FIGO classification of uterine bleeding

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The International Federation of Gynecology and Obstetrics (FIGO) is an international organization that links about 125 international professional societies of Obstetricians and Gynecologists. In 2011 FIGO recognized two systems designed to aid research, education, and clinical care of women with abnormal uterine bleeding (AUB) in the reproductive years. This page is a summary of the systems and their use in contemporary gynecology.

Contents

FIGO System 1. The system for definition and nomenclature of normal and abnormal uterine bleeding (AUB) in the reproductive years. System 1 Nomenclature and Definitions 2016.jpg
FIGO System 1. The system for definition and nomenclature of normal and abnormal uterine bleeding (AUB) in the reproductive years.

Background

FIGO System 2. The PALM-COEIN System for classification of causes of abnormal uterine bleeding (AUB) in the reproductive years. FIGO PALM-COEIN System for Classification of Causes of AUB in the Reproductive Years.jpg
FIGO System 2. The PALM-COEIN System for classification of causes of abnormal uterine bleeding (AUB) in the reproductive years.

Abnormal uterine bleeding (AUB) in the reproductive years, unrelated to pregnancy, is rarely life-threatening, but is frequently life altering. The symptoms frequently interfere with quality of life and those girls and women affected by chronic AUB spend significant amounts of personal resources on menstrual products and medications. Such women are 30 per cent less productive at work, and, consequently, suffer a similar reduction in income. [1] [2] For low resource countries, the combination of poor nutrition, lack of access to simple therapy with iron replacement, and the symptom of heavy menstrual bleeding (HMB) are collectively responsible for the global epidemic of iron deficiency anemia, a circumstance that sets up a pregnant population vulnerable to peripartum hemorrhage and its sequellae, including death. The prevalence of AUB in the reproductive years is high; it is estimated that it affects 30% of all women at some time in their lives. Approximately 5% seek care each year; and up to 30% of all visits to gynecologists are for an AUB symptom. The problem of AUB burdens the economy, employers, as well as women and their families. The total annual direct and indirect costs of AUB are estimated to exceed US$37 billion. [3] There is evidence that, even in developed countries, only about half of those affected actually seeks care, and that many who do are not satisfied with the results. [4] For many, hysterectomy remains a common therapy for those who have access to healthcare.

With the massive worldwide impact of both acute and chronic AUB, the relevance of safe and effective clinical care cannot be overestimated. Although common sense interventions such as iron therapy are often underused in developed countries and frequently unavailable in developing nations, these and related therapies deal with reducing the consequences HMB the symptom, not the cause itself. Abnormal uterine bleeding in the reproductive years comprises a complex set of disorders that include abnormalities in endocrine, endometrial and hemostatic function and a number of structural anomalies that include polyps, adenomyosis and leiomyomas or fibroids. It is important to understand that many of the structural abnormalities may not contribute to the patient's symptoms – they may lie asymptomatic while the cause or causes of the AUB may be elsewhere.

Determination of the causes of AUB in the reproductive years remains a major challenge for investigators, clinicians and educators. Investigators have to conceive and then execute relevant bench and clinical investigation; clinicians must deal with the patient in their office or hospital and educators of medical students and postgraduate trainees such as residents and fellows are encumbered with the task of providing a mechanism for understanding AUB that facilitates proper investigation and therapy.

For a number of investigators and educators, it became apparent that there were at least two major impediments to dealing with these challenges. The first was a disjointed collection of poorly defined and inconsistently used terms and definitions that undermined effective communication among investigators, clinicians and trainees alike. [5] The second was the absence of a system for classifying the potential causes, or contributors to AUB symptoms in a specific patient. These circumstances lead to difficulties with the interpretation of both basic science research and clinical trials as since specimens and patients could be "contaminated" with potential confounders. As a result, in order to obtain clearly informative basic science as well as translational and clinical investigation, a comprehensive approach to both investigation and categorization was needed.

It was in this context that the FIGO (International Federation of Gynecology and Obstetrics) Menstrual Disorders Working Group was created. Starting in 2005, a group of experts that comprised those from the FDA, related professional societies and gynecologic medical journals, and representatives from the basic, translational, and clinical sciences were assembled to tackle the issues in a systematic fashion. [6] [7]

The FIGO Systems of Nomenclature of Terms and Classification of Causes of AUB in the Reproductive Years

