Post Coital Bleeding Emam

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 – pregnancyLactation-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 TestNegative

Aceto-white area(s) not present

Acetic Acid TestPositive

Aceto-white area(s) 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. [email protected]