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The two FIGO systems for normal and abnormal uterine bleeding symptoms
and classification of causes of abnormal uterine bleeding in the reproductive
years: 2018 revisions

Article  in  International Journal of Gynecology & Obstetrics · September 2018

DOI: 10.1002/ijgo.12666

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Received: 18 May 2018    Revised: 23 July 2018    Accepted: 6 September 2018

DOI: 10.1002/ijgo.12666

FIGO SPECIAL ARTICLE

Gynecology

The two FIGO systems for normal and abnormal uterine

bleeding symptoms and classification of causes of abnormal
uterine bleeding in the reproductive years: 2018 revisions

Malcolm G. Munro1,2,* | Hilary O.D. Critchley3 | Ian S. Fraser4 | for the FIGO Menstrual

Disorders Committee

1
Departments of Obstetrics and Gynecology,
David Geffen School of Medicine at UCLA, Abstract
University of California, Los Angeles, CA, USA Background: The International Federation of Gynecology and Obstetrics (FIGO) sys-
2
Kaiser Permanente, Los Angeles Medical
tems for nomenclature of symptoms of normal and abnormal uterine bleeding (AUB)
Center, Los Angeles, CA, USA
3 in the reproductive years (FIGO AUB System 1) and for classification of causes of AUB
MRC Centre for Reproductive Health, The
University of Edinburgh, The Queen’s Medical (FIGO AUB System 2; PALM-­COEIN) were first published together in 2011. The pur-
Research Institute, Edinburgh, UK
pose was to harmonize the definitions of normal and abnormal bleeding symptoms
4
School of Women’s and Children’s Health,
Royal Hospital for Women, University of New and to classify and subclassify underlying potential causes of AUB in the reproductive
South Wales, Randwick, NSW, Australia years to facilitate research, education, and clinical care. The systems were designed to

*Correspondence be flexible and to be periodically reviewed and modified as appropriate.

Malcolm G. Munro, Kaiser Permanente, Objectives: To review, clarify, and, where appropriate, revise the previously
Los Angeles Medical Center, Los Angeles,
CA, USA. published systems.
Email: [email protected] Methodology and outcome: To a large extent, the process has been an iterative one

Participating Members of the FIGO Menstrual involving the FIGO Menstrual Disorders Committee, as well as a number of invited
Disorders Committee, 2015–2018 are listed contributions from epidemiologists, gynecologists, and other experts in the field from
at the end of the paper.
around the world between 2012 and 2017. Face-­to-­face meetings have been held in
Rome, Vancouver, and Singapore, and have been augmented by a number of telecon-
ferences and other communications designed to evaluate various aspects of the sys-
tems. Where substantial change was considered, anonymous voting, in some instances
using a modified RAND Delphi technique, was utilized.

KEYWORDS
Abnormal uterine bleeding; Adenomyosis; Anovulatory bleeding; Arteriovenous malformation;
Coagulopathy; Endometrial hyperplasia; Endometrial polyp; FIGO; Heavy menstrual bleeding;
Heavy uterine bleeding; Intermenstrual bleeding; Irregular menstrual bleeding; Irregular uterine
bleeding; Isthmocele; Leiomyoma; Menorrhagia; Metrorrhagia; PALM-COEIN

1 |  INTRODUCTION origin.1–9 Approximately one third of women are affected at some time
in their life.3,6 Many of the published studies are restricted to estimates
The worldwide impact of abnormal uterine bleeding (AUB) in the repro- of the prevalence of the symptoms of heavy menstrual bleeding (HMB);
ductive years is substantial, with a prevalence of approximately 3%–30% when other symptoms, particularly those of irregular and intermenstrual
among reproductive aged women. The reasons for the wide spectrum bleeding are included, the prevalence rises to 35% or higher.9
of estimates are unclear but vary with age, being higher in adolescents Available evidence suggests that as many as half of affected women
and in the fifth decade of life, and varying somewhat with country of do not seek medical care, even if they have access to a healthcare

Int J Gynecol Obstet 2018; 1–16 © 2018 International Federation of |  1

wileyonlinelibrary.com/journal/ijgo  
Gynecology and Obstetrics
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2       Munro ET AL.

