Postcoital bleeding in females

INTRODUCTION — Postcoital bleeding refers to spotting or bleeding that occurs during or after sexual relations and is not related to menstruation. As postcoital bleeding can be caused by gynecologic malignancy and sexually transmitted infections, in addition to numerous benign conditions, postcoital bleeding can create significant worry for both patients and their health care providers.

This topic will discuss the potential causes, evaluation, and management of postcoital bleeding. Related topics on the differential diagnosis of all genital bleeding in females and abnormal uterine bleeding are presented separately.

●(See "Causes of female genital tract bleeding".)

●(See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Terminology, evaluation, and approach to diagnosis".)

●(See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Management".)

EPIDEMIOLOGY — Postcoital bleeding has a prevalence of 0.7 to 9 percent and an annual cumulative incidence among menstruating individuals of 6 percent [1,2]. It tends to occur more often in younger individuals, with an annual incidence of up to 12.6 percent in patients ages 20 to 24 years [3].

POTENTIAL CAUSES — As postcoital bleeding can originate anywhere from the external genitalia to the upper reproductive tract, all causes of genital tract bleeding must be considered (table 1). Benign etiologies are most common, but malignancy must also be excluded.

Common benign etiologies — Benign etiologies for postcoital bleeding include both infectious and noninfectious causes (table 1).

●Infectious – Infections of any part of the female genital and reproductive tract can result in postcoital bleeding. Sexually transmitted infections, including gonorrhea, chlamydia, and trichomoniasis, can cause cervicitis. Chlamydia cervicitis has been reported in approximately 2 percent of patients with postcoital bleeding [4,5]. In addition, upper tract infections, such as pelvic inflammatory disease or endometritis, have been reported [1].

•(See "Acute cervicitis".)

•(See "Vaginitis in adults: Initial evaluation".)

●Noninfectious – Noninfectious causes are numerous (table 1). Gynecologic etiologies are the most common causes of postcoital bleeding and include [4,5]:

•Cervical ectropion – 34 percent.

Cervical ectropion is the presence of columnar epithelium on the ectocervix and is commonly found in postpubertal adolescents, pregnant individuals, and those using estrogen-containing contraceptives (eg, oral estrogen-progestin pills, vaginal ring, or transdermal patch) (picture 1) [6]. (See "Benign cervical lesions and congenital anomalies of the cervix", section on 'Ectropion'.)

•Cervical intraepithelial neoplasia – 7 to 17 percent. (See "Cervical intraepithelial neoplasia: Terminology, incidence, pathogenesis, and prevention".)

•Cervical polyps and other anatomic lesions – 5 to 18 percent.

Anatomic lesions include cervical (picture 2) as well as uterine polyps, cervical or uterine fibroids, and vaginal or cervical endometriosis (picture 3). (See "Benign cervical lesions and congenital anomalies of the cervix".)

Other common, but less frequent, noninfectious gynecologic causes of postcoital bleeding include:

•Contraception – These can include changes in bleeding patterns from hormonal contraception as well as increased cervical ectropion from exogenous estrogen exposure. Intrauterine device (IUD)-related bleeding can occur with both correctly or malpositioned devices. (See "Combined estrogen-progestin contraception: Side effects and health concerns", section on 'Unscheduled bleeding'.)

•Atrophic vulvovaginal changes – These may present during lactation or after menopause. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Clinical manifestations and diagnosis".)

•Lacerations or granulation tissue – Granulation tissue can occur at the vaginal cuff following hysterectomy or at the site of obstetric injury, such as perineal laceration or episiotomy. Granulation tissue typically presents as a red, raised, lobular lesion and can be quite friable, which results in bleeding with contact. When formed at the site of obstetric lacerations, it is often painful to palpation. When biopsied, vaginal granulation tissue histologically shows abundant vascular growth, epithelial erosion, and intense inflammation [7]. (See "Postpartum perineal care and management of complications", section on 'Separation'.)

•Vulvar skin conditions – These include dermatitis or inflammatory conditions (eg, lichen planus or sclerosus).

-(See "Vulvar dermatitis".)

-(See "Vulvar lichen sclerosus: Clinical manifestations and diagnosis".)

-(See "Lichen planus".)

Malignancy — Malignancy as a cause of postcoital bleeding occurs in less than 5 percent of patients [4,5]. When postcoital bleeding is a result of malignancy, cervical cancer is the most common, but vulvar, vaginal, and uterine cancers can also cause the symptom (table 2).

