01OverviewDefinition, clinical context and the essential points that orientate the chapter.
Intermenstrual bleeding occurs between expected periods; postcoital bleeding is noticed during or after penetrative sex. They can coexist and neither phrase identifies anatomy. Start with timing, amount, recurrence, relation to cycle and sex, pain, dyspareunia, discharge, pregnancy possibility and source. Ask whether blood could come from urine, rectum, vulval skin or trauma. Establish menopausal status carefully because bleeding after 12 months of spontaneous amenorrhoea enters a postmenopausal pathway.
Pregnancy assessment comes early. Contraception reduces but does not remove probability, and implantation, miscarriage or ectopic bleeding may be mistaken for spotting. Seek consent for urine testing and use serum hCG or repeat testing if timing makes a negative uncertain. Pain, syncope, shoulder-tip symptoms or tenderness with hCG exposure requires early-pregnancy assessment. Do not perform an endometrial procedure until pregnancy is reasonably excluded.
Take a proportionate sexual history in private. Ask about partners and anatomical exposure, condoms, new discharge, dysuria, pelvic pain, previous infection and whether sex was wanted. Chlamydia or gonorrhoea can cause cervicitis and contact bleeding; NAAT sites follow exposure. Pelvic inflammatory disease is a clinical syndrome, so treatment may begin before results when pelvic pain and tenderness support it after pregnancy and acute surgical alternatives are considered.
Medication and contraception history is time-linked. Combined, progestogen-only, implant, injectable and intrauterine methods can produce unscheduled bleeding, especially after initiation, missed doses or enzyme-inducing interactions. Copper IUDs more often increase menstrual loss. Check correct use, vomiting, interacting medicines and pregnancy risk. A method effect remains a diagnosis of context: persistent new bleeding still requires assessment of infection, cervix and endometrium according to age and risk.
Examination is consented and focused. Inspect external skin for trauma, inflammation or lesions and use speculum examination to identify vaginal atrophy, laceration, discharge, cervical ectropion, polyp or suspicious lesion. Record whether the whole cervix was visualised. Bimanual examination adds uterine size, cervical motion and adnexal tenderness where pain or mass is relevant. A normal examination does not inspect the endometrial cavity and cannot exclude ectopic pregnancy or endometriosis.
Cervical ectropion exposes columnar epithelium and may bleed on contact, particularly in pregnancy or oestrogen exposure. Cervical polyps can also bleed. Treat only after infection and malignancy concern are addressed; symptomatic polyps may be removed or referred based on size, appearance and competence. An abnormal-looking cervix requires urgent diagnostic referral regardless of screening status. Screening samples are not designed to explain symptoms and should not delay colposcopy or gynaecology assessment.
Endometrial and cavity causes include polyps, submucosal fibroids, ovulatory dysfunction, hyperplasia and cancer. NICE NG88 prioritises outpatient hysteroscopy when persistent intermenstrual bleeding or endometrial risk accompanies heavy bleeding. Risk is greater with prolonged anovulation, obesity, PCOS, tamoxifen and previous hyperplasia. Biopsy is considered during hysteroscopy; blind sampling may miss focal lesions. Pelvic ultrasound is complementary for myometrial and adnexal disease.
Postcoital bleeding after menopause may come from genitourinary atrophy, but it still counts as postmenopausal bleeding and needs urgent cancer exclusion. In premenopausal patients with a normal cervix, negative pregnancy and infection tests and no endometrial risk, management may include lubricant, treatment of atrophy or method adjustment and review. Persistent or recurrent unexplained bleeding warrants local specialist referral even after initial benign results.
Key points
- Clarify whether blood is vaginal, cervical, uterine, urinary or rectal; timing noticed after sex does not prove the cervix is the source.
- Ask last normal period, pregnancy possibility, contraception and adherence, pain, discharge, sexual exposure, trauma, menopause status, anticoagulants and cervical screening history.
- Offer a pregnancy test whenever pregnancy is possible and interpret an early negative result cautiously; a positive result with symptoms requires pregnancy-location assessment.
- Speculum examination is the key initial localisation test when bleeding persists or cervical disease is possible: inspect vulva, vaginal walls and the entire visible cervix with consent and a chaperone.
- Take chlamydia and gonorrhoea NAAT from appropriate exposure sites when cervicitis risk exists; infection can be asymptomatic and treatment must include partner and reinfection planning.
- Cervical ectropion and polyps are common benign explanations, but a benign-looking finding should not override persistent symptoms, an abnormal cervix or endometrial risk.
- Cervical screening prevents cancer in asymptomatic populations; it is not a diagnostic test for postcoital bleeding and a negative result does not clear a suspicious lesion.
- Persistent intermenstrual bleeding or risk factors for endometrial pathology make outpatient hysteroscopy the NICE-prioritised investigation, with selected biopsy during the procedure.
- Unscheduled bleeding can occur after hormonal contraception starts or changes, but check pregnancy, correct use, interactions, STI risk and cervical screening before attributing it to the method.
