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Sunday, August 17, 2025

Vaginal bleeding between periods or after sex


Introduction

Vaginal bleeding that occurs between regular menstrual periods (intermenstrual bleeding) or after sexual intercourse (postcoital bleeding) is considered abnormal uterine bleeding (AUB). While it is common and often benign, it can also signal underlying gynecological pathology, including malignancy, and therefore requires careful evaluation.

Normal menstrual bleeding is cyclical, occurring every 21–35 days, lasting 2–7 days. Any deviation—especially bleeding outside expected menstruation or triggered by sexual activity—warrants investigation.

Causes

1. Structural Causes

  • Cervical pathology

    • Cervical ectropion (erosion) – fragile glandular tissue bleeds easily after sex.

    • Cervicitis (inflammation, often due to sexually transmitted infections).

    • Cervical polyps.

    • Cervical cancer (important to rule out).

  • Endometrial pathology

    • Endometrial polyps.

    • Endometrial hyperplasia.

    • Endometrial cancer.

  • Vaginal causes

    • Vaginitis or atrophic vaginitis (postmenopausal estrogen deficiency).

    • Trauma (from intercourse, foreign body).

    • Vaginal cancer (rare).

2. Hormonal Causes

  • Anovulatory cycles (common in adolescents, perimenopause).

  • Hormonal contraception (breakthrough bleeding with oral contraceptives, implants, IUDs).

  • Thyroid disease.

  • Hyperprolactinemia.

3. Infectious Causes

  • Sexually transmitted infections (STIs): Chlamydia, gonorrhea, trichomoniasis.

  • Pelvic inflammatory disease (PID).

4. Other Causes

  • Pregnancy-related: Early miscarriage, ectopic pregnancy.

  • Coagulation disorders.

  • Medications (anticoagulants, hormonal therapies).

Clinical Presentation

  • Intermenstrual bleeding: Bleeding episodes outside the normal menstrual cycle.

  • Postcoital bleeding: Vaginal spotting or bleeding following intercourse.

  • May be accompanied by:

    • Vaginal discharge (infection).

    • Pelvic or abdominal pain (PID, ectopic pregnancy).

    • Systemic symptoms (fever, weight loss in malignancy).

Diagnostic Evaluation

1. History

  • Menstrual history: cycle length, flow, changes.

  • Sexual history, contraception, STIs risk factors.

  • Obstetric history.

  • Medications (especially contraceptives, anticoagulants).

2. Examination

  • Speculum exam: Cervix for ectropion, polyps, lesions, infection.

  • Bimanual exam: Uterine or adnexal tenderness/mass.

3. Investigations

  • Pregnancy test (always first step in reproductive-age women).

  • Pap smear / HPV testing: To detect cervical dysplasia or cancer.

  • STI screening: Chlamydia, gonorrhea, trichomonas.

  • Blood tests: CBC, thyroid function, coagulation profile.

  • Pelvic ultrasound (transvaginal): For uterine/endometrial pathology.

  • Endometrial biopsy: If endometrial cancer or hyperplasia suspected.

  • Colposcopy: If abnormal cervix or abnormal cytology.

Management

Treatment depends on the underlying cause.

1. Infections

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

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

  • Trichomoniasis: Metronidazole 2 g orally single dose.

2. Cervical Lesions

  • Cervical ectropion: Often benign, no treatment unless symptomatic → cauterization/cryotherapy if persistent.

  • Cervical polyps: Polypectomy.

  • Cervical cancer: Managed with oncological protocols (surgery, radiotherapy, chemotherapy).

3. Endometrial Causes

  • Endometrial polyps: Hysteroscopic polypectomy.

  • Endometrial hyperplasia:

    • Progestins (Medroxyprogesterone 10–20 mg daily or Levonorgestrel intrauterine system).

    • If atypia or malignancy → hysterectomy.

4. Hormonal Causes

  • Breakthrough bleeding (contraceptives): Adjust contraceptive dose/formulation.

  • Anovulatory bleeding: Cyclical progestins (e.g., Norethisterone 5 mg three times daily for 10–14 days).

  • Thyroid disease: Treat underlying hypothyroidism/hyperthyroidism.

5. Atrophic Vaginitis (Postmenopausal)

  • Local estrogen therapy: Estradiol vaginal tablets (10 µg twice weekly) or estradiol cream (0.5 g twice weekly).

6. Pregnancy-Related Causes

  • Ectopic pregnancy: Urgent surgical or medical management (Methotrexate 50 mg/m² IM single dose for selected cases).

  • Miscarriage: Expectant, medical (Misoprostol 800 µg vaginally), or surgical evacuation.

Precautions

  • Always rule out cancer in postcoital bleeding.

  • Pregnancy should be excluded before giving hormonal treatment.

  • Avoid NSAIDs and anticoagulants unless necessary.

  • Monitor hemoglobin levels in recurrent bleeding.

Drug Interactions

  • Metronidazole + Alcohol: Risk of disulfiram-like reaction.

  • Doxycycline + Antacids/Iron supplements: Reduced absorption.

  • Oral contraceptives + Enzyme-inducing drugs (rifampicin, carbamazepine): Reduced efficacy.

  • Warfarin + Antibiotics (metronidazole, doxycycline): Increased anticoagulant effect.

Red-Flag Features Requiring Urgent Referral

  • Postcoital bleeding in women >35 years.

  • Persistent intermenstrual bleeding despite treatment.

  • Abnormal cervical appearance (ulcer, growth, irregular surface).

  • Heavy bleeding causing anemia or hemodynamic instability.

  • Suspicion of ectopic pregnancy.




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