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Palm coein clasification
The document discusses the new FIGO classification system for abnormal uterine bleeding (AUB). It introduces the PALM-COEIN system which provides a standardized terminology and classification. The system categorizes AUB into structural causes (polyps, adenomyosis, leiomyoma, malignancy) and non-structural causes (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not yet classified). It provides guidelines for evaluation and outlines the notation system for documenting multiple contributing factors to a patient's AUB. The standardized classification aims to improve management of AUB internationally through a unified terminology and focus on appropriate treatment concepts.
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Palm coein clasification
- 1. Abnormal Uterine Bleeding: NewFIGO Classification MAHMOUD MELEIS, MD
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- 4. Waves of change In 2006, FIGO identified as the appropriate body to provide supervision & international credibility to the ongoing evaluation of new terminology In 2009, FIGO Menstrual Disorders Group was formed. FIGO World Congress of Gynecology and Obstetrics , accepted the new terminology. In 2011, the PALM-COEIN Classification System created. In 2012, PALM-COEIN system was endorsed by ACOG
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- 7. AUB Validated Terminology AUB: Abnormal uterine bleeding Umbrella term for both regular and irregular bleeding HMB: Heavy menstrual bleeding Excessive menstrual bleeding IMB: Inter-menstrual bleeding Occurs between clearly defined cyclic and predictable menses Acute: Heavy bleeding that is of sufficient quantity to require immediate intervention to prevent further blood loss Chronic: Heavy bleeding that is of sufficient quantity to require immediate intervention to prevent further blood loss AUB Acute AUB IMB HMB Chronic AUB IMB HMB
- 8. Chronic AUB; Bleeding from the uterine corpus that is abnormal in volume, regularity and/or timing and has been present for the majority the past 6 months
- 9. Menstrual parameters Frequency 24-38 day Frequent Normal Infrequent Regularity <20D / 12 m Absent Regular Irregular Duration 4.5-8 days Prolonged Normal Shortened Volume 5-80 ml Heavy Normal Light Suggested “normal limits” for uterine bleeding in the mid-reproductive years Munro MG. Rev Endocr Metab Disorder (2012) 13: 225-234
- 11. Structural Abnormalities P– Polyps – scored as Present or Absent A – Adenomyosis - scored as Present or Absent L – Leiomyoma Primary level – Present or Absent Secondary level – Distinguish between submucosal (SM) & others (O) Tertiary level – Detail location/size of uterine fibroids M – Malignancy & hyperplasia
- 12. AUB-P; Polyps (8-35%) Diagnosis: US, SIS, hysteroscopy Further sub-classification: Dimensions, location & number Pre-menopausal polyps: 64 – 88% have symptoms Present with HMB, AUB, IMB, or post-coital bleeding Symptoms do NOT correlate with number, diameter & site Post-menopausal polyps: Most are symptom free Cause for 21-28% of PMP bleeding Associated with cervical polyps in 24-27% Incidence of carcinoma varies between 0–4.8%
- 14. AUB-A; Adenomyosis Ectopicendometrial glands & stroma within the myometrium Hypertrophy & hyperplasia of surrounding myometrium Usual presentation: HMB, uterine enlargement, & dysmenorrhea
- 15. Adenomyosis Linear Striations 80% PPV 71%Accurate Heterogeneous myometrium 81% PPV 69% Accurate
- 16. Sonographic findings of Adenomyosis Dueholmet al. Best Pract Res Clin Obstet Gynaecol 2006; 20: 569 82. Color Doppler: vessels following normal course through an indistinct mass
- 18. AUB-L; Leiomyoma 1rylevel: AUB-L 2ry level: Submucosal – AUB-LSM Other – AUB-LO 3ry level: Types 0-8
- 20. The three stageclassification system for leiomyoma
- 21. AUB-M; Malignancy & Hyperplasia Detected based upon results of office biopsy or curettage FIGO AUB Staged only as present or absent Use existing WHO and FIGO categorization Up to 40% of patients with a biopsy diagnosis of complex hyperplasia with atypia will have a concomitant endometrial adenocarcinoma present
- 23. Non-structural Abnormalities C– Coagulopathy O – Ovulatory Dysfunction E – Endometrial I – Iatrogenic N – Not yet classified
- 24. AUB-C; Coagulopathy Prevalence:3% of women presenting with HMB Etiologies: Von Willebrand’s disease (10%) Platelet Dysfunction Factor XI deficiency Factor X deficiency Category includes patient’s taking anti-coagulants
- 25. Coagulopathy History Screening HMBsince menarche One of the following: PPH Surgical related bleeding Bleeding associated with dental work Two or more of the following: Bruising 1-2 times/month Epistaxis 1-2 times/ month Frequent gum bleeding Family history of bleeding symptoms
- 26. AUB-O; Ovulatory Dysfunction Etiology: Polycystic Ovarian Syndrome (PCOS) Hypothyroidism Hyper-prolactinemia Mental stress Obesity Anorexia Weight loss Extreme exercise Adolescence Menopausal transition
- 27. AUB-E; Endometrial Itis diagnosed by exclusion Etiology: Deficiencies of local production of vasoconstrictors Endothelin-1 Prostaglandin F2a Excessive production of plasminogen activators Increased local production of vasodilators Prostaglandin E2 Prostacyclin I2 Disorders of endometrial repair (inflammation) Chlamydia
- 28. AUB-I; Iatrogenic Etiology: Breakthrough bleeding (BTB) using gonadal steroids is the major component of AUB-I : Oral contraceptives Continuous or cyclic progesterone IUD or implant related bleeding Cigarette smoking : reduces the level of steroids because of enhanced hepatic metabolism Systemic agents that interfere with dopamine metabolism : Serotonin uptake inhibitors
- 29. AUB-N; Not YetClassified Disorders that would be identified or defined only by biochemical or molecular biology assays Arterio-venous malformations Myometrial hypertrophy Category for new etiologies Pathological conditions of lower genital tract ??
