International Journal of Reproduction, Contraception, Obstetrics and Gynecology

Mitra N et al. Int J Reprod Contracept Obstet Gynecol. 2020 Feb;9(2):799-803

www.ijrcog.org pISSN 2320-1770 | eISSN 2320-1789

DOI: http://dx.doi.org/10.18203/2320-1770.ijrcog20200380
Original Research Article

Etiological factors of abnormal uterine bleeding according to PALM-

COEIN classification in perimenopausal women in a
tertiary care centre
Nishi Mitra*, Pooja Patil, Ayushi Sethia

Department of Obstetrics and Gynecology, L. N. Medical College and J. K. Hospital, Bhopal, Madhya Pradesh, India

Received: 25 December 2019

Accepted: 04 January 2020

*Correspondence:
Dr. Nishi Mitra,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Perimenopause is described as years prior to menopause that encompasses the change from normal
ovulatory cycle to cessation of menses, ending 12 months after the last menses. International federation of
gynaecology and obstetrics (FIGO) developed a new classification PALM-COEIN in order to standardize the factors
associated with AUB. It classifies AUB as polyp, adenomyosis, leiomyoma, malignancy and hyperplasia (PALM) -
structural abnormalities Coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not yet classified (COEIN) -
unrelated to structural abnormalities. Objectives of this study were to categorise the causes of AUB in perimenopausal
women in context to PALM COEIN classification system. Correlation of co-morbities (diabetes, hypertension and
thyroid disorders) with AUB in perimenopausal age group.
Methods: This is a retrospective study from the month of May 2019 to October 2019, considering 100 patients of
perimenopausal age group (40 to 55 years of age group) in J. K. Hospital Bhopal, Madhya Pradesh with complaints of
abnormal uterine bleeding, admitted in gynae ward.
Results: Most of the patients in the current study were between 45-50 years of age i.e. 44%. Menorrhagia was the
commonest menstrual disorder encountered in 52% of patients. As per FIGO; AUB-L constituted 42% AUB-O
constituted 12%, AUB-P constituted 11%, AUB-A 10%, AUB-M constituted 8% AUB-E constituted 8%, not yet
classified constituted 4% of total cases.
Conclusions: AUB (PALM-COEIN) for causes of abnormal uterine bleeding classification was very useful in
categorizing cases of AUB. It suggests that etiology of AUB and also gives place for presence of multiple factors as a
cause of AUB in a particular case.

Keywords: Abnormal uterine bleeding, Adenomyosis, Leiomyoma, Menorrhagia, PALM COEIN, Perimenopause

INTRODUCTION or after menopause in frequency, duration, and amount of

blood flow.1
Perimenopause is described as transitional years prior to
menopause that encompasses the change from normal Earlier there was a lot of discrepancy in the nomenclature
ovulatory cycle to cessation of menses. used to describe abnormal uterine bleeding (AUB). The
development of consistent and universally accepted
Abnormal uterine bleeding (AUB) is the commonest nomenclature was a step toward rectifying this
menstrual problem during peri menopause. AUB is a unsatisfactory circumstance, thus PALM COEIN
bleeding pattern differing from normal menstrual pattern classification was adopted by FIGO (international
federation of gynaecology and obstetrics) in order to

