Fibroids, polyps and adenomyosis: the PALM-COEIN framework for abnormal uterine bleeding

Abnormal uterine bleeding is a symptom, not a diagnosis, and many different conditions can sit behind it. In 2011 the International Federation of Gynecology and Obstetrics (FIGO) published a two-part system to describe the bleeding and to sort its possible causes, and revised it in 2018. The causes are grouped under the acronym PALM-COEIN: polyp, adenomyosis, leiomyoma (fibroid), malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial disorders, iatrogenic causes, and not yet classified. This article explains how the framework is built, then looks at what studies report about the three best-known structural findings, polyps, fibroids and adenomyosis. A recurring theme is that finding one of these on an image does not by itself show that it is the source of a person's bleeding. ^[1][2][3]

Why a classification system was needed

Before 2011, the vocabulary for abnormal bleeding was inconsistent, and a long list of potential causes could coexist in one person. ^[1] FIGO described the lack of a shared language as an obstacle to clinical care, to teaching, and to the design and interpretation of clinical trials. ^[2][3] System 1 was designed so that older terms such as menorrhagia, menometrorrhagia and dysfunctional uterine bleeding could be retired. ^[3]

The response was a consensus process. FIGO sought international agreement through a Delphi method (structured rounds of expert voting) beginning in 2005, which produced two linked systems. System 1 names the symptoms. System 2 classifies the potential causes. The two were published together in 2011 and revised in 2018. ^[1][2][3]

The authors of the 2011 paper describe a classification that clinicians, investigators and even patients can use to communicate about care and research, developed through an ongoing process. ^[1] That matters for the later sections, because categories have been moved since 2011 ^[3], and some entities are still not placed anywhere ^[3].

System 1: describing the bleeding before naming a cause

System 1 asks four questions about the previous six months. How often does bleeding start (frequency)? How many days does it last (duration)? How much does cycle length vary (regularity)? How heavy is it (flow volume)? It also records whether there is bleeding between periods and, for people using hormonal medications, unscheduled bleeding. ^[3]

The normal limits come from the 5th to 95th percentile of large clinical studies. In the FIGO description, a cycle length of 24 to 38 days is normal, bleeding for up to 8 days is within the normal range, and cycle-to-cycle variation of up to 7 days is normal between ages 26 and 41, with up to 9 days at ages 18 to 25 and 42 to 45. Before age 18 and after age 45, ovulatory disorders are frequent and the norms are less well defined. ^[3]

Flow volume is the one descriptor that is subjective. In System 1 it is classified as normal, light or heavy according to the person's own report. FIGO adopted a definition of heavy menstrual bleeding first published by the UK's National Institute for Health and Care Excellence: excessive menstrual blood loss that interferes with physical, social, emotional or material quality of life. ^[3][4] One review notes that objective measurement of volume is usually reserved for research, and that pictorial blood-loss charts are not recommended for routine clinical use. ^[4]

There is a reason for that caution. In a prospective validation study of 103 women complaining of heavy periods, a pictorial chart score correlated poorly with measured blood loss. ^[7] A later systematic review of nine validation studies found sensitivities from 58% to 97%, specificities from 7.5% to 95.5%, and cutoff scores that ranged from 50 to 185, and concluded that the lack of standardization limits use outside controlled research settings. ^[8]

Why describe the pattern first? The FIGO authors say System 1 works as a gateway to System 2. Regular cycles of normal length suggest that ovulation is occurring, while irregular onset suggests an ovulatory disorder. Bleeding between periods may point to a focal lesion such as a polyp, and may prompt consideration of hyperplasia or malignancy. Heavy bleeding with apparently ovulatory cycles may reflect a problem of local or systemic hemostasis (the body's control of bleeding). Early-cycle spotting may be linked to a cesarean scar defect. ^[3] These are patterns the authors describe as suggestive, and they are starting points for evaluation, not conclusions.

