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The Flexible FIGO Classification Concept for Underlying Causes of Abnormal

Uterine Bleeding

Article in Seminars in Reproductive Medicine · September 2011

DOI: 10.1055/s-0031-1287663 · Source: PubMed

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The Flexible FIGO Classification Concept for
Underlying Causes of Abnormal Uterine
Bleeding
Malcolm G. Munro, M.D.,1 Hilary O.D. Critchley, M.D.,2 and Ian S. Fraser, M.D.3

ABSTRACT

To this juncture, clinical management, teaching of medical providers, and the

design and interpretation of clinical trials has been hampered by the absence of a consensus

Downloaded by: University of California. Copyrighted material.

system for the classification of causes or potential causes of abnormal uterine bleeding
(AUB). Indeed, more than one possible mechanism may be involved in the development of
the bleeding symptoms experienced by a given individual. A consistent and universally
accepted classification system could be used by clinicians, investigators, and even patients to
facilitate communication, clinical care, and research. The ‘‘PALM-COEIN’’ AUB classi-
fication system is the result of several years of collaboration among a spectrum of
individuals involved in clinical medicine, teaching, and the basic and clinical sciences
and is proposed as a tool that meets the requirements just described but one that is capable
of adaptation to our evolving insight into the mechanisms involved in the genesis of AUB.
This system has been accepted by the International Federation of Gynecology and
Obstetrics (FIGO) as a suitable system for widespread international use.

KEYWORDS: Menstrual disorders, classification

BACKGROUND The investigative power of tools like meta-

Confusing and poorly defined terminologies have re-
cently been recognized as important contributing factors
to a misleading international literature around the in-
vestigation and management of abnormal uterine bleed-
ing (AUB)1–4 in nonpregnant women. The situation has
been exacerbated by a lack of standardized methods for
investigation and for categorization of potential under-
lying causes. This in turn has hampered the ability of
investigators to study and compare defined categories of
women with AUB.
analysis has been considerably compromised by this
lack of consistent definitions and by variable inves-
tigative processes. Reviews of past literature demon-
strate the uncertainty of characterizing studied clinical
populations.1 A widely accepted system of terminol-
ogies and definitions3,4 needs to be supplemented by
an accepted and logical approach to classification of
the range of underlying causes of AUB. This should
be an essential step in the evidence-based application
of clinical and laboratory-based research through into

