Station 87
Aisha Khan
Age: 35 year old female
Full Case
Patient’s Data
Patient’s name: Aisha Khan
Age: 35-year-old female
Past medical history:
- Iron deficiency anaemia secondary to heavy menstrual bleeding
Drug adn Allergy History
- Ferrous Sulfate 200 mg once daily
- Microgynon 30 (Recently stopped as requested by patient)
- No known drug allergies
Alerts and QOF
- Cervical screening up to date with no abnormalities on the most recent smear
Recent notes/ consultation
Seen 2 weeks ago by Dr Lucy Aldershot (Clinical Practioner role)
Presenting complaint: The patient reported experiencing heavy menstrual bleeding since stopping Microgynon 9 months ago, which she discontinued to begin trying for pregnancy. Recent blood tests revealed microcytic anaemia, with a haemoglobin level of 109 g/L. LMP: 2 weeks ago, not currently bleeding.
Examination: No pelvic tenderness or masses felt. Speculum examination was unremarkable with no abnormalities noted. Blood pressure was 121/65 mmHg and pulse was 70 bpm.
Plan: Ultrasound scan requested. Initiated treatment with ferrous sulfate. Provided safety netting and advice on when to seek further medical attention if symptoms worsen.
Pelvic ultrasound scan report.
A combined transabdominal and transvaginal pelvic ultrasound scan was performed. A chaperone was present throughout the examination.
The uterus is enlarged with a heterogeneous echotexture. Multiple fibroids are identified, consistent with intramural and subserosal locations. The largest fibroid is seen posteriorly and measures 4.2 cm in diameter. The endometrial thickness appears within normal limits for the reported phase of the menstrual cycle. Both ovaries are visualised and are normal in size and morphology. No adnexal masses or free fluid are observed.
Conclusion:
Ultrasound findings are consistent with multiple uterine fibroids, the largest measuring 4.2 cm. Clinical correlation is advised.
Reported by:
Chinyere Okonkwo
Advanced Reporting Ultrasonographer
Patient booked a telephone consultation to discuss hers can results.
Patient's Story (Role player’s brief)
Patient’s Story
You are Aisha Khan, a 35-year-old female.
Opening Statement: “Hi Doctor, I came to discuss my scan results.”
If asked why you had the scan: You have experienced heavy menstrual bleeding for most of your adult life, but this was well controlled when you were taking the combined oral contraceptive pill (Microgynon). However, you chose to stop the pill nine months ago as you and your husband are trying for a baby. Since then, for the past seven months, the heavy bleeding has returned and has become difficult to manage.
Your periods are regular (every 28 days), and although they are not painful, the bleeding is very heavy. You feel it is beginning to affect your quality of life. You often have to take time off work during your periods because of fatigue and inconvenience related to the bleeding. You do not experience dizziness, chest pain, or palpitations, but you do feel occasionally tired.
Gynaecology History: Your period started yesterday, and you are currently bleeding. You are sexually active with your husband, and do not experience pain or bleeding during intercourse. You have never been pregnant.
Family History: You recall that your sister had similar symptoms and was later diagnosed with fibroids.
Social History: You do not smoke or drink alcohol. You work full-time as a solicitor and live with your husband.
Ideas: You are not sure what the underlying cause is.
Concerns: You want the heavy bleeding to stop and are worried it might affect your ability to get pregnant.
Expectations: You would like the doctor to explain the scan results, clarify what is causing the heavy bleeding, and recommend treatment. You also stopped taking the iron tablets (ferrous sulfate) recently because they were causing constipation, and you would like advice on what to do next.
Say NO to any other questions asked outside of the details already provided in the scenario. Accept anything offered to you by the doctor.
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)