- 30. Pathway overview Whena woman presents with HMB : Take a proper history Decide whether the timing, amount of blood loss and/or duration of the bleeding is out of the norm. Give it a name. Do a proper assessment/evaluation. Make a (provisional) diagnosis. Initiate treatment or referral
- 31. Guidelines for investigations Guidelines Generalassessment Determine ovulatory status Screening for haemostasis disorders Evaluation of endometrium Evaluation of endometrial cavity structure Myometrial assessment
- 32. Guidelines for investigations 1. General assessment Not related to pregnancy Not emanating from cervix or another location Evaluate for anaemia – Hb 2. Determine ovulatory status Predictable cyclic menses every 22-35 days 3. Screening for systemic disorders of haemostasis Structured history : 90% sensitivity Positive screen: von Willebrand factor, hematologist
- 33. Guidelines for investigations 4. Evaluation of the endometrium Endometrial sampling if risk factors are persistent TVUS - endometrial thickness 5. Evaluation of structure of endometrial cavity To identify polyps, submucous myomas TVUS is not 100% sensitive –small lesions undetectable If suboptimal –proceed to SIS or hysteroscopy 6. Myometrial assessment US and +/- hysteroscopy MRI : leiomyoma - adenomyosis
- 35. Laboratory testing forevaluating Acute AUB Laboratory Evaluation Specific Laboratory Tests • Initial laboratory testing • CBC • Blood group • Pregnancy test • Initial laboratory evaluation for disorders of hemostasis • PTT & PT • Activated partial thromboplastin time • Fibrinogen • Initial testing for von Willebrand disease • VWF antigen • Ristocetin cofactor assay • Factor VIII • Other laboratory tests to consider • TSH • Serum Fe, total Fe binding capacity, and ferritin • Liver function tests • Chlamydia trachomatis
- 36. Imaging- US TVUS Assessment of myometrium, cervix, tubes, and ovaries Endometrial Polyps Adenomyosis Leiomyomas Uterine anomalies Endometrial thickening associated with hyperplasia and malignancy
- 37. Saline infusion Sonography SIS Improves the diagnosis of intrauterine pathology - polyps and fibroids Better discrimination of location and relationship to the uterine cavity May be useful prior to hysteroscopic or laparoscopic procedure for fibroids, polyps and uterine anomalies
- 38. MRI Rarely indicated Helps mapping the exact location of fibroids in planning surgery and prior to embolization When TVS or instrumentation of the uterus (i.e. congenital anomalies) cannot be performed
- 39. Hystroscopy Direct visualizationof cavitary pathology Directed biopsy (main benefit over "blind" D&C)
- 40. Notation for 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,0
- 41. Notation: each casehas 1 identified abnormality
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- 43. Notation: >1 positivecategory
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- 45. Conclusion Abnormal Uterine Bleeding FIGOnomenclature and PALM-COEIN classification
- 46. FIGO nomenclature & PALM-COEIN classification Simplifiedand unified terminology Allows clear focus of treatment concepts Facilitates clinical and scientific research collaboration Provides the basis to structure more effective clinical teaching
- 47. Take home massage The term DUB should be replaced by coagulopathy, endometrial & ovulatory disorders FIGO believes that the classification should be used widely in undergraduate & post-graduate education to facilitate the development of practitioners who are able to provide quality care for women with AUB