4: PALM-COEIN

Question 1

T/F Ovulatory abnormal bleeding tends to be cyclic and regular, although the bleeding patterns are often abnormal. The HPOA is intact and the steroid hormone profile is normal in ovulatory AUB.

Answer 1

True. This type of AUB is generally related to prolonged, heavy bleeding. It is commonly associated with AUB-P, AUB-A, and AUB-L. It can also be associated with AUB-C and AUB-E.

Question 2

Women with PCOS often experience _____ bleeding because of chronic anovulation.

Answer 2

Women with PCOS often experience estrogen breakthrough bleeding because of chronic anovulation.

Question 3

T/F There are no diagnostic tests that clinicians can use to confirm the presence of AUB-E; rather, it is a diagnosis of exclusion.

Answer 3

True

Question 4

It usually occurs in a predictive and cyclical manner and includes heavy menstrual bleeding. It can also present with intermenstrual or prolonged bleeding patterns.

Answer 4

Endometrial (AUB-E)

Question 5

What does PALM-COEIN stand for?

Answer 5

• Polyps (AUB-P)
• Adenomyosis (AUB-A)
• Leiomyoma (AUB-L)
• Malignancy and hyperplasia (AUB-M)
• Coagulopathy (AUB-C)
• Ovulatory dysfunction (AUB-O)
• Endometrial (AUB-E)
• Iatrogenic (AUB-I)
• Not yet classified (AUB-N)

Question 6

Estrogen levels increase the thickness of the endometrium; thus women with high sustained levels of estrogen tend to experience the _____ menstrual bleeding.

Answer 6

Estrogen levels increase the thickness of the endometrium; thus women with high sustained levels of estrogen tend to experience the heaviest menstrual bleeding.

Question 7

3 months without a menses once menses has been established.

Answer 7

Secondary amenorrhea

Question 8

Bleeding associated with these often occurs after sex.

Answer 8

Endocervical polyps (AUB-P)

Question 9

This condition is generally caused by one of three hormonal imbalances: estrogen withdrawal, estrogen breakthrough, or progesterone breakthrough.

Answer 9

Anovulatory uterine bleeding (AUB-O)

Question 10

The predominant predisposing factor for this condition is more than one pregnancy as well as history of miscarriage, curettage, endometrial resection, cesarean section, or tamoxifen use.

Answer 10

Adenomyosis (AUB-A)

Question 11

In PALM-COEIN, which half describes structural criteria and which half is unrelated to structural criteria?

Answer 11

• PALM = structural
• COEIN = nonstructural

Question 12

Rare in women of reproductive age and in women who have a normal body mass index (BMI) and who do not have polycystic ovarian syndrome (PCOS).

Answer 12

Malignancy and atypical hyperplasia (AUB-M)

Question 13

T/F Ultrasonography and occasionally magnetic resonance imaging (MRI) have been used to detect the severity of the adenomyosis, which may include uterine enlargement. It is proposed that ultrasound evaluation meets the minimum requirements for diagnosis, as MRI diagnosis is not readily available worldwide.

Answer 13

True

Question 14

How are polyps classified within the FIGO system?

Answer 14

Present or not present

Question 15

Which women have the highest risk for amenorrhea?

Answer 15

Women with a low BMI and low percentage of body fat combined with a high level of intensive physical activity have the highest risk for amenorrhea.

Question 16

This category encompasses many different presentations of AUB, including amenorrhea as well as light or heavy menses that can be more frequent, less frequent, or occurring in regular menstrual patterns.

Answer 16

Ovulatory dysfunction (AUB-O)

Question 17

T/F Anovulation in PCOS can be caused by insulin resistance.

Answer 17

True. Diseases or syndromes causing insulin resistance, such as PCOS, increase circulating levels of insulin, which in turn leads to an elevation in androgen production and concomitant anovulation.

Question 18

Caused by medications or devices that act on the endometrium.

Answer 18

Iatrogenic (AUB-I)

Question 19

The Mirena, Skyla, Liletta, and Paragard intrauterine systems can cause irregular spotting and bleeding after placement, although this phenomenon usually resolves within 3 to 6 months after the device’s placement. What category is this?

Answer 19

Iatrogenic (AUB-I)

Question 20

Antidepressant therapies including the _____ and _____ can cause AUB-I related to a disturbance in the HPOA.

