Intermenstrual and Post-Coital Bleeding

Intermenstrual bleeding (IMB) and post-coital bleeding (PCB) are common gynaecological presentations with a wide range of benign, infective, hormonal, structural and — uncommonly — malignant causes. They are symptoms, not diagnoses, and both require their own triage pathway distinct from heavy menstrual bleeding (HMB): it does not include other types of abnormal uterine bleeding such as intermenstrual bleeding and postcoital bleeding, and intermenstrual bleeding and postcoital bleeding require separate investigation and management; they should not be treated as for heavy menstrual bleeding.

Red flags

There are important not-to-miss causes of irregular bleeding: pelvic inflammatory disease (PID), pregnancy or ectopic pregnancy, cervical cancer, endometrial cancer.

Definitions and classification

• IMB is vaginal bleeding at any time other than during normal menstruation or following intercourse. PCB is vaginal bleeding after intercourse. (HNE HealthPathways’ own working definitions — bleeding between menses or between expected hormone withdrawal bleeds,” and “bleeding noted within 24 hours of vaginal intercourse” — are given below under the HNE approach.) “Neither IMB nor PCB is itself a diagnosis — both are symptoms that always warrant further assessment.

Abnormal uterine bleeding as a whole is classified using the FIGO PALM-COEIN system into structural causes — Polyp (endometrial or endocervical polyps, focal outgrowths of tissue that may be asymptomatic or cause intermenstrual bleeding), Adenomyosis, Leiomyoma (fibroids), and Malignancy and hyperplasia (endometrial hyperplasia and cancers, often presenting with unpredictable bleeding) — and non-structural causes: Coagulopathy (systemic bleeding disorders, eg von Willebrand disease, common causes of heavy menstrual bleeding particularly in adolescents and young adults), Ovulatory dysfunction (conditions like polycystic ovary syndrome, hypothalamic disorders, or thyroid dysfunction that lead to infrequent, irregular, heavy, or prolonged bleeding due to inconsistent ovulation), Endometrial, Iatrogenic (medications such as hormonal contraceptives, anticoagulants, or tamoxifen, or surgical injury such as Asherman syndrome), and Not otherwise classified.

Causes (Murtagh)

Periovulatory bleeding (normal variant); defective luteal phase (premenstrual spotting); endometriosis (pre- and postmenstrual spotting); hormonal contraceptives and copper IUD; menopausal hormone therapy; pregnancy — early loss or ectopic; cervical ectropion; STIs causing cervicitis or PID (especially if PCB); polyps (cervical, endometrial); uterine fibroids; cervical cancer; endometrial/myometrial hyperplasia and malignancy.

Cervical causes specifically

Because PCB in particular is so often cervical in origin, it is worth separating out causes of bleeding arising from the cervix itself: cervicitis, cervical endometriosis, severe pelvic organ prolapse, physical trauma (including insertion of objects, sexual assault), cervical polyps/cysts/papilloma, and cervical intraepithelial neoplasia or cancer. Cervical ectropion — eversion of the columnar endocervical epithelium onto the ectocervix — is a normal variant that bleeds readily on contact (intercourse, speculum or bimanual examination) and is not itself a marker of malignancy, but its diagnosis is one of exclusion once cancer and infection have been ruled out.

Examination and investigations

Perform an abdominal, bimanual pelvic examination and speculum examination. Check for cervical ectropion, presence of polyps, vaginal discharge and cervical tenderness. Note any friability of the cervix.

Investigations: cervical cancer “co-test” (i.e. HPV and liquid-based cytology), transvaginal ultrasound (especially for IMB), endocervical swabs for chlamydia and gonorrhoea PCR, pregnancy test (if appropriate).

RANZCOG best-practice recommendations

RANZCOG’s dedicated best-practice statement on IMB/PCB (C-Gyn 6, current July 2021) makes three consensus-based recommendations:

1. Genital tract malignancy is an uncommon cause of abnormal bleeding at any age, is rare in young women, but must be considered in all patients.
2. Women at risk of sexually transmitted infection should have appropriate tests performed. Women with persistent intermenstrual bleeding (IMB) should have a cervical co-test (HPV and LBC) in Australia and smear in New Zealand, a pelvic ultrasound and referral to a gynaecologist.
3. Women reporting postcoital bleeding (PCB) should have tests to exclude cervical cancer and chlamydia. It is commonly accepted that a single episode of PCB in a woman who has a normal cervical screening test and cervical appearance does not warrant immediate referral, but recurrence or persistence of this symptom mandates referral to a gynaecologist.

All three recommendations are graded consensus-based (insufficient robust trial evidence; agreed by RANZCOG’s Women’s Health Committee) rather than evidence-based — reflecting the genuine absence of RCT-level data driving IMB/PCB triage internationally, not a gap specific to this note.