provider,4,5,8 a circumstance that may explain the variation in reported and management, but also to be flexible enough to provide effective
prevalence. The manifestations vary from modest to severe disruption linkages with laboratory and research aspects.
of work productivity and quality of life,10,11 and increasing maternal The present report updates the FIGO recommendations for both
morbidity and mortality for pregnant women with pre-­existing AUB-­ FIGO-­AUB Systems 1 and 2, including clarifications on terminologies
related anemia.12,13 and definitions, as well as modifications in the PALM-­COEIN system
In 2011, recognizing the international need created by the impact that include reassignment of some entities, and guidance for subclas-
of AUB, the International Federation of Gynecology and Obstetrics sification of leiomyomas, much of which has been preliminarily pub-
(FIGO), published a pair of systems and a set of clinical recommenda- lished.18–20 These changes represent structured deliberative processes
tions with the aim of informing and aiding clinicians and investigators in that include use of a modified RAND Delphi process applied to the
the design and interpretation of investigations into AUB in the repro- attendees of a series of FIGO Menstrual Disorders Committee (MDC)
ductive years, as well as the provision of evidence-­based clinical care.14 sponsored expert meetings. To allow this report to function inde-
The present manuscript was designed to provide a detailed update pendently, and to provide context, there exists substantial but neces-
on the FIGO recommendations concerning terminologies, definitions, sary overlap with the original publication,14 and with other subsequent
and underlying causes of AUB in the reproductive years. Revised ter- and related publications produced by the MDC since 2011.18–24
minologies and definitions of normal menstrual parameters, and the The FIGO MDC is currently working on subclassification systems for
symptoms of AUB were initially published in 2007,15,16 while the sem- adenomyosis and endometrial polyps. The adenomyosis subclassifica-
inal 2011 publication14 presented both systems—Terminology and tion system is the most advanced and will be published soon in prelimi-
Definitions (FIGO-­AUB System 1) and Classification of Causes of AUB in nary form with planned validation studies to follow. The polyp system is
the Reproductive Years, the PALM-­COEIN system (FIGO-­AUB System being developed but a release date has not yet been determined. There
2). From the beginning, it was determined that these recommendations is consideration for subclassification systems for AUB-­C, -­O, -­E, and –I,
should be flexible and subject to ongoing regular review to incorpo- but these initiatives are still in the very early stages of development.
rate results of new research and analysis. These review periods were It is important that clinicians recognize that these FIGO systems relate
intended to broadly coincide with the triennial FIGO World Congresses. solely to assessment and management of nongestational AUB. There are
The first key recommendations, published simultaneously in 2007 other causes of genital tract bleeding and urinary tract or gastrointestinal
in Fertility Sterility and Human Reproduction,15,16 recommended a bleeding that do not come from the uterus. These can usually be identi-
substantial revision of existing terminologies and definitions for the fied by an appropriate case history and physical examination.
description of AUB features and, by doing so, redefined the normal
parameters of menstrual bleeding. Recommended was the abolition of
terms (largely of Latin and Greek origin) such as menorrhagia, metror- 2 | ACUTE VERSUS CHRONIC
rhagia, and dysfunctional uterine bleeding, which were poorly defined, NONGESTATIONAL AUB IN THE
used internationally in a disparate manner, and had no consistent REPRODUCTIVE YEARS
meaning for the general and academic communities.15–17
The second key publication14 presented a novel and pragmatic In the original system,14 FIGO introduced the concept of nonges-
approach to classification of the underlying causes of AUB in non-­ tational acute AUB in the reproductive years, distinguishing it from
pregnant women. No such systematic classification of underlying chronic AUB—an approach endorsed by the American College
causes existed at that time. This 2011 manuscript introduced the of Obstetricians and Gynecologists.25 These definitions remain
PALM-­COEIN classification based on clinical-­ and imaging-­based unchanged for 2018. Chronic nongestational AUB in the reproductive
stratification of causes into “structural” pathologies that can be years is defined as bleeding from the uterine corpus that is abnormal
“imaged” and/or defined histopathologically (Polyps, Adenomyosis, in duration, volume, frequency, and/or regularity, and has been pre-
Leiomyomas and Malignancy or atypical endometrial hyperplasia; sent for the majority of the preceding 6 months. Acute AUB, on the
PALM). The remaining causes were categorized as “non-­structural”, other hand, is defined as an episode of heavy bleeding that, in the
in that they cannot be imaged, but clinical assessment with detailed opinion of the clinician, is of sufficient quantity to require immediate
history and appropriate physical examination, sometimes supported intervention to minimize or prevent further blood loss. Acute heavy
by laboratory testing, can largely imply or make a diagnosis of cause menstrual bleeding may present in the context of existing chronic
(Coagulopathies, Ovulatory disorders, primary Endometrial disorders, AUB or can occur in the absence of such a background history.
Iatrogenic and Not otherwise classified; COEIN).
It rapidly became clear that each of these individual causes could
3 | FIGO-­A UB SYSTEM 1
require division into subclassifications of cause and phenotype to opti-
mize clinical management and support the broad spectrum of research
3.1 | Revision of terminologies and definitions of
needed. The subclassification of leiomyomas was an obvious starting
symptoms of abnormal uterine bleeding
point.14 Three key publications14–17 formed the foundation of a sim-
ple, flexible, and educationally sound pair of descriptive systems that The revised FIGO-­AUB System 1 is seen in Figure 1, with changes
were designed to provide a quick initial clinical direction of diagnosis summarized in Table 1. As determined by the multinational process
Munro ET AL. |
      3

F I G U R E   1   FIGO AUB System 1. Nomenclature and Definitions of AUB Symptoms. For 2018, intermenstrual bleeding has been added, and
there is now a practical definition for irregular menstrual bleeding created by using the 75th percentile, effectively excluding the occasional long
or short cycles experienced by many women. *The available evidence suggests that, using these criteria, 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., 2000.27 For clinical purposes, the definition of HMB
proposed by the UK National Institute for Health and Care Excellence has been adopted5,28 – “Excessive menstrual blood loss which interferes
with a woman’s physical, social, emotional, and/or material quality of life”. Abbreviations: AUB, abnormal uterine bleeding; FIGO, International
Federation of Gynecology and Obstetrics; HMB, heavy menstrual bleeding.

described in the original publications,14–16 terms such as menorrha- (18–25 years ≤9 days; 26–41 years ≤7 days; 42–45 years ≤9 days).27
gia, metrorrhagia, oligomenorrhea, and dysfunctional uterine bleed- For practical purposes, this normal variation in cycle length can be
ing have been abandoned. There is acknowledgement of the specific alternatively expressed as ±4 days.
changes in menstrual bleeding patterns that may be encountered Formally included is the term HMB, a symptom (not a diagnosis),
at each end of the reproductive spectrum (i.e. in adolescence or that has been defined (in clinical situations) by the National Institute
the peri-­menopause).26 for Health and Clinical Excellence as “excessive menstrual blood loss,
Preparation of the present 2018 recommendations is the result which interferes with a woman’s physical, social, emotional and/or
of sequential reviews of the FIGO-­AUB System 1 initially proposed in material quality of life”.5,28
2007 and 2009, and underwent slight modification for 2011. The cur-
rent revisions represent deliberations in meetings held in 2012, 2015,
4 | FIGO AUB SYSTEM 2
and 2017. These reviews have included comment, detailed question-
ing, and recommendations from many clinicians from around the world
4.1 | Revision of classification of underlying causes
but have only resulted in minor changes and refinement of definitions
of AUB (PALM-­COEIN)
from the original system.
In this revision of FIGO AUB System 1, the definition of regular- Highlights of changes since the original publication in 201114 are
ity has been changed from one where the shortest to longest varia- summarized in Table 2. The basic/core classification system is almost
tion is up to 20 days, to variation of 7–9 days, depending upon age unchanged and is presented in Figure 2. There remain the nine main
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4       Munro ET AL.

T A B L E   1   Summary of changes to FIGO System 1 (normal and T A B L E   2   Summary of changes to FIGO AUB System 2 Causes or
abnormal uterine bleeding). Contributors to AUB in the Reproductive Years (PALM-­COEIN).

