The FIGO Recommendations on Terminologies and Definitions for Normal and Abnormal Uterine Bleeding Ian S. Fraser, M.D.,1 Hilary O.D. Critchley, M.D.,2 Michael Broder, M.D.,3 and Malcolm G. Munro, M.D.4 ABSTRACT Over the past 5 years there has been a major international discussion aimed at reaching agreement on the use of well-defined terminologies to describe the normal limits and range of abnormalities related to patterns of uterine bleeding. This article builds on concepts previously presented, which include the abandonment of long-used, ill-defined, and confusing English-language terms of Latin and Greek origin, such as menorrhagia and metrorrhagia. The term dysfunctional uterine bleeding should also be discarded. Alternative terms and concepts have been proposed and defined. The terminologies and definitions described here have been comprehensively reviewed and have received wide acceptance as a basis both for routine clinical practice and for comparative research studies. It is anticipated that these terminologies and definitions will be reviewed again on a regular basis through the International Federation of Gynecology and Obstetrics Menstrual Disorders Working Group. KEYWORDS: Menstruation, menstrual cycle, abnormal uterine bleeding Over the past decade it has become abundantly two trials performed in the United States/Canada and clear that many terms used to describe menstrual symp- Europe/Australia (Clinical Trials.gov identifiers toms and causes of abnormal menstrual bleeding are ill NCT00293059 and NCT00307801) were set up sepa- Downloaded by: University of California. Copyrighted material. defined and confusing.1–4 This situation has led to rately, primarily because of difficulties in defining the difficulties in interpreting the scientific and clinical study populations using current terminologies.5,6 literature, in reaching agreement on the use of various A formal initiative was established with an inter- therapies, and in the establishment of acceptable clinical national workshop in Washington, D.C., in 2005,7 trials. Indeed, two phase 3 clinical trials on management which primarily addressed the most obvious and con- of heavy menstrual bleeding with a novel estradiol-based fusing of issues around terminologies, definitions, and oral contraceptive, using identical protocols, have just classifications of abnormal uterine bleeding but also been completed on opposite sides of the Atlantic. These addressed issues that were less prominent at that time. 1Department of Obstetrics and Gynaecology, University of Sydney, An International Perspective on Abnormal Uterine Bleeding; Guest Camperdown, Australia; 2MRC Centre for Reproductive Health, The Editors, Ian S. Fraser, M.D., Hilary O.D. Critchley, M.D., and University of Edinburgh, The Queen’s Medical Research Institute, Malcolm G. Munro, M.D. Edinburgh, United Kingdom; 3Partnership for Health Analytic Re- Semin Reprod Med 2011;29:383–390. Copyright # 2011 by search, LLC, Beverly Hills, California; 4Department of Obstetrics and Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, Gynecology, David Geffen School of Medicine, University of Cal- NY 10001, USA. Tel: +1(212) 584-4662. ifornia, Los Angeles, California. DOI: http://dx.doi.org/10.1055/s-0031-1287662. Address for correspondence and reprint requests: Ian S. Fraser, ISSN 1526-8004. M.D., Department of Obstetrics and Gynaecology, University of Sydney, NSW 2006, Australia (e-mail: ian.fraser@syndney. edu.au). 383 384 SEMINARS IN REPRODUCTIVE MEDICINE/VOLUME 29, NUMBER 5 2011 These additional issues included quality of life and The recommendations presented here are the obvious patient-based considerations; cultural issues, result of an extensive discussion and testing process but and controversies around investigations and manage- should still be regarded as a flexible living document, ment. scheduled for future review through the FIGO Men- A high level of agreement on terminologies was strual Disorders Working Group and sessions at FIGO obtained following extensive discussion and use of an World Congresses. audience keypad responder system. It was strongly If these recommendations continue to meet with recommended that poorly defined and confusing ter- wide approval, it is hoped they will be steadily incorpo- minologies such as menorrhagia, metrorrhagia,anddys- rated into daily professional and community use and be functional uterine bleeding be abandoned.2,3 In their translated into other languages. Journal editors will be place should be substituted clear and simple terms encouraged to offer guidelines for the use of these that women and men in the general community could terminologies and definitions in submitted articles. understand and could be easily translated into other languages. These terms should be