1. The Rawalpindi Medical University

2. The Rawalpindi Medical University
Reproduction Module
2nd year MBBS, Batch 49 (2023)
Case Based Learning (CBL) About
Menorrhagia
Date:-15th may2023
Dr. Muhammad Usman

3. The Rawalpindi Medical University
Table of Contents
Sr # Content Slide #
1 Motto, Vision 4
2 Professor Umar Model of Integrated Lecture 5
3 Bloom’s Taxonomy(Domains of learning) 6
4 Diagrammatic Representation of Blooms Taxonomy 7
5 Learning Objectives 8
6 Case Scenario 9-13
7 Horizontal Integration 14-15
8 Core Concept 16-22
9 Vertical Integration 23-27
10 Biomedical Ethics (lesson of the day) 28-32
11 Brainstorming (SEQ/MCQs relevant with lecture) 33-34
12 Suggested Research Article 35
13 Promoting IT and research culture(Digital Library) 36
14 References of this lecture 37

4. The Rawalpindi Medical University
Motto Vision; The Dream/Tomorrow
• To impart evidence based
research oriented medical
education
• To provide best possible
patient care
• To inculcate the values of
mutual respect and ethical
practice of medicine

5. The Rawalpindi Medical University
ProfessorUmarModel of Integrated Lecture
5
60%
CORE SUBJECT
20%
HORIZONTAL
INTEGRATION
Physiology
biochemistry
8%
VERTICAL
INTEGRATION
Pathology
pharmacology
7%
VERTICAL
INTEGRATION
Clinical
integration
5%
VERTICAL
INTEGRATION
Research,
professionalism
Ethics
Digital library

6. The Rawalpindi Medical University
BLOOM'S TAXONOMY : DOMAINS OF LEARNING
Sr. # Domain of
learning
Abbreviation Levels of
the domain
Meaning
1 cognition C C1 Recall / Remembering
2 C2 Understanding
3 C3 Applying / Problem solving
4 Psychomotor P P1 Imitation / copying
5 P2 Manipulation / Follows instructions
6 P3 Precision / Can perform accurately
7 Attitude A A1 Receiving / Learning
8 A2 Respond / Starts responding to the
learned attitude
9 A3 Valuing / starts behaving according to the
learned attitude

7. The Rawalpindi Medical University
BLOOM'S TAXONOMY OF THE
COGNITIVE DOMAIN

8. The Rawalpindi Medical University
LEARNING OBJECTIVES
8
Sr. # Learning Objective Domain of Learning
1 Recall the etiologist of abnormal uterine bleeding (C1) C1
2 Describe the epidemiology of abnormal uterine bleeding. C1
3 Explain the causes of abnormal uterine bleeding related to the
structure of the uterus versus the clotting pathway and the
disruption of the hypothalamic-pituitary-ovarian axis.
C2
4 Review the role of the interprofessional team in collaborating to
treat women with abnormal uterine bleeding.
C2
5 Apply the knowledge to learn diagnostic workup and therapeutic
interventions related to abnormal uterine bleeding. (C3)
C3

9. The Rawalpindi Medical University
Case Scenario
Sarah is a 38-years of age woman who presents
to her primary care physician's office with a
complaint of heavy menstrual bleeding for the
past six months. She reports soaking through a
tampon and pad every hour for the first three
days of her period, and passing several large
clots during this time.

10. The Rawalpindi Medical University
Case Scenario
She also reports that her periods last for 10-12
days, which is longer than her normal menstrual
cycle. Sarah reports feeling tired and weak
during her periods, and has noticed a decrease
in her usual level of activity during this time. She
denies any pain or other symptoms associated
with her menstrual cycle.

11. The Rawalpindi Medical University
Case Scenario (cont.)
History: Sarah reports no prior history of
abnormal uterine bleeding or gynaecological
conditions. She has regular menstrual cycles
every 28 days, and her last menstrual period
was two weeks ago. She is currently not using
any hormonal contraception, and has no history
of recent pelvic infections, surgeries, or
pregnancies.