●Cervical cancer – The risk of underlying malignancy in individuals who present with postcoital bleeding depends on a patient's age, Pap history, menopausal status, and demographics (ie, access to Pap screening). With improved cervical cancer screening, fewer cervical cancers are diagnosed due to symptoms, and more are found in asymptomatic individuals. A systematic review of 910 studies that included a wide range of clinical settings and access to Pap testing reported that as many as 39 percent of patients with cervical cancer have postcoital bleeding [3]. When analysis was limited to studies from developed countries, an estimated 11 percent of patients with cervical cancer reported postcoital bleeding. The authors then estimated the risk of cervical cancer in a patient presenting with postcoital bleeding based on age and prevalence of both postcoital bleeding and cervical cancer (table 2). Among the highest-risk age group for cervical cancer, postcoital bleeding was still only associated with a risk of 1 in 2400. (See "Invasive cervical cancer: Epidemiology, risk factors, clinical manifestations, and diagnosis".)

●Other gynecologic malignancy – Less commonly, postcoital bleeding can be associated with vulvar, vaginal, and uterine cancers. Gynecologic cancers often cause tissues to be more friable; friction from intercourse or vaginal sexual activity can cause bleeding from friable tissue at the vulva or vagina that was previously unrecognized. Seventy to 90 percent of cases of endometrial cancer present with abnormal uterine bleeding [8-10]. It is not known how many of these would present with postcoital bleeding only. Endometrial cancer should be considered as a cause for postcoital bleeding, especially in postmenopausal individuals. (See "Approach to the patient with postmenopausal uterine bleeding".)

Other — Other causes of postcoital bleeding include direct trauma or abuse. However, in approximately one-half of patients, no cause will be identified [4]. (See 'No identified diagnosis (idiopathic)' below.)

INITIAL DIAGNOSTIC APPROACH — Goals of the initial evaluation include identifying an obvious cause and excluding possible malignancy. However, the risk that postcoital bleeding represents a malignancy is quite low, and, in fact, most cases of postcoital bleeding will have no discernable cause. Despite the relatively common frequency with which this symptom is reported, there are no evidence-based guidelines for evaluation and management. We take the following approach:

History

●Is the patient actively bleeding?

•Yes – Acute ongoing postcoital bleeding can prompt individuals to seek urgent care, and they should be evaluated expediently when they do so. Postcoital bleeding resulting from vaginal tears or lacerations can be profuse and even life-threatening [11,12]. This is more likely in individuals who have had vaginal penetration for the first time; when there has been sexual trauma or abuse; in the setting of low estrogen states, such as after menopause or in lactating individuals; in patients with other tissue abnormalities, such as Ehlers-Danlos syndrome; or in patients who have undergone hysterectomy or other vaginal surgery [12]. It is critical to assess the extent of trauma and volume of bleeding and need for emergency treatment, or transfer the patient if such treatment cannot be provided on site. (See 'Active heavy bleeding' below.)

•No – In most cases, postcoital bleeding is self-limited and will have ceased prior to presentation in the outpatient setting.

●Assess reproductive status and possibility of pregnancy – Menstruating and reproductive-age individuals should be asked about their last menstrual period and if there is any chance that they could be pregnant.

•Pregnancy – Postcoital bleeding is much more common among pregnant individuals due to increased vascular supply to the genital tract as well as a larger and more friable cervical ectropion. (See "Benign cervical lesions and congenital anomalies of the cervix", section on 'Ectropion'.)

While vaginal bleeding in normal pregnancy is common, these patients should also be evaluated for pregnancy-related complications. (See "Evaluation and differential diagnosis of vaginal bleeding before 20 weeks of gestation".)

•Postpartum – Postpartum individuals may have friable granulation tissue at the site of repaired obstetric lacerations that can bleed. In addition, we ask about breastfeeding status as the hypoestrogenic state can result in atrophic changes with resultant postcoital bleeding.

•Postmenopausal – Postmenopausal individuals should be evaluated in a fashion similar to that which is recommended for postmenopausal bleeding in general, unless an obvious vaginal source of bleeding is found.

●Elaboration of symptoms – Questions to ask about bleeding include:

•Amount – What is the approximate volume of bleeding (eg, spotting, menstrual-like flow, or heavy bleeding)?

