Abnormal Uterine Bleeding

Last updated 1 Jun 2026 · Women's Health / Gynaecology

📋 Key Information Summary

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Abnormal uterine bleeding (AUB) is classified using the PALM-COEIN system: structural causes (Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia) and non-structural causes (Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified).
Heavy menstrual bleeding (HMB) is defined as excessive menstrual blood loss (>80 mL per cycle) or any menstrual loss that interferes with a woman's physical, emotional, social, and material quality of life — regardless of measured volume.
First-line for HMB is the levonorgestrel-releasing intrauterine system (LNG-IUS 52 mg, Mirena®). Alternatives include tranexamic acid, combined oral contraceptives, and NSAIDs (mefenamic acid).
Transvaginal ultrasound (TVUS) is the initial imaging of choice for AUB evaluation. Saline infusion sonography (SIS) or hysteroscopy should follow when TVUS is inconclusive.
Intermenstrual bleeding (IMB) and postcoital bleeding require speculum examination and cervical screening test to exclude cervical pathology; persistent IMB warrants pelvic ultrasound and possible hysteroscopy.
Postmenopausal bleeding (PMB) — any bleeding ≥12 months after the final menstrual period — must be investigated urgently to exclude endometrial cancer. Do not reassure without investigation.
Endometrial cancer is the most common gynaecological malignancy in Australia (~3,300 new cases annually). Transvaginal ultrasound with endometrial thickness ≤4 mm has a high negative predictive value; pipelle biopsy provides histological diagnosis.
Fibroids (leiomyomas) are the most common structural cause of HMB, affecting up to 40% of women aged >40 years. Management includes medical therapy, uterine artery embolisation, myomectomy, and hysterectomy.
Iron deficiency anaemia is a frequent complication of chronic HMB. Screen with full blood count and serum ferritin; treat with oral or intravenous iron replacement.
Inherited bleeding disorders (most commonly von Willebrand disease) should be suspected in women with HMB since menarche and a personal or family history of excessive bleeding.
Aboriginal and Torres Strait Islander women experience higher rates of gynaecological morbidity and later cancer diagnosis. Culturally safe care, community-based screening, and supported referral pathways are essential.
Urgent gynaecology referral is indicated for suspected malignancy, acute severe haemorrhage, failed medical management after 3–6 months, persistent symptoms impacting quality of life, and structural pathology requiring surgical assessment.

Introduction & Australian Epidemiology

Abnormal uterine bleeding (AUB) encompasses any deviation from normal menstrual parameters in terms of regularity, volume, frequency, or duration, as well as bleeding occurring outside the expected menstrual window. AUB is one of the most common reasons for presentation to general practice and gynaecology services in Australia, accounting for approximately 20% of all gynaecological outpatient referrals.

In reproductive-aged women, the prevalence of HMB is estimated at 10–30%, though many women under-report or accept heavy periods as normal. The condition significantly impacts quality of life, workplace productivity, and mental health. Iron deficiency anaemia secondary to HMB affects an estimated 5–10% of premenopausal Australian women.

Endometrial cancer incidence in Australia has risen steadily, with approximately 3,300 new diagnoses and 600 deaths annually. It is now the fourth most common cancer in Australian women. Five-year survival exceeds 80% when detected at an early stage, underscoring the importance of timely investigation of postmenopausal bleeding.

The Australian burden of AUB is compounded by disparities in access to specialist gynaecological care, particularly for women in rural and remote areas and Aboriginal and Torres Strait Islander communities. Telehealth, shared-care models, and point-of-care investigations are increasingly important in addressing these inequities.

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Clinical pearl: Do not attribute AUB to "hormonal imbalance" without structured evaluation. The PALM-COEIN classification system provides a systematic framework that prevents diagnostic anchoring and ensures both common and serious causes are considered.

Classification of Abnormal Uterine Bleeding

The International Federation of Gynecology and Obstetrics (FIGO) adopted the PALM-COEIN classification system in 2011, replacing the older terminology of "dysfunctional uterine bleeding." This system categorises causes of AUB in reproductive-aged women into structural and non-structural entities, each assigned a single letter code.