System 2: the PALM-COEIN categories

System 2 divides causes into four structural categories (PALM), four nonstructural categories (COEI), and one holding category (N). ^[3] The structural categories are the ones that can be seen, whether by imaging or by examination of tissue. ^[4] The nonstructural categories concern how blood clots, how ovulation occurs, how the endometrium (the uterine lining) controls its own bleeding, and what medications or devices do to those processes. ^[3]

FIGO's own authors state two cautions in the same paper. First, each cause can occur alone or together with others, and a person can be documented with several, for example leiomyoma, adenomyosis and an ovulatory disorder. Second, polyps, adenomyosis and most fibroids can be present without causing any symptoms, so finding one does not settle the question. Even after a structural finding, the nonstructural causes still need to be considered, because they may be the main contributor. ^[3]

Fibroids carry an additional label in the system. The L category is divided into leiomyomas with at least one submucosal component (LSM, touching the lining of the uterine cavity) and those that do not affect the cavity (Lo). ^[3] The rest of this article follows the order of the acronym for the three structural conditions in the title, then covers the others briefly.

Polyps (AUB-P)

An endometrial polyp is a focal outgrowth of the uterine lining that can contain glands, stroma (supporting tissue) and blood vessels. Polyps vary in size, number and position. Their exact origin and natural history remain unclear, and they are thought to arise from areas of epithelial and stromal overgrowth. ^[3]

How common are polyps?

A Danish study drew a random sample of 1,660 women aged 20 to 74 from the national civil registry. Of those invited, 686 took part, and 619 had a full evaluation with transvaginal ultrasound, saline contrast sonography and, where indicated, hysteroscopic resection with tissue examination. Polyps were found in 7.8% of the women. The proportion rose with age, from 0.9% under age 30 to 5.8% in premenopausal and 11.8% in postmenopausal women overall. ^[17]

Two findings of that study are worth stating plainly. Of the women with tissue-confirmed polyps, 82% had no symptoms. And abnormal bleeding was reported less often by women with polyps than by women without them. ^[17] The authors called this finding surprising. Participation was limited to a minority of those invited, so the figures may not describe every population, and the sample was from a single country.

A study of 714 premenopausal women attending a university hospital gynecology clinic found a different relationship. In that clinic population, polyps were associated with menorrhagia (odds ratio 2.81, 95% confidence interval 1.15 to 11.7). ^[27] The two studies recruited different groups, one from the general population and one from women already seeking gynecologic care, which may explain part of the difference.

An AAGL (American Association of Gynecologic Laparoscopists) practice report adds that polyps may regress on their own, with regression reported in up to 25%, particularly for polyps under 10 millimeters. ^[20] The report is a practice guideline that summarizes the literature rather than a new study.

Polyps and cancer risk

Concern about malignancy is often the reason polyps receive attention, so the numbers matter. A meta-analysis of 17 observational studies of women who had polyps removed reported premalignant or malignant findings in 1.7% of reproductive-age women and 5.42% of postmenopausal women. Among women with bleeding, the figure was 4.15%, compared with 2.16% among those without. ^[18] A later meta-analysis of 51 studies and 35,345 women reported a pooled prevalence of malignant polyps of 2.73%, with 1.12% in premenopausal and 4.93% in postmenopausal women, and 5.14% in symptomatic compared with 1.89% in asymptomatic women. That analysis noted very high heterogeneity between studies. ^[19]

Several limits apply. Both analyses pooled observational studies of women who underwent polyp removal, a group selected by someone having judged removal appropriate. Rates in prospective studies were higher than in retrospective ones in the later analysis. ^[19] The FIGO review summarizes the risk in premenopausal women with symptomatic polyps as approximately 1%, and also notes that the number of participants behind this estimate was small. ^[3] Taken together, the studies report that most polyps are benign and that risk is associated with age, menopausal status and bleeding, but they do not give a precise risk for any individual.

Detecting polyps

On ultrasound, polyps usually appear as hypoechogenic (darker) lesions, and accuracy is higher with contrast, such as saline infused into the cavity, a technique called sonohysterography. ^[3] A meta-analysis of 25 studies comparing the two techniques in the same patients found that transvaginal ultrasound had a pooled sensitivity of 55% and specificity of 91%, while saline contrast sonography had 92% and 93%. ^[22] An earlier study of 106 premenopausal women, using tissue examination after hysterectomy as the reference, found that polyps were missed in 9 of 12 cases on magnetic resonance imaging, 7 on transvaginal ultrasound, 4 on sonohysterography and 2 on hysteroscopy. ^[23] That study was published in 2001 and involved small numbers of lesions, but its pattern is consistent with the later meta-analysis: a polyp that is not seen on a standard scan has not necessarily been excluded.

