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Bleeding after sex is not uncommon. It may originate from the vagina, cervix or uterus. Before discussing possible causes, a bit of background on clinical anatomy is helpful.

Vaginal anatomy

The vagina is formed from two embryological structures. The superficial part of the vagina develops from the vaginal plate, while the deeper part of the vagina develops from the Mullerian ducts.

The vagina gets its rich blood supply from the anterior division of the internal iliac artery. The deeper part of the vagina is perfused by the vaginal branches of the uterine artery. The superficial part of the vagina is supplied by the vaginal artery. The hymen, where it exists, receives a variable number of small vessels from the main supplying arteries.

Causes of bleeding after sex are numerous, but only a few are common.

Causes of bleeding after sex

  • Trauma to the vagina - vaginal tears, losing one's virginity, breaking the hymen
  • Vaginitis (due to infections)
  • Cervicitis (due to infections)
  • Cervical cancer
  • Vascular abnormalities
  • Hematological causes
  • Incidental causes

When a patient presents with bleeding after sex a list just like this one goes through the gynecologist's mind. The priority and the order of the conditions change according to many patient factors like age, family history and co-morbidity.

Trauma to vagina

Injury is the most common cause of bleeding after sex. Any sexually active woman may bleed after rough or vigorous sex. Young girls who have sex for the first time may bleed when the hymen breaks.

A small amount of bleeding is normal. Coexisting causative factors may alter the actual amount of bleeding. (Example: clotting disorders may increase the duration and the amount of bleeding).

When the initial episode of bleeding is due to vaginal injury, a second episode is to be expected during healing. During the first to the third day of healing, a friable temporary tissue called granulation tissue forms. It contains capillaries and fibroblasts.

The slightest trauma damages this granulation tissue. Damage to granulation tissue will delay healing, making repeat bleeding more likely.

Vaginitis and cervicitis

Infections of the vagina and cervix come at a close second place as a cause of bleeding after sex.

These infections are quite common in women of child-bearing age, and they can be sexually transmitted or not. Candida, Trichomonas and Chlamydia are a few commonly encountered organisms. These organisms damage the superficial tissue layers and afterwards even mild friction may cause bleeding.

Antifungal treatment and antibiotics are common treatment choices, depending on the cause.

Cervical cancer

Bleeding after sex in middle-aged women requires immediate assessment and intervention. That is because the most common presentation of cervical cancer is post-coital bleeding. The risk of getting cervical cancer increases exponentially from the age of 35. The pre-cancer stage of cervical cancer is known as cervical intraepithelial neoplasia. If detected at early stages, cervical cancer is curable. The treatment protocol changes according to the stage of the cancer. Surgery, radiotherapy and chemotherapy are the main treatment modalities.

Vascular causes

Arterio-venous malformations are rare, but these may cause severe bleeding if damaged.

Hematological causes

Bleeding stops after a while due to clot formation. The first step of clotting is the formation of a platelet plug. When the platelet count or the platelet function is low, platelet plug takes more time to form. The second step is the formation of the definitive clot. Clotting factor deficiencies like hemophilia lead to poor clotting and excessive bleeding.

Incidental causes

The natural menstrual cycle should be considered because menstruation just after sex may be misinterpreted as pathological bleeding after sex. But it is easy to identify menstrual bleeding by the consistency and the texture.

During pregnancy, certain obstetric conditions may lead to bleeding after sex. A low-lying placental and vasa previa are two such conditions. These conditions require urgent obstetric review.

What should you do?

In general, please see your doctor immediately if you notice:

  • Excessive torrential bleeding
  • Severe pain
  • Foul-smelling vaginal discharge
  • If you are pregnant and experiencing vaginal bleeding
  • Post-coital bleeding in middle-aged women

It is always a good idea to see your doctor if you have any doubt.

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