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Postcoital Bleeding (893)

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Post-coital Bleeding (PCB) is bleeding from the genital tract which occurs after intercourse. PCB after the menopause should be regarded as PMB and investigated as such. PCB can be associated with genital tract carcinoma but only a very few women presenting with this symptom have such serious pathology, the remainder having benign causes.

It’s worth noting that approximately 13% of women age 20-24 will experience PCB in any given year but in this age group only 0.002% of PCB is due to cervical cancer. 80% of such cancers are visible to the naked eye on speculum.

Causes

Cervical

  • Ectopy
  • Cervicitis
  • STI
  • Condyloma
  • Carcinoma (rarely)

Vaginal/Vulval

  • Trauma
  • Vaginitis
  • Tumours (rarely)
  • Vulval Dermatoses

Uterine

  • Endometrial polyp
  • Dysfunctional Uterine Bleeding (DUB)
  • Endometritis
  • Endometrial Hyperplasia/malignancy

Iatrogenic

  • IUCD/IUS
  • Following smear or treatment to the cervix
  • Hormonal contraception

History

The following aspects should be covered in the history:

  • nature and timing of bleeding
  • menstrual history
  • smear/colposcopy history
  • contraception history
  • sexual history for STI where appropriate
  • medical History e.g. bleeding diathesis, diabetes
  • medication e.g. anticoagulants, antibiotics with secondary candidiasis
  • dyspareunia

Examination and Investigation

  • Bimanual examination
  • Speculum examination
  • HVS
  • STI screen where appropriate (Chlamydia and gonococcus)
  • Cervical smear if due
  • Urgent colposcopy referral in the event of clinical suspicion of cervical malignancy
  • If no lower genital tract cause found, consider TVS in women over the age of 40

Referral guidance

  • Women with PCB should be referred to Colposcopy as ‘URGENT: Suspicious of cancer’ and seen within 10 working days if the appearance of the cervix on speculum examination is suspicious of or consistent with cervical cancer.
  • Women with PCB with abnormal cervical screening should be referred to Colposcopy as per usual colposcopy protocols. Those in whom screening is absent or overdue should have a cervical smear and be referred based on the smear result and clinical examination findings.
  • Women with persistent PCB aged less than 40yrs with a normal smear history and normal speculum examination should have a self-obtained vulvovaginal swab for chlamydia and gonorrhea NAAT testing and, where appropriate, treatment for genital tract infection.
    Consideration should be given to a change of hormonal contraceptive if relevant. A therapeutic trial of Relactagel (PV for one week after menses and repeated for 2 months) should also be considered. If these measures are ineffective, patients can be referred as ‘Routine’ for further assessment to gynaecology / colposcopy depending on local service provision.
  • Women over 40 should be referred as urgent and seen within secondary care services within 14 days (gynaecology / coloposcopy).
  • Patients are invited to participate in the national cervical screening programme from the age of 25. PCB is not an indication for a cervical smear in those aged less than 25.

Differences in age cut off and referral times in these recommendations compared to the RCOG / BSGE Abnormal Uterine Bleeding Covid Guideline should be noted. Differences are due to the current GGC service structure and Scottish Government treatment time targets which differ from the UK system.

Management (where cervical pathology has been excluded)

  • Treat infection
  • Remove endocervical polyps
  • Consider change of contraceptive formulation or method
  • Consider Relactagel®/Balance Activ® gel to acidify vagina. This should be used after menses,nightly for 1 week and repeated for 2 months. (NB contra-indicated if patient or partner has shellfish allergy).
  • Topical oestrogen preparations in the presence of atrophic vaginitis e.g oestradiol pessary (Vagirux® or Vagifem®) or Orthogynest® cream
  • Endometrial assessment in women over 40 in whom the above measures have failed.

Editorial Information

Last reviewed: 03/12/2020

Next review date: 31/12/2025

Author(s): Morton Hair.

Approved By: Gynaecology Clinical Governance Group

Document Id: 893