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standardize the factors associated with AUB. It classifies headache, dizziness, palpitations, breast pain and
AUB as polyp, adenomyosis, leiomyoma, malignancy enlargement, joint aches and back pain
and hyperplasia (PALM) - structural abnormalities. • Other symptoms: urinary incontinence, dry, itchy
Coagulopathy, ovulatory dysfunction, endometrial, skin, weight gain
iatrogenic, not yet classified (COEIN) - unrelated to • Causes of perimenopausal bleeding range from
structural abnormalities.2 commonly anovulatory cycles; but heightened
concerns about pathologic anatomy (hyperplasia,
Another requirement is the development of a polyps, submucous myomas and even frank
classification system, on several levels for the causes of carcinoma) have made invasive diagnostic
AUB, which can be used by clinicians, investigators, and procedures common requirement in addition to
even patients to facilitate communication, clinical care, clinical3
and research and presents for consideration of the PALM- • Age of onset of perimenopause in 95% women is 39
COEIN classification system for AUB, which has been to 51 years. Average age of onset is 46 years. The
approved by the International Federation of gynaecology duration of perimenopausal transition is 2 to 8 years.
and obstetrics (FIGO) Executive Board as a FIGO The average duration of menopausal transition is 5
classification system. DUB should be replaced by years. Indian women menopause occurs at 45 years
coagulopathy, endometrial and ovulatory disorders.3 and thus 40 years can be taken as lower limit of
perimenopause.7 AUB is the commonest menstrual
Terminologies used for diagnosis that are now included problem during perimenopause which is defined as
in AUB the period of 2-8 years preceding menopause and 1
year after the final menses. Follicular development at
• Amenorrhea: The absence of menstrual bleeding for this time has been demonstrated to be erratic, with
more than 6 months consequent variability in oestrogen levels and an
• Breakthrough bleeding: intermenstrual bleeding that increased percentage of anovulatory cycles making
occur despite the use of exogenous hormones them more likely to experience abnormal uterine
• Dysmenorrhea: painful menses bleeding.8
• Menorrhagia: prolonged menstrual bleeding that is
excessive in amount, duration or both that occurs in METHODS
regular intervals
• Metrorrhagia: bleeding between menses This is a retrospective study from the month of May 2019
• Oligomenorrhea: bleeding that occurs less frequently to October 2019, considering 100 patients of
than every 35 days perimenopausal age group (40 to 55 years of age group)
• Polymenorrhea: bleeding that occurs more often than in J. K. Hospital Bhopal, Madhya Pradesh with
21 days complaints of abnormal uterine bleeding, admitted in
• Postmenopausal bleeding: uterine bleeding occurring gynae ward.
more than 12 months after the last menstrual period
of a menopausal women. Data collection from past files was done and patients with
complaints of AUB classified according to PALM-
Histological assessment remains the cornerstone in the COEIN classification.
current practice in patients of AUB as it provides the
diagnosis and guides for the correct management plan. Correlation made with respect to comorbidities, such as
diabetes, hypertension and thyroid disorders.
Abnormal uterine bleeding affects 10 to 30 percent of
reproductive-aged women and up to 50 percent of A proforma was filled by obtaining the detailed history
perimenopausal women.4,5 from the file of the patient which included: symptoms
like dysmenorrhea, dyspareunia, postcoital bleeding
Transitions are enumerated below6 intermittent spotting, unhealthy discharge, foul smelling
discharge, heaviness and discomfort in the lower
abdomen, backache and any other constitutional
• Changes in menstrual patterns includes: typical
symptoms.
Shorter cycles (by 2-7 days), longer cycles possible,
Irregular bleeding with spotting
A detailed obstetric history was also noted including total
• Vasomotor symptoms: hot flushes Night sweats,
number of deliveries weather normal/caesarean/forceps,
Sleep disturbances
no. of abortions. H/o sterilization, contraception,
• Psychological and metal disturbances: worsening of
especially IUCDs and OC Pills was also filled. Any
premenstrual symptoms, depression, mood swings,
postpartum / post-operative complications, past history of
irritability, loss of concentration, and poor memory
similar episode was noted and the details of the treatment
• Sexual dysfunction: vaginal dryness, decreased given, whether hormonal/surgical was also taken in
libido, painful intercourse. Somatic symptoms account. Personal, past and family history was also
recorded. In every patient per speculum examination and

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per vaginal examination performed was recorded. Table 2: Distribution of patients according to parity.
According to findings on history and clinical examination
provisional clinical diagnosis was made, which was later Parity No. of patients %
confirmed by ultrasonography and histopathology. <2 28 28%
2-4 45 45%
Inclusion criteria >4 27 27%

• All women in perimenopausal age group admitted in Table 3, in our study hypertension was found in 18%
gynae ward with complaint of Abnormal uterine patients, diabetes in 12% patients with AUB,
bleeding. hypothyroidism in 6% patients of AUB.
Exclusion criteria Table 3: Distribution of patients according
to comorbidities.
• All women with abnormal uterine bleeding with any
adnexal pathology, AUB With IUCD in situ, AUB Comorbidities No. of patients with AUB
with any other gynaecological comorbidities such as
Diabetes 12%
uterine prolapse.
Hypertension 18%
Statistical analysis Hypothyroidism 6%

Incidence rate Table 4, shows that menorrhagia was the commonest

menstrual disorder encountered in 52 cases (52%),
Patients presenting with different classes of AUB followed by metrorrhagia 16%, menometrorrhagia 12%,
(PALM − COEIN) hypomenorrhea 10%, polymenorrhea 8%, metropathica
= × 100 hemorrhagica in 2% cases.
Total no of patients
(sample size)
Table 4: Distribution of cases according to
The date was entered in Microsoft Excel 2016 (MSO) their symptoms.
and incidence rate was calculated using the above
formula. No. of
Menstrual complaint %
patients
RESULTS Menorrhagia 52 52%
Metrorrhagia 16 16%
Forty four percent women were in 45-50 years, 32% in menometrorrhagia 12 12%
40-45 years and 24% were in 50-55 years age group Polymenorrhhea 8 8%
(Table 1). Most of women were multiparous having 2-4 Hypomenorrhea 10 10%
children, i.e. 45% (Table 2). Hypertension as a Amenorrhea followed by
comorbidity was present in 18% of the patients (Table 3). prolonged bleeding per vaginum 2 2%
Majority of women came with chief complaint of (metropathica hemorrhagica)
menorrhagia (52%) followed by metrorrhagia (16%)
(Table 4).
50
Table 1: Distribution of cases according to age.
40

Age group of patients No. of patients % 30

40-45 32 32% 20
45-50 44 44% 10
50-55 24 24% 0

Table 1 shows that about 44% of patients of the

perimenopausal age group belong to 45-50 years
followed by 32% of patients belonging to 40-45 years of
age group. However, AUB in our study was found to be
less common in the age group of 50-55 years.

