Journal of Midwifery & Womens Health www.jmwh.

org
Brief Report

PALM-COEIN Nomenclature for Abnormal Uterine

Bleeding
CEU
Angela Deneris, CNM, PhD

Approximately 30% of women will experience abnormal uterine bleeding (AUB) during their life time. Previous terms defining AUB have been
confusing and imprecisely applied. As a consequence, both clinical management and research on this common problem have been negatively
impacted. In 2011, the International Federation of Gynecology and Obstetrics (FIGO) Menstrual Disorders Group (FMDG) published PALM-
COEIN, a new classification system for abnormal bleeding in the reproductive years. Terms such as menorrhagia, menometrorrhagia, metrorrha-
gia, dysfunctional uterine bleeding, polymenorrhea, oligomenorrhea, and uterine hemorrhage are no longer recommended. The PALM-COEIN
system was developed to standardize nomenclature to describe the etiology and severity of AUB. A brief description of the PALM-COEIN nomen-
clature is presented as well as treatment options for each etiology. Clinicians will frequently encounter women with AUB and should report findings
utilizing the PALM-COEIN system.
J Midwifery Womens Health 2016;61:376379  c 2016 by the American College of Nurse-Midwives.

Keywords: PALM-COEIN, abnormal uterine bleeding, polyps, adenomyosis, leiomyoma, endometrial intraepithelial neoplasia, endometrial
cancer, ovarian dysfunction, endometrial dysfunction

INTRODUCTION
Approximately 30% of women experience abnormal uterine
bleeding (AUB) during their lifetime, most often in the years
prior to menopause.1 The impact of AUB includes blood
loss, pain, and diminished sexual health and productivity; in-
creased use of health care services; and cost.2 The first sign
of endometrial cancer is chronic AUB and screening for this
condition should be kept in mind when evaluating a womans
symptoms. The American Cancer Society reports approx-
imately 52,000 women in the United States are diagnosed
with endometrial cancer annually.3 Many confusing terms
have been used to refer to abnormal uterine bleeding, includ-
ing menorrhagia, menometrorrhagia, metrorrhagia, dysfunc-
tional uterine bleeding, polymenorrhea, oligomenorrhea, and
uterine hemorrhage. A lack of clear definitions has hampered
research and interpretation of clinical data worldwide. Begin-
ning in 2005, an initiative by the International Federation of
Gynecology and Obstetrics (FIGO) began to clarify terms and
definitions. In 2010, FIGO adopted a system developed by the
FIGO Menstrual Disorders Group (FMDG) called the PALM-
COEIN Classification for Causes of Abnormal Bleeding.4 In
2013, the American College of Obstetricians and Gynecolo-
gists (ACOG) endorsed the PALM-COEIN system, and re-
searchers and clinicians are strongly advised to adopt the AUB
PALM-COEIN system worldwide.5 This article presents the
PALM-COIEN system as a resource for clinicians to encour-
age adoption of its use.
DEFINITION OF ABNORMAL UTERINE BLEEDING
When a woman subjectively reports changes outside of
her expected pattern of uterine bleeding to her health care
provider, her description meets the criteria for further evalu-
ation. A thorough history is considered sufficient to make the
diagnosis of AUB. There has been general confusion about
Address correspondence to Angela Deneris, CNM, PhD, College of Nurs-
ing, University of Utah, 2000 East 10 South, Salt Lake City, UT 84112.
E-mail: angela.deneris@nurs.utah.edu
previous terms to describe AUB and they have been applied
inconsistently. The PALM-COEIN system was developed
to simplify definitions of AUB and is recommended to be
utilized by clinicians, educators, and clinical investigators.
The terms menometrorrhagia and menorrhagia have been
replaced by chronic AUB, which is defined as abnormal
uterine bleeding for at least 4 out of 6 months, with abnormal
bleeding expressed as increased volume, regularity, and/or
timing. Acute AUB is defined as a single episode of severe
uterine bleeding that is sufficient to require immediate inter-
vention to prevent further blood loss. The term metrorrhagia
has been replaced by intermenstrual bleeding (AUB/IMB),
which is uterine bleeding that occurs between regular men-
strual cycles. Intermenstrual bleeding may be either random
or predictable.4 Heavy menstrual bleeding (AUB/HMB) is
defined by the womans description of increased menstrual
volume that interferes with her physical, emotional, and
social quality of life. It can be objectively defined by a drop in
hemoglobin and number of menstrual products used, such
as tampons and/or pads per day.6
THE INTERNATIONAL FEDERATION OF
GYNECOLOGY AND OBSTETRICS PALM-COEIN
CLASSIFICATION SYSTEM
There is a wide spectrum of causes of AUB, from reproduc-
tive tract disease, iatrogenic causes and systemic disease, as
well as proliferative bleeding in the perimenopause period.1 In
the PALM-COEIN classification system, PALM refers to the
structural causes of AUB, COEIN refers to the nonstructural
causes of AUB (Table 1).
Structural Causes of Abnormal Uterine Bleeding:
PALM
Polyp: AUB-P
Polyps are epithelial proliferations of the endometrial glands
and stromal tissue, with a vascular pedicle. Intrauterine polyps

