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Heavy menstrual periods

Clinical Discipline(s)/Organ System(s)
Obstetrics & Gynaecology, Reproduction & Development
Progress Test Topic(s)
Women's health
Description
A 45 year old NZ European woman presents to her GP with heavy periods for six months. She has completed her family. She is concerned as she is running out of sick leave at work.
Applied Science for Medicine 
   - Anatomy and function of the female reproductive tract
   - Physiology of the normal menstrual cycle
   - Physiology of the menopause and the peri-menopausal period; role of anovulation
   - Normal iron metabolism and response to iron deficiency
   - Pathophysiology of menorrhagia
   - Role of oestrogen in the aetiology of endometrial hyperplasia and carcinoma
   - Pharmacology of medical treatments for heavy menstrual bleeding: combined oral contraceptive pill, non-steroidal anti-inflammatory drugs, tranexamic acid, Depo Provera, Mirena intrauterine system (IUS)
   - Applied anatomy relevant to the surgical and interventional treatment approaches for heavy menstrual bleeding (endometrial ablation, polypectomy, myomectomy, hysterectomy, uterine artery embolisation)
Clinical and Communication Skills 
   - History of heavy menstrual bleeding including a menstrual, sexual and gynaecological history, and symptoms of anaemia
   - Recognise 'red flag' symptoms for gynaecological malignancy
   - Examination of the abdomen and pelvis; including speculum and bimanual pelvic examination
   - Symptoms and signs of perimenopause
   - Differential diagnosis of heavy menstrual bleeding (systemic, pelvic, hormonal/functional causes)
   - Interpret full blood count, ferritin
   - Indications for swabs, smear, endometrial biopsy (Pipelle), diagnostic hysteroscopy and curettage, colposcopy, transvaginal ultrasound
   - Risk factors for endometrial hyperplasia and malignancy
   - List the possible abnormal endometrial biopsy results and know their risk and timeframe of progression to malignancy
   - Management of menorrhagia: medical (hormonal and non-hormonal) and surgical options
   - Management of endometrial hyperplasia (medical and surgical)
   - Outline the staging and management of endometrial and cervical cancer
   - Contraception and hormone therapy during the perimenopause
Personal and Professional Skills 
   - Intimate examination and use of a chaperone
   - Challenges faced by women approaching menopause
   - Discussing management options in terms of quality of life (physical, emotional, social, financial)
   - Managing patient expectations of treatment outcomes
   - Breaking bad news and coping with cancer
   - Lifestyle change advice
Population Health 
   - Epidemiology of cervical and endometrial malignancy
   - Role of obesity in endometrial hyperplasia/malignancy
   - Health economics of the various treatments for heavy menstrual bleeding
   - New Zealand cervical screening programmes
   - Monitoring and success of cervical screening programmes
Conditions to be considered relating to this scenario
Common
fibroids, dysfunctional uterine bleeding, miscarriage (threatened, recurrent, spontaneous, complete or incomplete), adenomyosis, perimenopause, endocervical / vaginal infection, endometrial polyps, cervical polyps, side effects of contraception, thyroid dysfunction
Less common but 'important not to miss'
endometrial hyperplasia / carcinoma, coagulopathies, platelet defects, pelvic inflammatory disease, ectopic pregnancy, cervical dysplasia / carcinoma, ovarian carcinoma
Uncommon
cervical ectropian/erosion, drugs (warfarin, aspirin)
Related Scenarios
[Postmenopausal bleeding]