Abnormal Uterine Bleeding (AUB) New Standardized Terminology, Definitions, Classification

History Long time use of non-standardized, ambiguous terminology. English language terminologies with Greek or Latin roots are poorly defined and create ambiguity in meaning and usage. In 2005, interest group of 35 experts did historical review, and recommendations made for uniform terminology published. A Delphi panel created to analyze recommendations. They recommended discarding the confusing terminology, and replace with simple descriptive terms that could be understood by patients and translated into most languages. In 2006, FIGO identified as the appropriate body to provide supervision and international credibility to the ongoing evaluation of new terminology. Formed the FIGO Menstrual Disorders Group. In 2009, FIGO World Congress of Gynecology and Obstetrics (17 countries from 6 continents) accepted the new terminology. The PALM-COEIN Classification System created. Supported by ACOG (Practice Bulletin No. 128, July 2012) Recommendations for Discarded Terminology Menorrhagia Hypermenorrhea Hypomenorrhea Menometrorrhagia Polymenorrhea Polymenorrhagia Epimenorrhea Epimenorrhagia Uterine hemorrhage Dysfunctional uterine bleeding Functional uterine bleeding Metropathica hemorrhagica Oligomenorrhea Amenorrhea – retained term Accepted Abbreviations Describing Menstrual Symptoms AUB Abnormal uterine bleeding HMB Heavy menstrual bleeding HPMB Heavy and prolonged menstrual bleeding IMB Intermenstrual bleeding PMB Postmenopausal bleeding Recommended Normal Limits of Menstrual Dimensions Frequency of menses Frequent <24 days Normal 24 to 38 days Infrequent >38 days Regularity of menses, cycle to cycle Absent No bleeding Variation over 12 months Regular Variation + or - 2 to 20 days Irregular Variation >20 days Duration of flow Prolonged >8.0 days Normal 4.5 to 8.0 days Shortened <4.5 days

Recommended Terminology, Definitions, and Classifications of Symptoms of Abnormal Uterine Bleeding Disturbances of Regularity Irregular Menstrual Bleeding (IrregMB): Bleeding of >20 days in individual cycle lengths over a period of one year. Absent Menstrual Bleeding (amenorrhea): No bleeding in a 90-day period. Disturbances in Frequency Infrequent Menstrual Bleeding: One or two episodes in a 90-day period. Frequent Menstrual Bleeding: More than four episodes in a 90-day period. Disturbances of Heaviness of Flow Heavy Menstrual Bleeding (HMB): Excessive menstrual blood loss that interferes with the woman’s physical, emotional, social, and material quality of life and can occur alone or in combination with other symptoms. Heavy and Prolonged Menstrual Bleeding (HPMB): Less common than HMB. It is important to make a distinction from HMB given they may have different etiologies and respond to different therapies. Light Menstrual Bleeding: Based on patient complaint, rarely related to pathology. Disturbance of the Duration of Flow Prolonged Menstrual Bleeding: Menstrual periods exceeding 8 days in duration on a regular basis. Shortened Menstrual Bleeding: Uncommon, defined as bleeding of no longer than 2 days. Irregular Nonmenstrual Bleeding Irregular episodes of bleeding, often light and short, occurring between normal menstrual periods. Mostly associated with benign or malignant structural lesions. May occur during or following sexual intercourse. Bleeding Outside Reproductive Age Postmenopausal Bleeding (PMB): Bleeding occurring >1 year after the acknowledged menopause. Precocious Menstruation: Usually associated with other signs of precocious puberty, occurring before 9 years of age. Acute AUB An episode of bleeding in a woman of reproductive age, who is not pregnant, of sufficient quantity to require immediate intervention to prevent further blood loss. Chronic AUB Bleeding from the uterine corpus that is abnormal in duration, volume, and/or frequency and has been present for the majority of the last 6 months. Patterns of Bleeding The “shape” of the volume of the bleeding pattern over the days of one menstrual period. It is usually recognized that about 90% of the total menstrual flow is lost within the first 3 days of the cycle, with day 1 or 2 the heaviest. In women with AUB this pattern is variable. The PALM-COEIN Classification System for Causes of AUB PALM – visually objective structural criteria COEI – unrelated to structural anomalies N – entities not yet classified

Coagulopathy (AUB-C) Polyps (AUB-P) Ovulatory disorders (AUB-O) Adenomyosis (AUB-A) Endometrial (AUB-E) Leiomyoma (AUB-L) Iatrogenic (AUB-I) Malignancy (AUB-M) Not Classified

