Postcoital Bleeding Due to Cervical Ectropion

Postcoital bleeding due to cervical ectropion is bleeding after intercourse from the fragile glandular epithelium exposed on the ectocervix.

• It is a common benign cause of postcoital bleeding in young women and women on combined oral contraceptives.
• It is a diagnosis made only after cervical cancer and infection are excluded.
• Treatment is cautery or a change of contraceptive.

Light fresh bleeding or spotting immediately after intercourse, sometimes with increased mucoid discharge.

• The cervix shows a red velvety ring around the os that bleeds on touch.
• Differential diagnosis: cervical cancer, cervical intraepithelial neoplasia, cervicitis, cervical polyp, vaginal atrophy, vaginal trauma, genital warts.
• Complications: recurrent bleeding, anxiety, dyspareunia, and missed diagnosis of cancer if not investigated.

Diagnosis is by speculum examination, with screening and tests to exclude cancer and infection.

• Speculum examination of the cervix and vagina.
• Cervical cytology, HPV test or VIA; colposcopy and biopsy for any abnormal area, even when the cervix looks like an ectropion.
• NAAT for chlamydia and gonorrhoea; wet mount for trichomoniasis.
• Pregnancy test; HIV and syphilis tests.
• Haemoglobin if bleeding is frequent.

Reassure after cancer and infection are excluded, change the contraceptive if needed, and cauterise persistent ectropion.

• Supportive: reassure once cancer is excluded; use a water-based lubricant; avoid deep penetration for a few weeks; use sanitary pads for spotting.
• Pharmacological: change the combined pill to a progestogen-only method, for example depot medroxyprogesterone acetate 150 mg IM every 13 weeks or a levonorgestrel implant. Treat infection if found: ceftriaxone 500 mg IM single dose for gonorrhoea; doxycycline 100 mg oral 12-hourly for 7 days for chlamydia; metronidazole 400 mg oral 12-hourly for 7 days for trichomoniasis or bacterial vaginosis.
• Procedures: for persistent bleeding after screening is normal, cryotherapy (3 minutes freeze, 5 minutes thaw, 3 minutes freeze) or electrocautery of the ectropion. Silver nitrate cautery for small areas. Avoid intercourse for 4 weeks afterwards.
• Special groups: in pregnancy leave the ectropion alone; confirm that bleeding does not come from placenta praevia or cervical cancer. In HIV infection ensure screening is up to date before cautery.
• Red flags: irregular or ulcerated cervix, bleeding that continues after treatment, positive screening test, bleeding with weight loss or foul discharge.
• Follow-up: review at 6 weeks; repeat screening at the usual interval; re-examine if bleeding returns.