Abnormal Uterine Bleeding in Reproductive-Age Women - Terminology and PALM-COEIN Etiology Classification - UpToDate

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Abnormal uterine bleeding in reproductive-age women: Terminology and PALM-COEIN

etiology classification
Authors: Ian S Fraser, AO, DSc, MD, Malcolm G Munro, MD, FRCS(c), FACOG, Hilary OD Critchley, MD, FRCOG
Section Editor: Robert L Barbieri, MD
Deputy Editor: Alana Chakrabarti, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2020. | This topic last updated: Dec 16, 2019.
INTRODUCTION
Abnormal uterine bleeding (AUB) in nonpregnant reproductive-age women is a common gynecologic symptom. Over the history of medicine,
there has been a wide range of poorly defined terminology used to describe AUB symptoms and etiologies.
The beginning of conflicting terminology for AUB dates back to the late 1700s when William Cullen, Professor of Physic at the University of
Edinburgh, Scotland, began to write his medical research texts in English rather than in Latin [1]. However, he was fond of demonstrating his
classical language skills to his students and coined the Latin term menorrhagia, meaning "to burst forth monthly," to describe the excessive
bleeding that many of his patients experienced. The term dysfunctional uterine bleeding was coined, but never clearly defined, by Graves in 1935
[2,3].
The varied use of terminology to describe AUB symptoms has led to difficulties in many areas, including documenting symptoms; reaching
consensus on the use of various diagnostic techniques and medical and surgical therapies; design and interpretation of basic, translational, and
clinical research; and attempts to conduct multicenter or multinational clinical trials [1,4-6].
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These concerns led to the formation of the Menstrual Disorders Working Group within the International Federation of Gynecology and Obstetrics
(FIGO), which has subsequently become a standing committee, the Menstrual Disorders Committee. This group has developed internationally
supported recommendations on definitions and terminology for AUB symptoms [1,4,6-8] as well as a new classification of underlying causes of
AUB in the reproductive years [6]. Together, these terminology and classification systems provide the tools to improve precision in
communicating about etiologies, symptoms, diagnosis, and treatment of AUB in the reproductive years.
The terminology for AUB symptoms as well as the FIGO system for classification of AUB etiologies are reviewed here. The differential diagnosis
and approach to the evaluation of AUB are discussed in detail separately. (See "Approach to abnormal uterine bleeding in nonpregnant
reproductive-age women" and "Differential diagnosis of genital tract bleeding in women".)
The diagnosis and management of girls with premenarcheal bleeding, women with postmenopausal bleeding, and bleeding associated with
pregnancy are discussed elsewhere. (See "Evaluation of vulvovaginal bleeding in children and adolescents" and "Postmenopausal uterine
bleeding" and "Overview of the etiology and evaluation of vaginal bleeding in pregnant women".)
DEVELOPMENT OF THE FIGO SYSTEMS
Based on concerns about the confusing nature of AUB terminology raised by a multinational group of experts in gynecology, an international
workshop was convened in Washington, DC in 2005. The workshop addressed the most obvious and confusing issues regarding AUB
terminology, definitions, and classifications [1,4,6,7]. As a result of this workshop, an international working group was set up with oversight from
the International Federation of Gynecology and Obstetrics via a Menstrual Disorders Working Group (FIGO MDWG), and since 2012, this
working group has become a standing committee of FIGO, the FIGO Menstrual Disorders Committee (MDC).
The goals of the MDC include development of a system for defining and describing both normal uterine bleeding and AUB as well as one for the
classification of potential causes of AUB in the reproductive years. The system for AUB terminology was created in a clearly defined fashion;
written in simple English words that can be easily translated into other languages; and readily understood by clinicians, patients, and researchers
alike [8-10]. Where possible, the definitions were based on data derived from population-based studies. The classification system allows the
investigator, clinician, or educator to consider all possible causes or contributors to the AUB in a given patient, understanding that some imaged
lesions may indeed be asymptomatic. For both the terminology and classification systems, it is understood that with increased future knowledge

of menstrual physiology and the pathogenesis of AUB, modifications may be necessary to maintain their relevance for clinicians, educators, and
investigators.
The process of developing new definitions and terminology has included:
● Identifying terms describing AUB symptoms that should no longer be used because they are confusing and/or poorly defined [1,4,6,7]. A
range of terms was identified.
Among the most commonly used terms were menorrhagia and metrorrhagia. Menorrhagia was never clearly defined and has been used in
various ways to describe heavy uterine bleeding symptoms (regardless of context – predictable cyclical, irregular, or unpredictable) and, for
some clinicians and investigators, has even been used as a poorly defined diagnosis.
The expert group also recommended abandonment of the term dysfunctional uterine bleeding (DUB), which is another poorly defined
term. This term has been used with variability as both a vague symptom and/or a poorly defined diagnosis. Mainly, the term DUB has been
used as a diagnosis of exclusion in women with AUB in whom structural pathology has not been identified. However, scientific and
diagnostic advances have now led to a better understanding of underlying mechanisms of these symptoms, thereby supporting a more
defined set of actual causes [8,11-13].
Additional terms that are poorly defined and should no longer be used are listed in the table (table 1). The FIGO MDC classification for
etiologies is described below. (See 'PALM-COEIN classification of AUB etiologies' below.)
● An extension of the process regarding terminology has been the development of a classification system for underlying causes of AUB, which
is simple in concept and flexible in application and which highlights our modern ability to better define AUB etiologies [8].
● A series of international meetings were held by the MDC for clinicians and scientists to raise and respond to a wide range of questions
regarding the terminology, definitions, classification, and issues of clinical practice. Participants voted on and endorsed all major
recommendations regarding AUB terminology and the system of classification of potential etiologies addressed below [4,11].
DEFINITIONS OF UTERINE BLEEDING

