Womens Health & Gynecology
ISSN: 2369-307X
Assessment of Patients with Abnormal Uterine Bleeding in the
Reproductive Period According to the PALM-COEIN Classification
System
Pinar Solmaz Hasdemir1*, Mustafa Ulusoy2,
Esat Calik1, Ulas Solmaz3 and Tevfik Guvenal1
1
Celal Bayar University School of Medicine,
Department of Obstetrics & Gynaecology, Manisa,
45000 Turkey
2
Celal Bayar University School of Medicine,
Department of Family Physics, Manisa, 45000 Turkey
3
Tepecik Education and Research Hospital,
Obstetrics and Gynaecology Clinic, Izmir, 35000
Turkey
*Corresponding author: Pinar Solmaz Hasdemir,
Celal Bayar University School of Medicine,
Department of Obstetrics & Gynaecology, Manisa,
45000, Turkey, Tel: +(90) 236 444 42 28, Fax:+(90)
236 233 80 40, Email: solmazyildiz@yahoo.com
Volume 2 Issue 3 023
Research Article
This article was published in the following Scient Open Access Journal:
Womens Health & Gynecology
Received February 08, 2016; Accepted February 25, 2016; Published March 04, 2016
Abstract
Aim: The aim of this study is to assess reproductive-age patients with abnormal uterine
bleeding according to the new International Federation of Gynecology and Obstetrics
classification system (PALM-COEIN) and practicability of this classification system at a
gynecologic out-patient clinic of a tertiary reference center.
Methods: A total of 163 reproductive-age patients experiencing abnormal uterine
bleeding were included in this prospective study. Medical history, physical examination,
ultrasonography, and any necessary additional imaging techniques were performed
according to the PALM-COEIN classification system. The diagnostic value of this new
classification system and satisfaction of the resident physicians who used this system were
assessed with a questionnaire.
Results: The median age of the subjects was 30 years (range 13-53). The two most
common causes of abnormal uterine bleeding were ovulation dysfunction (69.9%), followed
by endometrial etiologies (17.2%). Forty (24.5%) patients were classified in more than one
etiology group. Endometrial sampling was performed in 17.2% of patients, and magnetic
resonance imaging was performed in two patients. Medical treatment was administered to
53.9% of the patients. A questionnaire among resident physicians (n=7) revealed that this
system is practical and easy to use.
Conclusion: The PALM-COEIN classification is a practical way of determining the
etiology and choosing the appropriate treatment modality in patients with abnormal uterine
bleeding in out-patient clinic.
Keywords: Abnormal uterine bleeding, Classification system, Endometrial polyp, FIGO, PALM-COEIN
Introduction
Abnormal uterine bleeding (AUB) is a common health problem for about 30%
of reproductive-age women and is experienced by 15-20% of women attending out-
patient gynecology clinics [1].
Currently used classification system of AUB is nomenclature based and
characterized by lack of standardized methods for investigation and categorization
of potential etiologies, therefore a new classification system had been introduced by
the International Federation of Gynecology and Obstetrics (FIGO) in 2011 [2]. This
classification system is called PALM-COEIN. PALM stands for the pathologies associated
with uterine structural anomalies (Polyps, Adenomyosis, Leiomyoma, Malignancy and
endometrial hyperplasia), and COEIN stands for the pathologies not associated with
uterine structural anomalies (Coagulopathy, Ovulatory dysfunction, Endometrial
causes, Iatrogenic, Not yet classified). The PALM-COEIN system classifies uterine
bleeding abnormalities based on a structured evaluation of the patient identifying
possible causes or contributors to the symptom. This system was developed because
of the non-standardized nature of terminology such as menorrhagia, metrorrhagia,
and dysfunctional uterine bleeding, and it does not accept the use of these terms in
describing abnormalities in uterine bleeding patterns [3].
The American College of Obstetricians and Gynecologists (ACOG) accepted
this classification system in 2012 and recommends its use in the diagnosis and
management of AUB cases [4]. After initial assessment and stabilization, the etiologies
of acute AUB should be classified using the PALM-COEIN system [5,6]. Any evaluation
www.scientonline.org Womens Health Gynecol
Citation: Pinar Solmaz Hasdemir, Mustafa Ulusoy, Esat Calik, Ulas Solmaz and Tevfik Guvenal (2016). Assessment of Patients with Abnormal
Uterine Bleeding in the Reproductive Period According to the PALM-COEIN Classification System
of women with AUB should include a through medical history and
physical examination, appropriate laboratory and imaging tests,
and consideration of age-related factors like adolescence and
premenopausal period [4].
The aim in this study was to assess the efficiency and
practicability of this classification system in clinical practice in
determining the etiology and treatment modality for patients
presenting with AUB at our out-patient clinic.
Materials and Methods
A total of 163 consecutive non-pregnant patients with AUB
presenting to the out-patient gynecology clinic of a Universit
Hospital were prospectively included between March 2014 and
September 2014. Medical history (including systemic illnesses,
drug use, contraception, weight changes, detailed menstrual
history), physical examination, routine ultrasound, and any
necessary additional imaging techniques were performed
according to the PALM-COEIN classification system [2,3]. The
diagnostic value and practicability of this new classification
system was also assessed by resident physician satisfaction
survey.
PALM-COEIN Classification components were defined as
follows;
P (polyps): Suspected by ultrasound (hyperechogenic focus
or >12 mm endometrial thickening) and diagnosed and treated
by hysteroscopy. Two patients who refused the hysteroscopic
examination were evaluated by saline infusion sonography.
A: Adenomyosis was suspected by medical history and
ultrasound (asymmetrical myometrial appearance accompanied
a large uterus); and diagnosed by magnetic resonance imaging
(MRI).
L: Leiomyomas were evaluated and diagnosed by ultrasound.
Size, location and existence of endometrial deviations were noted.
M: If malignant/premalignant lesion was suspected,
endometrial biopsy was performed by pipelle biopsy or curettage.
C: Coagulopathy was suspected by a structured medical
history [3,7] and diagnosed by coagulation tests including
full blood count, serum ferritin level, prothrombin time (PT),
activated partial thromboplastin time (APTT), von Willebrand
factor (VWF), factor VII (FVII) levels and liver and kidney function
tests.
O: Ovulatory dysfunction was assessed in three sub-categories
as endocrinopathies, extremes of reproductive age (adolescence
[ages between 13-18] and premenopausal period [ages after 40
to menopause]) and drug usage which were related to dopamine
metabolism, steroids and anti-psychotics.
E: Endometrial etiologies included anticoagulant drug
usage and endometrial infections. Chlamydial infections were
diagnosed by clinical history and cervical examination by
speculum. Chlamydial cultures were not performed routinely.
I: Intrauterine device (IUD), drugs (anticonvulsants and
antibiotics which metabolized at liver like rifampicin) were
considered in iatrogenic category.
N: Arterio-venous malformations, smoking (not a reason, but
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Page 2 of 5
a possible risk factor for AUB) and not yet classified patients were
considered under this sub-title.
The term abnormal uterine bleeding describes any departure
from any of the four characteristics of menstrual bleeding:
frequency of menses (days), regularity of menses (cycle to cycle
variation over 12 months), duration of flow (days), and volume
of monthly blood loss (mL). Values between the 5th and 95th
percentile were accepted as normal for the population [8]. The
term amenorrhea was used to describe the absence of menstrual
bleeding during a six-month reference interval [8].
A physician satisfaction survey was performed among
residents who had had at least two months active work at out-
patient clinic during the study period. Seven residents who
used PALM-COEIN Classification System were asked to choose a
number from 1 to 10 according to their satisfaction rate in order
to determine the practicability of this system (1: minimum and
10: maximum), if they prefer to use this classification in their
future practice and main advantages and diasadvantages of the
system.
The study was approved by the Institutional Research Ethics
Committee (the approval date and number were 2nd January,
2014 and 20478486-07) and informed consent was obtained by
all study participants. Statistical analysis was carried out using
Predictive Analytics Software (PASW), version 21.0 for Windows
(SPSS, Chicago, IL). Descriptive analysis was used for statistical
estimation. Median values with range (minimum-maximum) were
given for abnormally distributed variables. Chi-square testing
was used for comparisons of pathologies between different age
groups. P-value <0.05 was considered statistically significant.
Results
The study population consisted of 163 subjects. The median
age was 30 years old (range, 13-53), and the median gravidity and
parity rates were 1 (range, 0-10) and 1 (range, 0-6), respectively.
A hundered and three (63.2%) patients were married and 25
(15.3%) patients were smoker. Complaints of excessive bleeding,
irregular bleeding, and little or no bleeding were determined to be
similar in terms of frequency (50 cases (30.7%), 54 cases (33.1%),
and 59 cases (36.2%), respectively). Ovulation dysfunction was
determined as the most frequent reason for abnormal bleeding,
and adenomyosis was the least frequent reason, with just one
(0.6%) confirmed case (Table 1).
Distribution of etiologies of AUB based on age is shown at
Table 2. Ovulatory etiologies were the most common cause of
AUB regardless of patients age, particularly among adolescence.
Percentage of ovulatory etiologies decrease by age. Structural
pathologies were increased with age and more than half of the
patients with AUB after 40-years of age was found to have an
organic pathology. There was a significant increase in leiomyomas
(p=0.00018), malignant/premalignant lesions (p=0.003) and
endometrial pathologies (p=0.0015) after 40-years of age
compared to younger age group.
More than one etiologic group was found in 48 (29.5%) of the
patients, only one etiologic factor was found in 123 (75.4%) of
the patients, and no etiologic factor was found in 25 (15.3%) of
the patients.
Medical treatment (hormonal therapy or antibiotics) was
Womens Health Gynecol
Citation: Pinar Solmaz Hasdemir, Mustafa Ulusoy, Esat Calik, Ulas Solmaz and Tevfik Guvenal (2016). Assessment of Patients with Abnormal
Uterine Bleeding in the Reproductive Period According to the PALM-COEIN Classification System
Page 3 of 5

