Abnormal Uterine Bleeding: New FIGO Classification

MAHMOUD MELEIS, MD

Agenda

Terminology

New Excluded AUB Menorrhagia

MetrorrhagiaDUB

Waves of change

In 2006, FIGO identified as the appropriate body to provide supervision & international credibility to the ongoing evaluation of new terminology

In 2009, FIGO Menstrual Disorders Group was formed. FIGO World Congress of Gynecology and Obstetrics , accepted the new terminology.

In 2011, the PALM-COEIN Classification System created. In 2012, PALM-COEIN system was endorsed by ACOG

Nomenclature & Classification of AUB

AUB Validated Terminology AUB: Abnormal uterine bleeding

Umbrella term for both regular and irregular bleeding HMB: Heavy menstrual bleeding

Excessive menstrual bleeding IMB: Inter-menstrual bleeding

Occurs between clearly defined cyclic and predictable menses Acute:

Heavy bleeding that is of sufficient quantity to require immediate intervention to prevent further blood loss

Chronic: Heavy bleeding that is of sufficient quantity to require immediate

intervention to prevent further blood loss

AUB

Acute AUB

IMB HMB

Chronic AUB

IMB HMB

Chronic AUB; Bleeding from the uterine corpus that is abnormal in

volume, regularity and/or timing and has been present for the majority of the past 6 months

Menstrual parameters

Frequency24-38 day

Frequent

Normal

Infrequent

Regularity<20 D / 12 m

Absent

Regular

Irregular

Duration4.5-8 days

Prolonged

Normal

Shortened

Volume5-80 ml

Heavy

Normal

Light

Suggested “normal limits” for uterine bleeding in the mid-reproductive yearsMunro MG. Rev Endocr Metab Disorder (2012) 13: 225-234

Structural Abnormalities

P – Polyps – scored as Present or Absent A – Adenomyosis - scored as Present or Absent L – Leiomyoma

Primary level – Present or Absent Secondary level – Distinguish between submucosal (SM) & others

(O) Tertiary level – Detail location/size of uterine fibroids

M – Malignancy & hyperplasia

AUB-P; Polyps (8-35 %) Diagnosis: US, SIS, hysteroscopy Further sub-classification: Dimensions, location & number Pre-menopausal polyps:

64 – 88% have symptoms Present with HMB, AUB, IMB, or post-coital bleeding Symptoms do NOT correlate with number, diameter & site

Post-menopausal polyps: Most are symptom free Cause for 21-28% of PMP bleeding Associated with cervical polyps in 24-27% Incidence of carcinoma varies between 0–4.8%

AUB-A; Adenomyosis Ectopic endometrial glands & stroma within the myometrium Hypertrophy & hyperplasia of surrounding myometrium Usual presentation: HMB, uterine enlargement, & dysmenorrhea

Adenomyosis

Linear Striations80% PPV

71% Accurate

Heterogeneous myometrium

81% PPV69% Accurate

Sonographic findings of Adenomyosis

Dueholm et al. Best Pract Res Clin Obstet Gynaecol 2006; 20: 569 82.

Color Doppler: vessels following normal course through an

indistinct mass

AUB-L; Leiomyoma

1ry level: AUB-L 2ry level:

Submucosal – AUB-LSM

Other – AUB-LO

3ry level: Types 0-8

The three stage classification system for leiomyoma

AUB-M; Malignancy & Hyperplasia

Detected based upon results of office biopsy or curettage FIGO AUB Staged only as present or absent Use existing WHO and FIGO categorization Up to 40% of patients with a biopsy diagnosis of complex

hyperplasia with atypia will have a concomitant endometrial adenocarcinoma present

Non-structural Abnormalities

C – Coagulopathy O – Ovulatory Dysfunction E – Endometrial I – Iatrogenic N – Not yet classified

AUB-C; Coagulopathy Prevalence: 3% of women presenting with HMB Etiologies:

Von Willebrand’s disease (10%) Platelet Dysfunction Factor XI deficiency Factor X deficiency

Category includes patient’s taking anti-coagulants

CoagulopathyHistory Screening

HMB since menarche One of the following:

PPH Surgical related bleeding Bleeding associated with dental work

Two or more of the following: Bruising 1-2 times/month Epistaxis 1-2 times/ month Frequent gum bleeding Family history of bleeding symptoms

AUB-O; Ovulatory Dysfunction

Etiology: Polycystic Ovarian Syndrome (PCOS) Hypothyroidism Hyper-prolactinemia Mental stress Obesity Anorexia Weight loss Extreme exercise Adolescence Menopausal transition

