GynaecologyFree in the app
Heavy menstrual bleeding
PALM-COEIN, investigation and the treatment ladder.
Source: NICE NG88 · FIGOPALM (structural)
| P | Polyp |
|---|---|
| A | Adenomyosis |
| L | Leiomyoma (fibroid) |
| M | Malignancy / hyperplasia |
COEIN (non-structural)
| C | Coagulopathy |
|---|---|
| O | Ovulatory dysfunction |
| E | Endometrial |
| I | Iatrogenic |
| N | Not yet classified |
Investigate
- FBC for all; coagulation screen if heavy since menarche + history
- Ultrasound if uterus palpable or mass suspected
- Outpatient hysteroscopy if polyp/submucous fibroid/endometrial pathology suspected
- No blind biopsy or D&C alone
Treatment ladder
- LNG-IUS first-line (no pathology, fibroids <3 cm not distorting cavity, adenomyosis).
- Declined: tranexamic acid or NSAID; or combined pill / cyclical progestogen.
- Then: endometrial ablation or hysterectomy.
- Fibroids ≥3 cm: drugs, UAE, myomectomy or hysterectomy.
A summary for trained clinicians. Always check the full guideline, the patient in front of you and your hospital's protocol. Spotted an error? Tell us.