1
Department of Obstetrics and Gynecology, David Geffen School of
Medicine, University of California, Los Angeles, California; 2MRC
Centre for Reproductive Health, The University of Edinburgh, The
Queen’s Medical Research Institute, Edinburgh, United Kingdom;
3
Department of Obstetrics and Gynaecology, University of Sydney,
Camperdown, Australia.
Address for correspondence and reprint requests: Malcolm G.
Munro, M.D., Department of Obstetrics and Gynecology, David
Geffen School of Medicine at UCLA, Kaiser Permanente, Southern
California, 4900 Sunset Boulevard, Station 3-B, Los Angeles, CA
90027 (e-mail: mgmunro@ucla.edu; mgmunro@aol.com).
An International Perspective on Abnormal Uterine Bleeding; Guest
Editors, Ian S. Fraser, M.D., Hilary O.D. Critchley, M.D., and
Malcolm G. Munro, M.D.
Semin Reprod Med 2011;29:391–399. Copyright # 2011 by
Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York,
NY 10001, USA. Tel: +1(212) 584-4662.
DOI: http://dx.doi.org/10.1055/s-0031-1287663.
ISSN 1526-8004.
391
392 SEMINARS IN REPRODUCTIVE MEDICINE/VOLUME 29, NUMBER 5
clinical practice, now recognized as sound ‘‘transla-
tional research.’’
Such a classification system inevitably becomes
quite complex because of the high frequency of coex-
istence of more than one potential cause of AUB in any
given individual and the additional fact that lesions
capable of causing AUB may often be asymptomatic.
Any classification system for causes of AUB must con-
sider these circumstances.
Several nomenclature and classification systems
have been developed in the past for different gynecologic
pathologies, with varying degrees of success. The most
successful and best recognized is the FIGO (International
Federation of Gynecology and Obstetrics) classification
and staging system for gynecologic malignancies.5 This
system is practical, universally accepted, and a valuable
aid to clinicians and investigators in the guidance of
research, treatment, and prognostic assessment. This is
a flexible system that is regularly updated on evidence-
based principles. By contrast, the staging system for
endometriosis devised by the American Society for
Reproductive Medicine has been less successful.6 This
system requires detailed laparoscopic visual assessment
of the anatomical extent of disease and adhesions.
Unfortunately, its clinical value is hampered by the
need for surgical assessment, by inherent complexity,
and by the lack of any consistent relationship between
the visual staging of disease and symptoms, appropriate
treatment, and clinical outcomes.
A third classification system that has had mixed
reviews is the Pelvic Organ Prolapse Quantitative assess-
ment of pelvic floor defects. This system incorporates a
level of complexity that makes it difficult for many
clinicians to use in practice, but it does appear to have
clinical relevance.7
Clinical experience with these other classification
systems indicates it is important to develop a practicable
AUB nomenclature and classification system that fits
research and educational requirements, as well as clinical
needs.
This article proposes a new system for classifica-
tion of AUB with contributions from an international
group of clinician-investigators from 6 continents and
>17 countries.8,9 The definitive publication of this
FIGO classification of AUB with detailed examples
has appeared elsewhere.9 A FIGO system for symptom
nomenclature was also developed by this group and has
also been described in previous publications,3,4 and in
this volume.10 Presentation of the classification concepts
at a major international symposium with active audience
feedback strongly supported the concepts.11
DEVELOPMENT PROCESS SUMMARY
This multistage development process was in part attrib-
utable to the methodology described in Critchley et al and
2011
Munro et al in this issue of Seminars. The goal of our panel
was to develop a pragmatic classification system that could
be used worldwide by clinicians, educators, and clinical
investigators involved with the care of women with AUB
in the reproductive years. At the in-person meeting in
Washington, D.C., in 2005, the components of such a
system were identified. Following this, the Scientific
Committee of the group formulated a draft system that
was distributed to the members of the entire group for
comment and approval. Contentious issues were further
addressed by another short Delphi-type questionnaire.
The resulting modified system was distributed for com-
ments and then discussed at a face-to-face meeting held in
association with the 2009 FIGO World Congress in Cape
Town, South Africa, and presented to a group of 800
attendees, many of whom were provided electronic key-
pads to provide anonymous feedback as discussed else-
where in this issue. A preliminary version of the system
was included in the book Abnormal Uterine Bleeding.8
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Throughout, the concept was the creation of a living
document together with a system of periodic analysis and
appropriate modification and revision.
‘‘PALM-COEIN’’ Classification System
The classification system (Fig. 1) is divided into nine
basic categories arranged according to the acronym
PALM-COEIN [pahm—koin]: Polyp, Adenomyosis,
Leiomyoma, Malignancy and hyperplasia, Coagulop-
athy, Ovulatory Disorders, Endometrium, Iatrogenic,
and Not Yet Classified. The components of the
‘‘PALM’’ group are definable ‘‘structural’’ entities that
are measurable visually, using imaging techniques, and/
or with histopathology, whereas the COEI group is
related to entities not defined by imaging or histopa-
thology (‘‘nonstructural’’). The categories were designed
to facilitate the current or subsequent development of
classification subsystems. The primary classification sys-
tem would typically be used at a primary care level; the
subclassifications would be most relevant at the specialist
and research levels.
The system was constructed recognizing that any
patient could have one or a spectrum of entities that
could cause or contribute to AUB and that definable
entities such as adenomyosis, leiomyomas, and endocer-
vical or endometrial polyps may frequently be asympto-
matic and therefore not a contributor to the presenting
symptoms.
Polyps (AUB-P)
For the basic classification system, polyps are categorized
as either present or absent as defined by one or a
combination of ultrasound and hysteroscopic imaging
with or without histopathology. Although there is no
distinction regarding the size or number of polyps, it is
 CLASSIFICATION CONCEPT FOR ABNORMAL UTERINE BLEEDING/MUNRO ET AL 393

