Menstrual Disorders — Viva

Q1: PALM-COEIN (3 min)

"Describe the FIGO PALM-COEIN classification."

• PALM (structural): Polyps, Adenomyosis, Leiomyoma, Malignancy/hyperplasia
• COEIN (non-structural): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not classified
• Guides systematic workup and treatment

Q2: HMB Management (3 min)

"How do you manage heavy menstrual bleeding?"

• First-line: LNG-IUS 52mg (Mirena) — blood-loss reduction of up to 90% (Cochrane); effective within 3-6 months
• Second-line: tranexamic acid 1g TDS + mefenamic acid 500mg TDS during menses
• COCP alternative
• Surgical: endometrial ablation (completed family), hysterectomy (definitive)
• Iron supplementation for anaemia.^[1][2]

Q3: PMB (2 min)

"How do you investigate postmenopausal bleeding?"

• ALWAYS rule out endometrial cancer (pooled risk ~9%, 95% CI 8-11)
• Transvaginal US: endometrial thickness over 5 mm (5-mm threshold detects 96% of cancers) → hysteroscopy and biopsy
• Hysteroscopy + endometrial biopsy
• Urgent 2-week wait referral

Q4: Amenorrhoea (2 min)

"What are the causes of secondary amenorrhoea?"

• Pregnancy (always exclude first)
• Hypothalamic (stress, weight loss, exercise, eating disorder)
• PCOS (most common non-pregnancy cause)
• Hyperprolactinaemia (pituitary adenoma, drugs)
• Premature ovarian insufficiency (POI)
• Asherman's syndrome (intrauterine adhesions post-D&C)

References2ShowHide

1. [1]National Institute for Health and Care Excellence Heavy menstrual bleeding: assessment and management (NICE guideline NG88) NICE, 2026.Source
2. [2]Bofill Rodriguez M, Lethaby A, Jordan V. Progestogen-releasing intrauterine systems for heavy menstrual bleeding Cochrane Database Syst Rev, 2020.PMID 32529637