What are the causes and treatments of postcoital (after intercourse) bleeding?

Postcoital Bleeding: Causes and Management

All women with postcoital bleeding require a speculum examination to directly visualize the cervix and vagina, with presumptive STI treatment for high-risk women (age <25 or new/multiple partners) while awaiting test results. 1

Initial Risk Stratification

The most critical first step is determining cancer risk and infection probability:

• Women under 25 years or those with new/multiple partners are at highest risk for cervicitis from sexually transmitted infections 1
• Cancer probability increases with age: 1 in 44,000 for ages 20-24 versus 1 in 2,400 for ages 45-54 1
• Postmenopausal women (15% of cases requiring surgical repair) warrant heightened concern for atrophic changes or malignancy 2

Mandatory Physical Examination

Never skip the speculum examination—direct visualization is non-negotiable for all patients with postcoital bleeding. 1

The examination must assess for:

• Visible ulcerating or fungating cervical lesions (mandates urgent cancer referral) 1
• Cervicitis (mucopurulent discharge, cervical friability) 3, 1
• Cervical polyps or ectropion 4
• Vaginal lacerations (posterior fornix in 35-45% of traumatic cases, mid-vagina in 20%, hymenal ring in 30%) 2, 5
• Atrophic vaginitis in postmenopausal women 4

Laboratory Evaluation

Perform NAAT testing for Chlamydia trachomatis and Neisseria gonorrhoeae on all patients using cervical or urine specimens. 1

Additional testing includes:

• Wet mount to identify >10 WBCs per high-power field (suggests cervicitis) and evaluate for trichomoniasis or bacterial vaginosis 1
• Complete blood count if significant bleeding or hemodynamic instability (5% of traumatic cases require transfusion) 2

Treatment Algorithm

For High-Risk Women (Age <25 or New/Multiple Partners):

Initiate presumptive STI treatment immediately without waiting for test results: 1

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

For Traumatic Vaginal Lacerations:

Median time from bleeding onset to admission is 12 hours—do not delay evaluation if bleeding is significant. 2

• Hemodynamically unstable patients require immediate surgical consultation and potential blood transfusion 2
• Surgical repair with hemostatic suturing is required in 97% of traumatic cases 5
• Sexual abstinence for at least 2 weeks post-repair 5

For Cervical Lesions or Polyps:

• Urgent gynecology referral if frank malignancy suspected on examination 1
• Cervical polyp removal can be performed in office setting 4

Common Pitfalls to Avoid

Do NOT perform unscheduled PAP smears as part of postcoital bleeding evaluation—they are not recommended and delay appropriate management. 1

Do NOT miss frank cervical cancer by failing to perform speculum examination—all women require direct visualization regardless of age. 1

Do NOT delay referral when malignancy is suspected based on examination findings. 1

Do NOT assume bleeding is minor—40% of traumatic injuries occur with first-time intercourse, and 5% present with hemorrhagic shock. 2

Special Considerations

Traumatic Injuries:

• First-time intercourse accounts for 40% of vaginal injuries requiring surgical repair 2
• Complications may include hemoperitoneum, pneumoperitoneum, or retroperitoneal hematoma even without complete perforation 6
• Psychological support should be offered to patient and partner after traumatic injury 2

When No Cause Identified:

If examination is normal but bleeding persists, refer to gynecology for further evaluation including possible colposcopy. 1

The natural history shows most idiopathic postcoital bleeding resolves spontaneously, but persistent cases warrant investigation for subtle cervical pathology. 4