Abnormal Uterine Bleeding (AUB · PALM-COEIN) · Triage

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Acute vs chronic + hemodynamics
   Acute heavy bleeding or chronic? Hemodynamically stable? (Exclude pregnancy first in all women of reproductive age.)
   • Acute heavy bleeding, hemodynamically unstable → Acute unstable → resuscitation + hemostasis
   • Acute bleeding but hemodynamically stable → Acute stable → medical hemostasis + workup
   • Chronic AUB (abnormal most of the last 6 months) → Chronic · PALM-COEIN classification + sampling
2. [End] Acute unstable → resuscitation + hemostasis
   Acute heavy bleeding + hemodynamic instability → resuscitation (fluids/transfusion) + hemostasis: IV conjugated estrogen, high-dose progestin or oral contraceptives, tranexamic acid (TXA); if medical fails → intrauterine balloon tamponade, emergency curettage (diagnostic and therapeutic), uterine artery embolization if needed; investigate the cause once stable.
3. [End] Acute stable → medical hemostasis + workup
   Acute bleeding, stable → medical hemostasis (high-dose estrogen/progestin or COC, TXA, NSAIDs); concurrently assess the cause (TVUS, endometrial sampling if needed); exclude pregnancy.
4. [Decision] Chronic · PALM-COEIN classification + sampling
   PALM-COEIN classification? Meets endometrial sampling indications? (PALM (structural, imaging-visible): Polyp, Adenomyosis, Leiomyoma, Malignancy/atypical hyperplasia; COEIN (non-structural): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not classified. Sampling indications: ≥45 years; or <45 with unopposed estrogen exposure (obesity/PCOS/anovulation), Lynch, tamoxifen; or persistent AUB/medical failure.)
   • Structural (PALM: polyp/adenomyosis/leiomyoma/suspected malignancy) → Structural (PALM) → cause-directed/procedure
   • Non-structural (COEIN: coagulopathy/ovulatory/endometrial/iatrogenic) → Non-structural (COEIN) → cause-directed
   • Meets endometrial sampling indications (≥45 or risk factors or persistent) → Meets indications → endometrial sampling to exclude malignancy
5. [End] Structural (PALM) → cause-directed/procedure
   Structural (PALM) → cause-directed: polyp hysteroscopic resection; fibroid by FIGO type (submucosal hysteroscopic resection, others myomectomy/UAE/hysterectomy as needed); adenomyosis (medical/uterus-sparing surgery/hysterectomy); suspected malignancy/atypia → endometrial sampling and move to the hyperplasia/cancer pathway.
6. [End] Non-structural (COEIN) → cause-directed
   Non-structural (COEIN) → cause-directed: coagulopathy (test for vWD etc., TXA, hematology); ovulatory dysfunction (COC, cyclic progestin, LNG-IUS; PCOS weight loss/metformin); iatrogenic (adjust anticoagulant/hormone/IUD). LNG-IUS and TXA are common first-line measures to reduce flow.
7. [End] Meets indications → endometrial sampling to exclude malignancy
   Meets sampling indications → endometrial biopsy (office or hysteroscopic targeted) to exclude hyperplasia/cancer: especially ≥45 years, or with unopposed estrogen exposure (obesity/PCOS/anovulation), Lynch, tamoxifen, persistent bleeding/medical failure; results guide subsequent treatment.

Source guidelines & references

• Abnormal uterine bleeding classification and management (FIGO PALM-COEIN system; ACOG abnormal uterine bleeding guideline)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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