Modern Management of Abnormal Uterine Bleeding: An Algorithmic Approach Using the Palm– COEIN Classification

Background: Abnormal uterine bleeding (AUB) is a common gynecological condition affecting women across reproductive age groups and significantly impacting quality of life. To standardize evaluation and management, the International Federation of Gynecology and Obstetrics (FIGO) introduced the PALM–COEIN classification system, categorizing AUB into structural and non-structural etiologies. The “PALM” group includes structural causes—Polyp (AUB-P), Adenomyosis (AUB-A), Leiomyoma (AUB-L), and Malignancy & Hyperplasia (AUBM)—while the “COEIN” group comprises non-structural causes—Coagulopathy (AUB-C), Ovulatory dysfunction (AUB-O), Endometrial causes (AUB-E), Iatrogenic (AUB-I), and not yet classified (AUB-N). An algorithmic approach to AUB begins with a thorough clinical history, assessment of bleeding pattern, pregnancy exclusion, and evaluation of hemodynamic stability. Initial laboratory investigations include complete blood count, thyroid profile, coagulation studies (when indicated), and pregnancy testing. Imaging modalities such as transvaginal ultrasonography serve as first-line diagnostic tools for structural causes, with hysteroscopy and MRI reserved for selected cases. Endometrial sampling is recommended in women over 45 years or those with risk factors for endometrial carcinoma. Management is individualized based on etiology, severity, patient age, fertility desires, and comorbidities. Medical therapy remains first-line for most non-structural causes and includes tranexamic acid, NSAIDs, combined oral contraceptives, cyclic or continuous progestins, and the levonorgestrelreleasing intrauterine system (LNG-IUS). Surgical interventions such as hysteroscopic polypectomy, myomectomy, endometrial ablation, uterine artery embolization, and hysterectomy are reserved for refractory cases or structural pathology. The algorithmic integration of the PALM–COEIN system ensures systematic evaluation, reduces unnecessary interventions, and promotes evidence-based, patient-centered care. Early diagnosis and tailored therapy improve clinical outcomes and enhance quality of life in women with AUB. Conclusion: Abnormal uterine bleeding (AUB) remains a common and clinically significant gynecological problem, particularly among perimenopausal women. The present study of 45 patients demonstrates that structural causes are more prevalent than non-structural causes, with leiomyoma being the most common etiology. Ovulatory dysfunction emerged as the leading non-structural cause. Moderate anemia was frequently associated, emphasizing the need for early diagnosis and timely intervention.