QuestionSBA
QuestionChoice
Whilst post-coital bleeding may be a sign of cervical cancer, in the absence of any other signs or symptoms, and where the cervix appears normal, it is prudent to rule out other causes of post-coital bleeding such as sexually transmitted infection
50010
d
Refer to gynaecology under the two week wait
QuestionChoice
Regardless of the fact this woman is in a regular relationship, one of the most common causes of post-coital bleeding is sexually transmitted infection, so this is important to rule out.
50007
a
Test for sexually transmitted infections
QuestionChoice
Cervical smears are a screening test and, as such, are indicated in accordance with screening protocol - this is every 3-5 years in the UK, depending on age and location. Opportunistic smear tests are not indicated or encouraged.
50008
b
Routine cervical smear
QuestionChoice
Progestogen-only contraception is associated with irregular bleeding and spotting, however is not usually associated with post-coital bleeding. Replacement of the implant early is not indicated in this case.
50011
e
Replace her contraceptive implant
QuestionChoice
Whilst this woman may merit referral to colposcopy, routine tests such as testing for sexually transmitted infections should be performed in primary care first.
50009
c
Refer to colposcopy
QuestionComment
Good luck trying to get into sexual health screening these days...

28388
User
subscriber
Womb Syndrome
QuestionComment
Surely you would refer as STI screening takes time

52147
User
subscriber
Neutrophillia
Concept
Chapter
# Summary
  
 
Post-coital bleeding, a condition defined by vaginal bleeding after sexual intercourse, is a symptom that is almost always abnormal and requires medical attention. It can be indicative of various conditions such as cervical ectropion, endocervical and cervical polyps, cervical cancer, sexually transmitted infections, and atrophic vaginitis. Key investigations to diagnose these conditions often include speculum examination, screening for STIs and in some cases, biopsy. Management strategies are typically dependent on the underlying cause and range from conservative observation to medical therapies and surgical interventions.
  
  
# Definition
  
 
Post-coital bleeding refers to any vaginal bleeding occurring after sexual intercourse. This is a symptom that is not typically expected and is almost always indicative of an underlying abnormality, except in the case of first-time intercourse.
  

# Epidemiology
  
 
The prevalence of post-coital bleeding varies widely due to differences in study designs and populations. It is estimated that about 0.7% to 9% of menstruating women experience post-coital bleeding. The prevalence increases with age, particularly in post-menopausal women where atrophic vaginitis becomes more common.
  
 
# Aetiology
  
 
Post-coital bleeding is a symptom, not a disease. It can result from a number of conditions including:
  
 
  - Cervical ectropion
  - Endocervical and cervical polyps
  - Cervical cancer
  - Sexually transmitted infections
  - Atrophic vaginitis
  
 
# Signs and Symptoms
  
 
Post-coital bleeding is often accompanied by other symptoms, depending on the underlying cause. 
  
 
  - **Cervical ectropion:** Often asymptomatic. May present with post-coital bleeding or vaginal discharge.
  - **Endocervical and cervical polyps:** Often asymptomatic. May present with abnormal vaginal bleeding (post-coital, inter-menstrual, or menorrhagia).
  - **Cervical cancer:** May cause post-coital bleeding, spontaneous bleeding, or bleeding after urination. Other symptoms include urinary changes and vaginal discomfort.
  - **Sexually transmitted infections:** Common symptoms include discharge and pelvic pain, in addition to post-coital bleeding.
  - **Atrophic vaginitis:** The vaginal mucosa becomes drier and thinner, which can lead to bleeding, particularly after intercourse.
   
 
# Investigations
  
 
Investigations for post-coital bleeding include:
  
 **Bedside:**
  
  - Speculum examination
  - Cervical swab and cytology
  - Endocervical and high vaginal swabs 

**Bloods:**
  
  - FBC and CRP

None of the above conditions require **imaging** for diagnosis. Cervical cancer would require CT for staging. 

**Invasive:**

  - Colposcopy or biopsy if required (e.g. if suspicious lesion on speculum and/or if screening is overdue). 
  
 
# Management
  
 
The management of post-coital bleeding depends on the underlying cause. You can find short descriptions below, but please consult the page for each of the conditions for full management. 
  
 
  - Cervical ectropion (asymptomatic): conservative management. 
  - Endocervical and cervical polyps (symptomatic): polypectomy.
  - Cervical cancer: based on staging, and may include surgery, radiation therapy, or chemotherapy.
  - Sexually transmitted infections: antibiotics.
  - Atrophic vaginitis: topical oestrogen therapy. 

 
# References

[Owens et al. Investigation and Management of Postcoital Bleeding. 2022. *Wiley*.](https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1111/tog.12780)

[Patient Info](https://patient.info/doctor/intermenstrual-and-postcoital-bleeding)

[GP Notebook](https://primarycarenotebook.com/pages/gynaecology/postcoital-bleeding)

[North Tees and Hartlepool NHS Foundation Trust - Post-coital bleeding](https://www.nth.nhs.uk/resources/post-coital-bleeding/)
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Post-coital bleeding
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Gynaecology
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Post-coital bleeding
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Post-coital bleeding
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Quesmed Tutorial: Gynaecology 1
10038
A 43-year-old woman attends her general practitioner with three episodes of bleeding after sex.

She has a regular male partner and has a progestogen-only implant for contraception which has been in situ for two years. She is amenorrhoeic and denies any symptoms of vaginal discharge or pelvic pain.

Her cervical smear tests are up to date, and her last cervical smear was reported as normal. She is due her next one in 3 months time.

What is the most appropriate management?
a