•Frequency – Does postcoital bleeding occur with every episode of vaginal sexual activity or only sometimes? If it does not occur consistently, does it seem to occur with specific activities or partners?

•Associated symptoms – Is the bleeding associated with pain, vaginal dryness, or vaginal discharge?

Given the overall benign nature of postcoital bleeding, bleeding that is minimal or that occurs rarely is less likely to represent pathology. While work-up and examination to exclude malignancy, sexually transmitted infections, and anatomic abnormalities is still performed, these patients will be more likely to have a benign or idiopathic etiology. Postcoital bleeding associated with pain or dryness is more likely to be due to atrophic changes, lacerations, granulation tissue, or inadequate lubrication. Patients with concomitant pelvic pain should raise a clinician's suspicion for pelvic inflammatory disease. Patients who report coexisting vaginal discharge are more likely to have an infectious etiology, such as vaginitis or cervicitis.

●Contraceptive method – Combined estrogen-progestin contraceptive (oral pill, vaginal ring, and transdermal patch) methods can result in an enlarged cervical ectropion, which is a common cause of postcoital bleeding. Alternatively, progestin-only methods (implants, intrauterine devices [IUDs], injections, and pills) are commonly associated with breakthrough bleeding. In some individuals, this bleeding only becomes apparent with sexual activity. IUDs can contribute to postcoital bleeding through endometrial thinning (progestin-releasing IUDs), malposition, and inflammation.

•(See "Evaluation and management of unscheduled bleeding in individuals using hormonal contraception".)

•(See "Intrauterine contraception: Background and device types", section on 'Impact of device type on bleeding pattern'.)

•(See "Intrauterine contraception: Management of side effects and complications".)

●Menstrual abnormalities – Postcoital bleeding is differentiated from other menstrual abnormalities. Individuals with other menstrual abnormalities, including intermenstrual bleeding or heavy menstrual bleeding, are evaluated for those symptoms. Heavy or prolonged bleeding increases the suspicion for uterine fibroids or adenomyosis. Intermenstrual bleeding is associated with hormonal contraceptives; infections, such as vaginitis or cervicitis; endometrial polyps or fibroids; or malignancy. (See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Terminology, evaluation, and approach to diagnosis".)

●Pap screening history and results – Individuals should be asked about the timing of their last screening and result as well as their history of abnormal Paps or cervical dysplasia treatments, such as loop electrosurgical excision procedure, cervical cryotherapy, or cervical conization (cold knife cone biopsy). Individuals who have not been adequately screened or who have been previously treated for cervical dysplasia are at increased risk of a cervical precancer or cancer. The incidence of cervical cancer in patients who have had recent normal testing is low (0.6 percent) [4,5]. (See "Screening for cervical cancer in resource-rich settings".)

●History of bleeding or a known bleeding disorder – Symptoms of a bleeding diathesis can include easy bruising, bleeding gums, bleeding from paper cuts or other minor trauma, or heavy menstrual bleeding since onset of menses.

●Ask about history of sexual trauma or abuse – A trauma-informed approach is advised, which is discussed in related content. (See "Human trafficking: Identification and evaluation in the health care setting", section on 'Trauma-informed care'.)

Physical examination — Physical examination is performed with the goal of identifying an etiology for the patient's complaint. A detailed discussion of the gynecologic pelvic examination is presented elsewhere. (See "The gynecologic history and pelvic examination", section on 'Pelvic examination'.)

●Inspection of the external genitalia and urethra – We look for vulvar sources of bleeding, including vulvar lesions, varicosities, erythema and/or excoriations indicating possible yeast infection, skin changes suggesting lichen sclerosus or other vulvar skin disorders, ulcerations, or atrophic changes.

The urethra should also be inspected for any urethral caruncles or polyps. These are more common in postmenopausal individuals and can be quite friable, thus causing postcoital bleeding. (See "Urethral caruncle".)

●Speculum examination – We take the following approach to the speculum examination:

•Vaginal inspection – Evidence of atrophic changes or vaginal tears, prolapse with ulceration, vaginal cancer (rare), vascular neoplasms, or vaginal endometriosis.

•Assess vaginal discharge – Evidence of vaginitis. Candidiasis, trichomonas, and bacterial vaginosis can all cause increased friability of vaginal and cervical tissues and increase the chance of postcoital bleeding. In postmenopausal individuals, atrophic changes can also present with signs of vaginitis, such as desquamative inflammatory vaginitis.

