Abnormal Uterine Bleeding

Gynecology Update

Follow The Female Patient on and The Female Patient | VOL 37 JULY/AUGUST 2012 27

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Abnormal uterine bleeding (AUB) is defi ned as an alter-ation in the volume, pattern, and/or duration of men-strual blood fl ow and is the

most common reason for gynecologic re-ferrals.1 Over the past 10 years it has be-come increasingly clear that many of the terms used to describe disturbances in menstruation are ill defi ned and confus-ing.1-4 This lack of standardized and un-ambiguous terminology has led to dif-fi culties in developing and interpreting

research and creating evidence-based protocols to manage patients suffering with AUB.3

In February of 2005, an interest group of 35 physician and scientific experts in menstrual disorders met to develop recommendations for uniform termi-

Abnormal Uterine BleedingNew Defi nitions and Contemporary TerminologyArturo Garza-Cavazos, MD; J. Ricardo Loret de Mola, MD

Dr Garza-Cavazos is Fellow, Minimally Invasive and Robotic Surgery, Department of Obstetrics and Gynecology, Southern Illinois University, Springfi eld, IL. Dr Loret de Mola is Chairman, Department of Obstetrics and Gynecology, Southern Illinois University, Springfi eld, IL.

The updated terminologies, defi nitions, and classifi cations of abnormal uterine bleeding have received international acceptance and should facilitate future clinical research. Not only are these revisions expected to improve communication among clinicians around the world, but they should also simplify communication between clinicians and patients.

Abnormal Uterine Bleeding: New Defi nitions and Contemporary Terminology

28 The Female Patient | VOL 37 JULY/AUGUST 2012 All articles are available online at www.femalepatient.com

nologies and defi nitions related to AUB for international use.2-4 The meeting in-volved a multistage process that began with an assessment of how terms de-scribing abnormal bleeding have been defi ned and used to date. This led to an

excellent review on historical and cur-rent terminology and definitions for AUB published in 2008 that confi rmed the inconsistent and confusing nature of the clinical terminology pertaining to menstrual disorders.4

The next step was the organization of a Delphi panel to recommend defi nitions and terminologies with potential for in-ternational agreement. The Delphi panel approach is a nominal group process designed to elicit opinions on a clearly defi ned topic and has been used exten-sively to develop clinical guidelines on such topics as coronary revasculariza-tion, hysterectomy, and colonoscopy.3

The panelists concluded that English language terminologies with Greek or Latin roots are poorly defi ned and cre-ate ambiguity in meaning and usage. As a result, the panelists recommended that much of the current terminology be discarded (Table 1) and replaced by simple descriptive terms that could be understood by patients and translated into most languages (Tables 2 and 3).5-7

Another outcome of the Delphi panel was an agreement to establish an ongo-ing study group, and the International Federation of Gynecology and Obstet-rics (FIGO) was identifi ed as the most appropriate body to provide supervision

TABLE 1. Recommendations for Discarded Terminologya

Menorrhagia Polymenorrhea Uterine hemorrhage

Hypermenorrhea Polymenorrhagia Dysfunctional uterine bleeding

Hypomenorrhea Epimenorrhea Functional uterine bleeding

Menometrorrhagia Epimenorrhagia Metropathica hemorrhagica

a Data from Woolcock et al.4

TABLE 2. Accepted Abbreviations Describing Menstrual Symptomsa

AUB Abnormal uterine bleeding

HMB Heavy menstrual bleeding

HPMB Heavy and prolonged menstrual bleeding

IMB Intermenstrual bleeding

PMB Postmenopausal bleedinga Adapted with permission from Fraser et al.7

TABLE 3. Recommended Normal Limits for Four Key Menstrual Dimensions (Mid-Reproductive Years)a

Clinical Dimensions of Menstruation and Menstrual Cycle Cycle Descriptive Termsa Normal Limits (5th95th percentiles)

Frequency of menses (days) Frequent < 24

Normal 2438

Infrequent > 38

Regularity of menses, cycle to cycle variation over 12 months (days)

Absent No bleedingRegular Variation 220

Irregular Variation > 20 days

Duration of fl ow (days) Prolonged > 8.0Normal 4.58.0

Shortened < 4.5a Adapted from Fraser et al.7

Garza-Cavazos and Loret de Mola

The Female Patient | VOL 37 JULY/AUGUST 2012 29

Recommended Terminology, Defi nitions, and Classifi cations of Symptoms of Abnormal Uterine Bleedinga

Disturbances of Regularity

Irregular Menstrual Bleeding (IrregMB): Bleeding of > 20 days in individual cycle lengths over a period of 1 year.

