Abnormal Uterine Bleeding (AUB): Updated 2026 FIGO PALM-COEIN Classification, Diagnosis, and Treatment Algorithms
Medical Disclaimer: This article is intended for educational and informational purposes only. It does not replace professional medical advice, diagnosis, or treatment. Individuals should always consult a qualified healthcare provider for personalized medical guidance.
Abnormal Uterine Bleeding (AUB): Updated 2026 FIGO PALM-COEIN Approach & Treatment Algorithms
Author: Dr. Humaira Latif, MBBS (KMU Peshawar)
Specialty: Gynae & OBS Specialist, Ultrasound Specialist
Experience: 14+ Years in Women’s Health
Last Updated: January 2026
Introduction
Abnormal Uterine Bleeding (AUB) is one of the most common gynecological concerns affecting adolescents, reproductive-age women, and those in the perimenopausal period. It refers to any variation from normal menstrual patterns in terms of frequency, regularity, duration, or volume of blood flow.
To standardize diagnosis and management, the International Federation of Gynecology and Obstetrics (FIGO) introduced the PALM-COEIN classification system, which remains the globally accepted framework. The 2026 updates further emphasize structured evaluation, minimally invasive diagnostics, and patient-centered, culturally sensitive care.
Overview and Definition
Abnormal Uterine Bleeding is defined as bleeding from the uterine corpus that is abnormal in:
- Volume (heavy or scanty bleeding)
- Duration (prolonged or shortened)
- Frequency (too frequent or infrequent)
- Regularity (irregular cycles)
AUB is a symptom, not a diagnosis, and requires systematic evaluation to identify underlying causes.
Why the FIGO PALM-COEIN System Matters
Before FIGO standardization, terminology such as “menorrhagia” or “dysfunctional uterine bleeding” was inconsistently used. The PALM-COEIN system provides:
- Clear classification of causes
- Improved communication among clinicians
- Evidence-based management pathways
- Better patient education and counseling
FIGO PALM-COEIN Classification (2026)
Structural Causes (PALM)
| Category | Description |
|---|---|
| P – Polyp | Endometrial or cervical polyps causing intermenstrual or post-coital bleeding |
| A – Adenomyosis | Endometrial tissue within the myometrium leading to heavy and painful periods |
| L – Leiomyoma | Uterine fibroids; submucosal types are most associated with heavy bleeding |
| M – Malignancy & Hyperplasia | Endometrial hyperplasia or cancer, especially in women over 40 years |
Non-Structural Causes (COEIN)
| Category | Description |
|---|---|
| C – Coagulopathy | Inherited or acquired bleeding disorders (e.g., von Willebrand disease) |
| O – Ovulatory Dysfunction | Anovulation common in PCOS, adolescence, or perimenopause |
| E – Endometrial | Primary disorders of endometrial hemostasis |
| I – Iatrogenic | Bleeding related to medications or devices (e.g., anticoagulants, IUCDs) |
| N – Not Yet Classified | Rare or emerging causes under ongoing research |
Risk Factors for Abnormal Uterine Bleeding
- Extremes of reproductive age (adolescence and perimenopause)
- Hormonal imbalance
- Obesity and metabolic disorders
- Polycystic ovary syndrome (PCOS)
- Use of hormonal contraception or intrauterine devices
- Chronic medical conditions affecting coagulation
Clinical Presentation and Symptoms
Commonly reported features include:
- Heavy menstrual bleeding affecting daily activities
- Bleeding between periods
- Cycles shorter than 21 days or longer than 35 days
- Postmenopausal bleeding
- Associated fatigue or symptoms of anemia
Diagnostic Evaluation (Step-Wise Approach)
1. Clinical Assessment
- Detailed menstrual history
- Obstetric and medical history
- Medication review
2. Laboratory Investigations
- Pregnancy test (where appropriate)
- Complete blood count
- Coagulation profile (if indicated)
- Hormonal evaluation in selected cases
3. Imaging
- Transvaginal ultrasound (first-line)
- Saline infusion sonography for suspected polyps
- MRI in complex adenomyosis or fibroid mapping
4. Endometrial Assessment
Endometrial biopsy is recommended for women aged ≥40 years or those with risk factors for endometrial pathology.
Management Pathways (2026 Evidence-Based)
Medical Management (First-Line for Most Patients)
- Combined hormonal contraceptives
- Progestin therapy
- Levonorgestrel-releasing intrauterine system (LNG-IUS)
- Non-hormonal options such as tranexamic acid or NSAIDs
Surgical Management (When Indicated)
- Hysteroscopic polypectomy
- Myomectomy for symptomatic fibroids
- Endometrial ablation (selected cases)
- Hysterectomy as definitive management when conservative measures fail
Compassionate and Culturally Sensitive Care
Modern AUB management emphasizes:
- Clear patient education using simple, non-technical language
- Bilingual counseling where possible
- Respect for cultural beliefs related to menstruation
- Shared decision-making
Prevention and Long-Term Monitoring
- Regular gynecological checkups
- Early evaluation of menstrual changes
- Management of underlying endocrine disorders
When to See a Doctor
Medical evaluation is recommended if a woman experiences:
- Bleeding lasting more than 7 days
- Bleeding between periods
- Postmenopausal bleeding
- Symptoms of anemia such as dizziness or fatigue
Frequently Asked Questions (FAQs)
Is abnormal uterine bleeding common?
Yes. AUB is one of the leading reasons for gynecological consultations worldwide.
Can AUB be managed without surgery?
In many cases, medical management is effective and considered first-line therapy.
Internal Educational Resources
- Women’s Health Educational Articles
- Menstrual Disorders Awareness Guides
References
- Munro MG, Critchley HO, Broder MS, Fraser IS. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet. 2011;113(1):3-13. (Original FIGO PALM-COEIN classification publication) 0
- Whitaker L, Critchley HO. Abnormal uterine bleeding: diagnosis and structured approach using the FIGO PALM-COEIN system. Best Pract Res Clin Obstet Gynaecol. 2016;34:54-65. (Clinical overview of PALM-COEIN and diagnostic approach)
- Contemporary evaluation of women and girls with abnormal uterine bleeding: FIGO Systems 1 and 2. Int J Gynecol Obstet. 2023;162(S2):29-42. (Updated FIGO Systems explanation including PALM-COEIN and System 1 definitions)
- Abnormal uterine bleeding: definition, classification, and clinical evaluation. StatPearls [Internet]. 2025 Jan [Updated]. (Overview of AUB definitions, clinical evaluation, and PALM-COEIN structure)
- Trivedi FJ, Deliwala KJ, Deliwala DJ, Patel SV. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in non-gravid women. Int J Reprod Contracept Obstet Gynecol. 2024 May;13(5):1140-1143. (Recent etiologic category distribution using PALM-COEIN)
- Alkhamis AA, AlDeghaither BS, Aldakhil LO. FIGO PALM-COEIN classification of abnormal uterine bleeding in Saudi women. Saudi J Med Med Sci. 2024;12(4):314-318. (Contemporary observational study applying FIGO PALM-COEIN in clinical population)
- ACOG Committee Opinion: Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women. American College of Obstetricians and Gynecologists. 2013 Apr. (Clinical guidance reference for acute AUB evaluation and PALM-COEIN categorization)
Author Note:
Dr. Humaira Latif is a registered medical practitioner, Gynae & OBS specialist, and ultrasound specialist with over 14 years of clinical and practical experience in women’s health. Her work focuses on patient education, preventive gynecology, and evidence-based clinical guidance.
Final Disclaimer: This article is intended for educational purposes only and does not replace professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider for personalized medical guidance.
Comments
Post a Comment