Standard definitions of normal menstrual bleeding form the framework for clear definitions and terminology for AUB. The International Federation
of Gynecology and Obstetrics Menstrual Disorders Committee (FIGO MDC) used an evidence-based approach to develop parameters of normal
menstrual bleeding based upon published population data and using medians and confidence intervals [1,6]. Anything outside these limits was
regarded as AUB.
In reviewing data regarding normal menstrual function, there are several challenges. Different population studies provide some differences in
data. There were some variations within "normal populations" in the regularity and frequency of menstrual bleeding when 5th to 95th percentiles
were utilized. These have been taken into account in developing the definitions below. Little is known about cultural, ethnic, or geographic
variations, since comparative large-scale studies have not been carried out [1,6].
Issues of defining the limits of normal menstrual function have led to considerable ongoing debate and resulted in a major review at a FIGO MDC
workshop in Vancouver in 2015 by a group of experts. The definitions and terminology supported by the group are included and reviewed in this
section.
Normal menstruation — Normal menstruation is defined as (table 2) [1,6]:
● Frequency – 24 to 38 days.
● Regularity – Variation ≤7 to 9 days. No more than seven to nine days difference between the shortest to longest cycles; cycle length is the
number of days from the first day of one menstrual cycle to the first day of the next. For some young girls who have occasional or frequent
long cycles, typically, but not always, the cycle length evolves spontaneously to fit norms. For others, such an evolution may not occur.
● Duration – ≤8 days. Up to eight days; duration is the number of days of bleeding in a single menstrual period. There are no specific clinical
entities that are associated with reduced duration below four days with the exception of amenorrhea.
● Volume – Clinical definition is subjective and defined as a volume that does not interfere with a woman's physical, social, emotional, and/or
material quality of life [14,15]. Research definition is ≤80 mL vaginal "blood" loss per cycle [16].
Abnormal uterine bleeding — AUB is the overarching term used to describe any symptomatic variation from normal menstruation (in terms of
frequency, regularity, duration, or volume) and also includes intermenstrual bleeding. This term covers the full range of symptoms of abnormal
bleeding (table 3) [17].
Acute abnormal uterine bleeding — The FIGO MDC defines acute AUB as:
● An episode of uterine bleeding in a woman of reproductive age, who is not pregnant, that is of sufficient quantity to require immediate
intervention to prevent further blood loss [8,17].
Chronic abnormal uterine bleeding — Chronic AUB is defined as:
● Bleeding from the uterine body (or corpus), that is abnormal in frequency, regularity, duration, and/or volume, and has been present for at
least the majority of the past six months (algorithm 1) [8,17].
DISTINGUISHING NORMAL MENSTRUATION FROM AUB
When reporting symptoms, the clinician should consider at least the previous six months. When assessing regularity, cycle length is defined as
the number of days from the start (day 1) of one period until the start (day 1) of the next (table 4).
Frequency — In normal menstruation, a woman has an episode of menstrual bleeding every 24 to 38 days (table 2 and figure 1) [14,18].
● If periods start more often than every 24 days, the patient is categorized as having frequent uterine bleeding.
● If they start less often than every 38 days, the category is infrequent. The International Federation of Gynecology and Obstetrics Menstrual
Disorders Committee (FIGO MDC) advised that the term oligomenorrhea be replaced by the term infrequent uterine bleeding.
For girls or women who have previously had regular menstrual cycles, when there is no bleeding for six months, menstrual periods are
categorized as absent, and the term secondary amenorrhea is used [17]. Since there is little controversy in the use or definition of the term
secondary amenorrhea, the term has been retained. However, the duration of the period of amenorrhea should be specified. The FIGO MDC has
agreed with this definition, but it is important to note that some experts would prefer to add a caveat that "secondary amenorrhea is the absence
of menses for more than three months in girls or women who previously had regular menstrual cycles or six months in girls or women who
previously had irregular menses." The FIGO MDC felt making this part of the official definition would lead to a large number of young women with
generally regular and normal menses being classified as "abnormal."

