What are the causes and management of postcoital bleeding?

Causes of Postcoital Bleeding

Postcoital bleeding has multiple etiologies ranging from benign cervicitis and polyps to cervical cancer, with the most critical step being urgent speculum examination to rule out visible malignancy, followed by STI testing and treatment for high-risk women. 1, 2

Primary Etiologic Categories

Infectious Causes

• Cervicitis from sexually transmitted infections is the most common benign cause, particularly Chlamydia trachomatis and Neisseria gonorrhoeae 1, 3
• Women under 25 years or those with new/multiple partners are at highest risk for STI-related cervicitis 1
• Trichomoniasis and bacterial vaginosis can also cause cervical inflammation leading to postcoital bleeding 1

Benign Structural Lesions

• Cervical polyps account for a significant proportion of cases, found in approximately 12.4% of women undergoing colposcopy for postcoital bleeding 4
• Cervical ectropion (columnar epithelium on ectocervix) is particularly common in younger women and those on hormonal contraception 3
• Vaginal trauma, including hymenal tears and posterior fornix lacerations, especially in nulliparous women 5

Premalignant and Malignant Lesions

• Cervical dysplasia (CIN 1-3) is found in approximately 8.3% of women presenting with postcoital bleeding 4, 6
• Cervical cancer represents the most serious cause, though relatively uncommon: the probability ranges from 1 in 44,000 for women aged 20-24 to 1 in 2,400 for women aged 45-54 7, 2
• Among women referred to colposcopy for postcoital bleeding, 0.6-0.7% have cervical cancer and 1.7% have high-grade dysplasia 4, 6

Risk Stratification

High-Risk Features Requiring Urgent Evaluation

• Visible ulcerating or fungating cervical lesion on examination mandates urgent referral for suspected malignancy 7, 2
• Advancing age significantly increases cancer risk (p = 0.037) 6
• Nulliparity is associated with higher risk of dysplasia (OR 2.56 compared to multiparous women) 4
• Current smoking increases risk of HPV atypia (p = 0.015) and CIN1 (p = 0.003) 6
• Abnormal PAP smear within the past year increases risk of CIN 1 or higher (OR 3.3,95% CI 1.31-8.35) 4

Lower-Risk Features

• Multiparity is protective (OR 0.39,95% CI 0.22-0.88) 4
• Younger age (20-24 years) has substantially lower cancer probability 7, 2

Diagnostic Evaluation Algorithm

Mandatory Initial Assessment

• Speculum examination is mandatory to assess for cervicitis, cervical lesions, polyps, ectropion, and vaginal trauma 1, 2
• If frank malignancy is visible, proceed directly to urgent gynecologic oncology referral 7, 2

Laboratory Testing

• NAAT testing for Chlamydia trachomatis and Neisseria gonorrhoeae on cervical or urine specimens 1
• Wet mount to assess for >10 WBCs per high-power field (suggests cervicitis) and evaluate for trichomoniasis or bacterial vaginosis 1
• Unscheduled PAP smears are NOT recommended outside the regular screening program 7, 2

Colposcopy Indications

• Persistent bleeding despite treatment of identified benign causes 1, 2
• Abnormal PAP smear result within the past year 4
• Nulliparous women with abnormal PAP smear have particularly high yield for colposcopy 4
• Among women undergoing colposcopy for postcoital bleeding, 48.9% require directed biopsy, with positive predictive value of 15.6% for koilocytosis/CIN 1 or higher 4

Management Approach

Presumptive Treatment for High-Risk Women

For women under 25 years or those with new/multiple partners, initiate presumptive cervicitis treatment: 1

• Azithromycin 1 g orally single dose OR
• Doxycycline 100 mg orally twice daily for 7 days 1
• Partner treatment is essential to prevent reinfection 1

Treatment of Identified Benign Causes

• Treat specific STIs based on culture/NAAT results 1, 2
• Cervical polyps may require polypectomy 3
• For persistent bleeding without identified pathology, consider NSAIDs for short-term treatment (5-7 days) or low-dose combined oral contraceptives if medically eligible 2

Referral Criteria

• Visible cervical malignancy requires urgent gynecologic oncology referral 7, 2
• Normal examination but persistent bleeding after treatment warrants gynecology referral 1, 2
• Any abnormal colposcopy or biopsy findings require appropriate specialist follow-up 4, 6

Common Pitfalls to Avoid

• Do not perform unscheduled PAP smears as part of postcoital bleeding evaluation—they are not recommended and delay appropriate management 7, 2
• Do not miss frank cervical cancer by failing to perform speculum examination—all women require direct visualization 7, 6
• Do not delay referral when malignancy is suspected based on examination findings 7, 2
• Do not forget partner treatment when STIs are identified or presumptively treated 1
• In 40% of cases, no cause is identified despite thorough evaluation, and these women may benefit from empiric hormonal or NSAID treatment 6, 2