Clinical overview
Heavy menstrual bleeding (HMB) is one of the most common reasons women consult primary care, and accounts for a large proportion of gynaecology referrals. The clinical definition has shifted from the old objective threshold (≥80 mL per cycle) to a patient-centred definition: excessive menstrual blood loss that interferes with a woman's physical, emotional, social, and material quality of life. This shift acknowledges that the patient's experience — flooding, double protection, large clots, severe anaemia, time off work — is what matters, not laboratory blood volume.
Management of HMB in 2026 is medical first, with surgical reserved for those who fail or cannot tolerate medical options. The Mirena (LNG-IUS) has revolutionised the management of HMB, and is the first-line intervention in most women with no structural pathology. Hysterectomy rates have fallen dramatically — appropriately. The chapter pairs with Heavy menstrual bleeding pathology which addresses the underlying causes; here we cover assessment, classification, investigation, the stepped medical-to-surgical management ladder, and the South African context.
Core knowledge
Definitions
- Heavy menstrual bleeding (HMB): excessive menstrual blood loss interfering with quality of life (NICE NG88 and FIGO definitions).
- Menorrhagia: older term, same meaning; gradually being replaced.
- Metrorrhagia: irregular bleeding between periods (different problem).
- Menometrorrhagia: heavy AND irregular bleeding.
- Intermenstrual bleeding (IMB): bleeding between periods — different aetiology.
- Postcoital bleeding (PCB): bleeding after intercourse — separate workup.
FIGO classification of abnormal uterine bleeding (AUB) — PALM-COEIN
PALM-COEIN separates structural uterine causes from systemic or functional causes of heavy menstrual bleeding.
A systematic classification of causes, not severity. Memorise it.
Structural (PALM):
- Polyp (endometrial or endocervical).
- Adenomyosis.
- Leiomyoma (fibroids — submucosal especially).
- Malignancy and hyperplasia.
Non-structural (COEIN):
- Coagulopathy (von Willebrand disease, platelet disorders, anticoagulants).
- Ovulatory dysfunction (PCOS, hypothyroidism, prolactinoma, perimenopause).
- Endometrial (primary endometrial dysfunction; diagnosis of exclusion).
- Iatrogenic (IUD, hormonal contraception, anticoagulants).
- Not otherwise classified.
This framework structures every assessment.
Assessment
History
- Cycle: length, regularity, duration of bleeding, heaviness (flooding, clots > 1 cm, doubling sanitary protection, nocturnal changes, daytime accidents).
- Pictorial Blood Loss Assessment Chart (PBAC) score >100 suggests true HMB.
- Impact: work, school, exercise, social, intimate life, mood.
- Dysmenorrhoea (often coexists).
- IMB or PCB (different differential — HPV pathology, polyps, Endometrial carcinoma).
- Pelvic pain or pressure symptoms.
- Reproductive intentions.
- Contraception history.
- Sexual history (rule out cervical/STI causes).
- Bleeding tendency: easy bruising, gum bleeding, family history of bleeding disorders.
- Medications: anticoagulants, antiplatelets, hormonal.
- Comorbidities: thyroid, liver, renal, PCOS, obesity.
- Smear history.