A 35-year-old woman with a 16-month history of heavy menstrual bleeding reports that her periods last 9 days and she passes large clots. She has tried tranexamic acid and mefenamic acid with minimal improvement. She has two children and does not wish for future pregnancy. Examination is normal and transvaginal ultrasound shows a normal uterus (8 cm length) with no fibroids and endometrial thickness of 6 mm on day 5 of cycle. Full blood count shows haemoglobin 101 g/L. She declines hormonal treatment. What is the most appropriate next management option?

Prescribe oral norethisterone for cycle regulation

Increase dose of tranexamic acid and mefenamic acid

Offer trial of levonorgestrel intrauterine system despite preferences

A 26-year-old woman presents to the emergency department with sudden onset severe left-sided pelvic pain, nausea, and one episode of syncope 2 hours ago. She has 7 weeks amenorrhoea. On examination, she is alert with heart rate 102 bpm, blood pressure 104/68 mmHg, and temperature 36.8°C. Abdominal examination reveals left iliac fossa tenderness with mild guarding but no rigidity. Transvaginal ultrasound shows an empty uterus, a 35 mm left adnexal mass with a hyperechoic ring, and a small amount of free fluid in the pouch of Douglas. Serum beta-hCG is 5600 IU/L. What is the most appropriate management?

Diagnostic laparoscopy with decision for salpingectomy or salpingotomy at surgery

Admit for observation with 4-hourly observations and repeat ultrasound in 24 hours

Arrange urgent MRI pelvis to better characterise the adnexal mass

A 41-year-old woman with a 10-month history of heavy menstrual bleeding undergoes hysteroscopy which reveals a 3 cm type 2 submucosal fibroid partially extending into the myometrium (>50% intramural component). She wishes to preserve her fertility. Transvaginal ultrasound confirms no other significant fibroids and normal endometrial cavity. What is the most appropriate initial management?

Trial of levonorgestrel intrauterine system

GnRH agonist therapy for 6 months

A 31-year-old woman presents to the emergency department with left-sided pelvic pain and 7 weeks amenorrhoea. Transvaginal ultrasound demonstrates an empty uterus and a 20 mm left adnexal mass. Initial serum beta-hCG is 1450 IU/L. She is clinically stable. Repeat beta-hCG 48 hours later is 1380 IU/L. What is the most appropriate management?

Expectant management with weekly beta-hCG monitoring

Repeat beta-hCG in 48 hours to confirm declining trend

Arrange MRI pelvis to confirm ectopic location

What is the primary mechanism by which endometrial ablation reduces menstrual bleeding in women with heavy menstrual bleeding?

Destruction of the endometrial basalis layer preventing regeneration

Reduction in endometrial blood vessel density through thermal injury

Decreased prostaglandin production from damaged endometrium

Hormonal suppression of endometrial proliferation

Formation of intrauterine adhesions reducing cavity volume

A 38-year-old multiparous woman with heavy menstrual bleeding has had a levonorgestrel intrauterine system in situ for 3 years. Initially, her bleeding improved significantly, but over the past 6 months, she has noticed gradually worsening menstrual bleeding returning to pre-treatment levels. She wishes to continue with hormonal management. Pelvic examination is normal. Transvaginal ultrasound shows the IUS in correct position with a normal uterine cavity and no fibroids. What is the most appropriate management?

Remove and replace the levonorgestrel intrauterine system

Add tranexamic acid during menstruation

Switch to combined oral contraceptive pill

Continue current IUS for remaining 2 years of licensed duration

A 34-year-old woman presents to the emergency department with sudden onset severe right-sided abdominal pain and syncope. She has 6 weeks amenorrhoea. On examination, she is pale with heart rate 118 bpm and blood pressure 88/54 mmHg. Abdominal examination reveals generalised tenderness with guarding. A bedside urine pregnancy test is positive. What is the most appropriate immediate management?

Insert two large-bore intravenous cannulae, cross-match 4 units blood, commence fluid resuscitation, and arrange emergency laparoscopy

Perform urgent transvaginal ultrasound to confirm diagnosis before proceeding to theatre

Administer intramuscular methotrexate and commence fluid resuscitation

Request urgent serum beta-hCG and proceed to laparoscopy only if levels are above 1500 IU/L

Arrange CT abdomen and pelvis with contrast to localise the ectopic pregnancy

A 52-year-old woman presents with a 6-month history of irregular vaginal bleeding occurring approximately every 2-3 weeks. She also reports a single episode of postcoital bleeding 2 months ago. She has never had an abnormal cervical smear and her last smear 18 months ago was normal. On speculum examination, the cervix appears healthy with no visible lesions. Bimanual examination reveals a bulky uterus. What is the single most important initial investigation?

Hysteroscopy and endometrial biopsy

A 46-year-old woman attends the gynaecology clinic with a 14-month history of increasingly heavy and irregular menstrual bleeding. Her periods occur every 18-45 days and last 7-10 days. She reports no intermenstrual or postcoital bleeding. Abdominal examination is unremarkable. Transvaginal ultrasound shows a normal-sized uterus with endometrial thickness of 18 mm. Both ovaries appear normal with multiple small follicles. What is the most appropriate next investigation?

