Red flag symptoms: Postcoital bleeding

Postcoital bleeding is a common symptom for women to present with but it rarely heralds any serious underlying pathology.

  • Altered menstrual cycle
  • Dyspareunia
  • Intermenstrual bleeding
  • Lower abdominal/pelvic pain
  • Change in vaginal discharge
  • Cystitis

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A systematic review identified that the risk of a woman in the community presenting with postcoital bleeding having cervical cancer ranges from 1 in 44,000 at age 20-24 years to 1 in 2,400 women aged 45-54 years.1

Credit: SPL

Cervical polyps may be found

A full pelvic examination will establish whether there are any polyps, discharge or any obvious sites of bleeding in the lower genital tract.

Cervical ectropion may be seen as a red ring around the cervix. Ectropion is particularly common in young women, pregnant women or those on the contraceptive Pill.

An infection may cause the cervix to become inflamed leading to bleeding. The inflamed cervix will appear red and will be tender to palpate.

Perform an STI screen and cervical smear if possible.

Chlamydia rates have been steadily increasing since the mid-1990s and chlamydia is now the most commonly diagnosed STI. Young people are particularly at risk. In females, chlamydia does not often present with any symptoms so it is important for young women to be aware of the risk even if they do not have any symptoms.

If symptoms are present, they may include postcoital bleeding as well as altered vaginal discharge, lower abdominal pain or dysuria. If left untreated, chlamydia can cause pelvic inflammatory disease.

Atrophic vaginitis
In menopausal or postmenopausal women atrophic vaginitis may cause postcoital bleeding as the vagina is not sufficiently lubricated due to reduced mucosal secretions. Coupled with an increased pH and thinning epithelium, this can lead to painful intercourse and bleeding.

Women with atrophic vaginitis may also experience vulval itching or burning. Estrogen preparations are an effective treatment.

Women taking HRT do not have the same decreased levels of estrogen, so exercise further caution when dealing with women in this group to exclude malignancy.

The NICE referral guidelines for suspected cancer recommend that a full pelvic examination, including speculum examination of the cervix, should be carried out in any woman presenting with postcoital bleeding and urgent referral if any features indicative of cervical cancer are found.

Gynaecological malignancies are rare in the UK. Risk factors for endometrial cancer include: nulliparity, diabetes, obesity, polycystic ovary syndrome, and use of estrogen-receptor blockers (tamoxifen).

Many cases of cervical cancer are detected by screening. When cases do present, postcoital or intermenstrual bleeding may be a symptom, along with a change in vaginal discharge and urinary symptoms.

Possible causes

  • Cervical ectropion.
  • Cervical or endometrial polyps.
  • Chlamydia.
  • Atrophic vaginitis.
  • Gynaecological malignancy.
  • Trauma.

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References

1. Shapley M, Jordon J, Croft P R. A systematic review of postcoital bleeding and risk of cervical cancer. Br J Gen Pract 2006; 56: 453-60.

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