Gynecology G ynecology U Update pdate

Abnormal Uterine Bleeding

New Definitions and Contemporary Terminology
Arturo Garza-Cavazos, MD; J. Ricardo Loret de Mola, MD

The updated terminologies, definitions, and classifications of abnormal uterine bleeding have received international acceptance and should facilitate future clinical research. Not only are these revisions expected to improve communication among clinicians around the world, but they should also simplify communication between clinicians and patients.
bnormal uterine bleeding (AUB) is defined as an alteration in the volume, pattern, and/or duration of menstrual blood flow and is the most common reason for gynecologic referrals.1 Over the past 10 years it has become increasingly clear that many of the terms used to describe disturbances in menstruation are ill defined and confusing.1-4 This lack of standardized and unambiguous terminology has led to difficulties in developing and interpreting

research and creating evidence-based protocols to manage patients suffering with AUB.3 In February of 2005, an interest group of 35 physician and scientific experts in menstrual disorders met to develop recommendations for uniform termi-

Dr Garza-Cavazos is Fellow, Minimally Invasive and Robotic Surgery, Department of Obstetrics and Gynecology, Southern Illinois University, Springfield, IL. Dr Loret de Mola is Chairman, Department of Obstetrics and Gynecology, Southern Illinois University, Springfield, IL.

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The Female Patient | VOL 37 JULY/AUGUST 2012 27

Abnormal Uterine Bleeding: New Definitions and Contemporary Terminology

nologies and definitions related to AUB for international use.2-4 The meeting involved a multistage process that began with an assessment of how terms describing abnormal bleeding have been defined and used to date. This led to an excellent review on historical and current terminology and definitions for AUB published in 2008 that confi rmed the inconsistent and confusing nature of the clinical terminology pertaining to menstrual disorders.4 The next step was the organization of a Delphi panel to recommend definitions and terminologies with potential for international agreement. The Delphi panel approach is a nominal group process designed to elicit opinions on a clearly defined topic and has been used extensively to develop clinical guidelines on such topics as coronary revascularization, hysterectomy, and colonoscopy.3 The panelists concluded that English language terminologies with Greek or Latin roots are poorly defi ned and create ambiguity in meaning and usage. As a result, the panelists recommended that much of the current terminology be discarded (Table 1) and replaced by simple descriptive terms that could be understood by patients and translated into most languages (Tables 2 and 3).5-7 Another outcome of the Delphi panel was an agreement to establish an ongoing study group, and the International Federation of Gynecology and Obstetrics (FIGO) was identified as the most appropriate body to provide supervision

TABLE 1.

Recommendations for Discarded Terminologya

Polymenorrhea Polymenorrhagia Epimenorrhea Epimenorrhagia Uterine hemorrhage Dysfunctional uterine bleeding Functional uterine bleeding Metropathica hemorrhagica

Menorrhagia Hypermenorrhea Hypomenorrhea Menometrorrhagia

a

Data from Woolcock et al.4

TABLE 2.

Accepted Abbreviations Describing Menstrual Symptomsa

Abnormal uterine bleeding Heavy menstrual bleeding Heavy and prolonged menstrual bleeding Intermenstrual bleeding Postmenopausal bleeding

AUB HMB HPMB IMB PMB

a

Adapted with permission from Fraser et al.7

TABLE 3.

Recommended Normal Limits for Four Key Menstrual Dimensions (Mid-Reproductive Years)a
Normal Limits (5th95th percentiles) < 24 2438 > 38 No bleeding Variation 220 Variation > 20 days > 8.0 4.58.0 < 4.5

Clinical Dimensions of Menstruation and Menstrual Cycle Cycle Descriptive Termsa Frequency of menses (days) Frequent Normal Infrequent Absent Regular Irregular Prolonged Normal Shortened

Regularity of menses, cycle to cycle variation over 12 months (days)

Duration of flow (days)

Adapted from Fraser et al.7

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Garza-Cavazos and Loret de Mola

Recommended Terminology, Definitions, and Classifications of Symptoms of Abnormal Uterine Bleedinga

