GPAtlas🧭 When to suspect
Heavy menstrual bleeding (HMB) is excessive menstrual blood loss that interferes with a woman's physical, social, emotional and/or material quality of life.
• The diagnosis is defined by its impact on the woman – not by a measured volume.
• The historical threshold of > 80 mL per cycle is obsolete; what matters is how the bleeding affects her life.
Suspect HMB when a woman describes:
• Flooding through sanitary protection.
• Passing large clots.
• Changing protection frequently or overnight.
• Needing double protection.
Suspect it also when she presents with the consequences of chronic blood loss, such as fatigue, breathlessness or palpitations from iron-deficiency anaemia.
Because the causes span structural lesions and systemic disorders, a practical framework is the International Federation of Gynecology and Obstetrics (FIGO) PALM–COEIN classification, separating structural (PALM) from non-structural (COEIN) causes.
| Structural causes (PALM) |
|---|
• Polyp – endometrial or endocervical |
• Adenomyosis – bulky, tender uterus with significant dysmenorrhoea |
• Leiomyoma (fibroid) – especially submucosal; the 3 cm threshold drives referral |
• Malignancy and hyperplasia – the key "must-not-miss" |
| Non-structural causes (COEIN) |
|---|
• Coagulopathy – e.g. von Willebrand disease; suspect if HMB since menarche |
• Ovulatory dysfunction – perimenopause, polycystic ovary syndrome, thyroid disease |
• Endometrial – primary disorder of endometrial haemostasis (a diagnosis of exclusion) |
• Iatrogenic – anticoagulants, antiplatelets, copper coil, hormonal agents |
• Not otherwise classified – rare causes (e.g. arteriovenous malformation) |
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