Patient handout

Abnormal uterine bleeding (reproductive age — FIGO PALM-COEIN)

PRODUCTION

1. Your condition

This handout is for abnormal uterine bleeding (reproductive age — figo palm-coein). Your care team identified this based on: heavy menstrual bleeding (hmb) — flooding/clots/double protection, interferes with qol (figo system 1; jain pmid 37538019).

Other reasons your team may use this plan: intermenstrual / irregular / infrequent bleeding (figo system 1 pattern descriptors; munro 2018 pmid 30198563); acute heavy uterine bleeding episode (acog co 557 pmid 23635706); post-coital bleeding (cervical/structural pivot; figo system 1).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
conjugated equine estrogen (IV)	25 mg IV q4–6h up to 24 h	IV	q4–6h	ACOG CO 557 first-line medical haemostasis for acute heavy AUB when estrogen not contraindicated; transition to oral maintenance after control (PMID 23635706). rxcui omitted — no clean in-repo precedent (contested code 6373 not reused)
high-dose monophasic combined oral contraceptive	monophasic 30–35 mcg ethinyl estradiol pill TID ×7 d then taper	PO	TID then taper	ACOG CO 557 multi-dose COC regimen for stable acute AUB; US-MEC must permit combined hormonal contraception (PMID 23635706; Nguyen PMID 39106314). rxcui omitted (no in-repo precedent)
medroxyprogesterone acetate (high-dose oral)	20 mg PO TID ×7 d then taper	PO	TID then taper	ACOG CO 557 oral progestin haemostasis when estrogen contraindicated (PMID 23635706). rxcui omitted (no in-repo precedent)
tranexamic acid	1 g IV (or 1.3 g PO TID)	IV/PO	q8h	ACOG CO 557 acute-AUB antifibrinolytic; reduces MBL 34–59 % (PMID 23635706; 21767224). In-repo validated rxcui 37798 (same ingredient PO/IV)
dilation & curettage / hysteroscopy / intrauterine tamponade	—	procedural	—	ACOG CO 557 — surgical management for unstable patients or medical failure; choice by underlying pathology and fertility desire (PMID 23635706)

Plan: Acute heavy AUB — haemostatic control (ACOG CO 557 PMID 23635706)

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — Controlled — acceptable bleeding, anaemia corrected

If you have:

Bleeding within acceptable/normal pattern on therapy (FIGO System 1; ECLIPSE PMID 26507206)
Haemoglobin/ferritin normalised
Taking LNG-IUS / COC / TXA / progestin as prescribed

Do this:

Continue prescribed therapy — do not stop because bleeding improved (ECLIPSE PMID 26507206)
Keep taking iron until your provider says stores are replete (Jain PMID 37538019)
Track your bleeding with a diary or app
Attend follow-up labs and any endometrial surveillance as scheduled (Mayo PMID 30711128)
Tell your provider before stopping/starting other medicines (some affect bleeding) (Munro PMID 21345435)

YELLOW — Inadequate control or new symptoms

If you have:

Bleeding still heavy or irregular after starting therapy
Fatigue, breathlessness, or palpitations (anaemia symptoms)
New irregular spotting on hormonal therapy

Do this:

Continue your therapy and contact your provider for review (ECLIPSE PMID 26507206)
Restart/optimise iron if anaemia symptoms recur (Jain PMID 37538019)
Do NOT stop an anticoagulant on your own if you take one — call your prescriber (Munro PMID 21345435)
Bring your bleeding diary to the visit

Call your provider if:

No improvement after a full treatment interval
Persistent bleeding despite therapy (may need imaging / biopsy / procedure) (Mayo PMID 30711128)
Bleeding between periods or after intercourse that is new

RED — Acute heavy bleeding / haemodynamic alarm

If you have:

Soaking through a pad/tampon every hour for several hours (ACOG CO 557 PMID 23635706)
Dizziness, fainting, fast heartbeat, or feeling like you might pass out
Passing very large clots with flooding
Possible pregnancy with bleeding

Do this:

Go to the emergency department now (ACOG CO 557 PMID 23635706)
Bring your medication list including any blood thinner and hormonal therapy
Tell ED staff this could be heavy uterine bleeding and whether pregnancy is possible

Call your provider if:

Always seek emergency care for soaking-fast bleeding with light-headedness/fainting (ACOG CO 557 PMID 23635706)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Acute heavy uterine bleeding with orthostasis / SBP < 90 / HR > 110 / falling Hb (ACOG CO 557 PMID 23635706)(life-threatening)
Positive β-hCG with uterine bleeding — AUB/PALM-COEIN does NOT apply; route to pregnancy-bleeding pathway (Munro PMID 21345435)
AUB at age ≥ 45 y, OR < 45 y with unopposed-oestrogen / obesity / PCOS / Lynch / tamoxifen / persistent or failed medical Rx — biopsy yield conditionally dependent on the age/unopposed-oestrogen prior (ACOG endometrial-assessment; Mayo PMID 30711128; Long PMID 32008795)
Any postmenopausal-pattern uterine bleeding — endometrial-cancer prior 7.7 %; mean endometrial thickness 16.4 mm (cancer) vs 4.1 mm (no cancer); 5-mm-cut-off LR+ is conditional on HRT (12 off-HRT vs 4.2 on-HRT) (Long PMID 32008795; Smith-Bindman PMID 9809732)
HMB since menarche, family bleeding history, or surgical/dental/postpartum bleeding — structured-screen sens 82 % (→ 95 % with PBAC>100); bleeding-disorder prior 39 % in adolescents vs 16 % adults; vWF-assay post-test conditional on this screen + age prior (Philipp PMID 18226613; Borzutzky PMID 31886837; Comishen PMID 39617186)
Intermenstrual/post-coital bleeding WITH pelvic pain, discharge, or cervical-motion tenderness — PID/cervicitis look-alike that is time-critical (FIGO System 1 post-coital descriptor; Munro PMID 21345435)

5. Follow-up

Treat-to-target sustained — revisit reproductive plan, contraception, and definitive options as fertility intent changes. Continued endometrial-malignancy surveillance for persistent AUB despite therapy (re-biopsy / hysteroscopy). Cross-refer: gyn.dysmenorrhea.core.v1 (overlap adenomyosis/endometriosis pain), endo.pcos.core.v1 (AUB-O cause), gynaecologic oncology if AUB-M. Counsel on long-term anaemia prevention (Jain PMID 37538019; Dutton PMID 36997220)

6. Sources

Guideline: FIGO PALM-COEIN System (Munro 2011/2018) + ACOG Committee Opinion 557 acute AUB + ACOG Practice Bulletin 128 (AUB-O) / 557 (acute AUB) / endometrial-assessment doctrine (CO 651/785) + US-MEC 2024 (CDC MMWR) + NICE NG88 HMB 2018/2021 + SOGC adenomyosis 2023 / leiomyoma management