Abnormal Uterine Bleeding (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)

Recommendations for Discarded Terminology

Menorrhagia Hypermenorrhea Hypomenorrhea
Menometrorrhagia Polymenorrhea Polymenorrhagia
Epimenorrhea Epimenorrhagia Uterine hemorrhage
Dysfunctional uterine bleeding Functional uterine bleeding Metropathica hemorrhagica
Oligomenorrhea

Amenorrhea – retained term

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 Absent No bleeding

Variation over 12 months 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
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 woman’s
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
Coagulopathy (AUB-C)
Polyps (AUB-P) Ovulatory disorders (AUB-O)
Adenomyosis (AUB-A) Endometrial (AUB-E)
Leiomyoma (AUB-L) Iatrogenic (AUB-I)
Malignancy (AUB-M) Not 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 **Indications for Endometrial Sampling
Positive screen comprises any of the following: Age >45 years
Heavy menstrual bleeding since menarche Family history of hereditary nonpolyposis colorectal
One of the following: cancer syndrome (HNPCC)
Postpartum hemorrhage Persistent AUB that is unexplained or fails treatment
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
Coding for Abnormal Uterine Bleeding
ICD-9 Codes

626 Disorders of menstruation and other abnormal bleeding from female genital tract
626.0 Amenorrhea (primary) (secondary)
626.1 Scanty or Infrequent menstruation, Hypomenorrhea, Oligomenorrhea
626.2 Excessive or frequent menstruation, Heavy periods, Menorrhagia,
Menometrorrhagia, Polymeorrhea
626.4 Irregular menstrual cycle, Irregular bleeding, Irregular menstruation, Irregular
periods
626.5 Ovulation bleeding, Regular intermenstrual bleeding
626.6 Metrorrhagia, Bleeding unrelated to menstrual cycle, Irregular intermenstrual
bleeding
626.8 Dysfunctional or functional uterine hemorrhage
627.1 Postmenopausal bleeding
621.0 Polyp of corpus uteri, Endometrium, Uterus
617.0 Endometriosis of uterus, Adenomyosis
625.3 Dysmenorrhea, Painful menstruation
218.0 Submucous leiomyoma of uterus
218.1 Intramural leiomyoma of uterus
218.2 Subserous leiomyoma of uterus
218.9 Leiomyoma of uterus, unspecified
182.0 Malignant neoplasm of body of uterus, endometrium
621.30 Endometrial hyperplasia, unspecified
621.31 Simple endometrial hyperplasia without atypia
621.32 Complex endometrial hyperplasia without atypia
621.33 Endometrial hyperplasia with atypia
621.34 Benign endometrial hyperplasia

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

Many of the suggestions for the new terminology might be included in the ICD-10 changes that
may be implemented in 2014.