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Dr. Andrew Rynne

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Noticed postcoidal bleeding. Pap smear done. Could it be a cervical cancer?

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Dr. Das Arindam

General & Family Physician

Practicing since :2008

Answered : 1416 Questions

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Posted on Thu, 27 Dec 2012 in Cancer
Question: Hi, Dr. Grief: I am a 44 year old female, with one 11 year old daughter. I am ascian ethnics background. recently I have been noticed postcoidal bleeding for the past couple of month. not always, I did a self examination with my finger and notice something growing from my cervix. I went to see OB doctor around May or XXXXXXX to get opinion and did Pap smear. I never heard my pap smear results. so I assume it is normal so they didn't call me. The doctor said the cyst or polyps outgrown on my cervix is fine. I asked if it is cervical cancer. he said cancer will be felf very hard. mine felt soft.
but one days ago, I had post coital bleeding again without pain right after intercourse. at begining only pink color on the napkin, then later the bleeding is fresh blood, not much amount but stop after 30 minute.
do you think it can be cervical cancer? this is my major concern. if it cervical cancer, how come pap smear is normal. how sensitive is Pap smear. how accuracy.
this symptom remind me of another disease, bladder cancer, painless bleeding.
i always think everything of painless and bleeding is not a good sign.
I need your opinion. do you think i need to see doctor again to get second opinion?
sincerely
looking forward to your kindness help and suggestion
XXXXXXX
YYYY@YYYY
doctor
Answered by Dr. Das Arindam 39 minutes later
Hello,
Thank you for posting a query.

Firstly, this type of bleeding you described can be seen in any cervical lesion, that may be benign or malignant.

Now, in case of `polyp, bleeding can be seen. But in most of the cases, it is intermenstrual. In case of cervical cancer, bleeding is irregular and even post-coital as you described. But, in some benign polyps, having high vascularity, post coital bleeding can also be seen. So, on the basis of just this bleeding, it is difficult to separate these two lesions.

Now Pap smear. It is a screening procedure. In this method, the cells that are being exfoliated from the epithelial surface are examined under microscope. So, it is very much important in diagnosis of cervical lesions. But its accuracy and sensitivity varies. In high grade lesions, its sensitivity is 55 – 80%. But sensitivity increases in low grade lesions. One most important point is adequacy of the specimen obtained.

Bladder cancer is not a possibility. Because, in that case, bleeding was seen in urine. Per vaginal bleeding in bladder cancer is seen in last stage with infiltration in cervix. So, that is ruled out.

So, overall from your clinical examination you told, and normal Pap smear examination, i think there is less chance of being this lesion a cervical cancer.

Now, you have some options.

1.     Consult with another doctor for a repeat clinical examination and for second opinion. In this regard, you must understand, that clinical examination is a most valuable point. If clinically, the lesion seems to be a polyp then, there is less chance of any other abnormality.
2.     Ask the doctor to repeat the pap smear examination. Look for the report. You can even upload that report to me for another opinion.
3.     Consult with your doctor for taking biopsy for histopathological examination from that lesion to confirm the diagnosis.
4.     If you have normal pap smear examination this time, you should keep following up with your doctor for pap smear examination every year.
5.     If the diagnosis is confirmed as a benign polyp, consult with your doctor for surgical removal of it.

Hope this information suffices. Let me know, if you have any more question.

Regards.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Das Arindam 17 minutes later
Thanks for your reply.
when I mentioned bladder cancer, what I mean is painless bleeding is not a good sign. I know my bleeding is from vaginal or cervix or maybe uterus (which is rare in my case i think).
so polyps or cyst can have post intercourse bleeding?
anyhow, when you mention cervical cancer bleeding, you said it is irregular, what does this mean? can you be more detailed and specific.
if the polyps grow or enlarge, does it mean it is malignant?
the purpose of doing bx on the polyps is to see if it is benign or malignant, right?
if it benign, is it still necessary to remove it?
if it is removed, it suppose should stop bleeding after intercourse. that will indirectly prove it. otherwise, if I still have the same problem, that will be something else, right?
is it possible, neither polyps nor cervical cancer, but idiopathic?
I remembered I had my pap smear done almost 11 years ago after I had my daugher. it is normal. in between I haven'n done any pap smear. only when I noticed the polyps this time.
other than that, I am pretty normal. no any other chronic disease so far. no weight loss. for the past 20 years, my weight keep at 120 pound.
Is it possible HPV infection?
doctor
Answered by Dr. Das Arindam 21 minutes later
Hello,
Thank you for writing back.

