Most useful investigation in a 55-year-old postmenopausal woman with diabetes mellitus and hypertension who has presented with postmenopausal bleeding is:

Transvaginal ultrasound examination

A 32-year-old woman presents with irregular, heavy menstrual bleeding. After thorough evaluation including pelvic ultrasound, hormonal assays, coagulation profile, and endometrial sampling, no structural abnormalities, systemic disorders, or medication-related causes are identified. This clinical scenario is best described as:

Presence of identifiable organic causes

A 45 year old woman presents with continuous vaginal bleeding for 15 days. Her bleeding should be controlled by:

Curettage followed by progestogens

Abnormal Uterine Bleeding: Classification for FMGE: High-Yield Obstetrics and Gynecology Lessons

AUB Classification - Decoding the Flow

AUB: Uterine bleeding abnormal in frequency, regularity, duration, or volume.
Normal: Freq 24-38d; Dur ≤8d; Vol 5-80mL.
HMB: >80mL; IMB: Intermenstrual bleeding.
FIGO's PALM-COEIN: Standard AUB cause classification.
- PALM (Structural): Polyp, Adenomyosis, Leiomyoma, Malignancy.
- COEIN (Non-structural): Coagulopathy, Ovulatory, Endometrial, Iatrogenic, Not yet classified.

⭐ FIGO's PALM-COEIN system is the standard classification for AUB causes in non-pregnant reproductive-aged women.

PALM Structural Causes - Anatomy's Anomalies

📌 PALM (Polyp, Adenomyosis, Leiomyoma, Malignancy/Hyperplasia) is the FIGO classification system's acronym for structural causes of Abnormal Uterine Bleeding (AUB). These are anatomical abnormalities typically identifiable via imaging techniques or histopathological examination.

FIGO classification of abnormal uterine bleeding , Malignancy/Hyperplasia)

Component	Definition	Key Clinical Findings & Diagnostic Clues
Polyp (AUB-P)	Localized benign endometrial/cervical overgrowths.	Intermenstrual bleeding (IMB), heavy menstrual bleeding (HMB). Dx: Transvaginal sonography (TVS), sonohysterography, hysteroscopy.
Adenomyosis (AUB-A)	Endometrial glands & stroma within myometrium.	HMB, dysmenorrhea, symmetrically enlarged, tender, "boggy" uterus. Dx: TVS (myometrial heterogeneity), MRI.
Leiomyoma (AUB-L)	Benign uterine smooth muscle tumors (fibroids). Submucosal (AUB-Lsm) or other.	HMB, pelvic pressure/pain, infertility. AUB-Lsm most linked to HMB. Dx: TVS, hysteroscopy, MRI.
Malignancy & Hyperplasia (AUB-M)	Endometrial hyperplasia or carcinoma.	Postmenopausal bleeding (PMB) (red flag!), HMB, IMB, esp. with risk factors (obesity, PCOS). Dx: Endometrial biopsy.

COEIN Non-Structural Causes - Systemic Snafus

AUB-C (Coagulopathy): Systemic hemostasis disorders.
- Examples: von Willebrand disease (commonest inherited), platelet defects.
- Clues: Menorrhagia since menarche, easy bruising, family history. Screen: CBC, coagulation profile.
AUB-O (Ovulatory Dysfunction): Hormonal imbalances disrupting ovulation.
- Examples: PCOS, thyroid issues, hyperprolactinemia, HPO axis immaturity/senescence.
- Clues: Irregular, unpredictable bleeding (often heavy).
⭐ Ovulatory dysfunction (AUB-O) is a very common cause of AUB, particularly at the extremes of reproductive age (adolescence and perimenopause).
AUB-E (Endometrial): Primary endometrial cause; diagnosis of exclusion.
- Mechanism: Dysregulation of local endometrial hemostasis (e.g., prostaglandins, fibrinolytics).
- Clues: Cyclical HMB or IMB with normal ovulation & coagulation.
AUB-I (Iatrogenic): Caused by medical treatment.
- Examples: Hormonal contraceptives (breakthrough bleeding), IUDs, anticoagulants, certain psychotropics.
- Clues: Bleeding pattern change after new medication/device.
AUB-N (Not Yet Classified): Rare or poorly defined causes.
- Examples: Arteriovenous malformations (AVMs), chronic endometritis (if not AUB-E).
- Clues: Persistent AUB after other causes excluded; may need specialized imaging.

AUB Investigation Approach - Pathway Pointers

⭐ A structured history focusing on bleeding patterns, associated symptoms, and medical/drug history is crucial for initially categorizing AUB within the PALM-COEIN framework.

High‑Yield Points - ⚡ Biggest Takeaways

PALM-COEIN is the FIGO classification for AUB in non-pregnant women.

PALM = Structural causes: Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia.

COEIN = Non-structural causes: Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not classified.

Leiomyomas are the most common structural cause of AUB.

Ovulatory dysfunction is common at extremes of reproductive age.

Endometrial causes are diagnosed by exclusion of other pathologies.

Always rule out pregnancy first in any AUB case.

Continue reading on Oncourse

CONTINUE READING — FREE

or get the app

App Store|Google Play

Abnormal Uterine Bleeding: Classification