The role of transvaginal color doppler indices to predict malignancy in abnormal uterine bleeding according to PALM-COEIN classification.

INTRODUCTION: The objective of this study is to analyze the differences in transvaginal color Doppler parameters in premenopasual women with abnormal uterine bleeding (AUB) among PALM-COEIN groups. MATERIALS AND METHOD: This cross-sectional study was performed in a training and educational hospital, included 147 premenopausal women with AUB. Patients were divided into four groups according to PALM-COEIN. All subjects were evaluated by transvaginal Doppler sonography and uterine artery (UA) pulsatility and resistive indexes (PI, RI) were calculated then compared. RESULTS: Four groups named AUB-P, AUB-E, AUB-M and AUB-O included 39, 30, 32 and 46 patients, respectively. The mean age of patients was 44.82 (35-55 years), EC rate was 3.4 %. UA-PI was lower in the AUB-M group compared with AUB-P and AUB-O (p < 0.001). UA-RI was different among gruops (p < 0.001). UA-RI was lowest in the AUB-M, and highest in the AUB-O (0.60 ± 0.15; 0.85 ± 0.05 respectively). The cut-off values of ET, UA-PI and UA-RI for detecting AUB-M were 13.5, 1.55 and 0.71 respectively. CONCLUSION: Transvaginal color Doppler sonography may be beneficial in detecting the etiology of AUB in premenopausal women.

Biomarkers in abnormal uterine bleeding†.

Abnormal uterine bleeding (AUB) is an extremely common problem and represents a clinical area of unmet need. It has clinical implications and a high cost for the healthcare system. The PALM-COEIN acronym proposed by FIGO may be used as a foundation of care; it improves the understanding of the causes of AUB, and in doing so facilitates effective history taking, examination, investigations, and management. Heavy menstrual bleeding, a subset of AUB, is a subjective diagnosis and should be managed in the context of improving the woman's quality of life. Available evidence suggests that there is poor satisfaction with standard treatment options often resulting in women opting for major surgery such as hysterectomy. Such women would benefit from a tailored approach, both for diagnosis and treatment, highlighting the deficiency of biomarkers in this area. This article focuses on the causes of AUB as per the PALM-COEIN acronym, the researched biomarkers in this area, and the potential pathogenetic mechanisms. In the future, these approaches may improve our understanding of AUB, thereby enabling us to direct women to most suitable current treatments and tailor investigative and treatment strategies to ensure best outcomes, in keeping with the principles of personalized or precision medicine.

Prevalence of abnormal uterine bleeding according to new International Federation of Gynecology and Obstetrics classification in Chinese women of reproductive age: A cross-sectional study.

The PALM-COEIN classification for causes of abnormal uterine bleeding (AUB) was proposed by the International Federation of Gynecology and Obstetrics (FIGO) in 2011, which has been gradually applied in the diagnosis of AUB in the past 2 years in China. However, there are no reports yet on the causes of chronic AUB among Chinese women with this new classification system.The purpose of this study was to describe the prevalence of the causes of chronic AUB among Chinese women of reproductive age using the PALM-COIEN classification system.This is a cross-sectional study. Beijing Shijitan Hospital, Capital Medical University.A total of 1053 women aged 15 to 55 years with chronic AUB were evaluated between November 2016 and May 2017.Prevalence of the causes of chronic AUB using the PALM-COEIN classification. AUB-O was the most frequent finding in women with chronic AUB, accounting for 608 (57.7%) cases. AUB-P was found in 171 (16.2%) women, AUB-L in 130 (12%) women, AUB-A in 52 (4.94%) women, AUB-E in 28 (2%) women, AUB-I in 23 (2%) women, AUB-M in 20 (1.9%) women, AUB-C in 10 (1%) women, and AUB-N in 10 (0.9%) women.Ovulatory dysfunction (AUB-O) is the most common cause of AUB among the nonstructural causes. Endometrial polyps (AUB-P) are the most common among the structural causes, followed by uterine fibroids (AUB-L) and uterine adenomyosis (AUB-A).