Hysteroscopy and endometrial biopsy

Serum follicle-stimulating hormone and luteinising hormone

Repeat ultrasound in early proliferative phase

Abnormal uterine bleeding for UKMLA AKT: High-Yield Women’s Health Lessons

Quick Overview

Abnormal uterine bleeding (AUB) affects 14-25% of reproductive-age women. NICE NG88 provides evidence-based investigation and management pathways. Understanding the PALM-COEIN classification is essential for systematic assessment and appropriate treatment selection, particularly the distinction between structural (PALM) and non-structural (COEIN) causes.

Core Facts & Concepts

Definitions & Thresholds:

Heavy menstrual bleeding (HMB): Excessive blood loss interfering with physical, emotional, social, or material quality of life
Intermenstrual bleeding (IMB): Bleeding between regular menstrual periods
Postcoital bleeding (PCB): Bleeding after sexual intercourse
Postmenopausal bleeding (PMB): Any bleeding >12 months after last menstrual period

PALM-COEIN Classification:

Structural (PALM)	Non-Structural (COEIN)
Polyp	Coagulopathy
Adenomyosis	Ovulatory dysfunction
Leiomyoma	Endometrial
Malignancy/hyperplasia	Iatrogenic
	Not yet classified

Figure 1: Transvaginal ultrasound showing thickened endometrium measuring 16mm

Key Investigation Thresholds (NICE NG88):

📊 Transvaginal USS: First-line structural imaging
📊 Endometrial biopsy indicated if:
- Age ≥45 years with persistent IMB
- Treatment failure for HMB
- Endometrial thickness >12mm postmenopausal
- Suspected endometrial pathology on imaging

Problem-Solving Approach

NICE NG88 Investigation Pathway:

History & Examination:
- Impact on quality of life (patient-reported severity)
- Pattern: cyclical vs irregular, volume, associated symptoms
- Risk factors: age, obesity, PCOS, family history
- Cervical screening status
First-line Investigations:
- Full blood count (exclude anaemia: Hb <120 g/L women)
- Coagulation screen if HMB since menarche or family history
- Thyroid function tests if additional symptoms
Imaging Decision Points:
- 🚩 Always USS if: Palpable pelvic mass, examination difficult/abnormal, pharmaceutical treatment failed
- Consider hysteroscopy if: Persistent IMB, suspected submucosal fibroids, endometrial polyps
Endometrial Sampling:
- Pipelle biopsy (outpatient)
- Hysteroscopy with biopsy if Pipelle inadequate

Figure 2: Hysteroscopy view showing endometrial polyp

🚩 Red Flags: PMB, persistent IMB >45 years, visible cervical lesion, pelvic mass = urgent investigation

Analysis Framework

First-Line Management Options (NICE NG88):

Treatment	Mechanism	Key Facts	First Choice When...
Levonorgestrel-IUS (52mg)	Endometrial suppression	80-90% reduction in blood loss, contraceptive	No contraindications, wants contraception
Tranexamic acid	Antifibrinolytic	40-50% reduction, taken during menses only	Prefers non-hormonal, no structural cause
NSAIDs (mefenamic acid)	Prostaglandin synthesis inhibition	20-30% reduction, helps dysmenorrhoea	Mild HMB with dysmenorrhoea
Combined hormonal contraceptive	Endometrial thinning	Regular bleeding pattern	Wants contraception, <40 years

Contraindications to Consider:

LNG-IUS: Distorted uterine cavity (>3cm submucous fibroid), active infection, undiagnosed bleeding
Tranexamic acid: History of thromboembolism (relative)
NSAIDs: Peptic ulcer disease, renal impairment

Visual Aid

Second-Line/Surgical Options:

Option	Indications	Notes
Endometrial ablation	HMB, no structural cause, family complete	80% satisfaction, not suitable if >10cm uterus
Hysteroscopic resection	Submucosal fibroids <3cm, polyps	Day case procedure
Uterine artery embolisation	Symptomatic fibroids	Preserves uterus
Hysterectomy	Failed conservative management	Definitive treatment

Key Points Summary

✓ PALM-COEIN classification: Systematic approach separating structural (PALM) from non-structural (COEIN) causes

✓ NICE NG88 endometrial biopsy indications: Age ≥45 with persistent IMB, treatment failure, endometrial thickness >12mm postmenopausal

✓ First-line pharmaceutical: Levonorgestrel-IUS 52mg (80-90% reduction), tranexamic acid (40-50% reduction), or NSAIDs (20-30% reduction)

✓ USS indications: Palpable mass, abnormal examination, failed pharmaceutical treatment

✓ Red flags requiring urgent investigation: PMB, persistent IMB >45 years, visible cervical lesion, palpable pelvic mass

✓ Patient-centred approach: Impact on quality of life determines treatment need, not objective blood loss measurement

✓ Common pitfall: Forgetting coagulation screen in HMB since menarche (13% have bleeding disorder, most commonly von Willebrand disease)

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