Parameter Change System 2

category Change
Frequency Amenorrhea is now part of the frequency
category AUB-­A Refined sonographic diagnostic criteria
Regularity Refined definition of regularity AUB-­L Inclusion of Type 3 as a submucous leiomyoma
 Normal variation (shortest to longest) 7-9 d Type definitions and distinctions
 Slight variance depends on age Distinction between Types 0 and 1; 6 and 7
Duration Now only two categories for duration Distinction between Types 2 and 3; 4 and 5
 Normal: ≤8 d AUB-­C No longer includes AUB associated with pharmacologic
 Prolonged: >8 d agents that impair blood coagulation which are now
included in AUB-­I
Volume Definition of the symptom of HMB
AUB-­I Now includes AUB associated with all iatrogenic
 NICE definition5,28 processes including the use of pharmacological agents
 Bleeding volume sufficient to interfere with the used for anticoagulation and those thought to interfere
woman’s quality of life with ovulation
Intermenstrual Definition of the symptom of inter-­menstrual AUB-­O Diagnostic threshold changes based upon the revisions
bleeding bleeding of System 1, described above
 Spontaneous bleeding occurring between No longer includes ovulatory disorders associated with
menstrual periods drugs known or suspected to interfere with ovulation
 Can be either cyclical, or random AUB-­N The name of the category has been changed from “Not
Yet Classified” to Not Otherwise Classified
Abbreviations: FIGO, International Federation of Gynecology and
Obstetrics; HMB, heavy menstrual bleeding; NICE, National Institute of There is a brief discussion of a potential new cause of
Care Excellence. AUB the so-­called uterine “niche” or isthmocele
following lower segment cesarean section

Abbreviations: AUB, abnormal uterine bleeding; FIGO, International

categories, arranged according to the acronym PALM-­COEIN (pro-
Federation of Gynecology and Obstetrics.
nounced “palm-­koin”): Polyp; Adenomyosis; Leiomyoma; Malignancy
and hyperplasia; Coagulopathy; Ovulatory dysfunction; Endometrial
disorders; Iatrogenic; and Not otherwise classified. Category N has diagnosis,31,32 but no consensus regarding how many and which of
undergone a change from “not yet classified” to “not otherwise classi- these findings are necessary before there is reasonable certainty that
fied” as we cannot be certain which, if any, of these entities will ulti- a diagnosis of adenomyosis is present. The eight criteria suggested by
mately be placed in a unique category. The components of the PALM the morphological uterus sonographic assessment (MUSA) group are
group are generally discrete (structural) entities that can be evaluated shown in Figure 3.31 The FIGO MDC is currently working on an inter-
or measured visually using some combination of imaging techniques national consensus for an imaging-­based adenomyosis classification
and histopathology; the COEI group comprises entities that are not system designed to phenotype the disorder in a standardized fashion
defined by imaging or histopathology (non-­structural). By its nature, that should facilitate research, education, and clinical care. However,
the “Not otherwise classified” category includes a spectrum of poten- for diagnosis the use of the transvaginal ultrasonography-­based MUSA
tial entities that may or may not be measured or defined by histopa- criteria31 for the diagnosis of adenomyosis for the purposes of FIGO
thology or imaging techniques. AUB System 2 is suggested.
The system has been constructed with the understanding that a The only subclassification system ratified so far is the leiomyoma
given patient may have one or more entities that could cause or con- subclassification system, essentially unchanged since the initial 2011
tribute to AUB symptoms and that structurally definable entities, such publication14 (Fig. 4). The only subtle difference is for Type 3 myomas,
as adenomyosis, leiomyomas, and endocervical or endometrial polyps where contact with the endometrium is a feature shared by other sub-
are often asymptomatic and, therefore, may not contribute to the pre- mucous leiomyomas (Types 0, 1, and 2), whereas intramural location,
senting symptoms. without focal distortion of the endometrial cavity, is a characteristic
14
Since the original publication of the FIGO AUB systems, there of Types 4 and higher. The system now recognizes this area of over-
have been advances in the diagnosis of adenomyosis, although its rela- lap. It is also recognized that there are some difficulties in applying
tionship to reproductive function and uterine bleeding is still under the leiomyoma subclassification system to the spectrum of leiomyo-
investigation. It has been demonstrated that two-­dimensional trans- mas that can be encountered, especially in large uteri with multiple
vaginal ultrasonography has similar sensitivity and specificity for the leiomyomas.33 There is now more detailed guidance for distinguishing
diagnosis of adenomyosis when compared to magnetic resonance amongst the leiomyoma subtypes.
imaging (MRI).29,30 There is some progress regarding the spectrum Distinguishing between Type 0 and 1, and between Type 6 and 7
of two-­dimensional ultrasonography findings associated with the leiomyomas is now accomplished by comparing the stalk diameter to
Munro ET AL. |
      5

F I G U R E   2   FIGO AUB System 2. PALM-­COEIN System for Classification of Causes of AUB in the Reproductive Years. 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 disorders; Iatrogenic
causes), and one reserved for entities categorized as “Not otherwise classified”. 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). Modified with permission.67
Abbreviations: AUB, abnormal uterine bleeding; FIGO, International Federation of Gynecology and Obstetrics.

the mean diameter of the leiomyoma. Types 0 and 7 now comprise leio- FIGO now provides additional guidance for investigators using the
myomas that have a stalk diameter that is 10% or less than the mean FIGO subclassification system for leiomyomas. A minimal data set for
diameter of the leiomyoma. Hysteroscopy has now been deemed the describing leiomyomas should include an estimate of total uterine vol-
standard for distinguishing between a Type 2 and 3 leiomyoma, with ume based on imaging (transabdominal or transvaginal ultrasonogra-
the determination based upon the lowest filling pressure that allows phy or MRI), as well as an estimate of the number of leiomyomas (1, 2,
visualization of the endometrial cavity. Distinguishing between Type 4 3, 4, or greater than 4). If such imaging is not available, such as may
and Type 5 leiomyomas should be based upon observation of distor- be the case in low-­resource countries, the minimum data set should
tion of the serosa (Type 5) as determined by ultrasonography or MRI. include an estimate of uterine size on clinical examination as equivalent

F I G U R E   3   Adenomyosis diagnostic criteria. Graphical depictions of the eight TVUS criteria proposed by the MUSA group are presented.
These include asymmetrical myometrial thickening (A); myometrial cysts (B); hyperechoic islands (C); fan shaped shadowing (D); echogenic
subendometrial lines and buds (E); translesional vascularity (F), where present; irregular junctional zone (G); and an interrupted junctional zone
(H). Identification and evaluation of the junctional zone may best be accomplished with three-­dimensional ultrasonography. For the present
at least, the presence of two or more of these criteria are highly associated with a diagnosis of adenomyosis. Reproduced with permission.31
Abbreviations: MUSA, Morphological Uterus Sonographic Assessment; TVUS, transvaginal ultrasonography.
 |
6       Munro ET AL.