Table 2 shows that AUB was more common in Figure 1: Incidence of causes of abnormal
multiparous patients than in primiparous patients. Among uterine bleeding.
the total AUB patients only 28% were primipara and the
rest 72% were multipara. Figure 1 shows that in our study 42% cases had
leiomyoma which is the leading cause of AUB in

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 Mitra N et al. Int J Reprod Contracept Obstet Gynecol. 2020 Feb;9(2):799-803

perimenopausal patients. AUB-O constituted 12%, AUB- Higher association of AUB is seen with submucosal type,
P constituted 11%, AUB-A 10%, AUB-M constituted 8% compared to intramural and subserous type. In
AUB-E constituted 8%, not yet classified constituted 4% perimenopausal years, ovulatory disorders are common
of total cases. due to derangements in the hypothalamo-pituitary-
ovarian axis resulting in derangements of follicular
DISCUSSION maturation, ovulation or corpus luteum formation,
anovulatory cycles are most frequent, and chronic
Previously, there use to be a general inconsistency in the anovulation is associated with an irregular and most
nomenclature to describe AUB (abnormal uterine unpredictable pattern of bleeding. This explains why
bleeding). As there was no universally accepted format to ovulatory disorders were found to be the second most
describe the commonest gynaecological problem. Thus, common cause of AUB in this study and many other
there was an urgent need for the development of studies. The other important cause of AUB was
consistent and universally accepted nomenclature of Adenomyosis. The unopposed oestrogenic action on the
abnormal uterine bleeding. So, development of PALM- endometrium in the anovulatory cycles found in
COEIN classification was a step toward to rectify this perimenopausal women predisposes them to develop
unsatisfactory circumstance. This manuscript describes hyperplasia and eventually endometrial carcinoma. This
an ongoing process designed to achieve these goals, and is due to the fact that perimenopausal women have more
presents for consideration of the PALM-COEIN (polyp; anovulatory cycles.3 In the majority of women with true
adenomyosis; leiomyoma; malignancy and hyperplasia; anovulatory bleeding, the menstrual history alone can
coagulopathy; ovulatory dysfunction; endometrial; establish the diagnosis with sufficient confidence and
iatrogenic; and not yet classified) classification system treatment can begin without any additional lab evaluation
for AUB, which has been approved by the International or imaging. In frequent, irregular, unpredictable
Federation of Gynecology and Obstetrics (FIGO) menstrual bleeding that varies in amount, duration and
Executive board as a FIGO classification system.9,10 This character and is not preceded by any recognisable or
universal classification system for the causes of AUB can consistent pattern are not difficult to interpret.
be used by all the clinicians, investigators, and even Conversely, regular monthly periods that are heavy or
patients worldwide to facilitate communication, clinical prolonged are more likely related to an anatomical cause
care, and research. In our study, we studied or a bleeding disorder.8 This may be because most
retrospectively, 100 cases of AUB in the perimenopausal women in this category tend to have no definable cause
age group (40-55 year). Most of the patients with AUB in of AUB.
the present study were between 45-50 years i.e. 44%.
There were 32% patients in 40-45 years’ age group, 24% CONCLUSION
in 50-55 years’ age group. AUB in our study was found
to be less common in the age group of 50-55 years. As In perimenopausal women after clinical examination
found in the study of Urvashi et al where AUB was found (speculum and bimanual) and Pap smear,
common in 44-47 years age group.11 AUB was more ultrasonography should be first investigation as it is
common in multiparous patients than in primiparous easily available, less expensive, safe and non-invasive
patients. Similar results have been shown by Dr. Kumar method. It excludes those adnexal or myometrial
Suneet in his study.12 In our study hypertension was pathologies which may be missed in clinical assessment.
found in 18% patients, followed by diabetes in 12%
patients of AUB, followed by hypothyroidism in 6% Funding: No funding sources
patients. In the study done by Subedi et al, thyroid Conflict of interest: None declared
disorders was present in 10.6% patients with AUB. Thus, Ethical approval: The study was approved by the
there stands an association among non-structural causes Institutional Ethics Committee
of AUB and medical disorders.13 Menorrhagia was the
commonest menstrual disorder encountered in 52 cases REFERENCES
(52%), followed by metrorrhagia 16%, menometrorrhagia
12%, hypomenorrhea 10%, polymenorrhea 8%, 1. Singh K, Agarwal C, Pujani M, Raychaudhuri S,
metropathica hemorrhagica in 2% cases. Our study Sharma N, Chauhan V, et al. A clinicopathological
correlated well with study done by Pillai GS et al.9 In our correlation of international federation of gynecology
study 42% cases had leiomyoma which was found to be and obstetrics’s PALM-COEIN classification of
the leading cause of AUB in perimenopausal patients. abnormal uterine bleeding: Indian scenario. J -Life
AUB-O constituted 12%, AUB-P constituted 11%, AUB- Health. 2019;10(3):147.
A 10%, AUB-M constituted 8% AUB-E constituted 8%, 2. Munro MG, Critchley HO, Fraser IS, FIGO
not yet classified constituted 4% of total cases. Similarly, Menstrual Disorders Committee, Haththotuwa R,
Study done by Singh A et al also showed leiomyoma as Kriplani A, Bahamondes L, Füchtner C, Tonye R,
the leading cause of AUB followed by ovulatory cause, Archer D, Abbott J. The two FIGO systems for
various other researchers also supported the study.4,14,15 normal and abnormal uterine bleeding symptoms and
Histopathological pattern of endometrium in women with classification of causes of abnormal uterine bleeding
AUB is quite variable depending upon age and parity.