376 1526-9523/09/$36.00 doi:10.1111/jmwh.12440 

c 2016 by the American College of Nurse-Midwives
 Abnormal uterine bleeding is a common problem during a womans lifetime.
Terms previously used to describe abnormal uterine bleeding have been confusing and imprecisely applied.
The PALM-COEIN system utilizes nomenclature that will uniformly define abnormal uterine bleeding and the causes of
the bleeding.
Midwives and other womens health clinicians will frequently manage women experiencing abnormal uterine bleeding or
refer for specialty care.
are frequently the cause of intermenstrual or chronic AUB and
infertility. The etiology of polyps is unknown; women have
an increased incidence of polyps as they age. Polyps are rarely
malignant. Endometrial biopsy is not effective for the diagno-
sis of polyps; they are most often diagnosed by transvaginal
ultrasound with or without saline infusion or 3-dimensional
ultrasound. Polyps can be single or multiple, and of variable
dimensions.7 The current PALM-COEIN system does not ad-
dress size or number of polyps.4 Although polyps are usually
benign, unless they are small, they will likely continue to cause
chronic AUB until they are removed, usually by hysteroscopy.7
Table 1. PALM-COEIN Classification Nomenclature
P Polyps
A Adenomyosis
L Leiomyoma
M Malignant and premalignant
C Coagulopathies
O Ovarian dysfunction
E Endometrial dysfunction
I Iatrogenic
N Not otherwise classified
Adenomyosis: AUB-A
Adenomyosis is a common disorder that causes uterine
enlargement, severe dysmenorrhea, and chronic AUB and is
usually diagnosed in women who are aged between 30 and
45 years. It is unclear why adenomyosis occurs; however, it
is more common after a history of uterine surgery, including
cesarean birth. Adenomyosis is defined by the presence of en-
dometrial glands and stroma found within the myometrium
and the depth of hyperplasia into the smooth muscle can
vary. Adenomyosis can be classified as diffuse, focal, or
polypoid.8 The current PALM-COEIN system does not de-
fine the extent of the adenomyosis. Historically, adenomyosis
was diagnosed histologically following hysterectomy, but
currently it is diagnosed by ultrasound or magnetic resonance
imaging (MRI). Treatment can include nonsteroidal anti-
inflammatory drugs (NSAIDs); a levonorgestrel-releasing
intrauterine device (LNG-IUD) (Mirena, Skyla, Liletta);
conservative excision if focal; and uterine artery embolization
or endometrial ablation if the adenomyosis depth is less
Journal of Midwifery & Womens Health r www.jmwh.org
than 2.5 mm.8,9 If the disease is extensive, hysterectomy is
recommended.
Leiomyoma: AUB-L
Uterine leiomyoma (fibroid or myoma) is a benign fibro-
muscular tumor of the myometrium. Leiomyomatas are the
most common pelvic tumor that occurs as women age. Most
leiomyomatas are asymptomatic, but if large, they can cause
significant morbidity, such as pelvic pressure and/or pain
and chronic AUB if they are submucosal.10 The primary
PALM-COEIN system only reflects the presence or absence
of leiomyoma, regardless of size, location, or number. How-
ever, a subclassification system indicates the location of the
leiomyomas, which is found in Figure 1.4 If a leiomyoma
is asymptomatic, no treatment is required, and the leiomy-
oma most likely will regress after menopause. If a leiomy-
oma is large enough to cause pain or pressure on pelvic or-
gans, gonadotropin-releasing hormone (GnRH) agonists (eg,
Lupron), mifepristone (Mifeprex/RU486), ulipristal acetate
(Ella), and aromatase inhibitors have all been used to reduce
the size of the leiomyoma before scheduling a myomectomy
or hysterectomy.10 Uterine artery embolization or hysterec-
tomy may be recommended depending on the womans age
