What causes bleeding after intercourse every time?

Postcoital Bleeding: Evaluation and Management

Bleeding after every episode of intercourse requires prompt evaluation with speculum examination to identify the source, as the most concerning etiology is cervical cancer, though benign causes like cervicitis and cervical polyps are far more common. 1

Initial Assessment

The evaluation should focus on:

• Age and sexual history: Women under 25 years or those with new/multiple partners are at higher risk for sexually transmitted infections causing cervicitis 2
• Characteristics of bleeding: Timing, volume, and associated symptoms (pain, discharge, dyspareunia) 2
• Cervical cancer risk factors: Age >30 years, lack of screening, HPV exposure 1
• Trauma history: Consensual vigorous intercourse can cause vaginal fornix lacerations, particularly in nulliparous women 3, 4

Physical Examination Findings

A speculum examination is mandatory and should assess for:

• Cervicitis: Mucopurulent endocervical discharge or sustained endocervical bleeding induced by gentle swab passage through the cervical os 2
• Cervical lesions: Polyps, ectropion, or visible malignancy 1, 5
• Vaginal trauma: Lacerations of the vaginal fornices (posterior fornix most common) or vaginal walls 3, 4
• Vulvar hematoma: Swelling and tenderness of labia if trauma-related 6

Diagnostic Testing

Laboratory evaluation should include:

• STI testing: NAAT testing for Chlamydia trachomatis and Neisseria gonorrhoeae on cervical or urine specimens 2
• Cervical cytology: Pap smear if not up to date with screening 1, 5
• Wet mount: Assess for >10 WBCs per high-power field (suggests cervicitis) and evaluate for trichomoniasis or bacterial vaginosis 2

Common Etiologies and Treatment

Cervicitis (Most Common in Young Women)

Presumptive treatment is indicated for women at high risk (age <25, new/multiple partners) even before test results:

• Azithromycin 1 g orally single dose OR Doxycycline 100 mg orally twice daily for 7 days 2
• Add gonorrhea coverage if local prevalence >5% 2
• Treat partners and advise abstinence for 7 days after treatment completion 2

Cervical Polyps or Ectropion

• Benign lesions requiring no treatment unless symptomatic 1
• Polyp removal can be performed if bleeding persists 1

Vaginal Trauma

Vaginal fornix lacerations from consensual intercourse can cause severe bleeding:

• May present with hemorrhagic shock requiring transfusion 3, 4
• Surgical repair indicated in 97% of cases 4
• Sexual abstinence for at least 2 weeks post-repair 4
• Most common in nulliparous women after vigorous intercourse 3, 4

Cervical Cancer

The most serious cause requiring urgent referral:

• Prevalence of postcoital bleeding ranges from 0.7-9.0% in menstruating women 1
• Any visible cervical lesion warrants immediate colposcopy and biopsy 1, 5
• Women >30 years with persistent postcoital bleeding require specialist evaluation even with normal examination 5

Management Algorithm

1. Perform speculum examination - never perform digital examination first 2
2. If obvious trauma with active bleeding - assess hemodynamic stability, consider surgical consultation 3, 4
3. If cervicitis signs present - initiate presumptive STI treatment for high-risk women 2
4. If cervical lesion visible - refer for colposcopy/biopsy 1, 5
5. If examination normal but bleeding persists - refer to gynecology, especially if age >30 years 5

Critical Pitfalls

• Do not delay evaluation: Cervical cancer can present with postcoital bleeding as the only symptom 1, 5
• Do not assume benign etiology in older women: Risk of malignancy increases with age 1, 5
• Do not miss vaginal trauma: Can cause life-threatening hemorrhage requiring emergency surgery 3, 4
• Do not forget partner treatment: Reinfection with STIs is common without partner management 2