Vaginal Bleeding After Sex – What To Do, What Not To Do

• Background
  • Prior recommendations used age cut-off of 35 years, however, Endometrial Cancer is uncommon age <45 years
  • As of 2019, Age over 45 years with Abnormal Uterine Bleeding indicates evaluation
    1. Consider in age >=35, if persistent or refractory Abnormal Uterine Bleeding, or known Unopposed Estrogen
• A combination approach may be best
  • Endometrial Cancer Screening and Endometrial Biopsy (preferred first line) or, Dilatation and Curettage
  • Structural evaluation, Transvaginal Ultrasound (preferred first line) or Hysteroscopy
• Non-Invasive investigation
  • Transvaginal Ultrasound
    • Time Ultrasound to end of Menses when the endometrium is thinnest (if still menstruating)
    • Endometrial Biopsy for stripe >5 mm
    • Cancer is very unlikely if stripe <4 mm (Negative Predictive Value 99.3%)
    • Incomplete imaging in 10% of cases, Occurs most commonly if prior uterine procedures, fibroids, Obesity or atypical uterine positioning, Saline infusion improves sensitivity (but with an increased False Positive Rate)
  • Endometrial Biopsy
    • See Endometrial Biopsy for efficacy
    • Sensitive and specific for Endometrial Cancer, Misses Endometrial Polyps and focal lesions
    • Insufficient samples are common (no glandular cell), Requires another study (non-diagnostic)
• Invasive procedures (performed by gynecology)
  • See Endometrial Cancer Screening
  • Dilatation and Curettage, No significant advantage over Endometrial Biopsy
  • Saline Infusion Sonography
  • Hysteroscopy
    • Insufflation with carbon dioxide or warmed saline, Risk of tumor dissemination
    • Flexible 3 mm hysteroscope (Same size as Pipelle)
    • Improves diagnosis with D&C and Endometrial Biopsy
    • identifies most structural lesions (e.g. polyps)

Treatment of Postcoital Bleeding

The majority of women presenting to their primary care physician with complaints of postcoital bleeding will be found to have no obvious underlying cause for their bleeding based on history, exam, or laboratory investigation [rx]. Nevertheless, the reassuring aspect is that 60% of naturally menstruating women with postcoital bleeding will have spontaneous resolution of symptoms within six months [rx]. Half of these women will maintain resolution for two years [rx].

• Infection – Any woman who is found to have evidence of genital tract infection should be immediately treated to prevent long term repercussions. Treatment options should be guided based on laboratory and microscopy findings. With respect to a clinical diagnosis of pelvic inflammatory disease, treatment should not be withheld if testing for chlamydia and gonorrhea are negative as the three major criteria needed for the diagnosis of pelvic inflammatory disease per the Centers for Diseases Control and the World Health Organization include cervical motion tenderness, bilateral adnexal tenderness, and abdominal tenderness.
• Cervical Ectropion – Cervical ectropion does not require treatment unless the bleeding is persistent and bothersome to the patient. Prior to proceeding with treatment, one should ensure that they have ruled out underlying malignancy as certain treatments for cervical ectropion may mask or exacerbate malignant lesions. Cervical ablation with either cryotherapy or electrocautery is effective in mitigating further postcoital bleeding. However, there are significant side effects to include copious vaginal discharge until healing is complete and cervical stenosis which can affect subsequent pregnancies [rx]. Alternative therapy may be to use acidifying agents such as boric acid suppositories 600 mg vaginally at bedtime [rx].
• Polyps – Clinicians should consider the removal of symptomatic polyps or when they appear atypical with concerns for malignancy. A cervical polypectomy can often be performed in the office without sedation. Removal is performed by first placing a speculum into the vagina to visualize the cervical polyp. A forceps may then be used to grasp the polyp at its base and twist it off. If the base is visualized, then cauterization should be performed to prevent further bleeding. All polyps that are removed should be sent to pathology to be evaluated for malignancy [rx–rx]. Furthermore, if there is a concern for endometrial polyps, then the patient should be referred to operative hysteroscopy with possible dilation and curettage.
• Cancer – Colposcopy with directed biopsies is indicated for patients with abnormal cytology. If patients are found to have CIN on cervical biopsy, then one may follow the guidelines established by the American College of Obstetricians and Gynecologists or the American Society for Colposcopy and Cervical Pathology to determine whether the patient needs to be referred for an excisional procedure versus surveillance. Patients who are found to have genital tract cancer such as vaginal or cervical cancer should be referred to a gynecologic oncologist for further evaluation and treatment.
• Vaginal Atrophy – Postcoital bleeding associated with vaginal dryness may first be treated with vaginal moisturizers and lubricants which can be used prior to and during intercourse. Although these methods may assist with ameliorating discomfort during intercourse, they do not have any direct effect on improving atrophic changes. Women who continue to experience postcoital bleeding despite lubricants may require vaginal estrogen therapy. Estrogen therapy is one of the most effective treatment options for vaginal atrophy as it thickens the vaginal epithelium and decreases dryness. Low-dose vaginal estrogen therapy should be the first-line treatment for postmenopausal women with only vaginal complaints as it is more effective and also prevents possible side effects of systemic treatment. Special considerations should be made with the use of estrogen therapy for women who have breast cancer and/or cardiovascular disease.

Where does post-coital bleeding come from?

A woman’s reproductive system can be divided into upper and lower parts:

• The upper part – includes the body of your uterus, your fallopian tubes, and your ovaries. Bleeding during your period occurs when the lining of your uterus breaks down as part of a normal monthly cycle.
• The lower part – of a woman’s reproductive system is the neck of your womb (cervix), your vagina, and your vulva and labia, which are on the outside of your body.

References