F I G U R E   4   FIGO leiomyoma subclassification system. System 2 classification system including the FIGO leiomyoma subclassification system.
The system that includes the tertiary classification of leiomyomas categorizes the submucous group according to the original Wamsteker et al.
system68 and adds categorizations for intramural, subserosal, and transmural lesions. Intracavitary lesions are attached to the endometrium
by a narrow stalk (≤10% or the mean of three diameters of the leiomyoma) and are classified as Type 0, whereas Types 1 and 2 require a
portion of the lesion to be intramural—with Type 1 being less than 50% of the mean diameter and Type 2 at least 50%. Type 3 lesions are
totally intramural but also about the endometrium. Type 3 are formally distinguished from Type 2 with hysteroscopy using the lowest possible
intrauterine pressure necessary to allow visualization. Type 4 lesions are intramural leiomyomas that are entirely within the myometrium, with no
extension to the endometrial surface or to the serosa. Subserous (Types 5, 6, and 7) leiomyomas represent the mirror image of the submucous
leiomyomas—with Type 5 being at least 50% intramural, Type 6 being less than 50% intramural, and Type 7 being attached to the serosa by a
stalk that is also ≤10% or the mean of three diameters of the leiomyoma. Classification of lesions that are transmural are categorized by their
relationship to both the endometrial and the serosal surfaces. The endometrial relationship is noted first, with the serosal relationship second
(e.g. Type 2–5). An additional category, Type 8, is reserved for leiomyomas that do not relate to the myometrium at all, and would include
cervical lesions (demonstrated), those that exist in the round or broad ligaments without direct attachment to the uterus, and other so-­called
“parasitic” lesions. Modified with permission.67 Abbreviation: FIGO, International Federation of Gynecology and Obstetrics.

to a gravid uterus of “X” weeks. When transvaginal ultrasonography or AUB associated with the use of selected categories of systemic
MRI are available, the location (anterior, posterior, left, right, or center) pharmacotherapy or intrauterine systems or devices, is classified as “iat-
and the estimated volume of up to four individual leiomyomas should rogenic”.38 In addition to gonadal steroids such as estrogens, progestins,
be recorded. Additionally, the location in the vertical plane should be and androgens, and agents that directly affect their production or local
described; upper half, lower half, or both. When more than four are function, this category now includes nonsteroidal pharmaceuticals that
present, the volume of the largest leiomyoma should be recorded, as contribute to ovulatory disorders, such as those that affect dopamine
a minimum. If other leiomyomas are judged to be of equal or greater metabolism, including phenothiazines and tricyclic antidepressants. In
relevance for clinical decision making based on location, the volume of the original categorization, women with AUB associated with the use
these lesions should be recorded as well. If the endometrium is visual- of anticoagulants were categorized with coagulopathies (AUB-­C); in this
ized, then the relationship between the documented myomas and the revision, they are considered iatrogenic and classified as AUB-­I. This
endometrium should be described using the FIGO classification system. includes the modern, non-­vitamin-­K antagonists such as rivaroxaban
Women with AUB and associated malignant or premalignant that appears to have a greater impact on the volume of menstrual bleed-
lesions of the uterus (e.g. endometrial carcinoma, leiomyosarcoma, ing than the traditional, vitamin K antagonists, typified by warfarin.39,40
and atypical endometrial hyperplasia sometimes, referred to as endo- Category “N”, “not otherwise classified” was created in the original
34,35
metrial intraepithelial neoplasia or EIN ), are categorized as having system to accommodate entities that are rarely encountered or are ill
AUB-­M. Their categorization is further defined using existent WHO defined. These include, but are not limited to, entities such as arte-
and FIGO classification and staging systems.36,37 riovenous malformations (AVMs)41 and the lower segment or upper
Munro ET AL. |
      7

cervical niche or “isthmocele” frequently found in association with The abbreviated FIGO description of the patient previously described
previous cesarean delivery and sometimes attributed to as a cause would be AUB-­LSM; -­O.
of AUB.42,43 FIGO now encourages clinicians and investigators to consider the
use of a matrix for the evaluation of patients with AUB in the repro-
ductive years (Fig. 5). This allows for the identification and documen-
5 | NOTATION tation of the status of the investigation.

After the patient has undergone appropriate investigation, discussed

below, she could be found to have one or more potential causes of, 6 | RECOMMENDATIONS FOR
or contributors to, the AUB symptoms. Consequently, the system has CLINICAL INVESTIGATION
been designed to enable appropriate multi-­category notation. While
it is recognized that this increased level of complexity will be of most A woman presenting with AUB may have one or a number of fac-
value to specialists and researchers, it should have utility for any tors that may contribute to the genesis of the symptoms. Using FIGO
healthcare provider. AUB System 1 to define the types of AUB symptoms present is a
This approach has been designed following the example of the prerequisite to evaluation for the elements in FIGO AUB System 2.
WHO TNM staging of malignant tumors, with each component A number of pathological entities (e.g. subserous leiomyoma) may be
addressed for all women investigated for AUB symptoms using the present that are possibly or even unlikely to be a contributor to the
two FIGO AUB Systems. For example, if an individual was suspected to symptoms. Consequently, the investigation of women with AUB dur-
have a disorder of ovulation, a type 2 leiomyoma, and no other anoma- ing the reproductive years must be undertaken in as comprehensive
lies, they would be categorized as follows in the context of a complete but practicable fashion given the clinical situation and the available
evaluation: AUB P0 A0 L1(SM) M0 -­ C0 O1 E0 I0 N0. It was recognized resources, with the findings carefully interpreted for their role in the
that in clinical practice the use of such full notation might be consid- symptoms. For example, available evidence would suggest that a sin-
ered cumbersome, so an option for abbreviation has been developed. gle 1-­cm polyp would not be the cause of the symptom of HMB.