Absent Menstrual Bleeding (amenorrhea): No bleeding in a 90-day period. It was recommended that the term amenorrhea be retained because there is little controversy in its use or defi nition.

Disturbances in Frequency

Infrequent Menstrual Bleeding (oligomenorrhea): one or two episodes in a 90-day period. It is recommended that the term oligomenorrhea be abolished.

Frequent Menstrual Bleeding: More than four episodes in a 90-day period (frequent menstruation, not erratic intermenstrual bleeding).

Disturbances of Heaviness of Flow

Heavy Menstrual Bleeding (HMB): Excessive menstrual blood loss that interferes with the womans physical, emotional, social, and material quality of life and can occur alone or in combination with other symptoms. The most common presentation of AUB.

Heavy and Prolonged Menstrual Bleeding (HPMB): Less common than HMB. It is important to make a distinction from HMB given they may have different etiologies and respond to different therapies.

Light Menstrual Bleeding: Based on patient complaint, rarely related to pathology.

Disturbance of the Duration of Flow

Prolonged Menstrual Bleeding: Menstrual periods exceeding 8 days in duration on a regular basis, it is commonly associated with heavy menstrual bleeding.

Shortened Menstrual Bleeding: Uncommon, defi ned as bleeding of no longer than 2 days.

Irregular Nonmenstrual Bleeding

Irregular episodes of bleeding, often light and short, occurring between normal menstrual periods. Mostly associated with benign or malignant structural lesions, may occur during or following sexual intercourse.

Bleeding Outside Reproductive Age

Postmenopausal Bleeding (PMB): Bleeding occurring > 1 year after the acknowledged menopause.

Precocious Menstruation: Usually associated with other signs of precocious puberty, occurring before 9 years of age.

Acute AUB

An episode of bleeding in a woman of reproductive age, who is not pregnant, of suffi cient quantity to require immediate intervention to prevent further blood loss.

Chronic AUB

Bleeding from the uterine corpus that is abnormal in duration, volume, and/or frequency and has been present for the majority of the last 6 months.

Patterns of Bleeding

The shape of the volume of the bleeding pattern over the days of one menstrual period. It is usually recognized that about 90% of the total menstrual fl ow is lost within the fi rst 3 days of the cycle, with day 1 or 2 the heaviest. In women with AUB this pattern is variable.a Adapted with permission from Fraser et al.7


30 The Female Patient | VOL 37 JULY/AUGUST 2012

and international credibility. This led to the formation of the FIGO Menstrual Disorders Group in 2006.6 After several important publications, the group met for a pre-congress workshop prior to the FIGO World Congress of Gynecology and Obstetrics in October 2009 to review the recommendations.7 The recommenda-tions were then presented for approval through an audience responder system at the FIGO World Congress and were met with a high level of acceptance.7

The Washington Meeting in 2005 also discussed a future classifi cation system for AUB with a primary objective of de-veloping an ongoing process with inter-national debate.5 The FIGO Menstrual Disorders Group developed an agree-ment protocol to recommend a clear and simple classifi cation system having the potential for wide acceptance.6 The sys-tem was developed with contributions from an international group of both clinical and nonclinical investigators from 17 countries.6,7 The result was the designation of the PALM-COEIN Classi-fi cation System, which stratifi es causes of AUB into nine basic categories and a fi nal grouping reserved for causes yet to be classifi ed (see box).6,8

