Vaginal Bleeding During or After Sex

Causes range from trauma and infection to cancer

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Vaginal bleeding after sex (also known as postcoital bleeding) is not an entirely uncommon situation among menstruating women, and it's even more common in postmenopausal women. While the bleeding can sometimes be distressing, the cause is relatively benign in most cases. The same can be said for those who experience bleeding during sex; many of the causes of postcoital bleeding overlap.

According to research, as many as nine percent of menstruating women will experience vaginal bleeding, irrespective of their period, after sex.

By contrast, anywhere from 46 percent to 63 percent of postmenopausal women will experience dryness, itching, tenderness, spotting, or bleeding during or after sex due to hormonal changes that affect the elasticity of vaginal tissues.

While most of these causes of bleeding are of no concern, there are times when bleeding could be a sign of a more serious problem. Among some of the more common causes of bleeding during and/or after sex:

Sexually Transmitted Infections

Sexually transmitted infections (STIs) such as chlamydia and gonorrhea are associated with a range of vaginal symptoms ranging from pelvic pain, itching, and burning to vaginal discharge and frequent, painful urination. The inflammation caused by these STIs can cause surface blood vessels to swell and burst more readily, with the severity of bleeding often associated with the severity of the infection.

Trichomoniasis is another type of STI caused by a single-celled parasite.

Cervical discharge and cervical bleeding are two of the most common characteristics of the disease. As with chlamydia and gonorrhea, a Trichomonas infection is easily treated with an antibiotic.

Other STIs such as syphilis and genital herpes can cause open, ulcerative lesions that are prone to bleeding if irritated.

While the sores often appear externally, they can sometimes develop inside the vagina and, in the case of syphilis particularly, be entirely painless and unnoticed.

Benign Polyps

Benign growths on the cervix (cervical polyps) or uterus (uterine or endometrial polyps) are a common cause of bleeding during or after sex.

Cervical polyps tend to develop in women in their 40s and 50s who have had multiple pregnancies. The polyps are typically red or violet with a tube-like structure rich with capillaries that can bleed easily when touched.

Uterine polyps are small, soft lumps of tissue protruding from within the uterus. Polyps of these sort are prone to bleeding between periods, after menopause, and during sex. They also tend to develop in women between the ages of 36 and 55.

The majority of polyps are benign, but some can develop into cancer over time. Polyps will sometimes disappear spontaneously, but surgical removal may be needed in some cases.

Other noncancerous growths of the genital tract, such as a hemangioma, can also lead to postcoital bleeding, although these are far less common causes.

Cervical Ectropion

Cervical ectropion is a non-cancerous condition where the cells that normally line the inside of the cervix protrude outside through the cervical os (the opening of the cervix).

When this happens, the abnormal distention of cervical tissue can cause already-fragile blood vessels to dilate and become inflamed. As a result, bleeding is common due to intercourse, the use of tampons, and even the insertion of a speculum during a pelvic exam.

Cervical ectropion can occur in adolescents, women taking birth control pills, and pregnant women whose cervixes are softer than normal. It usually does not require treatment unless there is excessive vaginal discharge or bleeding.

Atrophic Vaginitis

Postmenopausal women will often bleed during or after sex because diminishing estrogen levels cause the vaginal walls to literally thin and produce less lubricating mucus.

This is referred to as atrophic vaginitis, a condition that is also associated with vaginal itching and burning.

Atrophic vaginitis can also be treated with estrogen therapy, either taken orally in pill form, as a dermal patch or cream, or inserted intravaginally with a suppository. Oral estrogen replacement therapy does carry some risk, however. According to data from the Women’s Health Initiative, estrogen-only pills can increase the risk of endometrial cancer and, as such, should either be used for short-term treatment or substituted with another form of estrogen therapy. Vaginal lubricants can also ease dryness and decrease pain.

While younger women can also have vaginitis, typically caused by a bacterial or yeast infection, postcoital bleeding is a far less common symptom.

Endometriosis

Endometriosis occurs when the lining of the uterus (the endometrium) extends outside of the uterus. When this happens, the endometrial tissue can attach itself to the surfaces of other organs, often resulting in excruciating pain and, in some cases, infertility. It is a condition that affects anywhere from five percent to 10 percent of women of reproductive age and remains poorly understood both in its cause and available treatments.

Two of the characteristic features of endometriosis are painful intercourse and painful orgasm, both of which are caused by the added strain and pressure placed on already-vulnerable tissues. Postcoital bleeding is not uncommon when this occurs.

Hormone therapy used to reduce estrogen levels is often effective at reducing pain. Pain and bleeding may also be reduced by changing the positions you commonly use during sex. Some, like the missionary position, place added stress on the vagina that may be relieved by, say, a side-to-side position.

Trauma

While postcoital bleeding is often associated with infections and abnormalities of the uterus, vagina, or cervix, bleeding can also result from a direct trauma to these vulnerable tissues.

It may be caused by vigorous sex which can lead to cuts, scrapes, tears on the vagina. This is more likely to occur if there if there is vaginal dryness, such as can occur during menopause, when a woman is breastfeeding, or if there is excessive douching.

More distressingly, bleeding can occur as a result of sexual abuse or violence. Forced entry can severely damage vaginal tissues and lead to the formation of fissures, which can repeatedly heal and reopen unless medically treated.

Cancer

While cancer is a less likely cause of postcoital bleeding, it is one of the possible signs of cervical, vaginal, and uterine cancer. Every year, around 14,000 women are diagnosed with invasive cervical cancer in the United States, leading to more than 4,000 deaths.

Tumors can vary depending on the type of cancer involved, but they tend to be fed by a dense, haphazard network of blood vessels. As the tumor grows, these vessels can become strained and prone to bursting. Sexual intercourse can sometimes cause this.

Without or without sex, bleeding is a common feature of cervical cancer. This may include:

  • Bleeding after menopause or in between menstrual periods
  • Heavy or longer-than-usual periods
  • Vaginal discharge streaked with blood (sometimes mistaken for spotting)

To evaluate a woman for cervical cancer, a gynecologist will perform a pelvic exam, a Pap smear, and occasionally a visual exam called a colposcopy. If a doctor is suspicious of cancer, a tissue sample may be taken by biopsy to be examined under a microscope.

A Word From Verywell

Bleeding during or after should never be considered normal. Even if it occurs as a result of an accidental trauma, it is best to have it looked at if only to find ways to avoid such injuries in the future.

If you don’t know what is causing vaginal bleeding with intercourse, don’t avoid seeing a doctor for fear of receiving a cancer diagnosis. Cancer is, in fact, one of the less likely causes. If cancer does turn out to be the reason you are bleeding, an early diagnosis affords early treatment and a greater chance curing the malignancy before it becomes serious.

Sources:

Jyotsna, V. "Postmenopausal hormonal therapy: Current status." Ind J Endocrinol Metab. 2013; 17(Suppl1): S45-S49; DOI: 10.4103/2230-8210.119504.

Kim, H.; Kang, S.; Chung, Y. et al. "The Recent Review of the Genitourinary Syndrome of Menopause." J Menopausal Med. 2015; 21(2): 65-71; DOI: 10.6118/jmm.2015.212.65.

Tarney, C. and Han, J. "Postcoital Bleeding: A Review on Etiology, Diagnosis, and Management." Obstet Gyn Int. 2014; article ID 182087; DOI: 10.1155/2014/182087.

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