Vaginal Bleeding After Sex/Postcoital bleeding consists of spotting or bleeding that is not related to menstruation and occurs during or after sexual intercourse. Vaginal bleeding not related to menstruation is a common multifactorial gynecologic complaint seen by the primary care clinician and is a source of distress both to provider and patient as this can be a sign of underlying malignancy. The point prevalence ranges from 0.7 to 9.0% with one report indicating that the annual cumulative incidence is 6% among menstruating women [rx–rx].
Postcoital bleeding is bleeding from the vagina in women after sexual intercourse and may or may not be associated with pain.[rx] The bleeding can be from the uterus, cervix, vagina, and other tissue or organs located near the vagina. Postcoital bleeding can be one of the first indications of cervical cancer.[rx][rx]
Causes of Postcoital Bleeding
Vaginal bleeding after sex is a symptom that can indicate:
- pelvic inflammatory disease
- Pelvic organ prolapse
- uterine disease[rx]
- chlamydia or other sexually transmitted infection
- atrophic vaginitis[rx]
- childbirth
- inadequate vaginal lubrication[rx]
- benign polyps
- cervical erosion (inflammation of the cervix)
- cervical or vaginal cancer[rx]
- anatomical abnormality of the uterus, vagina or both.[rx]
- pregnancy
- endometrial polyps
- endometrial hyperplasia
- endometrial carcinoma
- leiomyomata
- cervicitis
- cervical dysplasia
- endometriosis
- coagulation defects
- trauma[rx]
Bleeding from hemorrhoids and vulvar lesions can be mistaken for postcoital bleeding. Post-coital bleeding can occur with discharge, itching, or irritation. This may be due to Trichomonas or Candida.[rx] A lack of estrogen can make vaginal tissue thinner and more susceptible to bleeding. Some have proposed that birth control pills may cause postcoital bleeding.[rx]
Common causes of postcoital bleeding.
Benign growths | |
Endometrial polyps | |
Cervical polyps | |
Cervical ectropion | |
Infection | |
Cervicitis | |
Pelvic inflammatory disease | |
Endometritis | |
Vaginitis | |
Genital/vulvar lesions | |
Herpes simplex virus | |
Syphilis | |
Chancroid | |
Lymphogranuloma venereum | |
Condyloma accumulate | |
Benign conditions | |
Vaginal atrophy | |
Pelvic organ prolapse | |
Benign vascular neoplasms | |
Endometriosis | |
Malignancy | |
Cervical cancer | |
Vaginal cancer | |
Endometrial cancer | |
Trauma | |
Sexual abuse | |
Foreign bodies |
Risk factors for developing postcoital bleeding are: low estrogen levels, rape and ‘rough sex’.[rx]
Symptoms of Postcoital Bleeding
The symptoms you may experience along with postcoital bleeding vary depending on the cause. If you aren’t menopausal, have no other risk factors, and have only minor spotting or bleeding that goes away quickly, you probably don’t need to see a doctor.
If you have any vaginal bleeding after menopause, see your doctor right away.
You should also consult your doctor if you have any of the following symptoms:
- vaginal itching or burning
- stinging or burning sensation when urinating
- painful intercourse
- heavy bleeding
- severe abdominal pain
- lower back pain
- nausea or vomiting
- unusual vaginal discharge
Diagnosis of Postcoital Bleeding
History
- Approach: Key questions
- Pregnancy status
- Quantify bleeding (20-30 ml blood per saturated pad or tampon)
- Abdominal or Pelvic Pain
- Associated symptoms to suggest Hemorrhagic Shock (e.g. Shortness of Breath, Palpitations)
- Red Flags suggestive of serious pathology
- Post-coital Bleeding (e.g. Cervicitis, Cervical Cancer)
- Perimenopause, postmenopausal patient (Endometrial Cancer)
- See Postmenopausal Bleeding
- See Endometrial Cancer Screening
- Pelvic Pain
- Consider Pelvic Inflammatory Disease, Endometriosis, structural lesions
- Consider Trauma (e.g. sexual abuse)
- Pregnancy Symptoms
- See Uterine Bleeding in Pregnancy
- Medication changes
- See Medication Causes of Abnormal Uterine Bleeding
- See Oral Contraceptive-Related Uterine Bleeding Management
- Missed Oral Contraceptive pill(s)
- Recently started or modified medications
- Bleeding Disorder
- Von Willebrand Disease is the most common
- Consider if onset at Menarche, Family History, bleeding from other sites (e.g. prolonged Epistaxis >10 min)