The components of the PALM group are defi ned by visually objective struc-tural criteria. In contrast, the COEI is unrelated to structural anomalies. The N group, for entities not yet classifi ed, allows for the addition and modifi cation of existing classifi cation as new fi ndings on AUB become available and facilitates

the current or subsequent development of subclassifi cation systems.6,8

Components of the PALM-COEIN Classifi cation System Polyps (AUB-P)Endometrial polyps are a common gy-necologic condition associated with symptoms of AUB.8 Abnormal vaginal bleeding is the most common present-ing symptom of endometrial polyps and accounts for all causes of abnormal vag-inal bleeding in 39% and 21% to 28% of pre- and postmenopausal women, respectively.9

Polyps are categorized as either pres-ent or absent in the basic classifi cation system. The primary diagnostic ap-proaches include noninvasive trans-vaginal ultrasonography (TVUS), with or without 3D imaging and contrast.9 However, other imaging techniques, such as saline infusion sonography and hysteroscopic imaging with or without histopathology, may be employed.6 Hys-teroscopic resection should be used for histopathology.9

There is potential in this category to develop a subclassifi cation based on vari-ables that include size, location, number, morphology, and histology. It is impor-tant to exclude polypoid-appearing en-dometrium from this category since this fi nding may be a normal variant.6

Adenomyosis (AUB-A)Approximately 70% of patients with ad-enomyosis have symptoms of AUB; 30% have symptoms of dysmenorrhea; and 19% present with both.10 Traditionally, diagnosis has been established with histopathology after hysterectomy; how-ever, because adenomyosis can be ac-curately detected with ultrasound and magnetic resonance imaging (MRI), the FIGO system calls for the use of diag-nostic imaging.6,10 Given the limited ac-cess to MRI in some communities, it has been further proposed that ultrasound imaging criteria comprise the minimum requirements for assigning a diagnosis of adenomyosis.6

The PALM-COEIN Classifi cation System for Causes of Abnormal Uterine Bleedinga

Polyps (AUB-P) Coagulopathy (AUB-C)

Adenomyosis (AUB-A) Ovulatory disorders (AUB-O)

Leiomyoma (AUB-L) Submucosal/Other Endometrial (AUB-E)Malignancy (AUB-M) Iatrogenic (AUB-I)

Not classifi ed (AUB-N)a Adapted with permission from Munro et al.6



Leiomyomas (AUB-L)Uterine fi broids are the most common benign tumor of the female genital tract. Age is the most common risk factor, and recent longitudinal studies have esti-mated the lifetime risk in women over the age of 45 to be more than 60%. Race also contributes to risk: the estimated incidence rates of fi broids by age 50 is greater than 80% in African-American women and 70% in white women. The age-specifi c incidence of fi broids in Af-rican-American women is 2 to 3 times more than white women.11,12 Additional factors associated with increased inci-dence are nulliparity, cigarette smok-ing, and a prolonged menstrual cycle. Fibroids originate from a single cell (the monoclonal origin); however, candidate genes for common uterine fi broids have not yet been identifi ed. Uterine fi broids

can also increase the risk for infertility depending on their location, with sub-mucosal fibroids increasing both the risks for infertility and AUB.

Primary, secondary, and tertiary clas-sifi cation systems have been submitted. Like the classifi cation system for endo-metrial polyps, the primary classifi ca-tion system for leiomyomas refl ects only the presence or absence of one or more leiomyomas, regardless of location, num-ber, or size. In the secondary system, dif-ferentiation of leiomyomas that are sub-mucosal (SM) from others (O) is required

because of the higher association of AUB with submucosal lesions. The tertiary system is based on an adopted design by the European Society for Human Repro-duction and Embryology for subendome-trial or submucosal leiomyomas, which includes categorization of intramural and subserosal leiomyomas. Important-ly, the tertiary system has great potential for both research and clinical use.6,8

Malignancy (AUB-M)The primary symptom of endometri-al neoplasia is AUB, which typically prompts an endometrial biopsy to rule out endometrial carcinoma, the most common gynecologic malignancy in the United States. Approximately 70% of postmenopausal women with abnor-mal uterine bleeding are diagnosed with benign fi ndings, 15% with endometrial hyperplasia, and 15% with endome-trial carcinoma. Although the risk of endometrial carcinoma is much lower in women of reproductive age, endo-metrial evaluation is recommended for those at high risk, such women with chronic anovulation, obesity, Lynch syn-drome, or diabetes mellitus. Because one of the most common risk factors, obesity, is epidemic in the United States and es-calating worldwide,13,14 the international incidence of endometrial carcinoma is expected to increase in the coming years.

