Clinical Guidelines and Standards · Diagnostic Criteria and Classification
Contemporary evaluation of women and girls with abnormal uterine bleeding: FIGO Systems 1 and 2
Jain V,Munro MG,Critchley HOD
Published August 2023International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics, 162 Suppl 2(Suppl 2), 29-42
Jain, V., Munro, M. G., & Critchley, H. O. D. (2023). Contemporary evaluation of women and girls with abnormal uterine bleeding: FIGO Systems 1 and 2. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics, 162 Suppl 2(Suppl 2), 29-42. https://doi.org/10.1002/ijgo.14946
Jain V, Munro MG, Critchley HOD. Contemporary evaluation of women and girls with abnormal uterine bleeding: FIGO Systems 1 and 2. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2023;162 Suppl 2(Suppl 2):29-42. doi:10.1002/ijgo.14946
Jain, Varsha, et al. "Contemporary evaluation of women and girls with abnormal uterine bleeding: FIGO Systems 1 and 2." International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics, vol. 162 Suppl 2, no. Suppl 2, 2023, pp. 29-42.
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Kaiser Permanente West Los Angeles Medical Center031caxb92
FIGO's two systems sort abnormal uterine bleeding by pattern and cause
FIGO's first system describes the bleeding pattern, and its second system sorts the possible causes. This 2023 review by three gynecology experts explains how to use the first as a gateway to the second. The authors draw on published studies and expert agreement.
Key Findings
Recent surveys found heavy menstrual bleeding alone may affect over 50% of reproductive-age women. Patient-record data yield a lifetime estimate of at least one in three women with abnormal uterine bleeding.
System 1 records four features: frequency, duration, regularity and flow volume. FIGO's normal range is a 24 to 38 day cycle, with bleeding of up to eight consecutive days.
System 2 lists causes under PALM-COEIN: polyp, adenomyosis, leiomyoma, malignancy, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and N for not otherwise classified.
Polyps, adenomyosis and most leiomyomas may be symptom-free. The review advises assessing nonstructural causes even after a structural finding.
No diagnostic tests exist for primary endometrial disorders (AUB-E), so clinicians make a presumed diagnosis.
Interpretation
This narrative review brings together published studies and FIGO consensus work on evaluating and classifying abnormal uterine bleeding. The one in three lifetime estimate comes from patient records, and the over 50% figure comes from direct surveys of heavy bleeding alone. The review points to barriers to seeking care as a likely reason for that gap. The authors call for further study of leiomyoma location, endometrial aging, and the effects of COVID-19 and its vaccines on menstrual cycles.
RRM Context
Restorative reproductive medicine (RRM) looks for the cause before treating. System 1 follows that order: bleeding history first, then cause. The review names daily basal body temperature and a progesterone blood test late in the cycle as measures that may clarify ovulatory status when the history leaves doubt. Birth control pills are designed to suppress or alter ovulation, so unscheduled bleeding on them counts as abnormal.
Our editorial summary of this paper, not the article's abstract.
Abstract
Abnormal uterine bleeding (AUB) is common, often debilitating, and may affect over 50% of reproductive-aged women and girls. Whereas AUB is a collection of symptoms that include intermenstrual bleeding and abnormalities in period duration, cycle length, and regularity, it is heavy menstrual bleeding (HMB) that is most contributory to iron deficiency and related anemia. It is apparent that AUB, in general, and HMB, in particular, remain underrecognized and underreported. FIGO created two systems for assessing and classifying AUB. FIGO System 1 defines the bleeding pattern using four primary descriptors: frequency, duration, regularity, and flow volume. FIGO System 2 provides a structured classification system of possible causes of AUB, using the acronym PALM-COEIN. "PALM" refers to structural causes of AUB (Polyp, Adenomyosis, Leiomyoma, Malignancy), and "COEI" refers to nonstructural causes (Coagulopathy, Ovulatory dysfunction, Endometrial, and Iatrogenic). The "N" is reserved for those entities that are currently not otherwise classified. Using FIGO System 1 as a gateway to FIGO System 2 streamlines the investigation of reproductive-aged women and girls with AUB. Understanding the pathogenesis of the FIGO System 2 "PALM-COEIN" causes helps interpret investigations and the onward management of AUB. Numerous evidence gaps exist concerning AUB; however, if researchers and trialists universally adopt FIGO Systems 1 and 2 for the assessment and diagnosis of AUB, clear translatable research findings can be applied globally.