A critical review of the literature described blind biopsy or curettage as having low diagnostic accuracy for polyps. ^[21] The review also noted that high-quality randomized evidence on diagnosis and management of polyps is scarce. ^[21]

Leiomyomas, or fibroids (AUB-L)

Fibroids are benign tumors made of smooth muscle cells and fibroblasts within a dense extracellular matrix. They are clonal, meaning each arises from a single altered cell, and they vary greatly in size, number, location and symptoms. ^[11]

How common are fibroids?

One often-cited U.S. study screened 1,364 randomly selected women aged 35 to 49 who belonged to an urban health plan. Medical records and self-report established fibroid status in those who no longer menstruated. Premenopausal women were screened by ultrasound whatever their symptoms. Thirty-five percent of premenopausal women had already received a fibroid diagnosis. Among those without a previous diagnosis, 51% had fibroids on ultrasound. The authors estimated cumulative incidence by age 50 at above 80% for Black women and nearly 70% for white women, a difference with an odds ratio of 2.9. ^[9]

A systematic review of 60 publications found incidence reported from 217 to 3,745 cases per 100,000 woman-years and prevalence from 4.5% to 68.6%, with the range depending on study population and diagnostic method. Black race was the only factor repeatedly reported to raise risk, by two to three times compared with white race, though the review identified 11 other factors with effects of similar or greater size, including age, hypertension and family history. ^[10] Another review describes fibroids as more common and more severe among African American women and notes that the causes of that disparity are poorly understood. ^[13] The Nature Reviews review states that Black women tend to develop fibroids earlier and to have more severe disease, and that fibroids account for one-third to one-half of hysterectomies. ^[11]

Those ranges reflect real differences in method. A study that screens everyone with ultrasound counts fibroids that nobody knew about. A study that counts diagnoses counts only those that were looked for. Neither is wrong, and each answers a different question. ^[9][10]

Do fibroids grow?

Fibroids are often described as growing steadily, and the research is more mixed than that. A prospective study followed 262 fibroids in 72 premenopausal women (38 Black and 34 white) with up to four MRI scans over 12 months. The median growth rate was 9% per six months, with a range from a 89% decrease to a 138% increase. Seven percent of fibroids shrank by more than 20%. Fibroids in the same woman grew at different rates, and size did not predict growth rate. ^[12] The sample was small and the follow-up one year, so the study describes short-term behavior in a specific group.

Which fibroids relate to heavy bleeding?

This is the question where the evidence is least settled, and the sources are open about it. The Best Practice & Research review states that the relationship between abnormal uterine bleeding and fibroids remains incompletely understood, that fibroids frequently coexist with abnormal bleeding, and that in many women a fibroid is an incidental finding in someone seeking help for bleeding. ^[4] A narrower paradox follows from the prevalence figures above: many women have fibroids and entirely normal bleeding. ^[4][9]

Studies point in different directions. In a U.S. study of 910 premenopausal women aged 35 to 49 who were screened by ultrasound and interviewed by telephone, women with fibroids (596 of them) were more likely to report gushing bleeding, and the relative risk increased with fibroid size: 1.4 for small fibroids under 2 centimeters, 1.6 for medium, and 1.9 for those over 5 centimeters. Nonsubmucosal fibroids were associated with heavy bleeding to about the same degree as submucosal fibroids of similar size. ^[14] That finding differs from the FIGO emphasis on the submucosal location.

A retrospective study from a tertiary care center included 1,665 premenopausal women with heavy menstrual bleeding who underwent office hysteroscopy, and 15.6% of them had submucosal fibroids. Those seen at hysteroscopy had lower hemoglobin (adjusted difference of 0.35 grams per deciliter) and higher odds of anemia (odds ratio 1.46). For fibroids identified on ultrasound, the difference was not significant after adjustment, and self-reported pictorial chart scores did not differ for either method. The authors suggested that the diagnostic method could explain the inconsistency in earlier literature. ^[15] In the clinic study of 714 women mentioned above, submucous fibroids were associated with menorrhagia (odds ratio 5.60), while the association for fibroids at any location was weaker (1.53, with an interval that included no effect). ^[27]

The FIGO review summarizes these data by saying that only submucosal fibroids appear to be directly linked to objectively measured increases in blood loss, that most fibroids do not appear to contribute to bleeding symptoms, and that the evidence has not distinguished whether Type 3 lesions are included. ^[3] The authors also state that there is a paucity of data on fibroids with no physical link to the endometrium. ^[3] Taken together, these studies suggest that location, size and the measurement method all affect what a study finds, and that the field has not reached a final answer.