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Figure 1 Basic classification system. The basic system comprises four categories that are defined by visually objective
structural criteria (Polyp, Adenomyosis, Leiomyoma, and Malignancy or hyperplasia [PALM]); four (COEI) that are unrelated to
structural anomalies; and one (N) reserved for entities that are not yet classified. The leiomyoma category (L) is subdivided into
those patients who have at least one submucosal myoma (Lsm) and those with myomas that do not impact the endometrial cavity
(Lo). (Reproduced with permission granted by FIGO from Munro et al. The FIGO classification system (PALM-COEIN) for causes of
abnormal uterine bleeding in non gravid women of reproductive age. Int J Gynecol Obstet 2011;113:3–13.9)

probably important to exclude polypoid-appearing en-
dometrium from this category, for such an appearance
may well be a variant of normal.
The ‘‘P’’ category allows for the development of a
subclassification for clinical or investigative use that may
include a combination of variables including polyp
dimensions, location, number, morphology, and histol-
ogy.12 Until that time, individual clinicians or investi-
gators could include such data, if appropriate, in their
own data collection systems.
Adenomyosis (AUB-A)
The relationship of adenomyosis to the genesis of AUB is
unclear, lending strength to the notion that extensive
additional research is required.13 The criteria for diagnos-
ing adenomyosis have traditionally been based on histo-
pathological evaluation of the depth of ‘‘endometrial’’
tissue beneath the endometrial–myometrial interface as
determined at hysterectomy. The histopathological cri-
teria vary substantially,14 and the requirement to diagnose
adenomyosis solely from specimens obtained at hysterec-
tomy is an approach that has limited value in a clinical
classification system. Consequently, and because there
exist both sonographic15 and magnetic resonance imaging
(MRI)-based diagnostic criteria,16,17 adenomyosis has
been provided a place in the classification system.
Recognizing the limited access of women to MRI
in the world community, it is proposed that sonographic
criteria for adenomyosis comprise the minimum require-
ments for assigning an individual the diagnoses of
adenomyosis in the PALM-COEIN classification sys-
tem.18 The sonographic appearance of adenomyosis is, in
part, related to the absolute presence of heterotopic
endometrial tissue in the myometrium and in part due
to the related myometrial hypertrophy. Issues that must
be addressed in such an imaging-based system include
the minimum sonographic criteria for diagnosis, the
distinctions between diffuse and focal (or multifocal)
disease, and whether or not a metric indicating volume
or extent of the disease should or can be included at this
time.
As with polyps and leiomyomas, adenomyosis is a
disorder that should have its own subclassification sys-
tem, and it is clear there should be an initiative to
standardize methods of both imaging and histopatho-
logical diagnosis.
Leiomyomas (AUB-L)
Benign fibromuscular tumors of the myometrium are
known by several names including leiomyoma, its ab-
breviated form, ‘‘myoma,’’ and the frequently used term
‘‘fibroid.’’ Leiomyoma is generally accepted as the more
accurate term and was selected for use in this system.
The spectrum of size and location (subendometrial,
intramural, subserosal, and combinations of same) and
the variable number of lesions in a given uterus requires
that leiomyomas be afforded a separate categorization in
the system. Like polyps and adenomyosis, many, if not
394 SEMINARS IN REPRODUCTIVE MEDICINE/VOLUME 29, NUMBER 5 2011

most, leiomyomas are asymptomatic, and frequently
their presence is not the cause of AUB in a given woman.
As a result of the above, several issues were
considered when constructing this classification system
including the following: (1) the relationship of the
leiomyoma to the endometrium and the serosa; (2) the
uterine location of the leiomyoma (upper segment, lower
segment: cervix, anterior, posterior, lateral); (3) the size
of the lesions; (4) the number of lesions; and (5) existing
leiomyoma classification systems.19,20
For leiomyomas, both secondary and tertiary
classification systems are submitted that have potential
clinical applications but that also should be useful for
clinical investigation (Fig. 2).
The primary classification system reflects only the
presence or absence of one or more leiomyomas, regard-
less of the location, number, and size. It is proposed that
the criteria for determining the presence of leiomyomas
would require only sonographic examination confirming
that one or more myomas are present.
In the secondary system, the clinician is required
to distinguish myomas that involve the endometrial
cavity (submucosal, or ‘‘SM’’) from others (O, because
it is generally considered that such (SM) lesions are
those that most likely contribute to the genesis of AUB.
The root of the tertiary classification system is a
design for subendometrial or submucosal leiomyomas
originally submitted by Wamsteker et al20 that was
subsequently adopted by the European Society for Hu-
man Reproduction and Embryology. This system has
been in use >15 years by numerous investigators world-
wide, and it was thought important to consider it when
designing the present system. As a result, the PALM-
COEIN system adds categorization of intramural and

