Intermenstrual and Post-coital Bleeding

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

Background/Epidemiology

• IMB and PCB commonly occur together
• Around a third of patients with heavy menstrual bleeding (occurs in around 14% of women) may have some intermenstrual bleeding.  Perimenopausal woman commonly experience some intermenstrual bleeding (up to 24%)
  • Although the majority of patients will not have a serious underlying cause, all patients should be investigated as such

History

• Where appropriate, take a full gynaecological history
  • Ask particularly about menstrual history (LMP; cycle- regularity, length, duration and amount of bleeding)
  • Any associated symptoms e.g. abdominal pain
    • Particularly those which may suggestive infective causes e.g. vaginal discharge, fever, dyspareunia
  • Ask about any factors that influence the bleeding and severity of bleeding
  • Any previous gynaecological history?
  • Smear history- last smear and results.
• Ask about chance of pregnancy? Any contraception (particularly new IU devices)?
• Ask about sexual history- previous history of STI, sexual partners etc
• General PMHx and current medications
• FHx of gynaecological and breast cancers

Examination

• Carry out a gynaecological examination

Investigation

• In all patients, exclude pregnancy with a pregnancy test and perform and STI screen for chlamydia and gonorrhoea
• Cervical smear if patient is overdue or if the cervix appears abnormal
• FBC and clotting should be done to check for anaemia
• TFTs can be done IF the patient has symptoms of thyroid dysfunction

Refer patients for further investigation…

• if there are abnormal findings on examination e.g. abdominal mass, abnormal cervix, protruding polyp which is not easily removed
• if the woman is at high risk of cancer e.g. family history, prolonged and irregular cycles, tamoxifen use, persistent symptoms despite suitable investigation/management

Further investigation may involve

• Colposcopy
• USS (abdominal or transvaginal)
• Pipelle biopsy and/or hysteroscopy (particularly in older women >40)

Causes

• Post-coital bleeding
  • Infection
  • Cervical Ectropion (particularly in women on the COC pill)
  • Cervical/Endometrial polyps
  • Vaginal Cancer
  • Cervical cancer
  • Trauma
• Intermenstrual Bleeding
  • Pregnancy-related bleeding
  • Physiological- i.e. spotting before menstruation; perimenopausal bleeding
  • Vaginal causes
    • Adenosis
    • Vaginitis
    • Cancer
  • Cervical causes
    • Infection (cervicitis secondary to STI)
    • Cancer (more commonly post-coital)
    • Cervical polyps
    • Cervical Ectropion
  • Uterine causes
    • Fibroids
    • Endometrial polyps
    • Cancer
    • Adenomyositis
    • Endometritis
  • Oestrogen-secreting ovarian cancers
  • Iatrogenic
    • Tamoxifen
    • Following smear or cervical treatment
    • New or Missed oral or intra-uterine contraceptive

NB See here for example guidelines- Although this is not Tayside guidelines- it is a useful document to refer to

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