The document discusses the new FIGO classification system for abnormal uterine bleeding (AUB). It introduces the PALM-COEIN system which provides a standardized terminology and classification. The system categorizes AUB into structural causes (polyps, adenomyosis, leiomyoma, malignancy) and non-structural causes (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not yet classified). It provides guidelines for evaluation and outlines the notation system for documenting multiple contributing factors to a patient's AUB. The standardized classification aims to improve management of AUB internationally through a unified terminology and focus on appropriate treatment concepts.
4. Waves of change
In 2006, FIGO identified as the appropriate body to provide supervision
& international credibility to the ongoing evaluation of new terminology
In 2009, FIGO Menstrual Disorders Group was formed. FIGO World
Congress of Gynecology and Obstetrics , accepted the new terminology.
In 2011, the PALM-COEIN Classification System created.
In 2012, PALM-COEIN system was endorsed by ACOG
7. AUB Validated Terminology
AUB: Abnormal uterine bleeding
Umbrella term for both regular and irregular bleeding
HMB: Heavy menstrual bleeding
Excessive menstrual bleeding
IMB: Inter-menstrual bleeding
Occurs between clearly defined cyclic and predictable menses
Acute:
Heavy bleeding that is of sufficient quantity to require immediate
intervention to prevent further blood loss
Chronic:
Heavy bleeding that is of sufficient quantity to require immediate
intervention to prevent further blood loss
AUB
Acute AUB
IMB HMB
Chronic
AUB
IMB HMB
8. Chronic AUB;
Bleeding from the uterine corpus that is abnormal in volume,
regularity and/or timing and has been present for the majority
the past 6 months
9. Menstrual parameters
Frequency
24-38 day
Frequent
Normal
Infrequent
Regularity
<20 D / 12 m
Absent
Regular
Irregular
Duration
4.5-8 days
Prolonged
Normal
Shortened
Volume
5-80 ml
Heavy
Normal
Light
Suggested “normal limits” for uterine bleeding in the mid-reproductive years
Munro MG. Rev Endocr Metab Disorder (2012) 13: 225-234
10.
11. Structural Abnormalities
P – Polyps – scored as Present or Absent
A – Adenomyosis - scored as Present or Absent
L – Leiomyoma
Primary level – Present or Absent
Secondary level – Distinguish between submucosal (SM) & others (O)
Tertiary level – Detail location/size of uterine fibroids
M – Malignancy & hyperplasia
12. AUB-P; Polyps (8-35 %)
Diagnosis: US, SIS, hysteroscopy
Further sub-classification: Dimensions, location & number
Pre-menopausal polyps:
64 – 88% have symptoms
Present with HMB, AUB, IMB, or post-coital bleeding
Symptoms do NOT correlate with number, diameter & site
Post-menopausal polyps:
Most are symptom free
Cause for 21-28% of PMP bleeding
Associated with cervical polyps in 24-27%
Incidence of carcinoma varies between 0–4.8%
13.
14. AUB-A; Adenomyosis
Ectopic endometrial glands & stroma within the myometrium
Hypertrophy & hyperplasia of surrounding myometrium
Usual presentation: HMB, uterine enlargement, & dysmenorrhea
16. Sonographic findings of
Adenomyosis
Dueholm et al. Best Pract Res Clin Obstet Gynaecol 2006; 20: 569 82.
Color Doppler: vessels following normal
course through an indistinct mass
21. AUB-M; Malignancy &
Hyperplasia
Detected based upon results of office biopsy or curettage
FIGO AUB Staged only as present or absent
Use existing WHO and FIGO categorization
Up to 40% of patients with a biopsy diagnosis of complex hyperplasia
with atypia will have a concomitant endometrial adenocarcinoma
present
22.
