Postcoital Bleeding: Causes, Evaluation, and Management

Postcoital bleeding (PCB) — vaginal bleeding after intercourse — affects 0.7–9% of menstruating women. While often benign, it requires systematic evaluation to exclude malignancy.

Common Causes

Cause	Mechanism	Typical Features
Cervical ectropion (erosion)	Columnar epithelium exposed to acidic vagina → friable, bleeds easily	Common in reproductive age, OCP use, pregnancy; asymptomatic or PCB
Cervicitis	Inflammation from C. trachomatis, N. gonorrhoeae, HSV, trichomonas, M. genitalium	Discharge, dyspareunia, intermenstrual bleeding; +NAAT
Cervical polyps	Benign endocervical projections	Visible on speculum; bleed with contact; easily removed
Atrophic vaginitis	Estrogen deficiency → thin, fragile epithelium	Postmenopausal; dryness, dyspareunia, petechial bleeding
Trauma	Mechanical abrasion/laceration	Rough intercourse, insufficient lubrication, foreign body
Endometrial/cervical cancer	Neoplastic vascular fragility	PCB is presenting symptom in ~11% of cervical cancers; postmenopausal bleeding = cancer until proven otherwise
IUD	String irritation, endometrial irritation	Spotting/PCB in first 3–6 months; may persist

Evaluation Algorithm

1. History: Timing, volume, pain, contraception, STI risk, menopausal status, last Pap/HPV.
2. Speculum exam: Visualize cervix (ectropion, polyps, lesions, discharge).
3. Cervical cancer screening: Pap + HPV co-testing (age 30–65) or Pap alone (21–29) if not current.
4. STI testing: NAAT for GC/CT, trichomonas; consider HSV, Mgen.
5. Pelvic ultrasound: If structural abnormality suspected (fibroids, polyps).
6. Endometrial biopsy: If age >45 or persistent bleeding with risk factors (obesity, PCOS, tamoxifen).
7. Colposcopy: If abnormal screening or visible lesion.

Management

• Treat infection (antibiotics/antivirals).
• Polyp removal (office polypectomy).
• Ectropion: usually observation; cautery/cryo if symptomatic.
• Atrophic vaginitis: vaginal estrogen (cream, tablet, ring).
• Trauma: lubricants, position modification, communication.
• Malignancy: urgent oncology referral.

Key Message

Never ignore postcoital bleeding. While usually benign, it is a red flag for cervical/endometrial cancer. Prompt, systematic evaluation is standard of care.