Primary amenorrhea is defined as the absence of menarche by age 15 years. (See "Evaluation and management of primary amenorrhea".)
Regularity — Creating a working definition of regular menstrual bleeding is challenging. Based on data from multiple studies, "normal" menses
should occur at regular and reasonably predictable intervals (figure 2) [1,6].
For cycle length, the 5th to 95th percentile for the difference between the longest and shortest cycle over a one-year period should be no more
than 20 days. However, the 20-day difference is based on the general population of women and includes those with occasional very short (<18
days) and very long (>43 days) cycles. Some women with long cycles may have had ovulatory dysfunction, such as polycystic ovarian syndrome.
When these very short and very long cycles are excluded, the variation in cycle length is seven to nine days, depending upon age [14]. Variation
in cycle length is typically longer in younger women (ages 18 to 25 years) and women approaching the menopausal transition (ages 43 to 45
years) (table 5).
Duration — The duration (normal of days of bleeding in a single menstrual period) of normal menstruation in the population studies was up to
eight days (figure 3) [14,18-21]. Consequently, when the duration of a woman's menstrual periods is consistently more than eight days, the
patient may be said to have prolonged menstrual bleeding. This phenomenon is often, but not always, associated with heavy menstrual
bleeding (HMB). Since there is no consensus on the lower limit of normal for the duration of menses, for the present time, the MDC has
determined that there is no clinically relevant definition of a "shortened" duration of bleeding.
Volume — The term HMB is a symptom of a woman's perception of increased daily or total monthly menstrual volume of flow, regardless of the
duration, the frequency, or whether the timing of onset is regular or irregular (figure 4). For clinical purposes, the definition is subjective and
defined as a volume that interferes with a woman's physical, social, emotional, and/or material quality of life [14,15], the definition described in
the United Kingdom National Institute for Health and Care Excellence guidelines [15]. Typically, HMB is part of a symptom complex that may
include variable degrees of dysmenorrhea, fatigue, and other symptoms.
Light menstrual bleeding is an infrequent complaint. For clinical purposes, this can only be based on a description or complaint by the patient.
This symptom is uncommon and is only rarely related to pathology, although it may be a presenting symptom of cervical stenosis or intrauterine
synechiae. Light menstrual bleeding is usually a complaint from women for whom a heavy, red bleed is a perceived sign of good health [22].
For research purposes, both HMB and light menstrual bleeding may be defined more objectively by direct or indirect methods for determining
menstrual volume. The volumetric definition of HMB is >80 mL vaginal "blood" loss per cycle [23,24]. The referent technique is the measurement
of actual blood loss per menstrual period, using the extraction of hemoglobin (alkaline hematin method) from menstrual sanitary towels, including
pads and tampons, which have been carefully collected after detailed counseling [20,25]. The somewhat cumbersome and expensive nature of
the alkaline hematin method has generated interest in the development of surrogate measures of menstrual volume, the most common technique
being the semi-quantitative pictorial blood loss assessment charts [25].
Both clinicians and researchers should also be aware that over 50 percent of the total menstrual loss is an endometrial transudate, and the whole
blood component usually varies between 30 and 50 percent [26]. These methods have been validated for modern sanitary pads containing
superabsorbent granules [27].
Intermenstrual bleeding — When AUB occurs between well-defined cyclical menses, the symptom is called intermenstrual bleeding (IMB)
(figure 5). This symptom may be virtually impossible to discern if the woman has irregular and/or very frequent menses. Thus, care must be taken
before applying the term IMB to these women.
Bleeding unrelated to the endometrium is common and is usually associated with focal lesions of the genital tract that may be serious, such as
cervical cancer. For many women with focal lesions of the lower genital tract, postcoital bleeding is a frequent symptom (table 6). Symptoms
arising from lesions of the cervix and vagina are not covered in this discussion of AUB, but careful examination of the vagina and cervix is
important before assuming that the abnormal bleeding arises from the endometrium or cervical canal. (See "Differential diagnosis of genital tract
bleeding in women".)
The symptom of IMB may be cyclical, with predictable bleeding occurring at midcycle, or in the follicular (early) or luteal (late) aspects of the
cycle. Alternatively, the symptom of IMB may be acyclical, occurring at random times between menses.
Cyclic midcycle intermenstrual bleeding — A small amount of clinically detectable vaginal bleeding arising from the uterine cavity around
midcycle is a common physiologic phenomenon. Small amounts of frank bleeding or blood-stained discharge around the approximate time of
ovulation can be recognized on a more or less regular basis in about 9 percent of healthy reproductive-age women [28]. This usually appears to
occur very shortly after ovulation and is thought to be associated with the midcycle drop in circulating estradiol levels that occurs at midcycle [29].
Occult intermenstrual bleeding, only detectable by vaginal swabbing or tampon testing in the laboratory, is a much more common phenomenon
and is regularly present in 90 percent of women shortly after ovulation [30].
Cyclic premenstrual or postmenstrual intermenstrual bleeding — Cyclical IMB that predictably occurs either early in the cycle (follicular
phase) or late (luteal phase) typically presents as very light bleeding for one or more days. These symptoms may be indicative of a luteal phase
defect (late cycle bleeding) or of other conditions, such as endometriosis, endometrial polyps, or other structural lesions of the genital tract.
Acyclic intermenstrual bleeding — When the IMB is not cyclical or predictable, it is called acyclical IMB. Such bleeding is typically
associated with benign lesions, such as chronic cervicitis or polyps of the cervix or endometrium. In some instances, this bleeding may be
associated with cervical or endometrial cancer as described above.
Women on hormonal medications — The descriptions above apply to women who are not taking local or systemic gonadal steroids or other
pharmaceutical agents that might directly impact gonadal steroid production or endometrial function. Such agents may include progestin-based
contraceptive agents with or without estrogen, gonadotropin-releasing hormone agonists, aromatase inhibitors, and selective estrogen or
progesterone receptor modulators.
It is important to have a standardized approach to describing AUB in women using gonadal steroids. Uterine bleeding patterns are almost
invariably modified by estrogen and/or progestogen therapies, sometimes in quite unpredictable ways. The least predictable patterns tend to
come with use of long-acting progestogen-only contraception [31]. Traditionally, distinguishing between bleeding and spotting with these agents
has been poorly defined. Heaviness of flow is difficult to assess in general in clinical care, and most of the hormonal methods lighten the flow
(and often greatly so).
To define terminology for this patient population, the FIGO MDC used the reference period of 90 days and the terminology for bleeding symptoms
promoted by the World Health Organization and others [19,32-35]. This terminology allows for a number of different analyses within each
reference period, which offers a useful degree of discrimination between different types of therapy. In regard to volume of bleeding, it was
decided that the only distinction that could usually be made was between bleeding and spotting based on the need for sanitary towel ("mini-pad")
usage (table 3).
Abnormal uterine bleeding in women on hormonal contraception is discussed in detail separately. (See "Evaluation and management of
unscheduled bleeding in women using contraception".)
PALM-COEIN CLASSIFICATION OF AUB ETIOLOGIES

Standard practice includes obtaining a structured history and appropriate use of the diagnostic tools necessary to identify the potential underlying
causes and contributors in many cases of AUB. A comprehensive but flexible classification system for underlying etiologies of AUB has been
developed by the International Federation of Gynecology and Obstetrics Menstrual Disorders Committee (FIGO MDC) [8].
The classification system is stratified into nine basic categories that are arranged according to the acronym PALM-COEIN: polyp, adenomyosis,
leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial dysfunction, iatrogenic, and "not otherwise classified"
(figure 6). In general, the components of the PALM group are discrete ("structural") entities that are measurable visually using imaging techniques
and/or with histopathology. Meanwhile, the COEI group is related to entities that are not defined by imaging or histopathology ("nonstructural").
These entities can be organized in the form of a "matrix" to facilitate documentation of clinical evaluation and results (table 7).
The categories were designed to facilitate the development of subclassification systems. The system was constructed recognizing that any
patient could have one or multiple entities that could cause or contribute to the AUB and that definable entities, such as adenomyosis,
leiomyomas, and endocervical or endometrial polyps, may frequently be asymptomatic and therefore not necessarily a contributor to the
presenting symptoms.
Regarding previous terminology, the FIGO MDC advised that the diagnoses frequently encompassed within the previous term "dysfunctional
uterine bleeding" could be classified under three definable headings [8]:
● Systemic disorders of hemostasis (the coagulopathies) (AUB-C).
● Ovulatory disorders (AUB-O) – Generally reflecting dysfunctional relationships in the hypothalamic-pituitary-ovarian axis that typically
manifest with symptoms of the irregular onset of uterine bleeding.
● Primary disorders of endometrial origin (AUB-E) – Disturbances principally caused by the molecular and cellular mechanisms responsible for
regulation of the volume of blood lost at menstruation. Other infectious endometrial disorders, such as chlamydial endometritis, should be
included here.
Polyps (AUB-P) — Polyps are localized epithelial tumors that include those in the endometrial cavity and the cervical canal. For the present,
FIGO categorizes polyps as either being present or absent as defined by hysterosonography (such as saline infusion sonography) and/or
hysteroscopic imaging with or without histopathology.