There are two different subtypes of en-dometrial carcinoma: estrogen-related type 1 (endometrioid), which comprises 70% to 80% of newly diagnosed cases, and nonestrogen-related type 2 (eg, papil-lary serous and clear cell). Type 1 is relat-ed to unopposed estrogen stimulation of the endometrium. Progesterone inhibits estrogen-induced proliferation and hy-perplasia by inducing glandular secreto-ry activity and decidual transformation of stromal fibroblasts; these secretory cells are then shed during withdrawal bleeding. Hormonal contraceptives, com-bined or progesterone only, reduce the risk of endometrial carcinoma.15

The widely used World Health Orga-nization (WHO) system classifi es endo-

FOCUSPOINTIn the secondary system, differentiation of leiomyomas that are submucosal from others is required because of the higher association of AUB with submucosal lesions.



metrial hyperplasia according to four combinations of glandular crowding and nuclear atypia: simple, complex, simple atypical hyperplasia, or complex atypical hyperplasia, although the two atypical hyperplasias are often classifi ed as one. Approximately 50% of women diagnosed with endometrial hyperplasia have con-current carcinoma. Emerging data indi-cate that the long-term risk of developing endometrial carcinoma among women with simple or complex hyperplasia is less than 5%, but the risk in atypical hy-perplasias is approximately 30%.16

The classifi cation system is not meant to replace the WHO and FIGO systems for categorizing hyperplasia or neoplasia. In-stead it has been proposed that premalig-nant and malignant lesions be classifi ed as AUB-M and then subclassifi ed using the appropriate WHO or FIGO system.6

Coagulopathies (AUB-C)It is important that coagulopathies are included in the classification system given that it has been demonstrated that 13% of women with heavy menstrual bleeding (HMB) have a disorder of he-mostasis that may be overlooked during the differential diagnosis. Testing for co-agulopathies should be conducted dur-ing the workup, and the history should include simple questions to screen for the presence of hemostasis disorders.6

Ovulatory Dysfunction (AUB-O)Patients in this category will mostly pres-ent with unpredictable menses with vari-able fl ow, and most are associated with endocrinopathies, such as polycystic ova-ry syndrome or hypothyroidism. As with coagulopathies, ancillary testing should be included in the diagnostic process of patients of ovulatory dysfunction.6,8

Endometrial Causes (AUB-E)Most patients in this category will have regular cycles, normal ovulation, and no defi nable cause of AUB. If this is the case, patients will likely present with HMB, which may indicate a disorder of endometrial hemostasis. Other patients

may present with intermenstrual bleed-ing (IMB), which may be secondary to inflammation, infection, or abnormal infl ammatory response. Currently, more research is needed to defi ne conditions in this category, which should be diag-nosed by exclusion.6,8

Iatrogenic (AUB-I)This category refers to AUB associated with the use of IUDs or exogenous gonad-al steroids and other systemic agents that affect blood coagulation or ovulation.6,8

Not Yet Classifi ed (AUB-N)This category is reserved for entities that are poorly defi ned and/or not well examined. Examples include arteriove-nous malformation and myometrial hy-pertrophy. With more evidence, entities such as these will likely be placed into a new or existing category.6,8

NotationA notation approach has also been de-signed to enable categorization, which should be especially useful to special-ists and researchers. Because a patient may be found to have more than one po-tential entity contributing to symptoms of AUB, this method addresses all com-ponents and is similar to the WHO TNM method of staging tumors.

For example, if a patient is found to have endometrial hyperplasia and ovu-lation dysfunction with no other abnor-malities, she would be categorized as follows: AUB P0 A0 L0 M1 C0 O1 E0 I0

FOCUSPOINTThe updated terminologies, defi nitions,

and classifi cations of AUB have received international acceptance and should

facilitate future clinical research.



