A C TA Obstetricia et Gynecologica

AOGS COM M ENT A R Y

Abnormal uterine bleeding: advantages of formal

classification to patients, clinicians and researchers
MAYANK MADHRA1, IAN S. FRASER2, MALCOLM G. MUNRO3,4 & HILARY O. D. CRITCHLEY1
1
MRC Centre for Reproductive Health, University of Edinburgh, Queen’s Medical Research Institute, Edinburgh, UK,
2
Department of Obstetrics and Gynaecology, Queen Elizabeth II Research Institute for Mothers and Infants, University
of Sydney, Sydney, New South Wales, Australia, 3Department of Obstetrics and Gynecology, David Geffen School of
Medicine, University of California, Los Angeles, California, USA, and 4Gynecologic Services, Kaiser Permanente Los
Angeles Medical Center, Los Angeles, California, USA

Key words Abstract

Abnormal uterine bleeding, FIGO
Classification, PALM-COEIN, terminology,
pathology
Correspondence
Hilary O. D. Critchley, MRC Centre for
Reproductive Health, University of Edinburgh,
The Queen’s Medical Research Institute, 47
Little France Crescent, Edinburgh EH16 4TJ,
UK.
E-mail: hilary.critchley@ed.ac.uk
Conflict of interest
The authors have stated explicitly that there
are no conflicts of interest in connection with
this article.
Please cite this article as: Madhra M, Fraser
IS, Munro MG, Critchley HOD. Abnormal
uterine bleeding: advantages of formal
classification to patients, clinicians and
researchers. Acta Obstet Gynecol Scand
2014; 93:619–625.
Received: 12 February 2014
Accepted: 2 April 2014
Objective. To highlight the advantages of formal classification of causes
of abnormal uterine bleeding from a clinical and scientific perspective.
Design. Review and recommendations for local implementation. Setting. In the
past, research in the field of menstrual disorders has not been funded ade-
quately with respect to the impact of symptoms on individuals, healthcare sys-
tems and society. This was confounded by a diverse terminology, which lead to
confusion between clinical and scientific groups, ultimately harming the under-
lying evidence base. To address this, a formal classification system (PALM-CO-
EIN) for the causes of abnormal uterine bleeding has been published for
worldwide use by FIGO (International Federation of Gynecology and Obstet-
rics). Population and main outcome measures. This commentary explains prob-
lems created by the prior absence of such a system, the potential advantages
stemming from its use, and practical suggestions for local implementation.
Results and conclusions. The PALM-COEIN classification is applicable globally
and, as momentum gathers, will ameliorate recurrence of historic problems,
and harmonise reporting of clinical and scientific research to facilitate future
progress in women’s health.
Abbreviations: AUB, abnormal uterine bleeding; FIGO, International Federation
of Gynecology and Obstetrics; HMB, heavy menstrual bleeding; ICD,
International Classification of Disease.

DOI: 10.1111/aogs.12390

Introduction
Heavy menstrual bleeding (HMB) has a negative impact
on the quality of life of many women globally and consti-
tutes a considerable proportion of the workload for clini-
cians worldwide. Costs of managing this condition in the
USA each year have been estimated at US$2000 for each
patient in direct, indirect and societal costs (1–3). This is
comparable to the average annual household cost of gas
and electricity combined in Europe (4).
Key Message
In women with symptoms of heavy menstrual bleed-
ing, a structured and consistent classification of the
underlying etiology has previously been lacking. This
review explains and justifies the utilization of the
FIGO classification of the causes of abnormal uterine
bleeding.

ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 619–625 619
Classification of AUB etiology
The objective measurement of menstrual blood loss
correlates poorly with presenting symptomatology and
health seeking behavior (5), therefore the symptom of
HMB for clinical purposes has been defined as “excessive
menstrual blood loss which interferes with the woman’s
physical, emotional, social and material quality of life,
and which can occur alone, or in combination with other
symptoms” (6).
The etiology of the symptom of HMB has had many
evolving facets, and has resulted in the development of
several classification frameworks. These models, with any
related terminology, evolved to have distinct local mean-
ings, meaning that literature on HMB was, at best, cau-
tiously interpretable across borders and, at worst,
unintentionally misleading and squandering of resources.
The discarded term “DUB” for dysfunctional uterine
bleeding in the UK referred to regular (cyclic and predict-
able) onset HMB after the exclusion of other pathology;
however, in the USA it mainly referred to irregular uter-
ine bleeding related to ovulatory disorders (7). Lack of
clarity over terminology in at least one well-publicized
case led to two entirely overlapping clinical trials, one
based in the USA and one in Europe, being set up simul-
taneously to answer the same clinical question (8). These
were not initially recognized as identical because of local
differences in the contemporary meaning of apparently
established terminology.
The International Statistical Classification of Diseases
and Health Related Problems (ICD) classification is
updated continuously by the World Health Organization.
Its national adaptations are used widely for disease
reporting, healthcare costing and resource allocation deci-
sions, with a strong tradition in Nordic Countries, which
employ the NordDRG adaptation of the ICD system.
The most current version at the time of writing, ICD-
10 (2010), uses descriptive terminology for symptoms of
HMB such as “metrorrhagia,” “menometrorrhagia” and
“polymenorrhea,” which do not relate to any specific
underlying pathological process, and may have been
assumed to be a “process” in their own right. It is not
always clear to what extent these terms refer to symptoms
experienced by women or a medical diagnosis used by cli-
nicians or both. Although the terms in these categories
(N91, N92, N93) have been defined through wide review
initially, there is the strong possibility that interpretation
of particular terms at the regional level is inconsistent,
maintaining an unsatisfactory status quo. In stark con-
trast, the ICD classification for acute myocardial infarc-
tion (I21.1) comprises specific areas of myocardial
necrosis without reference to symptomatology.
This ambiguity results in women with HMB of differing
underlying causes being corralled under the same termi-
nology or ICD code. The potential downstream effects of
620 ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 619–625
M. Madhra et al.
this in regard to HMB may have already manifested as
imprecise estimates of disease prevalence, leading to sub-
optimal resource allocation. Moreover, systematic reviews
and meta-analyses using such diagnostic criteria for HMB
may inadvertently recommend interventions with attenu-
ated benefit or concealed harms, due to unconscious over-
estimation of population homogeneity. This could have
further consequences. In terms of research, the number of
recruits to clinical trials will be greater than necessary to
demonstrate significant or meaningful differences between
treatment groups. This is not desirable from either a
resource or ethical standpoint. In terms of quality of clini-
cal care, all of the above would ultimately slow the evolu-
tion and degrade the value of the evidence base from
which improvements in clinical practice must stem.
These problems were recognized by the International
Federation of Gynecology and Obstetrics (FIGO) Men-
strual Disorders Working Group, and prompted several
years of robust, international cooperation and consensus
forming (9), which completed its first iteration in 2011
with the PALM-COEIN classification of causes of abnor-
mal uterine bleeding (AUB) (10) as detailed below.
Particular care has been taken with the terminology
used during development of the FIGO classification to
ameliorate many of the above concerns (11,12). AUB is
the preferred over-arching term, and was first used before
the FIGO process formally began, referring to a broader
range of clinical symptoms extending beyond the seman-
tic boundaries implied by use of the term “menstrual”,
but excludes bleeding coming from the cervix or lower
genital tract and that related to pregnancy.
Despite huge variation in healthcare resources globally,
the paradigm of history and examination supported by
investigation to reach a diagnostic opinion, followed by a
suitable management strategy, is pervasive. The PALM-
COEIN classification has an advantage over current systems
in that a healthcare provider employing it is encouraged to
consider the entire range of possible etiologies regardless of
any prior bias or preconception during the formation of a
working diagnosis. Furthermore, once likely causes have
been identified, they are guided towards further investiga-