The entity sometimes characterized as polypoid endometrium is not included. At the discretion of the clinician or clinical investigator, the size,
number, and location of the polyps can be documented. A subclassification system for endometrial and endocervical polyps is under
consideration [8].
Endometrial and endocervical polyps are discussed in detail separately. (See "Endometrial polyps" and "Benign cervical lesions and congenital
anomalies of the cervix", section on 'Polyps'.)
Adenomyosis (AUB-A) — Adenomyosis is the presence of endometrial-type glands and stroma within the myometrium, a diagnosis that
traditionally requires a histopathologic diagnosis. However, it is now apparent that transvaginal ultrasound or magnetic resonance imaging (MRI)
may be used to make a clinical diagnosis of adenomyosis.
The role that adenomyosis plays in the genesis of AUB is poorly understood, as some studies have concluded that there is little if any role
[36,37], while others define a population who suffer from both the symptom of heavy menstrual bleeding (HMB) and dysmenorrhea [38-40]. As
with polyps and leiomyomas, adenomyosis is a disorder that is being considered for its own subclassification system [8,41], including
standardization of methods for both imaging and ultimate histopathologic diagnosis.
Adenomyosis is discussed in detail separately. (See "Uterine adenomyosis".)
Leiomyomas (AUB-L) — Leiomyomas of the uterus (also referred to as myomas or uterine fibroids) are benign neoplasms of smooth muscle.
While the diagnosis of leiomyomas can be suggested by pelvic examination, pelvic imaging is necessary for a more accurate diagnosis. Such
images may be obtained using two-dimensional or three-dimensional ultrasound, often with contrast, or MRI depending on the clinical situation.
The FIGO MDC created a hierarchy of primary, secondary, and tertiary classification systems for uterine leiomyomas (figure 7 and figure 8):
● The primary classification reflects only the presence or absence of one or more leiomyomas, regardless of the location, number, and size.
This is determined by sonographic examination.
● In the secondary system, the clinician is required to distinguish myomas that abut the endometrium or distort the endometrial cavity (called
submucous [SM] leiomyomas) from leiomyomas in other locations (O). This is because SM lesions are most likely to contribute to AUB,
although there is some evidence that intramural myomas may also contribute to the total blood loss [42]. The determination of whether there
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is a SM leiomyoma should be made using either hysterosonography or hysteroscopy. (See "Uterine leiomyomas (fibroids): Epidemiology,
clinical features, diagnosis, and natural history", section on 'Heavy or prolonged menstrual bleeding'.)
● The tertiary classification system is a categorization of all types of leiomyomas depending on their relationship to the endometrium and/or
serosa (figure 8) as well as a category that includes lesions of the cervix and those that appear to be detached from the uterus, often called
"parasitic" because of their blood supply that arises from nonuterine sources [8,43]. This system is of particular value for reproductive
surgeons to determine the most appropriate methods for removal of leiomyomas – hysteroscopic or via abdominal approaches (laparoscopic
or laparotomy).
When a leiomyoma abuts or distorts both the endometrium and the serosa, it is categorized first by the SM categorization, then by the subserosal
location, with these two numbers separated by a hyphen (figure 7 and figure 8). The clinician or clinical investigator may also consider the size,
number, and location (eg, fundal, cervical) of the leiomyomas in the uterus.
Uterine leiomyomas are discussed in detail separately. (See "Uterine leiomyomas (fibroids): Epidemiology, clinical features, diagnosis, and
natural history".)
Malignancy and hyperplasia (AUB-M) — Endometrial hyperplasia with cytological atypia and carcinoma, including endometrial stromal
sarcomas, are epithelial neoplasms of the endometrium that are usually diagnosed with transcervical endometrial sampling. In addition, while
some cases of leiomyosarcoma are diagnosed with endometrial sampling, the sensitivity of the technique is much lower than for the epithelial
neoplasms.
When endometrial sampling of women in the reproductive years with AUB identifies atypical endometrial hyperplasia or uterine cancer, the
individual is categorized as having AUB-M and then subclassified based on histology using the appropriate World Health Organization system or
the FIGO cancer classification system, as appropriate [8,44,45].
Endometrial hyperplasia and carcinoma and uterine sarcoma, as well as postmenopausal bleeding, are discussed in detail separately. (See
"Classification and diagnosis of endometrial hyperplasia" and "Endometrial carcinoma: Clinical features, diagnosis, prognosis, and screening"
and "Uterine sarcoma: Classification, epidemiology, clinical manifestations, and diagnosis" and "Postmenopausal uterine bleeding".)

