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Abnormal Uterine Bleeding (AUB)

New Standardized Terminology, Definitions, Classification


Long time use of non-standardized, ambiguous terminology. English language terminologies with
Greek or Latin roots are poorly defined and create ambiguity in meaning and usage.
In 2005, interest group of 35 experts did historical review, and recommendations made for
uniform terminology published. A Delphi panel created to analyze recommendations. They
recommended discarding the confusing terminology, and replace with simple descriptive terms
that could be understood by patients and translated into most languages.

In 2006, FIGO identified as the appropriate body to provide supervision and international
credibility to the ongoing evaluation of new terminology. Formed the FIGO Menstrual Disorders
Group. In 2009, FIGO World Congress of Gynecology and Obstetrics (17 countries from 6
continents) accepted the new terminology. The PALM-COEIN Classification System created.
Supported by ACOG (Practice Bulletin No. 128, July 2012)

Recommendations for Discarded Terminology

Dysfunctional uterine bleeding

Functional uterine bleeding

Uterine hemorrhage
Metropathica hemorrhagica

Amenorrhea retained term

Accepted Abbreviations Describing Menstrual Symptoms


Abnormal uterine bleeding

Heavy menstrual bleeding
Heavy and prolonged menstrual bleeding
Intermenstrual bleeding
Postmenopausal bleeding

Recommended Normal Limits of Menstrual Dimensions

Frequency of menses
Regularity of menses, cycle to cycle
Variation over 12 months
Duration of flow




<24 days
24 to 38 days
>38 days

No bleeding
Variation + or - 2 to 20 days
Variation >20 days
>8.0 days
4.5 to 8.0 days
<4.5 days

Recommended Terminology, Definitions, and Classifications of

Symptoms of Abnormal Uterine Bleeding
Disturbances of Regularity

Irregular Menstrual Bleeding (IrregMB): Bleeding of >20 days in individual cycle lengths over a period of
one year.
Absent Menstrual Bleeding (amenorrhea): No bleeding in a 90-day period.

Disturbances in Frequency

Infrequent Menstrual Bleeding: One or two episodes in a 90-day period.

Frequent Menstrual Bleeding: More than four episodes in a 90-day period.

Disturbances of Heaviness of Flow

Heavy Menstrual Bleeding (HMB): Excessive menstrual blood loss that interferes with the womans
physical, emotional, social, and material quality of life and can occur alone or in combination with other
Heavy and Prolonged Menstrual Bleeding (HPMB): Less common than HMB. It is important to make a
distinction from HMB given they may have different etiologies and respond to different therapies.
Light Menstrual Bleeding: Based on patient complaint, rarely related to pathology.

Disturbance of the Duration of Flow

Prolonged Menstrual Bleeding: Menstrual periods exceeding 8 days in duration on a regular basis.
Shortened Menstrual Bleeding: Uncommon, defined as bleeding of no longer than 2 days.

Irregular Nonmenstrual Bleeding

Irregular episodes of bleeding, often light and short, occurring between normal menstrual periods. Mostly
associated with benign or malignant structural lesions. May occur during or following sexual intercourse.

Bleeding Outside Reproductive Age

Postmenopausal Bleeding (PMB): Bleeding occurring >1 year after the acknowledged menopause.
Precocious Menstruation: Usually associated with other signs of precocious puberty, occurring before 9
years of age.

Acute AUB

An episode of bleeding in a woman of reproductive age, who is not pregnant, of sufficient quantity to require
immediate intervention to prevent further blood loss.

Chronic AUB

Bleeding from the uterine corpus that is abnormal in duration, volume, and/or frequency and has been
present for the majority of the last 6 months.

Patterns of Bleeding

The shape of the volume of the bleeding pattern over the days of one menstrual period. It is usually
recognized that about 90% of the total menstrual flow is lost within the first 3 days of the cycle, with day
1 or 2 the heaviest. In women with AUB this pattern is variable.

The PALM-COEIN Classification System for Causes of AUB

PALM visually objective structural criteria

COEI unrelated to structural anomalies
N entities not yet classified

Polyps (AUB-P)
Adenomyosis (AUB-A)
Leiomyoma (AUB-L)
Malignancy (AUB-M)

Coagulopathy (AUB-C)
Ovulatory disorders (AUB-O)
Endometrial (AUB-E)
Iatrogenic (AUB-I)
Not Classified

Components of the PALM-COEIN Classification System

Polyps (AUB-P)

Abnormal vaginal bleeding is the most common presenting symptom. Accounts for all causes of abnormal vaginal
bleeding in 39% of pre-menopausal and 21-28% in post-menopausal women. Polyps are categorized as either
present or absent. Diagnosed by TVUS, saline infusion sonography, and hysteroscopy.

Adenomyosis (AUB-A)

70% of women with adenomyosis have symptoms of AUB. 30% have dysmenorrhea. 19% have both. Diagnosed by
ultrasound or MRI.