FIGO PALM-COEIN Classification

Code	Category	Type	Description
P	Polyp	Structural	Endometrial or endocervical polyps; typically benign, oestrogen-responsive
A	Adenomyosis	Structural	Ectopic endometrial glands and stroma within the myometrium; causes HMB, dysmenorrhoea, and uterine enlargement
L	Leiomyoma	Structural	Uterine fibroids; classified by FIGO sub-type (submucous 0–2, intramural 3–5, subserosal 6–7, other 8)
M	Malignancy & Hyperplasia	Structural	Endometrial hyperplasia (with or without atypia), endometrial carcinoma, uterine sarcoma, endocervical carcinoma
C	Coagulopathy	Non-structural	Von Willebrand disease (most common), platelet disorders, factor deficiencies, anticoagulant use
O	Ovulatory Dysfunction	Non-structural	PCOS, thyroid dysfunction, hyperprolactinaemia, hypothalamic dysfunction, perimenopause
E	Endometrial	Non-structural	Primary endometrial disorders of local haemostasis; inflammation, infection
I	Iatrogenic	Non-structural	Hormonal contraceptives, HRT, anticoagulants, tamoxifen, corticosteroids, IUD-related
N	Not Yet Classified	Non-structural	Causes not fitting other categories; arteriovenous malformations, myometrial hypertrophy

Terminology of AUB Patterns

Term	FIGO Definition	Cycle Pattern
Heavy menstrual bleeding (HMB)	Excess volume or duration within regular cycles	Cycle 21–35 days, duration >7 days or volume >80 mL
Intermenstrual bleeding (IMB)	Bleeding between clearly defined cyclical menses	Normal cycle with episodes of bleeding between periods
Infrequent menstruation	Cycle length >35 days	Oligomenorrhoea
Frequent menstruation	Cycle length <21 days	Polymenorrhoea
Amenorrhoea	Absence of menstruation for >3 months (or >6 months in previously regular cycles)	—
Postmenopausal bleeding (PMB)	Any bleeding ≥12 months after final menstrual period	Post-menopause

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Note: In postmenopausal women, the PALM-COEIN system is less commonly applied. The clinical priority shifts to exclusion of malignancy through endometrial assessment.

Heavy Menstrual Bleeding (HMB): Diagnostic Model & Management

Clinical Assessment

The diagnosis of HMB is primarily clinical. Menstrual blood loss exceeding 80 mL per cycle is the traditional objective threshold; however, practical assessment relies on patient-reported impact on quality of life. Useful clinical indicators include:

Passage of clots larger than 2.5 cm in diameter
Soaking through a pad or tampon every 1–2 hours for several consecutive hours
"Flooding" through to clothing or bedding
Requiring double sanitary protection
Restriction of daily activities, work, or social engagement during menstruation
Fatigue, dyspnoea, or symptoms of iron deficiency anaemia

A structured history should identify the onset, duration, pattern, associated symptoms (dysmenorrhoea, pelvic pressure, bloating), obstetric history, contraceptive use, medication history, and features suggesting coagulopathy (HMB since menarche, postpartum haemorrhage, frequent bruising, epistaxis, dental bleeding, family history of bleeding disorders).

Severity Stratification

Mild

Mild HMB

HMB with minimal impact on daily activities; Hb ≥120 g/L; no iron deficiency; manageable with over-the-counter analgesics and standard sanitary products.

Setting: General practice, trial of first-line therapy

Moderate

Moderate HMB

HMB affecting quality of life, work, or social activities; Hb 90–119 g/L or ferritin <30 µg/L; requires structured medical therapy and monitoring.

Setting: General practice with gynaecology referral if unresponsive at 3–6 months

Severe

Severe / Acute HMB

HMB with Hb <90 g/L, haemodynamic compromise, or acute heavy bleeding requiring urgent intervention. Consider admission, transfusion, and acute medical management.

Setting: Emergency department, gynaecology inpatient, acute stabilisation

Acute Severe HMB — Emergency Management

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Acute heavy uterine bleeding with haemodynamic instability: Secure IV access, take bloods (FBC, coagulation, cross-match), commence fluid resuscitation, and consult gynaecology urgently.

Resuscitate

IV access, FBC, coagulation, G&H / crossmatch. IV crystalloid resuscitation. Transfuse if Hb <70 g/L or haemodynamic instability.

High-dose hormonal therapy

Norethisterone 10–15 mg PO TDS or medroxyprogesterone acetate 20–40 mg PO TDS until bleeding stops, then taper over 2–4 weeks. Consider IV conjugated oestrogen (Premarin®) 25 mg IV 4-hourly (max 4 doses) if oral therapy not tolerated.

Tranexamic acid

1 g PO/IV TDS for up to 4 days. IV formulation: administer slowly over 10 minutes. Caution in active thromboembolic disease.

