Postcoital bleeding

Postcoital bleeding is vaginal bleeding during or shortly after intercourse that is not menstrual bleeding. The cause is usually benign (cervical ectropion, cervicitis, cervical polyp, vaginal atrophy), but cervical cancer must be excluded in every persistent case, including women with a normal recent screening result.

Clinical relevance. Cervical cancer, vaginal and vulval cancer, and endometrial cancer present with this symptom. Chlamydial cervicitis is a common treatable cause in young women.

Anatomy. The cervix has columnar epithelium in the endocervix and squamous epithelium on the ectocervix, with the transformation zone between them. Columnar epithelium is fragile and bleeds on contact. Ectropion is columnar epithelium visible on the ectocervix, common in adolescents, with combined hormonal contraception and in pregnancy.

Mechanisms. Friable epithelium, inflammation, contact with a polyp or tumour, atrophy, and trauma to the vagina or vulva.

Classification. By source: cervical, vaginal, vulval, uterine, and non genital (urethra, bladder, rectum). By timing: first episode, recurrent, or persistent over 3 months.

Key distinctions. Recurrent bleeding after each intercourse needs speculum examination and often colposcopy. New bleeding in a postmenopausal woman needs exclusion of endometrial and cervical cancer. Bleeding with pain after assault needs forensic and safeguarding care.

History

• Bleeding: frequency, volume, colour, relation to position or depth, intermenstrual bleeding, discharge, pain.
• Cervical screening: date of last test, results, and any previous colposcopy or treatment.
• HPV vaccination, smoking, immunosuppression (HIV, transplant, steroids), and diethylstilbestrol exposure in utero.
• Sexual history: new partners, previous sexually transmitted infection, and consent or assault.
• Contraception: combined hormonal, depot medroxyprogesterone acetate, implant, intrauterine device.
• Pregnancy possibility, recent delivery, and breastfeeding.
• Menopausal status and use of hormone therapy, tamoxifen or anticoagulants.
• Systemic: weight loss, pelvic or back pain, urinary or bowel symptoms, leg swelling.
• Bleeding disorder history.

Examination

• Speculum examination with good light: cervix (ectropion, polyp, friability, ulcer, growth, necrosis), vaginal walls (atrophy, lesion, laceration), vulva (fissure, ulcer), intrauterine device threads.
• Bimanual and rectovaginal examination for uterine size, adnexal mass, parametrial thickening or fixation.
• Abdomen, inguinal nodes, and urethral meatus.

Red flags

• Visible cervical ulceration, growth or necrosis, or a friable cervix with abnormal vascularity.
• Persistent bleeding over 3 months or new bleeding after menopause.
• Bleeding with weight loss, back or leg pain, haematuria or rectal bleeding.
• Pelvic mass, parametrial induration or fixed uterus.
• Pregnancy with bleeding (placenta praevia, cervical lesion).
• Immunosuppression or no previous screening.
• Haemodynamic instability.
• Disclosure of sexual assault, or any child with genital bleeding.

Special groups. Pregnancy: bleeding in the third trimester needs ultrasound for placental site before any digital examination. Postmenopausal women: atrophy is common but endometrial cancer must be excluded. Women with HIV: higher risk of cervical neoplasia.

Organised by site.

Cervix

• Cervical ectropion (commonest benign cause).
• Cervicitis: Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, herpes simplex virus, Mycoplasma genitalium.
• Cervical polyp (endocervical or decidual in pregnancy).
• Anogenital warts of the cervix.
• Cervical intraepithelial neoplasia.
• Serious: cervical cancer (squamous cell carcinoma and adenocarcinoma).
• Cervical endometriosis and nabothian cysts (uncommon).

Vagina and vulva

• Atrophic vaginitis.
• Vaginal laceration from intercourse, assault, foreign body or first intercourse.
• Vaginitis, including trichomoniasis.
• Vaginal intraepithelial neoplasia.
• Serious: vaginal cancer, vulval cancer.
• Lichen sclerosus with fissures.
• Vaginal adenosis (diethylstilbestrol exposure).
• Genital schistosomiasis in endemic regions.
• Vaginal varices.

Uterus

• Endometrial polyp, submucous fibroid, endometritis.
• Serious: endometrial hyperplasia and endometrial cancer.
• Intrauterine device related bleeding.
• Hormonal contraception breakthrough bleeding.

Pregnancy related. Cervical ectropion, placenta praevia, cervical polyp, early pregnancy loss, ectopic pregnancy.

Other sources. Urethral caruncle or prolapse, haemorrhoids and rectal bleeding, haematuria, bleeding disorders, anticoagulants, tamoxifen and cervical radiation.

Stepwise reasoning

1. Exclude pregnancy.
2. Examine the cervix and vagina with a speculum in every woman; take a swab and test for infection.
3. Biopsy any suspicious area, and do not rely on cervical screening to explain symptoms.
4. If the cervix is normal and bleeding persists, examine uterus and endometrium by ultrasound and, when indicated, endometrial sampling.
5. Review the cause of any bleeding in a woman who has had no screening or an inadequate result.

