, 2015. The current practice guidelines in Israel recommend colposcopy for every case of PCB. PCB patient records were sampled from a single colposcopy center and were reviewed. This center was chosen because of its supervised protection of patients’ records. All colposcopies were performed by a single practitioner with more than 20 years of experience. Conventional cytology and colposcopy-guided biopsy were performed on all PCB patients. Age, marital status, ethnic background, gravidity, parity, BMI, smoking status, address (as a socio-economic status indicator), most recent PAP smear result (within 1 year), colposcopy evaluation and biopsy results were recorded. Pap cytology was performed as liquid based and classified according to the 2001 Bethesda system . Pap test results were classified as within normal range, infectious, reactive, squamous cell abnormalities (atypical squamous cells of undetermined significance (ASC-US), atypical squamous cells high grade lesion not excluded (ASC-H), low grade squamous intraepithelial lesion (LSIL), high grade squamous intraepithelial lesion (HSIL) or squamous cell carcinoma and glandular atypia). For the purpose of analysis, all Pap smears classified as ASC-US or higher grade were considered pathological.
This study supported PCB as a common complaint in the primary care setting among women of reproductive age. The presence of PCB was correlated with cervical pathology; the risk was twice that of the background population. Among patients presenting with PCB, the probability of cervical pathology was independently related to nulliparity and to Pap smear classified as ASC-US or higher.