Postcoital Bleeding: Causes, Evaluation, and When to Worry

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

Common Causes

• Cervical ectropion (erosion): Eversion of columnar epithelium onto ectocervix; friable, bleeds easily with contact. Common with OCPs, pregnancy.
• Cervicitis: Inflammation from Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas, HSV, or non-infectious irritants.
• Cervical polyps: Benign, vascular, pedunculated lesions; easily removed.
• Atrophic vaginitis: Estrogen deficiency (menopause, breastfeeding) → thin, fragile vaginal epithelium.
• Trauma/lacerations: Inadequate lubrication, vigorous intercourse, foreign bodies.
• Hormonal contraception: Breakthrough bleeding with OCPs, IUDs, implants.

Serious Causes (Must Exclude)

• Cervical intraepithelial neoplasia (CIN) / cervical cancer
• Endometrial cancer/polyps
• Vaginal cancer (rare)

Evaluation Algorithm

1. History: Timing, amount, pain, contraception, STI risk, last cervical screening.
2. Speculum exam: Visualize cervix/vagina; look for lesions, discharge, atrophy.
3. Cervical screening: Co-test (Pap + HPV) if due or never done.
4. STI testing: NAAT for chlamydia/gonorrhea; wet mount for trichomonas.
5. Pregnancy test: Rule out implantation bleeding, ectopic pregnancy.
6. Colposcopy/biopsy: If abnormal screening, visible lesion, or persistent PCB despite treatment.
7. Endometrial sampling: If age >45 or risk factors for endometrial pathology.

Management

Treat underlying cause: antibiotics for cervicitis, excision for polyps, vaginal estrogen for atrophy, adjust contraception. Reassure if workup negative; PCB often resolves spontaneously.