Heavy and abnormal uterine bleeding: AU general practice guide

Heavy and abnormal uterine bleeding is one of the most common presentations in general practice gynaecology — affecting approximately 25% of women in their reproductive years — and carries significant impact on quality of life, work attendance, and mental health. It is also a leading cause of hysterectomy in Australia, although most cases respond well to medical management when assessed and treated systematically.

The two key concepts are heavy menstrual bleeding (HMB) — bleeding heavy enough to interfere with quality of life, not an absolute volume threshold — and abnormal uterine bleeding (AUB), the broader term covering any bleeding abnormal in regularity, frequency, duration, or volume. The FIGO PALM-COEIN classification provides the framework for identifying structural (PALM) and non-structural (COEIN) causes, directing targeted investigation and treatment rather than empirical suppression.

RANZCOG’s Heavy Menstrual Bleeding guideline and eTG: Reproductive health are the primary AU clinical references. Endometrial cancer in Australia accounts for approximately 3,500 new cases per year and is rising with the obesity epidemic — this makes systematic investigation of alarm features a clinical and medico-legal priority.

A. Core clinical — the AU general-practice framework

History

A thorough menstrual history defines the problem and guides investigation:

• Menstrual pattern — onset, duration, regularity, estimated flow (pads/tampons per day, flooding within one hour, clots, soaking through protection or bedding)
• Quality of life impact — work absences, social avoidance, anaemia symptoms (fatigue, dyspnoea on exertion, palpitations)
• Intermenstrual or postcoital bleeding — separate from HMB; prompts cervical and endometrial pathology workup
• Postmenopausal status — any bleeding ≥12 months after last period = urgent pathway
• Dyspareunia, dysmenorrhoea, dyschezia, infertility — endometriosis cluster
• Contraception and pregnancy history — IUD, hormonal methods; exclude early pregnancy complications
• Drug history — anticoagulants (warfarin, direct oral anticoagulants), hormonal therapies, tamoxifen, complementary medicines
• Family history — coagulopathy (von Willebrand’s), Lynch syndrome (endometrial, colorectal, ovarian, breast cancers)
• Adolescent onset from menarche — coagulopathy screen indicator

Examination

• General — pallor (anaemia), BMI (obesity elevates endometrial cancer and anovulatory risk)
• Abdominal — palpable uterus >12-week gestational size suggests significant fibroids
• Bimanual — uterine size, regularity, tenderness, adnexal masses
• Speculum — cervix appearance, cervical screening if due, discharge
• Vital signs — haemodynamic stability in acute severe bleeding

Investigations

First-line bloodwork:

• FBC — anaemia severity
• Ferritin — iron-deficiency anaemia (common with chronic HMB)
• TSH — thyroid disease causes anovulatory AUB
• β-hCG — exclude pregnancy complications
• Coagulation screen — order in adolescents with menorrhagia from menarche, family history of bleeding disorder, or clinical features of coagulopathy (von Willebrand’s disease is the most common cause)
• Cervical screening if due; STI screen (gonorrhoea/chlamydia NAAT) if intermenstrual or postcoital bleeding or STI risk

Transvaginal ultrasound (TVS) — the first-line imaging: endometrial thickness, fibroid number/location/size, adenomyosis features (bulky uterus, heterogeneous myometrium), ovarian pathology. In postmenopausal women, endometrial thickness ≥4 mm requires endometrial sampling.

Second-line/specialist:

• Saline infusion sonohysterography (SIS) — polyps, submucosal fibroids
• Hysteroscopy with biopsy — gold standard for postmenopausal bleeding, abnormal TVS, suspected hyperplasia, refractory HMB
• Outpatient pipelle endometrial biopsy — useful in the GP setting or outpatient clinic
• MRI pelvis — adenomyosis characterisation, deep infiltrating endometriosis

B. Pharmacological and surgical treatment

Medical management of HMB

The Cochrane systematic review (Lethaby 2015) comparing intrauterine devices with oral drug treatment established the Mirena LNG-IUD as the most effective pharmacological treatment for HMB, with approximately 90% blood loss reduction — substantially greater than oral alternatives.

Mirena LNG-IUD — first-line; PBS Authority required for menorrhagia indication (general schedule for contraception alone); also provides contraception and endometrial protection on systemic oestrogen. Insertion is the main limiting factor.

