{"paper_id":"892e9cec-e0af-4ed6-92aa-1b93093348a3","body_text":"~ 84 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2020; 4(1): 84-87 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2020; 4(1): 84-87 \nReceived: 04-11-2019 \nAccepted: 08-12-2019 \n \nSeetha PM \nProfessor, Department of \nObstetrics and Gynaecology, Sree \nMookambika Institute of Medical \nSciences, Kulasekaram, \nTamil Nadu, India \n \nAnto Venetia \nJunior Resident, Department of \nObstetrics and Gynaecology, Sree \nMookambika Institute of Medical \nSciences, Kulasekaram, \nTamil Nadu, India \n \nNeha Haridas \nJunior Resident, Department of \nObstetrics and Gynaecology, Sree \nMookambika Institute of Medical \nSciences, Kulasekaram, \nTamil Nadu, India \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nCorresponding Author: \nSeetha PM \nProfessor, Department of \nObstetrics and Gynaecology, Sree \nMookambika Institute of Medical \nSciences, Kulasekaram, \nTamil Nadu, India \n \nA study on distribution of causes of non-gestational AUB \nin reproductive age group as per the FIGO classification \nin a tertiary care centre \n \nSeetha PM, Anto Venetia and Neha Haridas \n \nDOI: https://doi.org/10.33545/gynae.2020.v4.i1b.445  \n \nAbstract \nBackground: Abnormal uterine bleeding is a common presenting complaints in the Gynaecology \noutpatient department in all age groups. Histopathological evaluation of the endometrial samples plays a \nsignificant role in the diagnosi s of abnormal uterine bleeding. Endometrial t issue can be collected  by \nsampling procedure such as Dilatation and Curettage (D&C), endometrial  biopsy, pippelle aspiration or \nHysteroscopy which is considered as gold standard. Variety of causes are there for AUB including causes \nwhich can be structural and can be imaged or non-structural which can be detected by history and \nlaboratory tests. In this study an attempt is made to find out the causes and categorize them as per FIGO \nsystem. \nAims and Objectives \n1. To find out the causes of AUB in the reproductive age group. \n2. To categorize the causes of AUB as per the FIGO system. \nMethodology and outcome : The study comprises 350 women of reproductive age group with AUB \nattending outpatient Gynae department of SMIMS, from Jun 2019 to Nov 2019. They were assessed on the \nbasis of structured history, physical examination, local pelvic  examination, investigations, USG and \nendometrial histopathology. Cause of AUB was detected and  treatment was given to the patient as \nappropriated by categorization done in agreement with t he palm-COEIN classification put forward by \nFIGO. \nResults: The most prevalent cause of AUB was ovulatory dysfunction (n=99, 28.2%). Next common cause \nwas leiomyoma  (n=90, 25.7%), followed by endometrial causes (n=52, 14.5%), adenomyosis (n=30, \n8.5%), not y et classified (n=32, 9.7%),  Malignancy & Hyperplasia (n=28, 8.1%), Polyp (n=9, 2.5%), \nIatrogenic (n=7, 2.2%) and Coagulopathy (n=1, 0.3%). \nConclusion: Ovulatory dysfunction and leiomyoma stands in front as the aetiological factors for AUB \nfollowed by endom etrial causes and adenomyosis.  The palm-COEIN classification helps to categorize the \ncause of AUB in a practical way thereby effectively direct the  correct treatment for AUB patients.  It helps \nin streamlining the investigations and management.  Utilizing th e advanced investigations , a better \ndefinition of the factors in palm COEIN can be done which will increase the pickup rate in various groups. \n \nKeywords: Distribution, AUB, FIGO classification \n \nIntroduction \nAbnormal uterine bleeding (AUB) is a common problem among women in the reproductive age \ngroup. AUB may be accompanied by significant social embarrassment, and have a substantial \neffect on health -related quality of life. AUB leads to loss of productivity  and may result in \nsurgical interventions including hysterectomy. AUB can be acute or chronic. It affects 3-30% of \nthe population.  Chronic AUB is identified if the symptoms last for more than 6 months.  \nSometimes an acute episode of AUB can complicate chronic AUB. Because of versatile causes \nof AUB, FIGO put forward a system called palm COEIN classification to help the clinician for \nstream lining the investigations and interpreting the results and also to provide evidence based \nclinical care. Abnormal uterine bleeding  can be due to causes which can be detected by clinical \nexamination, imaging and histopathology and these comes under palm group otherwise called \nstructural lesions. The causes which cannot be detected by imaging but  can be detected by \nclinical history supported by laboratory investigations  belongs to the COEIN group otherwise \ncalled as non -structural lesions. Patients on anticoagulant drugs and on hormones when they  \ndevelop AUB, it should be considered as iatrogenic and N category is named as “not otherwise \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 85 ~ \nclassified” because later on they may go to some unique group \nby further investigations like histopathological study or imaging \ntechniques. Dysfunctional uterine bleeding (DUB) is abnormal \nuterine bleeding that is exclusively due to HPO axis dysfunction. \nIn this cross sectional study, an attempt is made to classify the \nAUB as per the etiology by clinical, laboratory, imaging, and \nhistopathology and hysteroscopy examination \n \nMethods: A cross sectional study was carried out in the \nDepartment of obstetrics and G ynaecology Sree Mookambika \nInstitute of Medical Sciences Kulasekharan during the period \nfrom June 2019 to November 2019. The subject inclusion \ncriteria are as follows: \n1. Women aged 18 to 45 years \n2. Chronic AUB \n \nIncluding any of the following: \nMenstrual cycle o f <24 days; menstrual cycle of >38 days; \nirregularity of menses, cycle -to-cycle variation of >20 days \nduring 12 months; duration of flow of >8 days; duration of flow \nof <4 days;  flow volume as patient determined  \n(light/normal/heavy). \nThe exclusion criteria are as follows \n1. Vaginal bleeding caused by pregnancy and pregnancy -\nrelated factors. \n2. Vaginal bleeding caused by vaginitis. \n3. Vaginal bleeding caused by cervical diseases. \n \nThis study adopted a questionnaire investigation method, \nfollowing the principle of informed consent. Patient information, \nsuch as age, height, weight, menstrual history,  obstetric history, \nmedical history, surgical history was taken. And the relevant \nclinical examination and laboratory test results, including \nroutine blood test, hormonal as says, vaginal ultrasound, liver \nfunction, renal function, hysteroscopic examination, and \nhistopathological report were  obtained. At the same time, a \nlecture and training on AUB -related concepts were conducted, \nand a menstrual record paper was distributed to the patients to be \nkept as a menstrual diary for 3 months. The menstrual diary \nshould record abnormal menstruation (e.g., menstrual period \ncycle and duration, volume of monthly blood loss). After 3 \nmonths, the main causes of AUB were determined according  to \nthe medical history and physical and auxiliary examination \nresults. \n \nResults \n \nTable 1: Age distribution of study population \n \nAge group Total number Percentage \n18-20 years 5 01.4% \n21-30 years 15 04.2% \n31-40 years 131 37.4% \n41-45 years 167 47.7% \n \nTable 2: Distribution of study population based on presented \ncomplaints. \n \nSymptom (complaints) Total number Percentage \nHeavy Menstrual Bleeding 131 37.4% \nIrregular Heavy Bleeding 95 27.0% \nIntermenstrual Bleeding 7 02.0% \nFrequent Bleeding 77 22.0% \nPost-Menopausal Bleeding 28 08.0% \nInfrequent or Scanty Bleeding 12 03.4% \n \nAll the 350 women studied were placed in the nine categories of \npalm-COEIN classification. Maximum patients, 47.7%, were in \nthe age group of 40-50 years and 37.4% were in the 30 -40 years \nage group. Majority of patients, 37.4%, complained of heavy \nbleeding as chief complaint. 