and desire for reproduction. If the leiomyoma is submucosal
and causing chronic AUB, hysteroscopic resection is very ef-
fective in resolving symptoms.11
Malignancy and Hyperplasia: AUB-M
The M designation indicates either endometrial intraepithe-
lial neoplasia, a new term for atypical complex hyperplasia,
which is a premalignant condition, or endometrial cancer.4
The incidence of both diagnoses is increasing as the number
of women with obesity and diabetes increases. Hyperplasia
and endometrial cancer are most commonly caused by un-
opposed estrogen exposure from anovulation and exogenous
estrogen use. Endometrial cancer is the fourth most common
cancer in women, and the peak age of incidence is 60 to
65 years.12,13 Clinicians should always keep this diagnosis
in mind when a woman presents with chronic AUB at any
age. Lynch syndrome, an autosomal dominant mutation, has
recently been implicated in early-age onset of endometrial
cancer. If a woman is diagnosed with endometrial intraepithe-
lial neoplasia and wishes to preserve her fertility, high-dose
progesterone treatment can be utilized with close follow-up;
377
 Figure 1. Fibroid subclassification system.
Source: Munro, M. et al. Int J Gynaecol Obstet. 2011 Apr.113(1):3-13.
otherwise, hysterectomy is recommended due to the high
incidence of progression to endometrial cancer.14
Nonstructural Causes of Abnormal Uterine Bleeding:
COEIN
Coagulopathy: AUB-C
Coagulopathies, either congenital or acquired, can be an un-
derlying cause of heavy chronic AUB. Additional symptoms
include a history of bruising and epistaxis, and anemia is
common. Von Willebrand, an autosomal dominant disorder,
is frequently diagnosed in adolescents; however, this disorder
can be diagnosed at any age, and von Willebrand Factor anti-
gen should be ordered as part of a diagnostic evaluation.15
Women who have thrombocytopenia or myelosuppression
caused by chemotherapy can also experience AUB-C. If these
diagnoses are suspected, a complete blood count with platelets
and coagulation studies are indicated. Medical management
includes tranexamic acid (Lysteda), combined hormonal con-
traception, a LNG-IUD, or endometrial ablation. Hysterec-
tomy is recommended if medical management fails and a
woman is hemodynamically at risk.16
Ovulatory dysfunction: AUB-O
Ovulatory dysfunction should be suspected if menses are un-
predictable in length, volume, and duration for 4 of 6 months.
Unpredictable ovulation or anovulation results in overstim-
ulation of the endometrium from endogenous estrogen
exposure. This is most common when ovulatory cycles are
first established after menarche or during the perimenopause
period. However, polycystic ovarian syndrome and obesity
significantly contribute to AUB-O. Other disorders that
can disrupt ovulation include hypothyroidism, hyperpro-
lactinemia, mental stress, anorexia, weight loss, and extreme
exercise.4,17 Prevention of anemia, endometrial intraepithelial
neoplasia, and endometrial cancer are the treatment goals.
Progestins are well-documented treatment choices for pre-
vention of endometrial intraepithelial neoplasia and endome-
trial cancer and can be administered via combined hormonal
contraception, medroxyprogesterone (Provera), injectable
378
medroxyprogesterone acetate (Depo-Provera), micronized
progesterone (Prometrium), or a LNG-IUD.5
Endometrial: AUB-E
When a woman has predictable and cyclic menstruation
with heavy chronic AUB and no other definable causes of
the AUB are identified, a primary dysfunction of the en-
dometrium should be considered. AUB-E can occur when
a woman has inadequate production of local vasoconstric-
tor prostaglandins. Additionally, there may be an increase