Disturbances of Regularity Irregular Menstrual Bleeding (IrregMB): Bleeding of > 20 days in individual cycle lengths over a period of 1 year. Absent Menstrual Bleeding (amenorrhea): No bleeding in a 90-day period. It was recommended that the term amenorrhea be retained because there is little controversy in its use or definition. Disturbances in Frequency Infrequent Menstrual Bleeding (oligomenorrhea): one or two episodes in a 90-day period. It is recommended that the term oligomenorrhea be abolished. Frequent Menstrual Bleeding: More than four episodes in a 90-day period (frequent menstruation, not erratic intermenstrual bleeding). 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. The most common presentation of AUB. 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, it is commonly associated with heavy menstrual bleeding. 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.
a

Adapted with permission from Fraser et al.7

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Abnormal Uterine Bleeding: New Definitions and Contemporary Terminology

and international credibility. This led to the formation of the FIGO Menstrual Disorders Group in 2006.6 After several important publications, the group met for a pre-congress workshop prior to the FIGO World Congress of Gynecology and Obstetrics in October 2009 to review the recommendations.7 The recommendations were then presented for approval through an audience responder system at the FIGO World Congress and were met with a high level of acceptance.7 The Washington Meeting in 2005 also discussed a future classification system for AUB with a primary objective of developing an ongoing process with international debate.5 The FIGO Menstrual Disorders Group developed an agreement protocol to recommend a clear and simple classification system having the potential for wide acceptance.6 The system was developed with contributions from an international group of both clinical and nonclinical investigators from 17 countries.6,7 The result was the designation of the PALM-COEIN Classification System, which stratifies causes of AUB into nine basic categories and a final grouping reserved for causes yet to be classified (see box).6,8 The components of the PALM group are defined by visually objective structural criteria. In contrast, the COEI is unrelated to structural anomalies. The N group, for entities not yet classified, allows for the addition and modification of existing classification as new findings on AUB become available and facilitates the current or subsequent development of subclassification systems.6,8

Components of the PALM-COEIN Classification System

Polyps (AUB-P) Endometrial polyps are a common gynecologic condition associated with symptoms of AUB.8 Abnormal vaginal bleeding is the most common presenting symptom of endometrial polyps and accounts for all causes of abnormal vaginal bleeding in 39% and 21% to 28% of pre- and postmenopausal women, respectively.9 Polyps are categorized as either present or absent in the basic classification system. The primary diagnostic approaches include noninvasive transvaginal ultrasonography (TVUS), with or without 3D imaging and contrast.9 However, other imaging techniques, such as saline infusion sonography and hysteroscopic imaging with or without histopathology, may be employed.6 Hysteroscopic resection should be used for histopathology.9 There is potential in this category to develop a subclassification based on variables that include size, location, number, morphology, and histology. It is important to exclude polypoid-appearing endometrium from this category since this finding may be a normal variant.6 Adenomyosis (AUB-A) Approximately 70% of patients with adenomyosis have symptoms of AUB; 30% have symptoms of dysmenorrhea; and 19% present with both.10 Traditionally, diagnosis has been established with histopathology after hysterectomy; however, because adenomyosis can be accurately detected with ultrasound and magnetic resonance imaging (MRI), the FIGO system calls for the use of diagnostic imaging.6,10 Given the limited access to MRI in some communities, it has been further proposed that ultrasound imaging criteria comprise the minimum requirements for assigning a diagnosis of adenomyosis.6

The PALM-COEIN Classification System for Causes of Abnormal Uterine Bleedinga

Polyps (AUB-P) Adenomyosis (AUB-A) Leiomyoma (AUB-L) Submucosal/Other Malignancy (AUB-M)
a

Coagulopathy (AUB-C) Ovulatory disorders (AUB-O) Endometrial (AUB-E) Iatrogenic (AUB-I) Not classified (AUB-N)

Adapted with permission from Munro et al.6

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Abnormal Uterine Bleeding: New Definitions and Contemporary Terminology

