New terminology :

Abnormal Uterine Bleeding

In 2009, FIGO World Congress of
Gynecology and Obstetrics (17
countries from 6 continents)
accepted the new terminology. The
PALM-COEIN Classification System
created.

Old Nomenculature

Menorrhagia
Hypermenorrhea
Hypomenorrhea
Menometrorrhagi
a
Polymenorrhea
Polymenorrhagia
Epimenorrhea
Epimenorrhagia

Uterine
hemorrhage
Dysfunctional
uterine bleeding
Functional
uterine bleeding
Metropathica
hemorrhagica
Oligomenorrhea

Accepted Abbreviations
Describing Menstrual Symptoms
AUB Abnormal uterine bleeding
HMB Heavy menstrual bleeding
HPMB Heavy and prolonged menstrual
bleeding
IMB Intermenstrual bleeding
PMB Postmenopausal bleeding

Recommended Normal Limits of

Menstrual Dimensions
Frequency of menses
Frequent <24 days
Normal 24 to 38 days
Infrequent >38 days

Regularity of menses, cycle to cycle variation over 12 months

Absent No bleeding
Regular Variation + or - 2 to 20 days
Irregular Variation >20 days

Duration of flow
Prolonged >8.0 days
Normal 4.5 to 8.0 days
Shortened <4.5 days

Prevalance of HMB
20% have > 80cc/month
5% (age 30-49) present for
consultation each year
30% affected by HMB at some time
in their life

The PALM-COEIN Classification System for

Causes of AUB

PALM visually objective structural

criteria
COEI unrelated to structural
anomalies
N entities not yet classified

PALM : Structural
Abnormalities

Polyps (AUB-P)
Adenomyosis (AUB-A)
Leiomyoma (AUB-L)
Malignancy (AUB-M)

COEIN : Non Structural

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

Diagnostic Evaluation of
AUB

Medical History
Physical Exam
Labaratory Tests
Diagnostic and Imaging Tests
Tissue sampling

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)
Indications for Endometrial Sampling
Age >45 years
Family history of hereditary nonpolyposis
colorectal cancer syndrome (HNPCC)
Persistent AUB that is unexplained or fails
treatment

Treatment
Trial of meds
NSAIDs
Progestins
OCPs
Levonorgestril IUCD
Tranxenamic Acid

Surgical intervention
Endomtrial Ablation

Leiomyoma related AUB

Fertility Sparing /
Enchancing

Removes Fertility

Medical

Surgical

Gonadal Sterioids
SPRMs
GnRHa
Others

Myomectomy
Myoma ablation
Uterine Artery
Embolization/Occlusio
n
Hysterectomy
(Total / Supracervical)

Thank You