Postcoital bleeding is a distressing symptom that affects 0.7%–9% of patients1,2
Poistcoital bleeding is nonmenstrual bleeding that occurs after penetrative intercourse and often coexists with intermenstrual bleeding.1,3 Cervical ectropion (19%–34%), cervical or endometrial polyps (5%–18%), infection (e.g., vaginitis, cervicitis), pregnancy and trauma are common causes in premenopausal patients, and atrophy is a common cause after menopause (Appendix 1, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.230143/tab-related-content).1
Careful inspection of the vulva, vagina and cervix to identify visible causes and bimanual examination for cervicitis should be undertaken
Screening for sexual abuse should also take place.1 Cervical ectropion can be treated immediately in office with silver nitrate, and cervical polyps can be removed.3 If there is no visible cause, cervical cytology sample (beyond regular screening), vaginal and cervical swabs, and urine or serum β human chorionic gonadotropin should be collected as appropriate.1,3
Transvaginal ultrasonography is indicated in the 50% of patients who have no identified cause on physical examination1
Increased endometrial thickness, endometrial polyps or submucosal fibroids may be identified with transvaginal ultrasonography. When ultrasonography is normal, sonohysterography can be considered to exclude intrauterine lesions.4
Cervical or endometrial malignant disease should be excluded when no obvious cause is identified
Postcoital bleeding is attributable to cervical intraepithelial neoplasia and cervical cancer in 7%–18% and 3%–5% of affected patients, respectively.1,3 Abnormal cervical cytology or visible lesions on the vulva, vagina or cervix warrant urgent gynecology referral for colposcopy.1–3 Endometrial biopsy is recommended in patients older than 40 years or with 1 of irregular menstrual cycles, obesity or pertinent family history.3,4
Spontaneous resolution within 6 months occurs in 60% of patients with postcoital bleeding without identified cause1,3
Referral to gynecology is appropriate at any stage but especially if all above investigations are normal and postcoital bleeding has not resolved in this time frame.
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Footnotes
Competing interests: None declared.
This article has been peer reviewed.
References
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