O&G SAQs · Gynaecological health — menstrual disorders
Abnormal uterine bleeding — structured SAQ (15 marks)
FRANZCOG-format structured SAQ on abnormal uterine bleeding: the PALM-COEIN classification reproduced verbatim, localising the likely cause from a System 1 history, the structured workup, and the 2018 revisions. Per-sub-part marking rubric included.
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Prompt
A 35-year-old nonpregnant woman presents with heavy menstrual bleeding since her teens, easy bruising and a family history of bleeding. Her cycles are regular. (a) Reproduce the FIGO System 2 (PALM-COEIN) classification, separating structural from non-structural causes. (4 marks) (b) State which PALM-COEIN cause is most likely in this woman and justify it from the history. (3 marks) (c) Describe the structured assessment and initial workup you would perform. (5 marks) (d) State the key 2018 revisions to the classification and explain how they apply to a woman on warfarin. (3 marks)
How this SAQ is marked
Marks come from the verbatim classification, the correctly localised cause, a structured workup, and the precise 2018 revisions. Write in short labelled points. [1]
Reveal model answer and mark schemeShowHide
(a) Reproduce PALM-COEIN, structural vs non-structural (4 marks)
One mark per quadrant correctly listed. [1][3]
- PALM — structural: Polyp, Adenomyosis, Leiomyoma, Malignancy and hyperplasia.
- COEI — non-structural: Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic.
- N — Not otherwise classified.
- Note the principle: PALM causes are identified on imaging or histology; COEI are inferred from history and testing; more than one can coexist.[3]
(b) Most likely cause (3 marks)
- AUB-C (coagulopathy) is the most likely cause.
- HMB since menarche, with bruising and a family history, in the context of regular (ovulatory) cycles points to an intrinsic bleeding disorder, classically von Willebrand disease.
- A structural cause is less likely given the regular cycles and the systemic bleeding history; the FIGO coagulopathy screen (about 90% sensitive) would be positive.[3]
(c) Structured assessment and initial workup (5 marks)
One mark per point, maximum five. [3][4]
- Exclude pregnancy first (always, before labelling nongestational AUB).
- System 1 history (frequency, duration, regularity, flow volume; intermenstrual and unscheduled bleeding) plus the FIGO coagulopathy screen, and impact on quality of life.
- Focused examination: BMI, anaemia signs, androgen excess, abdominal and speculum examination (visualise the cervix, take cervical screening if due), bimanual exam.
- Bloods: FBC and ferritin for iron-deficiency/anaemia; when the screen is positive, a coagulopathy panel (von Willebrand factor antigen, ristocetin cofactor activity, aPTT, platelet function, factor VIII).
- Imaging: transvaginal ultrasound first; saline-infusion sonohysterography or 3D ultrasound for any intracavity lesion (polyps about 97%, leiomyomas about 99.5% sensitivity, comparable to hysteroscopy).[3]
(d) 2018 revisions and the warfarin patient (3 marks)
- In 2018, FIGO moved anticoagulants from AUB-C to AUB-I, and moved ovulation-disrupting agents from AUB-O to AUB-I; the leiomyoma category was subdivided into LSM (submucous) and Lo (other).
- A woman on warfarin with heavy bleeding is therefore AUB-I, not AUB-C.
- AUB-C is now reserved for intrinsic coagulation disorders (e.g. von Willebrand disease).[2]
References5ShowHide
- [1]Munro MG, Critchley HO, Broder MS, et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet, 2011.PMID 21345435
- [2]Munro MG, Critchley HOD, Fraser IS The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynaecol Obstet, 2018.PMID 30198563
- [3]Jain V, Munro MG, Critchley HOD Contemporary evaluation of women and girls with abnormal uterine bleeding: FIGO Systems 1 and 2. Int J Gynaecol Obstet, 2023.PMID 37538019
- [4]Marnach ML, Laughlin-Tommaso SK Evaluation and Management of Abnormal Uterine Bleeding. Mayo Clin Proc, 2019.PMID 30711128
- [5]Wright TS, Cygan PH Closing the Diagnostic Gap in Adolescents and Young Adult Women With Bleeding Disorders: Missed Opportunities. Obstet Gynecol, 2023.PMID 37411028