Abnormal uterine bleeding: PALM-COEIN classification & assessment (FIGO 2018)

A woman sits in your clinic with irregular, heavy bleeding she has tolerated for two years because her mother "had it too". Your job is not to label it "menorrhagia" and reach for a pill — it is to describe the bleeding precisely, exclude pregnancy, run a structured cause-finding workup, and treat the cause. The FIGO PALM-COEIN system exists to stop doctors calling the symptom a diagnosis. This topic is the framework every later gynaecology topic plugs into.^[2][7]

Overview and definition

AUB is an umbrella term for bleeding from the uterine corpus that is abnormal in volume, regularity or timing in a nonpregnant woman of reproductive age. FIGO separates it by tempo:^[2][4]

• Chronic AUB — abnormal in volume, regularity and/or timing, present for the majority of the past 6 months. This is the clinic presentation.
• Acute AUB — an episode heavy enough that, in the clinician's judgement, it needs immediate intervention to stop further blood loss. This is the emergency.^[4]

Both definitions are FIGO's, verbatim, and worth quoting. The two systems that structure the whole encounter are:^[2][4]

• FIGO System 1 — nomenclature and definitions of the bleeding pattern (the "what").
• FIGO System 2 (PALM-COEIN) — classification of the causes (the "why").^[2][4]

^[4]

References12ShowHide

1. [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. [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. [3]Munro MG, Critchley HO, Fraser IS The FIGO classification of causes of abnormal uterine bleeding in the reproductive years. Fertil Steril, 2011.PMID 21496802
4. [4]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
5. [5]Munro MG, Balen AH, Cho S, et al. The FIGO ovulatory disorders classification system. Int J Gynaecol Obstet, 2022.PMID 35983674
6. [6]Marnach ML, Laughlin-Tommaso SK Evaluation and Management of Abnormal Uterine Bleeding. Mayo Clin Proc, 2019.PMID 30711128
7. [7]Chodankar RR, Munro MG, Critchley HOD Historical Perspectives and Evolution of Menstrual Terminology. Front Reprod Health, 2022.PMID 36303670
8. [8]Papakonstantinou E, Adonakis G Management of pre-, peri-, and post-menopausal abnormal uterine bleeding: When to perform endometrial sampling? Int J Gynaecol Obstet, 2022.PMID 34669187
9. [9]Habiba M, Guo SW, Benagiano G, et al. Adenomyosis and Abnormal Uterine Bleeding: Review of the Evidence. Biomolecules, 2024.PMID 38927019
10. [10]Wright TS, Cygan PH Closing the Diagnostic Gap in Adolescents and Young Adult Women With Bleeding Disorders: Missed Opportunities. Obstet Gynecol, 2023.PMID 37411028
11. [11]Vannuccini S, Petraglia F Recent advances in understanding and managing adenomyosis. F1000Res, 2019.PMID 30918629
12. [12]Bajaj S, Gopal N, Clingan MJ, et al. A pictorial review of ultrasonography of the FIGO classification for uterine leiomyomas. Abdom Radiol (NY), 2022.PMID 34581926