N0, with an option to abbreviate as AUB-M;O. If uterine fibroids were present, they would be categorized as AUB L1(SM) or L1(O), depending on the location of the leiomyoma. A tertiary classifi cation of leiomyomas, which is not discussed here, can be added to further classify the location of the leiomyoma.6,8

AssessmentPatients with chronic AUB should un-dergo a structured history and evaluation to determine the underlying factor or fac-tors contributing to this disorder (see fl ow chart). As discussed, women with AUB may have no, one, or multiple identifi able factors from the FIGO system. The history

AUB

Chronic

Detailed HistoryMedical History

Medications

AncillaryTesting

OvulationFunction

AUB O, I, C, and/or E

Acute

PhysicalExam

UterineEvaluation

Risk ofMalignancy

NormalAUB L, P, or A

AUB E or O

AUB M

TVUS EndometrialBiopsy

FIGURE. Flow Chart for Evaluation of Abnormal Uterine Bleeding (AUB). Keep in mind that saline infusion sonography, hysteroscopy, or MRI might be required to diagnose a target lesion after an abnormal transvaginal ultrasonography (TVUS). AUB category abbreviations: A, adenomyosis; C, coagulopathy; E, endometrial; I, iatrogenic; L, leiomyoma; M, malignancy; N, not classifi ed; O, ovulatory disorders; P, polyps. Adapted with permission from Munro et al.6



should determine ovulatory status, po-tentially related medical disorders, cur-rent medications, a screen for disorders of hemostasis, and fertility desires of the patient. Ancillary testing should include hemoglobin and/or hematocrit, and test-ing for conditions that could contribute to ovulatory dysfunction.

Uterine evaluation is guided by the history and examination. An endome-trial biopsy is warranted for those pa-tients with increased risk of hyperpla-sia or malignancy. Those patients with risk of a structural anomaly or who have failed medical management should un-dergo imaging with at least a screening TVUS. Saline infused sonography, hys-teroscopy, MRI, (and/or) hysteroscopy with or without biopsy should be used as indicated if neither TVUS nor endo-

metrial biopsy is diagnostic or further workup is required.6,8

Conclusion The updated terminologies, defi nitions, and classifi cations of AUB have received international acceptance and should fa-cilitate future clinical research. Not only are these revisions expected to improve communication between clinicians around the world, but they should also simplify communication between clini-cians and patients. Importantly, all defi -nitions and classifi cations are subject to ongoing review and future development by the established FIGO Menstrual Dis-orders Working Group. This process will address remaining controversies pertaining to AUB terminology and pro-vide a scheduled systematic review of

Coding for Abnormal Uterine Bleeding Philip N. Eskew Jr, MD

This article reviews and evaluates the current terminology associated with the condition of abnormal uterine bleeding and makes several recommendations for changes. However, as you will see from the ICD-9 codes, many of their suggestions are already included in the additional defi nitions of the appropriate codes. Many of the suggestions might be included in the ICD-10 changes that may be implemented in 2014. For this discussion, the ICD-9 codes mentioned in this article are:

Dr Eskew is past member, Current Procedural Terminology (CPT) Editorial Panel; past member, CPT Advisory Committee; past chair, ACOG Coding and Nomenclature Committee; and instructor, CPT coding and documentation courses and seminars.

626 Disorders of menstruation and other abnormal bleeding from female genital tract

626.0 Amenorrhea (primary) (secondary)626.1 Scanty or infrequent menstruation,

Hypomenorrhea, Oligomenorrhea626.2 Excessive or frequent menstruation, Heavy periods,

Menorrhagia, Menometrorrhagia, Polymenorrhea626.4 Irregular menstrual cycle, Irregular bleeding,

Irregular menstruation, Irregular periods626.5 Ovulation bleeding, Regular intermenstrual

bleeding626.6 Metrorrhagia, Bleeding unrelated to menstrual

cycle, Irregular intermenstrual bleeding626.8 Dysfunctional or functional uterine hemorrhage627.1 Postmenopausal bleeding621.0 Polyp of corpus uteri, Endometrium, Uterus617.0 Endometriosis of uterus, Adenomyosis625.3 Dysmenorrhea, Painful menstruation 218.0 Submucous leiomyoma of uterus218.1 Intramural leiomyoma of uterus218.2 Subserous leiomyoma of uterus