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Figure 2 Classification system including tertiary leiomyoma subsystem. The system that includes the tertiary classification of
leiomyomas categorizes the submucosal (sm) group according to the Wamsteker system20 and adds categorizations for the
intramural, subserosal, and transmural lesions. Intracavitary lesions are attached to the endometrium by a narrow stalk and are
classified as type 0, whereas types 1 and 2 require that a portion of the lesion be intramural, with type 1 50% and type 2 >50%.
The type 3 lesions are totally extracavitary but abut the endometrium. Type 4 lesions are intramural leiomyomas that are entirely
within the myometrium with no extension to the endometrial surface or to the serosa. Subserosal (types 5–7) myomas represent
the mirror image of the submucosal myomas with type 5 >50% intramural; type 6, 50% intramural, and type 7 attached to the
serosa by a stalk. The classification of transmural lesions are categorized by their relationship both to the endometrial and serosal
surfaces. The endometrial relationship would be noted first; the serosal relationship would be second (e.g., 2–3). An additional
category, type 8, is reserved for myomas that do not relate to the myometrium at all and would include cervical lesions, those that
exist in the round or broad ligaments without direct attachment to the uterus, and other so-called parasitic lesions. (Reproduced
with permission granted by FIGO from Munro et al. The FIGO classification system (PALM-COEIN) for causes of abnormal
uterine bleeding in non gravid women of reproductive age. Int J Gynecol Obstet 2011;113:3–13.9)
 CLASSIFICATION CONCEPT FOR ABNORMAL UTERINE BLEEDING/MUNRO ET AL
subserosal myomas as well as a category that includes
such types as the parasitic lesions that become detached
from the uterus after establishing blood supply from
another source. When a myoma abuts or distorts both
the endometrium and serosa, it is categorized first by the
submucosal classification, then by the subserosal loca-
tion, with these two numbers separated by a hyphen. It is
suspected that this tertiary classification will be most
useful for clinical investigators, but it is possible that
clinicians, particularly those who perform resectoscopic
myomectomy, would find immediate clinical utility.
Considered but not yet included is the size of the
uterus in weeks of gestation and/or the single longest
measurement, the location (e.g., fundus, lower segment,
cervix, etc.), and the estimated number of leiomyomas.
Clinicians and investigators would be free to include
such data in their recording systems and forms. For
example, an investigator could choose to categorize by a
single leiomyoma or could provide detailed classification
for each myoma identified in the uterus including
documentation of size by mean diameter or volume.
Malignancy and Premalignant Conditions
(AUB-M)
Although relatively uncommon, atypical hyperplasia and
malignancy are important potential causes of or findings
associated with AUB, and they must be considered in
virtually any woman in the reproductive years. This
classification system is not designed to replace those of
the World Health Organization (WHO) and FIGO for
categorizing endometrial hyperplasia and neoplasia.21,22
Consequently, when investigation of women in the
reproductive years with AUB identifies a premalignant
hyperplastic or malignant process, they would be classi-
fied as AUB-M and then ‘‘subclassified’’ by the appro-
priate WHO or FIGO system.
Coagulopathy (Systemic Disorders of
Hemostasis) (AUB-C)
The term coagulopathy is used to encompass the spectrum
of systemic disorders of hemostasis that may be associ-
ated with AUB. High-quality evidence demonstrates
that 13% of women with HMB have biochemically
detectable systemic disorders of hemostasis, most often
von Willebrand disease.23 However, it is not clear how
often these abnormalities cause or contribute to the
genesis of AUB and how often they are asymptomatic
or minimally symptomatic biochemical abnormalities.
Nevertheless, it seems important to consider these dis-
orders in part because they likely do contribute to some
cases of AUB and because evidence suggests that rela-
tively few clinicians consider systemic disorders of hemo-
stasis in the differential diagnosis of women with
HMB.24
395
For several reproductive-age women, chronic an-
ticoagulation is a necessary and life-preserving interven-
