Abstract
Post coital bleeding (PCB) and intermenstrual bleeding (IMB) are common gynaecological complaints that can result from a wide range of benign, infective, hormonal, structural, psychological and malignant conditions. Though a majority of these cases are benign in nature, persistent and unexplained bleeding warrants detailed assessments to rule out any sinister pathology. It can be a source of great distress in women and a comprehensive evaluation not only facilitates diagnosis and management but also can significantly improve the quality of life of the patients.
Introduction
Intermenstrual bleeding refers to vaginal bleeding that occurs between regular menstrual periods. This phenomenon can be concerning for individuals experiencing it, as it disrupts the typical menstrual cycle pattern. Postcoital bleeding refers to vaginal bleeding that occurs after sexual intercourse. Understanding the possible reasons behind intermenstrual and postcoital bleeding is essential for proper diagnosis and management. Many women can experience both symptoms as there is often a shared aetiology. While it can be alarming, these are relatively common occurrence with various potential causes, ranging from benign to more serious conditions. The main aim of the assessment is directed to identify serious pathology (cancer) and once this has been excluded then the management is directed at treating the underlying cause. As there may be a physiological cause, it’s important for the physician to understand the need for simple reassurance that the symptoms are normal but, in many cases, it might be bothersome to the patient and need further treatment.
Aetiology
A review of the literature unveils a diverse spectrum of potential causes contributing to intermenstrual and postcoital bleeding reflecting the complexity of this clinical presentation ( Table 1 ). Numerous studies have investigated and categorized these causes, highlighting both common and rare etiologies.
| Cause | Post coital bleeding | Intermenstrual bleeding |
|---|---|---|
| Benign cervical causes | Cervical ectropion (most common in younger, sexually active women), cervicitis (often chlamydia or other infections), cervical polyps | Cervical polyps, cervicitis, cervical ectropion |
| Malignancy | Cervical cancer, vaginal cancer | Endometrial cancer, cervical cancer, vaginal cancer |
| Infections | Cervicitis (chlamydia, gonorrhea, HPV), vaginitis | Endometritis, cervicitis (chlamydia, gonorrhoea), vaginitis |
| Endometrial causes | Rare in PCB but can include uterine causes like adenomyosis if bleeding follows intercourse | Endometrial polyps, endometrial hyperplasia, endometritis |
| Hormonal causes | Rarely causes PCB but hormonal contraceptives can impact bleeding | Hormonal contraceptives (e.g., IUDs, OCPs), hormone therapy, anovulatory cycles, PCOS |
| Structural abnormality | Uncommon, but uterine fibroids can sometimes cause PCB if cervix or vagina are involved | Uterine fibroids, adenomyosis, structural anomalies affecting endometrium |
| Trauma | Vaginal or cervical trauma due to intercourse, foreign objects, or procedures | Trauma less commonly linked to IMB but possible with instrumentation |
| Atrophic changes | Vaginal atrophy (common in postmenopausal women) | Vaginal atrophy |
| Medications | Anticoagulants, intrauterine devices (IUDs), oral contraceptives | Same as PCB; plus unopposed oestrogen in hormone replacement therapy |
| Pregnancy related | Ectopic pregnancy, miscarriage, placenta previa (if pregnant | Ectopic pregnancy, early miscarriage, subchorionic haemorrhage (if pregnant) |
| Haematological conditions | Coagulopathy but much rare | Von Willebrand disease, thrombocytopenia |
| Psychological factors | Less common cause | Stress, anxiety, emotional disturbance |
Key points
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PCB often suggests cervical or vaginal pathology, with cervical ectropion and polyps being common benign causes.
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IMB frequently involves endometrial or hormonal causes, such as polyps or hormonal contraceptives, and may indicate systemic issues such as PCOS.
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Red Flags: Persistent or recurrent PCB or IMB warrants investigation for malignancies, especially in older or high-risk patients.
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Postmenopausal Bleeding: Considered abnormal and requires evaluation for malignancy regardless of the aetiology suspected.
Clinical evaluation and investigations
When evaluating patients presenting with postcoital or intermenstrual bleeding, a thorough history-taking and physical examination are essential components of the assessment process ( Table 2 ). These steps help to elucidate potential underlying causes and guide further diagnostic and management strategies.