Exclude pregnancy

Urine or serum β-hCG — always, regardless of reported contraception status. Exclude ectopic pregnancy and miscarriage.

Surgical options

If medical therapy fails: urgent hysteroscopy and curettage, intrauterine balloon tamponade, or endometrial ablation. Hysterectomy as last resort.

Chronic HMB — Stepwise Management

Management of chronic HMB follows a stepwise approach guided by the underlying aetiology (PALM-COEIN classification), patient preference, fertility plans, and severity.

Treat underlying cause

Address coagulopathy, thyroid dysfunction, hyperprolactinaemia, or infection. Manage comorbidities (obesity, PCOS). Correct iron deficiency.

Levonorgestrel IUD (first-line)

LNG-IUS 52 mg (Mirena®) reduces menstrual blood loss by 71–96% at 12 months. Also provides contraception. Suitable for most women including nulliparous. Replaced at 5 years.

Pharmacological alternatives

Tranexamic acid (during menses only), combined oral contraceptive pill, cyclical oral progestogens, or NSAIDs (mefenamic acid). Choice guided by patient preference, contraindications, and fertility goals.

Gonadotrophin-releasing hormone (GnRH) agonists

Leuprorelin or goserelin — used pre-operatively for fibroid shrinkage (3–6 month course). Requires add-back HRT to prevent bone loss. Authority Required PBS listing.

Surgical management

Endometrial ablation (for women who have completed childbearing), myomectomy (for submucous fibroids, fertility-preserving), uterine artery embolisation, or hysterectomy (definitive treatment).

First-Line Pharmacotherapy for HMB

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Levonorgestrel IUD 52 mg

Mirena® · Levonorgestrel-releasing intrauterine system

Dose One intrauterine device releasing ~20 µg/day; effective for 5 years for HMB (8 years for contraception)

Mechanism Local progestogenic endometrial atrophy, decidualisation, reduced endometrial proliferation

Efficacy Reduces menstrual blood loss by 71–96% at 12 months; amenorrhoea in 20–50% of users by 12 months

Counselling Initial unscheduled bleeding common (first 3–6 months); settles in most women. Can be inserted in GP rooms or clinic

PBS status ✔ PBS General Benefit (Authority Required for HMB indication)

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Tranexamic acid

Cyklokapron® · Generic · Antifibrinolytic

Adult dose 1 g PO TDS for days 1–5 of menstruation (during heavy bleeding days only)

Paediatric dose 25 mg/kg PO TDS (adolescents with HMB); max 1 g per dose

Renal adjustment eGFR 30–60: reduce to 1 g BD; eGFR <30: reduce to 1 g OD or 500 mg TDS. Contraindicated if on dialysis

Key cautions Avoid in active thromboembolic disease. Caution with combined OCP (additive thrombotic risk). Visual disturbances reported rarely

PBS status ✔ PBS General Benefit

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Mefenamic acid

Ponstan® · Generic · NSAID (prostaglandin synthetase inhibitor)

Adult dose 500 mg PO TDS during menstruation (days 1–5). Also provides analgesia for dysmenorrhoea

Paediatric dose Not routinely recommended <14 years for this indication. Adolescents ≥14 years: adult dose

Renal adjustment Avoid if eGFR <30. Use with caution if eGFR 30–60

Key cautions GI ulceration risk — take with food. Avoid with anticoagulants. Contraindicated in severe hepatic impairment

PBS status ✔ PBS General Benefit

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Combined oral contraceptive pill

Various (Levlen ED®, Brenda-35 ED®, Yasmin®) · Ethinyloestradiol + progestogen

Adult dose Standard combined pill: 1 tablet PO daily, 21 days on / 7 days off. Extended cycling (84/7) can be used to reduce frequency of withdrawal bleeds

Renal adjustment No adjustment required

Key cautions Avoid if BMI >35, migraine with aura, age >35 and smoking, hypertension, active VTE. VTE risk ~3–9 per 10,000 woman-years

PBS status ✔ PBS General Benefit (most brands)

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Norethisterone

Primolut N® · Progestogen

Adult dose (acute HMB) 10–15 mg PO TDS until bleeding ceases (usually 48–72 hrs), then taper to 5 mg TDS for 2–3 weeks

Adult dose (cyclical) 5 mg PO BD–TDS from day 5 to day 26 of cycle (for regulation)

