What are the management strategies for each category of the PALM-COEIN (Polyps, Adenomyosis, Leiomyomas, Malignancy or hyperplasia, Coagulopathy, Ovulatory dysfunction, Endometrial causes, Iatrogenic causes, Not yet classified) classification system for abnormal uterine bleeding (AUB)?

Management Strategies for PALM-COEIN Classification of Abnormal Uterine Bleeding

The levonorgestrel-releasing intrauterine device (LNG-IUD) should be the first-line medical treatment for most categories of abnormal uterine bleeding, reducing menstrual blood loss by 71-95%, with hysterectomy reserved for medical management failures or contraindications. 1

Structural Causes (PALM)

P - Polyps

• Hysteroscopy with polypectomy is the definitive management for endometrial polyps causing abnormal bleeding 1
• Hysteroscopy allows direct visualization of the endometrial cavity and endocervix, diagnosing focal lesions that may be missed by endometrial sampling alone 1
• Medical management with LNG-IUD can be attempted first if surgical intervention is not immediately feasible 1

A - Adenomyosis

• LNG-IUD remains first-line therapy, providing significant reduction in menstrual blood loss 1
• Combined hormonal contraceptives (CHCs) with NSAIDs can reduce bleeding volume further 1
• Adenomyosis frequently coexists with fibroids and presents with heavy menstrual bleeding, dysmenorrhea, and dyspareunia, commonly affecting women in their 40s 1
• Hysterectomy is the definitive treatment when medical management fails, as adenomyosis cannot be surgically excised while preserving the uterus 2
• GnRH agonists or antagonists (elagolix, linzagolix, relugolix) can effectively reduce bleeding symptoms but provide only temporary relief 2

L - Leiomyomas (Fibroids)

• Medical management should be trialed first before considering hysterectomy 2
• First-line options include:
  • LNG-IUD (71-95% reduction in menstrual blood loss) 1
  • NSAIDs and estrogen-progestin oral contraceptives 2
  • Tranexamic acid as a non-hormonal alternative 2
  • GnRH antagonists (elagolix, linzagolix, relugolix) that can significantly reduce both bleeding symptoms and fibroid volume 2
• Surgical management hierarchy:
  • Endometrial ablation as a less invasive alternative to hysterectomy with efficacy comparable to LNG-IUD 1
  • Uterine artery embolization (UAE) demonstrates significantly greater short-term benefits compared to hysterectomy but has increased percentage of long-term reintervention 2
  • Hysterectomy is the most appropriate definitive treatment, accounting for three-quarters of fibroid treatment in the United States, providing complete resolution of all fibroid-related symptoms and eliminating recurrence risk 2
• Patient age and fertility desires are critical factors in decision-making 2
• The least invasive surgical route should be chosen for hysterectomy based on uterine size and surgical expertise 2
• Studies demonstrate hysterectomy provides significantly better health-related quality-of-life advantage compared to other therapies 2

M - Malignancy and Hyperplasia

• Endometrial sampling is necessary in patients with risk factors for endometrial cancer 2
• Postmenopausal women are at highest risk for endometrial cancer, which is the most serious etiology and the main focus of evaluation 2
• When transvaginal ultrasound cannot completely evaluate the endometrium, MRI or endometrial sampling should be considered 2
• Hysterectomy is usually appropriate as the next step for postmenopausal patients with symptomatic bleeding and confirmed malignancy or atypical hyperplasia 2

Non-Structural Causes (COEIN)

C - Coagulopathy

• Combined hormonal contraceptives are effective for managing bleeding related to coagulopathies 1
• LNG-IUD provides excellent local hemostatic control 1
• Tranexamic acid is particularly useful as a non-hormonal option that directly addresses the bleeding mechanism 2
• Hematology consultation should be obtained for underlying coagulation disorder management 2

O - Ovulatory Dysfunction

• Medical treatments are highly effective for ovulatory dysfunction:
  • Progestin-only contraception 2
  • Combined hormonal contraceptives (CHCs) 2, 1
  • Oral progestins administered for 21 days per month for menstrual blood loss reduction, effective for women with cyclic heavy bleeding related to menstrual cycle 1
• Perimenopausal women often experience AUB due to anovulation, but structural causes must be ruled out first 2
• Endometrial ablation or hysterectomy should be considered when medical treatment fails or is contraindicated 2

E - Endometrial

• LNG-IUD is first-line therapy for primary endometrial disorders 1
• Oral progestins for 21 days per month can reduce menstrual blood loss 1
• If bleeding persists despite initial medical therapy, further investigation with imaging or hysteroscopy is indicated 1
• Endometrial ablation provides a less invasive alternative to hysterectomy with comparable efficacy to LNG-IUD 1

I - Iatrogenic

• Management depends on the specific iatrogenic cause:
  • For hormonal contraceptive-related bleeding: counseling on expected bleeding patterns, switching formulations, or adding supplemental estrogen 1
  • For anticoagulant-related bleeding: tranexamic acid or hormonal management with LNG-IUD or CHCs 1
  • For IUD-related bleeding: NSAIDs, tranexamic acid, or device removal if persistent 1

N - Not Yet Classified

• Empiric treatment with LNG-IUD or combined hormonal contraceptives is appropriate while pursuing further diagnostic evaluation 1
• If bleeding persists despite initial medical therapy, further investigation with imaging or hysteroscopy is indicated 1

Critical Management Algorithm

Step 1: Attempt medical management first with LNG-IUD as the most effective option (71-95% reduction in menstrual blood loss) 1

Step 2: If LNG-IUD is contraindicated or declined, use combined hormonal contraceptives with NSAIDs or oral progestins for 21 days per month 1

Step 3: Consider tranexamic acid or GnRH antagonists for specific scenarios (fibroids, non-hormonal preference) 2

Step 4: If medical management fails after adequate trial, proceed to endometrial ablation as a less invasive surgical option 1

Step 5: Hysterectomy is the definitive treatment when medical management fails or is contraindicated, particularly in postmenopausal women or those with completed childbearing who desire permanent resolution 2, 1

Common Pitfalls to Avoid

• Do not proceed directly to hysterectomy without attempting medical management first, unless malignancy is confirmed or medical management is contraindicated 2
• Do not rely solely on endometrial sampling to rule out structural lesions; hysteroscopy may be necessary to visualize focal lesions missed by sampling 1
• Do not forget that adenomyosis frequently coexists with fibroids, affecting treatment planning 2, 1
• Do not overlook the need for endometrial sampling in patients with risk factors for endometrial cancer before initiating treatment 2
• Medical menopause with GnRH agonists/antagonists is temporary and symptoms return after discontinuation, so this should not be considered definitive management 2