Cervical Contact Bleeding

Cervical contact bleeding is bleeding that occurs when the cervix is touched, for example during speculum examination, cervical sampling or intercourse.

• It is a sign, not a diagnosis.
• Causes range from benign ectropion and cervicitis to cervical intraepithelial neoplasia and invasive cancer.
• Every woman with it needs cervical screening and examination.

Bleeding on touching the cervix with a swab, spatula or brush; post-coital spotting; sometimes discharge.

• The cervix may look red and granular, polypoid, ulcerated, or friable and irregular.
• Differential diagnosis: cervical ectropion, cervicitis, cervical polyp, cervical intraepithelial neoplasia, cervical cancer, genital herpes, genital warts, cervical endometriosis.
• Complications: anaemia from recurrent bleeding, delayed diagnosis of cancer, anxiety.

Diagnosis is by speculum examination, with screening and colposcopy to exclude neoplasia.

• Speculum examination with careful description of the cervix.
• Cervical cytology, HPV test and VIA or VILI.
• Colposcopy with biopsy of any abnormal area, and of any friable cervix even if screening is negative.
• NAAT for chlamydia and gonorrhoea; HSV PCR if ulcers; HIV and syphilis tests.
• Pregnancy test and full blood count.

Treat the cause found, control bleeding, and refer for colposcopy or excision where indicated.

• Supportive: reassure and explain that the cause is usually benign but must be checked; avoid intercourse until review if bleeding is heavy; use sanitary pads.
• Pharmacological: treat the cause found. Cervicitis: ceftriaxone 500 mg IM single dose plus doxycycline 100 mg oral 12-hourly for 7 days. Trichomoniasis: metronidazole 400 mg oral 12-hourly for 7 days. Genital herpes: aciclovir 400 mg oral 8-hourly for 7 to 10 days. Anaemia: ferrous sulphate 200 mg oral 8-hourly until haemoglobin normalises, then for 3 months.
• Procedures: silver nitrate or electrocautery to a bleeding point; cryotherapy or cautery for ectropion once cancer is excluded; excision of polyps; LEEP or cone biopsy for high-grade cervical intraepithelial neoplasia; referral for invasive cancer.
• Special groups: in pregnancy use gentle examination, avoid cautery and cryotherapy, and exclude placenta praevia by ultrasound; replace doxycycline with azithromycin 1 g oral single dose. In HIV infection screen every 1 to 3 years and refer for colposcopy early.
• Red flags: irregular or ulcerated cervix, bleeding that fills a pad, postmenopausal bleeding, weight loss, positive screening.
• Follow-up: review at 1 to 2 weeks for results; repeat examination at 3 months; continue screening at the usual interval.