F I G U R E   5   FIGO AUB System 2 diagnostic matrix. A simplified diagnostic matrix is illustrated in the left pane. Each of the primary
classification system elements are listed. If a patient has not been completely evaluated for a potential cause it is listed in the “?” column, if
evaluation has demonstrated no evidence of the abnormality the “N” column is checked, and if assessment is positive, an X is placed in the
appropriate box. An example is shown in the panel on the right. The patient has the symptom of HMB, and interim assessment, including
contrast hysterosonography documented in the left matrix has revealed a subserosal leiomyoma designated as Lo. However, the patient
had a positive 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 demonstrates that there is 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”. Abbreviations: AUB, abnormal uterine bleeding; FIGO, International Federation of Gynecology and Obstetrics;
HMB, heavy menstrual bleeding.
 |
8       Munro ET AL.

A suggested approach is illustrated in Figure 6A,B, and described in therapy were categorized as AUB-­C, but they now are included in the
brief below. AUB-­I category.

6.1 | General assessment 6.4 | Evaluation of the endometrium

When evaluating a woman of reproductive age with either acute Endometrial sampling is not required for all patients with AUB, so
or chronic genital tract bleeding thought to be AUB, the clinician it is necessary to identify the women for whom endometrial biopsy
should ensure that the bleeding is not related to pregnancy, and is appropriate. Selection for endometrial sampling is based on
is emanating from the cervical canal, rather than another location a combination of risk factors for the presence of premalignant or
such as the vagina, vulva, perineum, or perianal region. Pregnancy malignant changes, comprising some combination of age, personal,
may be reliably confirmed with a urine or serum assay for the pres- and genetic risk factors, and TVUS screening for endometrial echo-­
ence of the β-­subunit of human chorionic gonadotropin (hCG). It complex thickness.5,46–49 Although some studies have indicated that
is to be noted that determination of the location or viability of a age is not important as an independent variable,47 most suggest that
pregnancy is not considered to be within the domain of the FIGO-­ endometrial sampling be considered for all women over a certain
AUB systems. Women with both acute and chronic AUB should be age, usually 45 years.5 It is also evident that obesity contributes sig-
evaluated for iron deficiency, if possible, with serum ferritin, and for nificantly to the risk of premalignant and malignant change in the
related anemia by measuring hemoglobin and/or hematocrit (pref- endometrium, a feature that increases the risk of endometrial neo-
erably a full blood count, including platelets). Once the bleeding has plasia even in young women in the third and fourth decades of life.50
been confirmed, or suspected, to originate in the cervical canal or Women with a family history of hereditary nonpolyposis colorectal
endometrial cavity, the clinician should systematically evaluate the cancer syndrome, now called Lynch Syndrome, have a lifetime risk of
patient for each of the components of FIGO AUB System 2, the endometrial cancer of up to 60%, with the mean age at diagnosis of
PALM-­COEIN classification. 48–50 years.51,52 Regardless of the clinical guideline, when AUB is
persistent and either unexplained or inadequately treated, endome-
trial sampling is necessary—if possible—in association with hystero-
6.2 | Determination of ovulatory status
scopic evaluation of the uterine cavity.28 Sonohysterography is likely
Predictable cyclic menses every 24–38 days are usually (but not a reasonable substitute for hysterography to diagnose for polyps and
always) associated with ovulation whereas bleeding associated with submucous leiomyomas.53–55 There exist a number of techniques for
ovulatory disorders is typically irregular in timing and flow, and often endometrial sampling, but it is important that an adequate sample
interspersed with episodes of amenorrhea. be obtained before the patient can be considered at low risk for a
If, largely based on FIGO AUB System 1, a woman is found to malignant neoplasm.56
have AUB related to a ovulatory disorder, she is to be categorized as It is apparent that a relationship exists between chlamydial infec-
AUB-­O. If there is uncertainty regarding ovulatory status, measure- tion of the endometrium and AUB. Consequently, it may be prudent to
ment of serum progesterone, timed to the best estimate of mid-­luteal consider evaluating for the presence of the organism in symptomatic
phase, may be useful for confirming ovulation in the current cycle. patients.57 Although cervical assays seem reasonable, the relationship
Whereas endometrial biopsy is not recommended as a method for between cervically obtained specimens and the presence of absence
determination of ovulatory status, when performed and appropriately of endometrial infection is unclear.58 If chronic endometritis is identi-
indicated—to evaluate for the presence of premalignant or malignant fied, patients should be categorized as having AUB-­E.
endometrial change—histopathological findings reflecting secretory
change may confirm that ovulation has occurred.
6.5 | Evaluation of the structure of the
endometrial cavity
6.3 | Screening for systemic disorders of hemostasis
Evaluation for structural abnormalities affecting the endometrial
A structured history is a useful and effective screening tool. FIGO cavity is performed to identify pathology—including endometrial or
suggests a tool that has been demonstrated to have 90% sensitiv- endocervical polyps and submucous leiomyomas—that could contrib-
ity for the detection of these relatively common disorders (coagu- ute to AUB. Transvaginal ultrasonography (TVUS) is an appropriate and
44
lopathies) (Table 3). For those with a positive screening result, important screening tool and, in most instances, should be performed
further testing is necessary, often following consultation with a early in the course of the investigation. Ideally, the ultrasonography
physician with a special interest in disorders of coagulation, such as system must be of adequate quality to clearly display both myometrial
a hematologist. Such tests may include assays for von Willebrand and endometrial features, and the examiner should have the ability
factor, Ristocetin cofactor, partial thromboplastin time (PTT) and to operate the scanning device and interpret the images displayed.
other measures.45 If the results are positive, the woman with AUB Regardless, TVUS is not 100% sensitive even in ideal circumstances
would be being categorized as having AUB-­C. Previously, by conven- because polyps and other small lesions may elude detection, even in
tion, individuals with AUB associated with the use of anticoagulant the context of a normal study.59,60
Munro ET AL. |
      9

(A)

(B)

FIGURE 6 Investigative algorithms for patients with chronic AUB during the reproductive years. (A) Initial investigation comprises a structured
history, physical examination, and the use of appropriate ancillary investigations, in part based upon the history and physical assessment.
Evidence suggesting an ovulatory disorder prompts assessment for endocrinopathy, whereas a positive screening result for coagulopathy
(Figure 7) will indicate the need for appropriate hematological assessment. A complete blood count should be performed on all women with
the symptom of heavy menstrual bleeding. (B) A pragmatic guide to uterine assessment. If the initial evaluation (Figure 6A) suggests a low
risk for coagulopathy, structural or malignant/premalignant change, patients may be presumed to have AUB-­E or -­O and offered appropriate
treatment options. However, if there is an enhanced risk for endometrial hyperplasia or malignancy (left), endometrial sampling is recommended.
If an adequate specimen is not obtained, hysteroscopic examination and biopsy is recommended. If there is an enhanced risk for a structural
abnormality, transvaginal ultrasonography is the next step (right). If evaluation of the endometrium is suboptimal or there is a suggestion of an
abnormality affecting the endometrial cavity, either hysteroscopy or contrast hysterosonography is indicated. MRI may be occasionally indicated
if hysteroscopy or contrast hysterosonography are not feasible, such as in the case of virginal women. Abbreviations: AUB, abnormal uterine
bleeding; MRI, magnetic resonance imaging; TVUS, transvaginal ultrasonography. Images are used courtesy of Malcolm G. Munro.
 |
10       Munro ET AL.

