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 category having distinct diagnostic procedures and treatment plans. For the PALM (structural) category:

• Polyps present as focal growths with irregular bleeding, diagnosed via sonohysterography or hysteroscopy showing pedunculated masses, and treated with 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, with uterine artery embolization (UAE) also being a viable option for symptom control, as shown in recent studies with long-term follow-up 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.
• Malignancy presents with irregular bleeding and is diagnosed through endometrial biopsy showing atypical cells, requiring surgical staging and treatment with hysterectomy plus adjuvant therapy based on stage.

For COEIN (non-structural) causes:

• Coagulopathy involves bleeding disorders with heavy menstrual bleeding, diagnosed through coagulation studies showing abnormal clotting factors, and treated with hormonal therapy plus specific factor replacement.
• Ovulatory disorders present with irregular bleeding patterns, diagnosed through hormone levels and ultrasound showing anovulation, and managed with hormonal regulation, including progestin-only contraception and combined hormonal contraception 1.
• Endometrial disorders cause unpredictable bleeding without structural abnormalities, diagnosed by excluding other causes, and treated with hormonal therapy.
• Iatrogenic causes stem from medications or devices, diagnosed through medication review, and managed by modifying the causative agent.
• Not otherwise classified includes rare conditions requiring specialized testing and individualized treatment plans.

The most recent and highest quality study, 1, provides a comprehensive overview of the PALM-COEIN classification system and its application in clinical practice, emphasizing the importance of a thorough history, physical examination, and appropriate laboratory tests, as well as imaging to assess for structural abnormalities. The use of the PALM-COEIN classification system, in conjunction with the latest diagnostic and treatment options, can significantly improve patient outcomes and quality of life.

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.