Clinicopathological evaluation of women with postcoital bleeding

*Corresponding author: Ankita A Bagade Copyright © 2025 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution Liscense 4.0. Clinicopathological evaluation of women with postcoital bleeding Ankita A Bagade *, Nasrin Fatima, Latika Sahu, Asmita M Rathore, Preeti Singh, Pallavi Pathak and Rachita Garg Department of obstetrics and gynecology, MAMC and Lok Nayak Hospital, Delhi, India. World Journal of Biology Pharmacy and Health Sciences, 2025, 22(03), 391-404 Publication history: Received on 07 May 2025; revised on 15 June 2025; accepted on 18 June 2025 Article DOI: https://doi.org/10.30574/wjbphs.2025.22.3.0604 Abstract Aim-To determine the percentage of postcoital bleeding and study the correlation between demographic data, clinical findings, cytology, colposcopy and histopathological reports among women with postcoital bleeding. Materials and Methods: Women ≥18 years of age with postcoital bleeding attending the gynaecology OPD were included in the study. After proper consent, physical and gynaecological examinations were done in 100 patients with postcoital bleeding. Liquid-based cytology was taken from all patients, and colposcopy and cervical biopsy were done when indicated. The percentage of women with postcoital bleeding in this study was 0.115%. The study identified various causes of postcoital bleeding among women, in which 28 cases were linked to inflammation, 17 cases to infections, and 5 cases had unknown causes (idiopathic). Additionally, 25 cases are non-cancerous (benign), 5 cases show early signs of potential cancer (premalignant), and 20 cases involve confirmed cancerous cells, highlighting the diverse reasons behind postcoital bleeding. The study establishes a significant correlation (p = 0.02) between pap smear results and cervical biopsy outcomes in 100 women with postcoital bleeding. A significant correlation (p = 0.002) was observed between colposcopy grading and cervical biopsy results. This study establishes the correlation between cervical biopsy results with final diagnoses, 45 women underwent biopsy, revealing a range of pathologies. Among cases diagnosed with inflammation, chronic inflammation, and focal dysplasia were noted. Benign diagnoses predominantly consisted of polyps, while premalignant cases included one carcinoma in situ. All 19 malignant cases were confirmed as invasive cancer on histopathological examination (HPE), underscoring cervical biopsy's significance as the gold standard for confirming malignancy, supported by a significant p-value of 0.00 at the 95% Confidence Interval. ConclusionAll women experiencing post-coital bleeding should undergo a comprehensive assessment, including pelvic examination followed by a pap smear, colposcopy, and biopsy if necessary. If a cervical smear appears normal in women with post-coital bleeding, it does not necessarily exclude the presence of cervical intraepithelial neoplasia or invasive cancer. Post-coital bleeding should be considered a potentially alarming sign of increased risk for invasive cervical cancer and cervical intraepithelial neoplasia. Timely workup and intervention are recommended. Keywords: Postcoital bleeding; Pap smear; Gynaecological examination; Cervical intraepithelial neoplasia; Cervical cancer 1. Introduction Post coital bleeding defined as vaginal bleeding unrelated to menstruation that occurs after sexual intercourse and is a common but often overlooked gynaecological symptom. While it can be associated with benign conditions in many cases, such as cervical ectropion or cervical polyp, or infections. Post coital bleed may also be a harbinger of serious World Journal of Biology Pharmacy and Health Sciences, 2025, 22(03), 391-404 392 underlying pathology, including cervical cancer or pre-cancerous lesions [1]. Its incidence is estimated to range from 0.7% to 9% in reproductive-aged women, with variability depending on