Postcoital BleedingPostcoital Bleeding : :The Role Of GynecologistThe Role Of Gynecologist

ByBy

Mohammad EmamMohammad EmamProf. Prof.

Obstetrics and Gynecology Obstetrics and Gynecology Mansoura Faculty of Medicine, EGYPTMansoura Faculty of Medicine, EGYPT

20072007

RationaleRationalePostcoital bleeding (PCB) is a missed Postcoital bleeding (PCB) is a missed

topic in most gynecology text books.topic in most gynecology text books. PCB PCB may be a symptom of a serious may be a symptom of a serious

underlying problem .underlying problem .Pitfalls ttt ( haemostatic , veinotonic & Pitfalls ttt ( haemostatic , veinotonic &

antiprostglandins antiprostglandins …… ) )

CausesCausesPhysiological Physiological PathologicalPathologicalPregnancyPregnancy

Physiological CausesPhysiological Causespost defloration post defloration bleedingbleeding( not ( not last more than last more than a day or two). a day or two).

Causes In PregnancyCauses In PregnancyEcstasies of vagina or Ecstasies of vagina or

cervix.cervix.Concomitant :Concomitant :

Bleeding early in Bleeding early in pregnancy pregnancy

Bleeding late in Bleeding late in pregnancy.pregnancy.

Pathological CausesPathological Causes1.1. Vaginal trauma.Vaginal trauma.2.2. STDs ( chlamydia , gonorrhea ).STDs ( chlamydia , gonorrhea ).3.3. Cervical polyp. Cervical polyp. 4.4. Cervicitis (e.g Eversion = Ectopy).Cervicitis (e.g Eversion = Ectopy).5.5. Vaginal dryness.Vaginal dryness.6.6. Post hysterectomy.Post hysterectomy.7.7. Precancerous cervical lesions& Precancerous cervical lesions&

cancer cervixcancer cervix..8.8. Concomitant pathologyConcomitant pathology

Cervical Eversion Cervical Eversion (Ectopy = Erosion !!)(Ectopy = Erosion !!)

Eversion (Dynamic process).Eversion (Dynamic process).95% metaplasia.95% metaplasia. Metaplastic epitheliaMetaplastic epithelia (Neonatal (Neonatal

Period –puberty – pregnancy-Period –puberty – pregnancy-Lactation-Hormones).Lactation-Hormones).

True erosion is very rare.True erosion is very rare.

Cervical Eversion Cervical Eversion (Ectopy = Erosion !!)(Ectopy = Erosion !!)

Not rush to Not rush to cauterization!!!!!cauterization!!!!!

May hide May hide premalignancy.premalignancy.

VIA is VIA is mandatory mandatory before decision.before decision.

Dryness Of VaginaDryness Of Vagina1.1. MenopauseMenopause2.2. Postpartum Postpartum ( loss of ( loss of

placental estrogen).placental estrogen).

3.3. Hyperprolactinemia.Hyperprolactinemia.

4.4. Antiestrogen.Antiestrogen.

5.5. Cigarette smoking.Cigarette smoking.

Bleeding after hysterectomyBleeding after hysterectomyNormal post hysterectomy bleeding can last Normal post hysterectomy bleeding can last

for several days. for several days.

Sometimes there may be a burst of bleeding Sometimes there may be a burst of bleeding at 2-3 weeks if there was a collection of blood at 2-3 weeks if there was a collection of blood clot in the pelvis. clot in the pelvis.

Occasionally at 2 - 8 weeks, there may be Occasionally at 2 - 8 weeks, there may be vaginal spotting as sutures dissolve .vaginal spotting as sutures dissolve .

PCB after hysterectomyPCB after hysterectomy• Vault :Vault :

• Endometriosis.Endometriosis.• Granulation tissue .Granulation tissue .• Prolapse of a fallopian tubeProlapse of a fallopian tube ( ( + Dysparunia ) + Dysparunia ) ..• Cancerous growth.Cancerous growth.

* * Vaginal:Vaginal:– Atrophic vaginitis due to low estrogen levels Atrophic vaginitis due to low estrogen levels

and traumatic irritation .and traumatic irritation .Pathology in cervix ( subtotal). Pathology in cervix ( subtotal).

Diagnosing cause of PCB is by exclusionDiagnosing cause of PCB is by exclusion::

Thoroughly history , exam and investigation. Thoroughly history , exam and investigation.

May be simple such as a vaginal infection.May be simple such as a vaginal infection.

Serious pathology like Preinvasive cx. Serious pathology like Preinvasive cx. Lesions or cancer cervix should be excluded Lesions or cancer cervix should be excluded ( suspicious cx)( suspicious cx)

Cervical Cancer Cervical Cancer WorldwideWorldwide

230,000 women die of 230,000 women die of cervical cancer every cervical cancer every yearyear

80 % occur in developing 80 % occur in developing countries.countries.

Report of WHO 2001”Report of WHO 2001”

Incidence of Cancers in Incidence of Cancers in Egyptian WomenEgyptian Women

0055

1010151520202525

Breast Breast CancerCancer

Cervical Cervical CancerCancer

Ovarian Ovarian CancerCancer

UterineUterineCancerCancer

PercentPercent

Source: GLOBOCAN 2000.Source: GLOBOCAN 2000.