Key cautions Avoid with active VTE. Hepatotoxicity with high doses. Not suitable long-term — consider LNG-IUS or other alternatives

PBS status ✔ PBS General Benefit

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Medroxyprogesterone acetate

Provera® · Depot formulation: Depo-Provera® · Progestogen

Oral dose 10 mg PO OD for 10–14 days per cycle (days 16–25), or 10 mg PO OD continuously for amenorrhoea

IM dose (Depo-Provera®) 150 mg IM every 12 weeks. Causes amenorrhoea in ~50% at 12 months

Key cautions BMD loss with long-term DMPA — consider calcium and vitamin D supplementation. Weight gain. Delayed return to fertility (up to 18 months)

PBS status ✔ PBS General Benefit

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Leuprorelin acetate

Lucrin Depot PDS® · GnRH agonist

Adult dose 3.75 mg SC/IM monthly or 11.25 mg SC/IM every 3 months. Duration: 3–6 months pre-operative for fibroid shrinkage

Add-back therapy Tibolone 2.5 mg PO daily or low-dose HRT to prevent bone loss and vasomotor symptoms (mandatory for courses >3 months)

Key cautions Menopausal symptoms (hot flushes, mood changes, vaginal dryness). BMD loss without add-back. Max 6 months continuous use without add-back

PBS status ⚠ PBS Authority Required

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Iron (ferrous sulfate)

Ferro-Gradumet® · Ferro-Grad C® · Various generics

Oral dose 325 mg ferrous sulfate (105 mg elemental iron) PO daily–ODS. Take on empty stomach with vitamin C to enhance absorption

IV iron (for intolerance/absorption failure) Iron polymaltose (Ferrosig®) or ferric carboxymaltose (Ferinject®) — total dose infusion. Recheck ferritin at 6–8 weeks

Target Ferritin >30 µg/L (ideally 50–100 µg/L). Hb response expected within 2–4 weeks

PBS status ✔ PBS General Benefit (oral). IV iron: ⚠ Authority Required

Quick Reference — HMB Pharmacotherapy Comparison

LNG-IUS (Mirena®)

Levonorgestrel 52 mg IUD

5 years

First-line. Reduces loss by 71–96%. Also contraception.

Tranexamic acid

1 g PO TDS, days 1–5

Each cycle

Non-hormonal. Reduces loss ~40–50%. No contraception.

COCP

Standard or extended cycle

Ongoing

Contraception + cycle regulation. Contraindicated in VTE, migraine with aura.

Mefenamic acid

500 mg PO TDS, days 1–5

Each cycle

Analgesic benefit for dysmenorrhoea. Reduces loss ~20–30%.

Intermenstrual & Postcoital Bleeding

Overview

Intermenstrual bleeding (IMB) is bleeding occurring between otherwise regular menstrual periods. Postcoital bleeding (PCB) is bleeding occurring during or after sexual intercourse. While both are commonly benign, they warrant structured investigation to exclude cervical pathology, endometrial polyps, infection, and rarely malignancy.

PCB affects approximately 5% of women presenting to general practice. The most common causes include cervical ectropion (particularly in young women using the COCP), cervicitis (Chlamydia trachomatis), cervical polyps, and endometrial polyps. Cervical cancer must always be considered, particularly in women aged 25–70 years who have not had adequate cervical screening.

Differential Diagnosis

Category	Causes	Key Features
Cervical	Cervical ectropion, cervical polyps, cervicitis (STI), CIN, cervical cancer	Bleeding on contact (PCB); visible on speculum; STI screen positive
Endometrial	Endometrial polyps, submucous fibroids, endometrial hyperplasia/cancer, endometritis	IMB, often cyclical; identified on ultrasound or hysteroscopy
Vulvovaginal	Atrophic vaginitis, vaginal infections, vaginal lacerations, vaginal cancer	Postmenopausal women; vaginal dryness; visible on speculum
Hormonal	Ovulatory spotting, breakthrough bleeding on OCP/HRT, contraceptive-related	Related to hormonal use; typically self-limiting in first 3–6 months of hormonal therapy
Other	Urethral pathology, rectal bleeding, trauma, foreign body	Exclude non-gynaecological sources

Investigation Pathway

History & Speculum Examination

Assess pattern, timing, and associated symptoms. Perform speculum examination to visualise cervix. Assess for cervical ectropion, polyps, discharge, or visible lesions. Take cervical screening test if due.