(A)

(B)
Munro ET AL. |
      11

(C)

(D)
 |
12       Munro ET AL.

F I G U R E   7   Four examples of the use of a matrix to guide FIGO-­based evaluation of patients with chronic AUB. (A) Patient with the symptom
of heavy menstrual bleeding (duration of menses 10 d and perceived and affecting the patient’s quality of life). Contrast sonohysterography
demonstrates a posterior Type 2 leiomyoma 1.85 by 1.49 cm in diameter. All other investigations have been completed and are negative. Diagnosis:
AUB-­LSM. (B) Here the cycle length varies from 14 to 60 d, the duration of menstrual bleeding from 2 to 11 d, and the volume ranging from light
to heavy. Transvaginal sonography shows a posterior Type 6 leiomyoma. Other investigations are normal save the thyroid-­stimulating hormone,
which is elevated. Diagnosis: AUB-­Lo; -­O with the primary cause of AUB the ovulatory disorder secondary to hypothyroidism. (C) In this example the
patient’s menstrual parameters are normal with the exception of her complaint of intermittent intermenstrual bleeding. Contrast sonohysterography
shows an endometrial polyp and a Type 5 leiomyoma (not shown). The hysteroscopic view at the time of the polypectomy is shown. Diagnosis:
AUB-­P; -­Lo with the primary cause of the AUB the endometrial polyp. (D) This patient has the complaint of lifelong heavy menstrual bleeding that
is becoming heavier, with clots, and associated with worsening dysmenorrhea that lasts the entire period. She has a history of easy bruising and
frequently bleeds when brushing her teeth. Her menses are cyclically predictable with a normal cycle length of 33 d. Transvaginal ultrasonography
shows a globular uterus, an asymmetrically thickened posterior myometrium, and fan-­shaped shadowing. All of the coagulation parameters
measured were abnormal, and consistent with vWD Type 1. Diagnosis: AUB-­A, -­C. Abbreviations: AUB, abnormal uterine bleeding; FIGO,
International Federation of Gynecology and Obstetrics; vWD, von Willebrand disease. Images are used courtesy of Malcolm G. Munro.

If good ultrasonic images fail to show findings suggestive of relationships of the leiomyoma with the endometrium and myome-
endometrial polyps or submucous leiomyomas, the clinician may ini- trium are distorted. As described above, FIGO now recommends that
tially presume that the structure of the endometrial cavity is normal. the distinction between Type 2 and 3 leiomyomas be based upon hys-
However, if there are imaging features that indicate the presence of teroscopy performed using the lowest pressure necessary to evaluate
endometrial polyp(s), if there are leiomyomas that may encroach on these relationships. The use of sonohysterography for this purpose is
the endometrial cavity, or if the examination is suboptimal, imag- considered to be a suitable and more practical substitute in a variety
ing with more sensitive techniques is recommended. These gener- of clinical situations.
ally include hysteroscopy and/or transvaginal ultrasonography with
intrauterine contrast, either gel or saline, termed sonohysterography.
6.6 | Myometrial assessment
Which of these techniques is used will depend on the resources avail-
able to the clinician.53–55 In most instances, sonohysterography will be For the primary leiomyoma categorization, the myometrium is assessed
more readily available, particularly when the only available resources primarily with a combination of TVUS and transabdominal ultrasonog-
for hysteroscopy reside in an operating room. However, if office hys- raphy to identify leiomyomas, with any such identified lesion leading
teroscopy is available, there may be additional value, particularly when to an “L” assignment. For the secondary subclassification, it is neces-
polyps are suspected, as hysteroscopically directed polypectomy will sary to determine the relationship (contact or not) of the endometrium
be feasible in the same setting. with the leiomyoma by performing some combination of TVUS, con-
In some parts of the world, notably in the UK (managed by the trast sonohysterography, hysteroscopy, and MRI. Should one or more
British National Health Service), there is an emphasis on conducting submucous leiomyomas be found (Types 0, 1, 2, or 3) then the woman
investigation and management of the symptom of HMB at the first is stated to have LSM, if only Type 4, 5, 6, 7, and/or 8 are identified, the
consultation (“One stop management”, including key history, examina- categorization is Lo.
tion, transvaginal ultrasonography, and hysteroscopy, if indicated, at Tertiary subclassification of leiomyoma type requires that the clini-
the same visit).28 This type of management has been assisted by the cian clarify the relationship of the leiomyomas with the endometrium,
systematic application of the two FIGO AUB Systems – clearly defining endometrial cavity, myometrium, and uterine serosa. At least for those
the symptoms using FIGO AUB System 1, and then, following an appro- leiomyomas that do not distort the endometrial cavity (Types 3 and
priately structured evaluation, categorization of the findings or assess- up), this distinction requires the use of imaging, either ultrasonogra-
ments using FIGO AUB System 2, the PALM-­COEIN classification. phy, or, more accurately MRI as described previously.
When vaginal access is difficult or impossible, a circumstance often The myometrium should also be evaluated for the presence of
encountered with adolescents and virginal women, TVUS, contrast adenomyosis or to distinguish between leiomyomas and localized col-
sonohysterography, and office hysteroscopy may not be feasible. In lections of adenomyosis or adenomyomas.31,61 The sonographic and
such instances, there is a role for MRI. Alternatively, hysteroscopic MRI criteria for the diagnosis of adenomyosis are described elsewhere
examination with indicated biopsies, performed under appropriate in the present document. While the FIGO MDC is currently develop-
anesthesia may be the best approach. ing a system for the classification of adenomyosis, for the present, an
With the PALM-­COEIN classification, the presence of a polyp or assignment of AUB-­A is best based on imaging findings consistent
polyps (AUB-­P) is confirmed only with documentation of one or more with TVUS as described above31 (Fig. 3) or, if available, using MRI.30
clearly defined polyps, generally with either hysteroscopy or sonohys- Although promising for the diagnosis of adenomyosis, the role of both
terography. Usually, a patient may be categorized with one or more three-­dimensional TVUS62,63 and sonographic elastography64,65 is still
submucous leiomyomas (AUB-­LSM) with either sonohysterography a subject of investigation.
or hysteroscopy. When using either, the clinician should take care to If available, MRI may be necessary for evaluation of the myo-
infuse the distending medium with low pressure so that the natural metrium to distinguish between leiomyomas and adenomyosis. MRI
Munro ET AL. |
      13

