Post-coital bleeding: causes, tests and when to see a GP

Post-coital bleeding (PCB) is bleeding from the genital tract that happens during or after sexual intercourse and is not part of a period. The North Tees and Hartlepool NHS Foundation Trust leaflet explains that the blood may come from the cervix or the lining of the vagina, can range from light spotting to heavier bleeding, is often painless and may look bright red or brown.

It is more common than people think. A Greater Glasgow and Clyde NHS guideline says that approximately 13% of women aged 20 to 24 will experience PCB in any given year, and that in this age group only 0.002% of cases are due to cervical cancer. The guideline stresses that only very few women with this symptom have serious pathology and that the remainder have benign causes.

The North Tees leaflet says that often no cause is found for bleeding after sex. When one is found, the common causes listed are the following.

• Infections, including sexually transmitted infections. The NHS lists bleeding after sex or between periods among the symptoms of chlamydia in women, though most people with chlamydia have no symptoms.

• Polyps, which are non-cancerous growths on the cervix or womb.

• Vaginal dryness. The NHS says vaginal dryness can follow menopause, pregnancy or breastfeeding, some medicines such as hormonal contraceptives or antidepressants, and cancer treatments.

• Minor trauma or irritation.

• Cervical ectropion, described as a harmless change where cells from inside the cervix are present on its outer surface.

• Abnormal cervical cells (pre-cancerous changes).

• Cervical or vaginal cancer, which is rare.

Bleeding after sex should be reported even if it happens only once or seems light. The NHS vaginal dryness page lists bleeding after sex, in between periods or after menopause among reasons to see a GP, and for postmenopausal bleeding the NHS says to see a GP even if it is only a small amount or has only happened once, because it can be a sign of cancer and cancer may be easier to treat when found early.

You do not need to wait for a routine cervical screening appointment. The NHS invites women aged 25 to 64 to cervical screening every 5 years, but screening is for people without symptoms; bleeding after sex is a symptom that needs its own assessment. The Glasgow guideline says PCB is not an indication for a cervical smear in those aged under 25, who would instead be assessed clinically.

The Glasgow guideline lists what the history should cover: the nature and timing of the bleeding, menstrual history, smear and colposcopy history, contraception, sexual history for infection where appropriate, and medical history and medicines such as anticoagulants. Examination includes a bimanual examination and a speculum examination, with swabs and a screen for chlamydia and gonorrhoea where appropriate and a cervical smear if one is due.

The North Tees leaflet describes the clinic visit. A doctor or specialist nurse asks about your health, medicines, periods and contraception or HRT, then inserts a speculum, as in cervical screening, to look at the cervix and vaginal walls. Photographs may be taken for the record, and if an abnormality such as abnormal cells or a polyp is seen, a biopsy may be recommended. The leaflet says biopsy results usually arrive by letter within 4 weeks, with a copy to your GP. Inhaled pain relief is available if the examination is uncomfortable.

Your GP may arrange cervical swabs before referral and review your smear history. The guideline says that women with suspicious findings should be referred to colposcopy as urgent and seen within 10 working days, whereas women with persistent bleeding, a normal smear history and a normal speculum examination are tested for infection and treated where appropriate. Waiting times and thresholds differ between UK nations and local services.

Treatment depends entirely on the cause. For cases where cervical disease has been excluded, the Glasgow guideline lists treating infection, removing endocervical polyps and considering a change of hormonal contraceptive. For vaginal atrophy it lists topical oestrogen, and for women over 40 in whom those measures have failed, assessment of the womb lining.

The NHS suggests that for vaginal dryness, water-based lubricants before sex and vaginal moisturisers can help, and that a GP may prescribe hormone creams, gels or patches where hormone changes are the cause. If chlamydia is found, the NHS says it is treated with antibiotics and partners need to be tested.

The Glasgow guideline says women with an abnormal cervical screening result are referred to colposcopy under the usual protocols. Most people, however, have benign findings and need reassurance or simple treatment.

For most people the outlook is good, because the usual causes are minor and treatable and many episodes settle without a specific cause. A recurrence should be reported again rather than assumed to be the same harmless problem.

On the NHS, the route is a GP or sexual health clinic, with referral to a gynaecology or colposcopy clinic if needed. Private gynaecology appointments can offer quicker access to examination and colposcopy, but the assessment follows the same principles, and any biopsy or screening history will still need to be shared with your GP.