STI Screen

Nucleic acid amplification test (NAAT) for Chlamydia trachomatis and Neisseria gonorrhoeae from endocervical or self-collected vaginal swab. Also consider Mycoplasma genitalium if available.

Transvaginal Ultrasound

Assess endometrial thickness, polyps, fibroids, and adnexal pathology. Saline infusion sonography (SIS) improves sensitivity for endometrial polyps. MBS item 55628.

Hysteroscopy & Biopsy

If ultrasound is abnormal or bleeding persists despite normal initial assessment. Gold standard for endometrial pathology. Can be done in-office (outpatient hysteroscopy) or under GA. MBS item 35556.

Colposcopy

If cervical abnormality is seen on speculum or if cervical screening results are abnormal. Referral to gynaecologist or colposcopist.

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Red flags requiring urgent referral: Persistent or recurrent postcoital bleeding, visible cervical lesion, abnormal cervical screening result, presence of risk factors for endometrial cancer (obesity, unopposed oestrogen, nulliparity, family history of Lynch syndrome), or age >45 with new-onset IMB.

Management by Cause

Cervical ectropion: Reassurance if asymptomatic. If bothersome, options include topical silver nitrate cauterisation or short-course combined OCP. No treatment needed if screening is normal.
Cervicitis: Treat Chlamydia with doxycycline 100 mg PO BD for 7 days (or azithromycin 1 g PO stat if compliance concern). Treat gonorrhoea per current Australian STI guidelines (ceftriaxone 500 mg IM stat + azithromycin 1 g PO stat). Treat partner(s).
Cervical polyps: Simple polypectomy (avulsion in clinic or in theatre). Histology required to exclude dysplasia.
Endometrial polyps: Hysteroscopic polypectomy. Histology to exclude hyperplasia/malignancy.
Hormonal breakthrough bleeding: Reassurance in first 3–6 months of hormonal therapy. If persistent, switch formulation or consider alternative contraception. Exclude other causes first.

Postmenopausal Bleeding & Endometrial Cancer

Postmenopausal Bleeding — Definition & Significance

Postmenopausal bleeding (PMB) is defined as any vaginal bleeding occurring ≥12 months after a woman's final menstrual period. It affects approximately 5–10% of postmenopausal women and is the presenting symptom in approximately 90% of endometrial cancers. All episodes of PMB require investigation to exclude malignancy, even if the woman is on hormone replacement therapy (HRT).

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Do not reassure without investigation. Although 90% of PMB has a benign cause, the consequences of missing endometrial cancer are serious. Refrain from attributing PMB to HRT, atrophic vaginitis, or age without completing a structured evaluation pathway.

Causes of Postmenopausal Bleeding

Cause	Approximate Frequency	Key Features
Atrophic vaginitis / endometritis	~60–70%	Thin, pale vaginal mucosa; fragile endometrium; reduced oestrogen effects
Endometrial polyps	~10–15%	Usually benign; identified on ultrasound or hysteroscopy
Endometrial hyperplasia	~5–10%	Simple/complex ± atypia; atypical hyperplasia has ~30% risk of concurrent carcinoma
Endometrial cancer	~5–10%	Most common gynaecological malignancy; peak incidence 65–75 years
HRT-related	~5–10%	Cyclical withdrawal bleeds (expected) or breakthrough bleeding (unopposed oestrogen risk)
Other	~5%	Cervical pathology, uterine sarcoma, coagulopathy, exogenous hormones, trauma

PMB Investigation Pathway

Initial Assessment

Detailed history (HRT use, tamoxifen, anticoagulants, risk factors for endometrial cancer). Speculum examination to assess vaginal mucosa and cervix. Cervical screening test if overdue.

Transvaginal Ultrasound (first-line)

Measure endometrial thickness (ET). ET ≤4 mm has >99% negative predictive value for endometrial cancer. If ET >4 mm or heterogeneous, proceed to tissue sampling. MBS item 55628.

Pipelle Endometrial Biopsy

Office-based outpatient procedure. Sensitivity ~90% for detecting endometrial cancer when disease is present. Adequate sample in ~60–80% of postmenopausal women. Inadequate sample warrants hysteroscopy.

Hysteroscopy & Dilatation and Curettage (D&C)

If pipelle biopsy is inadequate, non-diagnostic, or ultrasound suggests focal pathology. Gold standard for endometrial assessment. MBS item 35556.

Endometrial Cancer — Australian Context

Endometrial cancer is the most common gynaecological malignancy in Australia, with approximately 3,300 new cases and 600 deaths per year. Incidence has increased by approximately 30% over the past two decades, driven by rising rates of obesity, type 2 diabetes, and an ageing population. Five-year survival exceeds 80% for stage I disease but drops below 20% for stage IV, emphasising the importance of early detection.

Risk Factors for Endometrial Cancer

Obesity (BMI ≥30): 2–4× increased risk — the strongest modifiable risk factor
Unopposed oestrogen: HRT without progestogen, prolonged anovulation (PCOS), oestrogen-secreting tumours
Type 2 diabetes mellitus: 2× increased risk independent of BMI
Tamoxifen use: 2–7× increased risk; endometrial stimulation by oestrogenic metabolite
Lynch syndrome (HNPCC): 40–60% lifetime risk of endometrial cancer
Nulliparity and late menopause
Family history: First-degree relative with endometrial or colorectal cancer
Age >60 years: Median age at diagnosis is 63 years

Endometrial Cancer — Key Histological Types

Type	Frequency	Risk Factors	Prognosis
Type I — Endometrioid	~80%	Obesity, oestrogen excess, hyperplasia progression	Generally favourable (5-year survival >80% stage I)
Type II — Non-endometrioid	~20%	Not oestrogen-driven; p53 mutations; atrophic endometrium	Serous, clear cell — more aggressive, worse prognosis

Initial Staging & Referral

All confirmed or suspected endometrial cancer requires urgent referral to a gynaecological oncologist. Initial staging investigations include:

Pelvic MRI (gold standard for local staging — depth of myometrial invasion, cervical involvement)
CT chest/abdomen/pelvis for distant metastases
CA-125 (serous types, monitoring)
FBC, LFTs, renal function
Consider genetic testing for Lynch syndrome (immunohistochemistry on tumour specimen, or germline testing if indicated)

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Tamoxifen users: Women on tamoxifen should be counselled to report any vaginal bleeding promptly. Routine ultrasound screening is not recommended, but any PMB requires investigation via the standard pathway. The levonorgestrel IUD may offer endometrial protection during tamoxifen use — discuss with oncology.

Investigations & Diagnostic Approach

Investigations for AUB are tailored to the clinical scenario, patient age, and suspected aetiology. The following table summarises key investigations with Australian availability and Medicare Benefits Schedule (MBS) item numbers.

Essential Full Blood Count (FBC) Assess for iron deficiency anaemia (low Hb, low MCV, low MCH). Available in all Australian pathology services. No MBS restriction.

Essential Serum Ferritin Confirms iron stores depletion. Ferritin <30 µg/L indicates depleted stores; <15 µg/L confirms iron deficiency. Screen all women with HMB.

Essential Pregnancy Test (urine or serum β-hCG) Exclude pregnancy in all premenopausal women with AUB, regardless of contraception history. Serum β-hCG is more sensitive for early pregnancy and ectopic pregnancy.

Available Thyroid Function Tests (TSH, fT4) Hypothyroidism and hyperthyroidism can cause AUB. Screen if ovulatory dysfunction suspected or other thyroid symptoms present.

Available Prolactin Elevated prolactin can cause oligomenorrhoea or amenorrhoea. Order if cycle irregularity with galactorrhoea or suspected pituitary pathology.

Available Coagulation Screen PT, APTT, fibrinogen. Screen if HMB since menarche, personal/family history of bleeding disorder, or history of postpartum haemorrhage. Consider referral to haematology for von Willebrand disease screen.

Essential Cervical Screening Test (CST) HPV-based screening in Australia (replaced Pap smear). Ensure up to date in all women aged 25–74. Self-collection option available. MBS item 73065/73075.

Essential Transvaginal Ultrasound (TVUS) First-line imaging for AUB. Assess endometrial thickness, myometrial pathology (fibroids, adenomyosis), polyps, and ovarian pathology. MBS item 55628. Available in metropolitan and most regional centres.

Available Saline Infusion Sonography (SIS) Enhanced TVUS with intrauterine saline instillation. Higher sensitivity for endometrial polyps and submucous fibroids than standard TVUS. Available in specialist and some GP ultrasound services. MBS item 55636.

Specialist Pipelle Endometrial Biopsy Outpatient endometrial sampling for histology. Indicated for PMB, persistent IMB, risk factors for endometrial cancer, or abnormal ultrasound. Sensitivity ~90% for endometrial cancer. Available in specialist and some advanced GP settings.