12. The Rawalpindi Medical University
Case Scenario (cont.)
Sarah denies any significant medical history,
including thyroid disorders or bleeding
disorders. She takes no medications, and has no
known allergies.
Physical Examination: Vital signs are within
normal limits.

13. The Rawalpindi Medical University
Case Scenario (cont.)
On pelvic examination, the cervix appears healthy
and normal in size and shape, with no palpable
masses or tenderness.
The uterus is slightly enlarged and globular in
shape, with no palpable masses or tenderness. No
adnexal masses or tenderness is noted.
The remainder of the physical examination is
unremarkable.

14. The Rawalpindi Medical University
Horizontal integration
(With Anatomy)
Horizontal integration

15. The Rawalpindi Medical University
Horizontal integration
(With Biochemistry)
Horizontal integration

16. The Rawalpindi Medical University
Core concept
Core concept

17. The Rawalpindi Medical University
DEFINITION OF
ABNORMAL UTERINE BLEEDING
• Abnormal uterine bleeding is a broad term
that describes irregularities in the menstrual
cycle involving frequency, regularity, duration,
and volume of flow outside of pregnancy.
Core concept

18. The Rawalpindi Medical University
Epidemiology Of
Abnormal Uterine Bleeding
• Up to one-third of women will experience
abnormal uterine bleeding in their life, with
irregularities most commonly occurring at
menarche and perimenopause.
• A normal menstrual cycle has a frequency of
24 to 38 days and lasts 2 to 7, with 5 to 80
millilitres of blood loss. Variations in any of
these 4 parameters constitute abnormal
uterine bleeding.
Core concept

19. The Rawalpindi Medical University
CAUSES OF ABNORMAL UTERINE
BLEEDING
PALM-COEIN is a useful acronym provided by
the International Federation of Obstetrics and
Gynaecology (FIGO) to classify the underlying
etiologies of abnormal uterine bleeding.
Core concept

20. The Rawalpindi Medical University
CAUSES OF ABNORMAL UTERINE
BLEEDING
• P: Polyp
• A: Adenomyosis
• L: Leiomyoma
• M: Malignancy and hyperplasia
• C: Coagulopathy
• O: Ovulatory dysfunction
• E: Endometrial disorders
• I: Iatrogenic
• N: Not otherwise classified
Core concept

21. The Rawalpindi Medical University
PATHOPHYSIOLOGY ABNORMAL
UTERINE BLEEDING
• The uterine and ovarian arteries supply blood to
the uterus. These arteries become the arcuate
arteries; then, the arcuate arteries send off radial
branches which supply blood to the two layers of
the endometrium, the functionality and basalis
layers.
• Progesterone levels fall at the end of the
menstrual cycle, leading to enzymatic breakdown
of the functionalis layer of the endometrium. This
breakdown leads to blood loss and sloughing,
which makes up menstruation.
Core concept

22. The Rawalpindi Medical University
PATHOPHYSIOLOGY ABNORMAL
UTERINE BLEEDING
• Functioning platelets, thrombin, and vasoconstriction
of the arteries to the endometrium control blood loss.
• Any derangement in the structure of the uterus (such
as leiomyoma, polyps, adenomyosis, malignancy, or
hyperplasia), derangements to the clotting pathways
(coagulopathies or iatrogenically), or disruption of the
hypothalamic-pituitary-ovarian axis (through
ovulatory/endocrine disorders or iatrogenically) can
affect menstruation and lead to abnormal uterine
bleeding.
Core concept

23. The Rawalpindi Medical University
Vertical integration
(With Clinical and Para-clinical Sciences)
Vertical integration

24. The Rawalpindi Medical University
Differential Diagnosis For
Dysfunctional Uterine Bleeding (DUB)
Vertical integration

25. The Rawalpindi Medical University
Descriptive Terms For Dysfunctional
Uterine Bleeding (DUB)
Vertical integration

26. The Rawalpindi Medical University
Diagnostic Workup For Evaluation of
Dysfunctional Uterine Bleeding (DUB)
Vertical integration

27. The Rawalpindi Medical University
Management Of Dysfunctional Uterine
Bleeding (DUB)
Vertical integration

28. The Rawalpindi Medical University
Promoting Biomedical Ethics Culture
BIOMEDICAL ETHICS
(Lesson of The Day)
 Core biomedical ethical principles are
fundamental guidelines that shape and govern
ethical decision-making and behavior.
 These principles provide a framework for
individuals and organizations to determine
what is morally right or wrong in various
contexts.