Abnormal Uterine Bleeding: Treatment Options.

Abnormal uterine bleeding is one of the most common reasons for outpatient gynecologic visits. Proper evaluation and diagnosis is essential and allows the clinician to present individualized treatment options to their patients.

Critical evaluation of the PALM-COEIN classification system among women with abnormal uterine bleeding in low-resource settings.

OBJECTIVE: To assess the feasibility of the PALM-COEIN system for the classification of abnormal uterine bleeding (AUB) in low-resource settings and to suggest modifications. METHODS: A prospective study was conducted among women with AUB who were admitted to the gynecology ward of a tertiary care hospital and research center in central India between November 2014 and October 2016. All patients were managed as per department protocols. The causes of AUB were classified before treatment using the PALM-COEIN system (classification I) and on the basis of the histopathology reports of the hysterectomy specimens (classification II); the results were compared using classification II as the gold standard. RESULTS: The study included 200 women with AUB; hysterectomy was performed in 174 women. Preoperative classification of AUB per the PALM-COEIN system was correct in 130 (65.0%) women. Adenomyosis (evaluated by transvaginal ultrasonography) and endometrial hyperplasia (evaluated by endometrial curettage) were underdiagnosed. CONCLUSION: The PALM-COEIN classification system helps in deciding the best treatment modality for women with AUB on a case-by-case basis. The incorporation of suggested modifications will further strengthen its utility as a pretreatment classification system in low-resource settings.

A Population-Based Study of the Prevalence of Abnormal Uterine Bleeding and its Related Factors among Iranian Reproductive-Age Women: An Updated Data.

BACKGROUND: Abnormal uterine bleeding (AUB) is one of the most common gynecologic complaints among reproductive-age women. The purpose of this study was to investigate the prevalence of AUB and its related factors among reproductive age Iranian women. METHODS: A population-based cross-sectional study was conducted on 1393 women aged 15 - 45 years who participated in the Tehran Lipid and Glucose Study in 2009 - 2012. FIGO terminology and previous definitions were used for classification of AUB. Logistic regression was used to estimate adjusted odds ratios (OR) and 95% confidence intervals to check the association between AUB and the women's demographic characteristics. P < 0.05 was considered statistically significant. RESULTS: A total of 35.8% (95% CI: 31.5% - 40.2%) of the participants suffered from one or more types of AUB. About 10.6% (95% CI: 6.3% - 12.5%) of them had disturbances of regularity and 23.8% (95% CI: 18.4% - 26.1%) reported experiencing disturbances of frequency. Also, disturbances of heaviness of flow and duration of flow were reported in 16% (95% CI: 12.7% - 19.2%) and 11.5% (95% CI: 8% - 15.4%), respectively. About 4.3% of the women (95% CI: 2.1% - 10.5%) reported irregular non-menstrual bleeding. According to previous definitions, the prevalence of heavy periods, metrorrhagia, polymenorrhea, oligomenorrhea, amenorrhea and inter-menstrual bleeding in reproductive aged women was 15.2%, 18.9%, 10.6%, 15.2%, 2.2%, and 4.3%, respectively. In addition, the proportions of women with AUB rose in the early and late reproductive years. After adjustment of confounders, logistic regression analysis showed that age (adjusted OR = 1.08, 95% CI: 1.07 - 3.97, P = 0.03) and BMI (adjusted OR = 1.05, 95% CI: 1.02 - 3.04, P = 0.04) had statistically significant associations with AUB. CONCLUSION: The prevalence of AUB as a possible clinical indicator of underlying disorders was high among Iranian reproductive age women. Healthcare providers and policy makers are required to acknowledge these disorders and provide education and counseling opportunities for the public to inform them when and how to seek medical advice.

Abnormal Uterine Bleeding: Current Classification and Clinical Management.

Abnormal uterine bleeding is now classified and categorized according to the International Federation of Gynecology and Obstetrics classification system: PALM-COEIN. This applies to nongravid women during their reproductive years and allows more clear designation of causes, thus aiding clinical care and future research.

