Red Flags
- Heavy bleeding with haemodynamic compromise (tachycardia, hypotension, syncope) — emergency resuscitation, IV fluids, transfusion, gynaecology[1]
- Postcoital bleeding with abnormal cervix on examination — same-day gynaecology and colposcopy (rule out cervical malignancy)[1]
- Postmenopausal bleeding — pelvic ultrasound and endometrial sampling within 2 weeks (endometrial cancer until proven otherwise)[1]
- AUB with persistent anaemia despite iron and tranexamic acid — investigate for coagulopathy (von Willebrand, platelet dysfunction); haematology[1]
First-line treatment
Interventions
- PALM-COEIN-directed management[1]Structural causes (Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia) need targeted procedures. Non-structural causes (Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified) typically respond to medical therapy
- Iron repletion alongside bleed control[1]Oral elemental iron 100–200 mg daily (or alternate-day for tolerance) in mild–moderate IDA; IV iron (ferric carboxymaltose) for severe anaemia, oral intolerance, or imminent surgery
- Surgical / interventional options[1]Endometrial ablation for completed family with no structural pathology; uterine artery embolisation or myomectomy for fibroids; hysteroscopic polypectomy; hysterectomy as definitive when other options fail or contraindicated
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Tranexamic acid[1] | Antifibrinolytic | 1 g PO TDS during menstruation × up to 5 days | 10–15 mg/kg/dose PO TDS × up to 5 days | Reduces menstrual blood loss by 40–60%; non-hormonal and non-contraceptive; avoid with active thromboembolic disease |
| Combined oral contraceptive (cyclic or extended)[1] | Estrogen-progestogen combined hormonal contraceptive | Standard low-dose COC (ethinyl-estradiol 20–30 µg + progestogen) cyclic or continuous regimen | — | First-line for ovulatory AUB without contraindication; avoid in migraine with aura, smoking ≥35, hypertension, VTE history, breast cancer |
| Levonorgestrel intrauterine system (LNG-IUS)[1] | Progestogen intrauterine device | 52 mg LNG-IUS device — 5–8 year duration depending on brand | — | Most effective medical therapy for heavy menstrual bleeding (~80% reduction); concurrent contraception; preferred long-term in women without family-completion pressure |
| Norethisterone (cyclic progestogen)[1] | Progestogen | 5 mg PO TDS days 5–26 of cycle (long course); 5 mg TDS × 10 days for acute heavy bleed | — | Short-term acute control of heavy bleeding; cyclic regimen for ovulatory dysfunction; not contraceptive at standard cyclic doses |
| GnRH agonist (leuprolide) ± add-back HRT[1] | Gonadotropin-releasing hormone agonist | Leuprolide 3.75 mg IM monthly or 11.25 mg IM 3-monthly + add-back HRT after 3 months | — | Pre-operative shrinkage of fibroids; bridge in perimenopause; bone loss with prolonged use; reserve >6 months only with add-back |
| Ulipristal acetate or relugolix (selected fibroids)[1] | Selective progesterone receptor modulator / GnRH antagonist combination | Ulipristal 5 mg PO daily × up to 3 months (per local restrictions); relugolix-estradiol-norethisterone combination 1 tab PO daily | — | Symptomatic uterine fibroids; hepatic safety considerations with ulipristal; relugolix combination preserves bone density |
Tranexamic acid[1]
Antifibrinolytic
- Adult
- 1 g PO TDS during menstruation × up to 5 days
- Paediatric
- 10–15 mg/kg/dose PO TDS × up to 5 days
Reduces menstrual blood loss by 40–60%; non-hormonal and non-contraceptive; avoid with active thromboembolic disease
Combined oral contraceptive (cyclic or extended)[1]
Estrogen-progestogen combined hormonal contraceptive
- Adult
- Standard low-dose COC (ethinyl-estradiol 20–30 µg + progestogen) cyclic or continuous regimen
- Paediatric
- —
First-line for ovulatory AUB without contraindication; avoid in migraine with aura, smoking ≥35, hypertension, VTE history, breast cancer
Levonorgestrel intrauterine system (LNG-IUS)[1]
Progestogen intrauterine device
- Adult
- 52 mg LNG-IUS device — 5–8 year duration depending on brand
- Paediatric
- —
Most effective medical therapy for heavy menstrual bleeding (~80% reduction); concurrent contraception; preferred long-term in women without family-completion pressure
Norethisterone (cyclic progestogen)[1]
Progestogen
- Adult
- 5 mg PO TDS days 5–26 of cycle (long course); 5 mg TDS × 10 days for acute heavy bleed
- Paediatric
- —
Short-term acute control of heavy bleeding; cyclic regimen for ovulatory dysfunction; not contraceptive at standard cyclic doses
GnRH agonist (leuprolide) ± add-back HRT[1]
Gonadotropin-releasing hormone agonist
- Adult
- Leuprolide 3.75 mg IM monthly or 11.25 mg IM 3-monthly + add-back HRT after 3 months
- Paediatric
- —
Pre-operative shrinkage of fibroids; bridge in perimenopause; bone loss with prolonged use; reserve >6 months only with add-back
Ulipristal acetate or relugolix (selected fibroids)[1]
Selective progesterone receptor modulator / GnRH antagonist combination
- Adult
- Ulipristal 5 mg PO daily × up to 3 months (per local restrictions); relugolix-estradiol-norethisterone combination 1 tab PO daily
- Paediatric
- —
Symptomatic uterine fibroids; hepatic safety considerations with ulipristal; relugolix combination preserves bone density
Safety-net
- Severe bleeding (soaking pad/tampon hourly for ≥2 hours, clots ≥2 cm, lightheadedness, breathlessness) — same-day medical review or A&E[1]
- Bleeding after sex, between periods, or after menopause is never normal — book a gynaecology review even if mild[1]
- While on hormonal therapy, attend follow-up — efficacy review at 3 months and side-effect check (mood, BP, breast symptoms)[1]
Referral criteria
- Postmenopausal bleedingGynaecology with endometrial sampling within 2 weeks[1]
- Failed medical management at 3–6 months or significant fibroid diseaseGynaecology for surgical/procedural options[1]
- Suspected coagulopathy or family history of bleeding disorderHaematology for vWF, factor levels, platelet function[1]
- Acute heavy bleeding with anaemia or haemodynamic compromiseEmergency department; gynaecology[1]
Clinical summary
Diagnosis using PALM-COEIN classification and stepwise management of heavy menstrual bleeding in non-pregnant reproductive-age women.