population and healthcare access [2]. It is a relatively recurrent symptom and multifactorial in women. Spontaneous resolution has been noted in 51% of naturally menstruating premenopausal women after two years, with no subsequent signs of recurrence [3]. About 30% of women experiencing postcoital bleeding also encounter abnormal uterine bleeding, while 15% report dyspareunia [4]. Most women with post coital bleeding will have a benign condition such as cervical polyp, ectropion, urogenital atrophy or cervicitis secondary to chlamydial infection. However post coital bleeding can also be associated with cervical cancer and understandably causes anxiety in women presenting with this symptom [5]. The prevalence of cervical cancer in women with post coital bleeding is 3-5.5%, and the prevalence of CIN is 6.8-17.8% [6]. Post coital bleeding is reported as the chief presenting symptom in 11% of women diagnosed with cervical cancer [7]. It’s important to know that cervical cancer can be prevented by regular Pap smear tests, planned gynaecological examinations, HPV tests, Colposcopy and cervical vaccines [8]. Recent studies have emphasized the importance of a thorough clinical evaluation in all cases of postcoital bleeding, particularly due to its potential association with high grade CIN 2/3 and invasive malignancies. The integration of HPV testing, colposcopy and cytological assessment has improved diagnostic accuracy and early detection rates. Furthermore, updated guidelines by organisations such as ACOG and FIGO highlight the necessity of considering post coital bleeding as an alarm symptom, especially in women over 35 or those with persistent bleeding [9]. Aims and objectives To determine the percentage of postcoital bleeding in women visiting the gynaecology OPD in Lok Nayak Hospital, New Delhi. To determine the association between demographic characteristics, clinical presentation, and physical examination findings with histopathology of various conditions causing postcoital bleeding. 2. Materials and Methods A cross-sectional study was conducted after obtaining ethical clearance from Institutional Ethics Committee among women of age ≥18 years attending Gynaecology OPD in the Department of Obstetrics and Gynaecology at Maulana Azad Medical College and Lok Nayak Hospital from September 2022February 2024. Sexually active women of age ≥18 years with postcoital bleeding were included in the study and pregnant women, women who underwent hysterectomy, diagnosed case of carcinoma cervix and postcoital tear were excluded. A complete history including high-risk factors, menstrual history, gynaecological history, medical history like any bleeding disorder, and current medication were taken. A detailed clinical and gynaecological examination was done including per speculum, pervaginal and per recital examination. A liquid based cytology (LBC) was taken and was reported using the Bethesda system. Colposcopy was considered if there were any suspicious lesions on the cervix or if the LBC report showed some abnormality.The grade was calculated by SWEDE score for classifying the colposcopy findings. Grade I was given a score of 0-4, Grade II was 5-6 and Grade III was from 7-10 depending upon the acetic acid uptake, iodine staining, vessels, margins, and the size of the lesion. A score of 0-4 indicates normal cervix or low-grade lesion (CIN1), a score of 5-6 indicates high-grade and non-invasive lesions (CIN2+), and a score of 7-10 indicates high-grade lesions with suspected invasion.If indicated, a biopsy was taken and sent for histopathology. After a thorough clinical and histopathological examination, the diagnosis was made and the percentage of diagnosed benign, premalignant, and malignant lesions was noted. 