tion or treatment by the explicit acknowledgement of pos-
sible etiologies. PALM-COEIN is practical, becoming
widely accepted, and aids clinicians and investigators in
terms of treatment, prognostication and research (10).
Crucial to the development of the FIGO classification
was the need to clarify terminology used for initial history
taking, achieved by reducing traditional or regional de-
scriptors to their fundamental meaning, thereby providing
simple, translatable and unambiguous definitions to accu-
rately describe AUB symptoms. These are stated in
Table 1 and are used in comparison to a 3-month refer-
ence time frame prior to consultation.
M. Madhra et al.
The mnemonic PALM-COEIN refers to the structural
(polyps, adenomyosis, leiomyoma, and malignancy/hyper-
plasia) and non-structural (coagulopathy, ovulatory disor-
ders, endometrial dysfunction, iatrogenic, not otherwise
classified) causes of AUB. Each is discussed in brief below
with its suggested shorthand nomenclature.
Polyps
Polyps (endometrial and cervical) are classified as absent,
or present (AUB-P), through imaging (radiological or
hysteroscopic) or histology. Although often asymptom-
atic, benign endometrial and endocervical polyps are gen-
erally felt to play some role in AUB (13).
Adenomyosis
Due to varying criteria for diagnosis of adenomyosis, even
after hysterectomy, and radiologically by transvaginal
ultrasound or magnetic resonance imaging, there is a
wide range in reported prevalence (14). As ultrasound is
much more accessible to women worldwide, it is generally
used to identify adenomyosis based on a series of criteria
reflecting the appearance of heterotopic endometrial tis-
sue in the myometrium (10). Magnetic resonance imaging
criteria have also been defined for adenomyosis.
Leiomyoma
Uterine leiomyomas (fibroids) are present in up to 70%
of women of reproductive age (15) many of whom
report significant symptoms (16). In other women, fib-
roids may be asymptomatic or incidental findings. Sur-
gery is the mainstay of clinical management of
symptomatic fibroids. The relationship between AUB
and the presence of fibroids is most convincing in sub-
mucous leiomyomas which distort the endometrial cav-
ity, and thus earn a sub-classification AUB-LSubmucous
(AUB-LSM). This determination is distinct from AUB-
LOther (AUB-LO), which signifies the sonographic pres-
ence of at least one single non-submucous leiomyoma
regardless of size or position.
Table 1. Terminology used to accurately describe AUB symptoms
when initially taking patient history.
Volume Heavy Normal
Regularity Irregular Regular
Frequency Frequent Normal
Duration Prolonged Normal
Other Intermenstrual, Premenstrual, Post-coital,
Unscheduled bleeding (in association with the
use of sex steroids)
ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 619–625
Classification of AUB etiology
Malignancy and hyperplasia
PALM-COEIN is intended to complement and not to
replace the existing FIGO classification for gynecological
malignancy (17,18). Despite a higher incidence of this
condition in post-menopausal women, atypical hyperpla-
sia or frank malignancy (AUB-M) should be considered
in almost all women suffering AUB, particularly those
with a high-risk profile, for example, raised body mass
index, persistent anovulation and older age (6).
Coagulopathy
The prevalence of an intrinsic coagulation disorder, most
commonly von Willebrand disease, in women presenting
with HMB is 12–14% (19). A simple set of screening
questions offers the clinician a rapid way to identify
women at high risk of a hemostatic disorder and to
ration formal testing before classification as AUB-C (20).
By convention, women treated with therapeutic anti-
coagulation are classified under Coagulopathy rather than
Iatrogenic.
Ovulatory disorders
Numerous endocrine disorders can cause a deviation
from normal ovulation and regular, predictable progester-
one withdrawal from the corpus luteum such as hyper-
prolactinemia or polycystic ovarian syndrome. Many are
commonplace at the extremes of reproductive life (21).
AUB ranging from amenorrhea, to light sporadic bleed-
ing, to extreme blood loss requiring transfusion or sur-
gery can result. Disruption to normal ovarian function by
any cause, such as by concomitant medications and
weight changes, should be recorded as AUB-O.
Endometrial dysfunction
AUB-E is presently reserved as a diagnosis of exclusion
among other causes of AUB, and may represent a primary
endometrial disorder. There is evidence linking subclinical
infection with Chlamydia trachomatis to AUB, whereas a
link is lacking for a histopathological diagnosis of endo-
metritis (22,23). Most AUB-E cases appear to be due to
disturbances of metabolic molecular pathways, such as
those involving tissue fibrinolytic activity, prostaglandins,
other inflammatory or vasoactive mediators (24). It is
Light
Absent
anticipated that specific routine tissue assays may become
Infrequent available to test for these in the future. To be confident of
Shortened attributing AUB-E as the primary cause of a woman’s
symptoms, as no validated tests are currently available for
clinical use, all other causes of AUB need to be considered
and then determined less likely to be causative.
621
Classification of AUB etiology M. Madhra et al.

