Heavy Menstrual Bleeding (HMB)

HMB: any heavy menstrual bleeding affecting woman's quality of life — patient-defined; no need to quantify. PALM-COEIN classification: • PALM (structural): Polyp, Adenomyosis, Leiomyoma (fibroid), Malignancy. • COEIN (non-structural): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not otherwise classified. Investigations: • FBC (anaemia), ferritin. • Coagulation screen if heavy from menarche / family hx (vWF, fibrinogen, PT/APTT). • TFTs. • Pelvic USS (transvaginal where appropriate). • Endometrial sampling if persistent intermenstrual bleeding, age ≥45, treatment failure, risk factors for endometrial cancer. • Cervical screen up to date.