Heavy menstrual bleeding
Gynaecology
Gynaecology or family practice clinic
The first question
Is she anaemic, and is the cause structural?
- 01
Exclude pregnancy
Every time.
- 02
Describe the bleeding
FIGO system 1: frequency, regularity, duration, volume; intermenstrual or postcoital bleeding named separately.
- 03
Classify
PALM-COEIN: examination, ultrasound, bloods, and endometrial sampling when age or risk factors call for it.
- 04
Treat
Iron; medical options by preference and eligibility; procedures for structural causes.
Where it is
Each opens the structure on the 3D pelvis.
History that discriminates
- Cycle pattern and the change from before
- Clots, flooding, protection use, days off work
- Bleeding since menarche, bruising, family history (coagulopathy)
- Pain, pressure, urinary or bowel symptoms (fibroids, adenomyosis)
- Intermenstrual or postcoital bleeding
- Contraception, anticoagulants, IUD
- Symptoms of anaemia, thyroid disease, hyperprolactinaemia
- Fertility wishes
Examination that discriminates
- Pallor, BMI, signs of thyroid disease or hyperandrogenism
- Abdominal masses
- Speculum: cervix, polyps, lesions; screening if due
- Bimanual: uterine size, contour, tenderness, adnexal masses
Investigations
- Pregnancy test
- CBC, ferritin
- TSH, prolactin if cycles irregular
- Coagulation screen and von Willebrand studies if the history suggests
- Transvaginal ultrasound; saline sonography for the cavity
- Endometrial biopsy if 40 or over, or risk factors, or failed treatment
The differential
| Diagnosis | Favours | Against | Urgency |
|---|---|---|---|
| Endometrial (no structural cause) | Regular heavy cycles, normal scan | Structural finding | routine |
| Leiomyoma | Bulky uterus, submucosal fibroid on scan | Normal uterus | routine |
| Adenomyosis | Painful heavy periods, globular tender uterus, scan features | Normal uterus | routine |
| Coagulopathy | Heavy since menarche, bruising, family history | New onset in adult life | routine |
| Ovulatory dysfunction | Irregular unpredictable cycles, PCOS, perimenopause, thyroid disease | Regular cycles | routine |
| Hyperplasia or malignancy | Age over 40, obesity, anovulation, persistent bleeding, thickened endometrium | Young, no risk factors | urgent |
| Iatrogenic | Anticoagulants, hormonal method, copper IUD | No medication | routine |
Pitfalls this pathway refuses
- Skipping the pregnancy test
- Attributing bleeding to a fibroid that is subserosal
- Not sampling the endometrium in a 45-year-old with persistent bleeding