International Journal of Reproduction, Contraception, Obstetrics and Gynecology Volume 9 · Issue 2 Page 802
 Mitra N et al. Int J Reprod Contracept Obstet Gynecol. 2020 Feb;9(2):799-803

in the reproductive years: 2018 revisions. Int J reproductive age. Int J Gynecol Obstet. 2011;113:3-
Gynecol Obstet. 2018;143(3):393-408. 13.
3. Palwade JM, Borole CS. A study of causes of 11. Verma U, Garg R, Singh S, Yadav P, Rani R.
abnormal uterine bleeding with respect to FIGO Diagnostic Approach in Perimenopausal Women
classification in the patients at perimenopausal age. with Abnormal Uterine Bleeding. J South Asian Fed
Int Med J. 2016;3(11):5. Menopause Soc. 2014 Jan 1;2:12-4.
4. Sun Y, Wang Y, Mao L, Wen J, Bai W. Prevalence 12. Kumar S. Clinicopathological study of abnormal
of abnormal uterine bleeding according to new uterine bleeding in North Indian patients. Asian J
International Federation of Gynecology and Biomed Pharma Sci. 2016;6(53):50-1.
Obstetrics classification in Chinese women of 13. Subedi S, Banerjee B, Manisha C. Thyroid disorders
reproductive age: a cross-sectional study. Medicine in women with dysfunctional uterine bleeding. J
(Baltimore). 2018;97(31):e11457. Pathol Nepal. 2016 Sep 24;6(12):1018-20.
5. Prentice A. When does heavy flow merit treatment? 14. Singh A, Choudhary A. A study of PALM-COEIN
Practitioner. 2000;244:174-9. Classification of Abnormal Uterine Bleeding (AUB)
6. Jones HW, Rock JA, Te Linde's Operative in Perimenopausal Women at a Tertiary Care
gynecology, 11th ed. 2015:555. Teaching Hospital. J Med Sci Clinical Res.
7. Singh S, Yadav P, Rani R, Verma U. Diagnostic 2018;6(6):287-92.
approach in perimenopausal women with abnormal 15. Sabbioni L, Zanetti I, Orlandini C, Petraglia F, Luisi
uterine bleeding. J SAFOMS. 2014;2(1):12-4. S. Abnormal uterine bleeding unrelated to structural
8. Mishra D, Sultan S. FIGO’s PALM-COEIN uterine abnormalities: management in the
Classification of abnormal uterine bleeding: a perimenopausal period. Minerva Ginecol.
clinico-histopathological correlation in Indian 2017;69(1):75-83.
setting. J Obstet Gynecol India. 2017;67(2):119-25.
9. Sethi B, Dhaded AV, Mathur PR. Dysfunctional Cite this article as: Mitra N, Patil P, Sethia A.
uterine bleeding. J Obstet Gynecol India. Etiological factors of abnormal uterine bleeding
2002;52(3):87-9. according to PALM- COEIN classification in
10. Munro MG, Critchley HOD, Broder. FIGO perimenopausal women in a tertiary care centre. Int J
classification system (PALM-COEIN) for causes of Reprod Contracept Obstet Gynecol 2020;9:799-803.
abnormal uterine bleeding in nongravid women of

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