FIGO's PALM-COEIN Classification of Abnormal Uterine Bleeding: A Clinico-histopathological Correlation in Indian Setting

Effect of norethisterone dose and duration in the management of abnormal uterine bleeding: a narrative review and case report

Abnormal uterine bleeding (AUB) is an acute/chronic variation in the normal menstrual cycle that affects adolescents, women of reproductive age and perimenopausal women. AUB affects approximately 3-30% of reproductive-aged women worldwide, and reduces their quality of life and productivity whilst increasing the overall healthcare burden. Its management requires thorough medical evaluation and individualized treatment. Depending on the severity and cause of AUB, its treatment ranges from lifestyle modifications and hormonal therapies to more invasive procedures or surgery. Although hormonal therapy is the preferred first-line measure in AUB, the available pharmacological options have various adverse effects. There exists a need for safer and more efficient treatment regimens with high patient compliance to effectively treat AUB. Norethisterone, also known as norethindrone, is a widely used synthetic analogue of progestogen. Controlled release formulations of norethisterone/ norethisterone acetate help maintain constant drug levels in the blood and exert minimal side-effects; therefore, they are promising therapeutic agents for effective AUB management. The present review summarizes the epidemiology and diagnosis of AUB, with a focus on the safety, efficacy and tolerability of norethisterone/ norethisterone acetate in AUB management. We also report a case of AUB in a 40-year-old woman, who was treated with NETA tablets. The treatment resulted in favourable outcomes, and patient satisfaction.

National survey of abnormal uterine bleeding according to the FIGO classification in Japan

AIM

To investigate the status of abnormal uterine bleeding (AUB) in Japan using the International Federation of Gynecology and Obstetrics (FIGO) classification (AUB system 1 and 2; PALM-COEIN) and to clarify the relationship between AUB symptoms and the diseases causing AUB.

METHODS

In a nationwide study, we enrolled first-time patients who visited target facilities during two consecutive weeks from December 1, 2019 to January 31, 2020. The FIGO classification was used to investigate patients with symptoms and causative diseases of AUB. Based on the proportion of patients in the nationwide study, 373 cases were included in the detailed survey. Survey items included symptoms of AUB according to AUB system 1, examination details, and causative diseases according to the PALM-COEIN classification.

RESULTS

Within the study period, we encountered 61 740 first-time patients, of which 8081 (13.1%) were diagnosed with AUB. Among them, 39.9% had abnormal menstrual cycles and 56.9% had abnormal menstrual bleeding. In the survey, PALM had the highest percentage of AUB-L and COEIN had the highest percentage of AUB-O. Correspondence analysis showed that COEIN was strongly associated with abnormal menstrual cycles and PALM with abnormal menstrual bleeding.

CONCLUSION

We conducted the first nationwide survey of AUB in Japan. The FIGO classification was a useful tool for the diagnosis of AUB, with a strong correlation between symptoms of AUB by AUB system 1 and the causative disease of AUB by PALM-COEIN. Conversely, a high percentage of AUB-N and AUB-E suggests that AUB system 1 and PALM-COEIN are ambiguous as diagnostic tools.

A Histopathological Study of Endometrial Biopsy Samples in Abnormal Uterine Bleeding

BACKGROUND

Abnormal uterine bleeding (AUB) is the most common health issue in women, defined as any bleeding pattern that differs in frequency, duration, and amount. Endometrial sampling and its histopathological examination is the first-line test in patients presenting with AUB. The aim of this study was to analyze the histopathological patterns of endometrium in women with AUB and to find the predominant histopathologic pattern in the different age groups of women with AUB.

METHODS

The study was conducted at the Indira Gandhi Medical College and Research Institute, Puducherry, from January 2019 to December 2020. Endometrial biopsies of patients with AUB, in whom gestational causes were ruled out, were included in this study.

RESULTS

Out of the 160 cases analyzed, the maximum number of biopsies were from the age group of 41-50 years; the majority of patients presented with complaints of menorrhagia. The bleeding pattern was significantly associated with age groups (p=0.00). Of 160 cases, 104 cases were related to functional causes. The association of functional and organic causes with age group was not significant (p=0.67 and p=0.99, respectively). The most common histological pattern was the normal cyclical pattern showing proliferative (56) and secretory phase (30) in 86 cases. Of 42 cases of endometrial hyperplasia, 9 cases had atypical hyperplasia. The endometrial polyp was the other common organic lesion observed. Only two cases of endometrial carcinoma were reported during the present study period.

CONCLUSION

Although a regular cyclical pattern is observed commonly, endometrial sampling should be considered in the peri- and post-menopausal age groups wherein the incidence of endometrial hyperplasia and endometrial carcinoma is more common.