tion but one that may result in the undesirable side effect
of AUB, most often HMB. Although such AUB could
justifiably be considered to be iatrogenic and classified
accordingly, the group determined it would be more
appropriate to classify such women as having a coagul-
opathy (AUB/HMB-C).
Ovulatory Disorders (AUB-O)
Ovulatory dysfunction can contribute to the genesis of
AUB, generally manifesting in some combination of
unpredictable timing of bleeding and a variable amount
of flow (AUB), which in some cases results in HMB.25,26
For many regions, particularly, but not only, in the United
States, ovulatory disorders comprised most, if not the
entirety of cases encompassed by the now-discarded term
dysfunctional uterine bleeding. It is recognized that disor-
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ders of ovulation may manifest in a spectrum of menstrual
abnormalities ranging from amenorrhea, to extremely
light and infrequent bleeding, to episodes of unpredictable
and extremely HMB that require medical or surgical
intervention. Some of these manifestations relate to the
absence of predictable cyclical production of progesterone
from the corpus luteum in the ovary every 22 to 35 days,
but in the late reproductive years many relate to unusual
‘‘disturbed’’ ovulations that have been labeled ‘‘luteal out-
of-phase’’ (LOOP) events.25
Although most ovulatory disorders elude a defined
etiology, many can be traced to endocrinopathies (e.g.,
polycystic ovarian syndrome, hypothyroidism, hyperpro-
lactinemia, mental stress, obesity, anorexia, weight loss,
or extreme exercise such as that associated with elite
athletic training). In some instances, the disorder may be
iatrogenic, caused by gonadal steroids or drugs that have
an impact on dopamine metabolism such as phenothia-
zines and tricyclic antidepressants. It is also well recog-
nized that otherwise unexplained ovulatory disorders
frequently occur at the extremes of reproductive age:
menarche and the climacteric, before menopause.
Endometrial Causes (AUB-E)
When AUB occurs in the context of predictable and
cyclical ovulatory cycles, particularly when no other
definable causes are identified, the mechanism is likely
a primary disorder residing in the endometrium.27,28 If
the symptom is HMB, a primary disorder of mechanisms
regulating local endometrial ‘‘hemostasis’’ itself may exist.
Indeed, high-quality evidence has demonstrated defi-
ciencies in local production of vasoconstrictors such as
endothelin-1 and prostaglandin F2a and/or accelerated
lysis of endometrial clot because of excessive production
of plasminogen activator29 and increased local produc-
tion of substances that promote vasodilation such as
396 SEMINARS IN REPRODUCTIVE MEDICINE/VOLUME 29, NUMBER 5
prostaglandin E2 and prostacyclin (I2).30,31 Despite this
evidence, some of which has been available >20 years,
tests measuring such abnormalities are not currently
available to clinicians.
There may be other primary endometrial disorders
that do not manifest in HMB per se but may, for
example, cause intermenstrual (IMB) or prolonged
bleeding. Prolonged bleeding may be a manifestation of
deficiencies in the molecular mechanisms of endometrial
repair. Such disorders may be secondary to endometrial
inflammation or infection, to abnormalities in the local
inflammatory response, or to aberrations in endometrial
vasculogenesis. However, the role of infection and other
local inflammatory disorders in the genesis of AUB is not
well defined and is sometimes confounded by the normal
presence of inflammatory cells in the endometrium.
Retrospective evaluation of women with chronic endo-
metritis has failed to demonstrate a consistent relation-
ship between the histopathological diagnosis and the
presence of AUB,32,33 but there are data suggesting a
relationship between otherwise subclinical infection with
Chlamydia trachomatis and AUB.34
As a result of these issues, and for the present, the
diagnosis of endometrial disorders should likely be one
determined by exclusion of other identifiable abnormal-
ities in women of reproductive years who appear to have
normal ovulatory function.
Iatrogenic (AUB-I)
Medical interventions or devices can cause or contribute
to AUB (AUB-I) via several mechanisms. These include
medicated or inert intrauterine systems and pharmaco-
logical agents that directly impact the endometrium,
interfere with blood coagulation mechanisms, or influ-
ence the systemic control of ovulation.
