Palm coein classification its clinical significance -final

Describes the PALM COEIN classification for abnormal uterine bleeding using the FIGO publications of 2011 and 2018 on the topic.

1. PALM-COEIN classification & its clinical significance Dr Mamta Rath Datta, Chief Consultant, Department of Obstetrics & Gynaecology , Tata Main Hospital, Past President, Jamshedpur ObGy Society, Vice President , ISOPARB Jamshedpur Chapter 1

2. References 2

3. PALM-COEIN classification & its clinical significance Agenda: What is PALM COEIN Classification? Evolution of AUB classification systems 1 and 2 Clinical significance of PALM-COEIN classification (AUB system 2) Terminologies that are no longer used How to use the system in clinical practice Drawbacks of the system 3

4. What is PALM COEIN ? System of classification of abnormal uterine bleeding in non gravid reproductive age women 4

5. EVOLUTION OF PALM COEIN SYSTEM FIGO recommended 2 AUB systems Terminology & definition( FIGO AUB system 1) 2. Classification of causes ( FIGO AUB system 2 –PALM COIEN ) 5

6. Why PALM –COIEN system was developed? Approximately 3%–30% among reproductive aged women suffer from AUB Cause modest to severe disruption of work productivity and QOL Increasing maternal morbidity and mortality for pregnant women with pre-existing AUB related anemia A bsence of a consensus system for the classification of causes or potential causes of abnormal uterine bleeding Need : consistent and universally accepted classification system could be used by clinicians, investigators, and even patients to facilitate communication, clinical care and research PALM-COEIN was proposed as a tool that met the requirements & was capable of adaptation to evolving insight into the mechanisms involved in AUB 6

7. Evolution of AUB classification systems 7

8. 2005 FIGO MDWG (International Federation of Gynecology and Obstetrics) Menstrual Disorders Working Group was created) Experts from the FDA, related professional societies and gynecologic medical journals, and representatives from the basic, translational, and clinical sciences assembled Aim : T o tackle the issues in a systematic fashion 8

9. 2007 - AUB System 1 First publication in Fertility Sterility and Human Reproduction Recommended a substantial revision of existing terminologies and definitions for the description of AUB features Redefined the normal parameters of menstrual bleeding Abolition of terms (largely of Latin and Greek origin) such as menorrhagia, metrorrhagia, and dysfunctional uterine bleeding 9

10. 2011 – AUB System 2 10

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12.  ACUTE VERSUS CHRONIC NONGESTATIONAL AUB IN THE REPRODUCTIVE YEARS Chronic AUB bleeding from the uterine corpus that is abnormal in duration, volume, frequency, and/or regularity has been present for the majority of the preceding 6 months Acute AUB an episode of heavy bleeding that is of sufficient quantity to require immediate intervention to minimize or prevent further blood loss Acute AUB may present in the context of existing chronic AUB or can occur in the absence of such a background history 12

13. 2018 revision 13

14. 2011 2018 14

15. 2018 modifications Intermenstrual bleeding added A practical definition for irregular menstrual bleeding includes 75th percentile, effectively excluding the occasional long or short cycles experienced by many women The available evidence suggests the normal range (shortest to longest) varies with age: 18–25 y of age, ≤9 d; 26–41 y, ≤7 d; and for 42–45 y, ≤9 d (Harlow et al., 2000) Definition of HMB proposed by the NICE has been adopted “Excessive menstrual blood loss which interferes with a woman’s physical, social, emotional, and/or material quality of life”. Frequency parameter has been updated from ‘Infrequent ( <24d) to frequent(<24d) & irregular to > 8 -10 d 15

16.  Revision of terminologies and definitions of symptoms of abnormal uterine bleeding Revised AUB System 1 Summary of changes 16

17. defined by visually objective structural criteria unrelated to structural anomalies FIGO AUB System 2 -2018 FIGO AUB System 2 -2011 17

18.   Revision of classification of underlying causes of AUB (PALM-COEIN) 18

19. AUB- A Adenomyosis diagnostic criteriaproposed by the MUSA (Morphological Uterus Sonographic Assessment group) Presence of two or more of these criteria are highly associated with a diagnosis of adenomyosis 8 TVUS criteria A- asymmetrical myometrial thickening B - myometrial cysts C - hyperechoic islands D - fan shaped shadowing E - echogenic subendometrial lines and buds F - translesional vascularity G - irregular junctional zone H - interrupted junctional zone (3D USG best), 19