Coagulopathy (AUB-C) — The term coagulopathy is used to encompass the spectrum of systemic disorders of hemostasis. Such disorders are
identifiable in up to 24 percent of women with the symptom of HMB, most commonly mild von Willebrand disease [8,46-49].
The approach to identifying these patients starts with a structured history to assess symptoms or risk factors for coagulation disorders (table 8)
[47]. Confirmation requires laboratory testing. (See "Approach to abnormal uterine bleeding in nonpregnant reproductive-age women", section on
'Coagulation tests'.)
Ovulatory dysfunction (AUB-O) — Ovulatory dysfunction occurs when a woman is not ovulating, has infrequent ovulation, or, especially in the
late reproductive years, experiences luteal out-of-phase events [50]. A luteal out-of-phase event occurs when there is early, luteal phase
recruitment of a follicle that then matures precociously, resulting in high circulating levels of estradiol and associated increased menstrual volume.
Women with AUB-O typically experience some combination of irregularity of bleeding and a variable volume, which in some cases includes the
symptom of HMB [8].
To be classified as an ovulatory disorder, based on the 5th to 95th percentiles of population data, the individual should have a cycle length in the
previous 12 months that varies by more than seven days.
While there is often no identifiable cause, ovulatory dysfunction can be related to psychological stress; weight loss or gain; excessive exercise;
medications that affect dopamine metabolism; or an endocrine abnormality that impacts the hypothalamic-pituitary-ovarian axis, such as
hyperprolactinemia, thyroid disease, and polycystic ovary syndrome. Women with AUB-O should be evaluated with clinical evaluation, including
appropriate laboratory testing. Those ovulatory disturbances caused by drug treatment, as mentioned above, are now classified under AUB-I
(iatrogenic causes). (See "Approach to abnormal uterine bleeding in nonpregnant reproductive-age women", section on 'Irregular bleeding
(ovulatory dysfunction)'.)
It should be recognized that anovulatory cycles might also appear to be normal cycles with a cycle length of 24 to 38 days. Some data show a
significant incidence of "anovulation" at all ages, sometimes even when cycles were deemed "regular" [51]. Hence, in infertile patients, clinicians
should consider evaluating other ovulatory parameters such as measurement of progesterone in the suspected luteal phase.
Endometrial causes (AUB-E) — In women with predictable and cyclic menses suggestive of normal ovulation who have AUB, particularly the
symptom of HMB but can also include intermenstrual bleeding, and absent other definable causes, the patient is classified as having AUB-E [8].
Most often, the cause of such bleeding is a primary disorder of the endometrium.
If the symptom is HMB, the patient may have a primary disorder of mechanisms regulating local endometrial hemostasis [12,52-55]. At the
present time, there are no available tests for these disorders, so AUB-E is assigned after excluding other etiologies of AUB in women of
reproductive years. The clinician should understand that AUB-E may be present even in the presence of other findings such as adenomyosis or
leiomyomas types 4 to 8 (figure 7), as the latter are less likely to contribute to the symptom of HMB. There may exist other causes of AUB-E,
such as endometritis secondary to, for example, Chlamydia trachomatis [56].
Iatrogenic causes (AUB-I) — The AUB-I category includes AUB due to medical devices, mainly intrauterine contraception systems, or
pharmaceutical therapy. Medications that may cause AUB-I include:
● Gonadal steroids (eg, estrogens, progestins, androgens).
● Gonadal steroid-related therapy (eg, gonadotropin-releasing hormone analogues, aromatase inhibitors, selective estrogen receptor
modulators, selective progesterone receptor modulators).
● Anticoagulants.
● Systemic agents that contribute to disorders of ovulation, for example, those that interfere with dopamine metabolism or cause
hyperprolactinemia (table 9).
● Intrauterine devices – Bleeding disturbances associated with these devices are recorded as AUB-I. Such systems may be inert, are
frequently composites of copper and plastic, or take the form of a local progestogen-releasing system.
AUB related to specific therapies is discussed in detail in the relevant topics. (See "Evaluation and management of unscheduled bleeding in
women using contraception" and "Abnormal uterine bleeding and uterine pathology in women on tamoxifen therapy" and "Management of
bleeding in patients receiving direct oral anticoagulants" and "Causes of hyperprolactinemia".)
Not otherwise classified (AUB-N) — There exist a number of additional entities that may contribute to or cause AUB in a given individual.
These have either been poorly defined, inadequately examined, and/or are extremely rare. Collectively, these entities, those known now or to be
discovered in the future, have been placed in a category AUB-N for "not otherwise classified" [8]. Examples include arteriovenous malformation
[57] and AUB in the context of a uterine isthmocele secondary to a lower segment cesarean section [58]. As further evidence becomes available,
these entities may be allocated a separate category or be placed into one of the existing categories in the FIGO terminology system.
Documentation — Following appropriate investigation, a woman with AUB symptoms may be found to have one or multiple potential causes or
contributors. The FIGO systems have been designed to allow both categorization and documentation. The formal approach follows the example
of the World Health Organization tumor-node-metastasis staging of malignant tumors, with each component addressed for all patients (figure 9)
[8]. Recognizing that, in clinical practice, the full documentation might be considered to be cumbersome, abbreviating the notation to only the
positive findings can be considered. For example, a patient with adenomyosis, irregular bleeding, and a type 6 leiomyoma could be recorded as:
AUB-A, -Lo, -O. A patient with an endometrial polyp and a type 2 leiomyoma would be recorded as: AUB-P, -Lsm.
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See
"Society guideline links: Abnormal uterine bleeding".)
SUMMARY
● Abnormal uterine bleeding (AUB) in nonpregnant reproductive-age women is a common gynecologic symptom. The varied use of
terminology to describe AUB symptoms has led to difficulties in clinical and research communication and documentation. The International
Federation of Gynecology and Obstetrics (FIGO) has developed definitions and terminology for AUB symptoms and classification of AUB
etiologies in the reproductive years. (See 'Introduction' above.)
● Normal menstruation is defined as (table 2) (see 'Normal menstruation' above):
• Frequency – 24 to 38 days.
• Regularity – No more than seven to nine days difference between the shortest to longest cycles; cycle length is the number of days from
the first day of one menstrual cycle to the first day of the next.
• Duration – Up to eight days; duration is the number of days of bleeding in a single menstrual period.

• Volume – Clinical definition is subjective and defined as a volume that does not interfere with a woman's physical, social, emotional,
and/or material quality of life; research definition is ≤80 mL vaginal "blood" loss per cycle.
● AUB is the term used to describe any symptomatic variation from normal menstruation (in terms of frequency, regularity, duration, or volume)
and also includes intermenstrual bleeding. This term covers the full range of symptoms of abnormal bleeding (table 3). (See 'Abnormal
uterine bleeding' above.)
● In terms of severity and duration of symptoms, acute AUB is defined as an episode of uterine bleeding in a woman of reproductive age, who
is not pregnant, that is of sufficient quantity to require immediate intervention to prevent further blood loss. Chronic AUB is defined as uterine
bleeding that is abnormal in frequency, regularity, duration, and/or volume and has been present for at least the majority of the past six
months (algorithm 1). (See 'Abnormal uterine bleeding' above.)
● The FIGO classification system for AUB etiologies in reproductive-age women is stratified into nine basic categories that are arranged
according to the acronym PALM-COEIN: polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction,
endometrial dysfunction, iatrogenic, and "not otherwise classified" (figure 6). (See 'PALM-COEIN classification of AUB etiologies' above.)
● The PALM-COEIN system has a subclassification system for uterine leiomyoma locations (figure 7 and figure 8). (See 'Leiomyomas (AUB-L)'
above.)
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REFERENCES
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52. Gleeson NC. Cyclic changes in endometrial tissue plasminogen activator and plasminogen activator inhibitor type 1 in women with normal
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complications. J Minim Invasive Gynecol 2013; 20:562.
Topic 14213 Version 12.0

GRAPHICS
Terminology for menstrual abnormalities prior to the FIGO Menstrual Disorders Working Group
Major terms
Menorrhagia (all usages, including "essential menorrhagia," "idiopathic menorrhagia," "primary menorrhagia," "functional menorrhagia," and "ovulatory or anovulatory
menorrhagia")
Metrorrhagia
Other terms
Dysfunctional uterine bleeding
Epimenorrhagia
Epimenorrhea
Functional uterine bleeding
Hypermenorrhea
Hypomenorrhea
Menometrorrhagia
Metropathica hemorrhagica
Polymenorrhagia
Polymenorrhea
Uterine hemorrhage
FIGO: International Federation of Gynecology and Obstetrics.
Graphic 103237 Version 2.0