27% had irregular heavy bleeding \nand 22% had frequent bleeding. As per the palm-COEIN \nclassification, Leiomyoma was the most common in the palm \ngroup and ovulatory dysfunction was  the most prevalent cause \nof AUB in the COEIN group. Simple ovarian cysts and PCOS \nwere common sonographic findings. Hypothyroidism was  also \nnoted. Next common category was Leiomyoma AUB L(n=90, \n25.7%), followed by Endometrial AUB-E causes (n=52, 14.5%), \nadenomyosis AUB-A (n=30, 8.5%), Malignancy AUB-M (n=28, \n8.1%), Not classified AUB-N (n=32, 9.7%), Polyp AUB-P (n=9, \n2.5%), iatrogenic AUB-I (n=7, 2.2%) and coagulopathy AUBC \n(n=1, 0.3%)  \n \nTable 3: Distribution of study population according to palm-COEIN classification (total 350 patients) \n \nCauses Total Number Percentage \nStructural \nPolyp (AUB-P) 9 2.5% \nAdenomyosis (AUB-A) 30 8.5% \nLeiomyoma (AUB-L) 90 25.7% \nMalignancy (AUB-M) 28 8.1% \nNon-structural \nCoagulopathy (AUB-C) 1 0.3% \nOvulatory Dysfunction (AUB-O) 99 28.2% \nEndometrial (AUB-E) 52 14.5% \nIatrogenic (AUB-I) 7 2.2% \nNot yet classified (AUB-N) 32 9.7% \n \nDiscussion \nIn this study the most common cause for AUB is Ovulatory \ndysfunction followed by leiomyoma as mentioned in other \nstudies. The incidence of endometritis and endometrial \nmalignancy were relatively  high compared to other study. \nAdenomyosis were relatively less. \nSome patient had more than 1 lesion but the main contributory \nlesion for her symptoms is taken for categorization.  The conduct \nthis study was to find out the causes of AUB and to test the \nefficiency and practicality of palm-COEIN classification system \nin clinical practice in determining the cause of disease and \ntreatment modality for patient with AUB. The new FIGO \nclassification was developed to clear long standing confusions \nregarding terminologies and definitions related to AUB. This \nstudy focuses to categorize the patient of AUB as per the \nPALM-COEIN classification and is similar to studies by Khrouf \net al. [8] Munro et al. [6] Madhra et al. [9] Bahamondes and Ali [10]. \nIn present study, most of the patients presented with AUB were \nin age group 40 -45 years (47.7%) and 30 -40 years (37.4%). \nRegarding presenting symptoms heavy menstrual bleeding \n(37.4%) was the most com mon, followed by irregular heavy \nbleeding and frequent bleeding 27 % and 22% respectively. It \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 86 ~ \nwas also noted that infrequent and scanty bleeding was more \ncommon in obese and PCOS women. According to study done \nby Gouri et al. [11] in May, 16, most patients belongs to ovulatory \ndysfunction (27%), followed by leiomyoma (24.7%). In study \ndone by Goel P et al. [12], ovulatory dysfunction was found to be \nthe most common cause of AUB (28.3%) followed by \nleiomyoma (22.7%). In present study also ovulatory dysfunctio n \nwas found to be the most common cause of AUB (28.2%) \n(Table 4). PCOS, hormonal dysfunction, thyroid dysfunction, \nsimple ovarian cyst were included in this category. In study done \nby Qureshi and Yusuf [13] in 2013, leiomyoma was most \ncommon category (25%)  followed by ovulatory dysfunction \n(24%). In study for Ratnani R et al  [14] in Sep’17, leiomyoma \n(35%) was the most common cause of AUB, followed by \nmalignancy and hyperplasia, adenomyosis and ovulatory \ndysfunction. In present study, leiomyoma was found in 25.7% of \nwomen and endometrial category was in 14.5% patients. In \nstudy done by Gouri et al. and Goel P et al, endometrial causes \nwere found on 9% and 20.7 % respectively. This study \nencapsulates the ease of use and implementation of this \nclassification sy stem. Moreover, treatment of pathology was \neasier where the cause of AUB was determined. In present \nstudy, we could understand the major causes of AUB and they \ncan be grouped into structural and non -structural cause. In both \nmanagement plans were different , hence management was more \nfocused and tailored to specific cause. The major disadvanta ge \nwas in cases of patients who belonged to AUB -N category to \nwhom treatment is vague in absence of diagnosis. Also, COEIN \npart of classification needs further improvem ent through \nelaborate research. Further sub  classification and screening by \nMRI scan, coagulative studies, ovulatory function study can give \na better picture regarding diagnosis. In our study it is found that \ncause can be one or more and considerable overl apping is \npresent. But endometritis and malignancy was slightly high.  