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

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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