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Saturday, August 23, 2025

Bleeding between periods or after sex


Intermenstrual bleeding and Postcoital bleeding

Introduction

Abnormal uterine bleeding (AUB) refers to bleeding outside of normal menstrual patterns. Two common types are:

  • Intermenstrual bleeding (IMB): Bleeding between regular menstrual periods.

  • Postcoital bleeding (PCB): Bleeding that occurs after sexual intercourse.

While often benign, these symptoms should never be ignored, especially in women over 35, since they can be early signs of cervical or endometrial cancer.

Causes

1. Benign Gynecological Conditions

  • Cervical ectropion: Fragile glandular cells on cervix bleed easily.

  • Cervicitis: Inflammation of cervix (infective or non-infective).

  • Vaginitis: Infections such as Candida albicans, Trichomonas vaginalis.

  • Polyps: Cervical or endometrial polyps.

  • Fibroids: Submucosal fibroids can cause spotting.

2. Malignancy and Precancerous Conditions

  • Cervical cancer.

  • Endometrial cancer.

  • Vaginal cancer (rare).

  • Precancerous cervical lesions (CIN).

3. Hormonal / Endocrine Causes

  • Anovulatory cycles (common in adolescence, perimenopause).

  • Hormonal contraception (breakthrough bleeding with OCPs, IUDs).

  • Thyroid disorders, hyperprolactinemia.

4. Trauma

  • Vaginal or cervical tears after intercourse.

  • Foreign body.

5. Systemic / Medications

  • Anticoagulants (warfarin, DOACs, heparin).

  • Bleeding disorders (Von Willebrand disease, thrombocytopenia).

Clinical Features

  • Symptoms:

    • Light spotting or heavier flow between periods.

    • Vaginal bleeding after sex.

    • May be painless (ectropion, cancer) or painful (infection, trauma).

  • Associated symptoms:

    • Vaginal discharge, odor, itching (infection).

    • Pelvic pain, dyspareunia (fibroids, endometriosis).

    • Systemic symptoms: weight loss, fatigue (cancer).

    • Menstrual irregularities (hormonal imbalance).

Diagnostic Approach

1. History

  • Age, menstrual history, pattern of bleeding.

  • Contraceptive use, pregnancy risk.

  • History of STIs, Pap smear screening.

  • Associated symptoms (pain, discharge, systemic illness).

2. Examination

  • General: pallor, thyroid, bruising (bleeding disorder).

  • Pelvic exam: cervix (ectropion, polyps, masses, friability).

  • Bimanual exam: uterus size, adnexal tenderness.

3. Investigations

  • Pregnancy test (exclude early pregnancy or ectopic).

  • Cervical smear (Pap test): Cervical dysplasia, cancer.

  • HPV testing for high-risk strains.

  • STI swabs: Chlamydia, gonorrhea, trichomonas.

  • Transvaginal ultrasound (TVUS): Endometrial thickness, fibroids, polyps.

  • Endometrial biopsy: If >40 years or risk of cancer.

  • Colposcopy with biopsy: If abnormal cervix or Pap test.

  • Blood tests: CBC (anemia), TSH, prolactin, coagulation profile.

Management and Treatment

Treatment depends on cause, age, and reproductive goals.

A. General Measures

  • Reassure in benign, self-limiting causes (e.g., hormonal spotting).

  • Correct anemia with Ferrous sulfate 325 mg orally once or twice daily.

  • Manage risk factors (obesity, diabetes, hypertension).

B. Pharmacological Treatment

1. Infections

  • Chlamydia: Doxycycline 100 mg orally twice daily × 7 days.

  • Gonorrhea: Ceftriaxone 500 mg IM single dose + Doxycycline 100 mg orally twice daily × 7 days.

  • Trichomonas: Metronidazole 2 g orally single dose or 500 mg orally twice daily × 7 days.

  • Candidiasis: Fluconazole 150 mg orally single dose.

2. Hormonal Therapy

  • Combined oral contraceptive pills (COCPs): Regulate cycles.

  • Progestins:

    • Norethisterone 5 mg orally two to three times daily.

    • Medroxyprogesterone acetate 10 mg orally daily × 10–14 days per cycle.

  • Levonorgestrel intrauterine system (LNG-IUS): Reduces intermenstrual bleeding.

3. Bleeding Disorders

  • Tranexamic acid 1 g orally three times daily during bleeding episodes.

C. Procedural / Surgical Treatment

  • Cervical ectropion: Cryotherapy, cauterization if symptomatic.

  • Polyps: Hysteroscopic polypectomy.

  • Fibroids: Myomectomy or hysterectomy if symptomatic.

  • Endometrial hyperplasia/cancer: Hysterectomy ± radiotherapy/chemotherapy.

  • Cervical cancer: Depends on stage (surgery, radiotherapy, chemotherapy).

Complications

  • Iron-deficiency anemia.

  • Missed cancer diagnosis.

  • Infertility (from chronic infections, endometrial disease).

  • Psychological stress, sexual dysfunction.

Prognosis

  • Young women with hormonal or infectious causes: Excellent once treated.

  • Benign lesions (polyps, ectropion): Easily managed with minor procedures.

  • Cervical/endometrial cancer: Prognosis depends on early detection — hence screening is critical.

Patient Education

  • Any bleeding between periods or after sex should be evaluated by a healthcare professional.

  • Regular Pap smears and HPV vaccination reduce cancer risk.

  • Practice safe sex to prevent STIs.

  • Maintain healthy weight and control chronic conditions.

  • Report red flags: persistent bleeding, postmenopausal bleeding, associated pain, discharge, weight loss.




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