Tranexamic acid 1 g three times daily on days of bleeding (maximum four days) — approximately 30–50% reduction; non-hormonal; suitable for women seeking to avoid hormones or maintain fertility; PBS general schedule; contraindicated in personal history of VTE.

NSAIDs (mefenamic acid 500 mg three times daily, ibuprofen, or naproxen during menses) — approximately 30% reduction; useful when concurrent dysmenorrhoea is present; PBS and OTC availability; avoid in renal impairment or significant gastrointestinal risk.

Combined oral contraceptive (COC) — cycle suppression with approximately 30–40% reduction; continuous or extended cycle to reduce episode frequency; per WHO Medical Eligibility Criteria.

Cyclical progestogen (norethisterone 5 mg three times daily, days 5–26) — modest cycle control; less effective than Mirena; useful short-term or where COC is contraindicated.

GnRH analogues (goserelin, leuprorelin) — Authority Required; profound suppression but significant vasomotor effects and bone loss; used as pre-surgical downstaging or short-term bridge; always prescribe with add-back hormone replacement therapy for bone and vasomotor protection.

Relugolix-oestradiol-norethindrone (Ryeqo) — oral GnRH antagonist combination; TGA-approved 2023 for HMB with uterine fibroids; PBS Authority Streamlined for fibroids (maximum 24 months continuous); emerging option.

Ulipristal (Esmya) — withdrawn or restricted in Australia due to hepatic safety signal; do not prescribe.

Postmenopausal bleeding

Any vaginal bleeding occurring 12 or more months after the final period is postmenopausal bleeding (PMB) — endometrial cancer until proven otherwise. The investigation pathway is:

1. TVS — endometrial thickness ≥4 mm triggers biopsy
2. Endometrial sampling (pipelle, hysteroscopy with biopsy) — if abnormal TVS or persistent bleeding despite normal TVS
3. Referral to gynaecology-oncology if cancer confirmed

Women on tamoxifen develop endometrial pathology at elevated rates and require endometrial assessment for any abnormal bleeding.

Iron deficiency anaemia

Replete iron alongside treating the bleeding. Oral iron (100–200 mg elemental iron daily) is first-line; intravenous iron (ferric carboxymaltose, iron sucrose) is indicated for oral intolerance, severe anaemia, or refractory cases. The interaction between chronic HMB and iron-deficiency anaemia is bidirectional — anaemia worsens fatigue and quality of life, while untreated HMB perpetuates depletion.

C. Specific causes and their management

Fibroids (leiomyomata) — submucosal fibroids cause disproportionate HMB relative to their size; intramural and subserosal fibroids are less directly causative. Management ranges from GnRH analogues pre-surgery, through uterine artery embolisation (preserves uterus; specialist interventional radiologist; uncertain fertility outcomes), myomectomy (laparoscopic, abdominal, or hysteroscopic per fibroid position), to hysterectomy for definitive treatment.

Adenomyosis — endometrial glands and stroma within the myometrium; bulky symmetrical uterus; severe dysmenorrhoea and HMB; MRI is the most accurate non-invasive test. Mirena is first-line pharmacological management; systemic hormonal suppression is second-line; hysterectomy is curative.

Endometrial polyps — hysteroscopic polypectomy under direct vision; most are benign but all warrant histopathology.

Endometrial hyperplasia — without atypia: progestogen therapy (Mirena or oral); with atypia: gynaecology-oncology referral; hysterectomy is generally recommended.

PCOS-related anovulatory bleeding — unopposed oestrogen drives endometrial proliferation; ensure at least four withdrawal bleeds per year to reduce endometrial cancer risk via COC, progestogen, or Mirena. Lifestyle and metformin address underlying insulin resistance.

Coagulopathy (von Willebrand’s disease) — haematology co-management; tranexamic acid; desmopressin pre-procedure or during heavy bleeds; avoid aspirin and NSAIDs.

D. Australian operations

MBS billing. Standard GP consultation items 23, 36, and 44. TVS is rebated under item 55066 range. Hysteroscopy with biopsy under item 35711 range (specialist). IUD insertion under items 35503 and 35506. Pipelle biopsy under outpatient pathology items. GPCCMP (items 965/967) where chronic HMB and comorbidities (anaemia, endometriosis, fibroids, mental health impact) warrant allied health planning. 45–49 Health Assessment (item 701) and 75+ Health Assessment (item 705) provide systematic review opportunities. ATSI Health Assessment (item 715).