The development of these systems was in large part based upon a process was conducted using RAND's Delphi process. The results allowed for a collective recognition of the disparity and inconsistency in definitions and terminology a circumstance that was a surprise to many. The result of this process was a near unanimous decision to create a new set of descriptive and unambiguous terms that could be translated into a wide spectrum of languages. This process resulted in the first FIGO system; one that provided both definitions and nomenclature of normal and abnormal uterine bleeding using the 5th to 95% percentiles from the available large-scale epidemiological studies. [6] [7] Included in this set of definitions was the adoption of the term HMB - a symptom (not a diagnosis) - that was described by the National Institute for Health and Clinical Excellence as "excessive menstrual blood loss, which interferes with a woman's physical, social, emotional and/or material quality of life". [8] These findings and recommendations were published simultaneously in 2007, in Fertility and Sterility and Human Reproduction. What is now FIGO's system of nomenclature and definitions has undergone very modest modifications that will continue to be modified and revised as appropriate. [6] [7]

The classification system, known by the acronym "PALM-COEIN", was developed and first published a textbook, [9] and then, after ratification by the Working Group, was accepted by FIGO in 2010 and finally published together with the nomenclature system and definitions in 2011. [10] Each of the first eight letters stands for a discernable category of disorder, potentially found in an individual with an AUB symptom (Figure 2). The "PALM" categories comprise disorders that are definable by imaging and/or histopathological evaluation (polyps, adenomyosis, leiomyomas, malignancy and hyperplasia), while the "COEI" classifications are not definable structurally (coagulopathies, ovulatory disorders, endometrial disorders, iatrogenic). Coagulopathies require confirmation by laboratory testing, while, at least for the present, ovulatory and endometrial disorders are primarily, and at least clinically, defined by a structured history. Irregular ovulation or anovulation can be supported by a number of laboratory and histopathological assessments, not typically applied in clinical settings. The "N" classification, originally "Not yet classified" now "Not otherwise classified" is reserved for entities that are rare or of undetermined relationship to AUB symptoms.

It is recognized that each of the major categories may include subgroups that are known or suspected to have clinical relevance. The first of these "subclassification systems" was for leiomyomas (Figure 3), recognizing their prevalence and the already existing classification system for submucous leiomyomas first published by Wamsteker et al. [11] and then adopted by the European Society of Human Reproduction and Embryology (ESHRE). Added was a category for submucous myomas that make contact with the endometrium but do not distort the endometrial cavity (Type 3), and subclassification for intramural leiomyomas and the various types of subserous myomas.

The 2011 publication, [10] as well as other publications authored or coauthored by the FIGO Menstrual Disorders Working Group, also explicitly included the process of investigation – that is, from the identification that a patient actually has one or more symptoms of AUB (FIGO System 1) to the classification of her condition as categorized by FIGO System 2, the PALM-COEIN System. [12] The systems have been endorsed by a number of national organizations including the American College of Obstetricians and Gynecologists (ACOG Practice Bulletin 128).

Related Research Articles

Gynecologic hemorrhage represents excessive bleeding of the female reproductive system. Such bleeding could be visible or external, namely bleeding from the vagina, or it could be internal into the pelvic cavity or form a hematoma. Normal menstruation is not considered a gynecologic hemorrhage, as it is not excessive. Hemorrhage associated with a pregnant state or during delivery is an obstetrical hemorrhage.

<span class="mw-page-title-main">Hysterectomy</span> Surgical removal of the uterus

Hysterectomy is the partial or total surgical removal of the uterus. It may also involve removal of the cervix, ovaries (oophorectomy), fallopian tubes (salpingectomy), and other surrounding structures. Partial hysterectomies allow for hormone regulation while total hysterectomies do not.

<span class="mw-page-title-main">Dysmenorrhea</span> Pain during menstruation

Dysmenorrhea, also known as period pain, painful periods or menstrual cramps, is pain during menstruation. Its usual onset occurs around the time that menstruation begins. Symptoms typically last less than three days. The pain is usually in the pelvis or lower abdomen. Other symptoms may include back pain, diarrhea or nausea.

Heavy menstrual bleeding (HMB), previously known as menorrhagia or hypermenorrhea, is a menstrual period with excessively heavy flow. It is a type of abnormal uterine bleeding (AUB).

Abnormal uterine bleeding (AUB), also known as (AVB) or as atypical vaginal bleeding, is vaginal bleeding from the uterus that is abnormally frequent, lasts excessively long, is heavier than normal, or is irregular. The term dysfunctional uterine bleeding was used when no underlying cause was present. Vaginal bleeding during pregnancy is excluded. Iron deficiency anemia may occur and quality of life may be negatively affected.

The anovulatory cycle is a menstrual cycle by varying degrees of menstrual intervals and the absence of ovulation and a luteal phase. In the absence of ovulation, there will be infertility.

