Heavy menstrual bleeding: quality-of-life diagnosis, PALM-COEIN, and practical GP pathways
A GP-facing summary of Associate Professor Talat Uppal and Dr Sarah Whitburn’s interview-style seminar — what counts as HMB, FIGO classification, essential versus selective investigations, adolescent Holly, and perimenopausal Simmy with fibroids and iron deficiency.
- Associate Professor Talat Uppal
- Gynaecologist and visiting medical officer, Macquarie University; clinical educator with niche expertise in managing abnormal menstrual bleeding. Otter heard the name as “Talaat Apal” — surname spelling used here as provided for this package; not independently verified beyond the seminar intro.
- Dr Sarah Whitburn
- Medical Director, Sexual Health Victoria; genital health, menopause, and IUD insertion training. Interviewed Talat in a panel-style format.
Key messages
- Heavy menstrual bleeding (HMB) is a quality-of-life diagnosis — not only “more than 80 mL” (the older menorrhagia volume cut-off).
- About one in four women of reproductive age have heavy periods; roughly half of that group also have some form of coexistent pelvic pain.
- Classify causes with FIGO PALM-COEIN (structural vs non-structural).
- Do FBC and ferritin for almost everyone; target thyroid, coagulopathy work-up, pregnancy/STI mindfulness, and day 5–10 TVUS by clinical need.
- Do not let someone leave the first visit without a plan and a script.
- Medical efficacy pyramid (research settings as presented): NSAIDs ~10–20% bleeding reduction; tranexamic acid ~40–50%; 52 mg LNG-IUD up to ~90–95% at 3–4 months.
- In perimenopause with risk factors and fibroids: proactive IV iron, endometrial biopsy consideration, and bridge medical therapy while awaiting gynaecology.
What is heavy menstrual bleeding?
Sarah opened with the day-to-day GP question: when someone says “heavy bleeding,” what actually counts? Talat’s answer: HMB is essentially a quality-of-life diagnosis. Previously, anything over about 80 mL was labelled menorrhagia — but many women do not know their volume, and quality of life is more patient-centred.
Current framing: excessive menstrual loss that affects quality of life — physical, emotional, social, and/or material. Examples from the talk: the adolescent who cannot get through school; the person at work who cannot focus. HMB may occur alone or with other symptoms such as pelvic pain.
Statistically one in four women of reproductive age have heavy periods, and half of that group also have some form of coexistent pelvic pain. Assessment remains mainly symptom- and QoL-based, organised with FIGO classification.
FIGO PALM-COEIN
HMB is the most common form of abnormal uterine bleeding, but abnormal bleeding also includes intermenstrual bleeding, prolonged bleeding, and irregular patterns. Think in terms of frequency, duration, volume, and regularity.
FIGO’s PALM-COEIN divides causes into two groups:
- PALM — structural (uterus-facing): Polyps; Adenomyosis; Leiomyoma (fibroids); Malignancy and hyperplasia.
- COEIN — non-structural: Coagulopathy (inherited or acquired); Ovulatory dysfunction; Endometrial; Iatrogenic; Not otherwise classified (e.g. caesarean section niche causing abnormal bleeding).
PCOS / anovulatory cycles were placed under the non-structural / ovulatory-dysfunction angle in the discussion.
Essential vs selective investigations
The speakers referenced the Australian Heavy Menstrual Bleeding Clinical Care Standard as structuring management. Investigation priorities as discussed:
| Category | What / when |
|---|---|
| Essential (almost all) | FBC (haemoglobin) and ferritin / iron studies — do not miss iron deficiency; anaemia is a late-stage manifestation |
| Selective — thyroid | If symptoms suggest thyroid disease |
| Selective — coagulopathy | Bleeding since menarche; family bleeding tendency; excess bleeding with dental work or surgery |
| Mindful — pregnancy / STI | Reproductive-age context: do not miss pregnancy-related bleeding; STI may contribute to abnormal bleeding — not required for every HMB case, but keep in the differential |
| Imaging | Prefer transvaginal ultrasound where appropriate; ideally day 5–10 when lining is thinnest (speaker analogy: looking for “views” through a thin curtain) so cavity-distorting lesions show better |
Pelvic ultrasound is more targeted when history or examination raise structural concern — significant pain pointing toward endometriosis/adenomyosis, or a large/bulky uterus suggesting fibroids. In a younger person without red flags, a full pelvic examination is not always required at the first visit; use holistic clinical decision-making.
Case: Holly, 17
Holly is 17 with a regular 28-day cycle, very heavy bleeding over three days, and severe pain with bleeding. She denies sexual activity after careful, respectful exploration. No systemic pressure or urinary symptoms were flagged in the vignette; fatigue was not described but should not be ignored in real life.
