Cervical Bleeding: Causes, Evaluation, and When to Seek Care

The cervix—the lower uterine segment opening into the vagina—can bleed from physiologic, iatrogenic, or pathologic causes.

Common Causes

• Menstruation: Cyclic endometrial shedding via cervical canal.
• Ovulation bleeding: Mid-cycle spotting from estrogen dip.
• Implantation bleeding: ~6–12 DPO; light, brief.
• Postcoital bleeding: Cervical ectropion (columnar epithelium eversion), cervicitis, polyp, malignancy.
• Hormonal contraception: Breakthrough bleeding (pills, IUD, implant, injection)—common in first 3–6 months.
• Cervicitis: C. trachomatis, N. gonorrhoeae, M. genitalium, HSV, Trichomonas; mucopurulent discharge, friability.
• Cervical polyps: Benign endocervical growths; bleed easily.
• Cervical intraepithelial neoplasia (CIN) / cancer: Postcoital, intermenstrual, postmenopausal bleeding—never ignore.
• Pregnancy complications: Miscarriage, ectopic, placental abruption, previa.
• Atrophic vaginitis/cervicitis: Postmenopausal; friable, bleeding.
• Iatrogenic: Post-procedure (biopsy, LEEP, colposcopy, IUD insertion).

Red Flags – Urgent Evaluation

• Postmenopausal bleeding (any amount)
• Postcoital bleeding (persistent/recurrent)
• Intermenstrual bleeding >3 cycles
• Heavy/prolonged menstrual bleeding
• Associated pelvic pain, dyspareunia, abnormal discharge

Diagnostic Approach

1. Speculum exam: visualize cervix, note lesions, discharge.
2. Pap/HPV co-testing (per guidelines).
3. STI NAATs (chlamydia, gonorrhea, trich, Mgen).
4. Colposcopy ± biopsy if abnormal screening or visible lesion.
5. Transvaginal US if pregnancy-related or structural concern.
6. Endometrial biopsy if AUB + age >45 or risk factors.

Most causes are benign/treatable; malignancy must be excluded.