Etiologies of Postmenopausal Bleeding in Elderly Women using PALM-COEIN Classification

Introduction: Postmenopausal bleeding (PMB) is a kind of abnormal uterine bleeding that has different underlying etiologies as compared to perimenopausal and nonelderly women. The present study was carried out to study the spectrum of underlying etiologies of PMB in an elderly population using PALM-COEIN classification.

This study evaluated the hospital records of 118 elderly women (>60 years) presenting with PMB. Age, obstetric history, menopausal history, duration of complaints, and medical and surgical history were noted. All the patients underwent complete clinical, laboratory, and sonographic evaluations. Cases with suspicious etiology underwent endometrial biopsy. Final diagnosis was made with clinical, sonographic, and histopathological correlation using PALM-COEIN classification. Data were displayed as numbers and percentages or mean ± standard deviation.

The mean age of women was 68.73 ± 5.98 years. The mean time since menopause was 22.30 ± 6.57 years. The mean duration of current complaints was 6.82 ± 7.97 days. PALM (structural) etiologies were ascertained in 99 (83.9%) patients, while COEIN (nonstructural) etiologies were established in 19 (16.1%) women. Adenomyosis (26.3%), polyps (24.6%), and leiomyoma (22.9%) were the common PALM etiologies. Malignancy rate was 10.2%. Nonstructural etiologies were dominated by endometrial causes (9.3%). None of the patients had ovulatory causes.

Elderly patients with PMB had a dominance of structural etiologies. Malignancy rate in these patients was quite high.

Postmenopausal bleeding (PMB) is a significant clinical concern, occurring in approximately 4%–11% of postmenopausal women, with a higher prevalence in those aged 55–65 years. PMB is defined as uterine bleeding after 12 months of amenorrhea in the absence of exogenous hormone therapy. While many causes are benign, PMB warrants thorough evaluation due to its strong association with endometrial cancer, which accounts for 5%–10% of cases.[1-3] The most common cause of PMB is endometrial or vaginal atrophy, responsible for nearly 60%–80% of cases. In postmenopausal women, declining estrogen levels lead to thinning of the endometrial and vaginal epithelium, increasing fragility, and susceptibility to bleeding. Hormone replacement therapy is another frequent contributor, particularly when regimens are unbalanced or improperly monitored.[4] Endometrial polyps, benign localized overgrowths of endometrial tissue, are identified in 10%–15% of cases and are more prevalent with advancing age. In addition, cervical and vaginal cancers or their precursors can manifest as PMB, though these are less common. Uterine fibroids, while more typically associated with premenopausal women, may also degenerate or become a source of bleeding in older patients.[5] Rare but noteworthy causes include systemic coagulopathies and iatrogenic factors such as anticoagulant use. Infections, such as endometritis, though less common in this demographic, may also contribute to PMB.[6] Given the potential for malignancy, prompt evaluation of PMB is crucial. Complete clinical history and vaginal examination including vaginoscopy are done in all patients. Transvaginal ultrasonography serves as a first-line diagnostic tool, assessing endometrial thickness, with a cutoff of ≤4 mm indicating a low likelihood of malignancy. Biopsy remains the gold standard for diagnosing endometrial pathology.[7,8] Comprehensive assessment ensures timely identification of underlying causes, enabling appropriate management and improved outcomes. PALM-COEIN classification, proposed by the International Federation of Gynaecologists and Obstetricians (FIGO), is widely used for classification to describe the etiologies of abnormal uterine bleeding including PMB.[9,10] In this system, PALM refers to structural causes of abnormal uterine bleeding-AUB (polyp, adenomyosis, leiomyoma, and 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.[10] PMB is very important, especially in elderly women, where it is often associated with an increased risk of cancer. In this study, we document our experience of PMB at a specialty hospital in Lucknow and describe the underlying etiologies using FIGO’s PALM-COEIN classification. PATIENTS AND METHODS This study involved review of clinical records of postmenopausal elderly women (aged >60 years; amenorrhea for >1 year) who presented with complaints of PMB from January 2017 to November 2024 at SCT Memorial Mother and Child Trust Hospital, Lucknow. Patients who did not undergo complete investigations and diagnostic workup and those with incomplete records were excluded from the study. For this descriptive study, the sample size estimation was done at 95% confidence at a projected flip-coin probability (P = 0.5) at an estimated precision of 10%. The calculated sample size was 96. During the study period, a total of 118 women fulfilling the eligibility criteria were enrolled. At enrollment, age, parity, clinical symptoms, duration of symptoms, and amount of blood loss were noted. The presence of any associated comorbidities such as hypertension, diabetes, and any history of previous hormonal or operative treatment was recorded. General physical and systemic examination was performed; then, a provisional diagnosis was made. Laboratory investigations such as complete blood count, blood sugar, renal function, thyroid function, liver function, bleeding time, and clotting time were done. Vaginal smear specimen was obtained for cytological study using Pap smear. All women were subjected to sonographic evaluation. Patients with suspected structural diagnosis following clinical, laboratory, and sonographic evaluation underwent endometrial biopsy. Biopsy specimens were evaluated histopathologically. Diagnosis of cause of bleeding was done using PALM-COEIN classification into structural and nonstructural etiologies based on clinicosonographic and pathological correlation. Data analysis The data were analyzed using SPSS 25.0 software (IBM Corp., USA). Categorical data were depicted as numbers and percentages. Central tendency was depicted as mean ± standard deviation. Owing to its noncomparative nature, no tests for hypothesis testing were employed.