Frequency (%) Detection method (%) Size (cm) (%) Number (%)
SIS: 2 (1.2) <0,5: 6 (3.7)
1: 13 (8)
Polyp 16 (9.8) USG: 7 (4.3) 0,5-1: 4 (2.5)
>1: 3(1.8)
H/S: 7 (4.3) >1: 6 (3.7)
Adenomyosis 1 (0.6) MRI: 2 (1.2)
USG;
Subserozal: 5 3cm: 11 1: 19
Leiomyoma 22 (13.2)
ntramural: 14 <3cm: 11 >1: 3
Submucous: 3
Pipelle bx: 16 (9.8)
Malignant/premalignant lesion 15 (9.2)
Curettage: 12 (7.4)
Coagulopathy 16 (9.8) Laboratory analysis
Etiology Frequency (%)
Ovulatory etiologies PCOS 36 (22.1)
Endocrinopathies Hypothyroidism 11 (6.7)
Hyperthyroidism 6 (3.7)
Hyperprolactinemia 1 (0.6)
Mental stress 12 (7.4)
Obesity 7 (4.3)
Anorexia 1 (0.6)
Diabetes Mellitus 3 (1.8)
Extremes of reproductive age Adolescence 8 (4.9)
Premenopause 4 (2.5)
Drugs Steroids/dopamine metabolism related 14 (8.6)
Psychiatric drugs 11 (6.7)
Anticoagulant drugs 14 (8.6)
Endometrial etiologies
Chlamydial infection 14 (8.6)
RIA 15 (9.2)
Iatrogenic
Drugs (anticonvulsant, antibiotic etc.) 5 (3.1)
AVM 0 (0)
Not yet classified Smoking 25 (15.3)
Not yet classified 25 (15.3)
SIS: salin infusion sonography, USG: ultrasonography, H/S: hysteroscopy, MRI: magnetic resonance imaging, PCOS: polycystic ovary syndrome, AVM: arterio-venous
malformation.
Table 1. Etiologies of abnormal uterine bleeding according to PALM-COEIN Classification System