Normal menstruation parameters
Clinical dimensions of menstruation and

Descriptive terms Normal limits (5 th to 95 th centiles)
menstrual cycle
Frequency of menses (days) Absent
Infrequent >38
Normal 24 to 38
Frequent <24
Regularity of menses (variation defined as shortest to Regular Variation ≤7 to 9 days*

longest cycle length, in days)
Irregular Variation >7 to 9 days*
Duration of flow (days) Normal ≤8 days
Prolonged >8 days
Volume of monthly blood loss (objective) Heavy >80
Normal 5 to 80
Light <5
Volume of monthly blood loss (subjective) Heavy Clinical definition is subjective and defined as
a volume that does not interfere with a
Normal
woman's physical, social, emotional, and/or
Light quality of life
* Normal variation depends on age; these data are calculated excluding short and long outliers.
Data from:
1. Fraser IS, Critchley HO, Munro MG, Broder M. A process designed to lead to international agreement on terminologies and definitions used to describe abnormalities of
menstrual bleeding. Fertil Steril 2007; 87:466.
2. Fraser IS, Critchley HO, Munro MG, Broder M. Can we achieve international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding?
Hum Reprod 2007; 22:635.
3. Fraser IS, Munro MG, Broder M, Critchley HO. International recommendations on terminologies and definitions for normal and abnormal uterine bleeding. Semin Reprod Med
2011.

Uterine bleeding patterns
Bleeding pattern Definition
Bleeding Any bloody vaginal discharge that requires the use of such protection as pads or tampons
Spotting Any bloody vaginal discharge that is not large enough to require sanitary protection
Bleeding/spotting episode One or more consecutive days on which bleeding or spotting has been entered on the diary card
Bleeding/spotting-free interval One or more consecutive days on which no bleeding or spotting has been entered on the diary card
Bleeding/spotting segment One bleeding/spotting episode and the immediately following bleeding/spotting-free interval
Reference period The number of consecutive days upon which the analysis is based (usually taken as 90 days for women using long-
acting hormonal systems, and 28 or 30 days for women using once-a-month systems, including combined oral
contraception)
Different types of analysis, which can be Number of bleeding/spotting days

undertaken on bleeding patterns within a reference Number of bleeding/spotting episodes
period Mean, range of lengths of bleeding/spotting episodes (or medians and centiles for box-whisker plot analysis)
Mean, range (medians and centiles) of lengths of bleeding/spotting-free intervals
Number of spotting days and spotting-only episodes
Data from: Fraser IS. Bleeding arising from the use of exogenous steroids. Baillieres Best Pract Res Clin Obstet Gynaecol 1999; 13:203.

Normal and abnormal uterine bleeding patterns in reproductive-age women
HMB: heavy menstrual bleeding.
Reproduced with permission from Malcom G Munro, MD, FRCS(c), FACOG.

FIGO uterine bleeding symptom worksheet
Category Normal Abnormal ✓
Frequency Absent (no periods or bleeding) = amenorrhea
Frequent (<24 days)
Normal (24 to 38 days)
Infrequent (>38 days)
Duration Prolonged (>8 days)
Normal (≤8 days)
Regularity Regular variation (cycle length variation is ±4 days)
Irregular (cycle length variation is >±4 days)
Flow volume Heavy
Normal
Light
Intermenstrual bleeding (IMB) None

(bleeding between cyclically regular onset of
Random
menses)
Cyclic (predictable) Early cycle
Mid cycle
Late cycle
Unscheduled bleeding on hormone Not applicable (not on hormone medication)

medication
(eg, birth control pills, rings, or patches) None (on hormone medication)
Present
FIGO: International Federation of Gynecology and Obstetrics.

Frequency of menses
The normal frequency of onset of menstrual periods is from 24 to 38 days, based on large databases and
using the 5 th to the 95 th percentiles. The top panel demonstrates an individual with a 27-day cycle that is
"normal"; the middle panel is a cycle length of 44 days, outside the normal range (infrequent); the bottom
panel depicts a cycle length of 22 days, and is therefore defined as being "frequent."

Regularity of menses
Regular and irregular frequency of mesnses. "Regular" means "cyclically predictable" and generally reflects
the presence of consistently predictable ovulation, typically about 14 days prior to the onset of menses. The
top panel depicts a 65-day interval where the first cycle length is 29 days and the second is 31 days, with
each menstrual period lasting five days and day 2 having the heaviest volume. This variation of 2 days is well
within the definition of regularity: cycle length from first day of one period to the next is fairly consistent,
with each cycle length within 4 days of the others. The bottom panel demonstrates and irregular cycle, with
the first cycle with a length of 13 days and a second cycle of 39 days. This variation in cycle length is outside
the normal range for any age and suggests that the patient is not ovulating regularly or not ovulating at all.
Note the variable duration and flow of the menses, also consistent with some ovulatory disorders, but not
necessary for defining "irregular" onset of menses.

Variation in menstrual cycle by age
Age (years) Difference between longest and shortest cycles (days)*
18 to 25 ±4 days
26 to 41 ±4 days
42 to 45 ±4 days
* There are slight differences between age strata, but ±4 days is noted for each age range for the sake of simplicity. These slight differences have limited value in clinical situations,
but may be useful for the design and interpretation of epidemiological and clinical studies.
Data from:
1. Harlow SD, Lin X, Ho MJ. Analysis of menstrual diary data across the reproductive life span applicability of the bipartite model approach and the importance of within-woman
variance. J Clin Epidemiol 2000; 53:722.

Duration of menses
The panel above demonstrates the two definitions of duration of menses. When a menstrual period is present
and lasts up to 8 days, it is considered "normal," while if it is in excess of 8 days, regardless of volume, as
depicted in the center and right cluster, it is deemed "prolonged."