defined, and ideally the definitions should be based on statistics derived RECOMMENDATIONS ON from population studies. TERMINOLOGIES These initial discussions and publications were followed by lectures, teleconferences, and the establish- Terminologies That Should Be Discarded ment of the International Federation of Gynecology and Extensive international discussions have strongly recom- Obstetrics (FIGO) Menstrual Disorders Working mended that certain terminologies be abandoned be- Group. Members of this group met again for a Pre- cause of their controversial, confusing, and poorly Congress Workshop immediately prior to the FIGO defined usage (Table 1).2–4 These terminologies partic- World Congress of Gynecology and Obstetrics in Cape ularly include several English-language terms with Latin Town in October 2009 and reviewed a series of recom- and Greek origins: mendations, which are described here. Many of these recommendations were posed as questions through an ‘‘Menorrhagia’’ is confusingly used as a symptom and audience responder system to a large multicultural audi- diagnosis. ence at a symposium on ‘‘Abnormal Uterine Bleeding’’ ‘‘Metrorrhagia’’ is poorly defined. within the main scientific program of the FIGO World Most other terms of Latin and Greek origin are Congress. These audience responses are addressed in recommended to be abandoned as listed in Table 1. 8 detail in the article by Munro et al in this issue. A further term strongly recommended to be abandoned is dysfunctional uterine bleeding (DUB), which was first used in 1935, never clearly defined,4 and is METHODOLOGY variably used as a symptom and a diagnosis.2–4 It has The methodology behind the recommendations pre- mostly been used as a diagnosis of exclusion where the 2,3,7 sented here has been described in detail elsewhere. underlying pathology has not been defined, but these Briefly, this involved prereading of a series of discussion documents and the answering of a series of questions Downloaded by: University of California. Copyrighted material. 9 Table 1 Menstrual Terminologies That Recent before the workshop in a Delphi process by the partic- Agreement Indicates Should Be Discarded4 ipants in the Washington Expert Workshop in 2005. Menorrhagia (all usages, including ‘‘essential menorrhagia,’’ These issues were then addressed in detailed discussions ‘‘idiopathic menorrhagia,’’ ‘‘primary menorrhagia,’’ and the questions revisited using an audience responder ‘‘functional menorrhagia,’’ ‘‘ovulatory or anovulatory system, in the Delphi process manner. The recommen- menorrhagia’’) dations received a high level of agreement. Subsequently Metrorrhagia these recommendations were published (with simulta- Hypermenorrhea neous publication in Fertility and Sterility and Human Hypomenorrhea Reproduction),2,3 and they were also tested in presenta- Menometrorrhagia tions at international meetings. Several areas of uncer- Polymenorrhea tainty were specifically addressed during discussions by a Polymenorrhagia multicultural Working Group at the FIGO Cape Town Epimenorrhea Congress. This Working Group also assisted in design- Epimenorrhagia ing questions to test the acceptability of the recom- Metropathica hemorrhagica mended terminologies, definitions, and classifications Uterine hemorrhage with a large multicultural audience in the Congress on Dysfunctional uterine bleeding Abnormal Uterine Bleeding Symposium using the Functional uterine bleeding Audience Responder System.8 FIGO RECOMMENDATIONS ON MENSTRUAL TERMINOLOGY/FRASER ET AL 385 underlying mechanisms are being increasingly re- determining a definition is challenging. Using the pub- searched and defined.10 Hence it is now recommended lished data from several population studies (2,3) gives a that the diagnoses encompassed within dysfunctional definition of >20 days in individual cycle lengths over a uterine bleeding can be classified11 under three definable period of 1 year, which is the definition we prefer. A very headings: (1) disorders of endometrial origin (disturban- detailed analysis of the largest single database gives a ces of the molecular mechanisms responsible for regu- definition of ‘‘a range of varying lengths of bleeding-free lation of the volume of blood lost at menstruation); (2) intervals exceeding 17 days within one 90-day reference disorders of the hypothalamic-pituitary-ovarian axis; period.’’2,13 These data include women of varying ages and (3) disorders of hemostasis (the ‘‘coagulopathies’’). but with no known pathology or hormonal therapy. The These three groups of diagnoses are sometimes referred databases undoubtedly include women with polycystic to as ‘‘nonstructural’’ causes of abnormal uterine bleeding ovaries but no formal diagnosis of polycystic ovary (AUB).12 syndrome. Absent menstrual