Tuesday, March 10, 2009

Post-Coital Bleeding, Not Bliss

Dr. Kate,

I am 20 years old, and I have been on birth control for about a year and a half now. I first got on birth control because I had painful and very heavy periods (went through the highest absorbency tampon in 2 or 3 hours!). My boyfriend and I have been sexually active together for maybe five months. He has been with others but I have not. I have been bleeding (just a little) after we have sex. It may or may not have been ever since the beginning, but it definitely has been going on for months now. I went to the Student Health Clinic at my university, where I was tested for STDs and pregnancy. All the tests came back negative. The nurse put me on a Z-pack anyway, just in case it was a kind of bacteria we couldn't test for. She said that if it didn't work, she would have to refer me to a gynecologist. I can't afford a gynecologist: I'm a poor college student!

I finally looked "down there" to check it out after a bleeding episode and I found that the pain came from a flap of skin at the bottom of the entrance to my vagina (the bleeding had stopped at that time, but I can only assume that's where the bleeding came from...). Is that my hymen? Could it be my hymen won't break completely but tears a little each time? What else could it be?

Hanging On Hymen

Dear Hanging,

Nothing kills a post-sex high like bleeding in bed. I don't worry when a patient has one episode of post-coital bleeding, but when it lasts for months, there's generally an explanation. There are multiple reasons why we may bleed after the deed--the most common 3 reasons are:
  • Infection. Your clinic was right to test you for both "normal" vaginal infections and STDs. Chlamydia, gonorrhea, trichomonas, even a wicked yeast infection can cause enough inflammation in your cervix or vagina to cause bleeding.
  • Trauma. Your hymen doesn't really "break" (what an awful mental image)--the membrane does open up, though, generally from physical activity in girlhood. If you've been seeing menstrual bleeding for years, you're "open" enough. But small scratches or lacerations around your vaginal opening can be caused by toys, fingernails, or not enough lubricant. If you can see a bleeding spot yourself, try using a generous amount of lube to make things easier on your vagina. And make sure you get enough foreplay to be really aroused before intercourse.
  • Period jump-start. If you're seeing bleeding in the days before your period starts, it may be the first signs of menses (sex can "shake loose" the first drops). Similarly, if it's in the day or so after your period ends, it may be the leftover blood that you see.
After these three, there are some less-likely causes of bleeding after sex:
  • Polyps and fibroids. Polyps are fleshy overgrowths in your cervix or uterus--think skin tags the size of a golf pencil--and fibroids are benign muscle tumors that can both cause irregular bleeding. A gyno can often pick these up on an ultrasound, but they would be unusual causes in someone your age (they're more common for women in their 30s).
  • Hormonal imbalance. Abnormalities of your thyroid or prolactin hormone can cause irregular bleeding, and can be checked by a blood test. But if your periods are otherwise normal, and you're feeling otherwise healthy, these are unlikely causes.
  • Cervical dysplasia. Post-coital bleeding can point to pap smear abnormalities. But you don't need a pap till you're 21 years old, if you've only been having sex for a few months.
  • Endometriosis. This usually presents with other symptoms, too, like chronic pelvic pain, ovarian cysts or wicked pain with your periods--it's unlikely that post-coital bleeding is the only sign.

If you're worried, the gynos at Planned Parenthood can do a further work-up on a sliding scale (only charging you what you can afford). If the gyno rules all of these out, your bleeding may remain a mystery for now...but try not to worry. If none of these causes show up, your gyn health is clearly excellent, and something to celebrate.

Have any of you had bleeding after sex?

No comments: