The document provides a summary of new standardized terminology, definitions, and classification for abnormal uterine bleeding (AUB) developed by an international expert panel. It outlines recommendations to replace outdated, ambiguous terminology with simple descriptive terms. The panel developed the PALM-COEIN classification system to categorize causes of AUB. The system includes evaluation, diagnostic testing, coding, and management guidelines to provide a uniform approach for understanding and treating AUB.
The document provides a summary of new standardized terminology, definitions, and classification for abnormal uterine bleeding (AUB) developed by an international expert panel. It outlines recommendations to replace outdated, ambiguous terminology with simple descriptive terms. The panel developed the PALM-COEIN classification system to categorize causes of AUB. The system includes evaluation, diagnostic testing, coding, and management guidelines to provide a uniform approach for understanding and treating AUB.
The document provides a summary of new standardized terminology, definitions, and classification for abnormal uterine bleeding (AUB) developed by an international expert panel. It outlines recommendations to replace outdated, ambiguous terminology with simple descriptive terms. The panel developed the PALM-COEIN classification system to categorize causes of AUB. The system includes evaluation, diagnostic testing, coding, and management guidelines to provide a uniform approach for understanding and treating AUB.
The document provides a summary of new standardized terminology, definitions, and classification for abnormal uterine bleeding (AUB) developed by an international expert panel. It outlines recommendations to replace outdated, ambiguous terminology with simple descriptive terms. The panel developed the PALM-COEIN classification system to categorize causes of AUB. The system includes evaluation, diagnostic testing, coding, and management guidelines to provide a uniform approach for understanding and treating AUB.
New Standardized Terminology, Definitions, Classification
History
Long time use of non-standardized, ambiguous terminology. English language terminologies with Greek or Latin roots are poorly defined and create ambiguity in meaning and usage. In 2005, interest group of 35 experts did historical review, and recommendations made for uniform terminology published. A Delphi panel created to analyze recommendations. They recommended discarding the confusing terminology, and replace with simple descriptive terms that could be understood by patients and translated into most languages.
In 2006, FIGO identified as the appropriate body to provide supervision and international credibility to the ongoing evaluation of new terminology. Formed the FIGO Menstrual Disorders Group. In 2009, FIGO World Congress of Gynecology and Obstetrics (17 countries from 6 continents) accepted the new terminology. The PALM-COEIN Classification System created. Supported by ACOG (Practice Bulletin No. 128, July 2012)
Heavy menstrual bleeding Heavy and prolonged menstrual bleeding Intermenstrual bleeding Postmenopausal bleeding
Recommended Normal Limits of Menstrual Dimensions
Frequency of menses Regularity of menses, cycle to cycle Variation over 12 months Duration of flow
Frequent Normal Infrequent
Absent Regular Irregular
Prolonged Normal Shortened
<24 days 24 to 38 days >38 days
No bleeding Variation + or - 2 to 20 days Variation >20 days >8.0 days 4.5 to 8.0 days <4.5 days
Recommended Terminology, Definitions, and Classifications of
Symptoms of Abnormal Uterine Bleeding Disturbances of Regularity
Irregular Menstrual Bleeding (IrregMB): Bleeding of >20 days in individual cycle lengths over a period of one year. Absent Menstrual Bleeding (amenorrhea): No bleeding in a 90-day period.
Disturbances in Frequency
Infrequent Menstrual Bleeding: One or two episodes in a 90-day period.
Frequent Menstrual Bleeding: More than four episodes in a 90-day period.
Disturbances of Heaviness of Flow
Heavy Menstrual Bleeding (HMB): Excessive menstrual blood loss that interferes with the womans physical, emotional, social, and material quality of life and can occur alone or in combination with other symptoms. Heavy and Prolonged Menstrual Bleeding (HPMB): Less common than HMB. It is important to make a distinction from HMB given they may have different etiologies and respond to different therapies. Light Menstrual Bleeding: Based on patient complaint, rarely related to pathology.
Disturbance of the Duration of Flow
Prolonged Menstrual Bleeding: Menstrual periods exceeding 8 days in duration on a regular basis. Shortened Menstrual Bleeding: Uncommon, defined as bleeding of no longer than 2 days.
Irregular Nonmenstrual Bleeding
Irregular episodes of bleeding, often light and short, occurring between normal menstrual periods. Mostly associated with benign or malignant structural lesions. May occur during or following sexual intercourse.
Bleeding Outside Reproductive Age
Postmenopausal Bleeding (PMB): Bleeding occurring >1 year after the acknowledged menopause. Precocious Menstruation: Usually associated with other signs of precocious puberty, occurring before 9 years of age.
Acute AUB
An episode of bleeding in a woman of reproductive age, who is not pregnant, of sufficient quantity to require immediate intervention to prevent further blood loss.
Chronic AUB
Bleeding from the uterine corpus that is abnormal in duration, volume, and/or frequency and has been present for the majority of the last 6 months.
Patterns of Bleeding
The shape of the volume of the bleeding pattern over the days of one menstrual period. It is usually recognized that about 90% of the total menstrual flow is lost within the first 3 days of the cycle, with day 1 or 2 the heaviest. In women with AUB this pattern is variable.
The PALM-COEIN Classification System for Causes of AUB
PALM visually objective structural criteria
COEI unrelated to structural anomalies N entities not yet classified
Components of the PALM-COEIN Classification System
Polyps (AUB-P)
Abnormal vaginal bleeding is the most common presenting symptom. Accounts for all causes of abnormal vaginal bleeding in 39% of pre-menopausal and 21-28% in post-menopausal women. Polyps are categorized as either present or absent. Diagnosed by TVUS, saline infusion sonography, and hysteroscopy.
