Postcoital Bleeding

Postcoital bleeding is vaginal bleeding that occurs during or after sexual intercourse, not related to a period. The commonest cause is cervical ectropion, followed by cervicitis (chlamydia, gonorrhoea, trichomonas), cervical polyps, vaginal atrophy, genital trauma and, importantly, cervical intraepithelial neoplasia and cervical cancer. It matters because it can be the first sign of cervical cancer, so the cervix must be examined and screened.

• Risk factors: hormonal contraception, pregnancy, sexually transmitted infection, HPV infection, HIV, smoking, no or late cervical screening, menopause with vaginal dryness.
• Most cases have a benign cause, but the cervix must always be examined.
• Cervical cancer must be excluded in every woman with persistent bleeding.

Women have light or heavy bleeding after intercourse, sometimes with discharge, pelvic pain or painful intercourse. The cervix may bleed on touch.

• Red, friable cervical tissue (ectropion) or polyp at the os.
• Pale thin vaginal skin in oestrogen deficiency; discharge with infection.
• Differential diagnosis: cervical ectropion, cervicitis, cervical polyp, cervical intraepithelial neoplasia, cervical cancer, vaginal atrophy, vaginal or vulval trauma, trichomonas infection, endometrial polyp, vaginal cancer, intrauterine device effect.
• Complications: anaemia, anxiety and avoidance of intercourse, delayed diagnosis of cervical cancer, pelvic inflammatory disease, infertility.

The approach is speculum examination of the cervix with screening for cancer and infection.

• Urine hCG; speculum examination and bimanual pelvic examination, with inspection for polyp, ectropion, mass or ulcer.
• Cervical screening (HPV test or Pap smear) if due, and colposcopy with biopsy for any suspicious cervix, whatever the screening result.
• Chlamydia, gonorrhoea and trichomonas tests, high vaginal swab; HIV test.
• Transvaginal ultrasound if bleeding persists; full blood count.

The principle is to exclude cervical cancer, then to treat the cause found.

• Supportive: abstain from intercourse until examined; reassurance when the cervix is normal or has a benign ectropion; condom use; partner treatment for infection; water based lubricant for dryness.
• Pharmacological: chlamydia: doxycycline 100 mg oral 12-hourly for 7 days (or azithromycin 1 g oral as a single dose); gonorrhoea: ceftriaxone 1 g IM as a single dose; trichomonas: metronidazole 400 mg oral 12-hourly for 7 days; vaginal atrophy: oestradiol 10 micrograms vaginal tablet inserted nightly for 2 weeks then twice weekly for 3 months; ectropion on the combined pill: switch to a progestogen-only pill with levonorgestrel 30 micrograms oral once daily or to a copper intrauterine device; paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours) for pain.
• Procedures: colposcopy with directed biopsy; removal of cervical polyp in clinic; cryotherapy, thermal ablation or silver nitrate cautery for symptomatic ectropion after a normal screening result; loop excision for cervical intraepithelial neoplasia grade 2 or 3; referral for staging and treatment of cervical cancer.
• Special groups: pregnant women have speculum examination and Pap smear, with biopsy only for a suspicious lesion and care to avoid heavy bleeding; women with HIV have yearly cervical screening and early colposcopy with a low threshold for biopsy; postmenopausal women have vaginal oestradiol and endometrial assessment if bleeding persists.
• Red flags: friable or ulcerated cervix, abnormal screening result, persistent bleeding after treatment, foul discharge, pelvic mass, weight loss, back or leg pain.
• Follow-up: repeat swabs 3 weeks after treatment of infection; colposcopy review at 3 to 6 months after treatment; repeat cervical screening at the interval set by the result; annual review for women with HIV.