Management (RANZCOG framework)

All women with persistent PCB require the cervical cancer co-test and gynaecologist referral for colposcopy. Immediate referral is not required after a single episode, provided examination and the co-test are normal. A second episode mandates referral.

If the suspected cause of PCB is cervical ectropion, persistent bleeding still requires referral. Various ablative treatment methods are available, but are appropriate only once pathology has been excluded.

While irregular bleeding is common with many hormonal therapies, investigation is required and referral should be considered if bleeding is excessively frequent, prolonged or new in onset.

Persistent IMB requires gynaecologist referral for hysteroscopy with endometrial biopsy.

HNE HealthPathways approach

Intermenstrual bleeding refers to bleeding that occurs between menses or between expected hormone withdrawal bleeds in women using some forms of hormonal contraception. Post-coital spotting refers to vaginal bleeding that is noted within 24 hours of vaginal intercourse.

Early referral for gynaecological assessment is recommended for women with: high-risk factors for malignancy; a history of chronic anovulation; age >40 years; exposure to tamoxifen or unopposed oestrogens; a strong family history of endometrial or bowel cancer. Using a menstrual diary or app can be useful in assessment.

Assessment. Practice point: do not delay appropriate investigations, including a diagnostic co-test (HPV and LBC), because of the presence of blood in women with abnormal vaginal bleeding. Assess for pregnancy and miscarriage and ectopic pregnancy and manage promptly. For non-pregnant patients, assess as follows.

Post-coital bleeding: take a careful history, including sexual history. Examine with speculum and bimanual palpation, looking at appearance of cervix and checking for cervical polyps. Perform STI testing and a diagnostic co-test (HPV and LBC). In patients of any age with recurrent or persistent post-coital bleeding, refer for gynaecology assessment, even with a normal negative co-test — see also the Cancer Council’s Investigation of Women With Abnormal Bleeding.

Irregular bleeding related to hormone contraception: enquire about correct use of hormone contraception — missed pills, continuous taking of hormone pills over several months, only started hormonal contraception in the last 3 months, or using a progesterone-only method or low-dose combined pill. Check for medications that may interact with contraceptives by inducing CYP3A4: aprepitant, bosentan (moderate), carbamazepine (strong), corticosteroids, dabrafenib, efavirenz (moderate), etravirine (moderate), modafinil (moderate), nevirapine, phenobarbitone, phenytoin (strong), rifabutin, rifampicin (strong), ritonavir, St John’s wort (strong), tipranavir, vemurafenib. If indicated, or the patient is aged <30 years, perform a cervical screening test and STI testing.

Intermenstrual bleeding: take a careful history, including sexual history, quantity of bleeding, and impact on quality of life — a menstrual diary or app can help. Examine the cervix (look for cervical polyps), vagina and vulva, and perform a bimanual pelvic examination checking for cervical excitation for PID, and for uterine size and adnexal tenderness. Perform a diagnostic co-test (HPV and LBC). Perform STI testing for all patients aged ≤30 years, and at-risk patients. If heavy or significant bleeding, follow the Heavy or Irregular Menses pathway; if the patient is postmenopausal, follow the Post-menopausal Bleeding pathway — see also the Cancer Council’s Investigation of Women With Abnormal Bleeding.

Management. For pregnant patients, see Miscarriage and Ectopic Pregnancy. Pre-menopausal women who have a single episode of postcoital bleeding and a clinically normal cervix do not need to be referred for colposcopy if oncogenic HPV is not detected and LBC is negative. Refer all patients of any age with recurrent or persistent post-coital bleeding for gynaecology assessment, even with a negative co-test. Refer all patients with unexplained intermenstrual bleeding or post-menopausal bleeding for gynaecology assessment regardless of co-test (HPV and LBC) result. If HPV is detected and/or LBC is abnormal, or there’s concern about the appearance of cervix, vagina, or vulva, refer for gynaecology assessment. If recent-onset adnexal, uterine or cervical motion tenderness and either age <30 years or a change in sexual partner, treat as Pelvic Inflammatory Disease (PID). For STIs, follow Sexual Health pathways per the Australasian STI Management Guidelines.

If the bleeding appears related to the contraceptive method and the patient has been on their current form of contraception for at least 3 months, consider increasing the progestogen or the oestrogen dose up to 35 micrograms; if the patient is on a progestogen-only method (POP, depot medroxyprogesterone acetate, or an etonogestrel implant), consider a Mirena IUD. If symptoms persist ≥3 months and are not thought related to hormonal contraception, refer for routine gynaecology assessment. If suggestive of a polyp, follow the Cervical Polyps pathway. Review at 3 months to ensure abnormal bleeding has resolved, there are no abnormal results and no significant risk factors. If any abnormality persists, refer for routine gynaecology assessment — otherwise, advise the patient to return for review if they notice any new changes or are concerned about their menstrual bleeding pattern.

From https://hne.communityhealthpathways.org/15985.htm