Abnormal Uterine Bleeding (PALM-COEIN)
Clinical detail
Additional detail checked 2026-10-17 against the linked sources. This check covers the section below; the rest of the module retains its displayed verification status.
Assess bleeding impact and anaemia. A heavy-menstrual-bleeding pathway does not replace assessment for pregnancy, acute haemorrhage or suspected malignancy.
Assessment & interpretation
- Take a full blood count. Persistent intermenstrual bleeding or risk of endometrial pathology favours hysteroscopic assessment; uterine enlargement or a pelvic mass favours ultrasound.
Decisions that change management
- For no identified pathology, non-cavity-distorting fibroids below 3 cm or adenomyosis, NICE considers an LNG-IUS first.
- Plan endometrial sampling during hysteroscopy in higher-risk cases; do not use blind biopsy as the routine HMB investigation.
Follow-up & safety-netting
- Review bleeding burden, anaemia and treatment acceptability. Escalate persistent or severe symptoms and discuss fertility preferences before procedural treatment.
Admission & discharge
Admission/discharge guidance checked 2026-10-18 against the linked sources. This is a clinical checklist for an individual decision, not an automatic discharge order.
When admission or continued hospital care is needed
- Admit uncontrolled heavy bleeding, instability/syncope, severe symptomatic anaemia, suspected infection or a surgical emergency. Acute pain requires assessment for other causes rather than assuming fibroids.
When clinic, day care or home care may be suitable
- Stable bleeding/fibroid symptoms can usually be investigated and treated through gynaecology follow-up. Exclude pregnancy where relevant and assess anaemia and cancer risk.
Before going home
- Bleeding is controlled to a safe level, observations and symptoms are satisfactory and the investigation/definitive treatment plan is documented.
- If a procedure occurred, recovery, pain, bladder function and complications have been assessed; anaemia needs its own treatment/response plan.
Discharge medicines and treatment changes
- Use the selected bleeding-control/contraceptive or iron regimen with duration and review dates, after contraindication assessment. Do not prescribe all listed alternatives together.
Medicine doses — use only when indicated
Use the medicines selected for this patient. Listed alternatives are not instructions to prescribe all of them together. Confirm the actual remaining course, pregnancy/postnatal context and monitoring plan.
Only the selected heavy-menstrual-bleeding course after contraindication review.
- Indication: Heavy uterine bleeding unrelated to pregnancy after assessment
- Renal / hepatic: Reduce dose with renal impairment
- Bleeding response, Hb/iron deficiency; investigate persistent or changed bleeding
For suitable pain symptoms; severe/worsening pain still needs assessment.
- Indication: Short-term maternal postoperative/postpartum pain or other mild pain after assessment; adult ≥50 kg
- MSF oral monograph: no pregnancy or breastfeeding contraindication. The dose does not replace assessment of the cause of pain.
- Pain and functional recovery; investigate increasing pain, fever or other warning symptoms.
- Check all prescribed/OTC paracetamol, weight and hepatic risk; suspected excess dosing requires urgent assessment.
Tests, pending results and their reviewer
- Review CBC and any indicated imaging/endometrial sampling; assign responsibility for pathology and persistent/abnormal bleeding results.
Home care and counselling
- Explain expected bleeding, what counts as deterioration, treatment adherence, contraception/fertility goals and access to the next review.
Follow-up: when and what to review
| When | Action / responsible service |
|---|---|
At the booked gynaecology/result review | Assess response and complete evaluation of persistent bleeding or a suspected structural/malignant cause. |
2–4 weeks if treating anaemia | Check Hb response and investigate inadequate improvement. |
Return urgently
- Very heavy bleeding, fainting, chest pain/breathlessness, severe pain or fever requires urgent assessment.
Treatment
① Immediate stabilization — first minutes
③ First-line treatment & drug regimens
| Goal | Options |
|---|---|
Chronic HMB non-hormonal | TXA 1 g QID days 1-4 · NSAIDs mefenamic acid 500 mg TDS |
Chronic HMB hormonal | LNG-IUS 52 mg FIRST-LINE · COCP cyclic/continuous · norethisterone 5 mg days 5-26 |
Fibroid adjuncts | GnRH agonist short pre-op courses; ulipristal regulatory/liver caution - verify Indian approval status |
- Heavy menstrual bleeding after evaluating uterine/cervical/endometrial pathology
- 52 mg systems/indications are not interchangeable with lower-dose IUS products. HMB symptom recurrence requires reassessment before assuming device failure.