Components of the PALM-COEIN Classification System Polyps (AUB-P) Abnormal vaginal bleeding is the most common presenting symptom. Accounts for all causes of abnormal vaginal bleeding in 39% of pre-menopausal and 21-28% in post-menopausal women. Polyps are categorized as either present or absent. Diagnosed by TVUS, saline infusion sonography, and hysteroscopy. Adenomyosis (AUB-A) 70% of women with adenomyosis have symptoms of AUB. 30% have dysmenorrhea. 19% have both. Diagnosed by ultrasound or MRI. Leiomyomas (AUB-LSM or AUB-LO) Most common benign tumor of the genital tract. Age is most common risk factor with lifetime risk in women over age 45 to be more than 60%. Higher association of AUB with submucosal lesions, compared to intramural and subserosal leiomyomas. Malignancy (AUB-M) AUB is the primary symptom of endometrial neoplasia. 70% of PMB with AUB have benign findings, 15% have hyperplasia, and 15% have endometrial cancer. Approximately 50% of women diagnosed with endometrial hyperplasia have concurrent carcinoma. AUB-M includes both premalignant and malignant lesions. Coagulopathies (AUB-C) 13% of women with HMB have a disorder of hemostasis that may be overlooked during the differential diagnosis. Ovulatory Dysfunction (AUB-O) Patients with unpredictable menses with variable flow are usually associated with endocrinopathies, such as polycyctic ovary syndrome or hypothyroidism. Evaluate for ovulatory dysfunction. Endometrial Causes (AUB-E) Most patients in this category will have regular cycles, normal ovulation and no definable cause of AUB. Usually present with HMB, which may indicate a disorder of endometrial hemostasis. Others may present with IMB, which may be secondary to inflammation, infection, or abnormal inflammatory responses. Iatrogenic (AUB-I) Causes include IUD, exogenous gonadal steroids and other systemic agents that affect blood coagulation or ovulation. Bleeding from anticoagulation therapy is listed under AUB-C rather than AUB-I. Not Yet Classified (AUB-N) Reserved for entities that are poorly defined and/or not well examined, such as arteriovenous malformation and myometrial hypertrophy. With more evidence, entities such as these will likely be placed into a new or existing category.

Notation of 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;O

Diagnostic Evaluation of AUB Medical History Age of menarche and menopause Menstrual bleeding patterns Severity of bleeding (clots or flooding) Pain (severity and treatment) Medical conditions Surgical history Use of medications Symptoms and signs of possible hemostatic disorder Physical Exam General physical Pelvic Examination External Speculum with Pap test, if needed. Bimanual Laboratory Tests Pregnancy test (blood or urine) Complete blood count TSH Chlamydia trachomatis Targeted screening for bleeding disorders (when indicated, based on history*): PT, PTT, specific tests for von Willebrand disease, von Willebrand-ristocetin cofactor activity, von Willebrand factor antigen, and factor VIII Available Diagnostic or Imaging Tests (when indicated) Saline infusion sonohysterography Transvaginal ultrasonography Magnetic resonance imaging Hysteroscopy Available Tissue Sampling Methods (when indicated**) Office endometrial biopsy Hysteroscopy directed endometrial sampling (office or operating room) *Clinical Screening for an Underlying Disorder of Hemostasis in the Patient with Excessive Menstrual Bleeding **Indications for Endometrial Sampling Positive screen comprises any of the following: Age >45 years Heavy menstrual bleeding since menarche Family history of hereditary nonpolyposis colorectal One of the following: cancer syndrome (HNPCC) Postpartum hemorrhage Persistent AUB that is unexplained or fails treatment 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

Coding for Abnormal Uterine Bleeding ICD-9 Codes 626 Disorders of menstruation and other abnormal bleeding from female genital tract 626.0 Amenorrhea (primary) (secondary) 626.1 Scanty or Infrequent menstruation, Hypomenorrhea, Oligomenorrhea 626.2 Excessive or frequent menstruation, Heavy periods, Menorrhagia, Menometrorrhagia, Polymeorrhea 626.4 Irregular menstrual cycle, Irregular bleeding, Irregular menstruation, Irregular periods 626.5 Ovulation bleeding, Regular intermenstrual bleeding 626.6 Metrorrhagia, Bleeding unrelated to menstrual cycle, Irregular intermenstrual bleeding 626.8 Dysfunctional or functional uterine hemorrhage 627.1 Postmenopausal bleeding 621.0 Polyp of corpus uteri, Endometrium, Uterus 617.0 Endometriosis of uterus, Adenomyosis 625.3 Dysmenorrhea, Painful menstruation 218.0 Submucous leiomyoma of uterus 218.1 Intramural leiomyoma of uterus 218.2 Subserous leiomyoma of uterus 218.9 Leiomyoma of uterus, unspecified 182.0 Malignant neoplasm of body of uterus, endometrium 621.30 Endometrial hyperplasia, unspecified 621.31 Simple endometrial hyperplasia without atypia 621.32 Complex endometrial hyperplasia without atypia 621.33 Endometrial hyperplasia with atypia 621.34 Benign endometrial hyperplasia CPT Codes 58100 Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation, any method (separate procedure) 58555 Hysteroscopy, diagnostic (separate procedure) 58558 hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D&C 76830 Ultrasound, transvaginal 76831 Saline infusion sonohysterography (SIS), including color flow Doppler, when performed Many of the suggestions for the new terminology might be included in the ICD-10 changes that may be implemented in 2014.