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Postcoital Bleeding: More of Your Questions Answered

By Jane Harrison-Hohner, RN, RNP

Bleeding after sex or “postcoital bleeding” (PCB) generates many questions from our readers here at WebMD. I answered some of them in my previous post. Let’s take a look at more of your questions.

Should I worry about cancer?
To answer this question let’s take a quick look at three published articles which offer some of the most sound information. An older study of women in Finland identified 2,646 women with PCB. Of those only 12 had invasive cervical cancer; this is about 0.4%.  Interestingly, 93% of all overt cervical cancers did not show bleeding with intercourse (Hakama, 1975).

Khattab and colleagues (2005) evaluated a much smaller number of women with PCB. They broke down the 284 women with PCB into two groups. One group came into the evaluation with normal PAP smear results, the second group with known abnormal PAPs. Cancer was found in 3.6% of those with normal PAPs and 5% of those with known abnormal PAP smear. Precancerous dysplasia (CIN 1) was identified in 9% of those entering with normal PAPs, and 66% of those with known abnormal PAPs. No cervical pathology was evident in 50% of women with normal PAPs, and in 17% of women with known abnormal PAPs.  These numbers would suggest that a known abnormal PAP in a woman with PCB can be correlated to various types of CIN and cervical cancer. Yet even in a PCB woman with a prior normal PAP, further investigation of the cervix may be advised.

In a very large analysis of 910 studies of PCB, the prevalence of bleeding after sex in women surveyed ranged from 0.7- 9.0 %. Among women with cervical cancer the prevalence of PBC was up to 39% (Shapley, 2006).  What all these suggest is that PCB may be more common with abnormal PAPs and cervical cancer, but that all PCB is not cervical cancer.

Does my age matter?
In terms of risks for your PCB being caused by cervical cancer; yes, age may matter. For women in general, aged 20-24, with PCB there is a 1 in 44,000 risk of a cervical cancer. For those aged 45-54, the risk is 1 in 2,400 for a cervical cancer (Shapley, 2006).

Age may also impact the likelihood of other causes of PCB. Chlamydia is most common in young, sexually active women up through age 24. Problems with an overly thickened uterine lining, or uterine lining cancer, tend to increase with age. One expert suggests doing a biopsy of the lining of the uterus after age 35 if there is abnormal bleeding. Also biopsies should be done to investigate PCB after menopause (Alfhaily, 2010).

What is considered a good exam for PCB?
While there are no standard protocols for working up PCB, most of the research and attempts to create a more uniform exam are originating in the UK. Based upon the most current evidence Alfhaily and Ewies (2010) suggest the following be done:

How does my GYN measure up?
In one study of 614 GYNs in the UK, only 49% stated they would redo a PAP smear if there had been a normal result within the usual screening interval. About 80% said they would perform testing for chlamydia. Only 12% would do a biopsy of the lining of the uterus in selected patients (Alfhaily, 2009). According to another British publication (Sonnex, 2010), many GYNs “considered themselves not well trained” in colposcopy.

Are there any over the counter remedies for PCB?
Alas, there are not. Most infections will require prescription antibiotics. A cervix with increased amounts of fragile tissue can be frozen (cryotherapy) or treated with heat by a GYN to decrease bleeding from this source. Polyps can be removed. Problems from hormonal sources may be improved with a change in medications.

When should I go in and get checked?
Cancer is the most concerning cause. It is good to be aware that while small studies did not find age a predictor for cancer (Khattab, 2005 & Alfhaily, 2010), the largest overview study (Shapley, 2006) found an increased incidence in cancer-caused PCB in the perimenopausal years. Increased duration of PCB was found to be predictive of cancer in one, but not all studies.

Some 90% of women wait at least four weeks before being seen for their PCB (Alfhaily, 2010). It makes sense for a woman experiencing apparent breakthrough bleeding on birth control pills to wait a month and see if the bleeding after sex abates.

If one is nervous about going to the GYN, it should be reassuring to know that in 50% of cases no pathology could be found — even after a thorough work up (Rosenthal, 2001; Sahu, 2007; Kattab, 2005).

Vampire movies excluded, blood on the sheets or on one’s sexual partner is not considered normal. Given the multiple causes of PCB one should see their GYN or clinic when the problem persists or is recurrent.

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