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Heavy menstrual bleeding and abnormal uterine bleeding

ACOG-based diagnosis and acute abnormal-uterine-bleeding management; chronic stable treatment remains an explicit source gap.

JurisdictionUnited States
Source check2026-08-20
Clinical reviewiatroX editorial team 路 Clinical editorial review 路 reviewed 2026-08-20 路 due 2027-08-20
AudienceUnited States healthcare professionals
This is an iatroX educational summary of named United States sources, not an official guideline. It does not replace the complete source documents, local policy, specialist advice or clinical judgement. Use the named authority, current FDA labeling, applicable state law, payer rules and local protocol where relevant.

Scope of this summary

Adolescents and reproductive-aged adults with bleeding that is heavy, prolonged, irregular or intermenstrual. Pregnancy-related bleeding, postmenopausal bleeding and known gynecologic cancer follow separate pathways; acute hemodynamic instability is an emergency.
sources for this section:ACOG PB 128ACOG CO 557

The Bottom Line

  • Describe timing, duration, volume, cycle regularity and impact, then classify likely causes with PALM鈥揅OEIN rather than treating every heavy period as ovulatory dysfunction.
  • Exclude pregnancy when biologically possible and assess anemia, iron deficiency, medication exposure, endocrine contributors and inherited bleeding disorders from the history.
  • Use pelvic imaging and endometrial sampling selectively from age, persistent bleeding, unopposed-estrogen exposure, treatment failure and structural or malignancy concern.
  • Do not infer a treatment sequence for chronic stable heavy menstrual bleeding from these sources: one addresses diagnosis and the other acute abnormal uterine bleeding.
  • Acute abnormal uterine bleeding requires simultaneous stabilization, cause assessment and rapid control; medical management is preferred first when the patient is stable and suitable.
sources for this section:ACOG PB 128ACOG CO 557

Practical clinical workflow

1
Quantify bleeding pragmatically with flooding, clots, overnight changes, protection changes, school or work disruption and anemia symptoms, while asking about pain and intermenstrual or postcoital bleeding.
2
Check vital signs and pregnancy status, obtain a blood count and targeted ferritin, coagulation, thyroid or infection tests, and perform pelvic examination when needed to localize the source.
3
Use ultrasound for suspected structural disease and sample the endometrium according to ACOG age and risk criteria rather than relying on endometrial thickness alone in a cycling patient.
4
For acute abnormal uterine bleeding, use the acute ACOG source and patient-specific contraindications; for chronic stable treatment, leave this page and retrieve an exact current US authority rather than reusing the acute regimen.
5
Track diagnostic completion and acute stabilization. Longitudinal treatment choice, response thresholds and procedural escalation remain outside this summary until a chronic-management source is attached.
sources for this section:ACOG PB 128ACOG CO 557

Safety boundaries and escalation

  • Syncope, tachycardia, hypotension, ongoing flooding, severe anemia symptoms or pregnancy-related bleeding needs urgent resuscitation, blood preparation and gynecologic assessment.
  • Do not extrapolate an acute ACOG treatment option into chronic use; every hormonal or nonhormonal treatment requires an exact chronic-management authority and its current contraindication source.
  • Persistent intermenstrual bleeding, a pelvic mass, failed treatment or risk for endometrial hyperplasia or cancer requires tissue-conscious evaluation and must not be repeatedly suppressed without diagnosis.
  • Endometrial ablation selection is not established by the attached diagnosis and acute-management sources and must not be presented here as a chronic-treatment recommendation.
sources for this section:ACOG PB 128ACOG CO 557

Localization

ACOG uses PALM鈥揅OEIN, but the attached documents cover diagnosis and acute abnormal uterine bleeding, not a chronic stable heavy-menstrual-bleeding sequence. add an exact chronic source and gynecologic review before adding chronic-treatment recommendations.
sources for this section:ACOG PB 128ACOG CO 557

Source documents

Use the linked source documents for complete recommendations, evidence grading, exclusions and implementation detail.

  1. American College of Obstetricians and GynecologistsDiagnosis of Abnormal Uterine Bleeding in Reproductive-Aged WomenPractice Bulletin No. 128 路 Reaffirmed 2024 路 published 2012-07-01 路 accessed 2026-08-20
    view source
  2. American College of Obstetricians and GynecologistsManagement of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged WomenCommittee Opinion No. 557 路 published 2013-04-01 路 accessed 2026-08-20
    view source
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