23. Non-structural Abnormalities
C – Coagulopathy
O – Ovulatory Dysfunction
E – Endometrial
I – Iatrogenic
N – Not yet classified
24. AUB-C; Coagulopathy
Prevalence: 3% of women presenting with HMB
Etiologies:
Von Willebrand’s disease (10%)
Platelet Dysfunction
Factor XI deficiency
Factor X deficiency
Category includes patient’s taking anti-coagulants
25. Coagulopathy
History Screening
HMB since menarche
One of the following:
PPH
Surgical related bleeding
Bleeding associated with dental work
Two or more of the following:
Bruising 1-2 times/month
Epistaxis 1-2 times/ month
Frequent gum bleeding
Family history of bleeding symptoms
27. AUB-E; Endometrial
It is diagnosed by exclusion
Etiology:
Deficiencies of local production of vasoconstrictors
Endothelin-1
Prostaglandin F2a
Excessive production of plasminogen activators
Increased local production of vasodilators
Prostaglandin E2
Prostacyclin I2
Disorders of endometrial repair (inflammation)
Chlamydia
28. AUB-I; Iatrogenic
Etiology:
Breakthrough bleeding (BTB) using gonadal steroids is the major
component of AUB-I :
Oral contraceptives
Continuous or cyclic progesterone
IUD or implant related bleeding
Cigarette smoking : reduces the level of steroids because of enhanced
hepatic metabolism
Systemic agents that interfere with dopamine metabolism :
Serotonin uptake inhibitors
29. AUB-N; Not Yet Classified
Disorders that would be identified or defined only by biochemical or
molecular biology assays
Arterio-venous malformations
Myometrial hypertrophy
Category for new etiologies
Pathological conditions of lower genital tract ??
30. Pathway overview
When a woman presents with HMB :
Take a proper history
Decide whether the timing, amount of blood loss and/or duration of the
bleeding is out of the norm.
Give it a name.
Do a proper assessment/evaluation.
Make a (provisional) diagnosis.
Initiate treatment or referral
31. Guidelines for investigations
Guidelines
General assessment
Determine ovulatory
status
Screening for
haemostasis disorders
Evaluation of
endometrium
Evaluation of endometrial
cavity structure
Myometrial assessment
32. Guidelines for investigations
1. General assessment
Not related to pregnancy
Not emanating from cervix or another location
Evaluate for anaemia – Hb
2. Determine ovulatory status
Predictable cyclic menses every 22-35 days
3. Screening for systemic disorders of haemostasis
Structured history : 90% sensitivity
Positive screen: von Willebrand factor, hematologist
33. Guidelines for investigations
4. Evaluation of the endometrium
Endometrial sampling if risk factors are persistent
TVUS - endometrial thickness
5. Evaluation of structure of endometrial cavity
To identify polyps, submucous myomas
TVUS is not 100% sensitive –small lesions undetectable
If suboptimal –proceed to SIS or hysteroscopy
6. Myometrial assessment
US and +/- hysteroscopy
MRI : leiomyoma - adenomyosis
34.
35. Laboratory testing for evaluating Acute
AUB
Laboratory Evaluation Specific Laboratory Tests
• Initial laboratory testing • CBC
• Blood group
• Pregnancy test
• Initial laboratory evaluation for
disorders of hemostasis
• PTT & PT
• Activated partial thromboplastin time
• Fibrinogen
• Initial testing for von
Willebrand disease
• VWF antigen
• Ristocetin cofactor assay
• Factor VIII
• Other laboratory tests to
consider
• TSH
• Serum Fe, total Fe binding capacity,
and ferritin
• Liver function tests
• Chlamydia trachomatis
36. Imaging- US
TVUS
Assessment of myometrium, cervix, tubes, and ovaries
Endometrial Polyps
Adenomyosis
Leiomyomas
Uterine anomalies
Endometrial thickening associated with hyperplasia and malignancy
37. Saline infusion Sonography
SIS
Improves the diagnosis of intrauterine pathology - polyps and fibroids
Better discrimination of location and relationship to the uterine cavity
May be useful prior to hysteroscopic or laparoscopic procedure for
fibroids, polyps and uterine anomalies
38. MRI
Rarely indicated
Helps mapping the exact location of fibroids in planning surgery and
prior to embolization
When TVS or instrumentation of the uterus (i.e. congenital anomalies)
cannot be performed
40. Notation for 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,0
46. FIGO nomenclature
&
PALM-COEIN classification
Simplified and unified terminology
Allows clear focus of treatment concepts
Facilitates clinical and scientific research
collaboration
Provides the basis to structure more effective
clinical teaching
47. Take home massage
The term DUB should be replaced by coagulopathy, endometrial &
ovulatory disorders
FIGO believes that the classification should be used widely in
undergraduate & post-graduate education to facilitate the
development of practitioners who are able to provide quality care for
women with AUB