Post Coital Bleeding
Spotting or bleeding not related to menstruation and occurs during or after sexual intercourse.
Prevalence 0.7 to 9.0% with one report indicating that the annual cumulative incidence is 6% among menstruating women.
Spontaneous resolution occurs in 51% of premenopausal women at two years with no recurrence.
About 30% of patients with postcoital bleeding also experience abnormal uterine bleeding and 15% have dyspareunia.
The prevalence of cervical cancer in women with postcoital bleeding is 3.0 to 5.5% and prevalence of CIN is 6.8% to 17.8%
Only 2% of women seen in secondary care with post-coital bleeding have cervical cancer.
The majority of cases of post-coital bleeding are not due to malignant disease, and in younger individuals chlamydial infection or problems with contraception are more likely causes
Management of Postcoital Bleeding
Frequency, severity and duration of symptoms
Smear History: regular, irregular, including date and result of last smear
Details of previous colposcopy, any treatments such as LLETZ/cold coagulation/laser
Relevant past medical/surgical history (including haematological/ coagulation disorders)
Current regular medication
Screen patients for domestic abuse and/or sexual abuse as genital tract trauma can lead to postcoital bleeding
Examination of vulva, vagina and cervix with a speculum for abnormal findings (e.g. normal, ectropion, cervicitis, cervical polyp, trauma, ulceration)
Chlamydia and STI screening, pregnancy test
Cervical Ectropion / Ectopy
Cervical ectropion can be caused by hormone imbalance, pregnancy or the pill.
Does not require treatment unless bleeding is persistent and bothersome to the patient.
Prior to treatment exclude underlying malignancy as certain treatments for cervical ectropion may mask or exacerbate malignant lesions.
Consider changing the type of contraceptive
An alternative therapy may be to use acidifying agents such as boric acid suppositories 600 mg vaginally at bedtime, Relactagel or Balance Active vaginally.
Cervical ablation with either cryotherapy or electrocautery is effective in mitigating further postcoital bleeding and a routine referral can be made for this to secondary care.
However, there are significant side effects to include copious vaginal discharge until healing is complete and cervical stenosis which can affect subsequent pregnancies.
2WW Suspected Cancer Referral
If cervix appears suspicious of malignancy on examination or if the pattern of bleeding is suspicious – refer under 2WW suspected cancer referral system.
- Suspicious looking cervix
- Suspicious vulval lesion
- Suspicious vaginal mass
Take a cervical smear only if a woman is due or overdue for her regular screening.
No additional smear tests should be performed where the patient is not due a repeat.
Negative smear test should not stop referral.
Referral should not be delayed for results of smear when cancer is suspected.
Routine Gynaecological Referral (18 Week Pathway to General Gynae Clinic)
- Persistent PCB; 6 weeks and negative STI / Chlamydia and no obvious abnormality on examination.
- Persistent PCB; 12 weeks after treatment of STI / Chlamydia and no obvious abnormality on examination.
- Cervical polyps unable to remove in Primary Care
- Post coital or intermenstrual bleeding and abnormal appearance of cervix that is not suspicious of malignancy such as ectropion, inflammation.
N.B. Contact bleeding at the time of cervical sampling may occur and is not an indication for referral to colposcopy in the absence of other symptoms.
IF THERE IS AN ABNORMALITY ON EXAMINATION, THEN REFER 2WW