Intermenstrual and Post-coital Bleeding

Intermenstrual bleeding (IMB) refers to vaginal bleeding (other than post-coital) at any time during the menstrual cycle other than during normal menstruation.
Post-coital bleeding (PCB) is non-menstrual bleeding that occurs immediately after sexual intercourse.

Self-reported IMB and PCB have an annual cumulative incidence of 17% and 6% respectively in menstruating women from a questionnaire study based on subjects within an urban English, general practice setting.² PCB occurs in 0.7-39% of women with cervical cancer. The risk of a woman seen in the community with PCB having cervical cancer is approximately 1 in 44,000 in 20-24 year olds and 1 in 2,400 in 45-54 year olds.³

In an English study, looking at pathological findings from a group of women referred to colposcopy for PCB but with a negative previous cervical smear:¹⁰

• 7% had CIN (i.e. abnormal histology despite a normal smear)
• 12% had cervical polyps
• 33.% had an ectropion
• 2% had chlamydia
• 50% had no pathology
• Nobody had invasive cancer

Thus, we can reassure patients that there is no serious pathology in the majority of women experiencing PCB.

Only 2% endometrial cancers occur before 40 years old. Risk factors include:

• Nulliparity
• Diabetes
• Obesity
• Polycystic ovary syndrome
• Chronic anovulatory cycles
• Use of tamoxifen

Women at high risk of endometrial cancer with IMB should be fully investigated.

History

• Menstrual history:
  • Age of menarche
  • Regularity and cycle length
  • Presence of menorrhagia
  • Duration of bleeding
  • Regular or irregular bleeding
  • Timing of bleeding in the menstrual cycle
  • Associated symptoms e.g. abdominal pain
  • Factors that aggravate bleeding e.g. exercise, intercourse
• Gynaecological history:
  • Use of contraception
  • Smears - most recent test results, any previous smear abnormalities, colposcopy, treatment for abnormalities etc.
  • Previous gynaecological investigations or surgery
  • Sexually transmitted infections
• Medical history - e.g. bleeding disorders, diabetes
• Current medication (including unprescribed)

Examination

• Establish that the bleeding is from the vagina, not the rectum or in the urine. Any doubt can be eliminated by inserting a tampon which will confirm presence of blood in the vagina.
• Pregnancy test if appropriate. If positive, exclude ectopic pregnancy.
• BMI - high BMI is an independent risk factor for endometrial cancer.
• Abdominal examination noting the presence/absence of pelvic masses.
• PV examination (speculum and bimanual) looking for obvious genital tract pathology. Note whether any contact bleeding occurs, friability of tissue, cervical tenderness, presence of ulceration, polyps or discharge and any other lower genital tract sites of bleeding. Common findings include:
  • Cervical ectropion (or erosion) - appears as a red ring around the external os due to extension of the endocervical columnar epithelium over the ectocervix.
  • Cervical polyp - mass arising from the endocervix, usually protruding through the external os into the vagina. They can be avulsed and sent to histology. Occasionally endometrial polyps can be seen extruding through the cervix.
  • Cervicitis - the cervix appears red, congested and sometimes oedematous. There may be purulent discharge and the cervix is usually tender to palpation. The most common causes of infection are Neisseria gonorrhea and Chlamydia trachomatis. A rarer cause is Trichomonas vaginalis where the cervix is friable, with prominent papillae and punctate haemorrhages and is commonly described as a 'strawberry cervix'. Herpetic cervicitis gives rise to multiple ulcerated regions.
• If appropriate, take a cervical smear and a STI screen as part of the examination.

Other possible investigations include:

• Blood tests:
  • FBC
  • Clotting
  • Thyroid function
  • FSH/LH levels (if onset of menopause suspected)
• Transvaginal ultrasound - Ultrasound should ideally be done immediately postmenstrually as the endometrium at its thinnest and polyps and cystic areas tend to be more obvious. An endometrial thickness of 8 mm or less is significantly less likely to be associated with a malignant pathology.¹¹ Pathology can be missed on ultrasound in the presence of an IUCD due to reflections and shadowing even by an experienced operator.¹²
• Endometrial biopsy - Endometrial biopsy may be done as a surgery or clinic-based procedure using the Pipelle device or Vabra aspirator.¹³ Their disadvantage is that they miss up to 18% of focal lesions.⁴
• Hysteroscopy - Hysteroscopy with biopsy is the current gold-standard for investigating the uterine cavity, allowing direct visualisation and tissue diagnosis.¹⁴ In many centres, it can be done as a clinic procedure.
• Colposcopy

Despite the low rate of serious pathologies seen in referred PCB cases, there is a concern that these women are at an increased risk of CIN even with a negative recent smear and continue to warrant colposcopy referral.¹⁵

Management is dependant on the cause of the bleeding:

• If gynaecological cancer is suspected, refer urgently for investigation. Do not wait on the results of a smear test or be deterred by a previous negative result where clinical suspicion is high.
• Cervical ectropions:
  • May resolve if the COCP is stopped or following pregnancy
  • Can be treated conservatively
  • If treatment is desired, options include thermal cautery and diathermy, cryosurgery, laser or microwave therapy.¹⁶
• Cervical polyps:
  • Avulse and send for histology
  • They are accompanied by endometrial polyps in about 25%,¹⁷ so further investigation (ultrasound +/- hysteroscopy), particularly in older women, can be indicated.
• Cervicitis:
  • Antibiotics dependent on organism involved
  • Contact tracing and treatment of sexual partners
  • Electrocautery of secondarily infected Nabothian follicles in chronic cervicitis
• Dysfunctional uterine bleeding (DUB) is the most common cause of abnormal vaginal bleeding (usually menorrhagia) during a woman's reproductive years. However, it is a diagnosis of exclusion and should only be diagnosed after pregnancy, iatrogenic and systemic causes and genital tract pathology have been excluded.¹² It is most common at the edges of reproductive life, in the pubertal and perimenopausal phases and is associated with anovulatory cycles in 70% of cases and, in these cases, is caused by endometrial hyperplasia.