Post-Coital Bleeding

Written by: Leanne Dupley from Manchester University,

 

Postcoital bleeding (PCB) is non-menstrual bleeding that occurs immediately after sexual intercourse. Not only can it be very alarming for patients, but it can also be a sign of a serious underlying pathology. It is a symptom, rather than a diagnosis and therefore warrants further investigation.

 

Usually, the bleeding originates from the vagina, or cervix, rather than the endometrium. 

 

Epidemiology of PCB

 

  • Self-reported PCB from patient questionnaires was 6% in premenopausal women.
  • Studies vary, and between 1 and 39% of women with cervical cancer will complain of PCB.
  • Just 1 in 220 women with PCB will be found to have cervical carcinoma after investigations.

 

Causes of PCB

Polyps

Cervical Polyps

These are common growths on the cervix, or endocervix, which are rarely malignant. However, around 1% are found to be either pre-cancerous or cancerous so they are always excised and sent to histology.

 

Cervical polyps are often asymptomatic, but they can cause abnormal bleeding. i.e. PCB, IMB and postmenopausal bleeding (PMB)

 

Treatment of cerivcal polyps is removal. This can be done in a GP surgery, or clinic, with simple twisting of the polyp. Some more persistant, or larger polyps, which are more likely to bleed may require electrosurgical excision or hysteroscopic polypectomy if they appear to be coming from the endocervix or higher. 

 

Endometrial Polyps

These are generally non-cancerous growths of the uterus, which can be singular or multiple. They can be a source of IMB, menorrhagia, PMB, or PCB if they hang through the cervix. 

 

A hysteroscopy +/- polypectomy is needed. Histological investigation of the endometrial tissue must be done due to the association of endometrial carcinoma and endometrial polyps. 

 

Cervical Ectropion

A cervical ectropion is when the central columnar epithelium, of the cervical canal, migrates downwards and replaces the stratified squamous epithelium on the vaginal portion of the cervix.

 

This columnar epithelium is not as resilient as the sqaumous epithelium it is replacing. It is also highly vascularised and so this combined with its friability, leads to easy bleeding.

 

On speculum examination, the cervix will have a bright red area surroundng the external os. This can be seen on the picture to the left. 

Ectropions are often asymptomatic, but patients may present with infection or bleeding. It is very common amongst teenagers, pregnant women and also women taking the combined oral contraceptive pill. Generally after pregnancy, or stopping the COCP will resolve the ectropion.

 

Treatment is usually conservative, however, if troublesome, laser therapy, cryotherapy and diathermy to cauterise the lesion. Microwave therapy is also in the pipeline. 

Figure 1

Cervicitis

 

  • Many patients may be asymptomatic
  • Clear, white, yellow or green discharge is possible with varying infective organisms. On examiniation mucopurulant discharge may be seen around the cervix.
  • Bleeding, especially PCB, is common.
  • Dysuria is also common.

 

Common organisms include:

 

  • Chlamydia trichomatis (50% of cases)
  • Neisseria gonarrhoeae
  • Trichomonas vaginalis
  • Herpes simplex virus II and
  • Human papilloma virus. 

 

Treatment

  • Should be guided by swab results and using the correct antimicrobial agent. 
  • Chlamydia is treatable with Doxycycline 100mg twice daily for 7 days (contraindicated in pregnancy) or Azithromycin 1gm orally stat dose.
  • Gonorrhoea is treatable with Ceftriaxone 250mg IM stat dose or Cefixime 400mg oral stat dose.

 

Vaginitis

Infective Vaginitis

This is infection of the vagina by various possible organisms, which results in any of the following symptoms: itching, burning, dyspareunia, dysuria, PCB or abnormal discharge.

 

Common organisms include: Gardnerella ´╗┐Vaginalis (Bacterial Vaginosis 50%), Candida Albicans (vulvovaginal candiasis – thrush (40%), and Trichomoniasis Vaginalis (Trichomonas infection 5%). It is important to note that Bacterial Vaginosis and Candidiasis are NOT sexually transmitted infections (STI).

 

A dedicated article on STI's and their treatment can be found here.

 

Atrophic Vaginitis

A dedicated article on this topic can be found here.  

 

In menopausal or postmenopausal women the amount of oestrogen released by the ovaries decreases. The oestrogen normally keeps the vagina moist and maintains the vaginal and vulval skin. Therefore, when the oestrogen levels fall, the vulvovaginal skin becomes dry and thin. 

 

Atrophic vaginitis may cause postcoital bleeding as the vagina is not sufficiently lubricated due to reduced mucosal secretions (due to reduced oestrogen). This coupled with an increased pH and thinning epithelium, this can lead to painful intercourse and bleeding.

 

Symptoms of soreness, irritation, superficial dyspareunia and discharge, which may be purulent and blood stained, are common. However, it is important to note any postmenopausal bleeding is endometrial carcinoma until proven otherwise so thorough investigation is needed. 

 

Treatment is often with topical HRT to replace the missing oestrogen around the vagina. Vaginal pessaries, rings and creams can all be used to good effect. If other symptoms of the menopause are present, systemic HRT may be used. Patients should also be recommended lubricants for sexual intercourse to reduce discomfort from dryness. 

 

History taking in PCB

Referral and Investigations

If, on examination the cervix looks normal, it is important to consider bleeding from the uterus, particularly in women over 40 years of age.

 

Postmenopausal bleeding is endometrial cancer until proven otherwise. See the Nice Guidelines on Referral for suspected cancer: quick reference guide.