Even at the first visit, try not to have someone leave without a plan and without a script. Offer all options; respect preferences; some care is better than no care.
Talat framed options as a pyramid from least to most invasive — and stressed talking about efficacy (“which is our best soldier for heavy bleeding”).
| Option | Role / efficacy (research settings as presented) |
|---|---|
| NSAIDs | Useful when pain coexists — reduce inflammation, pain, and bleeding; bleeding change only ~10–20% |
| Tranexamic acid | Stronger for bleeding (~40–50%); not for pain; good if she prefers to avoid hormones |
| 52 mg LNG-IUD (Mirena; not Kyleena) | Most effective medical option discussed — up to ~90–95% reduction at 3–4 months |
| Combined or progesterone-only pill | Offer if IUD feels too interventional; efficacy more variable — framed around roughly two thirds for some oral regimens |
| Iron | Proactive oral replacement; low threshold for IV if bleeding heavily while medical control builds |
A Cochrane comparison was cited: Mirena performed best; tranexamic acid middle; cyclic oral progesterone (short or long cycle) poorest in that context — longer cyclic progesterone better than short cycle, but still behind tranexamic acid. That undercuts relying on “10 days of progesterone” alone when better options exist.
Case: Simmy, 47 — fibroids and anaemia
Simmy (also heard as Cindy/Sidney in parts of the Otter transcript) is 47, one prior normal vaginal delivery, sexually active with a male partner. Cycles are irregular (about 28–40 days) with up to 10 days of heavy bleeding, occasional intermenstrual bleeding, pelvic pressure, and urinary frequency. Raised BMI; clinically mild anaemia; sensitive pelvic exam shows a bulky, mildly tender uterus.
Work-up already started with FBC, ferritin, day 5–10 TVUS, and symptom-control with tranexamic acid. Results: Hb 108, ferritin 7, ultrasound with multiple fibroids. STI testing was clear.
Can she still have medical management?
Yes — but think holistically across three goals: diagnosis, “vapour plumbing” (symptom control), and replacing losses with iron. With ongoing heavy loss and significant anaemia/iron deficiency, go straight to IV iron while figuring out treatment preference.
- Pelvic pressure is often multifactorial — fibroids commonly; also consider UTI and perimenopausal urinary symptoms.
- Endometrial cancer lifetime risk framed as about one in 44; risk rises with diabetes, age >45, high BMI, family history / Lynch syndrome, and symptomatic bleeding. This woman needs endometrial biopsy consideration and referral.
- For fibroids ask: How big? Where located? (submucous fibroids particularly drive heavy bleeding); single vs multiple. Guidance cited (NICE-style): fibroids <3 cm may still suit a Mirena.
If you refer to gynaecology, still start medical management (e.g. Mirena, pill, tranexamic acid). Public wait lists can leave women through more anaemic cycles despite best intentions.
Referral, polyps, and surgical ladder
Simmy’s risk factors and structural findings mean yes — refer. Ultrasound may say “fibroid,” but theatre sometimes reveals a polyp (“chandelier” surprise). Most polyps are benign; some can be malignant; they are notorious for intermenstrual bleeding — think bigger picture, then narrow to common structural pathology.
Where malignancy concerns are addressed and medical options suitable, the Heavy Menstrual Bleeding Clinical Care Standard encourages trying medical care first. Surgical / procedural options discussed:
- Endometrial ablation where suitable
- Hysteroscopic myomectomy for a relatively small submucous fibroid
- Myomectomy and radiological options — radiology usually needs tissue diagnosis first (often via hysteroscopy)
- Hysterectomy — may be preferred if pressure symptoms dominate or she chooses that path; intracavitary “housekeeping” will not fix extrinsic pressure
Helpful shared-decision question: if she could remove one symptom, would it be pain, bleeding, or pressure?
Resources and take-homes
- Heavy Menstrual Bleeding Clinical Care Standard (national) — about five of eight recommendations relevant to primary care; patient-facing document used in practice.
- RANZCOG patient resources mentioned.
- Industry education packs (e.g. chosen IV iron, Mirena) as practical “homework bags.”
- Interest flagged in more personalised digital resources rather than one-size leaflets for a 14-year-old vs a perimenopausal woman.
HMB is common and QoL-defining. Assess with history, examination, and clinical standards; use PALM-COEIN. Adolescents: lean non-invasive first-line options early. Perimenopause: risk-assess and refer early when indicated. The 52 mg levonorgestrel IUD is the most effective long-term medical option to discuss, in a shared decision-making way, for both age groups.