How the endometrium may be affected

Proposed biological explanations include changes in the blood vessels near a fibroid and changes in the lining's chemistry. Laboratory studies have found that the endometrium of women with fibroids produces excess transforming growth factor beta 3 in association with reduced levels of several proteins that regulate clot breakdown, which could disturb the lining's control of bleeding. The reviews describe such findings as putative and the exact role of fibroid location as unconfirmed. ^[3][4]

The FIGO fibroid subclassification

The classification sorts fibroids by position relative to the endometrium and the outer surface of the uterus. Types 0, 1 and 2 are submucosal and project into the cavity. Type 3 touches the endometrium without distorting the cavity. Type 4 is intramural, surrounded by muscle. Types 5, 6 and 7 touch the outer (serosal) surface, with Type 7 being pedunculated. Type 8 covers fibroids not connected to the muscle at all, such as those in the cervix. A fibroid touching both surfaces receives two numbers, such as 2-5. ^[3]

Imaging fibroids

The FIGO review gives transvaginal ultrasound a sensitivity of 90% to 99% for fibroids. Sonohysterography can improve accuracy for lesions that involve the cavity. MRI gives more detail on number, location and size, but the review notes that its reliability for distinguishing malignant change remains uncertain. ^[3] In the hysterectomy-based comparison of 106 women, MRI had a sensitivity of 1.0 for submucous fibroids, against 0.83 for transvaginal ultrasound, 0.90 for sonohysterography and 0.82 for hysteroscopy. ^[23]

A 2024 review reports that fibroids affect more than 60% of women aged 30 to 44, that a large proportion are asymptomatic and found by chance, and that roughly 30% affect quality of life, with abnormal bleeding the most common complaint. ^[16] The review summarizes several sources rather than reporting a single study.

Adenomyosis (AUB-A)

Adenomyosis is the presence of endometrium-like glands and stroma within the myometrium (the muscular wall of the uterus), usually surrounded by overgrowth of smooth muscle. How it arises is not settled. Proposed routes include extension from the lining into the muscle, invasion from endometriosis outside the uterus, and origin from stem cells. ^[3]

From a surgical diagnosis to an imaging diagnosis

For many years adenomyosis was diagnosed under the microscope after hysterectomy, typically in perimenopausal women whose bleeding or pain had prompted surgery. A comprehensive review explains that imaging has changed this, so that more women of reproductive age now receive an ultrasound or MRI diagnosis. The same review notes that criteria are not universally agreed, that some women have no symptoms, and that adenomyosis often coexists with endometriosis and fibroids. ^[24]

That history affects every prevalence figure. An epidemiology review points out that studies limited to hysterectomy specimens describe only women who had surgery, which makes valid population estimates difficult. ^[25] A prospective study of 985 consecutive women attending a university hospital gynecology clinic used structured transvaginal ultrasound and found adenomyosis in 206 (20.9%). It was associated with age, number of pregnancies and pelvic endometriosis. In the women who later had a hysterectomy, ultrasound and tissue findings agreed moderately well (kappa 0.62). The authors say their figure is probably higher than in the general population because the clinic's patients had symptoms. ^[26]

Ultrasound features and the idea of a spectrum

Ultrasound features of adenomyosis are described in a consensus system called Morphological Uterus Sonographic Assessment, or MUSA. A 2022 modified Delphi procedure among 16 European experts revised the definitions and separated direct features, which indicate misplaced endometrial tissue in the muscle (such as myometrial cysts, hypoechoic islands, and echogenic lines and buds), from indirect features, which reflect changes in the surrounding muscle (such as a globular uterus, asymmetric wall thickening, fan-shaped shadowing and an irregular junctional zone). ^[3][28] Consensus was reached on most definitions, but not on all, and it was not reached for the definitions of subendometrial lines and buds or the interrupted junctional zone. ^[28]

