Here is a bank of analytical questions you can use in an integrated teaching session on Abnormal Uterine Bleeding (AUB). They are organised by domain to reflect the multi-system integration that makes AUB an ideal topic for this format.

Q1. A 28-year-old woman with regular 28-day cycles presents with heavy menstrual bleeding lasting 9 days and blood loss estimated at 120 mL per cycle. Using the normal parameters for the menstrual cycle (24-38 day interval, 4-8 day duration, <80 mL blood loss), explain how the interplay between estrogen and progesterone normally limits endometrial shedding - and what happens when this balance is disrupted.

Expected integration: HPO axis, corpus luteum function, progesterone withdrawal, endometrial spiral artery vasoconstriction.

Q2. Anovulation leads to unopposed estrogen. Trace the pathophysiological sequence from absent ovulation to heavy, irregular uterine bleeding. Why does this pattern differ from the predictable, cyclic bleeding of a normal period?

Expected integration: Ovulation physiology, corpus luteum failure, endometrial proliferation without secretory transformation, fragile endometrial vasculature.

Q3. A 42-year-old woman is found to have a submucosal fibroid on ultrasound. Explain why the location of a fibroid (submucosal vs. intramural vs. subserosal) determines whether it causes AUB - and why submucosal fibroids are disproportionately associated with heavy menstrual bleeding compared with subserosal ones of the same size.

Expected integration: Leiomyoma histology, distortion of endometrial surface area, impaired contractility of the myometrium, angiogenesis.

Q4. A 50-year-old obese woman presents with intermenstrual bleeding. You are considering endometrial biopsy. Construct a risk-stratified argument: which patients under 45 still require biopsy, and why is obesity a specific red flag for endometrial hyperplasia/malignancy?

Expected integration: Peripheral aromatization of androgens to estrogen in adipose tissue, unopposed estrogen → endometrial hyperplasia → carcinoma sequence, Lynch syndrome risk.

Q5. A 16-year-old girl presents with heavy bleeding at menarche requiring hospitalization. Her mother also reports heavy periods. What haematological diagnosis must you exclude, how would you investigate for it, and how does the mechanism of bleeding in von Willebrand disease differ from that of a structural uterine cause?

Expected integration: Von Willebrand disease (present in up to 13% of AUB cases per Rosen's Emergency Medicine), platelet plug formation, primary vs. secondary haemostasis, menorrhagia since menarche as a red-flag pattern.

Q6. A patient on anticoagulation therapy for a DVT develops heavy uterine bleeding. Using the PALM-COEIN framework, classify this cause and outline the pharmacological dilemma you face in managing her AUB without compromising her anticoagulation.

Expected integration: Iatrogenic category (I in COEIN), risk-benefit analysis of anticoagulant reversal, role of tranexamic acid, hormonal haemostasis, haematology-gynaecology co-management.

Q7. A 32-year-old woman with AUB and oligomenorrhoea is found to have a TSH of 12 mIU/L. Explain the mechanism by which hypothyroidism causes AUB, linking thyroid hormone deficiency to menstrual cycle disruption at both the central (HPO axis) and peripheral (coagulation/endometrial) levels.

Expected integration: Thyroid hormone effects on SHBG, anovulation secondary to TRH-driven hyperprolactinaemia, coagulation factor deficiencies in hypothyroidism, initial workup labs (TSH, prolactin) for AUB.

Q8. Polycystic ovary syndrome (PCOS) is a common cause of AUB via ovulatory dysfunction. A 26-year-old with PCOS has not had a period in 4 months and now presents with heavy bleeding. Why is she at risk for endometrial hyperplasia despite being only 26, and what is the pathophysiological link between insulin resistance and anovulation in PCOS?

Expected integration: Insulin-IGF1 axis, androgen excess, anovulation, chronic unopposed estrogen, endometrial proliferation without progesterone-driven secretory transformation.

Q9. For a 35-year-old woman with AUB secondary to ovulatory dysfunction who does not desire pregnancy, compare the mechanisms of action of: (a) the levonorgestrel IUD, (b) combined oral contraceptive pills, and (c) tranexamic acid - as medical treatments for AUB. Under what clinical circumstances would each be preferred over the others?

Expected integration: LNG-IUD - local progestogenic decidualization and endometrial atrophy; COCPs - systemic HPO suppression; tranexamic acid - antifibrinolytic, no hormonal effect, ideal for women who cannot use hormones.

Q10. A hemodynamically unstable patient arrives in the emergency department with acute AUB and a haemoglobin of 6.5 g/dL. Using a stepwise, integrated approach: (a) what is your immediate resuscitative priority, (b) what pharmacological agent can rapidly reduce uterine bleeding while awaiting specialist review, and (c) under what conditions would you escalate to surgical management?

Expected integration: IV high-dose conjugated oestrogen or IV tranexamic acid for acute haemostasis, resuscitation principles, escalation to hysteroscopic resection / endometrial ablation / hysterectomy based on haemodynamic stability, fertility wishes, and failed medical therapy - as per ACOG guidance.

Q11. You are given this single clinical fact: "A 55-year-old postmenopausal woman presents with vaginal bleeding." Explain why this scenario is categorically different from AUB in a reproductive-age woman, why the PALM-COEIN system does not apply here, and construct your differential diagnosis in order of clinical priority.

Expected integration: Postmenopausal bleeding as a separate entity, endometrial atrophy as the most common cause, but endometrial carcinoma must be excluded first, role of transvaginal ultrasound endometrial thickness measurement (<4 mm reassuring), mandatory endometrial sampling.

Q12. The PALM-COEIN classification replaced older terms like "menorrhagia," "metrorrhagia," and "dysfunctional uterine bleeding." Critically evaluate why this shift was made. What was the clinical problem with the old descriptive terminology, and how does a cause-based classification improve patient management decisions?

Expected integration: Descriptive terms describe the pattern but not the etiology; cause-based classification directs targeted investigation and treatment; avoids treating a fibroid patient the same as a coagulopathy patient.

These questions are designed to push beyond recall and require students to synthesize pathophysiology, pharmacology, diagnostics, and clinical management - the core goal of integrated teaching. You can use them as case triggers, small-group discussion starters, or OSCE-style written stations.