Abnormal uterine bleeding

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.

References

1.FOGSI Good Clinical Practice Recommendations on Management of Abnormal Uterine Bleeding (2016, refreshed); FIGO PALM-COEIN classification (2018 revision); ACOG Practice Bulletin 232 (2018)