- Accounts for 20% of patients with Menorrhagia (esp. adolescent girls)
- Endocrinopathy
- Hypothyroidism and Hyperthyroidism symptoms
- Hyperandrogenism (e.g. PCOS)
- Hyperprolactinemia (e.g. Galactorrhea
Exam
- Vital Signs
- Assess for hemodynamic instability
- Findings suggestive of compensated shock (should trigger emergent stabilization)
- Lethargy
- Tachycardia
- Tachypnea
- Peripheral vasoconstriction (Cyanosis)
- General exam
- Thyromegaly
- Obesity
- Associated with Polycystic Ovary Syndrome
- Associated with Unopposed Estrogen, Endometrial Hyperplasia, and Endometrial Cancer
- Abdominal exam
- Peritoneal signs
- Focal abdominal tenderness
- Vaginal and cervical exam (by speculum or frog-legged position for children)
- Vaginal Lacerations or lesions
- Vaginitis
- Vaginal foreign body
- Cervical polyps or other lesions
- Cervicitis (e.g. Chlamydia)
- Cervical os with blood or IUD strings
- Pelvic exam
- Uterine Size
- Cervical motion tenderness
- Adnexal tenderness or masses
- Rectovaginal exam
Labs: Emergency Department
Tests and detailed examination are used to determine the cause of the bleeding:
- A pregnancy test
- A pelvic examination[rx]
- Obtaining tissue samples
- Pap smear
- Colposcopic examination of the vagina and cervix
- Ultrasound
- Histogram
- Cultures for bacteria[rx]
- Biopsy of tissues[rx]
- Urine Pregnancy Test (bHCG) or blood qualitative Pregnancy Test
- Obtain in all women of reproductive age
- Urinalysis
- Chlamydia PCR screen
- Thyroid Stimulating Hormone (TSH)
- Complete Blood Count (CBC) with platelets
- Consider point-of-care Hemoglobin if significant blood loss
- Consider that Hemoglobin will not reflect full extent of blood loss
- Comprehensive metabolic panel (includes liver and Kidney tests)
- Coagulation profile (INR, PTT)
- Type and crossmatch
Labs: Ambulatory – Selected based on Menorrhagia versus Metrorrhagia
- Initial testing
- Urine Pregnancy Test (bHCG) or blood qualitative Pregnancy Test
- Pap Smear
- Chlamydia PCR screen
- Thyroid Stimulating Hormone (TSH)
- Serum Prolactin
- Complete Blood Count (CBC) with platelets
- Consider Ureaplasma culture
- Additional Testing to Consider
- Glucose to Insulin Ratio
- Hyperandrogenism labs
- Coagulation studies
- ProTime (PT)
- Partial Thromboplastin Time (PTT)
- Platelet Closure Time (Von Willebrand’s Disease suspected)
Diagnostics: Evaluation over age 35-45 years
- 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
- 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)
- Transvaginal Ultrasound
- 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
Lubricants
If your bleeding is caused by vaginal dryness, vaginal moisturizers can help. Applied regularly, these products are absorbed by the walls of the vagina. They increase moisture and help restore the natural acidity of the vagina. Shop for vaginal moisturizers online.
Vaginal lubricants also reduce uncomfortable friction during intercourse. Shop for some water-based and silicone-based lubricants online.
Caution
- Petroleum-based lubricants, such as Vaseline (petroleum jelly), can damage latex condoms and diaphragms. Don’t mix Vaseline and condoms. Use a lubricant containing water or silicone if this is a concern.
Estrogen therapy
- If your vaginal dryness is caused by menopause or removal of the ovaries, talk with your doctor about estrogen therapy. Topical estrogen products include vaginal estrogen creams and suppositories.
- Another option is an estrogen ring. This is a flexible ring that’s inserted in the vagina. It releases a low dose of estrogen for 90 days.
- Oral hormone therapy, which replaces the hormones estrogen and progestin, is another option for some. Talk with your doctor about the risks and benefits of this treatment.
Additional treatments
- Vaginitis can be caused by an infection or vaginal dryness. The cause may also be unknown. Depending on the cause, your doctor may prescribe an antibiotic.
- Antibiotics may also be prescribed to treat pelvic inflammatory disease and STIs.
- If your cervix has been damaged by an infection, your doctor may remove affected cells using silver nitrate or cryosurgery. In this process, damaged cells are frozen and killed.
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
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