Specialist Hysteroscopy (outpatient or inpatient) Gold standard for direct visualisation of the endometrial cavity. Allows directed biopsy and therapeutic intervention (polypectomy, myomectomy). Outpatient hysteroscopy increasingly available. MBS item 35556.

Referral Pelvic MRI For staging of endometrial cancer (depth of myometrial invasion, cervical stromal involvement) and characterisation of complex fibroids or adenomyosis. Referral to radiology or gynaecological oncology.

Referral Von Willebrand Disease Screen Von Willebrand antigen, ristocetin cofactor activity, factor VIII. Refer to haematology if suspected. False negatives can occur; repeat testing may be required (vWF is an acute-phase reactant).

Special Populations

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Paediatric & Adolescent

Puberty-associated bleeding: Irregular, anovulatory cycles are normal in the first 1–2 years after menarche. Most settle spontaneously.

When to investigate: HMB since menarche, bleeding requiring hospitalisation, Hb <100 g/L, or bleeding persisting >2 years from menarche — suspect coagulopathy (especially von Willebrand disease).

Management: Tranexamic acid (25 mg/kg PO TDS), low-dose COCP, or LNG-IUS (Mirena can be considered in adolescents, though off-label in Australia for those <18 years for this indication). Iron replacement essential.

Doxycycline is contraindicated <8 years. Use erythromycin or azithromycin for cervicitis in young adolescents.

STI screen (NAAT) is recommended for sexually active adolescents with IMB or PCB.

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Pregnancy

Always exclude pregnancy in any premenopausal woman presenting with AUB, including those reporting reliable contraception.

First trimester bleeding: Threatened miscarriage, ectopic pregnancy, molar pregnancy, and cervical causes must be considered urgently. β-hCG and TVUS are essential first steps.

Postpartum AUB: Retained products of conception, endometritis, uterine atony. Managed by obstetric team.

Tranexamic acid is category B3 in pregnancy — use only under specialist guidance for life-threatening haemorrhage. NSAIDs are contraindicated in the third trimester.

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Elderly / Postmenopausal

All PMB requires investigation — do not attribute to atrophic vaginitis or HRT without completing the investigation pathway.

Endometrial cancer risk increases with age — median age at diagnosis is 63 years. Highest incidence in women 65–75 years.

Atrophic vaginitis is the most common benign cause. Treat with topical vaginal oestrogen (Ovestin® cream or Vagifem® pessaries). Reassess if bleeding recurs.

Tamoxifen users: persistent endometrial stimulation; investigate any new bleeding promptly.

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Renal Impairment

Tranexamic acid: Dose reduction required — eGFR 30–60: 1 g BD; eGFR <30: 1 g OD or 500 mg TDS. Avoid in dialysis patients.

NSAIDs (mefenamic acid): Avoid if eGFR <30; use cautiously if eGFR 30–60. Monitor renal function.

Iron: IV iron preferred if eGFR <30 or oral iron poorly tolerated. Ferric carboxymaltose (Ferinject®) allows total dose infusion.

Chronic kidney disease can contribute to platelet dysfunction and increased bleeding risk — uraemic bleeding may present as AUB.

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Hepatic Impairment

Combined OCP: Contraindicated in severe hepatic impairment (Child-Pugh C). Use with caution in moderate impairment. Progestogen-only methods are generally safer.

Norethisterone: High doses can cause hepatotoxicity. Monitor LFTs if prolonged use. Avoid in active liver disease.

Tranexamic acid: No specific dose adjustment, but use with caution given potential hepatic clearance involvement.

Coagulopathy secondary to liver disease can contribute to AUB — check INR and coagulation profile.

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Immunocompromised

HIV-positive women: Increased risk of cervical pathology (CIN, cervical cancer) — ensure cervical screening is up to date per Australian guidelines (annual for HIV-positive).

Transplant recipients: Increased risk of endometrial and cervical cancer. Cyclical immunosuppression does not contraindicate LNG-IUS but discuss with transplant team.

Chemotherapy/radiotherapy: Can cause AUB through direct endometrial/cervical damage. Investigate if unexpected.

IUD insertion in immunocompromised women: discuss infection risk with specialist. Generally safe if CD4 count is adequate and no active pelvic infection.

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander women experience a disproportionate burden of gynaecological morbidity, including higher rates of hospitalisation for AUB-related conditions, later presentation of gynaecological cancers, and reduced access to specialist gynaecological services, particularly in remote and very remote communities.

