Heavy Menstrual Bleeding

PALM-COEIN, first-line work-up & the medical ladder

Field: Women's HealthCode: WH-03Updated: June 2026Reference: RANZCOG / NICE NG88

HMB is defined by impact on quality of life, not measured blood volume. The hormonal IUD is commonly first-line medical therapy — offer it before the combined pill or surgery — and treat any iron deficiency at the first visit rather than waiting for the bleeding to settle.

PALM-COEIN classification

Structural (PALM): polyp, adenomyosis, leiomyoma (submucosal fibroids most symptomatic), malignancy.
Non-structural (COEIN): coagulopathy (e.g. von Willebrand), ovulatory dysfunction, endometrial, iatrogenic (anticoagulants, copper IUD), not otherwise classified.

Medical management ladder

Hormonal IUD: commonly first-line; ~90% reduction in flow at 12 months; suits adenomyosis and small submucosal fibroids.
Tranexamic acid during menses: reduces loss by around half; suits women wanting fertility preserved.
NSAIDs during menses: reduce loss by around a third; useful adjunct for dysmenorrhoea.
Combined pill (cyclic or extended): around 40% reduction; avoid if contraindicated.
Cyclic oral progestogen: an option when the combined pill is contraindicated.

First-line investigations

FBC & ferritin in all; TFTs and a coagulation screen if HMB since menarche, family history, or easy bruising. Transvaginal ultrasound on day 5–10 of the cycle. Endometrial biopsy if age >45, persistent intermenstrual or post-menopausal bleeding, or other risk factors.

Treat iron deficiency at first visit

Ferritin <30 is deficient. Start oral iron; consider IV iron if haemoglobin <100 or oral iron isn't tolerated — don't wait for the bleeding itself to be controlled first.

Acute heavy bleeding — office

Tranexamic acid, continued for 5 days or until bleeding settles. Oral norethisterone for 7 days will withdraw-bleed once stopped — counsel the patient. Refer for IV management or transfusion if haemoglobin <70, or there is haemodynamic instability.

PBS listings — LNG-IUS & TXA. PBS listing status and authority requirements for the hormonal IUD and tranexamic acid change — confirm current criteria at pbs.gov.au.

Safety

Don't attribute heavy bleeding to a benign cause without excluding malignancy where risk factors are present.
Treat iron deficiency proactively — it is common and easily missed.
Counsel that norethisterone causes a withdrawal bleed when stopped.

Red flags / refer

Any post-menopausal bleeding, or persistent intermenstrual/post-coital bleeding regardless of age.
Endometrial thickness >11mm pre-menopause or >4mm post-menopause, or a suspicious mass on imaging.
Failed medical therapy after 3–6 months, fibroids >3cm or submucosal, or a fertility concern.
Haemoglobin <80, transfusion-dependent, or haemodynamic compromise → same-day or ED.

WH-03 v1.0 · Reviewed Jun 2026 · Review Jun 2027

For health-professional use. Framework: RANZCOG HMB guidance, NICE NG88, RACGP Red Book. Doses are a guide only — confirm current PBS status & exact dosing at pbs.gov.au / eTG.