3. Observations and Results The study was conducted in the Department of Obstetrics and Gynaecology, Maulana Azad Medical College, and Associated Lok Nayak Hospital during the period from September 2022 to February 2024. Approximately, 86900 women attended the Gynaecology OPD out of which 100 women met the inclusion criteria and were included in the study. The percentage of women with postcoital bleeding was 0.115%. The clinicopathological evaluation of 100 women with complaints of postcoital bleeding was done to find out the diagnosis. World Journal of Biology Pharmacy and Health Sciences, 2025, 22(03), 391-404 393 Table 1 Demographic details of the study patients Age Frequency (n=100) Percentage (%) 21-30 22 22.0 31-40 36 36.0 41-50 30 30.0 51-60 12 12.0 Body mass index (BMI) <18.4 0 0 18.5-22.9 18 18.0 23-24.9 21 21.0 25-29.9 56 56.0 >30 5 5.0 Residence Rural 57 57.0 Urban 43 43.0 Religion Hindu 44 44.0 Muslim 56 56.0 Education Illiterate 75 75.0 Pre-school 9 9.0 Primary 6 6.0 Secondary 7 7.0 Graduation 2 2.0 Post-graduation 1 1.0 Socioeconomic status Lower 29 29.0 Upper lower 51 51.0 Lower middle 17 17.0 Upper middle 3 3.0 Upper 0 0 High risk factors Multiple sexual partners 1 1.0 Poor hygiene 99 99.0 Multiparity 88 88.0 Smoking 4 4.0 OCP use 15 15.0 World Journal of Biology Pharmacy and Health Sciences, 2025, 22(03), 391-404 394 Immunocompromised state 5 5.0 Low socio-economic status 70 70.0 Parity (P) Nullipara 6 6.0 Primigravida 8 8.0 Multigravida 86 86.0 Contraception None 60 60.0 Barrier methods 6 6.0 Oral contraceptive pills 15 15.0 Intrauterine devices 7 7.0 Tubal ligation 12 12.0 Past history Hypertension 13 13.0 Diabetes 7 7.0 Thyroid disorder 6 6.0 Tuberculosis 6 6.0 Seizure disorder 1 1.0 Heart disease 1 1.0 Poliomyelitis 1 1.0 History of blood transfusions 2 2.0 Other malignancy 1 1.0 cholecystectomy 2 2.0 Tonsillectomy 1 1.0 Family history Chronic medical illness 2 2.0 Not significant 97 97.0 History of malignancy 1 1.0 Personal history Reduced appetite 3 3.0 Altered bladder habits 1 1.0 Drug abuse 4 4.0 Not significant 93 93.0 In this study group, the most affected age group with postcoital bleeding was 31-40 years. Among 100 patients with postcoital bleeding, 56% belonging to the overweight group (25-29.9), 75% were illiterate and 51% belonged to the upper lower class group. The common high risk factors in this study was poor hygiene, multiparity and low socioeconomic status. Around 86% were multigravida, 60% did not use any contraception methods and 12% used oral contraceptive pills. In this study group, 13% had hypertension, 7% had diabetes, 1% had history of malignancy and 1% had family history of malignancy. Majority of them no significant family and personal history. [Table-1] World Journal of Biology Pharmacy and Health Sciences, 2025, 22(03), 391-404 395 Table 2 Clinical presentation and gynaecological examination findings in the patients Clinical presentation-symptoms Frequency (n=100) Percentage (%) Lower abdominal pain 35 35.0 Dyspareunia 9 9.0 Discharge per vaginum 28 28.0 Something coming out of vagina 7 7.0 Heavy menstrual bleeding 11 11.0 Abnormal uterine bleeding 6 6.0 Postmenopausal bleeding 6 6.0 Burning micturition 9 9.0 Infertility 3 3.0 Others 12 12.0 Amount of postcoital bleeding Spotting 33 33.0 Mild (superficially stained single pad) 36 36.0 Moderate (single pad-half soaked) 15 15.0 Heavy (single pad-3/4th to fully soaked) 16 16.0 Per-abdomen examination Uterus not palpable 94 94.0 Uterus palpable 4 4.0 Cystic mass palpable 2 2.0 Per speculum examination Cervix normal 7 7.0 Cervical ectropion 22 22.0 Cervical hyperthrophy 29 29.0 Cervical polyp 19 19.0 Cervical growth 22 22.0 Uterovaginal prolapse 1 1.0 Vagina Healthy 88 88.0 Unhealthy 12 12.0 Discharge Present 34 34.0 Absent 66 66.0 Bleeding Present 39 39.0 Absent 61 61.0 World Journal of Biology Pharmacy and Health Sciences, 2025, 22(03), 391-404 396 Per vaginal examination Cervix Normal 16 16.0 Bulky 42 42.0 Polyp 21 21.0 Growth 14 14.0 Flushed with vagina 2 2.0 Prolapse 1 1.0 Cervical motion tenderness Absent 83 83.0 Present 17 17.0 Bilateral fornix Bilateral fornix free 81 81.0 