The age of patients ranged from 60 to 82 years. The mean age of patients at the time of presentation was 68.73 ± 5.98 years. The mean age at menopause was 46.42 ± 2.70 years. The mean duration of menopausal status was 22.30 ± 6.52 years. The duration of current bleeding complaints ranged from 1 to 63 years. The mean duration was 6.82 ± 7.97 days. There were 27 (22.9%) women with prior/recurrent history of PMB [Table 1]. Age, menstrual history, and duration of complaints (n=118) The mean parity was 2.17 ± 1.41. A history of hypertension, diabetes, thyroid disorder, heart disease, and cerebrovascular disease was positive in 37.3%, 22.9%, 3.4%, 7.6%, and 9.3% of cases, respectively. A total of 18 (15.3%) women had a history of anticoagulant use. Nonobstetric surgical history was reported by 29 (24.6%) cases [Table 2]. On clinical, sonographic, and pathological correlation, majority (n = 99, 83.9%) of the women had structural (PALM) causes, while 19 (16.1%) women were diagnosed to have nonstructural (COEIN) etiologies. Among structural etiologies, the most common was adenomyosis (n = 31; 26.3%), followed by polyps (n = 29; 24.6%), leiomyoma (n = 27; 22.9%), and malignancy (n = 12; 10.2%). Nonstructural (COEIN) causes included endometrial causes (n = 11; 9.3%), coagulopathy (n = 3; 2.5%), not otherwise classified (n = 3; 2.5%), and iatrogenic (n = 2; 1.7%) causes [Table 3]. Etiologies of postmenopausal bleeding as per PALM-COEIN classification

PMB, particularly in women above 60 years of age, is an issue of concern and is often an indicator of structural etiologies. Unlike younger reproductive age group women or perimenopausal women presenting with abnormal uterine bleeding who have a dominance of nonstructural or hormonal etiologies, these women having attained a hormonal equilibrium present with more serious and pathologically concerning etiologies including malignancies.[3,11] Although PALM-COEIN classification is a widely used criteria to describe etiologies of abnormal uterine bleeding for more than a decade, this has remained slightly less commonly used to describe PMB etiologies in elderly women. In the present study, we found a dominance of PALM (structural) etiologies (83.9%) over nonstructural etiologies (16.1%). In their study,[11] however, reported a dominance of endometrial atrophy (61.3%). In another study[3] of PMB reported a dominance of nonstructural etiologies, however, in their study proportion of women in elderly age group was only 37.1% whereas in our study all the women were aged above 60 years. A retrospective data analysis of 499,176 PMB cases aged 50 years or above found a dominance of structural etiologies, including 12.6% cases of leiomyoma, 9.7% benign neoplasms or cysts, 5.1% cervical abnormality, and 8.5% nongynecological cancers.[12] Thus, PMB, particularly in elderly women, has increased the risk of structural abnormalities in general and malignancies in particular. There are almost negligible studies describing etiologies of PMB in elderly women using FIGO’s PALM-COEIN classification. Ours is perhaps the first study reporting it using this classification. There are some studies using PALM-COEIN classification for etiological classification of AUB in perimenopausal women. One such recent study that evaluated 200 perimenoausal women for AUB[13] also found a dominance of PALM component over COEIN component. In their study, leiomyoma (41.5%) and polyps (23%) were the most common PALM etiologies. About 9% of their cases were placed under malignant/hyperplasia etiologies. As such, increase in proportion of hyperplasia/malignant etiologies with increasing age is not abnormal.[14] PMB is an important clinical indicator of increased risk of malignancy or other structural pathologies, especially in elderly women.[15] The findings of the present study also endorse this viewpoint. The present study, thus, showed that the use of PALM-COEIN classification to describe etiologies of PMB in elderly women is feasible. Moreover, the study also showed that elderly women PMB in elderly women should be dealt as a medical emergency as it may reveal some serious underlying etiologies including malignancy. Further studies on a larger sample size are also recommended.

