What are the differential diagnoses and management for postcoital (after sexual intercourse) bleeding?

Postcoital Bleeding: Differential Diagnoses

Postcoital bleeding requires urgent speculum examination to exclude cervical cancer, followed by systematic evaluation for infectious, structural, and neoplastic causes, with colposcopy indicated for high-risk patients regardless of cytology results.

Differential Diagnoses by Category

Malignant and Premalignant Conditions

• Cervical cancer is the most serious cause, occurring in 0.6-4% of women presenting with postcoital bleeding, with risk increasing significantly with age 1, 2, 3
• Cervical intraepithelial neoplasia (CIN) is found in approximately 17% of women with postcoital bleeding, with CIN 1 in 6.6% and high-grade dysplasia (CIN 2/3) in 1.7% 4, 2, 3
• Endometrial cancer can rarely present with postcoital bleeding 3

Infectious Causes

• Cervicitis (including Chlamydia trachomatis infection) is a common benign cause, found in approximately 34% of biopsied cases 1, 5, 6
• Human papillomavirus (HPV) infection with koilocytosis accounts for approximately 30% of pathological findings 6, 4

Structural/Benign Causes

• Cervical polyps are identified in 5-12% of cases 6, 3
• Cervical ectropion is a common benign finding 6
• Vaginal atrophy particularly in postmenopausal women 6
• Trauma from intercourse 6

No Identifiable Pathology

• Approximately 40-49% of women with postcoital bleeding have no identifiable cause on complete evaluation 2, 3

Management Algorithm

Initial Assessment

• Perform urgent speculum examination to identify visible ulcerating or fungating lesions that require immediate referral 1, 5
• Test for Chlamydia trachomatis and treat if positive 1, 5
• Assess cervical cytology status within the past year 5, 4

Risk Stratification for Colposcopy

High-risk patients requiring colposcopy referral:

• Any visible cervical lesion on examination 1, 5
• Abnormal cervical cytology (OR 3.3 for dysplasia) 4
• Nulliparous women (multiparity is protective with OR 0.39) 4
• Current smokers (significantly increased risk for HPV atypia and CIN 1) 2
• Age >45 years (increased cancer risk) 1, 2

Critical caveat: Normal cervical cytology does NOT exclude serious pathology—30% of women with significant pathology (including invasive cancer) had normal or inflammatory smears 3. Four women with invasive cervical cancer had normal smears before diagnosis 3.

Colposcopy Findings and Outcomes

• Positive predictive value for CIN 1 or higher is 15.6% among women undergoing colposcopy for postcoital bleeding 4
• Women with postcoital bleeding are 1.82 times more likely to have CIN 1 or higher compared to controls (OR 1.82,95% CI 1.02-3.33) 4
• Do not perform unscheduled cervical smears outside the regular screening program for evaluation of postcoital bleeding 1, 5

Treatment Based on Etiology

• If Chlamydia positive: Treat with appropriate antibiotics 1, 5
• If cervical polyps identified: Consider polypectomy 6
• If no identifiable cause: Consider short-term NSAIDs (5-7 days) or low-dose combined oral contraceptives if medically eligible 5
• If malignancy suspected or confirmed: Urgent referral to multidisciplinary gynecologic oncology team 1

Common Pitfalls to Avoid

Do not rely on negative cytology alone to exclude serious pathology—8% of cervical cancers in one series had normal smears, and two cancers were only visible with colposcopy 3. The probability of cervical cancer varies dramatically by age (1 in 44,000 for ages 20-24 vs. 1 in 2,400 for ages 45-54), but all age groups require thorough evaluation 1, 5.

Do not delay referral for visible cervical lesions while awaiting cytology results—these require immediate specialist assessment 1, 5.