- Bleeding/pain, expulsion/perforation symptoms, thread/insertion follow-up and pregnancy symptoms; investigate persistent/new abnormal bleeding
④ Drug treatment detail (1 agents)
- Indication: Heavy uterine bleeding unrelated to pregnancy after assessment
- Renal / hepatic: Reduce dose with renal impairment
- Bleeding response, Hb/iron deficiency; investigate persistent or changed bleeding
Definitive treatment
- Structural lesions: polypectomy/fibroid surgery
- Endometrial ablation or hysterectomy after medical failure per preference
Monitoring
- 8-12 wk response review; Hb recovery
Treatment failure
- Re-image cavity; escalate to hysteroscopy
Procedure / surgery
See procedure pages hysteroscopy/endometrial biopsy.
⑮ Complications & their management
Anaemia
Iron alongside bleeding control
Hyperplasia found
Progestogen vs hysterectomy per atypia - oncology input
Post-treatment care
- Surveillance per lesion; contraception alignment
Diagnosis & assessment
- Haemodynamic instability / severe anaemia -> acute pathway
Initial assessment
- PREGNANCY TEST first in every case
- Cervical inspection + cervical screening status check
- Endometrial sampling if >=45 y, or <45 with risk factors/refractory AUB
- CBC+ferritin; coagulation screen if HMB since menarche (von Willebrand!)
- TVS pelvis; SIS/hysteroscopy for cavity detail
Investigations
| Test | Looking for |
|---|---|
TVS pelvis | PALM structural lesions |
Coagulation screen | Bleeding disorders in adolescent HMB |
Principles & follow-up
Management principles
Sources (9)
14 March 2018 · updated 07 July 2026 · checked 2026-10-18 · verified-live
Open source ↗
Scope: additional clinical-detail explanation for aub, fibroids. Checked the assessment, management-decision and follow-up statements in that section against this source. This does not certify all pre-existing regimens, calculations or recommendations in the module. Additional admission/discharge ch…
· checked 2026-10-17 · verified-live
Open source ↗
Heavy abnormal uterine bleeding: 1 g three times daily, up to four times daily, at most 5 days, and renal/thrombotic cautions.
· checked 2026-10-18 · verified-live
Open source ↗
One sterile 52 mg system, trained insertion, contraindications; 8-year contraception, 5-year HMB then symptom review and maximum 8 years if continued, 4-year UK-labelled HRT endometrial protection. Indication-specific durations are not interchangeable. Additional admission/discharge check 18 October…
· checked 2026-10-18 · verified-live
Open source ↗
Full primary patient recovery page read: pain control, wounds, activity/VTE, urinary/bowel and infection warning signs, adult support and no driving/important decisions during the first 24 hours after general anaesthesia. Used as general recovery/handover principles, not operation-specific discharge…
· checked 2026-10-18 · verified-live
Open source ↗
Full primary oral monograph read: adult 1 g 3–4 times daily, maximum 4 g/day, ≥50 kg adult table, 500 mg tablets, duration according to response, hepatic caution and pregnancy/breastfeeding. Pain chapter also checked for 6–8-hour interval. Smaller adults require an individual weight-based prescripti…
· checked 2026-10-18 · verified-live
Open source ↗
Maternal/newborn transfer assessment, first void and effective feeding, handover, support/safeguarding, first midwife visit within 36 hours after transfer, postnatal danger symptoms. Full recommendations page read.
· checked 2026-10-18 · verified-live
Open source ↗
Normal-delivery discharge not less than 48 hours: full primary SOP PDF normal-delivery/discharge passages read. Corroborated by NHM CEmONC 2024 Part 1, chapter 8. This does not define a universal post-caesarean or complicated-case stay.
· checked 2026-10-18 · verified-live
Open source ↗
Official WHO summary read: at least 24-hour facility care after birth; additional contacts at 48–72 hours, 7–14 days and week 6; individual assessment/support. Summary facts only, not a claim that the full 242-page PDF was reviewed.
· checked 2026-10-18 · verified-live
Open source ↗
Full primary recommendations read, focusing on critical-care-to-ward transfer: structured written handover, shared plan, monitoring, rehabilitation and receiving-team capability. Step-down is distinct from home discharge; no universal organ-support discharge cutoff is asserted.