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OG23.1-3,OG24.1,OG25.1 | Puberty and Menstrual Disorders — Assignment
CLINICAL SCENARIO
Abnormal uterine bleeding (AUB) and amenorrhoea are among the most frequent presenting complaints in gynaecological outpatient practice. The FIGO PALM-COEIN classification (2011, updated 2018) replaced legacy terminology with a structured, aetiologically driven framework that directly guides investigation and management. This assignment requires you to apply the PALM-COEIN system to two clinical scenarios — one involving AUB and one involving secondary amenorrhoea — and demonstrate your ability to reason through differential diagnosis, systematic investigation, and evidence-based management.
Instructions
Read both clinical scenarios carefully. For each scenario, complete the analysis sections outlined in the scaffolding below. Your response should demonstrate clinical reasoning, not just knowledge recall. Use the FIGO PALM-COEIN framework explicitly when classifying AUB, and the compartment-based aetiology framework for amenorrhoea. Reference standard Indian/international guidelines (DC Dutta's Obstetrics and Gynaecology, FOGSI guidelines, NICE guideline NG88) where relevant. Do NOT use the phrase 'dysfunctional uterine bleeding' — this term has been superseded by the FIGO classification.
Length: 1000–1500 words total (approximately 400–500 words per scenario + 200–300 words for the comparative reflection).
What to Submit
SCENARIO A — Classification and Initial Management of AUB
Guidance: Scenario: Mrs PK, a 40-year-old nulliparous woman, presents with 8 months of heavy, irregular menstrual bleeding. Her cycles were previously regular (every 28 days, 5 days duration) but are now every 14–45 days, lasting 8–12 days, with passage of clots. She has no intermenstrual or post-coital bleeding. Her BMI is 32, she has mild hirsutism, and a fasting glucose of 6.3 mmol/L. Transvaginal ultrasound shows: uterus 9 × 6 × 7 cm, homogeneous endometrium 11 mm (day 8 of a 35-day cycle), bilateral polycystic ovaries (12 follicles per ovary, ovarian volume 11 mL each). FSH 5.2 IU/L, LH 14.3 IU/L, testosterone mildly elevated, prolactin normal. In this section: (1) Classify this patient's bleeding using the FIGO PALM-COEIN system — identify which categories apply and explain your reasoning. (2) List additional investigations needed and justify each. (3) Outline your initial management plan, addressing both the bleeding and the underlying disorder, including your choice of first-line treatment and contraceptive implications.
SCENARIO B — Systematic Workup of Secondary Amenorrhoea
Guidance: Scenario: Ms RV, a 24-year-old, presents with 7 months of secondary amenorrhoea after stopping the combined oral contraceptive pill. She had regular periods before starting the pill at age 19. She is an avid long-distance runner (60–70 km/week), BMI 18.2, no galactorrhoea, no hot flushes. On examination: normal secondary sexual characteristics, no thyroid abnormality, no visual field defect. Investigations: beta-hCG negative; FSH 4.1 IU/L, LH 3.6 IU/L, oestradiol low; prolactin normal; TFTs normal; progesterone challenge test negative (no withdrawal bleed). In this section: (1) Identify the compartment responsible for her amenorrhoea using the compartment-based aetiology framework. Justify your answer with the hormonal and clinical evidence. (2) Interpret the negative progesterone challenge — what does it and does NOT tell you here? (3) Outline the management approach, including lifestyle modifications and any hormonal treatment with its rationale.
Comparison and Critical Reflection
Guidance: In this section: (1) Compare the two cases — how does the FIGO classification in Scenario A differ mechanistically from the compartment localisation in Scenario B? What do these frameworks have in common? (2) Identify one clinical or ethical consideration in either case that you found challenging, and explain how you reasoned through it. (3) Identify one factual point in your analysis where you were uncertain and state what further reading or reference you used to verify it.
Grading Rubric — PALM-COEIN and Amenorrhoea Workup Rubric
| Criterion | Points | Full-marks descriptor |
|---|---|---|
| Correct FIGO PALM-COEIN classification and reasoning (Scenario A) | 30 pts | Correctly identifies AUB-O as the primary category; correctly notes the structural ultrasound findings do not constitute AUB-L (no fibroids) or AUB-P; explicitly links PCOS (anovulation, LH:FSH ratio >2, hyperandrogenaemia, BMI) to the ovulatory dysfunction mechanism; notes AUB-M must be excluded given the endometrial thickness and risk factors; demonstrates full understanding of the PALM-COEIN structure. |
| Compartment-based amenorrhoea workup and progesterone challenge interpretation (Scenario B) | 30 pts | Correctly localises to compartment III (hypothalamic) via hypogonadotrophic hormonal pattern; correctly explains why the progesterone challenge is negative (insufficient oestrogen priming due to FHA, not uterine absence) — explicitly uses the two-stage logic; links low BMI + exercise intensity to energy deficiency and KNDy/GnRH suppression; diagnosis of functional hypothalamic amenorrhoea stated clearly. |
| Investigation selection and management plans (both scenarios) | 25 pts | Scenario A: lists endometrial biopsy (to exclude hyperplasia/AUB-M), fasting insulin/HOMA-IR, lipid profile; management addresses both the AUB (LNG-IUS as first-line, or metformin for underlying PCOS) and the metabolic syndrome; contraceptive implications addressed (combined OCP caution with BMI + glucose intolerance). Scenario B: correctly recommends bone mineral density (DEXA) for low BMI + FHA; energy rehabilitation plan; oestrogen/progesterone HRT or COC if bone health at risk; referral for eating disorder/psychological assessment if indicated. |
| Comparative reflection and intellectual honesty | 15 pts | Thoughtful comparison of the two frameworks (PALM-COEIN = aetiological structural/functional taxonomy; compartment = anatomical axis localisation — complementary not competing); identifies a genuine ethical or clinical challenge (e.g. counselling the athlete about the female athlete triad, or balancing endometrial biopsy recommendation vs patient anxiety); acknowledges uncertainty and names a specific reference used. |
PEER REVIEW
You are reviewing a peer's case-based assignment on AUB and amenorrhoea. Please assess their work using the rubric above. For each criterion: (1) identify the strongest aspect of their reasoning, (2) identify one specific factual or analytical gap, and (3) suggest one concrete improvement. Focus on the accuracy and completeness of the PALM-COEIN classification, the compartment-based workup, and the management rationale. Be constructive and specific — avoid generic praise. Your review should be 300–400 words.