Answer 20

Antidepressant therapies including the tricyclics and phenothiazines can cause AUB-I related to a disturbance in the HPOA.

Question 21

Primary classification is present or not. Secondary classification gives location within the uterus.

Answer 21

Leiomyomas (AUB-L)

Question 22

Infections, such as _____ and _____, may cause irregular spotting due to irritation and inflammation of the tissues of the cervix or endometrium.

Answer 22

Infections, such as gonorrhea and endometritis, may cause irregular spotting due to irritation and inflammation of the tissues of the cervix or endometrium.

Question 23

Which inheritable clotting disorder is more commonly found in coagulopathies?

Answer 23

von Willebrand’s disease

Question 24

It can involve a premature release of blood from the endometrium or disorders of local endometrial hemostasis.

Answer 24

Endometrium (AUB-E)

Question 25

What is the pathophysiology of exercise-induced amenorrhea?

Answer 25

The pathophysiology of exercise-induced amenorrhea is complex and most likely due to the combination of low body fat and diminished secretion of GnRH. Lower GnRH levels result in fewer luteinizing hormone (LH) and follicle-stimulating hormone (FSH) pulses, which in turn decreases the amount of estrogen produced by the ovaries. The critical weight theory hypothesizes that some critical weight and amount of body fat exist that must be maintained for women to experience regular menstrual cycles.

Question 26

Absence of menses.

Answer 26

Amenorrhea (AUB-O)

Question 27

Normal menstrual function requires that what four anatomic and structural components are in working order?

Answer 27

1. Uterus
2. Ovary
3. Pituitary
4. Hypothalamus

Question 28

It is important to determine if the leiomyoma interferes with the _____ (submucosal), because this type is most likely to cause AUB. The “other” category includes subserosal and intramural leiomyomas.

Answer 28

It is important to determine if the leiomyoma interferes with the endometrium (submucosal), because this type is most likely to cause AUB. The “other” category includes subserosal and intramural leiomyomas.

Question 29

Commonly occurring, benign growths on the endocervix.

Answer 29

Endocervical polyps (AUB-P)

Question 30

Smooth, deep to bright red growths that are fragile and bleed with little encouragement during examination.

Answer 30

Endocervical polyps (AUB-P)

Question 31

T/F Tertiary classification of leiomyomas includes size.

Answer 31

False. There is currently not a tertiary system and size is not included elsewhere.

Question 32

New name for a category that used to be called dysfunctional uterine bleeding.

Answer 32

Ovulatory dysfunction (AUB-O)

Question 33

Amenorrhea associated with elevated prolactin levels is due to prolactin inhibition of the pulsatile secretion of _____.

Answer 33

Amenorrhea associated with elevated prolactin levels is due to prolactin inhibition of the pulsatile secretion of gonadotropin-releasing hormone (GnRH).

Question 34

Encompass a wide range of blood clotting disorders that can potentially cause AUB.

Answer 34

Coagulopathies (AUB-C)

Question 35

Would anticoag meds that contribute to bleeding be considered AUB-I or AUB-C?

Answer 35

Although this type of bleeding could be considered iatrogenic in nature, it is still termed AUB-C because of the rationale (coagulopathy disorder) for the drug therapy.

Question 36

This type of AUB is sometimes seen in women using progestin-only pills or other forms of progestin-only contraception. Heavy and/or irregular bleeding results from an imbalance in both the vasoconstricting and vasodilating properties of prostaglandins and platelet aggregation and inhibition. The abnormal microvasculature is probably the cause of the abnormal bleeding that results from this phenomenon.

Answer 36

Progesterone breakthrough bleeding

Question 37

When does ovulatory dysfunction bleeding (AUB-O) typically occur?

Answer 37

It is typically observed in the post-adolescent years and during the premenopausal years.

Question 38

In contrast to the typically regular, predictable bleeding experienced with ovulatory cycles, this frequently leads to abnormal cycle intervals, excessively heavy bleeding, or lighter than normal amounts of bleeding.

Answer 38

Anovulatory uterine bleeding (AUB-O)

Question 39

By definition, the anovulatory woman is always in the _____ phase of the ovarian cycle and in the _____ phase of the endometrial cycle.

Answer 39

By definition, the anovulatory woman is always in the follicular phase of the ovarian cycle and in the proliferative phase of the endometrial cycle.

Question 40

Rarely, these polyps can resemble atypical or cancerous cells.