Categorical parameters Ages 13-18 (n=19) Ages 19-39 (n=89) Ages 40-53 (n=55)
Polyp - 9 (10.1%) 7 (12.7%)
Adenomyosis - 1 (1.1%) -
Leiomyoma 1 (5.3%) 5 (5.6%)* 16 (29.1%)*
Malignant/premalignant lesion - 4 (4.5%)* 11 (20%)*
Coagulopathy - 10 (11.2%) 6 (10.9%)
Ovulatory etiologies 17 (89.5%)* 61 (68.5%) 36 (65.5%)*
Endometrial etiologies - 10 (11.2%)* 18 (32.7%)*
Iatrogenic 2 (10.5%) 12 (13.5%) 6 (10.9%)
Not yet classified 2 (10.5%) 20 (22.5%)* 3 (5.5%)*
*p<0.05 (Chi-square test)
Table 2. Distribution of etiologies of abnormal uterine bleeding based on age

Resident Satisfaction Preference Disadvantage Advantage

1 10 yes N-group Easy to use, systematic
2 9 yes N-group Time-saving, accuracy
3 10 yes N-group, high percent of patients Systematic, accurate diagnosis
4 10 yes N-group, nothing to tell to the patient Systematic evaluation, accurate diagnosis
5 9 yes A-group, difficult to diagnose Time-saving, accuracy
6 9 yes A-group, difficult to diagnose Time-saving, Prevent over-diagnosis and treatment
7 8 yes A-group, N-goup Time-saving, systematic
Satisfaction: number 1 to 10 (1: min, 10: max). Preference: yes or no. Time means: less per/patient time need for patient evaluation.
Table 3. Resident physician satisfaction survey about the PALM-COEIN Classification System

administered to most of the patients (53.9%), and endometrial The summary of resident physician survey is shown in Table
sampling for diagnosis was required in 28 (17.2%) patients. 3. The main advantages of the system among residents were
MRI was necessary for two patients who were thought to have thought to be time saving per patient because of the systematic
adenomyosis. approach and accurate diagnosis especially in patients with more