- Give a clear review interval and urgent triggers; recurrent bleeding after an initially normal examination requires reassessment rather than repeated empirical treatment.
02AetiologyUnderlying causes, associations and risk factors, with why each one matters.
Cervical and vaginal lesions
Cervicitis, ectropion, polyps, atrophy, trauma and neoplasia create fragile surfaces that bleed spontaneously or with contact.
Endometrial and cavity disease
Polyps, submucosal fibroids, anovulatory instability, hyperplasia and malignancy can shed unpredictably between otherwise recognisable menstrual periods.
Pregnancy and treatment effects
Early pregnancy events and changing hormonal or intrauterine contraception can destabilise bleeding, while anticoagulants amplify loss from another lesion.
03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.
- 1Contact tissue fragility
Inflamed, neoplastic, atrophic or exposed columnar epithelium disrupts easily during penetration, causing visible surface capillary bleeding.
- 2Focal cavity shedding
Polyps and intracavity fibroids create irregular vascular tissue that bleeds independently of coordinated cyclical endometrial breakdown.
- 3Hormonal instability
Changing or inconsistent steroid exposure produces asynchronous endometrial growth and breakdown, commonly causing spotting while adaptation occurs.
- 4Invasion and angiogenesis
Cervical or endometrial malignancy generates friable abnormal vessels and tissue destruction, leading to recurrent contact or spontaneous bleeding.
04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.
Mucopurulent discharge, cervical friability, contact bleeding and relevant exposure suggests chlamydial or gonococcal cervicitis and directs NAAT and partner care.
A smooth red area around the os that bleeds on touch may reflect exposed columnar epithelium, commonly with oestrogen exposure.
Irregular, ulcerated, nodular, friable or spontaneously bleeding tissue requires urgent diagnostic referral rather than screening reassurance.
Persistent intermenstrual bleeding, infrequent heavy cycles with risk factors or postmenopausal bleeding supports direct cavity and histological assessment.
Spotting starts after method initiation, inconsistent use or interaction, but the expected temporal pattern is only accepted after important alternatives are assessed.
Laceration, dryness, force, pain or non-consensual penetration can cause contact bleeding and requires sensitive injury, sexual health and safeguarding care.
05InvestigationsWhat to request, why it matters and how to interpret it.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Pregnancy testFirst step - Why
- Detect pregnancy-related bleeding and prevent unsafe endometrial investigation or prescribing.
- Interpretation and limitations
- A positive test requires symptom-led location assessment. A negative result is only reliable when timing and assay sensitivity are appropriate.
- 02
Speculum examination - Why
- Localise bleeding and identify vaginal trauma, atrophy, discharge, ectropion, polyp or a suspicious cervix.
- Interpretation and limitations
- Record complete visualisation and objective morphology. Normal appearance does not exclude endometrial disease; suspicious tissue overrides screening results.
- 03
Chlamydia and gonorrhoea NAAT - Why
- Diagnose common infections that produce cervicitis or pelvic inflammatory disease.
- Interpretation and limitations
- Sample anatomical sites from exposure and explain window periods. Negative tests do not exclude non-infectious pathology or every cause of PID.
- 04
Cervical diagnostic referral - Why
- Obtain colposcopic assessment and biopsy when examination suggests cervical malignancy or unexplained persistent symptoms warrant specialist review.
- Interpretation and limitations
- Cervical screening is not an alternative diagnostic test. Histology establishes lesion type and urgency.
- 05
Outpatient hysteroscopy with selected biopsy - Why
- Assess a polyp, submucosal fibroid or endometrial disease causing persistent intermenstrual bleeding.
- Interpretation and limitations
- Direct cavity inspection detects focal lesions better than blind sampling. Histology is needed for hyperplasia or cancer.
- 06
Pelvic ultrasound - Why
- Evaluate fibroids, adenomyosis, adnexa and other structural disease when pain, mass or examination suggests it.
- Interpretation and limitations
- A normal scan does not clear the cervix or every endometrial polyp. Choose transvaginal imaging when acceptable and clinically useful.
06Differential diagnosisRealistic alternatives and the features that help distinguish them.
Pregnancy-related bleeding
Implantation, miscarriage and ectopic pregnancy may present as intermenstrual spotting, with pain or instability increasing urgency.
Urinary or rectal source
Haematuria, haemorrhoids and rectal disease can appear vaginal when noticed after toileting or sex and require source-specific assessment.
Trauma or assault
Consensual friction, dryness, foreign body and sexual assault can cause laceration; history and examination must preserve agency and forensic options.
Physiological ovulatory spotting
Brief light mid-cycle spotting can occur without disease, but it is accepted only after pregnancy and persistent warning features are considered.
07ManagementImmediate care, first-line treatment, alternatives and escalation.
01Initial sequenceLocalise, test pregnancy and inspect the cervixFirst stepBleeding is reported between periods or after penetrative sex.+
- 1Clarify source, timing, recurrence, amount, pain, discharge, menopause, contraception, medicine exposure and consensual sexual context in privacy.