Leiomyomas (AUB-L) Uterine fibroids are the most common benign tumor of the female genital tract. Age is the most common risk factor, and recent longitudinal studies have estimated the lifetime risk in women over the age of 45 to be more than 60%. Race also contributes to risk: the estimated incidence rates of fibroids by age 50 is greater than 80% in African-American women and 70% in white women. The age-specific incidence of fibroids in African-American women is 2 to 3 times more than white women.11,12 Additional factors associated with increased incidence are nulliparity, cigarette smoking, and a prolonged menstrual cycle. Fibroids originate from a single cell (the monoclonal origin); however, candidate genes for common uterine fibroids have not yet been identified. Uterine fibroids because of the higher association of AUB with submucosal lesions. The tertiary system is based on an adopted design by the European Society for Human Reproduction and Embryology for subendometrial or submucosal leiomyomas, which includes categorization of intramural and subserosal leiomyomas. Importantly, the tertiary system has great potential for both research and clinical use.6,8 Malignancy (AUB-M) The primary symptom of endometrial neoplasia is AUB, which typically prompts an endometrial biopsy to rule out endometrial carcinoma, the most common gynecologic malignancy in the United States. Approximately 70% of postmenopausal women with abnormal uterine bleeding are diagnosed with benign findings, 15% with endometrial hyperplasia, and 15% with endometrial carcinoma. Although the risk of endometrial carcinoma is much lower in women of reproductive age, endometrial evaluation is recommended for those at high risk, such women with chronic anovulation, obesity, Lynch syndrome, or diabetes mellitus. Because one of the most common risk factors, obesity, is epidemic in the United States and escalating worldwide,13,14 the international incidence of endometrial carcinoma is expected to increase in the coming years. There are two different subtypes of endometrial carcinoma: estrogen-related type 1 (endometrioid), which comprises 70% to 80% of newly diagnosed cases, and nonestrogen-related type 2 (eg, papillary serous and clear cell). Type 1 is related to unopposed estrogen stimulation of the endometrium. Progesterone inhibits estrogen-induced proliferation and hyperplasia by inducing glandular secretory activity and decidual transformation of stromal fibroblasts; these secretory cells are then shed during withdrawal bleeding. Hormonal contraceptives, combined or progesterone only, reduce the risk of endometrial carcinoma.15 The widely used World Health Organization (WHO) system classifies endo-

FOCUSPOINT In the secondary system, differentiation of leiomyomas that are submucosal from others is required because of the higher association of AUB with submucosal lesions.

can also increase the risk for infertility depending on their location, with submucosal fibroids increasing both the risks for infertility and AUB. Primary, secondary, and tertiary classification systems have been submitted. Like the classification system for endometrial polyps, the primary classification system for leiomyomas reflects only the presence or absence of one or more leiomyomas, regardless of location, number, or size. In the secondary system, differentiation of leiomyomas that are submucosal (SM) from others (O) is required

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Garza-Cavazos and Loret de Mola

metrial hyperplasia according to four combinations of glandular crowding and nuclear atypia: simple, complex, simple atypical hyperplasia, or complex atypical hyperplasia, although the two atypical hyperplasias are often classified as one. Approximately 50% of women diagnosed with endometrial hyperplasia have concurrent carcinoma. Emerging data indicate that the long-term risk of developing endometrial carcinoma among women with simple or complex hyperplasia is less than 5%, but the risk in atypical hyperplasias is approximately 30%.16 The classification system is not meant to replace the WHO and FIGO systems for categorizing hyperplasia or neoplasia. Instead it has been proposed that premalignant and malignant lesions be classified as AUB-M and then subclassified using the appropriate WHO or FIGO system.6 Coagulopathies (AUB-C) It is important that coagulopathies are included in the classification system given that it has been demonstrated that 13% of women with heavy menstrual bleeding (HMB) have a disorder of hemostasis that may be overlooked during the differential diagnosis. Testing for coagulopathies should be conducted during the workup, and the history should include simple questions to screen for the presence of hemostasis disorders.6 Ovulatory Dysfunction (AUB-O) Patients in this category will mostly present with unpredictable menses with variable flow, and most are associated with endocrinopathies, such as polycystic ovary syndrome or hypothyroidism. As with coagulopathies, ancillary testing should be included in the diagnostic process of patients of ovulatory dysfunction.6,8 Endometrial Causes (AUB-E) Most patients in this category will have regular cycles, normal ovulation, and no definable cause of AUB. If this is the case, patients will likely present with HMB, which may indicate a disorder of endometrial hemostasis. Other patients

may present with intermenstrual bleeding (IMB), which may be secondary to inflammation, infection, or abnormal inflammatory response. Currently, more research is needed to define conditions in this category, which should be diagnosed by exclusion.6,8