Volume of menses
The volume of a menstrual period comprises the total amount of red cells, serum, transudate, and tissue
discharged from the uterus. The menstrual volume can be quantified with research laboratory techniques, but for
clinical purposes, the patient's perception of volume is of primary importance. Each of the clusters in the above
panel represents a menstrual period. The first cluster would likely reflect the patient's perception of "normal"
volume with a normal period length of 7 days. The second cluster reflects increased volume, primarily because of
prolongation of the duration of the period – there is no increase in flow rate per day. The third cluster depicts
increased volume, but with a period of normal duration with increase in daily flow rate responsible for the
increased volume. The fourth cluster demonstrates a period with both increased duration and increased flow rate
contributing to the increase in perceived volume.

Intermenstrual bleeding
This depicts an individual with intermenstrual bleeding. She has three periods in this interval – the first period
starts day 1, the next period starts 29 days later, and the next 30 days after that. The lighter intermenstrual
bleeding is depicted as being on day 13 of the first cycle, and on day 25 of the second. This type of random
bleeding is typically seen with a focal lesion or inflammation, including: cervicitis, cervical or endometrial
polyp, or cervical cancer.

Causes of female genital tract bleeding in reproductive-age women
Pregnancy
Uterus
Polyps Endometrial
Endocervical
Adenomyosis
Leiomyomas Submucous
Other (no contact with endometrium)
Malignancy and hyperplasia EIN
Endometrial adenocarcinoma
Sarcoma
Endocervical malignancy
Coagulopathy Von Willebrand disease
Other coagulopathies, congenital and acquired
Ovulatory disorders
Endometrial disorders Disorders of local hemostasis
Endometritis
Other
Iatrogenic Anticoagulants
Gonadal steroid drugs or drugs that effect normal gonadal steroid production or function
Devices (intrauterine systems)
Other
Not otherwise classified Arteriovenous and other vascular malformations
Cesarean section scar bleeding
Endometriosis
Other
Exocervix Cervicitis, acute and chronic
Polyps
Malignancy
Vagina Trauma

Neoplasia
Other
Vulva Trauma
Neoplasia
Infection
Other
EIN: endometrial epithelial neoplasia.

PALM-COEIN classification system for abnormal uterine

bleeding in nongravid reproductive-age women
Basic classification system. The basic system comprises four categories that are defined
by visually objective structural criteria (PALM: polyp, adenomyosis, leiomyoma, and
malignancy and hyperplasia), four that are unrelated to structural anomalies (COEI:
coagulopathy, ovulatory dysfunction, endometrial, iatrogenic), and one reserved for
entities that are not yet classified (N). The leiomyoma category (L) is subdivided into
patients with at least one submucosal myoma (LSM) and those with myomas that do not
impact the endometrial cavity (LO).
Reproduced from: Munro MG, Critchley HO, Broder MS, Fraser IS, FIGO Working Group on
Menstrual Disorders. FIGO classification system (PALM-COEIN) for causes of abnormal uterine
bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet 2011; 113:3.
Illustration used with the permission of Elsevier Inc. All rights reserved.

Chronic abnormal uterine bleeding evaluation: PALM-COEIN worksheet
Name:
Date:
PALM-COEIN Not
Absent Present Diagnostic method ✓ Date Comment
category assessed
Polyps Vaginal ultrasound
Vaginal ultrasound with

contrast
Hysteroscopy
Hysterosalpingogram
MRI
Histopathology
Adenomyosis Vaginal ultrasound
Hysteroscopy
MRI
Histopathology
Leiomyoma Vaginal ultrasound

contrast
Hysteroscopy
Hysterosalpingogram
Laparoscopy
MRI
Histopathology
Malignancy and Endometrial biopsy

hyperplasia
Coagulopathy Laboratory
Ovulatory disorders History
Basal body temperature
Serum progesterone
Other
Other
Endometrial History
disorders
Iatrogenic History
Not otherwise Vaginal ultrasound

classified
contrast
Hysteroscopy
Hysterosalpingogram
Laparoscopy
MRI
Biopsy
Notes:
MRI: magnetic resonance imaging.

PALM-COEIN subclassification system for leiomyomas
From: Munro MG. Abnormal Uterine Bleeding. Cambridge: Cambridge University Press, 2010. Copyright © 2010 M. Munro.
Reprinted with the permission of Cambridge University Press.

PALM-COEIN AUB leiomyoma locations
(A) Submucous leiomyomas.

(B) Intramural and subserous leiomyomas, "other" or outside the endometrial cavity.
(C) Hybrid (transmural) leiomyomas.

Screening for bleeding disorders in women with heavy menstrual bleeding
Initial screening for an underlying disorder of hemostasis in patients with excessive menstrual bleeding should be structured by
medical history (positive screen comprises any of the following):*
Heavy menstrual bleeding since menarche
One of the following:

Postpartum hemorrhage
Surgery-related bleeding
Bleeding associated with dental work
Two or more of the following symptoms:

Bruising one to two times per month
Epistaxis one to two times per month
Frequent gum bleeding
Family history of bleeding symptoms
* Patients with a positive screen should be considered for further evaluation, including consultation with a hematologist and testing of von Willebrand factor and ristocetin cofactor.
Original figure modified for this publication. Kouides PA, Conard J, Peyvandi F, et al. Hemostasis and menstruation: appropriate investigation for underlying disorders of hemostasis in
women with excessive menstrual bleeding. Fertil Steril 2005; 84:1345. Table used with the permission of Elsevier Inc. All rights reserved.

Medications that cause hyperprolactinemia
Medication class Frequency of prolactin elevation* Mechanism
Antipsychotics, first generation
Chlorpromazine Moderate Dopamine D 2 receptor blockade within hypothalamic

tuberoinfundibular system.
Fluphenazine High
Haloperidol High
Loxapine Moderate
Perphenazine Moderate
Pimozide Moderate
Thiothixene Moderate
Trifluoperazine Moderate
Antipsychotics, second generation
Aripiprazole None or low Dopamine D 2 receptor blockade.
Asenapine Moderate
Clozapine None or low
Iloperidone None or low
Lurasidone None or low
Olanzapine Low
Paliperidone High
Quetiapine None or low
Risperidone High
Ziprasidone Low
Antidepressants, cyclic
Amitriptyline Low Not well understood. Possibly by GABA stimulation and

indirect modulation of prolactin release by serotonin.
Desipramine Low
Clomipramine High
Nortriptyline None
Antidepressants, SSRI
Citalopram, fluoxetine, fluvoxamine, paroxetine, None or low (rare reports) Same as for cyclic antidepressants.
sertraline

