Excessive menstrual blood loss interfering with physical, emotional, social, or material quality of life.
History taking
- • Cycle length, duration, clots, flooding, sanitary product use
- • Intermenstrual/postcoital bleeding, dyspareunia, pelvic pain
- • Symptoms of anaemia, contraception, pregnancy plans, drug history
Examination
- • Pallor, BP, thyroid
- • Abdominal and pelvic exam; speculum and bimanual
Red flags
- • Postcoital/intermenstrual bleeding, postmenopausal bleeding — exclude malignancy
- • Symptomatic anaemia
Differential diagnosis
- • PALM-COEIN: Polyp, Adenomyosis, Leiomyoma, Malignancy, Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not classified
Recommended investigations
- • CBC, ferritin, TSH, coagulation if indicated
- • Pregnancy test, Pap smear
- • TVS pelvis, endometrial biopsy if >45 y or risk factors
Diagnosis
- • Clinical + investigations to find PALM-COEIN cause
Initial treatment / management
- • Iron replacement
- • First-line: LNG-IUS (Mirena) if no fertility plan, or tranexamic acid + NSAIDs during menses
- • Second-line: combined OCP, oral progestogens
- • Refractory or structural: surgery (hysteroscopy, endometrial ablation, hysterectomy)
Prescription examples
- • Tab Tranexamic acid 1 g PO TDS x 3–5 d during menses
- • Tab Mefenamic acid 500 mg PO TDS during menses
- • Combined OCP cyclically
- • Mirena (LNG-IUS) insertion
Follow-up advice
- • Review at 3 months for symptom control
Patient counselling
- • Iron-rich diet, supplementation, lifestyle
- • Discuss reversible (medical) vs definitive (surgical) options
Referral criteria
- • Suspected malignancy, structural cause needing surgery, refractory bleeding
Clinical pearls
- • LNG-IUS is the most effective medical therapy and avoids surgery in many
- • Endometrial sampling mandatory in women >45 y with HMB or risk factors
References
- • NICE NG88: Heavy Menstrual Bleeding
- • FIGO PALM-COEIN Classification 2018
Educational outpatient guide — verify against local guidelines before clinical use.