-(See "Vaginitis in adults: Initial evaluation".)

-(See "Acute cervicitis".)

-(See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Clinical manifestations and diagnosis".)

•Cervical evaluation – Look for mucopurulent cervicitis, polyps, lesions, or cancer. Grossly visible cervical lesions must be sampled using direct biopsy; a Pap test is not adequate evaluation for such lesions. Evaluate if ectropion is present and if it appears friable. A Q-tip test can be performed in which a Q-tip is used to gently probe the cervical surface to see if bleeding is provoked.

-(See "Acute cervicitis".)

-(See "Benign cervical lesions and congenital anomalies of the cervix".)

-(See "Invasive cervical cancer: Epidemiology, risk factors, clinical manifestations, and diagnosis".)

•Visualization of IUD and/or strings – Malpositioned (ie, low-lying) IUDs can cause pelvic pain, dyspareunia, and postcoital bleeding. IUD manufacturers recommend cutting IUD strings to a length of 3 to 4 cm upon insertion. Strings that appear significantly longer than this can indicate that the IUD has become malpositioned into the cervical canal. The white base of the IUD can sometimes be seen at the external os when an IUD is too low and located within the cervix rather than the uterine cavity. If the IUD is not directly visualized, the possibility of a malpositioned IUD can be investigated with transvaginal ultrasound if no other cause for postcoital bleeding is elucidated.

●Bimanual examination – The bimanual examination includes palpation of the adnexa and uterus. We assess for cervical motion tenderness, which can indicate pelvic inflammatory disease or other inflammatory peritoneal processes. We also assess for uterine enlargement and/or fibroids.

●General physical findings – As elevated body mass index (BMI) and polycystic ovary syndrome are risk factors for endometrial cancer, we assess the patient's BMI and look for signs of hyperandrogenism.

•(See "Endometrial carcinoma: Clinical features, diagnosis, prognosis, and screening".)

•(See "Diagnosis of polycystic ovary syndrome in adults".)

Laboratory testing — At the initial evaluation, we perform the following:

●Exclusion of pregnancy, if applicable. (See "Clinical manifestations and diagnosis of early pregnancy", section on 'Laboratory findings'.)

●Pap testing – Although supporting data are limited, the author performs Pap testing for individuals who have not had Pap testing within the last 12 months, even if they are not yet due for routine screening. Human papillomavirus (HPV) testing is also performed, if indicated. (See "Screening for cervical cancer in resource-rich settings", section on 'Symptomatic patients'.)

●Collection of swabs for gonorrhea, chlamydia, and trichomoniasis. (See "Acute cervicitis", section on 'Laboratory evaluation'.)

●Vaginal pH and wet mount to evaluate for Candida, bacterial vaginosis, and trichomoniasis. (See "Acute cervicitis", section on 'Laboratory evaluation'.)

●Biopsy of visible lesions. (See "Vulvar lesions: Diagnostic evaluation".)

●Endometrial biopsy (or transvaginal ultrasound) in postmenopausal individuals or those at increased risk of endometrial cancer. (See "Endometrial carcinoma: Epidemiology, risk factors, and prevention", section on 'Risk factors'.)

●Test for bleeding diathesis, in particular von Willebrand disease, if other bleeding symptoms or suggestive history is present and when the bleeding is persistent [11]. (See "Approach to the adult with a suspected bleeding disorder".)

Colposcopy — The use of colposcopy to evaluate patients with postcoital bleeding is controversial. Although some studies suggest colposcopy as a standard part of the evaluation [13,14], other studies have reported it is unlikely to add benefit when the patient has a normal appearing cervix and normal Pap testing [3,15-17]. For example, the risk of cervical cancer in individuals reporting postcoital bleeding who have normal, no, or insufficient Pap tests and who have a normal appearing cervix has been estimated to be 1/635 or 0.16 percent [15].

In addition, few studies have examined the incidence of cervical intraepithelial neoplasia or cervical cancer among individuals who report postcoital bleeding and have had negative HPV screening as part of their evaluation. Although HPV testing has been associated with more false positives than cytology screening, the negative predictive value of a negative HPV test approaches 100 percent in most studies [18]. Therefore, it is extremely unlikely that colposcopy will add valuable information in individuals who have a normal appearing cervix and negative HPV testing as well as negative cytology. In one retrospective study including 83 patients with postcoital bleeding and a negative co-test (cytology and HPV) referred for colposcopy, no patients were found to have a high-grade squamous intraepithelial lesion (HSIL) or cervical cancer [19].

