Post-coital bleeding: what causes it and what to do when it occurs?

Post-coital bleeding occurs when a woman experiences blood loss from the vagina after sexual activity. It is bleeding that is not related to menstruation (1,2). Furthermore, the amount of blood is variable, as are the causes. Sometimes, the symptom appears on its own. At other times, it comes with pain during intercourse (3). 

Common causes of post-coital bleeding 

This symptom is often a cause for concern. When it happens, you think something may be wrong with your sexual health or gynaecological health. And while it is most often a temporary problem, it should not be underestimated (2). 

Among the common causes of post-coital bleeding, the most important are the following: 

• Irritation of the vagina: lack of vaginal wetness can lead to a lot of friction during intercourse. This is a problem that becomes more common as you go through menopause. Vaginal dryness can also be the result of atrophy, a thinning of the mucous membrane of the vagina (3). 

• Sexually transmitted infections (STIs): one of the signs of chlamydia or gonorrhoea is bleeding during intercourse. This is due to inflammation throughout the genital area (4). 

• Injuries: both the vagina and the cervix can suffer lacerations. These are usually caused by vigorous sexual activity or the use of objects for masturbation. After injury, subsequent intercourse may be accompanied by bleeding (5). 

• Hormonal changes: the decrease in oestrogen that comes with menopause leads to vaginal changes that may be associated with bleeding. It also occurs during pregnancy (6,7). 

Less common causes of post-coital bleeding 

On the other hand, there are more severe causes associated with bleeding after intercourse. They are rare, but will be considered by the doctor for diagnosis, for example: 

• Polyps: cervical polyps are abnormal growths on the cervix. They are tissue that is prone to bleed when vaginal penetration causes friction. Specifically, they cause inflammation and erosion of the surrounding tissues (1). 

• Ectropion: this occurs when the cells of the inner lining of the cervix move outwards. As the tissue is richer in blood vessels, their exposure promotes post-coital bleeding. These cells are more susceptible to friction and are considered more fragile (1,3). 

• Cancer: in less frequent cases, bleeding after sexual intercourse is a sign of vaginal or uterine cancer. It usually occurs when the disease is advanced. This is because the neoplasm invades nearby blood vessels. The invasion makes them more prone to bleed with any kind of trauma, such as during intercourse. Also, in advanced stages, bleeding ulcers may form in the affected tissue (8,9). 

Diagnosis and treatment 

In the presence of post-coital bleeding, you should appoint a medical consultation. The practitioner will make a detailed history. They will then ask about the characteristics of the bleeding and other accompanying symptoms and situations. For example, they will want to know if you use contraceptives, if you used a condom, and if there are signs of other sexually transmitted infections, such as warts in the anus (3). 

Then, they will perform a physical examination. This may include a colposcopy. In this procedure, the doctor visualises the cervix with an instrument (1,9). Depending on the initial findings, he may order additional methods. These may include blood tests for STIs and imaging tests, such as ultrasound or MRI (1,2,3). 

Treatment of post-coital bleeding will vary depending on the identified cause. The most used options are: 

• If the doctor detects an infection, they will prescribe specific antibiotics (3). 

• If you have cervical polyps, that will require a minimally invasive intervention to remove the lesions. Cauterisation or surgical removal may be chosen (10). 

• Dryness can be addressed with vaginal lubricants. In women going through menopause, the use of hormone replacement therapy to stabilise oestrogen levels will be considered. Sex education will play an important role, as knowledge of erogenous zones can improve foreplay and increase lubrication (6).  

Bleeding after intercourse does not only have a physical component. It may also affect sexual desire, as there is a fear of a repeated episode. This is why you need an accurate diagnosis to provide reassurance and solutions, so it is not advisable to delay the consultation.

Bibliographic references 

1. NHS. What causes a woman to bleed after sex? [Internet]. UK: National Health System; 2021 [cited 2024 Apr 4]. Available from: https://www.nhs.uk/common-health-questions/sexual-health/what-causes-a-woman-to-bleed-after-sex/

2. Ahmed N. Postcoital bleeding. [Internet]. InnovAiT; 2023 [cited 2024 Apr 4];16(5):254–8. Available from: http://dx.doi.org/10.1177/17557380231156626

3. Cleveland Clinic. Bleeding After Sex: What You Should Know. [Internet]. EE. UU.: Cleveland Clinic 2022 [cited 2024 Apr 4]. Available from: https://health.clevelandclinic.org/what-should-you-do-if-you-bleed-after-sex

4. Septiana N, Ramdhani D, Hapsari Y. Recognizing sexually transmitted infections and their treatment. KESANS: International Journal of Health and Science [Internet]. 2021 [cited 2024 Apr 4];1(2):104–16. Available from: https://kesans.rifainstitute.com/index.php/kesans/article/view/7/11

5. Shiragur S, Patil S, Gudadinni M, Patil V, Biradar A, Patil P. Vaginal Injuries Following Consensual Sexual Intercourse and Trauma - A Case Series [Internet]. International Journal of Anatomy, Radiology and Surgery; 2021 [cited 2024 Apr 4]; 10(2): SS01-SS02. Available from: https://digitallibrary.kohasupport.in/bitstream/123456789/4515/1/165_2021.pdf

6. Sarmento A, Costa A, Vieira P, Giraldo P, Eleutério J Jr, Gonçalves A. Genitourinary syndrome of menopause: Epidemiology, physiopathology, clinical manifestation and diagnostic. [Internet]. Front Reprod Health; 2021 [cited 2024 Apr 4];3. Available from: http://dx.doi.org/10.3389/frph.2021.779398

7. Kabiri D, Amsalem H, Watad H, Lipschuetz M, Haj-Yahya R, Alter R, Ezra Y. Assessing the clinical significance of third-trimester post-coital bleeding. Fetal Diagn Ther [Internet]. 2024 [cited 2024 Apr 4];51(2):168–74. Available from: https://karger.com/fdt/article-pdf/doi/10.1159/000535707/4059031/000535707.pdf

8. Cohen O, Schejter E, Agizim R, Schonman R, Chodick G, Fishman A, Hershko A. Postcoital bleeding is a predictor for cervical dysplasia. [Internet]. PLoS One; 2019 [cited 2024 Apr 4];14(5):e0217396. Available from: http://dx.doi.org/10.1371/journal.pone.0217396

9. Ardestani S, Dason ES, Sobel M. Postcoital bleeding. [Internet]. CMAJ; 2023 [cited 2024 Apr 4];195(35):E1180–E1180. Available from: https://www.cmaj.ca/content/cmaj/195/35/E1180.full.pdf

10. Burns S. Cervical Polyps. [Internet]. UK: National Health System Cornwall and Isles of Scilly; 2021 [cited 2024 Apr 4]. Available from: https://rms.cornwall.nhs.uk/rms/primary_care_clinical_referral_criteria/primary_care_clinical_referral_criteria/gynae/cervical_polyps