Elderly women with PMB had a dominance of structural etiologies. Malignancy was ascertained as the underlying cause in almost one in every ten elderly women presenting with PMB. The findings of the study indicated that PMB in elderly should be taken under cognizance at the earliest and should be evaluated thoroughly for underlying etiology. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

1. Singh S, Best C, Dunn S, Leyland N, Wolfman WL; Clinical Practice – Gynaecology Committee. Abnormal uterine bleeding in pre-menopausal women. J Obstet Gynaecol Can 2013;35:473-5. 2. Goldstein RB, Bree RL, Benson CB, Benacerraf BR, Bloss JD, Carlos R, et al. Evaluation of the woman with postmenopausal bleeding: Society of radiologists in ultrasound-sponsored consensus conference statement. J Ultrasound Med 2001;20:1025-36. 3. Gopalakrishna N, Fernandes J, Surjan P, Sonti S. Clinicopathological study of postmenopausal bleeding in a tertiary hospital: A retrospective analysis. Int J Reprod Contracept Obstet Gynecol 2022;11:2634-7. 5. Bengtsen MB, Veres K, Nørgaard M. First-time postmenopausal bleeding as a clinical marker of long-term cancer risk: A Danish nationwide cohort study. Br J Cancer 2020;122:445-51. 6. Munro MG; Southern California Permanente Medical Group’s Abnormal Uterine Bleeding Working Group. Investigation of women with postmenopausal uterine bleeding: Clinical practice recommendations. Perm J 2014;18:55-70. 7. Buckley E, Kondagari L. Sonography postmenopausal assessment, protocols, and interpretation. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2024. Available from: https://www.ncbi.nlm.nih.gov/books/NBK570641/. [Last updated on 2023 Jan 16]. 8. ACOG committee opinion no. 734: The role of transvaginal ultrasonography in evaluating the endometrium of women with postmenopausal bleeding. Obstet Gynecol 2018;131:e124-9. 9. 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. FIGO Working Group on Menstrual Disorders. Int J Gynaecol Obstet 2011;113:3-13. 10. Jain V, Munro MG, Critchley HO. Contemporary evaluation of women and girls with abnormal uterine bleeding: FIGO systems 1 and 2. Int J Gynaecol Obstet 2023;162 Suppl 2:29-42. 11. Jo HC, Baek JC, Park JE, Park JK, Cho IA, Choi WJ, et al. Clinicopathologic characteristics and causes of postmenopausal bleeding in older patients. Ann Geriatr Med Res 2018;22:189-93. 12. Xu X, Chen L, Nunez-Smith M, Clark M, Wright JD. Timeliness of diagnostic evaluation for postmenopausal bleeding: A retrospective cohort study using claims data. PLoS One 2023;18:e0289692. 13. Sowmiya DS, Varghese J, Shanmugham D, Nagarajan P. Understanding causes of abnormal uterine bleeding in perimenopausal women: A prospective observational study using the FIGO PALM COEIN classification system. JK Sci 2024;26:236-41. 14. Dumas L, Ring A, Butler J, Kalsi T, Harari D, Banerjee S. Improving outcomes for older women with gynaecological malignancies. Cancer Treat Rev 2016;50:99-108. South Asian Journal of Geriatric Medicine, Surgery, Palliative Care & Hospice1(1):26-29, Jan-Apr 2026. Email to Colleague Colleague's E-mail is Invalid Your Name: Colleague's Email: Separate multiple e-mails with a (;). Message: Thought you might appreciate this item(s) I saw in South Asian Journal of Geriatric Medicine, Surgery, Palliative Care & Hospice. Your message has been successfully sent to your colleague. Some error has occurred while processing your request. Please try after some time. Error Web Part Error: A Web Part or Web Form Control on this Page cannot be displayed or imported. You don't have Add and Customize Pages permissions required to perform this action. Correlation ID: 9e0517a2-e2cc-f0c3-d9ba-ff6467f3ec3d. Thought you might appreciate this item(s) I saw in South Asian Journal of Geriatric Medicine, Surgery, Palliative Care & Hospice. Your message has been successfully sent to your colleague. Some error has occurred while processing your request. Please try after some time. Export to End Note Procite

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