Describes the PALM COEIN classification for abnormal uterine bleeding using the FIGO publications of 2011 and 2018 on the topic.

1. PALM-COEIN classification & its clinical
significance
Dr Mamta Rath Datta,
Chief Consultant,
Department of Obstetrics & Gynaecology,
Tata Main Hospital,
Past President, Jamshedpur ObGy Society,
Vice President , ISOPARB Jamshedpur Chapter
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2. References
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3. PALM-COEIN classification & its clinical significance
• Agenda:
1. What is PALM COEIN Classification?
2. Evolution of AUB classification systems 1 and 2
3. Clinical significance of PALM-COEIN classification (AUB system 2)
1. Terminologies that are no longer used
2. How to use the system in clinical practice
3. Drawbacks of the system
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4. What is PALM COEIN ?
System of classification of abnormal uterine bleeding in non gravid
reproductive age women
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5. EVOLUTION OF PALM COEIN SYSTEM
FIGO recommended 2 AUB systems
1. Terminology & definition( FIGO AUB system 1)
2. Classification of causes ( FIGO AUB system 2 –PALM COIEN )
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6. Why PALM –COIEN system was developed?
• Approximately 3%–30% among reproductive aged women suffer from AUB
• Cause modest to severe disruption of work productivity and QOL
• Increasing maternal morbidity and mortality for pregnant women with pre-existing
AUB related anemia
• Absence of a consensus system for the classification of causes or
potential causes of abnormal uterine bleeding
• Need :
• consistent and universally accepted classification system
• could be used by clinicians, investigators, and even patients to facilitate
communication, clinical care and research
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7. Evolution of AUB classification systems
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8. 2005
• FIGO MDWG (International Federation of Gynecology and Obstetrics)
Menstrual Disorders Working Group was created)
• Experts from the FDA, related professional societies and gynecologic
medical journals, and representatives from the basic, translational, and
clinical sciences assembled
• Aim : To tackle the issues in a systematic fashion
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9. 2007 - AUB System 1
• First publication in Fertility Sterility and Human Reproduction
• Recommended a substantial revision of existing terminologies and
definitions for the description of AUB features
• Redefined the normal parameters of menstrual bleeding
• Abolition of terms (largely of Latin and Greek origin) such as
menorrhagia, metrorrhagia, and dysfunctional uterine bleeding
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10. 2011 – AUB System 2
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11. 11