The Role of FIGO PALM-COEIN Classification of the Underlying Causes of Abnormal Uterine Bleeding and Clinicopathological Correlation of Patients Undergoing Hysterectomy in a Tertiary Care Referral Center of Western Rajasthan

Background

The International Federation of Gynaecology and Obstetrics working group on menstrual disorders has developed a classification system (PALM-COEIN) for causes of the AUB in non-gravid women. The present study was conducted with the aim to study the two components of this system in clinical practice in general and establish a clinicopathological correlation of AUB with the context of the PALM component in particular.

Methodology

The data of 158 patients who underwent hysterectomy for abnormal uterine bleeding in 1 year at the tertiary care Centre of western Rajasthan was collected from old case records and analysed. The patients were initially worked up in the outpatient department with the history and clinical examination, followed by transabdominal or transvaginal ultrasonography depending on the uterine size and the pathology. The patients requiring more detailed pictures were advised computed tomography (CT) scan. All the patients were screened for common medical disorders like thyroid disorders, prolactin levels, and blood sugar levels. Thereafter an endometrial biopsy and liquid-based cytology were done for all the patients to rule out malignancy. The relative contribution of various causes of PALM (structural) and COEIN (functional) components and clinicopathological correlation was analysed.

Results

PALM and COEIN components contributed almost equally for AUB when assessed clinically. On the other hand, the histological examination revealed significantly more cases of PALM (structural or anatomical) component of AUB, i.e., 17.2% versus 82.8 %. AUB-L was the commonest (41.1 %) aetiology overall.

Conclusion

The PALM-COEIN classification system should consider both the clinical and histopathological diagnoses in women having AUB. It is concluded that the most common cause of AUB is leiomyoma and the most common age group undergoing hysterectomy is the 4th decade. Although the medical treatment options are there, patients of premenopausal age require hysterectomy who do not benefit from medical regimens.

Rate of Significant Endometrial Pathology in Women at Low Risk for Endometrial Hyperplasia or Cancer Presenting with Abnormal Uterine Bleeding

Background and Objectives

To determine the rate of significant endometrial abnormalities in premenopausal women at low risk for endometrial hyperplasia and cancer presenting with abnormal uterine bleeding (AUB).

Patients and Methods

This descriptive study was conducted from January 1, 2016 to March 31, 2019. The inclusion criteria were premenopausal women, 35-50 years, presenting with AUB, low risk for endometrial hyperplasia or endometrial cancer, and having undergone endometrial sampling or uterine curettage. Nulliparous, obesity, diabetes mellitus, polycystic ovary syndrome, chronic anovulation, infertility, tamoxifen therapy and/or a family history of uterine, ovarian, breast and colon cancer were excluded. Data regarding baseline characteristics were collected, and histopathology reports were reviewed.

Results

During the study period, 644 subjects were recruited, 557 of whom had adequate endometrial tissue for histopathology study. The pathology demonstrated benign in most cases (96%). The rate of significant abnormal endometrial pathology was 4% (23 cases) including 19 cases of endometrial hyperplasia without atypia (3.3%), and 4 cases of endometrial cancer (0.7%).

Conclusion

The rate of significant abnormal endometrial pathology in premenopausal women at low risk for endometrial hyperplasia or endometrial cancer presenting with AUB was very low. This information should be incorporated into the counseling process regarding the risks and benefits of endometrial sampling.

A Clinicopathological Correlation of International Federation of Gynecology and Obstetrics's PALM-COEIN Classification of Abnormal Uterine Bleeding: Indian Scenario

Background

Abnormal uterine bleeding (AUB) is a common problem affecting the women of reproductive age group and may also have a significant impact on their physical, social, and emotional aspects directly affecting their quality of life. The International Federation of Gynecology and Obstetrics (FIGO) devised a universally acceptable system of nomenclature and classification, namely PALM-COEIN classification of AUB in the year 2011. The objective of the present study was to analyze the structural (PALM) and functional (COEIN) component of FIGO system in the Indian scenario.

Materials and Methods

Three hundred patients with complaints of AUB were taken. A clinical diagnosis according to PALM-COEIN system was made after thorough history and clinical examination. Additional investigations if required were done, and endometrial sampling or hysterectomy was done whichever indicated. A histological diagnosis was made, and each case was allocated a category according to PALM-COEIN classification. A clinicopathological correlation was done in the hysterectomy cases for structural causes (PALM).

Results

Leiomyoma (30%) was the most common cause of AUB closely followed by adenomyosis (29.66%) overall. The clinicopathological correlation in hysterectomy cases was good with concordance rate of 85.03%. The concordance between clinical and pathological diagnoses for AUB-L, AUB-A, AUB-M, and AUB-A, L was statistically significant with P < 05 in positive cases. However, additional finding of adenomyosis was diagnosed in 48.2% of the cases apart from primary clinical diagnosis.

Conclusion

A good clinicopathological correlation was seen in the cases when classified according to PALM-COEIN classification. The system also provides for consideration of multiple etiologies contributing toward AUB both clinically and histopathologically. However, histopathology remains the cornerstone in establishing the accurate diagnosis as the cases without specific symptoms can be missed clinically.