- 2Offer pregnancy testing and relevant STI NAAT, then perform consented external and speculum examination when bleeding persists or cervical disease is possible.
- 3Treat urgent pregnancy, infection, injury or suspicious-cervix findings and assign a review point for results and recurrence.
02Abnormal cervixRefer diagnostically rather than screenThe cervix appears irregular, ulcerated, nodular, friable or suspicious on examination.+
- 1Document the lesion objectively, associated bleeding and whether complete visualisation was achieved, without performing traumatic repeated sampling.
- 2Refer through the suspected-cancer or urgent colposcopy pathway according to local criteria and communicate that screening status does not remove concern.
- 3EscalationTrack colposcopy and histology and provide escalation for increasing bleeding, pain or systemic symptoms while awaiting assessment.
03Persistent intermenstrual bleedingAssess the uterine cavity and endometriumBleeding continues after pregnancy, cervical and infection causes are addressed or endometrial risk is present.+
- 1Review cycle and risk factors including PCOS, obesity, tamoxifen and treatment failure, and check full blood count where loss is significant.
- 2Offer outpatient hysteroscopy and consider endometrial biopsy during the procedure when the risk profile meets NICE criteria.
- 3Use pelvic ultrasound for myometrial or adnexal questions and reconcile all results before diagnosing functional or contraceptive bleeding.
04Hormonal methodCheck use and competing disease before changing contraceptionUnscheduled bleeding starts after hormonal contraception is initiated or altered.+
- 1Check adherence, timing, vomiting, interactions, pregnancy risk, STI exposure, cervical screening eligibility and warning symptoms.
- 2Examine when bleeding persists, changes after initial months or cervix, pain and infection require assessment, and investigate endometrium by risk.
- 3AlternativeExplain expected patterns and offer an evidence-based method adjustment or alternative through contraception guidance, preserving the patient’s reproductive goals.
08ComplicationsImportant consequences, why they occur and why they matter clinically.
Delayed cancer diagnosis
Labelling recurrent contact bleeding as ectropion or contraception can postpone cervical or endometrial biopsy when symptoms or examination are concerning.
Ascending infection
Untreated cervicitis may progress to pelvic inflammatory disease, chronic pelvic pain, tubo-ovarian abscess, infertility or ectopic pregnancy.
Anaemia and functional impact
Frequent episodes can cause iron depletion, fatigue, sexual avoidance, anxiety and reduced quality of life even when each bleed seems small.
Iatrogenic distress
Repeated intimate examinations, unsafe communication or premature reassurance can retraumatise patients and reduce willingness to re-present when bleeding worsens.
09Monitoring and follow-upTreatment response, safety checks and longer-term review.
- Track pregnancy, NAAT, colposcopy, histology and imaging results to a named clinician and use a confidential contact route chosen by the patient.
- Review recurrence, relation to sex and cycle, pain, discharge, bleeding volume and response to infection or contraceptive treatment.
- Re-examine or refer persistent postcoital bleeding when the original cervix was incompletely seen or symptoms continue despite benign initial findings.
- Escalate any transition to postmenopausal bleeding, visible suspicious lesion, anaemia, mass, systemic infection or pregnancy-related pain.
- Document consent, chaperone, trauma or safeguarding needs and any declined examination so an incomplete assessment is not later read as normal.
10Special situationsVariants, exceptions and circumstances that change the usual approach.
After sex is not from cervix
Timing directs examination but blood may arise from vaginal trauma, vulval skin, uterus, urine or rectum, so anatomical localisation remains necessary.
Screening answers prevention
A screening result estimates cervical precancer risk in an asymptomatic programme; symptoms and visible abnormalities require diagnostic reasoning and sometimes biopsy.
Ectropion can coexist
A benign ectropion may explain contact bleeding, but it can sit alongside infection or endometrial disease and should not become premature closure.
Method bleeding has a timeline
Expected adjustment bleeding becomes less persuasive when it begins late, worsens, persists or carries pain, pregnancy, infection or cancer indicators.
Normal speculum is one compartment
A healthy visible cervix and vagina do not assess the uterine cavity, so persistent intermenstrual bleeding may still require hysteroscopy.
11Common pitfallsFrequent interpretation and management errors.
- 01
Sending a cervical screening sample as the only investigation for a symptomatic or suspicious cervix.
- 02
Attributing all unscheduled bleeding to contraception without checking pregnancy, adherence, interactions, infection and endometrial risk.
- 03
Treating ectropion repeatedly while persistent bleeding remains unexplained or the cervix was incompletely visualised.
- 04
Forgetting that postcoital bleeding after menopause is also postmenopausal bleeding requiring urgent assessment.
- 05
Performing hysteroscopy before pregnancy is reasonably excluded in a patient with uncertain cycle timing.
- 06
Assuming a negative chlamydia test excludes pelvic inflammatory disease or non-infectious cervical pathology.