Unscheduled endometrial bleeding that occurs
during the use of gonadal steroid therapy is termed
breakthrough bleeding, or BTB, the major component of
the AUB-I classification. Systemically administered go-
nadal steroids, including estrogens, progestins, and an-
drogens, administered alone or in combination, have an
impact on the control of ovarian steroidogenesis via
effects on the hypothalamus, pituitary, and/or ovary itself,
and they also exert a direct effect on the endometrium.
These features of gonadal steroids are exploited in the
form of hormonal contraceptive agents, including oral,
transdermal/vaginal, and injectable progestin or estro-
gen-progestin compounds. When estrogen-progestin
agents are administered cyclically, scheduled uterine
bleeding generally occurs in conjunction with the peri-
odic withdrawal of the steroidal agents. However, when
unscheduled bleeding occurs in the context of cyclical
administration, the woman may be considered to have
BTB and be categorized as AUB-I. Combined estrogen-
progestin preparations may be administered continuously
2011
(in the case of progestin-only agents such as depome-
droxyprogesterone acetate, continuous administration is
the norm) with the goal of achieving amenorrhea. In such
instances, any bleeding may be considered to be unsched-
uled and therefore considered to be AUB-I.
It is likely that many, if not most, episodes of
BTB are related to reduced circulating gonadal steroid
levels secondary to compliance issues such as missed,
delayed, or erratic use of pills, transdermal patches, or
vaginal rings. With the resulting reduced suppression of
follicle-stimulating hormone production, and subse-
quent development of follicles that produce endogenous
estradiol, additional and irregular stimulation of the
endometrium may result in BTB. In one pooled study
of seven trials, 35% of women with large follicles had
BTB.35 Other potential causes of reduced circulating
levels of circulating estrogens and progestins include the
use of agents such as anticonvulsants and antibiotics such
as rifampin and griseofulvin.36 Cigarette smoking can
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reduce levels of contraceptive steroids because of en-
hanced hepatic metabolism, an observation that may
explain the relatively high incidence of BTB in smok-
ers.37 In users of long-acting progestogen methods, such
as subdermal implants, BTB is typically associated with
the development of superficial, thin-walled and fragile
endometrial vessels.38
Up to 55% of women using the levonorgestrel-
releasing intrauterine system (LNG-IUS) can be expected
to experience BTB in the first 6 months of therapy.39
After that time, the incidence of this side effect reduces to
15 to 20%, and 20% become amenorrheic by the end
of the second year, rising to 50% by year 5.
Systemic agents that interfere with dopamine
metabolism have the potential to cause AUB secondary
to disorders of ovulation. Tricyclic antidepressants (e.g.,
amitriptyline, nortriptyline) and phenothiazines are two
of a group of drug types that have an impact on
dopamine metabolism by reducing serotonin uptake. It
is thought that the resulting reduced inhibition of
prolactin release causes prolactin-related disruption in
the hypothalamic-pituitary-ovarian axis and consequent
disorders of ovulation, including anovulation. Conse-
quently, any agent that impacts serotonin uptake is a
candidate for causing ovulatory dysfunction and result-
ing amenorrhea or irregular uterine bleeding.
Finally, HMB is a relatively common conse-
quence of the use of anticoagulant drugs such as war-
farin, heparin, and low molecular weight heparin. The
mechanism appears to be straightforward, as in such
instances there is impairment of the formation of an
adequate ‘‘plug’’ or clot within the vascular lumen. It was
apparent that women using such agents essentially have a
systemic disorder of hemostasis that is in many ways
similar in manifestation and management to those
women with inherited disorders of hemostasis. Conse-
quently, by convention, the group determined that this
 CLASSIFICATION CONCEPT FOR ABNORMAL UTERINE BLEEDING/MUNRO ET AL
type of iatrogenic AUB should be placed in the AUB-C
category.
Not Classified (AUB-N)
Several uterine entities may or may not contribute to or
cause AUB in a given individual for they have been
either poorly defined, inadequately examined, or both,
and include chronic endometritis, arteriovenous malfor-
