Menorrhagia — PALM-COEIN

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Menorrhagia — PALM-COEIN, Work-up & Treatment

Heavy menstrual bleeding (menorrhagia) is a common reason for women to see a gynaecologist and a leading cause of iron deficiency. This sheet gives the FIGO PALM-COEIN classification, how to assess, medical and surgical treatment, and the red flags.

🎯 AT A GLANCE — HEAVY MENSTRUAL BLEEDING (MENORRHAGIA)

Heavy menstrual bleeding (HMB) is excessive menstrual blood loss that interferes with a woman’s physical, social, emotional or material quality of life

The word “menorrhagia” is now replaced by “heavy menstrual bleeding”; the old term “dysfunctional uterine bleeding” has been dropped

Normal cycle: every 24–38 days, lasting up to 8 days; there is no fixed volume, so ask how the bleeding affects her life

Always classify the cause with PALM-COEIN: structural causes (P, A, L, M) and non-structural causes (C, O, E, I, N)

Many women with HMB have iron deficiency, so check haemoglobin and ferritin in every case

Treat the cause if there is one, and offer treatment that suits her wishes about fertility and contraception.

🚨 ADMIT, SCAN OR REFER IF…

Heavy bleeding with dizziness, fainting, a fast pulse or low blood pressure — treat as an emergency: resuscitate, check the haemoglobin, and call the gynaecologist

She is pregnant, or the pregnancy test is positive — think of miscarriage or ectopic pregnancy before anything else

Bleeding after menopause, or bleeding between periods or after sex — needs an endometrial and cervical assessment

She is over 45, or younger with risk factors (obesity, PCOS, tamoxifen), or treatment has failed — sample the endometrium (from memory)

Bleeding since the first period, or with easy bruising, nosebleeds, or bleeding after delivery or dental work — screen for a bleeding disorder, and refer to haematology

STEP 1 · CLASSIFY THE BLEEDING — normal values and the PALM-COEIN system

📏 WHAT IS NORMAL?

Parameter	Normal range (FIGO)	Abnormal terms
Frequency	Every 24–38 days	Frequent (under 24 days) or infrequent (over 38 days)
Regularity	Cycle length varies by 7–9 days at most, depending on age	Irregular if the variation is more
Duration	Up to 8 days	Prolonged: more than 8 days
Volume	No fixed number; judged by the woman	Heavy menstrual bleeding: interferes with her life
Other	Bleeding between periods (intermenstrual) can be cyclical or random	Always ask about it

🧩 THE PALM-COEIN CLASSIFICATION

Letter	Cause	Definition and clues
P	Polyp	Endometrial or endocervical polyp, found at hysteroscopy or sonohysterography
A	Adenomyosis	Diagnosed by imaging criteria on transvaginal ultrasound (MUSA); two or more criteria are strongly associated
L	Leiomyoma	Submucosal (types 0–3) or other (types 4–8, not distorting the cavity)
M	Malignancy and hyperplasia	Endometrial carcinoma, leiomyosarcoma, or atypical hyperplasia (EIN)
C	Coagulopathy	Systemic bleeding disorders such as von Willebrand disease
O	Ovulatory dysfunction	Unpredictable cycles; includes PCOS, thyroid disease, hyperprolactinaemia, adolescence and perimenopause (examples from memory)
E	Endometrial	A primary disorder of the endometrium, such as chronic endometritis; diagnosed by exclusion
I	Iatrogenic	Hormonal drugs, intrauterine devices and drugs that affect ovulation; anticoagulants were moved here in 2018
N	Not otherwise classified	Rare causes such as an arteriovenous malformation or a caesarean scar defect (niche)

STEP 2 · ASSESS — history, examination and tests

🩺 HISTORY AND EXAMINATION

Ask about the bleeding pattern: cycle length, duration, clots and flooding, bleeding between periods or after sex, and the effect on work and life

Ask how often she changes pads, whether blood leaks through at night, and about clots and flooding; these suggest heavy loss, but they are only rough guides (from memory)

Screen for a bleeding disorder: heavy periods since menarche, bleeding after delivery, surgery or dental work, bruising or nosebleeds once or twice a month, bleeding gums, or a family history. A positive screen needs haematology tests (von Willebrand factor and clotting)

Check the drugs: hormones, IUD, tamoxifen, anticoagulants, and aspirin (from memory)

Examine: pallor, thyroid, blood pressure, abdomen, speculum for the cervix, and bimanual examination for uterine size and tenderness (from memory)

🧪 INVESTIGATIONS

Urine or serum β-hCG to exclude pregnancy

Full blood count with platelets, and serum ferritin for anaemia and iron stores

Ovulation: predictable cycles usually mean ovulation; if unsure, a mid-luteal progesterone; TSH when thyroid disease is suspected (from memory)