T A B L E   3   Screening instrument for coagulopathies in women with not use MRI if it is deemed necessary and is available, with the results
the symptom of heavy menstrual bleeding.a,b used to categorize leiomyoma type or determine the presence, absence,
or location and extent of adenomyosis.
Initial screening for an underlying disorder of hemostasis in patients
with excessive menstrual bleeding should be by a structured history.
A positive screening result comprises any of the following:c
8 | CONCLUSION
1. Heavy menstrual bleeding since menarche
2. One of the following:
The present paper reports the changes to both FIGO AUB systems
a Postpartum hemorrhage
based on 6 years of analysis, discussion, and debate since the
b Surgical related bleeding original publication. The original seminal publications presented
c Bleeding associated with dental work effective approaches to the terminologies and definitions around
3. Two or more of the following symptoms: AUB (System 1), followed by development of a novel classification
a Bruising 1–2 times per month (PALM-­COEIN) of underlying causes of abnormal uterine bleed-
b Epistaxis 1–2 times per month ing in the reproductive years (System 2).14 These developments
c Frequent gum bleeding and refinements are integrated into the whole FIGO-­AUB model
d Family history of bleeding symptoms in this manuscript.
a
Reproduced with permission.45
b
This structured history-­based instrument is 90% sensitive for the pres-
AU T HO R CO NT R I B U T I O NS
ence of a coagulopathy in women with the symptom of heavy menstrual
bleeding. MGM, HODC, and ISF contributed to the development, drafting, and
c
Patients with a positive screening result should be considered for further
review of the present manuscript.
evaluation including consultation with a hematologist and/or testing of
von Willebrand factor and Ristocetin cofactor.

PART I C I PAT I NG M EM B ER S O F T HE FI G O M ENS T RUAL

imaging may also be superior to TVUS, sonohysterography, and hys-
D I S O R D ER S CO M M I T T EE, 2 0 1 5 – 2 0 1 8
teroscopy for measuring the myometrial extent of submucous leiomy-
omas.59 However, reliance on MRI is currently impractical, especially Rohana Haththotuwa, MD Chair; Alka Kriplani, MD, co-­Chair; Luis
for low-­resource nations, because of the relative or absolute lack of Bahamondes, MD, Ph.D; Hilary O.D. Critchley, MD; Ian S. Fraser, MD;
access within many healthcare systems.66 Carlos Füchtner, MD; Malcolm G. Munro, MD; Rebecca Tonye, MD.

L I S T O F CO NT R I B U TO R S TO T HE P RO C ES S
7 | DISCUSSION
The participants in this process have contributed substantially to the
AUB in women of reproductive age is a manifestation of any of a number evolving debate around several aspects of the common symptoms of
of disorders or pathologic entities. The FIGO systems for nomenclature AUB at workshops in Washington (2005), and/or Cape Town (2009),
and symptoms (System 1), and for classification of potential causes of and/or Rome (2012), and/or Vancouver (2015), and/or Singapore
AUB in the reproductive years (System 2) are designed to facilitate both (2017), and in private debate. They have all approved the listing of
basic science and clinical investigation, as well as the practical, rational, their names in the present manuscript. The names are listed alpha-
and consistent application of medical and surgical therapy for affected betically and none of the individuals represented the views of their
women. The current revisions of the two FIGO-­AUB systems are organizations. The following have personally participated in the
designed to clarify and modify, in a fashion that should improve the util- development of the FIGO systems as participants in workshops, on
ity of these systems for research, education, and clinical care. Clinicians, subcommittees, in some instances representing their organization as
educators, and investigators are encouraged to use the matrix concept indicated in the parentheses.
to guide the evaluation of women afflicted with chronic AUB, as well as David Archer, USA; Jason Abbott, Australia (Australasian
acute AUB once the patient is stabilized (Fig. 7). Gynaecologic Endoscopy Society [AGES]); Ahmad Abdel-­Wahed,
These systems, and their continued and appropriate revision, repre- Jordan; Luis Bahamondes, Brazil; Marina Berbic, Australia; Vivian
sent a collaboration involving clinicians, investigators, and other informed Brache, Dominican Republic; Daniel Breitkoph, USA (American
participants from six continents. This participation was designed to College of Obstetricians and Gynecologists [ACOG]); Andrew Brill,
develop an implementable System 1 and to provide input into the practi- USA (AAGL); Michael Broder, USA; Ivo Brosens, Belgium; Kristoph
cality of performing the investigations described for categorizing accord- Chwalisz, USA; Justin Clark, UK (Royal College of Obstetricians and
ing to System 2, the PALM-­COEIN classification. Currently, the routine Gynaecologists [RCOG]); Hilary O.D. Critchley, UK; Catherine d’Ar-
characterization of structural lesions of the uterus using MRI is not feasi- cangues, Switzerland (World Health Organization [WHO]); Margit
ble and its use is not included as a mandatory tool for evaluating patients Dueholm, Denmark; Hans Mark Emanuel, Netherlands; Cynthia
with chronic AUB. This does not mean that clinicians cannot or should Farquhar, New Zealand (Cochrane Collaboration on Menstrual
 |
14       Munro ET AL.