AUB-E; Endometrial It is diagnosed by exclusion Etiology:

Deficiencies of local production of vasoconstrictors Endothelin-1 Prostaglandin F2a

Excessive production of plasminogen activators Increased local production of vasodilators

Prostaglandin E2

Prostacyclin I2 Disorders of endometrial repair (inflammation)

Chlamydia

AUB-I; Iatrogenic Etiology:

Breakthrough bleeding (BTB) using gonadal steroids is the major component of AUB-I :

Oral contraceptives Continuous or cyclic progesterone IUD or implant related bleeding

Cigarette smoking : reduces the level of steroids because of enhanced hepatic metabolism

Systemic agents that interfere with dopamine metabolism : Serotonin uptake inhibitors

AUB-N; Not Yet Classified Disorders that would be identified or defined only by

biochemical or molecular biology assays Arterio-venous malformations Myometrial hypertrophy Category for new etiologies Pathological conditions of lower genital tract ??

Pathway overview When a woman presents with HMB :

Take a proper history Decide whether the timing, amount of blood loss and/or duration of

the bleeding is out of the norm. Give it a name. Do a proper assessment/evaluation. Make a (provisional) diagnosis. Initiate treatment or referral

Guidelines for investigations

Guid

elin

es

General assessment

Determine ovulatory status

Screening for haemostasis disorders

Evaluation of endometrium

Evaluation of endometrial cavity

structure

Myometrial assessment

Guidelines for investigations

1. General assessment Not related to pregnancy Not emanating from cervix or another location Evaluate for anaemia – Hb

2. Determine ovulatory status Predictable cyclic menses every 22-35 days

3. Screening for systemic disorders of haemostasis Structured history : 90% sensitivity Positive screen: von Willebrand factor, hematologist

Guidelines for investigations

4. Evaluation of the endometrium Endometrial sampling if risk factors are persistent TVUS - endometrial thickness

5. Evaluation of structure of endometrial cavity To identify polyps, submucous myomas TVUS is not 100% sensitive –small lesions undetectable If suboptimal –proceed to SIS or hysteroscopy

6. Myometrial assessment US and +/- hysteroscopy MRI : leiomyoma - adenomyosis

Laboratory testing for evaluating Acute AUB

Laboratory Evaluation Specific Laboratory Tests• Initial laboratory

testing• CBC• Blood group• Pregnancy test

• Initial laboratory evaluation for disorders of hemostasis

• PTT & PT• Activated partial thromboplastin

time• Fibrinogen

• Initial testing for von Willebrand disease

• VWF antigen• Ristocetin cofactor assay• Factor VIII

• Other laboratory tests to consider

• TSH• Serum Fe, total Fe binding

capacity, and ferritin• Liver function tests• Chlamydia trachomatis

Imaging- US TVUS

Assessment of myometrium, cervix, tubes, and ovaries Endometrial Polyps Adenomyosis Leiomyomas Uterine anomalies Endometrial thickening associated with hyperplasia and

malignancy

Saline infusion Sonography

SIS Improves the diagnosis of intrauterine pathology - polyps and

fibroids Better discrimination of location and relationship to the uterine

cavity May be useful prior to hysteroscopic or laparoscopic procedure

for fibroids, polyps and uterine anomalies

MRI Rarely indicated Helps mapping the exact location of fibroids in planning

surgery and prior to embolization When TVS or instrumentation of the uterus (i.e. congenital

anomalies) cannot be performed

Hystroscopy Direct visualization of cavitary pathology Directed biopsy (main benefit over "blind" D&C)

Notation for AUB A patient may be found to have more than one potential entity

contributing to symptoms of AUB. A notation approach has been designed to enable categorization.

For example, if a patient is found to have endometrial hyperplasia and ovulation dysfunction with no other abnormalities, she would be categorized as follows:

AUB P0 A0 L0 M1-C0 O1 E0 I0 N0 May be abbreviated as : AUB – M,0

Notation: each case has 1 identified abnormality

Classification CategorizationSingle Entity Examples

Notation: >1 positive category

Classification CategorizationMultiple Entity Examples

ConclusionAbnormal Uterine Bleeding

FIGO nomenclatureand

PALM-COEIN classification

FIGO nomenclature&

PALM-COEIN classificationSimplified and unified terminologyAllows clear focus of treatment conceptsFacilitates clinical and scientific research collaborationProvides the basis to structure more effective clinical teaching

Take home massage

The term DUB should be replaced by coagulopathy, endometrial & ovulatory disorders

FIGO believes that the classification should be used widely in undergraduate & post-graduate education to facilitate the development of practitioners who are able to provide quality care for women with AUB