A Clinicopathological Correlation of International Federation of Gynecology and Obstetrics's PALM-COEIN Classification of Abnormal Uterine Bleeding: Indian Scenario

Abstract

Background: Abnormal uterine bleeding (AUB) is a common problem affecting the women of reproductive age group and may also have a significant impact on their physical, social, and emotional aspects directly affecting their quality of life. The International Federation of Gynecology and Obstetrics (FIGO) devised a universally acceptable system of nomenclature and classification, namely PALM-COEIN classification of AUB in the year 2011. The objective of the present study was to analyze the structural (PALM) and functional (COEIN) component of FIGO system in the Indian scenario.

Materials and methods: Three hundred patients with complaints of AUB were taken. A clinical diagnosis according to PALM-COEIN system was made after thorough history and clinical examination. Additional investigations if required were done, and endometrial sampling or hysterectomy was done whichever indicated. A histological diagnosis was made, and each case was allocated a category according to PALM-COEIN classification. A clinicopathological correlation was done in the hysterectomy cases for structural causes (PALM).

Results: Leiomyoma (30%) was the most common cause of AUB closely followed by adenomyosis (29.66%) overall. The clinicopathological correlation in hysterectomy cases was good with concordance rate of 85.03%. The concordance between clinical and pathological diagnoses for AUB-L, AUB-A, AUB-M, and AUB-A, L was statistically significant with P < 05 in positive cases. However, additional finding of adenomyosis was diagnosed in 48.2% of the cases apart from primary clinical diagnosis.

Conclusion: A good clinicopathological correlation was seen in the cases when classified according to PALM-COEIN classification. The system also provides for consideration of multiple etiologies contributing toward AUB both clinically and histopathologically. However, histopathology remains the cornerstone in establishing the accurate diagnosis as the cases without specific symptoms can be missed clinically.

Keywords: Abnormal uterine bleeding; FIGO; Hysterectomy; PALM–COEIN.

Figure 1

Distribution of cases according to endometrial findings

Figure 2

Distribution of cases in abnormal uterine bleeding-M category

Figure 3

(a) A polyp lined on all sides by columnar epithelium and glands with dilated blood vessels in the stromal matrix (H and E, ×40), (b) adenomyosis with endometrial glands and stroma in the myometrium (H and E, ×40), (c) leiomyoma with a capsule and interlacing smooth muscle bundles (H and E, ×40)

Figure 4

(a) Simple hyperplasia with back-to-back arrangement of endometrial glands (H and E ×100), (b) endometrioid carcinoma with nuclear stratification and cells with high nucleus-cytoplasm ratio and vesicular chromatin (H and E, ×100)

Figure 5

Graphic representation of clinicopathological correlation of PALM component in hysterectomy cases