Volume 2 Issue 3 023 www.scientonline.org Womens Health Gynecol

Citation: Pinar Solmaz Hasdemir, Mustafa Ulusoy, Esat Calik, Ulas Solmaz and Tevfik Guvenal (2016). Assessment of Patients with Abnormal
Uterine Bleeding in the Reproductive Period According to the PALM-COEIN Classification System
than one etiologic cause. The main disadvantage was reported
to be due to group of patients who belong to N-group, because
treatment protocol is not clear in such patients. In addition, the
difficulty of diagnosing adenomyosis by ultrasound was pointed
out by 3 out of 7 resident physicians.
Discussion
The aim in this study was to assess the availability and
clinical advantages and/or disadvantages of the PALM-
COEIN classification system. This new FIGO classification
system was developed because of the longstanding confusion
about terminology and definitions relating to AUB. It was
not clear whether terms such as menorrhagia, metrorrhagia,
menometrorrhagia, and dysfunctional uterine bleeding referred
to symptoms or diagnosis. In addition, these terms did not give
information about the etiology of the AUB. This confusion caused
difficulties in the management of patients and in the designing of
clinical studies about AUB [3].
A consistent and universally accepted classification system
should be used by clinicians, investigators, and even patients to
facilitate communication, clinical care, and research. The PALM-
COEIN AUB classification system is the result of several years of
collaboration among a wide spectrum of individuals involved in
clinical medicine, teaching, and basic and clinical sciences [9].
Beginning with workshops in 2005, contributors from more
than 17 countries on six continents developed the PALM-COEIN
classification system to determine the causes of AUB in the
reproductive years. The basic system comprises nine categories;
the first four are defined as visually objective structural criteria
(PALM); the second four are unrelated to structural anomalies
(COEI); and the final one is reserved for entities that are not
yet classified (N). A draft system was developed and revised,
distributed for comments, and then discussed at a meeting held
in association with the 2009 FIGO World Congress in Cape Town,
South Africa [10].
According to the new FIGO classification system, in the absence
of structural etiology, the term dysfunctional uterine bleeding
should be avoided and clinicians should state if AUB is caused
by coagulation disorders (AUB-C), ovulation disorders (AUB-O),
or endometrial primary dysfunction (AUB-E) [11]. The PALM-
COEIN system allows clinicians to identify and classify women
with AUB and provides reliable information on classification and
for comparisons in research settings. Thus, accurate diagnosis
and adequate treatment according to the etiology could be
possible [12]. When we classified our patients according to
the age groups, we noticed that the organic pathologies were
increased with increasing age while ovulatory dysfunction was
a more common reason for AUB in adolescence. So, detailed
history taking for example asking about the body-mass index in
patients with younger ages for polycystic ovary syndrome could
be possible. This system also provides an approach to AUB in
different etiologic reasons and could prevent over-treatment for
organic etiologies like leiomyomas while it is not the only reason
of the AUB [13].
Since this classification was released, some countries have
revised their guidelines for the diagnosis and management of
what was formerly called dysfunctional uterine bleeding in
favor of the new FIGO classification [14]. ACOG recommended the
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Page 4 of 5
use of the PALM-COEIN classification for both acute and chronic
AUB in non-pregnant reproductive-age women [5]. According
to the Society of Obstetricians and Gynecologists of Canada,
implementing the guideline recommendations will improve the
health and well-being of women with abnormal uterine bleeding.
However, the economic cost of implementing these guidelines in
the Canadian health care system should be considered [15].
In our study, this classification system was easy to implement
and easy to use, especially among resident physicians who might
be confused about the etiologies of the wide range of complaints
associated with AUB. In addition, treatment of the pathology
was easier when the etiology for abnormal bleeding could be
determined. As we found most of the patients had more than one
possible etiologic factors, this classification provides a step by
step approach to the AUB patient. There was only one diagnosis of
adenomyosis, possibly because of the diagnostic difficulty of this
pathology using physical examination and ultrasound. Magnetic
Resonance Imaging (MRI) is a relatively expensive method for
diagnosing adenomyosis, and specific ultrasonographic criteria
should be described in future studies to decrease the need for
MRI in diagnosing this condition. Munro et al. emphasized that
investigations should be performed only if they will make a
material difference to the management approaches that can be
offered. This should be an important consideration when a range
of costly high-technology tests are available or when certain tests
only have limited availability [16].
The PALM-COEIN classification system is generally used in
cases of heavy and/or irregular menstruation [5]. However, 59
(36.2%) of our subjects complained of little and/or no bleeding;
these patient groups should be discussed in detail in the literature
about this new classification.
In conclusion, PALM-COEIN classification is a practical way of
determining the etiology and choosing the appropriate treatment
modality in patients with abnormal uterine bleeding in out-
patient clinic.
Conflicts of Interest
All authors declare that there is no conflicts of interest with
this work.
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Uterine Bleeding in the Reproductive Period According to the PALM-COEIN Classification System
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