<span class="mw-page-title-main">Adenomyosis</span> Extension of endometrial tissue into the myometrium

Adenomyosis is a medical condition characterized by the growth of cells that proliferate on the inside of the uterus (endometrium) atypically located among the cells of the uterine wall (myometrium), as a result, thickening of the uterus occurs. As well as being misplaced in patients with this condition, endometrial tissue is completely functional. The tissue thickens, sheds and bleeds during every menstrual cycle.

<span class="mw-page-title-main">Vaginal bleeding</span> Medical condition

Vaginal bleeding is any expulsion of blood from the vagina. This bleeding may originate from the uterus, vaginal wall, or cervix. Generally, it is either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproductive system, such as abnormal uterine bleeding.

<span class="mw-page-title-main">Uterine myomectomy</span> Surgical removal of uterine fibroid

Myomectomy, sometimes also called fibroidectomy, refers to the surgical removal of uterine leiomyomas, also known as fibroids. In contrast to a hysterectomy, the uterus remains preserved and the woman retains her reproductive potential. It still may impact hormonal regulation and the menstrual cycle.

Intermenstrual bleeding, previously known as metrorrhagia, is uterine bleeding at irregular intervals, particularly between the expected menstrual periods. It is a cause of vaginal bleeding.

<span class="mw-page-title-main">Endometrial ablation</span>

Endometrial ablation is a surgical procedure that is used to remove (ablate) or destroy the endometrial lining of the uterus. The goal of the procedure is to decrease the amount of blood loss during menstrual periods. Endometrial ablation is most often employed in people with excessive menstrual bleeding, who do not wish to undergo a hysterectomy, following unsuccessful medical therapy.

<span class="mw-page-title-main">Menstrual disorder</span> Medical condition affecting menstrual cycle

A menstrual disorder is characterized as any abnormal condition with regards to a woman's menstrual cycle. There are many different types of menstrual disorders that vary with signs and symptoms, including pain during menstruation, heavy bleeding, or absence of menstruation. Normal variations can occur in menstrual patterns but generally menstrual disorders can also include periods that come sooner than 21 days apart, more than 3 months apart, or last more than 10 days in duration. Variations of the menstrual cycle are mainly caused by the immaturity of the hypothalamic-pituitary-ovarian (HPO) axis, and early detection and management is required in order to minimize the possibility of complications regarding future reproductive ability.

Polymenorrhea, also known as frequent periods, frequent menstruation, or frequent menstrual bleeding, is a menstrual disorder in which menstrual cycles are shorter than 21 days in length and hence where menstruation occurs more frequently than usual. Cycles are regular and menstrual flow is normal in the condition. Normally, menstrual cycles are 25 to 30 days in length, with a median duration of 28 days.

The uterine sarcomas form a group of malignant tumors that arises from the smooth muscle or connective tissue of the uterus.

<span class="mw-page-title-main">Hematometra</span> Medical condition

Hematometra is a medical condition involving collection or retention of blood in the uterus. It is most commonly caused by an imperforate hymen or a transverse vaginal septum.

Uterine clear-cell carcinoma (CC) is a rare form of endometrial cancer with distinct morphological features on pathology; it is aggressive and has high recurrence rate. Like uterine papillary serous carcinoma CC does not develop from endometrial hyperplasia and is not hormone sensitive, rather it arises from an atrophic endometrium. Such lesions belong to the type II endometrial cancers.

Genital leiomyomas are leiomyomas that originate in the dartos muscles, or smooth muscles, of the genitalia, areola, and nipple. They are a subtype of cutaneous leiomyomas that affect smooth muscle found in the scrotum, labia, or nipple. They are benign tumors, but may cause pain and discomfort to patients. Genital leiomyoma can be symptomatic or asymptomatic and is dependent on the type of leiomyoma. In most cases, pain in the affected area or region is most common. For vaginal leiomyoma, vaginal bleeding and pain may occur. Uterine leiomyoma may exhibit pain in the area as well as painful bowel movement and/or sexual intercourse. Nipple pain, enlargement, and tenderness can be a symptom of nipple-areolar leiomyomas. Genital leiomyomas can be caused by multiple factors, one can be genetic mutations that affect hormones such as estrogen and progesterone. Moreover, risk factors to the development of genital leiomyomas include age, race, and gender. Ultrasound and imaging procedures are used to diagnose genital leiomyomas, while surgically removing the tumor is the most common treatment of these diseases. Case studies for nipple areolar, scrotal, and uterine leiomyoma were used, since there were not enough secondary resources to provide more evidence.

