Introduction

Postcoital bleeding refers to vaginal bleeding (or spotting) that occurs after sexual intercourse, and is not related to menstruation. It is important to consider cervical cancer as possible cause, although it is rare.

  • It occurs in about 5% of the general population at any given time
  • About 1/3 of patients will also have intermenstrual bleeding
  • Cervical cancer accounts for about 1 in 5000 cases of post coital bleeding (lower risk in younger populations and higher risk in older populations)

Bleeding may be reproducible upon examination of the cervix.

Causes

Infection
Chlamydia, gonorrhoea, trichomoniasis (rarer cause)
  • Risk factors – ask about partners (number of partners, protection, Hx of sexually transmitted infection etc)
  • Ask about other symptoms – discharge, pain

Cervical Ectropion

  • An ectropion occurs when the columnar epithelium of the cervix is exposed to the vaginal vault
  • Typically causes vaginal discharge, but occasionally associated with bleeding
  • Common in women taking the combined hormonal contraceptive pill
Cervical ectropion seen on speculum examination

Cervical ectropion seen on speculum examination

Cervicitis

  • Inflammation of the cervix
  • A sign rather than a true diagnosis
  • Has multiple causes:
    • Chlamydia (most common)
    • Bacterial Vaginosis
    • Other infective causes
  • Cervix may appear generally red and inflamed on examination and bleeding may be reproduced when the cervix is touched

Cervical / endometrial polyps

  • Benign
  • May be palpable on bimanual
  • Likely visible on speculum
  • Patient may be able to feel an unusual sensation when polyps are present
  • On examination – smooth red/purple growths that arise from the os. Usually painless, and can be easily removed.

Vaginal Cancer

  • Likely to be older populations

Cervical Cancer

  • Likely to be an older patient, but may be as young as mid/late twenties
  • Ask about smears
  • May cause bloody discharge
  • On examination – often a firm lump that will exhibit contact bleeding

Other uterine malignancies

  • Rarely cause post-coital bleeding, and in cases where they do, there is often also intermenstrual bleeding

Rare causes:

History Taking

  • Where is the bleeding coming from? – might seem a silly question, but sometimes it may be coming from the rectum or the urinary system. Bleeding may even be coming from the male sperm. Any doubt can be solved by using a condom to rule out haematospermia, and / or a tampon at the time of bleeding to asses to location.
  • Periods – normal? Heavy? Absent? Any change recently? Any intermenstrual bleeding?
    • These questions help to differentiate a cervical cause from an intrauterine cause.
  • Contraception what is she using?
  • Any symptoms of infection? – Any vaginal discharge? Pain (dyspareunia – pain during intercourse), dysuria, recent change of sexual partner?
  • When was the last cervical screening test and what was the result?

Examination

  • Examine the cervix as part of a speculum examination
  • Polyps, ectropion, cervicitis, prolapse and cervical cancer may all be visible

Investigation

  • Cervical smear test and HPV testing should be performed
  • High vaginal swabs for infection (chlamydia and gonorrhoea) – especially if there is any vaginal discharge in the history or cervical discharge seen on examination, or if there are any risk factors for STI
  • Biopsy – of the cervix maybe performed if any abnormal lesions are identified
  • Colposcopy should be performed for any woman with persistent post-coital bleeding without an identified cause from previous examination and investigation

Management

Treat the cause

  • Infection – treat the infection identified
  • Ectropion – does not require any specific treatment
  • Polyps – can be removed – simply by twisting at the base and pulling the polyp off. Cauterising the base may reduce the risk of recurrence and post procedure bleeding
  • CIN – manage as per CIN / cervical cancer guidelines

In many cases, symptoms resolve spontaneously.

References

  • Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
  • Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
  • Postcoital bleeding - uptodate

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