Abnormal uterine bleeding

Blog Post  by Malcolm G. Munro MD, FACOG, FRCS(c), Professor, Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Director of Gynecologic Services, Kaiser Permanante, Los Angeles Medical Center, Los Angeles, CA, USA

Many medical students, registrars/residents, primary care physicians and even gynecologic specialists struggle when confronted with a patient with abnormal uterine bleeding (AUB) in the reproductive years. This is no surprise as both the investigation and management of abnormal AUB in such women has been hampered by confusing and inconsistently applied nomenclature and the lack of standardized methods for investigation and categorization of the various potential causes of the problem.(1, 2) Terms such as “menorrhagia” and “dysfunctional uterine bleeding” frequently have different meanings in different environments, often resulting in misinterpretation of patients, colleagues, and textbooks or the medical literature. In addition, while many potential causes of AUB are invisible such as endometrial defects or coagulopathies, many uterine entities that are discernable, such as adenomyoais, leiomyomas, and endometrial polyps, are frequently asymptomatic.

This circumstance presents difficulties for everyone involved in the field of AUB. At the level of scientific investigation it is difficult for basic scientists to create meaningful laboratory models, and clinical investigators are challenged to find homogenous populations of patients experiencing AUB. Furthermore, it is difficult to compare studies performed by different investigators or research groups because study populations typically have not been defined using similar criteria. As a result, the performance of metaanalysis is undermined, and, in some instances, made counterproductive as inaccurate conclusions may result. The teaching of medical students and registrars or residents is also impacted by the inconsistencies in terminology and by variation in the clinical approach to investigation. Finally, at the patient level, and, to no one’s surprise, women suffering from AUB are often faced with a bewildering array of options and oft contradictory opinions.

As a result of the above, a universally accepted system of nomenclature and classification seems a necessary step in the evolution of collaborative research, the application evidence-based approaches to clinical practice and for the consistent and appropriately comprehensive education of health care providers and patients. Development of such a system is made somewhat more complex because a variety of potential causes may coexist in a given individual. Fortunately, in November of 2010, the FIGO (Fédération Internationale de Gynécologie et d’Obstétrique) system for classification of causes of AUB in the reproductive years was officially adopted, and will be officially published later this year. However, the system is already integrated into the design of the book Abnormal Uterine Bleeding, published by Cambridge Medical Press in 2010. (3)

The system is presented in the context of a new nomenclature system for symptoms that has been the subject of previous publications, and which discards the oft-confusing terms such as menorrhagia, metrorrhagia and dysfunctional uterine bleeding.(3, 4) It is based upon the mnemonic “PALM-COEIN” which  stands for polyp, adenomyosis, leiomyoma, malignancy – coagulopathy, ovulatory disorder, endometrial defect, iatrogenic, and not classified.  A structured, but appropriately detailed approach to the assessment of each of these components is an integral part of the classification process for each individual presenting with the disorder. For those designing and interpreting clinical studies of women experiencing AUB, compulsive evaluation of each component should aid in the identification of similar patients and should result in more reliable and comparable results.  Just as important, clinicians are provided a framework for investigation that is designed to facilitate identification of the most appropriate therapeutic options for dealing with the problem of AUB. 

1.         Woolcock JG, Critchley HO, Munro MG, Broder MS, Fraser IS. Review of the confusion in current and historical terminology and definitions for disturbances of menstrual bleeding. Fertil Steril. 2008;90:2269-80.

2.         Fraser IS, Critchley HO, Munro MG. Abnormal uterine bleeding: getting our terminology straight. Curr Opin Obstet Gynecol. 2007;19:591-5.

3.         Munro MG. Abnormal Uterine Bleeding. Cambridge: Cambridge University Press; 2010.

4.         Fraser IS, Critchley HO, Munro MG, Broder M. A process designed to lead to international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding. Fertil Steril. 2007;87:466-76.

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