PBS. Mirena — Authority Required for menorrhagia (general schedule for contraception). Tranexamic acid — general schedule. Mefenamic acid, ibuprofen, naproxen — general schedule or OTC. COC, POP — general schedule. Norethisterone — general schedule. GnRH analogues (goserelin, leuprorelin) — Authority Required. Relugolix combination (Ryeqo) — Authority Required Streamlined for fibroid HMB. Oral iron — general schedule. IV ferric carboxymaltose (Ferinject) — Authority Required for specific clinical criteria.

Cancer Council resources. Cancer Council Australia provides patient information on endometrial cancer, its relationship to postmenopausal bleeding, and gynaecological cancer screening.

Jean Hailes. Jean Hailes for Women’s Health is the leading AU consumer resource for women’s health including HMB, fibroids, and adenomyosis — evidence-aligned, freely accessible.

E. Special populations

Adolescent girls. Menorrhagia from menarche warrants coagulopathy screen (von Willebrand’s disease, factor VIII/IX deficiency). COC and progestogen are first-line medical management. Mirena placement in nulliparous adolescents requires case-by-case assessment. Iron deficiency frequently requires IV therapy in severe presentations.

Perimenopausal women (ages 45–55). Anovulatory cycles driven by fluctuating oestrogen are a common cause of irregular and sometimes heavy bleeding in perimenopause. Endometrial cancer risk rises with age and obesity, so investigation should be lower threshold. The Mirena is particularly valuable — it also provides contraception and endometrial protection if systemic MHT is used.

Immunosuppressed or anticoagulated women. NSAID use is higher risk in the context of renal impairment or anticoagulant therapy — tranexamic acid and Mirena are preferred. HMB in women on anticoagulation may require haematology input and consideration of target INR reduction.

Pregnancy. Heavy or abnormal bleeding in women who could be pregnant requires β-hCG first. Early pregnancy complications (threatened miscarriage, ectopic pregnancy) and late pregnancy antepartum haemorrhage have separate management pathways not covered here.

Cancer survivors. Women on tamoxifen for breast cancer have significantly elevated endometrial cancer risk — any abnormal bleeding requires prompt endometrial assessment. Women on hormone therapies for other cancers warrant oncology input before gynaecological hormonal management.

When to escalate

Refer or escalate when:

• Any postmenopausal bleeding — urgent gynaecology referral (endometrial cancer pathway)
• Suspected endometrial hyperplasia with atypia or cancer — gynaecology-oncology, same-week
• Severe haemodynamic compromise or severe anaemia — emergency department and urgent haematology/gynaecology input
• Failed first-line medical management (Mirena + tranexamic acid + COC) — gynaecology for surgical assessment
• Suspected fibroids or adenomyosis requiring surgical or UAE treatment — gynaecology
• Suspected coagulopathy — haematology co-management
• Fertility concerns — gynaecology for fertility-preserving surgical planning
• Perimenopausal HMB not responding to management — gynaecology to exclude hyperplasia before prescribing MHT

What this article is and is not

This is general health information drawn from current Australian general practice guidelines — RANZCOG, eTG, AMH, RACGP, NPS MedicineWise, Cancer Council Australia, and Jean Hailes for Women’s Health. It is not personal medical advice and does not create a doctor–patient relationship. Decisions about investigation, medication, and referral are made with your own GP and treating clinicians.

For consumer-friendly AU resources: Jean Hailes for Women’s Health, HealthDirect — Heavy periods, Better Health Channel — Heavy menstrual bleeding, Cancer Council Australia.

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Sources cited

1. RANZCOG — Heavy Menstrual Bleeding guideline
2. Therapeutic Guidelines (eTG)
3. Australian Medicines Handbook
4. Cancer Council Australia
5. RACGP
6. NPS MedicineWise
7. Jean Hailes for Women’s Health
8. HealthDirect — Heavy periods
9. Better Health Channel — Heavy menstrual bleeding
10. PBS
11. Lethaby A et al — Cochrane review LNG-IUD vs oral treatment for HMB (2015)