218.9 Leiomyoma of uterus, unspecifi ed182.0 Malignant neoplasm of body of uterus,

endometrium621.30 Endometrial hyperplasia, unspecifi ed621.31 Simple endometrial hyperplasia without atypia621.32 Complex endometrial hyperplasia without atypia621.33 Endometrial hyperplasia with atypia621.34 Benign endometrial hyperplasia

The procedures mentioned in this article have the following CPT codes:58100 Endometrial sampling (biopsy) with or without

endocervical sampling (biopsy), without cervical dilation, any method (separate procedure)

58555 Hysteroscopy, diagnostic (separate procedure)58558 Hysteroscopy, surgical; with sampling (biopsy)

of endometrium and/or polypectomy, with or without D & C

76830 Ultrasound, transvaginal76831 Saline infusion sonohysterography (SIS), including

color fl ow Doppler, when performed



the classifi cation system, allowing for ongoing revisions as recommended.

The authors report no actual or potential confl icts of interest in relation to this article.

References 1. Rahn DD, Abed H, Sung VW, et al. Systematic review

highlights diffi culty interpreting diverse clinical outcomes in abnormal uterine bleeding trials. J Clin Epidemiol. 2011;64(3): 293-300.

2. Fraser IS, Critchley HO, Munro MG. Abnormal uterine bleeding: getting our terminology straight. Curr Opin Obstet Gynecol. 2007;19(6):591-595.

3. Critchley HO, Munro MG, Broder M, Fraser IS. A fi ve-year international review process concerning terminologies, defi nitions, and related issues around abnormal uterine bleeding. Semin Reprod Med. 2011;29(5):377-382.

4. Woolcock JG, Critchley HO, Munro MG, Broder MS, Fraser IS. Review of the confusion in current and historical terminology and defi nitions for disturbances of menstrual bleeding. Fertil Steril.2008;90(6): 2269-2280.

5. Fraser I, Critchley HO, Munro M, Broder M. A process designed to lead to international agreement on termi-nologies and defi nitions used to describe abnormalities of menstrual bleeding. Fertil Steril. 2007;87(3):466-476.

6. Munro M, Critchley HO, Fraser I. The FIGO classifi cation of causes of abnormal uterine bleeding in the reproductive years. Fertil Steril. 2011;95(7):2204-2208.

7. Fraser IS, Critchley HO, Broder M, Munro MG. The FIGO recommendations on terminologies and defi nitions for normal and abnormal uterine bleeding. Semin Reprod

Med. 2011;29(5):383-390. 8. Munro MG, Critchley HO, Broder MS, Fraser IS. FIGO clas-

sifi cation system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet. 2011;113(1):3-13.

9. Salim S, Won H, Nesbitt-Hawes E, Campbell N, Abbott J. Diagnosis and management of endometrial polyps: a critical review of the literature. J Minim Invasive Gynecol. 2011;18(5):569-581.

10. Garcia L, Isaacson K. Adenomyosis: review of the litera-ture. J Minim Invasive Gynecol. 2011;18(4):428-437.

11. Baird DD, Dunson DB, Hill MC, Cousins D, Schectman JM. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol. 2003;188(1):100-107.

12. Templeman C, Marshall SF, Clarke CA, et al. Risk factors for surgically removed fi broids in a large cohort of teach-ers. Feril Steril. 2009;92(4):1436-1446.

13. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity in the United States, 20092010. NCHS data brief, no 82. Hyattsville, MD: National Center for Health Statistics. 2012.

14. Berghofer A, Pischon T, Reinhold T, Apovian CM, Sharma AM, Willich SN. Obesity prevalence from a European perspective: a systematic review. BMC Public Health. 2008;8:200.

15. Mueck AO, Seeger H, Rabe T. Hormonal contraception and risk of endometrial cancer: a systematic review. Endocr Relat Cancer. 2010;17(4):R263-271.

16. Lacey JV, Sherman ME, Rush BB, et al. Absolute risk of endometrial carcinoma during 20-year follow-up among women with endometrial hyperplasia. J Clinic Oncol. 2010;28(5):788-792.

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