Describe it first (FIGO system 1)
- Frequency: normal 24 to 38 days; frequent under 24; infrequent over 38.
- Regularity: cycle-to-cycle variation under 7 to 9 days is regular.
- Duration: up to 8 days.
- Volume: heavy menstrual bleeding is bleeding that interferes with quality of life, by the patient's account, not by a measured volume.
- Intermenstrual, postcoital and postmenopausal bleeding are named separately because each has its own differential.
- Acute AUB: bleeding heavy enough to need intervention now.
Classify the cause (FIGO system 2)
| PALM (structural) | COEIN (non-structural) |
|---|---|
| Polyp: intermenstrual bleeding; saline sonography or hysteroscopy | Coagulopathy: heavy periods from menarche, bruising, family history; von Willebrand disease in up to 13 percent of heavy bleeders |
| Adenomyosis: heavy painful periods, bulky tender uterus | Ovulatory dysfunction: irregular, unpredictable cycles; PCOS, thyroid, hyperprolactinaemia, perimenopause, adolescence |
| Leiomyoma: heavy bleeding when submucosal (FIGO types 0 to 2); pressure when large | Endometrial: regular heavy periods with no other cause; a diagnosis of exclusion |
| Malignancy and hyperplasia: postmenopausal bleeding, or persistent AUB with risk factors (obesity, anovulation, unopposed oestrogen, Lynch syndrome) | Iatrogenic: hormonal contraception, anticoagulants, IUD |
| Not otherwise classified: arteriovenous malformation, caesarean scar defect |
Large uterine fibroid (leiomyoma)
Transabdominal. A 9 cm well-defined solid mass with a whorled, heterogeneous echotexture.
Open in the Ultrasound LabAdenomyosis
Transvaginal. A bright endometrial stripe.
Open in the Ultrasound LabWork-up
- Pregnancy test first, every time, in anyone who could be pregnant.
- CBC and ferritin; coagulation screen and von Willebrand studies when the history suggests; TSH and prolactin with ovulatory dysfunction.
- Transvaginal ultrasound: fibroids and their location, adenomyosis, endometrial thickness, polyps (better on saline infusion sonography).
- Endometrial sampling: age 40 or over with AUB, or younger with risk factors or failed treatment; always for postmenopausal bleeding with an endometrium over 4 to 5 mm.
- Cervical screening if due; a speculum examination looks for cervical causes.
Treatment
| Option | Best for | Notes |
|---|---|---|
| Tranexamic acid, NSAIDs | Regular heavy bleeding, wants to conceive or avoid hormones | Taken during menses; NSAIDs also help pain |
| Levonorgestrel IUD | Heavy menstrual bleeding of most causes | Most effective medical option; reduces loss by about 90 percent |
| Combined hormonal contraception | Irregular or heavy bleeding, needs contraception | Cyclical or continuous; check eligibility (MEC) |
| Oral progestins | Anovulatory bleeding | Cyclical to regulate; continuous to suppress |
| Acute heavy bleeding | Haemodynamic concern | Intravenous conjugated oestrogen or high-dose oral progestin or combined pill taper; tranexamic acid; balloon tamponade or evacuation if needed |
| Hysteroscopic resection | Submucosal fibroids, polyps | Day surgery |
| Endometrial ablation | Completed family, no cavity distortion | Not contraception; pregnancy after ablation is dangerous |
| Myomectomy, hysterectomy | Fibroids with fertility wish; definitive treatment | Uterine artery embolisation as an alternative for fibroids |
Check
A 16-year-old with heavy periods since menarche, iron deficiency and easy bruising. Which PALM-COEIN category comes first in your mind?
On the modelBody and myometriumEndometriumCervix