Abnormal uterine bleeding — structured oral station (12 minutes)

Opening prompt — "How do you classify her bleeding, and what does it tell you?"

Model response — System 1 then System 2: ^[2][3]

• "I would describe her pattern with FIGO System 1: her cycles are irregular and heavy, with intermenstrual bleeding — abnormal frequency, regularity, flow volume and IMB."
• "Then I classify the cause with System 2, PALM-COEIN. Her irregularity points to ovulatory dysfunction (AUB-O); the intermenstrual bleeding raises a focal lesion — a polyp (AUB-P) — and at 47 I must exclude malignancy/hyperplasia (AUB-M)."
• "Critically, I have excluded pregnancy first, and more than one cause can coexist."^[1][2]

Probe 1 — "What is your initial workup?"

• "A System 1 history plus the FIGO coagulopathy screen; a focused examination including speculum and bimanual; FBC and ferritin for iron deficiency; and a coagulopathy panel if her screen is positive. I image with transvaginal ultrasound first, and add saline-infusion sonohysterography or 3D for any cavity lesion."^[2][3]

Probe 2 — "Her TVUS shows a thickened endometrium and a possible polyp. What now?"

• "At 47 with persistent irregular bleeding and IMB, I must exclude malignancy — I would arrange endometrial sampling, ideally hysteroscopically-directed given the polyp, and removal of the polyp for histology."^[3][4]
• "Even if the polyp is benign, I complete the workup for non-structural causes — her irregularity still needs ovulation testing and the bleeding screen."^[2]

Probe 3 — "A colleague says the polyp explains it and the workup is complete. Do you agree?"

• "No — that is the coexistence trap. Finding a structural lesion does not close the case. More than one PALM-COEIN cause can coexist, and an incidental lesion may be asymptomatic. I treat the cause that most likely drives the symptom, and I finish the assessment for non-structural causes."^[2]

Probe 4 — "She is frightened it is cancer. What do you say?"

This is a scored communication domain — demonstrate it out loud: ^[3]

• Move to her eye level, use her name, acknowledge the fear: "Your bleeding needs investigation because at 47 we must rule out a serious cause — but most abnormal bleeding is not cancer. We will do the sampling to give you a clear answer, and I will explain every result as it comes."
• Offer a clear plan and timeline, and a named contact for between visits.^[3][4]

Probe 5 — "How would your approach differ in a 15-year-old?"

• "In an adolescent, anovulation and bleeding disorders predominate, so I would run the coagulopathy screen (HMB since menarche is the clue) and avoid invasive investigation initially. The bar to biopsy is much higher than in a 47-year-old."^[3]