Bilateral fornix fullness 19 19.0 Parametrium Involved 18 18.0 Free 82 82.0 Pelvic side wall Involved 10 10.0 Free 90 90.0 In this study , majority had normal physical examination finding except for 11% who were known case of hypertension on treatment,5% who had pallor and 2% had tachycardia. Among the 100 patients with postcoital bleeding, majority of them (36%) had mild bleeding. On Per Speculum examination, Most of the study subjects had an abnormal-looking cervix, 29% had cervical hypertrophy, 22% had cervical ectropion, whereas 19% had a cervical polyp and 22% had growth in the cervix. Around 7% had normal-looking cervix and 1% had uterovaginal prolapse,, bleeding is present in 39% and discharge in 34% .[Table-2] Table 3 Liquid based cytology (LBC), Colposcopy, cervical biopsy reports and diagnosis of the patients LBC Reports Frequency (n=100) Percentage (%) NILM 73 73.0 ASCUS 9 9.0 LSIL 4 4.0 HSIL 11 11.0 AGC 0 0.0 Malignant cell 3 3.0 Colposcopy findings Grade 1(0-4) 5 5.0 Grade 2(5-6) 2 2.0 Grade 3(7-10) 3 3.0 World Journal of Biology Pharmacy and Health Sciences, 2025, 22(03), 391-404 397 Cervical biopsy findings Chronic inflammation 7 7.0 Endocervical polyp 9 9.0 Adenomyomatosis polyp 3 3.0 Cervical fibroid 3 3.0 Focal dysplasia 3 3.0 Carcinoma in situ 1 1.0 Moderately differentiated carcinoma 2 2.0 Keratinizing squamous cell carcinoma 1 1.0 Non –keratinizing squamous cell carcinoma 13 13.0 Adenocarcinoma 1 1.0 Mixed malignant mullerian tumor 1 1.0 Diagnosis Inflammatory 28 28.0 Infection 17 17.0 Idiopathic 5 5.0 Benign 25 25.0 Premalignant 5 5.0 Malignant 20 20.0 In the study population, the Liquid-Based Cytology (LBC) was reported in all cases and 73 cases had Negative for Intraepithelial Lesion or Malignancy (NILM), indicating no abnormal cells were detected, 9 had Atypical Squamous Cells of Undetermined Significance (ASCUS), 4 cases of Low-Grade Squamous Intraepithelial Lesion (LSIL) and 11 cases of High-Grade Squamous Intraepithelial Lesions (HSIL), indicating varying degrees of abnormal cell changes that may require further evaluation. No cases of Atypical Glandular Cells (AGC) were reported, but 3 cases of Malignant Cells were detected. In the present study, colposcopy was done on 10 women among 100 study population, out of which 50% had Grade-I findings, 20% had Grade-II findings and 30% had Grade-III findings on colposcopy. Cervical biopsy was done in 45 (45%) out of 100 study populations. Out of 45 cervical biopsies, 7% had chronic inflammation, 15% had polyps, 9 had endocervical polyps, 3 had adenomyomatous polyps and 3 had cervical fibroids. Focal dysplasia was detected in 3 cases, carcinoma in situ was found in 1 case and 19 cases were found to be malignant. Among 19 malignant cases, moderately differentiated carcinoma is seen in 2 cases, 13 cases had non-keratinizing squamous cell carcinoma, moderately differentiated carcinoma in 2 cases, and adenocarcinoma in 1 case. Also, one rare finding which is mixed malignant Mullerian tumor was reported in 1 case. Among the study group, 28 cases exhibited signs of Inflammatory conditions, suggesting potential inflammation-related causes. Infection was detected in 17 cases, indicating the presence of infectious agents contributing to the bleeding episodes. 5 cases were diagnosed as Idiopathic, signifying that the cause of bleeding remains unclear despite evaluation. Additionally, 25 cases were classified as Benign, denoting non-cancerous origins, while 5 cases were identified as Premalignant, indicating abnormal cell changes with potential for cancer development. Finally, Malignant conditions were identified in 20 cases, highlighting the presence of cancerous cells as a significant contributor to postcoital bleeding among these women. World Journal of Biology Pharmacy and Health Sciences, 2025, 22(03), 391-404 398 Table 4 Sensitivity, specificity, positive predictive value (PPV), and negative predictive value [NPV] of LBC and