20. Leiomyoma The leiomyoma category (L) is subdivided into patients with at least one submucous myoma (LSM) and those with myomas that do not impact the endometrial cavity (Lo). 20

21. Leiomyoma subclassification system, essentially unchanged since the initial 2011 publication Distinguishing between type 0 and 1 / type 6 and 7 leiomyoma comparing the Stalk diameter to the mean diameter of the leiomyoma Types 0 and 7 now comprise leiomyomas that have a stalk diameter that is 10% or less than the mean diameter of the leiomyoma Distinguishing between a type 2 and 3 leiomyoma based upon the lowest filling pressure that allows visualization of the endometrial cavity Distinguishing between type 4 and 5 leiomyomas based upon observation of distortion of the serosa ( type 5 ) as determined by ultrasonography or MRI 21

22. Additional guidance for investigators using the FIGO subclassification system for leiomyomas A minimal data set for describing leiomyomas include an estimate of total uterine volume based on imaging(TAS/TVS/MRI) as well as an estimate of the number of leiomyomas (1, 2, 3, 4, or > 4) If such imaging is not available the minimum data set should include an estimate of uterine size on clinical examination as equivalent to a gravid uterus of “X” weeks 22

23. Contd. When transvaginal ultrasonography or MRI are available, RECORD location (anterior, posterior, left, right, or center) estimated volume of up to 4 individual leiomyomas location in the vertical plane should be described; upper half, lower half, or both If >4 are present, the volume of the largest leiomyoma should be recorded, as a minimum If the endometrium is visualized, then the relationship with the endometrium should be described using the FIGO classification system 23

24. Clinical application 24

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27. AUB diagnostic matrix not been completely evaluated - “?” column no evidence of the abnormality -N column assessment positive - Y column Eg : The patient has the symptom of HMB, assessment revealed a subserosal leiomyoma - Lo. patient had a + ve historical screening result for coagulopathy and hematological assessments for coagulation disorders are not yet available. Consequently, the “C” and “E” rows remain in the “?” category. The hematological assessment shows no evidence of coagulopathy, so the diagnosis of a primary disorder of endometrial hemostasis is made. The C row can now be assigned an “N” while the E category can be checked as “Y” 27

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30. Investigative algorithms for patients with chronic AUB during the reproductive years (A) Initial investigation 30

31. Investigative algorithms for patients with chronic AUB during the reproductive years. B) A pragmatic guide to uterine assessment 31

32. RECOMMENDATIONS FOR CLINICAL INVESTIGATION General assessment – exclude pregnancy,check anaemia Determination of ovulatory status – EB not essential Screening for systemic disorders of hemostasis – history +tests Evaluation of the endometrium –TVS, ES for at risk women Evaluation of the structure of the endometrial cavity TVS,Sonohysterography,hysteroscopy ,MRI Myometrial assessment TVS,TAS,MRI 32

33. Screening for systemic disorders of hemostasis b This structured history-based instrument is 90% sensitive for the presence of a coagulopathy in women with the symptom of heavy menstrual bleeding 33

34. Summary PALM COIEN system provides classification of causes of AUB Definitions and classification of causes of AUB have been refined TVS, Sonohysterography – good imaging modalities MRI is not a must EB for at risk patients Office hysteroscopy does provide advantages Leiomyoma and adenomyosis have been subclassified Notation and diagnostic matrix are useful tools More reviews are expected with subclassification for the other entities 34

35. Future reviews The FIGO MDC is currently working on subclassification systems for adenomyosis and endometrial polyps will be published soon in preliminary form with planned validation studies to follow The polyp system is being developed There is consideration for subclassification systems for AUB-C, -O, -E, and –I, but these initiatives are still in the very early stages of development 35

36. Drawbacks of the PALM COEIN system Deals with only non gestational AUB There are other causes of genital tract bleeding and urinary tract or gastrointestinal bleeding that do not come from the uterus These can usually be identified by an appropriate case history and physical examination Subclassification systems for other causes are yet to be developed – much work has to be done 36

37. Conclusion PALM COIEN (FIGO AUB Systems) designed to facilitate both basic science and clinical investigation, as well as the practical, rational, and consistent application of medical and surgical therapy current revisions are designed to improve the utility of these systems for research, education, and clinical care Clinicians, educators, and investigators are encouraged to use the notation and matrix concept to guide the evaluation of women 37

38. Thank you 38