Heavy & Prolonged Menstrual Bleeding with Clots: Evaluation Guide

Menstrual bleeding lasting >14 days with large clots (>2.5 cm) defines menorrhagia and warrants prompt gynecologic evaluation.

Structural Causes (PALM)

• P – Polyp: Endometrial; hysteroscopic removal.
• A – Adenomyosis: Endometrial glands in myometrium; MRI diagnosis; medical/surgical Rx.
• L – Leiomyoma (fibroid): Submucosal most bleeding; size/location guide therapy.
• M – Malignancy/hyperplasia: Endometrial cancer (postmenopausal) or atypical hyperplasia; biopsy mandatory >45 yr or risk factors.

Non‑Structural Causes (COEIN)

• C – Coagulopathy: VWD, platelet disorders; screen if menorrhagia since menarche.
• O – Ovulatory dysfunction: PCOS, thyroid, hyperprolactinemia, obesity.
• E – Endometrial: Primary disorder of local hemostasis (↑MMPs, ↓TIMPs).
• I – Iatrogenic: Anticoagulants, hormonal contraceptives (copper IUD ↑ bleeding).
• N – Not classified: Rare (AVM, endometritis).

Initial Evaluation

1. History: Pad/tampon count, clots, flooding, anemia symptoms.
2. Exam: Speculum, bimanual.
3. Labs: CBC, ferritin, TSH, prolactin, coagulation screen, pregnancy test.
4. Imaging: Transvaginal ultrasound (first line); saline infusion sonohysterography or MRI.
5. Endometrial sampling: Pipelle biopsy if >45 or risk factors.

Treatment Tailored to Etiology

• Medical: Tranexamic acid, NSAIDs, combined OCP, LNG‑IUD (first‑line for heavy bleeding), GnRH agonists (short‑term).
• Surgical: Hysteroscopic polypectomy/myomectomy, endometrial ablation, UAE, hysterectomy (definitive).

Do not ignore prolonged heavy bleeding – anemia, quality‑of‑life impact, and potential malignancy require investigation.