The FIGO review gives sensitivities for adenomyosis of about 84%, 85% and 94% for two-dimensional, three-dimensional and color Doppler ultrasound, and 88% to 93% for MRI, and recommends thinking of adenomyosis as a spectrum defined by the number and type of features rather than as present or absent. ^[3]

Adenomyosis and heavy bleeding

The clinic study of 714 premenopausal women found adenomyosis on ultrasound in 157 (22.0%). When adenomyosis was treated as present or absent, there was no significant association with menorrhagia. When the number of ultrasound features was counted, each additional feature was associated with 22% more estimated menstrual loss (odds ratio 1.21, 95% confidence interval 1.04 to 1.40). In the same analysis, submucous fibroids and polyps were significantly associated with menorrhagia. ^[27] This is one clinic, one ultrasound protocol and a single year of recruitment, but it illustrates how a yes-or-no label can hide a gradient and why the FIGO authors call for a spectrum approach.

Laboratory findings suggest possible mechanisms, including raised local estrogen activity, altered progesterone response, new blood vessel growth and activation of clotting and fibrinolytic pathways in adenomyotic tissue, but the review states that it is unknown exactly how adenomyosis leads to abnormal bleeding. ^[3]

Adenomyosis alongside fibroids

Because both conditions are common, they often appear together. In a retrospective case-control study of 255 women who had a hysterectomy, 85 had both adenomyosis and fibroids on pathology, and 170 had fibroids alone. Those with both were more likely to have pelvic pain (odds ratio 3.4) and had a smaller fibroid burden. The authors proposed that substantial pain with small fibroids might be associated with coexisting adenomyosis. ^[29] Because it included only women who underwent surgery, and relied on chart review, it cannot show how the two conditions relate in women who did not.

The nonstructural causes (COEI) in brief

Coagulopathy (AUB-C)

Bleeding disorders affect the whole body, and in the FIGO framework they are classified as AUB-C. The most common is von Willebrand disease. ^[3] A systematic review of 11 studies covering 988 women with menorrhagia found von Willebrand disease in 131 of them, an overall prevalence of 13% (95% CI 11 to 15.6%), with individual studies ranging from 5% to 24%. The authors attributed the variation in part to differences in recruitment, methods and the ethnic makeup of the populations studied. ^[30]

FIGO suggests a structured history as a screening step. It describes a screening tool of 90% sensitivity for a coagulation disorder, built on heavy bleeding since the first period combined with features such as postpartum hemorrhage, bleeding with surgery or dental work, frequent bruising or nosebleeds, bleeding gums and a family history of bleeding. ^[3] The American College of Obstetricians and Gynecologists, in its opinion on adolescents with heavy bleeding, states that evaluation should include assessment for anemia from blood loss, for an endocrine disorder causing anovulation, and for a bleeding disorder. ^[31] An international guideline on von Willebrand disease includes recommendations on heavy menstrual bleeding among its 12 recommendations. ^[32]

Ovulatory dysfunction (AUB-O)

Ovulatory disorders range from occasional delayed ovulation to chronic failure to ovulate, and they usually show up as irregular cycles. ^[3] A FIGO classification of ovulatory disorders, published in 2022 after a Delphi process with two face-to-face meetings and five voting rounds, replaced an older system described as more than three decades old. Its main levels are hypothalamic, pituitary and ovarian causes plus polycystic ovary syndrome, abbreviated HyPO-P. ^[33]

Endometrial disorders (AUB-E)

This category is used for people who appear to ovulate and who have heavy bleeding with no other identified cause. The FIGO review is candid that no diagnostic test exists, so the label is presumptive, and it suggests that the category is probably underdiagnosed. Proposed mechanisms include faulty vasoconstriction, altered clot formation and impaired repair of the lining. ^[3] A review of heavy bleeding mechanisms likewise concludes that understanding of menstrual bleeding and its disturbances is incomplete. ^[5]

Iatrogenic causes (AUB-I)

Iatrogenic means caused by a medical intervention. The category includes intrauterine devices, drugs that interfere with clotting, and drugs that interfere with ovulation. Breakthrough bleeding on hormonal medications is recorded within System 1. In the 2018 revision, anticoagulants moved from the coagulopathy category and ovulation-disrupting agents moved from the ovulatory category into the iatrogenic one. ^[3]

Malignancy and hyperplasia (AUB-M)

