Menorrhagia (Heavy Menstrual Bleeding)

🔍 When to Suspect

Excessive menstrual blood loss which interferes with a person's physical, emotional, social, and material quality of life (e.g., flooding, passing large clots)

From the full topic in The Ocean Library: Menorrhagia (Heavy Menstrual Bleeding)

🧭 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. Crucially, 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 80 mL per cycle is obsolete; what matters is how the bleeding affects her life.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, or needing double protection – or 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 FIGO PALM–COEIN classification, separating structural (PALM) from non-structural (COEIN) causes.

Structural causes (PALM)	Non-structural causes (COEIN)
• Polyp – endometrial or endocervical	• Coagulopathy – e.g. von Willebrand disease; suspect if HMB since menarche
• Adenomyosis – bulky, tender uterus with significant dysmenorrhoea	• Ovulatory dysfunction – perimenopause, polycystic ovary syndrome, thyroid disease
• Leiomyoma (fibroid) – especially submucosal; the 3 cm threshold drives referral	• Endometrial – primary disorder of endometrial haemostasis (a diagnosis of exclusion)
• Malignancy and hyperplasia – the key "must-not-miss"	• Iatrogenic – anticoagulants, antiplatelets, copper coil, hormonal agents
	• Not otherwise classified – rare causes (e.g. arteriovenous malformation)

Source: NICE NG88 · FIGO

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