Station 87

Aisha Khan

Age: 35 year old female

Examiner

Station List
Doctor
Patient
Full Case

Marking Scheme

Data Gathering and Diagnosis

  • Acknowledge the previous consultation and reason for the scan: “I can see you saw my colleague recently due to heavy menstrual bleeding and you were sent for a scan, is that right? How have things been since then?”
  • Ask about the duration and pattern of heavy menstrual bleeding and whether it has changed recently.
  • Ask if the bleeding is associated with pain .
  • Ask about her last menstrual period and whether her cycles are regular.
  • Ask about any intermenstrual bleeding (bleeding between periods).
  • Ask about pressure symptoms of fibroids such as urinary urgency, frequency, bloating, constipation or painful defecation. 
  • Ask if the patient is sexually active.
  • Ask about the number of sexual partners (if clinically relevant).
  • Ask about any bleeding during or after sex (postcoital bleeding).
  • Ask about pain during sex (dyspareunia).
  • Ask if she has had any difficulty conceiving and how long she and her partner have been trying for pregnancy.
  • Ask about family history of fibroids
  • Ask if the patient is currently using any form of contraception.
  • Screen for anaemia symptoms using the “3 head and 3 chest” approach: light-headedness, dizziness, headache; palpitations, shortness of breath, chest pain.
  • Ask about how the heavy bleeding is affecting her daily life including impact on work, mood, relationships, and quality of life.
  • Ask whether she has tried any previous treatments or medications to manage the heavy bleeding.
  • Ask about iron tablet side effects and current use.
  • Ask about smoking, alcohol use, occupation, and home support.
  • Explain scan results showing fibroids. 

Example of explanation to patient​

Thank you for coming in today, Aisha. I can see how much this has been affecting your daily life, and I want to reassure you that there are steps we can take to help.

Your ultrasound shows that you have what we call fibroids. Is that something you have heard of before? Fibroids are non-cancerous growths in the womb, and they are a common cause of heavy periods.

Now, because of their size and the fact that you are trying to conceive, I would recommend referring you to a gynaecologist (women specialist). They can give you more specialised advice and discuss options to help with both fertility and managing the fibroids. Are you following me so far?

The specialist might suggest treatments like medication to help shrink the fibroids or, in some cases, an operation to remove them. Are you happy for me to go ahead and arrange that referral?

In the meantime, I can prescribe you a medication called tranexamic acid. It helps to reduce the amount of bleeding during your periods. Most people tolerate it well, although like any medicine, it does have some side effects. It can rarely increase the risk of blood clots in the legs or lungs. That said, this is uncommon, but it is important you are aware of this. If you get any pain in your calves, chest pain or difficulty breathing, do let us know immediately. 

How does that sound so far?

I would like to encourage you to restart your iron tablets, as they play an important role in treating your anaemia. To help minimise side effects like constipation, you can take them on alternate days, ideally with orange juice or after food.

Alternatively, we can consider adding a laxative to help ease the constipation. What would you prefer? 

If you notice any new symptoms like feeling dizzy, light-headed, or if your heart starts racing, please get medical help straight away. These could be signs that your low blood level (anaemia) is getting worse.

Management

Management

  • Offer a referral to Gynaecology due to the presence of fibroids larger than 3 cm and the patient’s concerns regarding fertility. 
  • Offer a trial of tranexamic acid to help manage menorrhagia. 
  • Inform the patient about potential side effects of tranexamic acid, such as an increased risk of blood clots in the legs or lungs. Reassure her that this is uncommon and does not affect everyone.
  • Encourage the patient to restart her iron tablets, but to take them on alternate days, ideally with orange juice or with/after food to reduce gastrointestinal side effects. Alternatively, if she prefers, a laxative can be prescribed to help manage the constipation. 
  • Provide safety netting advice: advise the patient to seek urgent medical attention if she develops dizziness, light-headedness, palpitations, or chest pain, as these may be signs of worsening anaemia.

Learning point from this station: ​

Uterine fibroids are a common cause of heavy menstrual bleeding and can contribute to iron deficiency anaemia.

Refer to gynaecology if: 

  • The fibroids are greater than 3 cm 
  • Fibroids are submucosal 
  • Fibroids are distorting the uterine cavity 
  • The patient is experiencing pressure symptoms, such as bladder or bowel compression, 
  • There are concerns about fertility 
  • Symptoms cannot be managed in primary care  
  • Or the fibroids are growing after menopause, which raises concern for other pathology (refer urgently)  
Further reading