This category applies when tissue taken from the uterus of a reproductive-age woman with abnormal bleeding shows premalignant change or cancer. It includes atypical endometrial hyperplasia, also called endometrial intraepithelial neoplasia, which is considered a precursor of endometrial cancer. Samples are usually obtained by suction biopsy or under hysteroscopic guidance. ^[3]

Endometrial hyperplasia is a spectrum of changes in the lining, and the atypical forms are regarded as premalignant. A review of classification systems reports that traditional histologic systems have shown wide and varying diagnostic reproducibility, which can make standardized management difficult. ^[34]

For postmenopausal bleeding, a meta-analysis of 129 studies and 40,790 women found that 91% of women with endometrial cancer had experienced postmenopausal bleeding, while the pooled risk of endometrial cancer in women with such bleeding was 9%, ranging from 5% in North America to 13% in Western Europe. The authors concluded that most women with postmenopausal bleeding will not be diagnosed with endometrial cancer. ^[35] The FIGO framework itself is written for the reproductive years, and age shapes how it is applied. The FIGO authors give the example that a 19-year-old with presumed ovulatory dysfunction may not need hysteroscopy or imaging, whereas a 49-year-old with a similar history may. ^[3]

Not yet classified (AUB-N)

The N category holds entities that are rare, whose relationship to bleeding is unclear, or that are not covered elsewhere. At present it includes uterine arteriovenous malformations and cesarean scar defects. ^[3] A systematic review and meta-analysis of 60 studies found that people with a scar defect were more likely to have abnormal bleeding (relative risk 3.47, six studies, 1,385 patients), with a characteristic pattern of prolonged menstruation and early-cycle bleeding between periods. The prevalence of abnormal bleeding among those with a defect ranged from 25.5% in people with at least one cesarean delivery to 76.4% in those who were referred for imaging for a gynecologic reason, and heterogeneity was high. The authors argued that scar defects deserve a place of their own in classification systems. ^[36] The N category illustrates the point that the system is expected to change.

Heavy bleeding, iron and the burden that goes unreported

FIGO authors single out heavy menstrual bleeding as the symptom that contributes most to iron deficiency and anemia. They also say the condition is underrecognized and underreported, that surveys suggest more than half of reproductive-age women may experience abnormal bleeding, and that social taboos around menstruation may contribute. ^[3] Estimates differ with the method. One review reports that heavy bleeding affects 14% to 25% of women of reproductive age. ^[4] An internet survey of 4,506 women in five European countries found that 27.2% had experienced two or more predefined heavy-bleeding symptoms in the past year. Of these, 46.0% had never consulted a doctor. Among 330 women who completed a detailed survey, 208 (63.0%) had at some time been diagnosed with iron deficiency or iron deficiency anemia. ^[6] The survey was self-reported and web-based, so it reflects women who respond to online surveys.

What this does not tell you

This article describes a classification and the studies behind it. It cannot say what is causing any individual person's bleeding, and no part of it should be read as a diagnosis or a recommendation about tests or treatment. Several limits are worth keeping in mind.

A finding on an image is not the same as a cause. The FIGO authors say that polyps, adenomyosis and most fibroids may be asymptomatic and unrelated to a person's symptoms. ^[3] A normal scan is also not the same as the absence of a lesion, since studies show that ultrasound and even MRI miss some polyps. ^[22][23]

Percentages depend on who was studied and how. Fibroid prevalence of 4.5% to 68.6%, adenomyosis prevalence of about 21% in a clinic, and polyp prevalence of 7.8% in a registry-based sample are answers to different questions. ^[10][17][26] Many studies reported here come from North America, Europe or a single center, and some include only women who had surgery. ^{[9][15][27][29]}

The percentages for racial groups in fibroid research describe average differences between groups in particular studies. They do not predict anything about an individual, and the reasons for the differences are not established. ^[10][13]

Evidence on how fibroids, adenomyosis and polyps cause bleeding is incomplete. Reviews describe the mechanisms as putative or unknown, and several note that diagnostic tests for some categories do not exist. ^[3][4][5]

Symptoms, imaging, hysteroscopy and pathology answer different questions. A reported bleeding pattern, a scan, a camera view inside the cavity, and tissue under the microscope are separate kinds of evidence, and the framework asks readers to keep them apart. The classification is a tool for description and research that is expected to be revised. ^[1][3]

References

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