What are the salient features, diagnostic procedures, and treatment plans for each condition in the PALM-COEIN (Polyp, Adenomyosis, Leiomyoma, Malignancy and Hyperplasia, Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, and Not yet classified) classification of Abnormal Uterine Bleeding (AUB)?

From the Guidelines

The PALM-COEIN classification system is the most effective way to categorize and manage abnormal uterine bleeding (AUB), with each condition having distinct diagnostic procedures and treatment plans. The PALM-COEIN system categorizes AUB into structural (PALM) and non-structural (COEIN) causes.

Structural Causes (PALM)

• Polyps: present as focal growths with irregular bleeding, diagnosed via sonohysterography or hysteroscopy showing pedunculated masses, and treated with hysteroscopic polypectomy 1.
• Adenomyosis: involves endometrial tissue within the myometrium causing heavy, painful periods, diagnosed through MRI or transvaginal ultrasound showing thickened junctional zone, and managed with hormonal therapy (OCPs, progestins, or LNG-IUD) or hysterectomy for severe cases 1.
• Leiomyomas (fibroids): are benign smooth muscle tumors causing heavy bleeding and pelvic pressure, identified via ultrasound or MRI showing well-circumscribed masses, and treated based on size and symptoms with options including watchful waiting, hormonal therapy, uterine artery embolization, myomectomy, or hysterectomy 1.
• Malignancy and hyperplasia: involve abnormal endometrial growth with irregular bleeding, diagnosed through endometrial biopsy showing atypical cells or invasion, and treated with hysterectomy plus adjuvant therapy for cancer or progestin therapy for hyperplasia 1.

Non-Structural Causes (COEIN)

• Coagulopathy: involves bleeding disorders causing heavy menstrual bleeding, diagnosed through coagulation studies showing abnormal clotting factors, and treated with hormonal therapy plus specific factor replacement 1.
• Ovulatory disorders: present with irregular, unpredictable bleeding, diagnosed through hormone levels and ultrasound showing anovulation, and managed with hormonal regulation using OCPs or cyclic progestins 1.
• Endometrial disorders: involve abnormal local hemostasis causing heavy regular bleeding, diagnosed by excluding other causes, and treated with NSAIDs, tranexamic acid, or hormonal methods 1.
• Iatrogenic causes: stem from medications or devices disrupting normal patterns, diagnosed through medication review, and managed by modifying the causative agent 1.
• Not otherwise classified: includes rare conditions like arteriovenous malformations, diagnosed through specialized imaging, and treated based on the specific underlying condition 1. The most recent and highest quality study 1 supports the use of the PALM-COEIN classification system for the diagnosis and management of AUB, with a focus on individualized treatment plans based on the underlying cause of bleeding.

From the Research

Salient Features of PALM-COEIN Classification

• The PALM-COEIN classification system is used to categorize the causes of Abnormal Uterine Bleeding (AUB) in non-pregnant women into structural (PALM) and non-structural (COEIN) causes 2, 3, 4, 5, 6.
• PALM refers to discrete structural entities such as polyp, adenomyosis, leiomyoma, malignancy, and hyperplasia 3, 4, 5, 6.
• COEIN refers to non-structural etiologies such as coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified 3, 4, 5, 6.

Diagnostic Procedures for AUB

• A complete patient history combined with appropriate imaging, histopathologic analysis, or laboratory evaluation is necessary for accurate diagnosis and treatment approaches to AUB 3.
• Ultrasound is usually the first-line imaging technique for the differential diagnosis of causes of AUB 2.
• Computed Tomography (CT) may be useful if ultrasound findings are unclear, especially in emergency settings 2.
• Magnetic Resonance Imaging (MRI) is an excellent second-line diagnostic tool for a better non-invasive characterization of the underlying cause of AUB 2.
• Endometrial biopsy is indicated for women with AUB who are older than 45 years or have postmenopausal bleeding, or if specific risk factors for endometrial cancer are present 5.

Treatment Plans for AUB

• 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 5.
• Patients with structural lesions may require surgical procedures 5.
• Management should be individualized and patient desire for current or future fertility should be considered 5.