I am giving you the answers one by one.

1. When a polyp has increased vascularity, it may lead to post coital bleeding.

2. Here irregular means bleeding from per vagina in between two normal periods.That may occur anytime when you are not expecting any bleeding. I also mentioned it as intermenstrual bleeding.

3. For diagnosis of a polyp as a benign or malignant, histopathological examination is must. Increased size does not always mean a malignancy.

4. Yes, purpose of doing biopsy is to confirm diagnosis of a benign polyp or any other lesion.

5. If it is benign, as i told previously, the decision of removal depends upon the treating doctor. There are some factors like symptoms, size, biopsy reports, which should be considered together.

6. If removal of the polyp does not give you relief from the symptoms, search should be made for any other lesions.

7. If the bleeding is from cervix, it should not be idiopathic. But, in case of dysfunctional uterine bleeding, it may be idiopathic. As i told previosly, if bleeding does not stop after removal, search should be made for presence of other lesions.

8. If it is a HPV infection, Pap smear is sufficient for diagnosis. HPV infection is easily diagnosed in Pap smear examination by presence of Koilocytic changes.

Regards.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Das Arindam 48 minutes later
Thanks for your precious help. It is super useful and helpful. I really appreciate.

1. I don't have irregular bleeding in between my nl mense. My mense is very very regular (28 days) in the past 40 years (my menarche starts when I was 12 yo). But recent couple of years, maybe I am in my premenapause, my mense is not that regular. sometime it can last for 7-9 days to stop. i thought it is probably due to unopposed estrogen without progesterone. but I don't recall I have irregular bleeding in between.

2. My pregancy and labor is also quite nl. even the doctor and the nurse said I am just like textbook.

3. My first sex only starts when I was 21. during the past 20 years, I have 7 sex partner. never have multi sex partner at the same time. always one sex partner during sex. The reason I am telling you this is because I don't think I have the predisposing risk factor for cervical cancer. but I do notice my recent sex partner, his penis shaft has warts, not califlower kind, pretty regular round shape, like papule, different in size, some big, some small. less than 1cm in diameter. But I noticed some grow larger. and some new papule comes out also. He said he starts to have this six years ago. Do you think this can be HPV infection. I have had sex with him for one year.
so when I noticed the painless postcoidal bleeding, the first thing pop up in my mind is cervical cancer. This is really bothered me and concerned me. That is why I decided to consult with and found this very useful website.

4. what do you think this polyps coming from. I mean the etiology. do you think it is due to hormonal change? I am pretty sure I only have it in recent year.
is cervical polyps very common?

That is all I can think of the question so far.
looking forward to hearing from you.
thank you so much for your very very helpful answer.
very useful

XXXXXXX
doctor
Answered by Dr. Das Arindam 1 hour later
Hello,
Thank you for writing back.

Firstly, I am glad that you have find out my suggestions helpful.

Now, about your past history, they are really very good. But, in our medical terminology, irregular bleeding does not mean irregular menses. Any abnormal bleeding occurring irregularly can be stamped as irregular bleeding.

Secondly, your partner really seems to have HPV infection. So, you are also exposed to it. What you have to do, is use condom during intercourse. Consult your treating doctor for a pap smear examination from more representative areas. I assure you that, if there is any possibility of HPV infection, PAP smear should reflect that. You can also do serological tests for detection of IgG and IgM specific for HPV 16 and 18.

Regarding etiology of polyp, it is just benign proliferation of fibrocollageneous tissue, and vessels in any area. But any definite etiology is not known.

If you have your answers then you can close this discussion. Rating and review given by you will be appreciated.

Regards.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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