異常子宮出血（AUB · PALM-COEIN）

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1. 【判断】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 血行動態安定 → Acute stable → medical hemostasis + workup
   • Chronic AUB (abnormal most of the last 6 months) → Chronic · PALM-COEIN classification + sampling
2. 【終点】Acute unstable → resuscitation + hemostasis
   Acute heavy 出血 + hemodynamic instability → 蘇生 (輸液/輸血) + hemostasis: IV conjugated estrogen, high-dose progestinまたは経口 contraceptives, tranexamic acid (TXA);の場合medical fails → intrauterine balloon tamponade, emergency curettage (diagnostic・therapeutic), uterine artery 塞栓術の場合needed; investigate the cause once stable.
3. 【終点】Acute stable → medical hemostasis + workup
   異常子宮出血（AUB · PALM-COEIN）の当該分岐。適応・禁忌を確認し、最新ガイドラインと施設プロトコルに沿って実施。必要時専門医に相談。
4. 【判断】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. 【終点】Structural (PALM) → cause-directed/procedure
   Structural (PALM) → cause-directed: polyp hysteroscopic 切除; fibroidによりFIGO type (submucosal hysteroscopic 切除, others 筋腫核出/UAE/子宮全摘 as needed); adenomyosis (medical/uterus-sparing 手術/子宮全摘); suspected malignancy/atypia → endometrial sampling・moveへthe hyperplasia/cancer pathway.
6. 【終点】Non-structural (COEIN) → cause-directed
   異常子宮出血（AUB · PALM-COEIN）の当該分岐。適応・禁忌を確認し、最新ガイドラインと施設プロトコルに沿って実施。必要時専門医に相談。
7. 【終点】Meets indications → endometrial sampling to exclude malignancy
   Meets sampling 適応s → endometrial 生検 (officeまたはhysteroscopic targeted)へexclude hyperplasia/がん: especially ≥45 年,または〜あり unopposed estrogen exposure (obesity/PCOS/anovulation), Lynch, tamoxifen, persiステント 出血/medical failure; results guide subsequent treatment.