Antidepressants, other
Bupropion, venlafaxine, mirtazapine, nefazodone, None Not applicable.

trazodone
Antiemetic and gastrointestinal
Metoclopramide High Dopamine D 2 receptor blockade.
Domperidone (not available in United States) High
Prochlorperazine Low
Antihypertensives
Verapamil Low Not well understood. Specific to verapamil. May involve

calcium influx inhibition within tuberoinfundibular
dopaminergic neurons.
Methyldopa Moderate Decreased conversion of L-dopa to dopamine;

suppression of dopamine synthesis.
Most other antihypertensives (including other calcium None Not applicable.

channel blockers)
Opioid analgesics
Methadone, morphine, others Transient increase for several hours following dose Potentially an indirect effect of mu opiate receptor
activation.
Medication-induced hyperprolactinemia can cause decreased libido and erectile dysfunction in men and galactorrhea and amenorrhea in women.
GABA: gamma-aminobutyric acid; SSRI: selective serotonin reuptake inhibitor.

* Frequency of increase to abnormal prolactin levels with chronic use: high: >50 percent; moderate: 25 to 50 percent; low: <25 percent; none or low: case reports. Effect may be
dose dependent.
Data from:
1. Molitch ME. Drugs and prolactin. Pituitary 2008; 11:209.
2. Molitch ME. Medication induced hyperprolactinemia. Mayo Clin Proc 2005; 80:1050.
3. Coker F, Taylor D. Antidepressant-induced hyperprolactinaemia: incidence, mechanisms and management. CNS Drugs 2010; 24:563.
4. Drugs for psychiatric disorders. Treat Guidel Med Lett 2013; 11:53.

PALM-COEIN AUB terminology documentation form


(A) Single entity.

(B) Multiple entity.
AUB: abnormal uterine bleeding; P: polyps; A: adenomyosis; L: leiomyoma; SM: submucosal; M:

malignancy and hyperplasia; C: coagulopathy; O: ovulatory disorders; E: endometrial disorders;
I: iatrogenic; N: not otherwise classified.

Contributor Disclosures
Ian S Fraser, AO, DSc, MD Grant/Research Support: MSD Merck [AUB treatment and contraception trials]; Bayer Healthcare [AUB treatment and
contraception trials]. Speaker's Bureau: Bayer Healthcare [AUB treatment]; MSD Merck [Contraception trials]; Vifor Pharma [Contraception trials].
Consultant/Advisory Boards: Bayer Healthcare [Advisory boards on contraception and AUB treatment]; MSD Merck [Advisory boards on contraception and AUB
treatment]; Vifor Pharma [Advisory boards on contraception and AUB treatment]. Malcolm G Munro, MD, FRCS(c), FACOG Grant/Research/Clinical Trial
Support: AbbVie [Adenomyosis]. Consultant/Advisory Boards: Aegea Medical [Abnormal uterine bleeding]; Caldera Medical [Abnormal uterine bleeding];
Channel Medical [Abnormal uterine bleeding]; Daiichi Sankyo [Abnormal uterine bleeding]; Boston Scientific [Abnormal uterine bleeding]; Gynesonics [Abnormal
uterine bleeding]; Hologic [Abnormal uterine bleeding]; Vifor Pharma [Abnormal uterine bleeding]; Myovant [Leiomyomas/abnormal uterine bleeding]. Patent
Holder: EMIG Simulation Systems. Equity Ownership/Stock Options: Aegea Medical; Channel Medical; Gynesonics; CrossBay Medical. Hilary OD Critchley,
MD, FRCOG Grant/Research/Clinical Trial Support: Bayer Ag [Abnormal uterine bleeding]. Consultant/Advisory Boards: Bayer Ag [Abnormal uterine bleeding];
Gedeon Richter/PregLem [Abnormal uterine bleeding]; Vifor Pharma [Abnormal uterine bleeding]; AbbVie Inc [Abnormal uterine bleeding]; Myovant [Abnormal
uterine bleeding]. Robert L Barbieri, MD Nothing to disclose Alana Chakrabarti, MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review
process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

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Abnormal Uterine Bleeding in Reproductive-Age Women - Terminology and PALM-COEIN Etiology Classification - UpToDate

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25/03/2020 Abnormal uterine bleeding in reproductive-age women: Terminology and PALM-COEIN etiology classiﬁcation - UpToDate

Official reprint from UpToDate®

Abnormal uterine bleeding in reproductive-age women: Terminology and PALM-COEIN

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DEVELOPMENT OF THE FIGO SYSTEMS

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The process of developing new definitions and terminology has included:

DEFINITIONS OF UTERINE BLEEDING

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Normal menstruation — Normal menstruation is defined as (table 2) [1,6]:

Chronic abnormal uterine bleeding — Chronic AUB is defined as:

DISTINGUISHING NORMAL MENSTRUATION FROM AUB

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PALM-COEIN CLASSIFICATION OF AUB ETIOLOGIES

● Systemic disorders of hemostasis (the coagulopathies) (AUB-C).

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Adenomyosis is discussed in detail separately. (See "Uterine adenomyosis".)

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● Gonadal steroids (eg, estrogens, progestins, androgens).

SOCIETY GUIDELINE LINKS

● Normal menstruation is defined as (table 2) (see 'Normal menstruation' above):

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Topic 14213 Version 12.0

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Functional uterine bleeding

FIGO: International Federation of Gynecology and Obstetrics.

Graphic 103237 Version 2.0

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Normal menstruation parameters

Clinical dimensions of menstruation and

Frequency of menses (days) Absent

Regularity of menses (variation defined as shortest to Regular Variation ≤7 to 9 days*

Duration of flow (days) Normal ≤8 days

Prolonged >8 days

Volume of monthly blood loss (objective) Heavy >80

Graphic 103238 Version 3.0

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Uterine bleeding patterns

Bleeding pattern Definition

Different types of analysis, which can be Number of bleeding/spotting days

Graphic 103240 Version 1.0

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Normal and abnormal uterine bleeding patterns in reproductive-age women

HMB: heavy menstrual bleeding.

Reproduced with permission from Malcom G Munro, MD, FRCS(c), FACOG.

Graphic 109654 Version 1.0

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FIGO uterine bleeding symptom worksheet

Category Normal Abnormal ✓

Frequency Absent (no periods or bleeding) = amenorrhea

Frequent (<24 days)

Normal (24 to 38 days)