Post coital bleeding (PCB) is any vaginal bleeding or spotting that occurs during or after sex, that is separate to a period (or menstruation). While this can occur for a number of reasons (mostly innocent), it can sometimes be a sign of an infection or abnormal cells. So such bleeding should be investigated if it is: recurrent (occurs more than once); heavy; or associated with other symptoms.

What are some “normal” changes that can cause post-coital bleeding?

The vagina and cervix are sensitive to hormonal changes, specifically oestrogen. These can cause changes to the cells that may make you more susceptible to bleeding.

Cervical ectropion

During periods of high oestrogen (usually during reproductive years, and especially with the combined oral contraceptive pill or pregnancy), the delicate cells that line the inside of the cervix migrate to the outside of the cervix. This is a completely normal and benign event. The cervix appears red, and sometimes is more likely to bleed when touched (ie: during sex).

Atrophy

‘Atrophy’ is a thinning of the skin in the vulva, vagina and cervix due to a lack of oestrogen. This is most commonly seen in women who have gone through menopause, although is also common after having a baby (in the ‘post-partum’ period), and breastfeeding women. It may also be associated with symptoms of dryness or itch and irritation. It is another common reason that women may have bleeding during or after sex.

What are some other causes of post-coital bleeding?

Trauma / cuts

Just like any skin on the body, the skin cells in the vagina can bleed due to trauma or cuts. It is possible to have vaginal tearing during sex, or even some small grazes (or ‘micro-tears’) that may cause spotting. This is more common if: there is a lack of lubrication; sex is very vigorous; foreign objects are used; or there is underlying ‘atrophy’ (see above). The first time someone has penetrative sex, there can be tearing of the hymen (skin at the opening of the vagina), which may cause light bleeding or spotting for a few days afterwards.

Infections

One of the common reasons for post-coital bleeding is an infection in the cervix, or ‘cervicitis’. This is often caused by sexually transmitted infections – such as chlamydia, gonorrhea, or trichomoniasis. Yeast infections (or thrush) can also cause inflammation in the vagina, and make you more likely to have bleeding with sex.

Dysplasia (abnormal pre-cancerous cells) or malignancy (cancerous cells)

The cells on the cervix can develop abnormal cells known as dysplasia or cervical intra-epithelial neoplasia (CIN). These are considered pre-cancerous changes, and are usually easily treatable with a day procedure. This is an important cause of post-coital bleeding that needs to be excluded. Rarely, post-coital bleeding can be a sign of cervical cancer.

Polyps

Polyps are like little skin tags that grow on the cervix. They are usually benign, but contain delicate cells that are more likely to bleed when touched. They are often easily removed.

No cause found

In up to 50% of women with post-coital bleeding, no cause for the bleeding can be found. Although this can be distressing, if serious conditions, such as infections and abnormal cells have been excluded, then you can be reassured that her bleeding is not a sign of something abnormal.

What tests or investigations do I need?

If you have post-coital bleeding that is heavy or recurrent, it is important you see your GP. Initial tests include a physical exam, where your doctor will use a speculum to look at the vagina and cervix, and see if there is any abnormality. They may also perform swabs for infections, and a cervical screening test (previously called a Pap smear) to look for abnormal pre-cancerous cells.

If these investigations are all normal, and your post-coital bleeding continues, then some women may require a pelvic ultrasound to look for other possible causes, such as a polyp.

Colposcopy is a test where a gynaecologist looks are the cervix with a microscope. Please see this blog post for more details about colposcopy.

Colposcopy is not usually required if your cervical screening test is normal. Current guidelines recommend a colposcopy for post-coital bleeding only if the cervical screening test is abnormal, the cervix looks abnormal, or if the bleeding is persistent or recurrent.

Is there any treatment for post-coital bleeding?

The treatment for post-coital bleeding depends on the cause.

• Infections can be treated with antibiotics or anti-viral medications
• Atrophy can be treated with vaginal oestrogen
• Polyps can be removed (often in a gynaecologist’s office)
• Dysplasia or abnormal cells usually require a day procedure where the abnormal cells are removed from the cervix
• Sometimes swapping to a different form of contraception can also help

In the vast majority of women where no cause is found, the bleeding spontaneously resolves and does not recur.

Frequently asked questions

I’ve had bleeding after sex: should I see a doctor?

Post-coital bleeding is very common. It is important to see a doctor if the bleeding is heavy or recurrent. It is also important to see a doctor if you are worried about a sexually transmitted infection, or if your cervical screening test is overdue.

When do I need to see gynaecologist for post-coital bleeding?

It is recommended that you see a gynaecologist if the initial tests are all normal (no cause found), and your symptoms are persistent.

What will a gynaecologist do for post-coital bleeding?

We will take a full gynaecological history, including your current symptoms, sexual, menstrual and contraceptive history. We will also perform an exam to look at the cervix. We will review the tests that have already been done, and order any other investigations required. If your bleeding is recurrent, you may need to have a colposcopy – where we look at your cervix with a microscope.