Based on the available evidence, the author does not perform colposcopy for individuals with normal Pap testing and a normal appearing cervix. However, colposcopy is performed for patients with any Pap abnormality, a cervix that appears abnormal or friable, or in cases of persistent postcoital bleeding in which no other cause is identified.

Imaging — Imaging of the uterus can be obtained if the etiology is not identified with the above approach and especially if bleeding persists. Pelvic ultrasound is the preferred imaging choice. Hysteroscopy can be performed if endometrial polyps or submucosal fibroids are identified on pelvic ultrasound. No studies have examined the utility of imaging with computed tomography or magnetic resonance imaging for postcoital bleeding, and these would be unlikely to add value in the work-up.

ACTIVE HEAVY BLEEDING — Rarely, patients will present with active heavy bleeding after vaginal intercourse. When this occurs, the patient is expediently evaluated, and steps are quickly taken to control the bleeding source.

Causes

●Bleeding cervical mass – Advanced cervical cancer can present with a visible and often quite friable lesion.

●Vaginal tear or laceration – Vaginal tears from sexual trauma or consensual intercourse can, on occasion, cause acute and life-threatening bleeding, particularly in patients with prior hysterectomy (ie, vaginal cuff dehiscence). Vaginal tears are more likely to affect the posterior fornix due to its weaker layer of endopelvic fascia as well as the expansion and lengthening that occurs in the upper vagina during coitus [20].

●Bleeding anatomic abnormalities – Cervical polyps, prolapsing uterine fibroids, cervical cancers, or even large benign cervical ectropions can sometimes begin to bleed briskly upon examination with a speculum.

Management

●Heavy bleeding from cervix or laceration – Heavy bleeding can occur with invasive cervical cancers and vaginal tears, dehiscence, or laceration. We immediately attempt to tamponade the bleeding by packing the vagina with gauze or applying a pressure pack to the vulva, if possible. The patient is then urgently transferred to the operating room or the applicable clinical setting where bleeding control or repair can be performed. For hemodynamically stable patients with bleeding cervical cancer in whom tamponade of the bleeding can be achieved, vessel embolization may be appropriate.

For patients who are hemodynamically stable, grossly visible cervical lesions are sampled using direct biopsy; a Pap test is not an adequate evaluation for such lesions. Patients with hemodynamic instability can undergo biopsy once resuscitation has been completed and the bleeding is controlled.

●Bleeding from an anatomic abnormality – Patients with cervical polyps, prolapsed fibroids, and extensive ectropion can present with persistent slow bleeding. In addition, the speculum examination can cause bleeding from these lesions. In these instances, we apply pressure to the bleeding site with large cotton swabs (eg, Scopette) or gauze. Silver nitrate or Monsel solution can be applied to focal bleeding lesions. If these measures are ineffective or impractical to perform in the primary clinical setting, urgent transfer to a gynecology provider or the emergency department may be necessary.

TREAT INITIAL DIAGNOSES AND REASSESS — Individuals in whom a likely etiology is identified are treated accordingly. If the bleeding resolves with the intervention, then no further evaluation or treatment is indicated. Individuals who do not respond in an appropriate time frame are then reassessed for possible atypical presentation of common diagnoses or less common diagnoses. (See "Acute pelvic pain in nonpregnant adult females: Evaluation", section on 'Pursue less common diagnoses if symptoms persist'.)

Identified diagnoses — Management of postcoital bleeding depends on whether an identifiable cause of the bleeding has been determined or if bleeding remains idiopathic.

●Infectious – Treatment of common infections that can cause postcoital bleeding is discussed in related topics.

•(See "Acute cervicitis", section on 'Treatment'.)

•(See "Bacterial vaginosis: Initial treatment".)

•(See "Candida vulvovaginitis in adults: Treatment of acute infection".)

•(See "Trichomoniasis: Clinical manifestations and diagnosis".)

●Vulvar skin disorders – These include dermatoses such as lichen sclerosus or eczema. Typically, improving vulvar skin health will resolve postcoital bleeding related to vulvar skin disorders.