29. The Rawalpindi Medical University
 The core pillars/principles of medical ethical
include:
Promoting Biomedical Ethics Culture

30. The Rawalpindi Medical University
Beneficence
Promoting Biomedical Ethics Culture

The principle of beneficence is the obligation of
physician to act for the benefit of the patient and
supports a number of moral rules to protect and
defend the right of others, prevent harm, remove
conditions that will cause harm, help persons with
disabilities, and rescue persons in danger.

It is worth emphasizing that, the language here is one
of positive requirements. The principle calls for not just
avoiding harm, but also to benefit patients and to
promote their welfare.

31. The Rawalpindi Medical University
Promoting Biomedical Ethics Culture
A previously healthy 73-year-old man comes to the physician at his wife's
insistence because of a skin lesion on his back. He lives with his wife and works for
a high-profile law firm where he represents several major clients. Physical
examination shows a 7-mm, brownish-black papule with irregular borders. When
the physician starts to mention possible diagnoses, the patient interrupts her
and says that he does not want to know the diagnosis and that she should just do
whatever she thinks is right. A biopsy of the skin lesion is performed and
histological examination shows clusters of infiltrative melanocytes. Upon repeat
questioning, the patient reaffirms his wish to not know the diagnosis. Which of
the following is the most appropriate response from the physician?
A. "I have a moral obligation as a physician to inform you about the diagnosis."
B. "I would like to do further testing to investigate how far this cancer has
spread."
C. "I don't have to tell you, but I will have to tell your wife so we can plan your
therapy."
D. "I'll have to consult with the ethics committee to determine further steps."
E. "I would like to know more about why you don't want to hear your test
results."

32. The Rawalpindi Medical University
Promoting Biomedical Ethics Culture
Correct Answer: C

33. The Rawalpindi Medical University
Brainstorming/Recall About Topic
Under Consideration
A 36-year woman presents to her gynecologist with complaints of
irregular and heavy menstrual bleeding for the past six months. She
reports that her menstrual cycles occur every 20-25 days and last for 8-
10 days. The patient denies any history of hormonal contraception use
or recent pregnancy. On further evaluation, her thyroid-stimulating
hormone (TSH) levels are within normal limits. An endometrial biopsy
reveals a benign proliferation of glands without evidence of atypia.
Based on these findings, what is the most likely diagnosis for this
patient's condition?
A. Polycystic ovary syndrome (PCOS)
B. Endometriosis
C. Dysfunctional uterine bleeding (DUB)
D. Uterine fibroids
Brainstorming/Recall

34. The Rawalpindi Medical University
Key
Correct Answer: C
Brainstorming/Recall

35. The Rawalpindi Medical University
Suggested research article
https://doi.org/10.1034/j.1600-0412.2003.00097.x
Promoting IT & Research Culture

36. The Rawalpindi Medical University
• Steps to Access HEC Digital Library
1. Go to the website of HEC National Digital Library.
2. On Home Page, click on the INSTITUTES.
3. A page will appear showing the universities from Public
and Private Sector and other Institutes which have access
to HEC National Digital Library HNDL.
4. Select your desired Institute.
5. A page will appear showing the resources of the
institution
6. Journals and Researches will appear
7. You can find a Journal by clicking on JOURNALS AND
DATABASE and enter a keyword to search for your desired
journal.
How To Access Digital Library
Promoting IT & Research Culture

37. The Rawalpindi Medical University
REFERENCE BOOKS:
1. Guyton And Hall textbook of Medical Physiology
14th Edition.
2. Davidson's Principles and Practice of Medicine -
24th Edition
3. Oxford Handbook of Clinical Medicine
4. Oxford Handbook of Obstetrics and Gynecology

38. The Rawalpindi Medical University