Advertisement

The FIGO systems for nomenclature and classification of causes of abnormal uterine bleeding in the reproductive years: who needs them?

Published:February 10, 2012DOI:https://doi.org/10.1016/j.ajog.2012.01.046
      In November 2010, the International Federation of Gynecology and Obstetrics formally accepted a new classification system for causes of abnormal uterine bleeding in the reproductive years. The system, based on the acronym PALM-COEIN (polyps, adenomyosis, leiomyoma, malignancy and hyperplasia–coagulopathy, ovulatory disorders, endometrial causes, iatrogenic, not classified) was developed in response to concerns about the design and interpretation of basic science and clinical investigation that relates to the problem of abnormal uterine bleeding. A system of nomenclature for the description of normal uterine bleeding and the various symptoms that comprise abnormal bleeding has also been included. This article describes the rationale, the structured methods that involved stakeholders worldwide, and the suggested use of the International Federation of Gynecology and Obstetrics system for research, education, and clinical care. Investigators in the field are encouraged to use the system in the design of their abnormal uterine bleeding–related research because it is an approach that should improve our understanding and management of this often perplexing clinical condition.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Obstetrics & Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Munro M.G.
        • Critchley H.O.
        • Broder M.S.
        • Fraser I.S.
        The FIGO classification system (“PALM-COEIN”) for causes of abnormal uterine bleeding in non-gravid women in the reproductive years, including guidelines for clinical investigation.
        Int J Gynaecol Obstet. 2011; 113: 3-13
        • Munro M.G.
        Abnormal uterine bleeding.
        Cambridge University Press, Cambridge, UK2010
        • Woolcock J.G.
        • Critchley H.O.
        • Munro M.G.
        • Broder M.S.
        • Fraser I.S.
        Review of the confusion in current and historical terminology and definitions for disturbances of menstrual bleeding.
        Fertil Steril. 2008; 90: 2269-2280
        • Fraser I.S.
        • Critchley H.O.
        • Munro M.G.
        • Broder M.
        Can we achieve international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding?.
        Hum Reprod. 2007; 22: 635-643
        • Fraser I.S.
        • Critchley H.O.
        • Munro M.G.
        • 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: 466-476
        • Critchley H.O.
        • Munro M.G.
        • Broder M.
        • Fraser I.S.
        A five-year international review process concerning terminologies, definitions, and related issues around abnormal uterine bleeding.
        Semin Reprod Med. 2011; 29: 377-382
        • Munro M.G.
        • Lukes A.S.
        Abnormal uterine bleeding and underlying hemostatic disorders: report of a consensus process.
        Fertil Steril. 2005; 84: 1335-1337
        • Lukes A.S.
        • Kadir R.A.
        • Peyvandi F.
        • Kouides P.A.
        Disorders of hemostasis and excessive menstrual bleeding: prevalence and clinical impact.
        Fertil Steril. 2005; 84: 1338-1344
        • Kouides P.A.
        • Conard J.
        • Peyvandi F.
        • Lukes A.
        • Kadir R.
        Hemostasis and menstruation: appropriate investigation for underlying disorders of hemostasis in women with excessive menstrual bleeding.
        Fertil Steril. 2005; 84: 1345-1351
        • Kadir R.A.
        • Lukes A.S.
        • Kouides P.A.
        • Fernandez H.
        • Goudemand J.
        Management of excessive menstrual bleeding in women with hemostatic disorders.
        Fertil Steril. 2005; 84: 1352-1359
        • Fraser I.S.
        • Bonnar J.
        • Peyvandi F.
        Requirements for research investigations to clarify the relationships and management of menstrual abnormalities in women with hemostatic disorders.
        Fertil Steril. 2005; 84: 1360-1365
        • Munro M.G.
        • Heikinheimo O.
        • Haththotuwa R.
        • Tank J.D.
        • Fraser I.S.
        The need for investigations to elucidate causes and effects of abnormal uterine bleeding.
        Semin Reprod Med. 2011; 29: 410-422
        • Munro M.G.
        • Broder M.
        • Critchley H.O.
        • Matteson K.
        • Haththotuwa R.
        • Fraser I.S.
        An international response to questions about terminologies, investigation, and management of abnormal uterine bleeding: use of an electronic audience response system.
        Semin Reprod Med. 2011; 29: 436-445
        • Fraser I.S.
        • Critchley H.O.
        • Broder M.
        • Munro M.G.
        The FIGO recommendations on terminologies and definitions for normal and abnormal uterine bleeding.
        Semin Reprod Med. 2011; 29: 383-390
        • Treloar A.E.
        • Boynton R.E.
        • Behn B.G.
        • Brown B.W.
        Variation of the human menstrual cycle through reproductive life.
        Int J Fertil. 1967; 12: 77-126
        • Snowden R.
        • Christian B.
        Patterns and perceptions of menstruation, a World Health Organization International collaborative study.
