PALM-COEIN for etiologies of vaginal bleeding introduced in 2011 by FIGO (International Federation of Gynecology and Obstetrics) and adopted by ACOG (American College of Obstetricians and Gynecologists):
PALM (Structural causes)
Polyp, Adenomyosis, Leiomyoma, Malignancy and hyperplasia
COEIN (Non-structural causes)
Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified
Many women experience random bleeding during their perimenopausal and menopausal journey.Although menstrual irregularity is normal during perimenopause, unusual bleeding could be a sign of a problem.
Abnormal uterine bleeding (AUB) is among the most common gynecologic complaints of
reproductive-age women in ambulatory care settings. It is estimated to affect 11 to 13 percent of
reproductive-age women at any given time. Prevalence increases with age, reaching 24 percent
in women aged 36 to 40.
Some other causes of irregular or abnormal bleeding include:
•taking the emergency contraceptive pill
•injury or disease of the vagina – for example, from having rough sex, an infection, ulcer or varicose veins
•a recent abortion – if you’re bleeding heavily, seek medical advice
•sexually transmitted infections (STIs) such as chlamydia – if you’ve recently had unprotected sex with a new partner, it’s a good idea to get tested
•reproductive hormones not working normally – this is common in women approaching the menopause or in women with polycystic ovary syndrome (PCOS)
•harmless changes to the cervix (neck of the womb) – this may be called ectropion or cervical erosion
Uterine bleeding is a common presentation to the Emergency Department and rarely these patients are SICK. When they come in sick, its not the time to be googling the American College of Obstetricians and Gynecologist (ACOG) recs on managing uterine bleeding.
To diagnose the cause, we first must determine the source of the bleeding. Is it coming from the uterus, the cervix, or the vagina? Sometimes, bleeding that is thought to be coming from the vagina may actually be from the bladder or the bowels.
Establishing the source of bleeding is an essential first step when assessing women* who present with per vaginum (PV) bleeding. Often the source of bleeding is the uterus, however, bleeding from other parts of the genital tract (e.g. vulva, vagina or cervix) must also be considered. Bleeding from the urinary or gastrointestinal tracts may be mistaken by patients for PV bleeding and should be excluded.
Any woman complaining of abnormal vaginal bleeding should be examined. Occasionally, you will find a laceration of the vagina, a bleeding lesion, or bleeding from the surface of the cervix due to cervicitis. More commonly, you will find bleeding from the uterus coming out through the cervical os.
Excluding pregnancy, there are really only three reasons for abnormal uterine bleeding:
Dysfunctional uterine bleeding (DUB) is a common presentation in the emergency department and has a wide differential. Most presentations of DUB are in hemodynamically stable patients and can be evaluated as an outpatient.
For women over the age of 40, there are, pardon the pun..."red flags" that should clearly tell you it's time to ditch the stoicism and pursue medical care. In gynecology we call this condition abnormal uterine bleeding. It can occur at any age. From age 13 to 18 it's typically associated with immature physiology, pelvic infection, blood disorders or tumors...
Abnormal vaginal bleeding can relate to an issue with your reproductive system (a gynecologic condition) or to other medical problems or certain medications. If you've gone through the menopausal transition — 12 consecutive months without a menstrual period — any vaginal bleeding is a particular cause for concern.
Abnormal vaginal bleeding is a flow of blood from the vagina that occurs either at the wrong time during the month or in inappropriate amounts. In order to determine whether bleeding is abnormal, and its cause, the doctor must consider three questions:
Is the woman pregnant?
What is the pattern of the bleeding?
Is she ovulating?
Under normal circumstances, a woman's uterus sheds a limited amount of blood during each menstrual period (less than 5 tablespoons or 80 mL). Bleeding that occurs erratically or excessive regular menstrual bleeding is considered to be abnormal uterine bleeding. Once a woman who is not taking hormone therapy enters menopause and the menstrual cycles have ended, any uterine bleeding is considered abnormal.
Abnormal uterine bleeding can be caused by many different conditions.
Menorrhagia is menstrual blood loss which interferes with a woman's physical, emotional, social, and material quality of life, and which can occur alone or in combination with other symptoms. Any intervention should aim to improve her quality of life. Research studies usually take menorrhagia to be a monthly menstrual blood loss in excess of 80 ml.