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General diagnosis of HMB –
The HELP Diagnostic Algorithm

The HELP diagnostic algorithm consists of five steps to assist you in diagnosing and managing HMB in your patients.

1 Establish if HMB is a problem for this woman

How much does she bleed?

  • Changes sanitary protection during the night
  • On her heavy days, changes sanitary protection<2 hours
  • Experiences excessively long, frequent and/or unpredictable periods

Does it affect her physically?

  • Passes large blood clots
  • Feels faint or breathless during her period

Does her monthly bleeding affect her daily life?

  • Organizes social activities or plans clothing around menstrual bleeding
  • Worries about having accidents related to bleeding

Does one or more of the above apply, and have the symptoms been occurring for 3+ months?

If yes, HMB is impacting negatively on quality of life. Take further action to identify cause and appropriate treatment options.

2 Take a structured medical history and conduct physical examination

What do you need to consider?

Potential factors contributing to presence of HMB

  • Obesity
  • Diabetes
  • Lifestyle (smoking, alcohol intake)
  • Age (> 40years)
  • Hereditary factors
  • Medications
  • Unopposed estrogen
  • Anovulation

Other physical symptoms which may indicate pathology

(besides frequent and/or heavy bleeding)

  • Post-coital bleeding
  • Intermenstrual bleeding
  • Pelvic pressure
  • Pain

3 Consider if there is an identifiable (PALM-COEIN3) cause for her HMB

Structural causes

  • Polyps
  • Adenomyosis
  • Leiomyomas (submucosal or other)
  • Malignancy & hyperplasia

NON-Structural causes 

  • Coagulopathy
  • Ovulatory dysfunction
  • Endometrial
  • Iatrogenic
  • Not yet specified

For the majority of women, there is no identifiable cause of HMB4

4 Conduct further investigations where indicated

Complete blood count 

Required for all women


Thyroid function  

If endocrine cause suspected 


Inherited coagulation disorders   

If indicated by structured history


Ultrasound scan  

To rule out structural cause of HMB


Endometrial biopsy  

If endometrial pathology suspected

5 Provide reassurance and offer treatment

Treatment of anemia 

If present 


Medical or surgical treatment  

Using the algorithm overleaf 


Interim treatment 

While awaiting further investigation or test results

Diagnostic Algorithm

The algorithm covers the essentials of diagnosing and treating HMB, including which factors to look out for when taking a medical history as well as further investigations to consider and a flow diagram to aid you in selecting an appropriate treatment strategy.

HELP Group HMB diagnostic algorithm

PALM COEIN

PALM-COEIN Classification: Causes and treatment of HMB

Learn more about the structural and non-structural causes of HMB as well as suitable treatment approaches.

HMB Teaching and Resources Library

Find informative content such as guidelines, publications and images covering a range of HMB topics for educational use or your daily practice.


References

  1. Hurskainen R, et al. Acta Obstet Gynecol Scand 2007;86(6):749–57
  2. Singh S, et al. SOGC Clinical Practice Guideline. J Obstet Gynaecol Can 2013;35(5 eSuppl):S1-S28
  3. Munro MG, et al. Int J Gynecol Obstet 2011;113(1):3-13
  4. NICE Heavy Menstrual Bleeding Clinical Guideline 44, 2007.

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