inter-menstrual or post-coital bleeding. She uses no regu-

Iatrogenic
AUB-I comprises the spectrum of uterine bleeding prob-
lems related to intrauterine contraceptive systems, exoge-
nous sex-steroid administration or agents such as
gonadotrophin releasing hormone agonists that directly
affect sex steroid production. This encompasses ‘break-
through bleeding’ experienced outside the expected bleed-
ing from cyclical sex-steroid withdrawal, or that experi-
enced during continuous progestogen use (25). Further
causes classified as AUB-I include those related to changes
in target tissue drug bioavailability. Examples include
anti-epileptic or anti-tuberculous drugs such as carbamaz-
epine or rifampicin, respectively, significantly altering
hepatic enzyme activity.
Not otherwise classified
AUB-N is reserved for those causes that require further
description or delineation in their clinical relevance, such
as uterine aterio-venous malformations. Recognizing that
the knowledge base may change over time, the PALM-
COEIN classification is due for three-yearly revision to
allow it to remain a relevant and useful document, and
during which time causes currently designated AUB-N
may earn appropriate re-allocation.
Worked examples
Case 1
A 37-year-old nulliparous woman presents with regular
(cyclical) HMB associated with severe menstrual pain.
She has abdominal bloating and nocturia. There is no
lar medications other than analgesia during menses, and
is using barrier contraception. She has a normal body
mass index, no previous surgical history, and no
significant family history.
A lower central mass is palpable abdominally and on
bimanual examination. There is no abnormality of the
lower genital tract. An ultrasound scan confirms the
presence of a 10 cm antero-fundal uterine mass but can-
not define its origin nor clearly image the endometrium.
Both ovaries are ultrasonically normal.
At this point, applying the PALM-COEIN classification
to this hypothetical case using the table in Figure 1 would
make most non-structural causes unlikely to be contribu-
tory but would require further investigation of structural
causes. Reader’s individual preferences and resource avail-
ability when managing such a patient may not agree with
that stated in Figure 1 and may possibly alter the order
or nature of subsequent investigations. Under the age of
40, and particularly with regular (cyclic) onset of men-
strual bleeding, the risk of hyperplasia or malignancy is
very low; in this case we feel we would not require histo-
logical confirmation of healthy endometrium. “Coagulop-
athy” in Figure 1 relates to asking the woman the
screening questions referred to earlier, and marking this
as ‘Absent’ implies her responses indicating a low risk of
a hemostatic disorder.
A subsequent MRI scan revealed a normal endometrial
cavity, with a 12 cm transmural lesion with characteristics
consistent with adenomyosis, associated with a pressure
effect on the urinary bladder. Updating the classification
with this further information would identify the likely
cause of the AUB to be adenomyosis, thereby categorizing
the patient as AUB-A (Figure 2).

Abnormal Uterine Bleeding Classification Supporting Evidence

Coagulopathy
Hysteroscopy
Drug History
Examination
Ultrasound
Unknown

Histology
Present

History
Absent

Other
MRI

Polyps (Endometrial) AUB-P X X

Adenomyosis AUB-A X X X
Leiomyoma/Fibroids AUB-L(SubMucosal) X X
AUB-L(Other) X X X
Malignancy/ Hyperplasia AUB-M X X
Coagulopathy AUB-C X X
Ovulatory AUB-O X X
Endometrial AUB-E X X
Iatrogenic AUB-I X X
Not otherwise classified AUB-N X X

Figure 1. Classification after initial history, examination and ultrasound for Case 1.