Most Cancers Develop Most Cancers Develop In The Unscreened In The Unscreened

And The Under screened And The Under screened populationspopulations

Cervical Cancer is Cervical Cancer is PREVENTABLEPREVENTABLEScreening detects PREINVASIVE Screening detects PREINVASIVE

STAGE.STAGE.

Has Has good prognosis if found in earlygood prognosis if found in early stage. stage.

Early stage can be detected by noninvasive Early stage can be detected by noninvasive means (the Pap smear , cervicography&means (the Pap smear , cervicography&VIAVIA). ).

Ideal Screening test For Ideal Screening test For Preinvasive Cervical Preinvasive Cervical

LesionsLesions☼ PAP smear test is considered to be the gold standard – Has limitations ?..& Alternatives

Cytology discovers the crime & Colposcopy locates the culprit.

Limitations of Pap SmearLimitations of Pap SmearComplex laboratory test .Complex laboratory test .Requires trained cytotechnician .Requires trained cytotechnician .Reports take minimum 1-2 Reports take minimum 1-2

weeks.weeks.Follow-up of women is difficult.Follow-up of women is difficult.Usually available only in large Usually available only in large

cities.cities.

Alternatives to Pap Alternatives to Pap smearsmear

– Automated pap screening.Automated pap screening.

– HPV testing.HPV testing.– Polar probe.Polar probe.

–Visual inspection with acetic acid Visual inspection with acetic acid

11 . .Simple & quickSimple & quick22. Inexpensive. Inexpensive3. 3. Acceptable to Acceptable to populationpopulation4. 4. AccurateAccurate5. 5. RepeatableRepeatable6. Sensitive6. Sensitive

77 . .SpecificSpecific????????????

Advantages of Advantages of VIAVIA

`̀

ColposcopyColposcopy

How to do VIAHow to do VIA??

Reporting Visual Reporting Visual Inspection FindingsInspection Findings

Acetic Acid Test- Negative

Aceto-white area(s) not present

Acetic Acid Test-Positive

Aceto-white area(s) present 1)Density of whiteness2)Time needed for whiteness to appear and disappear3)Sharpness of demarcation

Meaning Of Positive VIAMeaning Of Positive VIA

–Healing or regenerating epithelium.Healing or regenerating epithelium.– Inflammation.Inflammation.– Immature squamous metaplasia.Immature squamous metaplasia.–HPV infection.HPV infection.–CIN.CIN.–Adenocarcinoma.Adenocarcinoma.– Invasive squamous cell carcinoma.Invasive squamous cell carcinoma.

Suspicious positive VIASuspicious positive VIARapid intake of acetic acidRapid intake of acetic acid..Slow disappearance of Slow disappearance of

whiteness.whiteness.Whiteness towards glazed.Whiteness towards glazed.Sharpness of borders. Sharpness of borders. uneven contouruneven contour

Negative VIANegative VIA

Positive VIAPositive VIA

Suspicious for Suspicious for CancerCancer

VIA DISCOVERS THE VIA DISCOVERS THE CRIMECRIME

LOCATES THE LOCATES THE CULPRIT CULPRIT With/Without With/Without COLPOSCOPYCOLPOSCOPY

And Can And Can

Limitations Of VIALimitations Of VIAModerate Moderate specificityspecificity ( ( increase false increase false

positive casespositive cases).).

Less accurate among Less accurate among post-post-menopausal women.menopausal women.

ConclusionsConclusionsPost-coital bleeding (PCB) Post-coital bleeding (PCB)

Can occur for a number of Can occur for a number of reasons and is nothing to take reasons and is nothing to take lightly.lightly.

The diagnosis of the cause is The diagnosis of the cause is usually a matter of exclusion.usually a matter of exclusion.

ConclusionsConclusions The upper extremity of the The upper extremity of the

causes is causes is precancerous precancerous cervical lesions and cervical cervical lesions and cervical carcinomacarcinoma which is not which is not uncommon. uncommon.

ConclusionsConclusionsPatients complaining of Patients complaining of

PCB should be subjected PCB should be subjected to visual inspection by to visual inspection by acetic acid acetic acid ( VIA)( VIA) or smear or smear and Colposcopy on finding and Colposcopy on finding suspicious cervix. suspicious cervix.

ConclusionsConclusions There is no role for There is no role for

empirical empirical tttttt in PCB in PCB……So So Patients should be subjected Patients should be subjected to to VIAVIA or smear and or smear and Colposcopy on finding Colposcopy on finding suspicious cervix. suspicious cervix.

PCB PCB should remain an should remain an indication for indication for referral to referral to ECDUECDU for detailed for detailed evaluation of the lower evaluation of the lower genital tract ,although genital tract ,although the the most common cause is not most common cause is not cancer.cancer.

RecommendationsRecommendations

Early Cancer Detection UnitEarly Cancer Detection Unit

OB& GYN, Mansoura Faculty of MedicineOB& GYN, Mansoura Faculty of MedicineEGYPT

Telfax 0020502319922 & 0020502312299

Email. mae335@hotmail.com