•(See "Vulvar lichen sclerosus: Clinical manifestations and diagnosis".)

•(See "Lichen planus".)

•(See "Vulvar dermatitis".)

●Vulvovaginal atrophic changes associated with hypoestrogenic state – While typically associated with the menopausal state, other patients who may experience atrophic changes related to hypoestrogenism are those who are lactating or taking estrogen-reducing medications (eg, gonadotropin-releasing hormone analogues, tamoxifen, aromatase inhibitors). (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment".)

•Lubricants – Lubricants can decrease friction and postcoital bleeding and are highly recommended for both lactating individuals and postmenopausal individuals. A wide variety of lubricants is available, including use of natural oils. Water-based lubricants are necessary when condoms are used, as oil-based lubricants can degrade condoms and decrease effectiveness. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment", section on 'Initial therapy with moisturizers and lubricants'.)

•Vaginal estrogen – Vaginal estrogen can be extremely effective in treating postcoital bleeding due to atrophic changes related to hypoestrogenism (table 3). (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment", section on 'Vaginal estrogen therapy'.)

●Vaginal granulation tissue – This is most commonly seen postpartum after the repair of vaginal lacerations and tends to be more common in lactating individuals. Silver nitrate can be applied to granulation tissue. If granulation tissue is extensive, it can be infiltrated with local anesthesia, excised using small scissors, and then treated with silver nitrate.

●Cervical or endometrial polyps – These benign lesions can cause postcoital bleeding and should be removed if identified. (See "Endometrial polyps".)

●Cervical ectropion – Cervical ectropion is the presence of columnar epithelium on the ectocervix (picture 1) and a frequent cause of postcoital bleeding. It is seen more commonly in adolescents, pregnant individuals, and individuals using estrogen-containing birth control methods. It should be stressed to the patient that this is a physiologic finding and is not dangerous. (See "Benign cervical lesions and congenital anomalies of the cervix", section on 'Ectropion'.)

Pregnant patients are observed and reevaluated after six to eight weeks postpartum. Management options for nonpregnant patients in whom cervical ectropion is associated with bothersome or frequent postcoital bleeding include the following, which are presented in the order that they are to be performed:

•Reassurance – Educating the patient about the normalcy and benign nature of cervical ectropion is important. For cases in which postcoital bleeding due to ectropion is not frequent or overly bothersome, reassurance is often the best approach. Postcoital bleeding due to cervical ectropion can sometimes be lessened by avoiding deep penetration during vaginal sexual activity.

•Change to progestin-dominant birth control method if relevant and acceptable.

•Silver nitrate can be applied to the ectropion.

•Cryotherapy – Cryotherapy is performed only for the most resistant or bothersome cases due to risks of cervical stenosis following treatment. In a trial that assigned 164 patients with persistent symptoms from cervical ectropion to either cryotherapy or placebo, the cryotherapy group reported a significant reduction in postcoital bleeding after treatment [21]. Of note, the placebo group also reported a large reduction (44 to 24 percent). The authors reported no significant complications from treatment, but follow-up duration was limited to six months.

•Cauterization – Electrocauterization techniques can be applied to the ectropion. Similar to cryotherapy, this can result in cervical stenosis and should be reserved for refractory cases. One study compared cryotherapy with cauterization for cervical ectropion, not postcoital bleeding per se, and reported similar outcomes for both treatment groups when followed for 14 weeks postprocedure [22]. In this study, electrocautery was associated with a higher incidence of pain during the procedure but was more cost-effective.

●Malignancy – Referral to specialty gynecology or gynecologic oncology providers should be arranged promptly.

●Nongynecologic source – Rarely, patients may present with postcoital bleeding that results from nongynecologic pathology seen at the time of examination. Examples include inflammatory bowel disease (particularly those associated with vaginal fistulae), and urethral caruncle. These patients are referred to the appropriate specialist for evaluation and management.

•(See "Rectovaginal and anovaginal fistulas".)

•(See "Urethral caruncle".)

No identified diagnosis (idiopathic) — Following evaluation, approximately 50 percent of patients will have no identified source or cause of their postcoital bleeding [4]. When a diagnosis explaining the bleeding is not found, reassurance and observation are often the best course. More than 50 percent of menstruating individuals will have lasting spontaneous resolution of their symptoms.

