Abnormal uterine bleeding (AUB) is a common gynecological issue that affects women of all ages and can have significant implications for health and quality of life. The International Federation of Gynecology and Obstetrics (FIGO) has developed a standardized system for describing, classifying, and managing abnormal uterine bleeding, providing healthcare professionals with a framework to improve diagnosis and treatment. Understanding FIGO’s approach to abnormal uterine bleeding can help patients and clinicians communicate effectively, identify underlying causes, and choose appropriate interventions. This topic explores FIGO classification, causes, symptoms, diagnosis, and treatment options for abnormal uterine bleeding.
Definition of Abnormal Uterine Bleeding
Abnormal uterine bleeding refers to any variation from a woman’s normal menstrual pattern, which may involve changes in frequency, duration, or volume of bleeding. AUB can include heavy menstrual bleeding, intermenstrual bleeding, prolonged periods, or irregular cycles. FIGO defines abnormal uterine bleeding as any bleeding that deviates from a normal menstrual cycle, excluding bleeding during pregnancy. This definition allows clinicians to evaluate symptoms consistently and guide management strategies.
Symptoms Associated with AUB
Women experiencing abnormal uterine bleeding may report a variety of symptoms. These can range from mild to severe and may affect physical, emotional, and social well-being. Common symptoms include
- Heavy menstrual bleeding or passing large clots
- Frequent menstrual periods or cycles shorter than 21 days
- Prolonged bleeding lasting more than seven days
- Bleeding between periods or after intercourse
- Fatigue or anemia due to chronic blood loss
Early recognition of these symptoms is crucial for timely diagnosis and effective management of underlying causes.
FIGO Classification System
The FIGO classification system for abnormal uterine bleeding, also known as the PALM-COEIN system, is widely adopted to standardize the terminology and improve clinical care. It categorizes AUB into structural and non-structural causes, facilitating a systematic approach to diagnosis and treatment.
PALM-COEIN System
The acronym PALM-COEIN stands for
- P – Polyp
- A – Adenomyosis
- L – Leiomyoma (fibroids)
- M – Malignancy and hyperplasia
- C – Coagulopathy
- O – Ovulatory dysfunction
- E – Endometrial causes
- I – Iatrogenic causes (medications or procedures)
- N – Not yet classified or idiopathic
By organizing potential causes in this way, FIGO provides clinicians with a structured approach to identify, investigate, and treat abnormal uterine bleeding, ensuring that both common and rare causes are considered.
Structural Causes of AUB
Structural causes refer to physical abnormalities of the uterus or endometrium that contribute to abnormal bleeding. The PALM portion of FIGO’s classification addresses these conditions.
Polyps
Endometrial polyps are benign growths of the uterine lining that can cause irregular or heavy bleeding. They are often diagnosed through ultrasound or hysteroscopy and may require removal if symptomatic.
Adenomyosis
Adenomyosis occurs when endometrial tissue grows into the muscular wall of the uterus, leading to heavy or painful periods. Diagnosis may involve imaging techniques such as MRI or transvaginal ultrasound. Treatment can range from medical management with hormonal therapy to surgical options in severe cases.
Leiomyoma (Fibroids)
Uterine fibroids are non-cancerous growths of the uterine muscle that can cause heavy bleeding, pelvic pressure, or pain. Fibroids are common in women of reproductive age, and management depends on size, location, symptoms, and patient preferences. Options include medication, minimally invasive procedures, or surgery.
Malignancy and Hyperplasia
Abnormal uterine bleeding may sometimes indicate endometrial hyperplasia or malignancy. Risk factors include age, obesity, hormonal imbalances, and a history of polycystic ovarian syndrome. Early detection through biopsy and imaging is essential for appropriate management.
Non-Structural Causes of AUB
Non-structural causes, categorized under COEIN in the FIGO system, involve functional or systemic conditions that affect uterine bleeding.
Coagulopathy
Bleeding disorders such as von Willebrand disease can lead to heavy or prolonged menstrual bleeding. Diagnosis involves laboratory testing, and treatment may include clotting factor replacement or hormonal therapy.
Ovulatory Dysfunction
Disorders affecting ovulation, such as polycystic ovarian syndrome or thyroid disease, can result in irregular or absent periods. Hormonal therapy and lifestyle modifications are commonly used to manage these conditions.
Endometrial Causes
Abnormalities in the endometrial lining itself, such as inflammation or local vascular issues, can contribute to bleeding. Diagnosis may require endometrial biopsy or imaging, and treatment depends on the underlying pathology.
Iatrogenic Causes
Medications, contraceptive devices, and medical procedures can all lead to abnormal uterine bleeding. Adjusting medication or managing side effects often resolves these issues.
Not Yet Classified (Idiopathic)
Some cases of AUB cannot be attributed to a specific cause and are classified as idiopathic. Management focuses on symptom control and monitoring for changes over time.
Diagnosis of Abnormal Uterine Bleeding
Accurate diagnosis involves a combination of medical history, physical examination, laboratory testing, and imaging studies. Key steps include
- Reviewing menstrual history and symptom patterns
- Physical and pelvic examination
- Blood tests to evaluate anemia, hormonal levels, and clotting function
- Ultrasound, MRI, or hysteroscopy to assess structural abnormalities
- Endometrial biopsy when indicated to rule out hyperplasia or malignancy
FIGO guidelines emphasize a systematic approach to ensure all potential causes are considered and managed appropriately.
Treatment and Management
Management of abnormal uterine bleeding depends on the underlying cause, severity of symptoms, and patient preferences. Options include medical therapy, minimally invasive procedures, and surgical interventions.
Medical Management
- Hormonal therapies such as combined oral contraceptives, progestins, or levonorgestrel-releasing intrauterine devices
- Nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce menstrual blood loss and pain
- Tranexamic acid to minimize heavy bleeding
- Treatment of underlying conditions such as thyroid disease or bleeding disorders
Surgical Management
- Hysteroscopic polypectomy or myomectomy for structural lesions
- Endometrial ablation for persistent heavy bleeding
- Hysterectomy in severe or refractory cases
FIGO’s classification and management guidelines for abnormal uterine bleeding provide a comprehensive framework to diagnose and treat a condition that affects many women worldwide. By categorizing causes into structural (PALM) and non-structural (COEIN) groups, FIGO enables healthcare providers to identify underlying factors, tailor interventions, and improve patient outcomes. Understanding AUB, recognizing symptoms, and seeking timely medical care are essential for preventing complications such as anemia, decreased quality of life, or undiagnosed malignancies. With proper evaluation, treatment, and follow-up, women experiencing abnormal uterine bleeding can achieve symptom relief, maintain reproductive health, and improve overall well-being.