FOCUSPOINT The updated terminologies, definitions, and classifications of AUB have received international acceptance and should facilitate future clinical research.

Iatrogenic (AUB-I) This category refers to AUB associated with the use of IUDs or exogenous gonadal steroids and other systemic agents that affect blood coagulation or ovulation.6,8 Not Yet Classified (AUB-N) This category is reserved for entities that are poorly defined and/or not well examined. Examples include arteriovenous malformation and myometrial hypertrophy. With more evidence, entities such as these will likely be placed into a new or existing category.6,8 Notation A notation approach has also been designed to enable categorization, which should be especially useful to specialists and researchers. Because a patient may be found to have more than one potential entity contributing to symptoms of AUB, this method addresses all components and is similar to the WHO TNM method of staging tumors. 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

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Abnormal Uterine Bleeding: New Definitions and Contemporary Terminology

AUB

Acute

Chronic Ancillary Testing Detailed History Medical History Medications

Ovulation Function

Physical Exam AUB O, I, C, and/or E Uterine Evaluation Risk of Malignancy

TVUS

Endometrial Biopsy

AUB L, P, or A

Normal

AUB M

AUB E or O

FIGURE. Flow Chart for Evaluation of Abnormal Uterine Bleeding (AUB). Keep in mind that saline infusion sonography, hysteroscopy, or MRI might be required to diagnose a target lesion after an abnormal transvaginal ultrasonography (TVUS). AUB category abbreviations: A, adenomyosis; C, coagulopathy; E, endometrial; I, iatrogenic; L, leiomyoma; M, malignancy; N, not classified; O, ovulatory disorders; P, polyps.
Adapted with permission from Munro et al.6

N0, with an option to abbreviate as AUBM;O. If uterine fibroids were present, they would be categorized as AUB L1(SM) or L1(O), depending on the location of the leiomyoma. A tertiary classification of leiomyomas, which is not discussed here, can be added to further classify the location of the leiomyoma.6,8

Assessment
Patients with chronic AUB should undergo a structured history and evaluation to determine the underlying factor or factors contributing to this disorder (see flow chart). As discussed, women with AUB may have no, one, or multiple identifiable factors from the FIGO system. The history

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Garza-Cavazos and Loret de Mola

should determine ovulatory status, potentially related medical disorders, current medications, a screen for disorders of hemostasis, and fertility desires of the patient. Ancillary testing should include hemoglobin and/or hematocrit, and testing for conditions that could contribute to ovulatory dysfunction. Uterine evaluation is guided by the history and examination. An endometrial biopsy is warranted for those patients with increased risk of hyperplasia or malignancy. Those patients with risk of a structural anomaly or who have failed medical management should undergo imaging with at least a screening TVUS. Saline infused sonography, hysteroscopy, MRI, (and/or) hysteroscopy with or without biopsy should be used as indicated if neither TVUS nor endo-

metrial biopsy is diagnostic or further workup is required.6,8

Conclusion
The updated terminologies, definitions, and classifications of AUB have received international acceptance and should facilitate future clinical research. Not only are these revisions expected to improve communication between clinicians around the world, but they should also simplify communication between clinicians and patients. Importantly, all definitions and classifications are subject to ongoing review and future development by the established FIGO Menstrual Disorders Working Group. This process will address remaining controversies pertaining to AUB terminology and provide a scheduled systematic review of

