Postcoital bleeding

What it is

Post-coital bleeding is vaginal bleeding after coitus. It is one form of abnormal uterine bleeding, with inter-menstrual bleeding and menorrhagia. And note: in a woman with post-coital and inter-menstrual bleeding but no menorrhagia, do not write fibroid.

Causes and risk

The DDx of post-coital bleeding with inter-menstrual bleeding is cervical polyps, ectropion, cervical cancer, cervicitis and sexually transmitted ulcerations. Also on the list:

• Atrophic vaginitis, in postmenopausal women, with dyspareunia, vaginal dryness and itchiness; the same atrophic vaginal changes are part of menopause
• Trichomoniasis, with a green-yellow frothy discharge, no pruritis, dysuria and dyspareunia, and a strawberry cervix
• PID: abnormal uterine bleeding (post-coital, inter-menstrual, menorrhagia) occurs in one-third or more of patients, though the cardinal symptom there is lower abdominal pain

Cervical ectropion is when the central (endocervical) columnar epithelium protrudes out through the external os of the cervix onto the vaginal portion, undergoes squamous metaplasia and transforms to stratified squamous epithelium. For cervical cancer the risk factors are HPV 16 and 18, early onset of sexual activity, multiple sexual partners, smoking and immunosuppression (HIV); it presents in young women (24-29) with post-coital bleeding, inter-menstrual bleeding, dyspareunia and pelvic pain. Of them all, cervical ectropion is the most common identifiable cause of postcoital bleeding. For intermenstrual bleeding the answer is different: one of the most common causes there is a sexually transmitted infection such as Chlamydia, and cervical cancer, though it too causes intermenstrual bleeding and is often reported with post coital bleeding, is rarer than a sexually transmitted infection. A copper coil is an unlikely cause, since women with a copper coil have regular periods.