●Reassurance – Patients benefit from knowing that this symptom is not caused by malignancy or a sexually transmitted infection. Education that most cases will not have an identifiable cause and yet often still resolve on their own can be extremely helpful.

●Counsel and educate regarding the use of lubricants and adequate stimulation before penetration during vaginal sex.

●Encourage patients to return to care if symptoms persist, recur, or worsen.

PERSISTENT OR RECURRENT SYMPTOMS — When symptoms persist or worsen, we repeat the steps in the initial evaluation, with particular attention to risk factors for infection (eg, new sexual partner) and again ensure that the symptom is not due to cervical abnormalities, other dysplasia, or malignancy. If still no etiology is discovered, imaging and gynecologic referral can be pursued if not done previously. Colposcopy has been shown to be more helpful in finding occult malignancy or high-grade dysplasia when postcoital bleeding persists for more than four weeks and, thus, can be recommended at this time [23].

If not already done, we advise referral to a gynecologic specialist for individuals whose symptoms persist despite diagnostic tests and for individuals who experience persistent symptoms or frequent symptom recurrence following diagnostic test-directed therapy.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Abnormal uterine bleeding".)

SUMMARY AND RECOMMENDATIONS

●Causes – Postcoital bleeding can originate anywhere from the external genitalia to the upper reproductive tract, and all causes of genital tract bleeding must be considered (table 1). Benign etiologies are most common, but malignancy must also be excluded. Other causes of postcoital bleeding include direct trauma or abuse. However, in approximately one-half of patients, no cause will be identified. (See 'Potential causes' above.)

●Initial diagnostic approach – Despite the relatively common frequency with which this symptom is reported, there are no evidence-based guidelines for evaluation of postcoital bleeding; we take the following approach (see 'Initial diagnostic approach' above):

•History – The volume and frequency of bleeding are ascertained. Other relevant questions include whether or not the patient is actively bleeding, possibly pregnant, using a contraceptive method, and has had a Pap smear. (See 'History' above.)

•Physical examination – Physical examination is performed with the goal of identifying an etiology for the patient's complaint. The examination includes inspection of the external genitalia and urethra, speculum examination of the vagina and cervix, bimanual examination of the uterus and bilateral adnexa, and general physical assessment. (See 'Physical examination' above.)

•Laboratory – Laboratory testing is performed as directed by the history and may include pregnancy testing; collection of swabs for gonorrhea, chlamydia, trichomoniasis, Candida, and bacterial vaginosis; biopsy of the vulva or endometrium. (See 'Laboratory testing' above.)

•Colposcopy – The use of colposcopy to evaluate patients with postcoital bleeding is controversial. Although some studies support colposcopy as a standard part of the evaluation, other studies have reported it is unlikely to add benefit when the patient has a normal appearing cervix and normal Pap testing. The author reserves colposcopy for patients with any Pap abnormality, a cervix that appears abnormal or friable, or in cases of persistent postcoital bleeding in which no other cause is identified. (See 'Colposcopy' above.)

•Imaging – Imaging of the uterus, typically with pelvic ultrasound, can be obtained if the etiology is not identified with the above approach. (See 'Imaging' above.)

●Active heavy bleeding – Rarely, patients will present with active heavy bleeding after vaginal intercourse. When this occurs, the patient is expediently evaluated, and steps are quickly taken to identify and control the bleeding source. (See 'Active heavy bleeding' above.)

●Treatment – Individuals in whom a likely etiology is identified are treated accordingly. If the bleeding resolves with the intervention, then no further evaluation or treatment is indicated. Individuals who do not respond in an appropriate time frame are then reassessed for possible atypical presentation of common diagnoses or less common diagnoses. (See 'Treat initial diagnoses and reassess' above.)

●Persistent or recurrent symptoms – When symptoms persist or worsen, we repeat the steps in the initial evaluation, with particular attention to risk factors for infection (eg, new sexual partner) and again ensure that the symptom is not due to cervical abnormalities, other dysplasia, or malignancy. If still no etiology is discovered, imaging and gynecologic referral can be pursued if not done previously. Colposcopy has been shown to be more helpful in finding occult malignancy or high-grade dysplasia when postcoital bleeding persists for more than four weeks and, thus, can be recommended at this time. (See 'Persistent or recurrent symptoms' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Mark Shapley, DM, DCH, DRCOG, FRCGP, who contributed to an earlier version of this topic review.