The PALM-COEIN classification (FIGO 2011, updated 2018) for abnormal uterine bleeding (AUB) categorizes causes into structural (PALM) and non-structural (COEIN). A 38-year-old woman has AUB with heavy menstrual bleeding. Hysteroscopy shows no intrauterine pathology; endometrial biopsy shows secretory endometrium. CBC shows platelet count 82,000/µL; prothrombin time and aPTT are normal; ristocetin cofactor assay is decreased. What is the COEIN category, and what is the diagnosis?

• A Ovulatory dysfunction (O) category; anovulatory cycle causing endometrial buildup
• B Endometrial (E) category; primary endometrial hemostatic disorder
• C Iatrogenic (I) category; anticoagulant medication effect
• D Coagulopathy (C) category; von Willebrand disease type 1 (most common inherited bleeding disorder) ✓

Explanation

In the PALM-COEIN classification, 'C' stands for Coagulopathy—inherited or acquired bleeding disorders causing AUB. Decreased ristocetin cofactor activity (measures von Willebrand factor functional activity) in a woman with isolated heavy menstrual bleeding, no anatomical pathology, and normal PT/aPTT (with low-normal or mildly reduced platelets due to enhanced clearance) is diagnostic of von Willebrand disease (vWD). vWD is the most common inherited bleeding disorder (1% of population), and HMB (heavy menstrual bleeding) is often the presenting complaint in women. Type 1 vWD (partial quantitative deficiency) is the most common subtype, accounting for 75% of cases. Treatment includes tranexamic acid, DDAVP (desmopressin), hormonal therapy, or vWF concentrate for severe cases.

Reference: Shaw's Textbook of Gynaecology, 17th ed.

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Written and medically reviewed by the StethoPrep medical team.