        Croom Helm, London1983
      1. Heavy menstrual bleeding.
        London National Institute for Health and Clinical Excellence, January 2007 (Accessed Feb. 27, 2012)
        • Jensen J.T.
        • Parke S.
        • Mellinger U.
        • Machlitt A.
        • Fraser I.S.
        Effective treatment of heavy menstrual bleeding with estradiol valerate and dienogest: a randomized controlled trial.
        Obstet Gynecol. 2011; 117: 777-787
        • Hallberg L.
        • Nilsson L.
        Determination of menstrual blood loss.
        Scand J Clin Lab Invest. 1964; 16: 244-248
        • Newton J.R.
        • Barnard G.
        • Collins W.
        A rapid method for measuring blood loss using automatic extraction.
        Contraception. 1977; 16: 269-282
        • Haththotuwa R.
        • Goonewardene M.
        • Desai S.
        • Senanayake L.
        • Tank J.
        • Fraser I.S.
        Management of abnormal uterine bleeding in low- and high-resource settings: consideration of cultural issues.
        Semin Reprod Med. 2011; 29: 446-458
        • Wamsteker K.
        • Emanuel M.H.
        • de Kruif J.H.
        Transcervical hysteroscopic resection of submucous fibroids for abnormal uterine bleeding: results regarding the degree of intramural extension.
        Obstet Gynecol. 1993; 82: 736-740
        • Dueholm M.
        Transvaginal ultrasound for diagnosis of adenomyosis: a review.
        Best Pract Res Clin Obstet Gynaecol. 2006; 20: 569-582
        • Dueholm M.
        • Lundorf E.
        • Hansen E.S.
        • Sorensen J.S.
        • Ledertoug S.
        • Olesen F.
        Magnetic resonance imaging and transvaginal ultrasonography for the diagnosis of adenomyosis.
        Fertil Steril. 2001; 76: 588-594
        • Gordts S.
        • Brosens J.J.
        • Fusi L.
        • Benagiano G.
        • Brosens I.
        Uterine adenomyosis: a need for uniform terminology and consensus classification.
        Reprod Biomed Online. 2008; 17: 244-248
        • Lasmar R.B.
        • Barrozo P.R.
        • Dias R.
        • Oliveira M.A.
        Submucous myomas: a new presurgical classification to evaluate the viability of hysteroscopic surgical treatment: preliminary report.
        J Minim Invasive Gynecol. 2005; 12: 308-311
        • Tavassoli F.A.
        • Devilee P.
        World Health Organization Classification of Tumors: pathology and genetics of tumours of the breast and female genital organs.
        IARC Press, Lyon, France2003
        • Creasman W.T.
        • Odicino F.
        • Maisonneuve P.
        • et al.
        Carcinoma of the corpus uteri: FIGO 6th annual report on the results of treatment in gynecological cancer.
        Int J Gynaecol Obstet. 2006; 95: S105-S143
        • Shankar M.
        • Lee C.A.
        • Sabin C.A.
        • Economides D.L.
        • Kadir R.A.
        Von Willebrand disease in women with menorrhagia: a systematic review.
        BJOG. 2004; 111: 734-740
        • Kadir R.A.
        • Economides D.L.
        • Sabin C.A.
        • Owens D.
        • Lee C.A.
        Frequency of inherited bleeding disorders in women with menorrhagia.
        Lancet. 1998; 351: 485-489
        • Hale G.E.
        • Hughes C.L.
        • Burger H.G.
        • Robertson D.M.
        • Fraser I.S.
        Atypical estradiol secretion and ovulation patterns caused by luteal out-of-phase (LOOP) events underlying irregular ovulatory menstrual cycles in the menopausal transition.
        Menopause. 2009; 16: 50-59
        • Gleeson N.C.
        Cyclic changes in endometrial tissue plasminogen activator and plasminogen activator inhibitor type 1 in women with normal menstruation and essential menorrhagia.
        Am J Obstet Gynecol. 1994; 171: 178-183
        • Smith S.K.
        • Abel M.H.
        • Kelly R.W.
        • Baird D.T.
        A role for prostacyclin (PGi2) in excessive menstrual bleeding.
        Lancet. 1981; 1: 522-524
        • Smith S.K.
        • Abel M.H.
        • Kelly R.W.
        • Baird D.T.
        Prostaglandin synthesis in the endometrium of women with ovular dysfunctional uterine bleeding.
        BJOG. 1981; 88: 434-442
        • Critchley H.O.D.
        • Maybin J.
        Molecular and cellular causes of abnormal uterine bleeding of endometrial orign.
        Semin Reprod Med. 2011; 29: 400-409
        • Matteson K.A.
        • Munro M.G.
        • Fraser I.S.
        The structured menstrual history: developing a tool to facilitate diagnosis and aid in symptom management.
        Semin Reprod Med. 2011; 29: 423-435