in lysis of the endometrium due to increased production of
plasminogen activator. The withdrawal of progesterone her-
alds the onset of menses and a complex endometrial inflam-
matory response. Angiogenesis is critical to endometrial re-
pair after menses. Increased inflammation or defective repair
of endometrial tissue may contribute to heavy chronic AUB.
NSAIDs, tranexamic acid, combined hormonal contracep-
tion, a LNG-IUD, and menstrual ablation are recommended
therapies.1820
Iatrogenic: AUB-I
Iatrogenic medical intervention or treatment can cause un-
scheduled or breakthrough bleeding. A common example
of AUB-I occurs when a woman who experiences irregu-
lar bleeding in the first 6 months after a LNG-IUD is in-
serted. This type of AUB-I usually resolves spontaneously
and does not require treatment. AUB-I may also occur in
women who are taking pharmacologic agents that affect the
endometrium, control of ovulation, or coagulation system
such as steroid therapy, hypothalamic depressants, digitalis
(Digoxin), phenytoin (Dilantin), and anticoagulants.4 AUB-I
that is caused by a medication usually resolves when the med-
ication has been discontinued.
Not Classified: AUB-N
Not classified causes of AUB fall into an unexplained
reason or poorly understood reason for endometrial
instability. Examples could include arteriovenous malfor-
mations or a biochemical disorder that as of yet hasnt been
Volume 61, No. 3, May/June 2016
determined. Fortunately, these etiologies of AUB are rare,
but future research could determine a cause of AUB that
currently is not classified.4 The treatment goal for women
with AUB-N is to control AUB with previously mentioned
therapies.
IMPLICATIONS FOR CLINICAL PRACTICE
AUB is a leading reason for gynecologic visits. Midwives and
other primary care providers for women may be involved in
the diagnosis and management of many of the common causes
of AUB and coordinating specialty care when indicated. When
evaluating a woman for AUB, a structured history including
onset, duration, and amount of AUB is crucial; laboratory
evaluations should include a complete blood count, thyroid-
stimulating hormone, and, when indicated, coagulation stud-
ies. A digital and speculum pelvic examination is warranted
to evaluate the size, shape, and consistency of the uterus. A
transvaginal ultrasound should be ordered to evaluate the
uterus for polyps, leiomyomas, and endometrial thickness. If
a woman is of reproductive age, the ultrasound should be per-
formed immediately following the menses up to day 10 of her
cycle to measure endometrial thickness. If a woman is post-
menopausal, then a transvaginal ultrasound can be ordered at
any time. If the endometrium is greater than 7 mm in a woman
of reproductive age or greater than 4 mm in a postmenopausal
woman, an endometrial biopsy should be performed. Treat-
ment is based on the specific etiology of AUB, a womans
reproductive wishes, and prevention of morbidity from AUB.
Use of the PALM-COEIN system will help eliminate con-
fusion about the etiology of AUB and provide effective com-
munication of that diagnosis to other providers, which will re-
sult in better coordination of care. In addition, it is hoped that
use of the PALM-COEIN system will facilitate research on the
etiology and treatment of this condition and the prediction of
endometrial cancer.
AUTHOR
Angela Deneris, CNM, PhD, FACNM, is professor (clinical)
in the Nurse-Midwifery and Womens Health Nurse Practi-
tioner Programs at the University of Utah and provides care
to women in the Birth Care Health Care Practice.
CONFLICT OF INTEREST
The author has no conflicts of interest to disclose.
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