mations, and myometrial hypertrophy. In addition, other
disorders may exist, not yet identified, that would be
Figure 3 Notation. (A) For each case, the presence or
absence of each criteria is noted using ‘‘0’’ if absent, ‘‘1’’ if
present, and ‘‘?’’ if not yet assessed. Each of these cases has
one abnormality identified; from the top at least one sub-
mucosal leiomyoma, L1SM; adenomyosis, in this instance
both focal and diffuse (A); endometrial polyps (P), and an
absence of any abnormality leaving endometrial causes (E) as
a diagnosis of exclusion. (B) Each of these cases has more
than one positive category. In the top panel, there is a
submucosal leiomyoma (LSM), as well as atypical endometrial
hyperplasia (M) diagnosed by endometrial sampling. The
second case is found to have both endometrial polyps (P)
and adenomyosis (A). The next case is characterized by both
a subserosal leiomyoma (L0) and endometrial polyps (P); the
bottom case has a subserosal leiomyoma (L0) as well as a
coagulopathy determined by a positive screening test and
subsequent biochemical confirmation of von Willebrand dis-
ease. (Reproduced with permission granted by FIGO from
Munro et al. The FIGO classification system (PALM-COEIN)
for causes of abnormal uterine bleeding in non gravid women
of reproductive age. Int J Gynecol Obstet 2011;113:3–13.9)
397
defined only by biochemical or molecular biological
assays. Collectively, these entities (or future entities)
have been placed in a category termed ‘‘Not Classified.’’
As further evidence becomes available, they may be
allocated a separate category or be placed into one or
the existing categories in the system.
CLINICAL APPLICATION
Women with AUB may have none, one, or multiple
identifiable factors that may contribute to the genesis of
the abnormal bleeding. There may also be pathology,
such as a subserosal leiomyoma, that is present but which
is thought not to be a contributor to AUB. Conse-
quently, the investigation of the woman with AUB must
be undertaken in as diligent and comprehensive a fashion
as is practicable given the clinical situation and the
available resources. This suggested approach is discussed
in Munro et al in this issue.40
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Following appropriate investigation an individual
may be found to have one or multiple potential causes of
or contributors to their AUB symptoms. Consequently,
the system has been designed to allow categorization and
notation in a fashion that allows for this circumstance. It
is recognized that this increased level of complexity will
be of most value to specialists or researchers.
The formal approach follows the example of the
WHO TNM staging of malignant tumors, with each
component addressed for all patients (Fig. 3). For
example, if an individual was determined to have a
disorder of ovulation, a type 2 leiomyoma, and no other
abnormalities, in the context of a complete evaluation
the woman would be categorized as follows: ‘‘AUB P0-
A0-Lsm1-M0-C0-O1-E0-I0-N0.’’ Recognizing that in
clinical practice, the full notation might be considered
cumbersome, an abbreviation option has been developed.
The patient previously described would be noted ‘‘AUB-
Lsm; O.’’
CONCLUSIONS
A multinational group of clinician-investigators with
broad experience in the investigation of AUB has agreed
on a system of classification that should facilitate multi-
institutional investigation into the epidemiology, etiol-
ogy, and treatment of women with acute and chronic
AUB. The system should also foster meta-analysis of
clinical trials that are appropriately designed and re-
ported. It is also recognized that the system will require
periodic modification and occasional substantial revision
depending on advances in knowledge and technology,
and increasing availability of investigative options across
geographic regions. Consequently, a scheduled system-
atic review of the system is encouraged on a regular basis
by a permanent committee of an international organ-
ization such as FIGO, which has already endorsed the
398 SEMINARS IN REPRODUCTIVE MEDICINE/VOLUME 29, NUMBER 5
establishment of a suitable ongoing Menstrual Disorders
Study Group.
When an acceptable system has been agreed on,
journal editors and editorial boards will be encouraged to
request that materials, methods, and reporting sections
of manuscripts dealing with AUB be designed accord-
ingly.
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