Postcoital bleeding — structured oral station (12 minutes)

Opening prompt — "She bled after sex last night. What is the first thing you do?"

Model response: ^[1][2]

• "PCB is a symptom, not a diagnosis — it points to a focal lesion. The first thing I do is exclude pregnancy with a urine or serum beta-hCG, then perform a speculum examination to visualise the cervix."
• "I take a structured history: bleeding pattern, menstrual and contraceptive history, sexual history (new partners — she has one), cervical screening status, red flags (persistent or recurrent PCB, postmenopausal bleeding, discharge, weight loss)."^[1][2]

Probe 1 — "Her cervix looks normal. Her chlamydia NAAT is negative. Her last screen 1 year ago was HPV-negative. Do you reassure her?"

• "No. A single normal screen does not reassure in a symptomatic woman. Cervical screening is a population-level test for asymptomatic women — it is not diagnostic in a woman with persistent PCB."
• "I would perform a cervical screen now (HPV plus LBC co-test) and refer her for colposcopy, because recurrent or persistent PCB warrants gynaecology referral and colposcopy regardless of the screening result."
• "A normal-looking cervix does not exclude high-grade CIN or early cervical cancer — colposcopy with acetic acid is what reveals them."^[1][3]

Probe 2 — "She is frightened it is cancer. How do you counsel her?"

Communication domain — demonstrate it out loud: ^[2]

• Move to her eye level, use her name, acknowledge the fear: "Your bleeding after sex needs investigation because at 36 with persistent symptoms we must rule out a serious cause — but most postcoital bleeding is benign, especially in a young woman. We will do the speculum and the screen today, and I will refer you for colposcopy to give a clear answer."
• Offer a clear plan and timeline, and a named contact for between visits.^[2]

Probe 3 — "Colposcopy shows CIN 2. What now?"

• "CIN 2 is a high-grade squamous intraepithelial lesion. The standard treatment is large loop excision of the transformation zone (LLETZ), which is both diagnostic and therapeutic. I would counsel her on the procedure, the small risks (bleeding, infection, future cervical stenosis or preterm birth), and the surveillance pathway — HPV testing at follow-up intervals per the NCSP / NHS guidance."
• "I would also ensure her HPV vaccination status is current and discuss smoking cessation, which is a cofactor for CIN progression."^[2]

Probe 4 — "Suppose instead she were 22 with a single episode of PCB and a normal cervix. How would your pathway differ?"

• "In a 22-year-old with a single episode of PCB, a normal-looking cervix and no risk factors, the most likely cause is chlamydia or an ectropion. I would do the speculum, the chlamydia NAAT and the screen, treat any infection, and safety-net — advise her to return if the PCB recurs or becomes persistent. I would not refer for colposcopy on a single episode in a low-risk young woman."
• "The threshold for colposcopy is persistent or recurrent PCB — not a single episode."^[1][4]

Probe 5 — "She returns 6 months later with persistent IMB. How does that change the route?"

• "Persistent IMB in a perimenopausal woman (over 40) shifts the route to hysteroscopy plus endometrial biopsy (NICE NG88 1.3.4), because the endometrium is now the suspect rather than the cervix. The high-risk groups for biopsy (NICE NG88 1.3.10) include persistent IMB and irregular bleeding."
• "Colposcopy addresses the cervix; hysteroscopy addresses the endometrium. The route is chosen by where the lesion is most likely to be."^[1]