Answer 40

Endometrial polyps (AUB-P)

Question 41

Fibroids or fibromuscular benign tumors in the myometrium.

Answer 41

Leiomyomas (AUB-L)

Question 42

Approximately one-third of women with elevated prolactin levels will also have _____.

Answer 42

Approximately one-third of women with elevated prolactin levels will also have galactorrhea.

Question 43

Name the 3 subcategories for AUB-O.

Answer 43

1. Anovulatory uterine bleeding
2. Amenorrhea
3. Ovulatory uterine bleeding

Question 44

Common condition that rarely affects women who are multiparous and older than age 40.

Answer 44

Adenomyosis (AUB-A)

Question 45

The most common benign pelvic tumors in women and the leading indication for hysterectomy.

Answer 45

Leiomyomas (AUB-L)

Question 46

T/F the PALM-COEIN AUB system is meant to replace the oncology staging system only within conditions that relate to abnormal uterine bleeding.

Answer 46

False. It is not meant to replace the system at all, but to work with it. Oncology ratings are subclassifications of the PALM-COEIN rating.

Question 47

Evidence from histologic and molecular studies suggests that this is the result of an increased density of abnormal vessels that have a fragile structure prone to focal rupture, which is then followed by the release of lysosomes (proteolytic enzymes) from surrounding epithelial and stromal cells and migratory leukocytes and macrophages

Answer 47

Anovulatory uterine bleeding (AUB-O)

Question 48

3 most common causes of amenorrhea.

Answer 48

1. Pregnancy
2. Hypothalmic amenorrhea
3. PCOS

Question 49

Small areas of endometrial tissue within the myometrium.

Answer 49

Adenomyosis (AUB-A)

Question 50

Although infection is not thoroughly discussed, _____ has been found to be associated with endometritis, which can produce intermenstrual bleeding as observed with AUB-E.

Answer 50

Although infection is not thoroughly discussed, Chlamydia trachomatis has been found to be associated with endometritis, which can produce intermenstrual bleeding as observed with AUB-E.

Question 51

If you see any of these 3 criteria, you should evaluate for amenorrhea.

Answer 51

1. No menses by age 14 in the absence of growth or development of secondary sexual characteristics
2. No menses by age 16 regardless of the presence of normal growth and development of secondary sexual characteristics
3. In women who have menstruated previously, no menses for an interval of time equivalent to a total of at least three previous cycles, or 6 months

Question 52

The failure to begin menses by the age of 16.

Answer 52

Primary amenorrhea

Question 53

Benign growths of the endometrium consisting of connective, glandular, or muscular tissue; they are usually asymptomatic, but are generally thought to contribute to AUB in some women.

Answer 53

Endometrial polyps (AUB-P)

Question 54

_____, one of the disorders of AUB-O, occurs significantly less often than abnormal bleeding due to anovulation.

Answer 54

Ovulatory AUB, one of the disorders of AUB-O, occurs significantly less often than abnormal bleeding due to anovulation.

Question 55

This type of bleeding tends to be heavy secondary to the high and sustained levels of unopposed estrogen that can result in endometrial hyperplasia.

Answer 55

Anovulatory uterine bleeding (AUB-O)

Question 56

T/F Women who have leiomyomas generally have no symptoms and do not require treatment, although depending on their locations within the uterus the fibroids may have the potential to contribute to AUB.

Answer 56

True

Question 57

A unique tissue that releases blood as a part of normal physiology.

Answer 57

Endometrium

Question 58

T/F White blood cells are involved in endometrial hemostasis very marginally at the time of menstruation.

Answer 58

False. Platelets are involved in endometrial hemostasis very marginally at the time of menstruation.

Question 59

This category may be used when possible causes of AUB, other than those previously mentioned, are being explored.

Answer 59

Not yet classified (AUB-N)

Question 60

Women presenting with complaint of heavy menstrual bleeding who have history of easy bruising and prolonged bleeding following dental work or surgery warrant further follow-up for _____.

Answer 60

Women presenting with complaint of heavy menstrual bleeding who have history of easy bruising and prolonged bleeding following dental work or surgery warrant further follow-up for von Willebrand’s disease.

Question 61

T/F Many cases of AUB-O stem from endocrinopathies including thyroid disorders, polycystic ovarian syndrome, excessive exercise, or extreme mental distress.

Answer 61

True