Leiomyomas (AUB-LSM or AUB-LO)

Most common benign tumor of the genital tract. Age is most common risk factor with lifetime risk in women over age
45 to be more than 60%. Higher association of AUB with submucosal lesions, compared to intramural and subserosal

Malignancy (AUB-M)

AUB is the primary symptom of endometrial neoplasia. 70% of PMB with AUB have benign findings, 15% have
hyperplasia, and 15% have endometrial cancer. Approximately 50% of women diagnosed with endometrial
hyperplasia have concurrent carcinoma. AUB-M includes both premalignant and malignant lesions.

Coagulopathies (AUB-C)

13% of women with HMB have a disorder of hemostasis that may be overlooked during the differential diagnosis.

Ovulatory Dysfunction (AUB-O)

Patients with unpredictable menses with variable flow are usually associated with endocrinopathies, such as
polycyctic ovary syndrome or hypothyroidism. Evaluate for ovulatory dysfunction.

Endometrial Causes (AUB-E)

Most patients in this category will have regular cycles, normal ovulation and no definable cause of AUB. Usually
present with HMB, which may indicate a disorder of endometrial hemostasis. Others may present with IMB, which
may be secondary to inflammation, infection, or abnormal inflammatory responses.

Iatrogenic (AUB-I)

Causes include IUD, exogenous gonadal steroids and other systemic agents that affect blood coagulation or ovulation.
Bleeding from anticoagulation therapy is listed under AUB-C rather than AUB-I.

Not Yet Classified (AUB-N)

Reserved for entities that are poorly defined and/or not well examined, such as arteriovenous malformation and
myometrial hypertrophy. With more evidence, entities such as these will likely be placed into a new or existing

Notation of 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:


Diagnostic Evaluation of AUB

Medical History

Age of menarche and menopause

Menstrual bleeding patterns
Severity of bleeding (clots or flooding)
Pain (severity and treatment)
Medical conditions
Surgical history
Use of medications
Symptoms and signs of possible hemostatic disorder

Physical Exam

General physical
Pelvic Examination
Speculum with Pap test, if needed.

Laboratory Tests

Pregnancy test (blood or urine)

Complete blood count
Chlamydia trachomatis
Targeted screening for bleeding disorders (when indicated, based on history*):
PT, PTT, specific tests for von Willebrand disease, von Willebrand-ristocetin
cofactor activity, von Willebrand factor antigen, and factor VIII

Available Diagnostic or Imaging Tests (when indicated)

Saline infusion sonohysterography
Transvaginal ultrasonography
Magnetic resonance imaging

Available Tissue Sampling Methods (when indicated**)

Office endometrial biopsy

Hysteroscopy directed endometrial sampling (office or operating room)

*Clinical Screening for an Underlying

Disorder of Hemostasis in the Patient

with Excessive Menstrual Bleeding
Positive screen comprises any of the following:
Heavy menstrual bleeding since menarche
One of the following:
Postpartum hemorrhage
Surgery-related bleeding
Bleeding associated with dental work
Two or more of the following symptoms:
Bruising one to two times per month
Epistaxis one to two times per month
Frequent gum bleeding
Family history of bleeding symptoms

**Indications for Endometrial Sampling

Age >45 years
Family history of hereditary nonpolyposis colorectal
cancer syndrome (HNPCC)
Persistent AUB that is unexplained or fails treatment

Coding for Abnormal Uterine Bleeding

ICD-9 Codes

CPT Codes

Disorders of menstruation and other abnormal bleeding from female genital tract
Amenorrhea (primary) (secondary)
Scanty or Infrequent menstruation, Hypomenorrhea, Oligomenorrhea
Excessive or frequent menstruation, Heavy periods, Menorrhagia,
Menometrorrhagia, Polymeorrhea
Irregular menstrual cycle, Irregular bleeding, Irregular menstruation, Irregular
Ovulation bleeding, Regular intermenstrual bleeding
Metrorrhagia, Bleeding unrelated to menstrual cycle, Irregular intermenstrual
Dysfunctional or functional uterine hemorrhage
Postmenopausal bleeding
Polyp of corpus uteri, Endometrium, Uterus
Endometriosis of uterus, Adenomyosis
Dysmenorrhea, Painful menstruation
Submucous leiomyoma of uterus
Intramural leiomyoma of uterus
Subserous leiomyoma of uterus
Leiomyoma of uterus, unspecified
Malignant neoplasm of body of uterus, endometrium
Endometrial hyperplasia, unspecified
Simple endometrial hyperplasia without atypia
Complex endometrial hyperplasia without atypia
Endometrial hyperplasia with atypia
Benign endometrial hyperplasia

Endometrial sampling (biopsy) with or without endocervical sampling (biopsy),

without cervical dilation, any method (separate procedure)
Hysteroscopy, diagnostic (separate procedure)
hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or
polypectomy, with or without D&C
Ultrasound, transvaginal
Saline infusion sonohysterography (SIS), including color flow Doppler, when

Many of the suggestions for the new terminology might be included in the ICD-10 changes that
may be implemented in 2014.