12. ACUTE VERSUS CHRONIC NONGESTATIONAL
AUB IN THE REPRODUCTIVE YEARS
• Chronic AUB
• bleeding from the uterine corpus that is abnormal in duration, volume,
frequency, and/or regularity
• has been present for the majority of the preceding 6 months
• Acute AUB
• an episode of heavy bleeding that is of sufficient quantity to require
immediate intervention to minimize or prevent further blood loss
• Acute AUB may present in the context of existing chronic AUB or can
occur in the absence of such a background history
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13. 2018 revision
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14. 2011 2018
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15. 2018 modifications
• Intermenstrual bleeding added
• A practical definition for irregular menstrual bleeding
• includes 75th percentile, effectively excluding the occasional long or short cycles experienced by
many women
• The available evidence suggests the normal range (shortest to longest) varies with age:
• 18–25 y of age, ≤9 d; 26–41 y, ≤7 d; and for 42–45 y, ≤9 d (Harlow et al., 2000)
• Definition of HMB proposed by the NICE has been adopted
• “Excessive menstrual blood loss which interferes with a woman’s physical, social, emotional,
and/or material quality of life”.
• Frequency parameter has been updated from ‘Infrequent (<24d) to frequent(<24d) &
irregular to > 8 -10 d
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16. Revision of terminologies and definitions of
symptoms of abnormal uterine bleeding
Revised AUB System 1 Summary of changes
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17. defined by visually objective structural criteria unrelated to structural anomalies
FIGO AUB System 2 -2018
FIGO AUB System 2 -2011
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18. Revision of classification of underlying causes of AUB (PALM-COEIN)
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19. AUB- A
Adenomyosis diagnostic criteriaproposed by the MUSA (Morphological Uterus Sonographic
Assessment group)
Presence of two or more of these criteria are highly associated with a diagnosis
of adenomyosis
• 8 TVUS criteria
• A- asymmetrical myometrial thickening
• B - myometrial cysts
• C - hyperechoic islands
• D - fan shaped shadowing
• E - echogenic subendometrial lines and buds
• F - translesional vascularity
• G - irregular junctional zone
• H - interrupted junctional zone (3D USG best),
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20. Leiomyoma
The leiomyoma category (L) is subdivided into patients with at least one submucous
myoma (LSM) and those with myomas that do not impact the endometrial cavity (Lo).
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21. Leiomyoma subclassification system,
essentially unchanged since the initial
2011 publication
• Distinguishing between type 0 and 1 / type 6 and 7 leiomyoma
• comparing the Stalk diameter to the mean diameter of the leiomyoma
• Types 0 and 7 now comprise leiomyomas that have a stalk diameter that is 10% or
less than the mean diameter of the leiomyoma
• Distinguishing between a type 2 and 3 leiomyoma
• based upon the lowest filling pressure that allows visualization of the
endometrial cavity
• Distinguishing between type 4 and 5 leiomyomas
• based upon observation of distortion of the serosa ( type 5 ) as determined by
ultrasonography or MRI
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22. Additional guidance for investigators using the
FIGO subclassification system for leiomyomas
• A minimal data set for describing leiomyomas include
• an estimate of total uterine volume based on imaging(TAS/TVS/MRI)
• as well as an estimate of the number of leiomyomas (1, 2, 3, 4, or > 4)
• If such imaging is not available the minimum data set should include an
estimate of uterine size on clinical examination as equivalent to a gravid
uterus of “X” weeks
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23. Contd.
• When transvaginal ultrasonography or MRI are available, RECORD
• location (anterior, posterior, left, right, or center)
• estimated volume of up to 4 individual leiomyomas
• location in the vertical plane should be described; upper half, lower half, or both
• If >4 are present, the volume of the largest leiomyoma should be recorded,
as a minimum
• If the endometrium is visualized, then the relationship with the endometrium
should be described using the FIGO classification system
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24. Clinical application
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27. AUB diagnostic matrix
• not been completely evaluated - “?” column
• no evidence of the abnormality -N column
• assessment positive - Y column
• Eg: The patient has the symptom of HMB,
• assessment revealed a subserosal leiomyoma
- Lo.
• patient had a +ve historical screening result
for coagulopathy and hematological
assessments for coagulation disorders are not
yet available. Consequently, the “C” and “E”
rows remain in the “?” category.
• The hematological assessment shows no
evidence of coagulopathy, so the diagnosis of
a primary disorder of endometrial hemostasis
is made.
• The C row can now be assigned an “N” while
the E category can be checked as “Y” 27

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30. Investigative algorithms for patients with chronic AUB
during the reproductive years
(A) Initial investigation
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31. Investigative algorithms for patients with chronic
AUB during the reproductive years.
B) A pragmatic guide to uterine
assessment
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32. RECOMMENDATIONS FOR CLINICAL INVESTIGATION
• General assessment – exclude pregnancy,check anaemia
• Determination of ovulatory status – EB not essential
• Screening for systemic disorders of hemostasis – history +tests
• Evaluation of the endometrium –TVS, ES for at risk women
• Evaluation of the structure of the endometrial cavity
• TVS,Sonohysterography,hysteroscopy ,MRI
• Myometrial assessment
• TVS,TAS,MRI
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33. Screening for systemic disorders of hemostasis
b This structured history-based instrument is 90% sensitive for the presence of a coagulopathy in women with the
symptom of heavy menstrual bleeding 33

34. Summary
• PALM COIEN system provides classification of causes of AUB
• Definitions and classification of causes of AUB have been refined
• TVS, Sonohysterography – good imaging modalities
• MRI is not a must
• EB for at risk patients
• Office hysteroscopy does provide advantages
• Leiomyoma and adenomyosis have been subclassified
• Notation and diagnostic matrix are useful tools
• More reviews are expected with subclassification for the other entities
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35. Future reviews
• The FIGO MDC is currently working on subclassification systems for
adenomyosis and endometrial polyps
• will be published soon in preliminary form with planned validation studies to
follow
• The polyp system is being developed
• There is consideration for subclassification systems for AUB-C, -O, -E,
and –I, but these initiatives are still in the very early stages of
development
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36. Drawbacks of the PALM COEIN system
• Deals with only non gestational AUB
• There are other causes of genital tract bleeding and urinary tract or
gastrointestinal bleeding that do not come from the uterus
• These can usually be identified by an appropriate case history and physical
examination
• Subclassification systems for other causes are yet to be developed –
much work has to be done
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37. Conclusion
PALM COIEN (FIGO AUB Systems)
• designed to facilitate both basic science and clinical investigation, as
well as the practical, rational, and consistent application of medical
and surgical therapy
• current revisions are designed to improve the utility of these systems
for research, education, and clinical care
• Clinicians, educators, and investigators are encouraged to use the
notation and matrix concept to guide the evaluation of women
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38. Thank you
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