Disorders); Mario Festin, Switzerland (WHO); Yoke Fai Fong, Singapore 4. Harlow SD, Campbell OM. Epidemiology of menstrual disorders in
(Society of Endometriosis and Uterine Disorders [SEUD]); Ian S. Fraser, developing countries: A systematic review. BJOG. 2004;111:6–16.
5. Heavy Menstrual Bleeding. Excellence NIfHaC, editor. United Kingdom:
Australia (Royal Australian and New Zealand College of Obstetricians
National Institute for Health and Clinical Excellence; 2007.
and Gynaecologists [RANZCOG]); Marc Fritz, USA; Carlos Fuchner, 6. Liu Z, Doan QV, Blumenthal P, Dubois RW. A systematic review eval-
Bolivia (International Federation of Gynecology and Obstetrics uating health-­related quality of life, work impairment, and health-­
[FIGO]); Sun-­Wei Guo, China (Society of Endometriosis and Uterine care costs and utilization in abnormal uterine bleeding. Value Health.
2007;10:183–194.
Disorders [SEUD]); Stephan Gordts, Belgium (European Society of
7. Matteson KA, Raker CA, Clark MA, Frick KD. Abnormal uterine bleed-
Human Reproduction and Embryology [ESHRE]); Grigoris Grizimbis, ing, health status, and usual source of medical care: Analyses using
Greece (European Society of Gynecologic Endoscopy [ESGE]); the Medical Expenditures Panel Survey. J Womens Health (Larchmt).
Sioban Harlow, USA; Rohana Hathtootuwa, Sri Lanka (FIGO); Oskari 2013;22:959–965.
8. Fraser IS, Mansour D, Breymann C, Hoffman C, Mezzacasa A,
Heikinheimo, Finland; Martha Hickey, Australia; Jennifer Higham, UK;
Petraglia F. Prevalence of heavy menstrual bleeding and experiences
William Hurd, USA (Fertility Sterility); Keith Isaacson, USA (American
of affected women in a European patient survey. Int J Gynecol Obstet.
Society of Reproductive Medicine [ASRM]); Julia Johnson, USA 2015;128:196–200.
(ACOG); Alka Kriplani, India; Ricardo Lasmar, Brazil; Lee Learman, 9. Kazemijaliseh H, Ramezani Tehrani F, Behboudi-Gandevani S, Khalili
USA; Charles Lockwood, USA; Andrea Lukes, USA; Diana Mansur, UK; D, Hosseinpanah F, Azizi F. A population-­based study of the preva-
lence of abnormal uterine bleeding and its related factors among
Kristen Matteson, USA; Malcolm G. Munro, USA; Scott Monroe, USA
Iranian reproductive-­age women: An updated data. Arch Iran Med.
(Food and Drug Administration [FDA]); Ian Milsom, Sweden; Andrew 2017;20:558–563.
Mok, Canada (Society of Obstetricians and Gynecologists of Canada 10. Cote I, Jacobs P, Cumming DC. Use of health services associated with
[SOGC]); Evan Myers, USA; Anita Nelson, USA; Shaughn O’Brien, UK increased menstrual loss in the United States. Am J Obstet Gynecol.
2003;188:343–348.
(RCOG); David Olive, USA; Colin Pollard, USA (FDA); Rachel Pope,
11. Frick KD, Clark MA, Steinwachs DM, et  al. Financial and quality-­
Israel; Oskari Heikinheimo, Finland; Elisabeth Persson, Sweden; of-­life burden of dysfunctional uterine bleeding among women
Robert Rebar, USA (ASRM); Dorothy Shaw, Canada (FIGO); Shirish agreeing to obtain surgical treatment. Women’s Health Issues.
Sheth, India (FIGO); Sukbir (Sony) Singh, Canada (SOGC); Robert 2009;19:70–78.
12. Khaskheli MN, Baloch S, Sheeba A, Baloch S, Khaskheli FK. Iron defi-
Schenken, USA; James Spies, USA; Elizabeth Stewart, USA; Delphin
ciency anaemia is still a major killer of pregnant women. Pak J Med Sci.
Tan, Philippines; David Taub, USA; Rebecca Tonye, Cameroon; Zephne 2016;32:630–634.
van der Spuy, South Africa; Paolo Vercellini, Italy (ESHRE); Kirsten 13. Maswime S, Buchmann E. Causes and avoidable factors in mater-
Vogelsong, Switzerland (WHO); Pamela Warner, UK. nal death due to cesarean-­related hemorrhage in South Africa. Int J
Gynecol Obstet. 2016;134:320–323.
14. Munro MG, Critchley HO, Broder MS, Fraser IS; FIGO Working Group
CO NFLI CTS OF I NTE RE ST on Menstrual Disorders. FIGO classification system (PALM-­COEIN)
for causes of abnormal uterine bleeding in nongravid women of
Each author has received royalties from Up-­to-­Date. MGM and reproductive age. Int J Gynecol Obstet. 2011;113:3–13.
15. Fraser IS, Critchley HO, Munro MG, Broder M. A process designed
ISF have acted as consultants for, and/or given lectures for, and
to lead to international agreement on terminologies and definitions
received honoraria from Bayer AG (Berlin), Bayer Women’s Health,
used to describe abnormalities of menstrual bleeding. Fertil Steril.
and Vifor Pharma, which has partly funded this initiative (as out- 2007;87:466–476.
lined in the relevant publications). ISF has acted as a consultant 16. Fraser IS, Critchley HO, Munro MG, Broder M. Can we achieve
for Merk. MGM has functioned as a consultant to Abbvie, Datichi international agreement on terminologies and definitions used to
describe abnormalities of menstrual bleeding? Hum Reprod. 2007;
Sankyo, Myovant Sciences, and Hologic, the latter a contributor to
22:635–643.
funding to the FIGO Menstrual Disorders Committee. HODC has 17. Woolcock JG, Critchley HO, Munro MG, Broder MS, Fraser IS.
acted as a consultant (no personal honoraria received) for Bayer Review of the confusion in current and historical terminology and
AG, PregLem SA, Gedeon Richter, Vifor Pharma UK, AbbVie, and definitions for disturbances of menstrual bleeding. Fertil Steril. 2008;
90:2269–2280.
Myovant Sciences. Many other organizations and companies have
18. Fraser IS, Munro MG, Critchley HOD. Abnormal uterine bleeding in
contributed in direct or indirect ways to the development of this reproductive-age women: Terminology and PALM-COEIN etiology
process. The process has been approved by FIGO and the FIGO classification. Published 2017. https://www.uptodate.com/con-
Menstrual Disorders Committee. tents/abnormal-uterine-bleeding-in-reproductive-age-women-ter-
minology-and-palm-coein-etiology-classification. Accessed March
20, 2018.
19. Munro MG, Critchley H, Fraser IS. Research and clinical management
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