Red flag symptoms
- Age >35 and symptoms >4 weeks
- History of abnormal smears
- Systemic symptoms suggesting invasive malignancy - weight loss, night sweats
- A recent change in sexual partners
- History of lower abdominal pain and fever
- Abnormal looking cervix or vaginal walls on examination
- Presence of an unexplained cervical or vulval mass
Postcoital bleeding is not an uncommon presentation in primary care. It refers to the presence of bleeding after sexual intercourse.
There are a number of conditions causing this problem that can be treated in primary care, however more sinister conditions have the potential to cause this and will require urgent gynaecological assessment. A careful history and examination is required to establish the cause of the problem.
Women will often be very embarrassed about the problem so a sensitive approach is crucial to taking a good history.
|Possible causes of postcoital bleeding|
The following questions should allow a cause to be established.
- Is the patient pre- or post-menopausal?
- If pre-menopausal and of reproductive age, how often does the patient menstruate and are the cycles regular?
- Is there any history of intermenstrual bleeding?
- Is there any pain on intercourse (dyspareunia), and if so is it superficial or deep?
- If relevant, are the patient’s smears up to date?
- Is there a history of previous abnormal smears and if so, what treatment was required?
- How does the patient describe the problem? Is it genuinely after sexual intercourse?
- How long has it been a problem for? If they are over 35 years old and it has been persistent for 4 weeks, this may suggest a malignancy.
- Is it after each episode of sexual intercourse?
- Does the patient use any sexual instruments during intercourse?
- Has there been any recent change in partners and if so, has the patient undergone a full STI screen?
- Do they have a history of STIs?
- Has it happened before and if so, what was found to be the diagnosis?
- Is there any vaginal discharge and if so, what colour is it and does it have a distinctive odour?
- Is there any associated abdominal pain or fever?
- A full contraceptive history may be required paying close attention to the use of the combined oral contraceptive pill
- Is pregnancy a possibility?
- Are there any urinary symptoms to suggest UTI?
- Has there been any weight loss, night sweats or appetite loss?
Important! If the patient is over 35 years old and postcoital bleeding has been persistent for 4 weeks, this may suggest a malignancy
You may wish to examine the abdomen paying close attention to the suprapubic region. is there any evidence of rebound or guarding? An acute abdomen should be referred directly to your local surgical team or gynaecological team if you suspect acute PID.
A speculum examination may be necessary to establish a cause of the problem. Is there any obvious vaginal lesion present? if the patient is post-menopausal, is atrophic vaginitis evident? Have a good look at the cervix, is there any obvious lesion? Examine the cervix for polyps and/or ectropion. You may wish to check for cervical excitation.
- Triple swabs if relevant to exclude STIs
- Sexual health screen including HIV testing and syphilis testing if the history suggests this is appropriate
- Urinary pregnancy test
- Cervical smear test
- Transvaginal ultrasound scan (endometrial pathology)
- FBC if the bleeding is very heavy
Treatment will depend on the cause.
Refer patients with post coital bleeding >35 under the 2ww cancer pathway
Refer as an emergency patients with symptoms and signs of acute PID who are systemically unwell
Refer patients with an abnormal transvaginal ultrasound scan
- Dr Pipin Singh is a GP in Northumberland
This is an updated version of an article that was first published in March 2014.