Postcoital Bleeding :

The Role Of Gynecologist

By
Mohammad Emam
Prof.
Obstetrics and Gynecology
Mansoura Faculty of Medicine, EGYPT
2007
 Rationale
Postcoital bleeding (PCB) is a missed
topic in most gynecology text books.
 PCB may be a symptom of a serious
underlying problem .
Pitfalls ttt ( haemostatic , veinotonic &
antiprostglandins … )
 Causes
Physiological
Pathological
Pregnancy
Physiological Causes
post defloration
bleeding( not
last more than
a day or two).
Causes In Pregnancy
Ecstasies of vagina or
cervix.
Concomitant :
Bleeding early in
pregnancy

Bleeding late in
pregnancy.
Pathological Causes
– Vaginal trauma.
– STDs ( chlamydia , gonorrhea ).
– Cervical polyp.
– Cervicitis (e.g Eversion = Ectopy).
– Vaginal dryness.
– Post hysterectomy.
– Precancerous cervical lesions&
cancer cervix.
– Concomitant pathology
Cervical Eversion)!! )Ectopy = Erosion

 Eversion )Dynamic process).

 95% metaplasia.
 Metaplastic epithelia )Neonatal
Period –puberty – pregnancy-
Lactation-Hormones).
 True erosion is very rare.
 Cervical Eversion)!! )Ectopy = Erosion
Not rush to
cauterization!!!!!
May hide
premalignancy.
VIA is
mandatory
before decision.
 Dryness Of Vagina
1. Menopause
2. Postpartum ) loss of
placental estrogen).

4. Hyperprolactinemia.

6. Antiestrogen.

8. Cigarette smoking.
 Bleeding after hysterectomy
 Normal post hysterectomy bleeding can last
for several days.

 Sometimes there may be a burst of bleeding

at 2-3 weeks if there was a collection of blood
clot in the pelvis.

 Occasionally at 2 - 8 weeks, there may be

vaginal spotting as sutures dissolve .
 PCB after hysterectomy
• Vault :
• Endometriosis.
• Granulation tissue .
• Prolapse of a fallopian tube ( + Dysparunia ) .
• Cancerous growth.
* Vaginal:
– Atrophic vaginitis due to low estrogen levels
and traumatic irritation .
 Pathology in cervix ( subtotal).
:Diagnosing cause of PCB is by exclusion

 Thoroughly history , exam and investigation.

 May be simple such as a vaginal infection.

 Serious pathology like Preinvasive cx.

Lesions or cancer cervix should be excluded
( suspicious cx)
 Cervical Cancer
Worldwide
230,000 women die of
cervical cancer every
year

80 % occur in
developing countries.

Report of WHO 2001”

 Incidence of Cancers in
Egyptian Women
25
20

Percent 15
10
5
0
Breast Cervical Ovarian Uterine
Cancer Cancer Cancer Cancer
Source:  GLOBOCAN 2000.
 Most Cancers Develop
In The Unscreened
And The Under screened
populations
 Cervical Cancer isPREVENTABLE
 Screening detects PREINVASIVE
STAGE.

 Has good prognosis if found in early

stage.

 Early stage can be detected by noninvasive

means (the Pap smear , cervicography&VIA).
 Ideal Screening test For
Preinvasive Cervical
Lesions
☼ PAP smear test is considered to be the gold
standard – Has limitations ?..& Alternatives

Cytology discovers the crime &

Colposcopy locates the culprit.
 Limitations of Pap Smear
Complex laboratory test .
Requires trained cytotechnician .
Reports take minimum 1-2
weeks.
Follow-up of women is difficult.
Usually available only in large
cities.
Alternatives to Pap
smear
– Automated pap screening.

–Visual inspection with acetic acid

– HPV testing.
– Polar probe.
 Advantages of
VIA
Simple & quick .1
2. Inexpensive
3.Acceptable to
population
4.Accurate
5.Repeatable
6. Sensitive
.7??????Specific
?How to do VIA
`

Colposcopy
 Reporting Visual
Inspection Findings
Acetic Acid Test- Aceto-white area(s) not
Negative present

Acetic Acid Test- Aceto-white area(s)

Positive present
1)Density of whiteness
2)Time needed for whiteness to
appear and disappear
3)Sharpness of demarcation
Meaning Of Positive VIA

– Healing or regenerating epithelium.

– Inflammation.
– Immature squamous metaplasia.
– HPV infection.
– CIN.
– Adenocarcinoma.
– Invasive squamous cell carcinoma.
 Suspicious positive VIA
Rapid intake of acetic acid.
Slow disappearance of
whiteness.
Whiteness towards glazed.
Sharpness of borders.
 uneven contour
Negative VIA
Positive VIA
Suspicious for
Cancer
 VIA DISCOVERS THE
CRIME
And Can
LOCATES THE CULPRIT
With/Without
COLPOSCOPY
Limitations Of VIA
 Moderate specificity ) increase false
positive cases).

 Less accurate among post-

menopausal women.
 Conclusions
Post-coital bleeding (PCB)
Can occur for a number of
reasons and is nothing to take
lightly.

 The diagnosis of the cause is

usually a matter of exclusion.
 Conclusions
 The upper extremity of the
causes is precancerous
cervical lesions and cervical
carcinoma which is not
uncommon.
 Conclusions
Patients complaining of
PCB should be subjected
to visual inspection by
acetic acid ( VIA) or smear
and Colposcopy on finding
suspicious cervix.
 Conclusions

There is no role for
empirical ttt in PCB…So
Patients should be subjected
to VIA or smear and
Colposcopy on finding
suspicious cervix.
 Recommendations
PCB should remain an
indication for referral to
ECDU for detailed
evaluation of the lower
genital tract ,although the
most common cause is not
cancer.
 Early Cancer Detection Unit
OB& GYN, Mansoura Faculty of Medicine
EGYPT
Telfax 0020502319922 & 0020502312299
Email. mae335@hotmail.com