🌸 Heavy Menstrual Bleeding (Menorrhagia) Workup Simulator

Heavy Menstrual Bleeding Reported

Patient describes excessive menstrual blood loss and its impact.

• ~30%: Prevalence (of reproductive-age women)
• >80 mL: Definition (per cycle threshold)
• >7 days: Duration flag (prolonged bleeding)
• QoL: Impact (work, activity, iron stores)

Why heavy bleeding matters

Excess blood loss disrupts daily life and iron balance.

Initial history taking

Clinician asks about flow, clots, pad changes, flooding.

Subjective flow reports guide but rarely quantify blood loss.

Next diagnostic step

Objective blood-loss estimation follows the initial history.

Pictorial Blood Loss Assessment

A pictorial chart converts pad and tampon use into estimated volume.

• >100: PBAC score threshold (suggests >80 mL loss)
• 30-40 mL: Normal cycle loss (typical volume)
• 80 mL: Heavy threshold (clinical cutoff)
• >250 mL: Severe flooding (urgent evaluation)

Pictorial blood assessment chart

Scored images estimate saturation of pads and tampons.

Clots and flooding

Large clots and flooding raise the estimated score.

Severity slider mirrors rising PBAC-estimated blood loss.

From volume to cause

Quantified loss triggers the PALM-COEIN work-up.

PALM-COEIN Diagnostic Framework

FIGO's PALM-COEIN system splits causes into structural and non-structural.

• PALM: Structural causes (Polyp · Adenomyosis · Leiomyoma · Malignancy)
• COEIN: Non-structural causes (Coagulopathy · Ovulatory · Endometrial · Iatrogenic · Not-classified)
• 9: Categories total (FIGO classification groups)
• 2011: Adopted (FIGO consensus system)

Structural PALM causes

Polyps, adenomyosis, leiomyoma, or malignancy are visible lesions.

Non-structural COEIN causes

Coagulopathy, ovulatory, endometrial, iatrogenic, or unclassified causes.

Structural-probability slider shifts the diagnosis toward PALM or COEIN.

Why classify

Category determines which tests and treatments come next.

Ultrasound Evaluation of the Uterus

Transvaginal ultrasound confirms or excludes structural pathology.

• TVUS: First-line imaging (transvaginal ultrasound)
• >4 mm: Endometrial thickness flag (postmenopausal concern)
• Saline infusion: Polyp detection (sonohysterography adds detail)
• MRI: Fibroid mapping (reserved for complex cases)

What ultrasound looks for

Scan checks endometrium, myometrium, and adnexa for lesions.

Normal vs abnormal findings

Normal anatomy supports a non-structural diagnosis.

Structural findings on scan redirect care toward procedural referral.

Escalation pathway

Suspicious findings prompt biopsy or specialist referral.

Choosing Tranexamic Acid or Hormonal Therapy

Cause and severity guide the final treatment choice.

• Tranexamic acid: First-line medical option (antifibrinolytic, cycle days 1-5)
• LNG-IUS: Hormonal option (levonorgestrel intrauterine system)
• ~50%: Blood loss reduction (with tranexamic acid)
• Surgical: Structural referral (when PALM lesion confirmed)

Non-structural bleeding

Tranexamic acid or hormonal therapy treats most COEIN cases.

Structural bleeding

Polyps, fibroids, or malignancy need procedural or surgical referral.

Treatment readout combines cause, severity, and imaging findings.

Ongoing monitoring

Response is reassessed at the next menstrual cycle.