<span class="mw-page-title-main">Interstitial pregnancy</span> Medical condition

An interstitial pregnancy is a uterine but ectopic pregnancy; the pregnancy is located outside the uterine cavity in that part of the fallopian tube that penetrates the muscular layer of the uterus. The term cornual pregnancy is sometimes used as a synonym, but remains ambiguous as it is also applied to indicate the presence of a pregnancy located within the cavity in one of the two upper "horns" of a bicornuate uterus. Interstitial pregnancies have a higher mortality than ectopics in general.

Robert S. Neuwirth was an American physician, inventor, and real estate developer. Neuwirth devoted his career to crafting and refining noninvasive practices promoting women's health. He was one of the first doctors to employ endoscopy in gynecological practice, in which a small optical instrument called an endoscope is used to examine areas tucked deep into the body. He is known as the first doctor to introduce laparoscopy to the United States, in 1968.

Metropathia haemorrhagica, also known as metropathia haemorrhagica cystica, is a menstrual disorder which is defined as a specialized type of anovulatory dysfunctional uterine bleeding associated with endometrial hyperplasia and intermenstrual bleeding. The condition was defined by 1930. It has been agreed that the term "metropathia haemorrhagica" should be discarded along with many other older terms for menstrual disorders.

References

  1. ↑ Cote I; Jacobs P; Cumming DC (2003). "Use of health services associated with increased menstrual loss in the United States". American Journal of Obstetrics and Gynecology. 188 (2): 343–8. doi:10.1067/mob.2003.92. PMID   12592237.
  2. ↑ Frick KD; Clark MA; Steinwachs DM; et al. (2009). "Financial and quality-of-life burden of dysfunctional uterine bleeding among women agreeing to obtain surgical treatment". Women's Health Issues. 19 (1): 70–8. doi:10.1016/j.whi.2008.07.002. PMID   19111789.
  3. ↑ Liu Z; Doan QV; Blumenthal P; Dubois RW (2007). "A systematic review evaluating health-related quality of life, work impairment, and health-care costs and utilization in abnormal uterine bleeding". Value in Health. 10 (3): 183–94. doi: 10.1111/j.1524-4733.2007.00168.x . PMID   17532811.
  4. ↑ Fraser IS; Mansour D; Breymann C; Hoffman C; Mezzacasa A; Petraglia F (2015). "Prevalence of heavy menstrual bleeding and experiences of affected women in a European patient survey". International Journal of Gynaecology and Obstetrics. Vol. 128, no. 3. pp. 196–200.
  5. ↑ Woolcock JG; Critchley HO; Munro MG; Broder MS; Fraser IS (2008). "Review of the confusion in current and historical terminology and definitions for disturbances of menstrual bleeding". Fertility and Sterility. Vol. 90, no. 6. pp. 2269–80.
  6. 1 2 3 Fraser IS; Critchley HO; Munro MG; Broder M (2007). "A process designed to lead to international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding". Fertility and Sterility. 87 (3): 466–76. doi: 10.1016/j.fertnstert.2007.01.023 . PMID   17362717.
  7. 1 2 3 Fraser IS; Critchley HO; Munro MG; Broder M (2007). "Can we achieve international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding?". Human Reproduction. 22 (3): 635–43. doi: 10.1093/humrep/del478 . PMID   17204526.
  8. ↑ Excellence NIfHaC, ed. (2007). "Heavy menstrual bleeding". United Kingdom: National Institute for Health and Clinical Excellence.
  9. ↑ Munro MG (2010). Abnormal Uterine Bleeding. Cambridge: Cambridge University Press.
  10. 1 2 Munro MG; Critchley HO; Broder MS; Fraser IS (2011). "The FIGO Classification System ("PALM-COEIN") for causes of Abnormal Uterine Bleeding in Non-gravid Women in the Reproductive Years, Including Guidelines for Clinical Investigation". International Journal of Gynaecology and Obstetrics. 113 (1): 3–13. doi: 10.1016/j.ijgo.2010.11.011 . PMID   21345435. S2CID   205260568.
  11. ↑ Wamsteker K; Emanuel MH; de Kruif JH (1993). "Transcervical hysteroscopic resection of submucous fibroids for abnormal uterine bleeding: results regarding the degree of intramural extension". Obstetrics and Gynecology. Vol. 82, no. 5. pp. 736–40.
  12. ↑ Munro MG; Heikinheimo O; Haththotuwa R; Tank JD; Fraser IS (2011). "The need for investigations to elucidate causes and effects of abnormal uterine bleeding". Seminars in Reproductive Medicine. 29 (5): 410–22. doi:10.1055/s-0031-1287665. PMID   22065327.
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