Structured imaging technique in the gynecologic office for the diagnosis of abnormal uterine bleeding.

The aim in the diagnosis of abnormal uterine bleeding (AUB) is to identify the bleeding cause, which can be classified by the PALM-COEIN (Polyp, Adenomyosis, Leiomyoma, Malignancy (and hyperplasia), Coagulopathy, Ovulatory disorders, Endometrial, Iatrogenic and Not otherwise classified) classification system. In a gynecologic setting, the first step is most often to identify structural abnormalities (PALM causes). Common diagnostic options for the identification of the PALM include ultrasonography, endometrial sampling, and hysteroscopy. These options alone or in combination are sufficient for the diagnosis of most women with AUB. Contrast sonography with saline or gel infusion, three-dimensional ultrasonography, and magnetic resonance imaging may be included. AIM: The aim of this article is to describe how a simple structured transvaginal ultrasound can be performed and implemented in the common gynecologic practice to simplify the diagnosis of AUB and determine when additional invasive investigations are required. Structured transvaginal ultrasound for the identification of the most common endometrial and myometrial abnormalities and the most common ultrasound features are described. Moreover, situations where magnetic resonance imaging may be included are described. This article proposes a diagnostic setup in premenopausal women for the classification of AUB according to the PALM-COEIN system. Moreover, a future diagnostic setup for fast-track identification of endometrial cancer in postmenopausal women based on a structured evaluation of the endometrium is described.

Practical aspects of the two FIGO systems for management of abnormal uterine bleeding in the reproductive years.

The FIGO systems defining the nomenclature and symptoms of abnormal uterine bleeding (AUB) in the reproductive years (System 1) and the PALM-COEIN classification of causes of AUB (System 2) are designed to facilitate research, education, and the provision of optimum clinical care for affected women. Development of these systems has been the result of a collaborative effort of experts in bench and translational and clinical research from six continents aided by a spectrum of representatives from relevant medical societies, journals, and regulatory bodies. Integral to this development has been a decision to cease the use of poorly defined and inconsistently used terms such as menorrhagia, metrorrhagia, and dysfunctional uterine bleeding, to name a few, and replace them with a set of terms and definitions that are relatively easily understood and translated into the spectrum of languages used by medical providers and patients globally. The utilization of these systems requires a disciplined approach to obtaining a menstrual history, relatively simple laboratory investigations, and the appropriate use of imaging techniques accessible to most clinicians worldwide. This section describes the two systems, their crucial role in guiding investigation, and an approach to implementation, all designed to facilitate the creation of a menu of therapeutic options, considering the identified factors contributing to the problem of nongestational AUB.

Abnormal Uterine Bleeding: American College of Nurse-Midwives.

Variations in uterine bleeding, termed abnormal uterine bleeding, occur commonly among women and often are physiologic in nature with no significant consequences. However, abnormal uterine bleeding can cause significant distress to women or may signify an underlying pathologic condition. Most women experience variations in menstrual and perimenstrual bleeding in their lifetimes; therefore, the ability of the midwife to differentiate between normal and abnormal bleeding is a key diagnostic skill. A comprehensive history and use of the PALM-COEIN classification system will provide clear guidelines for clinical management, evidence-based treatment, and an individualized plan of care. The purpose of this Clinical Bulletin is to define and describe classifications of abnormal uterine bleeding, review updated terminology, and identify methods of assessment and treatment using a woman-centered approach.

PALM-COEIN Nomenclature for Abnormal Uterine Bleeding.

Approximately 30% of women will experience abnormal uterine bleeding (AUB) during their life time. Previous terms defining AUB have been confusing and imprecisely applied. As a consequence, both clinical management and research on this common problem have been negatively impacted. In 2011, the International Federation of Gynecology and Obstetrics (FIGO) Menstrual Disorders Group (FMDG) published PALM-COEIN, a new classification system for abnormal bleeding in the reproductive years. Terms such as menorrhagia, menometrorrhagia, metrorrhagia, dysfunctional uterine bleeding, polymenorrhea, oligomenorrhea, and uterine hemorrhage are no longer recommended. The PALM-COEIN system was developed to standardize nomenclature to describe the etiology and severity of AUB. A brief description of the PALM-COEIN nomenclature is presented as well as treatment options for each etiology. Clinicians will frequently encounter women with AUB and should report findings utilizing the PALM-COEIN system.