Transvaginal ultrasound when the uterus is enlarged or a mass is felt, bleeding is persistent, or treatment fails; add sonohysterography or hysteroscopy for polyps and submucosal fibroids

Endometrial sampling when risk of hyperplasia or cancer is present

Clotting tests only when the bleeding disorder screen is positive

STEP 3 · TREAT — medical first, then procedures

💊 MEDICAL TREATMENT: WHAT TO OFFER

Line	Option	Dose and notes
First	LNG-IUS 52 mg	More effective than oral treatment; keep for at least 12 months; warn about spotting in the first 6 months and persevere for 6 cycles
Second	Tranexamic acid	1 g three times a day for up to 4 days, started when the period begins (maximum 4 g a day). Check for a history of thrombosis (last point from memory)
Second	NSAIDs (mefenamic acid, ibuprofen, diclofenac)	Ibuprofen 200–400 mg three or four times a day, or diclofenac 75–150 mg a day in divided doses; preferred when there is period pain; take with food
Second	Combined oral contraceptive	Also gives contraception and cycle control; check the contraindications
Third	Cyclical progestogen (norethisterone 5 mg three times a day, day 5 to 26) or injectable medroxyprogesterone every 12 weeks	Less effective than the options above; low-dose luteal norethisterone is not effective
Add-on	GnRH analogue for a few months before surgery	To shrink an enlarged uterus or fibroids, or before endometrial ablation

Give NSAIDs or tranexamic acid for at least three cycles and continue if they help. If the first treatment fails, try another medical option before surgery. Treat the underlying cause (for example thyroid disease or a bleeding disorder).

🔪 PROCEDURES AND SURGERY

Surgery is mainly for proven pathology such as fibroids, or when medical treatment has failed or been refused

Uterus under about 10 weeks’ size: endometrial ablation (second-generation) is first line; she should not want a pregnancy

Larger uterus, wants to keep it: uterine artery embolisation or hysteroscopic myomectomy

Does not want to keep the uterus: hysterectomy, vaginal if possible; healthy ovaries should not be removed

Polyps: remove at hysteroscopy and send for histology (from memory)

Atypical hyperplasia or cancer: refer to a gynaecologist or gynaecological oncology team

🚑 ACUTE HEAVY BLEEDING

Assess airway, breathing, circulation; check pulse, blood pressure and haemoglobin; insert an intravenous line (from memory)

Tranexamic acid by mouth or slow intravenous injection, and consider a high-dose progestogen or oestrogen as per local protocol (from memory)

Transfuse for severe anaemia or shock; exclude pregnancy first (from memory)

If bleeding does not settle, call the gynaecologist for procedures such as curettage or hysteroscopy, or balloon or surgical measures (from memory)

🩸 TREAT THE ANAEMIA

Check haemoglobin and ferritin; start iron if she is iron deficient

Treat the anaemia as well as the bleeding; women may feel tired and breathless long before they seek help (from memory)

Give iron by mouth on alternate days or daily, and use intravenous iron if she cannot take or absorb tablets, or when a rapid rise is needed before surgery (from memory)

Recheck the blood count after a few weeks (from memory)

⚠️ COMMON PITFALLS

Starting treatment without a pregnancy test and a blood count

Missing a bleeding disorder in a girl with heavy bleeding since her first period

Treating with tablets when the uterus is large or a mass is felt, without a scan

Missing endometrial hyperplasia or cancer in an older or obese woman

Stopping the LNG-IUS too early because of spotting

Using cyclical low-dose norethisterone, which does not work

Treating the bleeding but not the anaemia

Memory Aid

PALM-COEIN

Nine causes of abnormal uterine bleeding.

S

Structural: PALM — Polyp, Adenomyosis, Leiomyoma, Malignancy and hyperplasia

N

Non-structural: COEIN — Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not otherwise classified

1

First tests — pregnancy test, blood count, ferritin

2

First treatment — LNG-IUS; then tranexamic acid, NSAID or the pill

Remember: classify the cause, treat the anaemia, and match the treatment to what she wants.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary. Checked against: the FIGO 2018 systems for normal and abnormal uterine bleeding (Munro et al: PALM-COEIN categories, normal menstrual parameters, definition of heavy menstrual bleeding, initial investigations, bleeding disorder screen); a primary care summary of the NICE NG88 heavy menstrual bleeding guidance (order of medical treatment, LNG-IUS, cyclical progestogen, GnRH analogue, surgical options by uterine size); and an NHS formulary page (tranexamic acid, ibuprofen and diclofenac doses, notes on the LNG-IUS and low-dose norethisterone). Items marked “from memory” (how to estimate blood loss, examples of ovulatory causes, red-flag situations, acute management, iron regimens, thyroid and other tests) were not checked. Regimens differ between countries: follow your local protocol and involve a senior gynaecologist.