622 ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 619–625
M. Madhra et al. Classification of AUB etiology

Abnormal Uterine Bleeding Classification Supporting Evidence

Coagulopathy
Hysteroscopy
Drug History
Examination
Ultrasound
Unknown

Histology
Present
Absent

History

Other
MRI
Polyps (Endometrial) AUB-P X X X
Adenomyosis AUB-A X X X X
Leiomyoma/Fibroids AUB-L(SubMucosal) X X X
AUB-L(Other) X X X X
Malignancy/ Hyperplasia AUB-M X X
Coagulopathy AUB-C X X
Ovulatory AUB-O X X
Endometrial AUB-E X X
Iatrogenic AUB-I X X
Not otherwise classified AUB-N X X

Figure 2. Final classification for Case 1.

As her endometrial thickness is greater than we would

Case 2
A 25-year-old woman, with one prior cesarean section,
experiences symptoms of cyclically predictable HMB with
a cycle length of 29 days. A cyclically administered com-
bination estrogen-progestin formulation provides her
contraception and improved the heaviness of her bleed-
ing. Her symptoms changed 8 months ago and she now
suffers heavier withdrawal bleeding, and also developed
the symptom of inter-menstrual bleeding. Prior to hospi-
tal referral, an ultrasound scan was performed revealing a
3 cm sub-serous fibroid (type 5), an endometrial thickness
of 24 mm, and ultrasonically normal ovaries. She has a
raised body mass index of 29, one previous cesarean sec-
tion, but no significant past medical or family history.
There have been no changes to her medications. Abdomi-
nal and bimanual examinations do not detect any abnor-
mality and there is no abnormality of the lower genital
tract.
expect, in particular with combined contraceptive use,
hysteroscopy was arranged. This identified a solitary 2.5
cm fundal endometrial polyp. This was removed, leaving
an endometrial cavity of normal appearance without
evidence of sub-mucous fibroids. Histological examina-
tion subsequently confirmed the polyp to be benign,
making the polyp the most likely cause of this woman’s
bleeding (AUB-P). The completed PALM-COEIN table
for this case is shown in Figure 3, but this case serves to
highlight that clinical judgment is required when multiple
possible causes of AUB are present in the same woman,
as is often the case. Contrast-infusion ultrasound is an
acceptable alternative to hysteroscopy for this case and is
likely to have also identified the endometrial polyp.
However, local guidance, expertise and resource availabil-
ity will also influence this choice, as well as patient
preference and clinical judgment.

Abnormal Uterine Bleeding Classification Supporting Evidence

Coagulopathy
Hysteroscopy
Drug History
Examination
Ultrasound
Unknown

Histology
Present
Absent

History

Other
MRI

Polyps (Endometrial) AUB-P X X X X

Adenomyosis AUB-A X X
Leiomyoma/Fibroids AUB-L(SubMucous) X X X
AUB-L(Other) X X
Malignancy/ Hyperplasia AUB-M X X X
Coagulopathy AUB-C X X
Ovulatory AUB-O X X
Endometrial AUB-E X X
Iatrogenic AUB-I X X
Not otherwise classified AUB-N X X

Figure 3. Final classification for Case 2.

ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 619–625 623
Classification of AUB etiology
Conclusions
The FIGO nomenclature and PALM-COEIN classification
systems simplify and unify terminology, focus treatment
concepts and facilitate clinical and scientific research col-
laboration. Furthermore they provide a scaffold to struc-
ture more effective clinical teaching, and serve to enhance
and clarify communication within and between special-
ties. Reviews highlighting the use of the new nomencla-
ture and the PALM-COEIN system have now been
published in the home journals of several countries, indi-
cating increasing awareness and acceptance (26–28). The
potential ongoing advantage and benefits of the PALM-
COEIN classification over current practice remain to be
fully realized at the present time, but will be in propor-
tion to its adoption.
Acknowledgments
We thank Dr. Marianne Hallamaa, Turku University
Hospital, Turku, Finland, for helpful discussions in man-
uscript preparation and Mrs. Sheila Milne for secretarial
assistance with manuscript preparation.
Funding
No specific funding was obtained in the preparation of
this manuscript.
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