Coding for Abnormal Uterine Bleeding

Philip N. Eskew Jr, MD

This article reviews and evaluates the current terminology associated with the condition of abnormal uterine bleeding and makes several recommendations for changes. However, as you will see from the ICD-9 codes, many of their suggestions are already included in the additional definitions of the appropriate codes. Many of the suggestions might be included in the ICD-10 changes that may be implemented in 2014. For this discussion, the ICD-9 codes mentioned in this article are: 626 626.0 626.1 626.2 626.4 626.5 626.6 626.8 627.1 621.0 617.0 625.3 218.0 218.1 218.2 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, Polymenorrhea 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 218.9 182.0 621.30 621.31 621.32 621.33 621.34 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

The procedures mentioned in this article have the following CPT codes: 58100 Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation, any method (separate procedure) 58555 Hysteroscopy, diagnostic (separate procedure) 58558 Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C 76830 Ultrasound, transvaginal 76831 Saline infusion sonohysterography (SIS), including color flow Doppler, when performed

Dr Eskew is past member, Current Procedural Terminology (CPT) Editorial Panel; past member, CPT Advisory Committee; past chair, ACOG Coding and Nomenclature Committee; and instructor, CPT coding and documentation courses and seminars.

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Abnormal Uterine Bleeding: New Definitions and Contemporary Terminology

the classification system, allowing for ongoing revisions as recommended.
The authors report no actual or potential conflicts of interest in relation to this article. Med. 2011;29(5):383-390. 8. Munro MG, Critchley HO, Broder MS, Fraser IS. 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. 9. Salim S, Won H, Nesbitt-Hawes E, Campbell N, Abbott J. Diagnosis and management of endometrial polyps: a critical review of the literature. J Minim Invasive Gynecol. 2011;18(5):569-581. 10. Garcia L, Isaacson K. Adenomyosis: review of the literature. J Minim Invasive Gynecol. 2011;18(4):428-437. 11. Baird DD, Dunson DB, Hill MC, Cousins D, Schectman JM. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol. 2003;188(1):100-107. 12. Templeman C, Marshall SF, Clarke CA, et al. Risk factors for surgically removed fibroids in a large cohort of teachers. Feril Steril. 2009;92(4):1436-1446. 13. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity in the United States, 20092010. NCHS data brief, no 82. Hyattsville, MD: National Center for Health Statistics. 2012. 14. Berghofer A, Pischon T, Reinhold T, Apovian CM, Sharma AM, Willich SN. Obesity prevalence from a European perspective: a systematic review. BMC Public Health. 2008;8:200. 15. Mueck AO, Seeger H, Rabe T. Hormonal contraception and risk of endometrial cancer: a systematic review. Endocr Relat Cancer. 2010;17(4):R263-271. 16. Lacey JV, Sherman ME, Rush BB, et al. Absolute risk of endometrial carcinoma during 20-year follow-up among women with endometrial hyperplasia. J Clinic Oncol. 2010;28(5):788-792.

References
1. Rahn DD, Abed H, Sung VW, et al. Systematic review highlights difficulty interpreting diverse clinical outcomes in abnormal uterine bleeding trials. J Clin Epidemiol. 2011;64(3): 293-300. 2. Fraser IS, Critchley HO, Munro MG. Abnormal uterine bleeding: getting our terminology straight. Curr Opin Obstet Gynecol. 2007;19(6):591-595. 3. Critchley HO, Munro MG, Broder M, Fraser IS. A five-year international review process concerning terminologies, definitions, and related issues around abnormal uterine bleeding. Semin Reprod Med. 2011;29(5):377-382. 4. Woolcock JG, Critchley HO, Munro MG, Broder MS, Fraser IS. Review of the confusion in current and historical terminology and definitions for disturbances of menstrual bleeding. Fertil Steril.2008;90(6): 2269-2280. 5. Fraser I, Critchley HO, Munro M, Broder M. A process designed to lead to international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding. Fertil Steril. 2007;87(3):466-476. 6. Munro M, Critchley HO, Fraser I. The FIGO classification of causes of abnormal uterine bleeding in the reproductive years. Fertil Steril. 2011;95(7):2204-2208. 7. Fraser IS, Critchley HO, Broder M, Munro MG. The FIGO recommendations on terminologies and definitions for normal and abnormal uterine bleeding. Semin Reprod

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