Comparison of classic terminology with the FIGO PALM-COEIN system for classification of the underlying causes of abnormal uterine bleeding.

OBJECTIVE: To compare classic terminology and the PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory disorders, endometrium, iatrogenic, and not classified) classification system among women who underwent surgery for abnormal uterine bleeding (AUB), and to subclassify the components of the PALM group for future studies. METHODS: In a retrospective study, data were obtained for nonpregnant women aged 18-55years who underwent hysterectomy, myomectomy, or polypectomy for AUB at a center in Turkey in 2014. The patients were retrospectively classified according to the PALM-COEIN system, and the two terminologies were compared. RESULTS: A total of 471 women were included. The term "hypermenorrhea" covered 15 different pathology combinations, "menorrhagia" nine, "metrorrhagia" 14, and "menometrorrhagia" 18. Of 92 patients with polyp, 5 (5.4%) had two polyps and 1 (1.1%) had three. Of 146 patients with adenomyosis, 131 (89.7%) had diffuse adenomyosis and 12 (8.2%) had adenomyoma. Of 309 patients with myoma uteri, 108 (34.9%) had submucous myoma and 201 (65.1%) had other types of myoma. CONCLUSION: Classic terminology for AUB is insufficient and confusing with respect to etiologic pathologies among nonpregnant women of reproductive age. Widespread adoption of the PALM-COEIN system for AUB classification will facilitate more meaningful communication among both clinicians and investigators, and clarify the populations that should be evaluated in clinical trials, thereby enhancing communication with patients.

Utility of the PALM-COEIN classification of abnormal uterine bleeding for Indian gynecologists.

OBJECTIVE: To study the clinical utility of the PALM-COEIN classification for abnormal uterine bleeding in day-to-day practice in India. METHODS: Between April and November 2014, a cross-sectional survey was undertaken of gynecologists practicing in Chittoor and Nellore. Doctors possessing a postgraduate degree in gynecology and obstetrics, and postgraduate students in the gynecology department of medical colleges were invited to participate. A validated questionnaire containing 15 questions was distributed, the opinions were collated, and the results analyzed. RESULTS: Among 150 invited gynecologists, 120 agreed to participate, and 119 completed the survey fully. Overall, 95 (79.8%) respondents were aware of the classification, and 56 (47.1%) responded that the PALM-COEIN system is very good, 46 (38.7%) that it is average, and 17 (14.3%) that it is poor. By subgroup, 16 of 20 (80.0%) faculty members, 46 of 56 (82.1%) postgraduate students, and 33 of 43 (76.7%) practitioners responded that the system is useful. CONCLUSION: Indian doctors generally believe that the PALM-COEIN system is clinically useful and a step forward in the management of abnormal uterine bleeding.

Abnormal uterine bleeding: advantages of formal classification to patients, clinicians and researchers.

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 adequately with respect to the impact of symptoms on individuals, healthcare systems and society. This was confounded by a diverse terminology, which lead to confusion between clinical and scientific groups, ultimately harming the underlying evidence base. To address this, a formal classification system (PALM-COEIN) for the causes of abnormal uterine bleeding has been published for worldwide use by FIGO (International Federation of Gynecology and Obstetrics). POPULATION AND MAIN OUTCOME MEASURES: This commentary explains problems 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.

A new look at abnormal uterine bleeding.

New universal terminology, classifications, and definitions recommended by the International Federation of Gynecology and Obstetrics and supported by the American College of Obstetricians and Gynecologists to describe abnormal uterine bleeding abnormalities in reproductive women are presented. Identification and management of anovulatory and ovulatory uterine bleeding are explored.