Tests

• Urine pregnancy test.
• Nucleic acid amplification tests for chlamydia and gonorrhoea (vulvovaginal swab), and tests for Trichomonas vaginalis and Mycoplasma genitalium. Vaginal pH and microscopy. Herpes simplex virus PCR from any lesion.
• Cervical screening with HPV testing if due. A normal result does not exclude cancer, and cytology or HPV testing does not replace colposcopy for a suspicious cervix.
• Colposcopy and punch biopsy of any abnormal area, or a wedge or loop biopsy for suspected invasive disease.
• Transvaginal ultrasound for uterine causes; endometrial thickness over 4 mm in a postmenopausal woman needs endometrial sampling or hysteroscopy.
• Full blood count and ferritin for blood loss.
• Coagulation screen (prothrombin time, activated partial thromboplastin time, fibrinogen) and von Willebrand tests if a bleeding disorder is suspected.
• HIV, syphilis and hepatitis B serology with infection.
• Staging after confirmed cancer: pelvic MRI, CT chest, abdomen and pelvis, and cystoscopy or proctoscopy as directed by the specialist.

Limitations. Ectropion is common and benign but can coexist with cancer, so a visible ectropion does not end the work up in a woman with persistent bleeding. Cervical screening misses adenocarcinoma and rapidly progressing cancers. Normal vaginal examination does not exclude an endocervical or uterine lesion.

Immediate steps. Control active bleeding with firm pressure using swabs or a speculum, and silver nitrate application to a bleeding point by an experienced clinician. Use vaginal packing and intravenous access for heavy bleeding, and resuscitate with fluids and blood products directed by the volume lost. Refer cancer or heavy bleeding the same day.

Cause specific treatment

• Chlamydia and cervicitis: doxycycline 100 mg orally twice daily for 7 days; maximum 200 mg daily; avoid in pregnancy and children under 12 (use azithromycin 1 g orally once in pregnancy, with a test of cure at least 4 weeks later).
• Gonorrhoea: ceftriaxone 1 g intramuscularly as a single dose.
• Trichomoniasis: metronidazole 400 mg orally twice daily for 7 days; maximum 4 g in 24 hours; avoid alcohol during treatment and for 48 hours after; treat partners.
• Herpes simplex first episode: aciclovir 400 mg orally three times daily for 5 days, extended to 10 days if new lesions appear; reduce in severe renal impairment.
• Atrophy: oestradiol 10 microgram vaginal tablet nightly for 2 weeks, then twice weekly; maximum one tablet daily; review at 3 months.
• Ectropion: review hormonal contraception. If troublesome bleeding persists, cervical cautery, cryotherapy or silver nitrate under specialist care.
• Cervical or endometrial polyp: removal with histology.
• Heavy or prolonged bleeding: tranexamic acid 1 g orally three times daily (up to four times daily) for up to 4 days from the onset; maximum 4 g daily; reduce for renal impairment (serum creatinine 120 to 249 micromol/L, 1 g twice daily; 250 to 500 micromol/L, 1 g once daily); contraindicated with active thromboembolism; caution with combined hormonal contraception.
• Vaginal laceration: pressure, local anaesthesia and suturing if bleeding persists; tetanus update if needed.
• Cervical, vaginal or vulval cancer: urgent multidisciplinary oncology care.

Sexual assault. Document findings and arrange:

• Forensic examination with consent
• Emergency contraception (levonorgestrel 1.5 mg orally within 72 hours, or ulipristal acetate 30 mg orally within 120 hours, or a copper intrauterine device within 5 days)
• HIV post exposure prophylaxis within 72 hours (tenofovir disoproxil 300 mg with emtricitabine 200 mg once daily plus dolutegravir 50 mg once daily for 28 days; adjust for renal function)
• Hepatitis B vaccination and screening for sexually transmitted infection

Offer psychological support.

Monitoring. Review at 2 to 4 weeks. Repeat testing for chlamydia and gonorrhoea at 3 months. Follow bleeding until it resolves. Check haemoglobin if bleeding was heavy.

Referral and escalation. Refer urgently within 2 weeks for a suspicious cervix, a vaginal or vulval lesion, or persistent bleeding with no cause. Refer to colposcopy for abnormal screening results. Refer to genitourinary medicine for sexually transmitted infection and partner notification. Involve safeguarding services for any child or when abuse is suspected.

Admission criteria. Heavy bleeding, haemodynamic instability, suspected invasive cervical cancer with obstruction or infection, and bleeding in late pregnancy.

Discharge and follow up. Outpatient care for benign causes with a specified date for results and review. Cervical screening should be up to date.

Safety netting. Return for heavier bleeding, pain, offensive discharge, fever, or any recurrence within 3 months.