colposcopy for premalignant and malignant lesions Procedure LBC (premalignant) LBC (malignant) Colposcopy (premalignant) Colposcopy (malignant) Sensitivity 50% 85% 50% 100% Specificity 53.7% 84% 25% 50% PPV 9.5% 81% 25% 50% NPV 91.7% 87.5% 50% 100% P-value 0.88 0.000 0.540 0.221 In the study, the sensitivity and specificity of LBC for detecting premalignant lesion was found to be 50% and 53.7% respectively. The positive predictive value (PPV) was 9.5% and the negative predictive value (NPV) was 91.7%. The accuracy of LBC for detecting premalignant lesion was 51.1%. The sensitivity and specificity of LBC for detecting malignant lesion was found to be 85% and 84%. The PPV and NPV was 81% and 87.5% respectively and the overall accuracy was 84.5%. With 95% confidence interval, the p-value was 0.000 which was significant. The sensitivity of colposcopy was 50%, specificity 25%, PPV was 25% and NPV was 50% for detecting premalignant lesions. The sensitivity of colposcopy was 100%, specificity 50%, PPV was 50% and NPV was 100% for detecting malignant conditions. Table 5 Comparison of high risk factors between the two groups with normal and abnormal pathology Demographic details Benign Premalignant/malignant P-value Age in years 36.5±8.06 47.12±8.98 0.001 Multiparity 64(85.3%) 24(96.0%) 0.155 Socio –economic status 46(61.3%) 24(96.0%) 0.001 Smoking 1(1.3%) 3(12%) 0.018 Multiple sexual partners 1(1.3%) 0 0.562 OCP intake 14(18.7%) 1(4%) 0.075 Women with premalignant/malignant conditions tend to be significantly older (mean age of 47.12 years) compared to those with benign conditions (mean age of 36.5 years) and it was statistically significant (p = 0.001). There was a higher proportion of multiparity among women with premalignant/ malignant conditions (96.0%) compared to those with benign conditions (85.3%), but the difference is not statistically significant (p = 0.155). A significantly higher percentage of women with premalignant/malignant conditions (96.0%) had a lower socioeconomic status compared to those with benign conditions (61.3%). The difference was statistically significant (p = 0.001). Women with premalignant/ malignant conditions reported taking oral contraceptive pills (4.0%) were compared to those with benign conditions (18.7%), and no significant association was found (p = 0.075). A significantly higher percentage of women with premalignant/ malignant conditions (12.0%) reported smoking habit compared to those with benign conditions (1.3%). The difference was statistically significant (p = 0.018). The difference in the proportion of women reporting multiple sexual partners between the benign and premalignant/malignant groups was not statistically significant (p = 0.562). World Journal of Biology Pharmacy and Health Sciences, 2025, 22(03), 391-404 399 Table 6 Correlation among Age, per speculum findings, LBC, colposcopy and cervical biopsy Age in years NILM ASCUS LSIL HSIL Total 21-30 22 0 0 0 22 31-40 28 2 1 5 36 41-50 21 5 1 2 30 51-60 2 2 2 4 12 Correlation of per speculum findings and LBC Per speculum Findings NILM ASCUS LSIL HSIL Total Normal cervix 7 0 0 0 7 Cervical ectropion 21 1 0 0 22 Cervical hypertrophy 22 4 1 2 29 Cervical polyp 17 1 1 0 19 Cervical growth 5 3 2 9 22 Uterovaginal prolapse 1 0 0 0 1 Correlation of LBC and cervical biopsy Biopsy report NILM ASCUS LSIL HSIL Total Inflammation 5 1 1 0 7 Endocervical polyp 9 0 0 0 9 Adenomyomatous polyp 3 0 0 0 3 Cervical fibroid 2 1 0 0 3 Focal dysplasia 2 1 0 0 3 Carcinoma in situ 0 0 0 1 1 Moderately differentiated squamous cell carcinoma 0 0 1 1 2 Keratinizing squamous cell carcinoma 0 0 0 1 1 Large cell non keratinizing squamous cell carcinoma 2 1 1 8 14 Adenocarcinoma 1 0 0 0 1 Mixed malignant mullerian tumor 0 0 0 0 1 P -value 0.02 Correlation of colposcopy and cervical biopsy Biopsy report Grade 1 Grade 2 Grade 3 Not applicable Total Inflammation 1 1 0 5 7 Endocervical polyp 0 0 0 9 9 Adenomyomatosis polyp 0 0 0 3 3