Introduction
This booklet is intended as a practical guide to patient care for registrars, medical officers, interns and medical students attached to the gynaecology units at the University of the Witwatersrand Academic Hospitals. Anyone can use it.
Causes of excessive vaginal bleeding
Excessive vaginal bleeding is a common complaint, frequently caused by a multi-fibroid uterus. Not all such women have significant bleeding. At times, this complaint may represent a plea for investigation of another problem, such as infertility. It is important to take a complete history.
DEFINITIONS – there have been some changes
(the first two terms on the left are to be abandoned for the terms on the right)
| Menorrhagia | heavy regular menstruation |
| Metro-menorrhagia | heavy irregular bleeding |
| Inter-menstrual bleeding | bleeding between regular periods |
| Post-coital bleeding | self explanatory |
| Normal menstruation | duration: 2-7 days, cycle: 21-35days (WHO definition) |
All unusual bleeding patterns are referred to as ‘Abnormal Uterine bleeding’ - AUB
Causes of excessive vaginal bleeding
- Gynaecological
- Fibroid uterus
- Cervical or endometrial malignancy & hyperplasia
- Adenomyosis
- Endometrial, cervical polyp
- Endometritis – PID
- Vaginal injury
- General
- Clotting disorder, e.g. von Willebrand’s disease – very rare
- Hypothyroidism – rare
- Pregnancy
- Miscarriage
- Secondary postpartum haemorrhage
- Iatrogenic
- Anticoagulants
- Contraception, e.g. injectable progestin or intrauterine device
- ‘Dysfunctional uterine bleeding’ – i.e. heavy bleeding with no easily identified cause & obviously normal anatomy in the reproductive age group….is now called AUB-N (‘Not yet specified’)
The Palm Coein System
The PALM COEIN system for classifying abnormal uterine bleeding was introduced by FIGO (the international gynaecological body) in 2010. It is an acronym.
PALM COEIN: ‘Structural causes’ (Polyps, Adenomyosis, Leiomyomas, Malignancy and hyperplasia), and ‘Non-structural causes’ (Coagulopathy, Ovulation disorders, Endometrial local disorders of haemostasis, Iatrogenic, Not yet specified. The system is open to further readjustment and includes causes (e.g. Endometrial) not fully understood, as well as the acknowledged uncertainty of ‘Not yet specified’. This classification may, in time, be changed.