Adenomyosis (AUB-A)
70% of women with adenomyosis have symptoms of AUB. 30% have dysmenorrhea. 19% have both. Diagnosed by ultrasound or MRI.
Leiomyomas (AUB-LSM or AUB-LO)
Most common benign tumor of the genital tract. Age is most common risk factor with lifetime risk in women over age 45 to be more than 60%. Higher association of AUB with submucosal lesions, compared to intramural and subserosal leiomyomas.
Malignancy (AUB-M)
AUB is the primary symptom of endometrial neoplasia. 70% of PMB with AUB have benign findings, 15% have hyperplasia, and 15% have endometrial cancer. Approximately 50% of women diagnosed with endometrial hyperplasia have concurrent carcinoma. AUB-M includes both premalignant and malignant lesions.
Coagulopathies (AUB-C)
13% of women with HMB have a disorder of hemostasis that may be overlooked during the differential diagnosis.
Ovulatory Dysfunction (AUB-O)
Patients with unpredictable menses with variable flow are usually associated with endocrinopathies, such as polycyctic ovary syndrome or hypothyroidism. Evaluate for ovulatory dysfunction.
Endometrial Causes (AUB-E)
Most patients in this category will have regular cycles, normal ovulation and no definable cause of AUB. Usually present with HMB, which may indicate a disorder of endometrial hemostasis. Others may present with IMB, which may be secondary to inflammation, infection, or abnormal inflammatory responses.
Iatrogenic (AUB-I)
Causes include IUD, exogenous gonadal steroids and other systemic agents that affect blood coagulation or ovulation. Bleeding from anticoagulation therapy is listed under AUB-C rather than AUB-I.
Not Yet Classified (AUB-N)
Reserved for entities that are poorly defined and/or not well examined, such as arteriovenous malformation and myometrial hypertrophy. With more evidence, entities such as these will likely be placed into a new or existing category.
Notation of AUB
A patient may be found to have more than one potential entity contributing to symptoms of AUB. A notation approach has been designed to enable categorization. For example, if a patient is found to have endometrial hyperplasia and ovulation dysfunction with no other abnormalities, she would be categorized as follows:
AUB P0 A0 L0 M1 C0 O1 E0 I0 N0 May be abbreviated as:
AUB M;O
Diagnostic Evaluation of AUB
Medical History
Age of menarche and menopause
Menstrual bleeding patterns Severity of bleeding (clots or flooding) Pain (severity and treatment) Medical conditions Surgical history Use of medications Symptoms and signs of possible hemostatic disorder
Physical Exam
General physical Pelvic Examination External Speculum with Pap test, if needed. Bimanual
Laboratory Tests
Pregnancy test (blood or urine)
Complete blood count TSH Chlamydia trachomatis Targeted screening for bleeding disorders (when indicated, based on history*): PT, PTT, specific tests for von Willebrand disease, von Willebrand-ristocetin cofactor activity, von Willebrand factor antigen, and factor VIII
Available Diagnostic or Imaging Tests (when indicated)
Saline infusion sonohysterography Transvaginal ultrasonography Magnetic resonance imaging Hysteroscopy
Available Tissue Sampling Methods (when indicated**)
Office endometrial biopsy
Hysteroscopy directed endometrial sampling (office or operating room)
*Clinical Screening for an Underlying
Disorder of Hemostasis in the Patient
with Excessive Menstrual Bleeding Positive screen comprises any of the following: Heavy menstrual bleeding since menarche One of the following: Postpartum hemorrhage Surgery-related bleeding Bleeding associated with dental work Two or more of the following symptoms: Bruising one to two times per month Epistaxis one to two times per month Frequent gum bleeding Family history of bleeding symptoms
**Indications for Endometrial Sampling
Age >45 years Family history of hereditary nonpolyposis colorectal cancer syndrome (HNPCC) Persistent AUB that is unexplained or fails treatment
Disorders of menstruation and other abnormal bleeding from female genital tract Amenorrhea (primary) (secondary) Scanty or Infrequent menstruation, Hypomenorrhea, Oligomenorrhea Excessive or frequent menstruation, Heavy periods, Menorrhagia, Menometrorrhagia, Polymeorrhea Irregular menstrual cycle, Irregular bleeding, Irregular menstruation, Irregular periods Ovulation bleeding, Regular intermenstrual bleeding Metrorrhagia, Bleeding unrelated to menstrual cycle, Irregular intermenstrual bleeding Dysfunctional or functional uterine hemorrhage Postmenopausal bleeding Polyp of corpus uteri, Endometrium, Uterus Endometriosis of uterus, Adenomyosis Dysmenorrhea, Painful menstruation Submucous leiomyoma of uterus Intramural leiomyoma of uterus Subserous leiomyoma of uterus Leiomyoma of uterus, unspecified Malignant neoplasm of body of uterus, endometrium Endometrial hyperplasia, unspecified Simple endometrial hyperplasia without atypia Complex endometrial hyperplasia without atypia Endometrial hyperplasia with atypia Benign endometrial hyperplasia
Endometrial sampling (biopsy) with or without endocervical sampling (biopsy),
without cervical dilation, any method (separate procedure) Hysteroscopy, diagnostic (separate procedure) hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D&C Ultrasound, transvaginal Saline infusion sonohysterography (SIS), including color flow Doppler, when performed
Many of the suggestions for the new terminology might be included in the ICD-10 changes that may be implemented in 2014.