Endometrial cancer survival outcomes are poorer for Indigenous Australians, with a five-year survival gap of approximately 10–15% compared with non-Indigenous Australians, driven by later-stage diagnosis, comorbidity burden (diabetes, obesity, renal disease), and barriers to timely treatment.

Key Considerations

Access to specialist care

Many Aboriginal women in remote communities do not have access to gynaecology services, ultrasound, or hysteroscopy locally. Telehealth, visiting specialist services (e.g., Remote Area Health Corps, RFDS), and supported retrieval for procedures are critical.

Cultural safety

Pelvic examinations and gynaecological procedures can be culturally sensitive. Offer female practitioners where possible. Ensure culturally safe communication. Use Aboriginal Health Workers/Practitioners (AHW/AHP) as key intermediaries and patient navigators.

Cervical screening

Aboriginal and Torres Strait Islander women have historically had lower cervical screening participation rates. The National Cervical Screening Program now offers self-collection HPV testing, which is a significant opportunity to increase screening in remote communities. Promote this option actively.

Comorbidity burden

Higher prevalence of obesity, type 2 diabetes, and renal disease in Aboriginal communities increases both the risk of HMB (ovulatory dysfunction) and endometrial cancer. Integrate AUB assessment with chronic disease management plans.

Menstrual health literacy

Menstrual health education may be limited in some communities. Normalise discussions about menstrual health through community-based health promotion. Recognise that some women may not present until anaemia is severe or complications have developed.

Iron deficiency

Iron deficiency anaemia prevalence is higher in Aboriginal and Torres Strait Islander women due to HMB, nutritional factors, and hookworm (in endemic areas). Ensure routine FBC and ferritin screening for women reporting heavy periods. IV iron infusion may be more practical than oral supplementation in remote settings where follow-up is limited.

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Closing the Gap: Support models of care that embed gynaecological care within Aboriginal Community Controlled Health Organisations (ACCHOs). Funded through the Practice Incentives Program (PIP) Indigenous Health Incentive and Indigenous Australians Health Programme (IAHP). Aim for continuity of care with trusted providers.

📚 References

1. Munro MG, Critchley HOD, Broder MS, Fraser IS; FIGO Working Group on Menstrual Disorders. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet. 2011;113(1):3–13.
2. National Institute for Health and Care Excellence (NICE). Heavy menstrual bleeding: assessment and management. NICE guideline [NG88]. Updated March 2021. Available from: www.nice.org.uk/guidance/ng88.
3. Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Heavy Menstrual Bleeding. Clinical Guideline C-Gyn 26. Melbourne: RANZCOG; 2021.
4. Australian Institute of Health and Welfare (AIHW). Cancer data in Australia. Cat. no. CAN 122. Canberra: AIHW; 2024.
5. Cancer Council Australia. Clinical practice guidelines for the management of endometrial cancer. Endometrial Cancer Guidelines Working Party. Sydney: Cancer Council Australia; 2023.
6. Australian Commission on Safety and Quality in Health Care (ACSQHC). Ovarian and Endometrial Cancers Clinical Care Standard. Sydney: ACSQHC; 2023.
7. Lethaby A, Hussain M, Rishworth JR, Rees MC. Cochrane review: progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev. 2015;(4):CD002126.
8. Committee on Practice Bulletins—Gynecology. Practice Bulletin No. 128: Diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol. 2012;120(1):197–206.
9. Marsh EE, Al-Hendy A, Mappus E, et al. Uterine fibroids: epidemiology, clinical presentation, and management. Obstet Gynecol Clin North Am. 2022;49(3):459–481.
10. National Health and Medical Research Council (NHMRC). National Cervical Screening Program: Clinical guidelines for the management of screen-detected abnormalities, screening in specific populations and investigation of abnormal vaginal bleeding. Canberra: NHMRC; 2023.
11. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework. Cat. no. IHW 222. Canberra: AIHW; 2023.
12. Davies J, Bukulatjpi S, Caldwell B, et al. Barriers to cervical cancer screening for Aboriginal and Torres Strait Islander women. Aust N Z J Obstet Gynaecol. 2023;63(2):175–182.
13. Committee on Practice Bulletins—Gynecology. Practice Bulletin No. 149: Endometrial cancer. Obstet Gynecol. 2015;125(4):1006–1026.
14. Australian Government Department of Health and Aged Care. Pharmaceutical Benefits Schedule (PBS). Canberra: Commonwealth of Australia; 2024. Available from: www.pbs.gov.au.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).