From the Guidelines
The PALM-COEIN classification system is the most effective approach to categorize and manage abnormal uterine bleeding (AUB) in women of reproductive age, as it encompasses both structural and non-structural causes 1.
Characteristics of PALM-COEIN
The PALM-COEIN system includes:
- Structural causes (PALM):
- Polyps: localized overgrowths of endometrial tissue
- Adenomyosis: endometrial tissue growing into the myometrium
- Leiomyoma: fibroids causing heavy bleeding and pelvic pressure
- Malignancy and Hyperplasia: presenting with postmenopausal bleeding or irregular heavy bleeding
- Non-structural causes (COEIN):
- Coagulopathy: heavy bleeding since menarche
- Ovulatory dysfunction: unpredictable bleeding patterns
- Endometrial: heavy regular bleeding
- Iatrogenic: medication side effects or IUD use
- Not yet classified: rare conditions like arteriovenous malformations
Diagnosis of PALM-COEIN
Diagnosis of each cause involves:
- Imaging studies such as ultrasound, MRI, or hysteroscopy
- Hormone level testing and ultrasound monitoring for ovulatory disorders
- Coagulation studies for coagulopathy
- Endometrial biopsy for malignancy, hyperplasia, and endometrial disorders
- History and physical examination for iatrogenic causes
Treatment of PALM-COEIN
Treatment options should be tailored to the specific cause of AUB, and may include medical management with progestin-only contraception, combined hormonal contraception, or other hormonal therapies, as well as surgical options such as polypectomy, myomectomy, or hysterectomy 1. Treatment options for each cause include:
- Medical management with GnRH agonists, hormonal therapy, or hemostatic agents like tranexamic acid
- Surgical options such as polypectomy, myomectomy, or hysterectomy
- Endometrial ablation for heavy regular bleeding
- Changing medications or removing/replacing IUDs for iatrogenic causes
- Embolization or surgery for rare conditions like arteriovenous malformations
From the Research
Characteristics of PALM-COEIN
- The PALM-COEIN classification system is used to define the underlying causes of abnormal uterine bleeding (AUB) in nonpregnant reproductive-aged women 2, 3, 4, 5, 6
- The system categorizes the causes of AUB into two main groups: structural (PALM) and nonstructural (COEIN) entities 3, 4, 6
- PALM refers to discrete structural entities, including:
- Polyp
- Adenomyosis
- Leiomyoma
- Malignancy and hyperplasia
- COEIN refers to nonstructural etiologies, including:
- Coagulopathy
- Ovulatory dysfunction
- Endometrial disorders
- Iatrogenic
- Not yet classified
Diagnosis of PALM-COEIN
- A complete patient history is essential in the evaluation of AUB, combined with appropriate imaging, histopathologic analysis, or laboratory evaluation to ensure accurate diagnosis and treatment approaches 2
- A focused menstrual history and pelvic examination are necessary to differentiate anovulatory bleeding from other causes of bleeding 4
- Endometrial biopsy is indicated for women with AUB who are older than 45 years or have postmenopausal bleeding, as well as for those with specific risk factors for endometrial cancer 6
Treatment of PALM-COEIN
- Management of AUB is determined by its etiology and typically consists of medical therapy, such as combination oral contraceptives, progestin-containing intrauterine devices, tranexamic acid, and nonsteroidal anti-inflammatory drugs 6
- Patients with structural lesions may require surgical procedures, such as hysterectomy, myomectomy, or polypectomy 5
- Management should be individualized, taking into account the patient's desire for current or future fertility 6