The \nmapping of fibroid can be improved by doing MRI scan and 3D \nscan. Adenomyosis can be picked up in a better way by high \nresolution TVS. Caesarean section leading to AUB due to the \ndevelopment of isthmocele was present in other studies but not \npicked up in this study.  \n \n \n \nFig 1: Adenomyosis diagnostic criteria. Graphic depictions of the eight TVUS criteria proposed by the MUSA group are presented \n \nAdenomyosis diagnostic criteria. Graphic depictions of the eight \nTVUS criteria proposed by the MUSA group are presented. \nThese include myometrial thickening \na. Myometrial cysts \nb. Hyperechoic islands \nc. Fan shaped shadowing \nd. Echogenic subendometrial lines and buds \ne. Translesional vascularity \nf. Irregular Junctional zone \ng. An interrupted Junctional zone \nh. Identification and evaluation \n \nOf the Junctional zone may best be accomplished with three -\ndimensional ultrasonography. For the present at least, the \npresence of two or more of these criteria are highly associated \nwith a diagnosis of adenomyosis. \n \nTable 4: Comparison of distribution of causes \n \n  Number of patients (%) \nCauses Category Present study Gouri et al. Goel et al. Qureshi & yusuf Ratnani et al. \nPolyp P 09(02.5%) 06(02.0%) 08(02.7%) 30(03.0%) 40(13.3%) \nAdenomyosis A 30(08.5%) 38(12.7%) 28(09.3%) 150(15%) 60(20.0%) \nLeiomyoma L 90(25.7%) 74(24.7%) 68(22.7%) 250(25%) 105(35%) \nMalignancy or hyperplasia M 28(08.1%) 15(05.0%) 08(02.7%) 66(06.7%) 65(21.6%) \nCoagulopathy C 01(00.3%) 09(03.0%) 03(01.0%) 03(03.0%) 02(00.6%) \nOvulatory Dysfunction O 99(28.2%) 81(27.0%) 85(28.3%) 236(24%) 60(20.0%) \nEndometrial E 52(14.5%) 27(09.0%) 62(20.7%) 48(05.0%) 12(04.0%) \nIatrogenic I 07(02.2%) 24(08.0%) 13(04.3%) 53(06.0%) 03(01.0) \nNot yet classified N 32(09.7%) 19(6.3%) 25(08.3%) 155(15%) 03(01.0%) \n \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 87 ~ \nTable 5: Palm-COEIN classification for the etiologies of abnormal uterine bleeding proposed by the International Federation of \nGynaecology and Obstetrics (FIGO) \n \nAUB causes Subclass Characteristics \nStructural causes Polyps  Present in endometrial and endocervical canal \n(AUB-P)  Categorized as absent or present \nAdenoma \n(AUB-A) \n The genesis is controversial but minimal criterion is \nidentification on ultrasound testing.  \nLeiomyoma \n(AUB-L) \n0: Submucosal types, do not \nimpact endometrial cavity \nOthres: \n1: < 50% Intramural \n2: ≥50% Intramural \n3: Totally extracavitary but lean on the endometrium, 100% \nintramural \n4: Intramural leiomyomas that are entirely within the \nmyometrium \n5: Subserosal and at least 50% intramural \n6: Subserosal and < 50% \nintramural \n7: Subserosal and attached to serosa by stalk \n8: Do not involve the myometrium include cervical \nlesions, lesions that exist in the round or broad \nligaments without direct attachment to the uterus, and \nparasitic lesions \nMalignancy & hyperplasia \n(AUB-M) \n May occur because of ovulatory disorder \n Sub-classification according to the WHO or FIGO system.  \nNon-structural causes Coagulopathy \n(AUB-C) \n Coagulopathy represents both inherited and acquired \n Most common is inherited von Willebrand disease \nOvulatory dysfunction \n(AUB-O)  Can lead to amenorrhea or heavy menstrual bleeding.  \nEndometrial \n(AUB-E) \n Likely to occur when other abnormalities are excluded \nin the presence of normal ovulatory function.  \nIatrogenic \n(AUB-I) \n Breakthrough bleeding during use of single or combined \ngonadal steroid therapy, intrauterine systems, or devices, \nsystemic agents that interfere with dopamine metabolism, or \nanticoagulant drugs. \n \nNot classified \n(AUB-N) \n Rare or ill-defined conditions: Chronic endometritis, \narteriovenous malformations, and myometrial hypertrophy  \n \nReferences \n1. 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