EXAMINER ONLY INFORMATION

QUESTIONS

Q1. How would you assess Sophie’s menstrual history and determine the likely cause of her symptoms?

• Prompt: What key aspects of the history are important?
• Prompt: What are the most likely differentials based on her symptoms?

Q2. What investigations would you order, and why?

• Prompt: What baseline blood tests are appropriate?
• Prompt: When is imaging required?

Q3. How would you manage Sophie’s menstrual symptoms and anaemia?

• Prompt: What are the first-line pharmacological and non-pharmacological options?
• Prompt: How would you address her concerns about long-term health and fertility?

Q4. When would you refer Sophie to a specialist?

• Prompt: What clinical features warrant gynaecology referral?
• Prompt: What role does endocrinology play in menstrual disorders?

Q5. What lifestyle and preventive measures would you recommend?

• Prompt: How can dietary and exercise modifications help?
• Prompt: What strategies can support menstrual health and overall well-being?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you assess Sophie’s menstrual history and determine the likely cause of her symptoms?

Sophie presents with irregular and heavy menstrual bleeding, dysmenorrhoea, and fatigue. A structured approach includes history, examination, and differential diagnosis.

1. History

• Menstrual history – cycle length, duration, heaviness, clots, pain severity
• Impact on daily life – work, social, emotional well-being
• Gynaecological history – contraceptive use, previous investigations, pregnancy history
• Family history – PCOS, endometriosis, thyroid disorders
• Systemic symptoms – weight changes, hirsutism, galactorrhoea (hormonal causes)

2. Differential Diagnosis

• Polycystic ovary syndrome (PCOS) – irregular cycles, obesity, possible insulin resistance
• Endometriosis – severe dysmenorrhoea, pelvic pain, deep dyspareunia
• Hypothyroidism – menstrual irregularities, fatigue, weight gain
• Dysfunctional uterine bleeding (AUB-O) – hormonal imbalance without structural cause

Sophie’s irregular, heavy cycles and mild anaemia suggest a possible hormonal imbalance (PCOS or AUB-O), requiring further assessment.

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Q2: What investigations would you order, and why?

1. Blood Tests

• Full blood count – assess anaemia severity
• Ferritin – confirm iron deficiency
• Thyroid function tests – rule out hypothyroidism
• Hormonal panel (if PCOS suspected):
  • FSH, LH, oestradiol (ovulatory function)
  • Testosterone, DHEA-S (hyperandrogenism)
  • Prolactin (pituitary disorders)
  • HbA1c, fasting insulin (insulin resistance in PCOS)

2. Pelvic Ultrasound (Indications)

• Irregular cycles + heavy bleeding → assess for structural abnormalities
• Suspected PCOS → look for ovarian morphology
• Persistent symptoms despite initial management

Investigations help confirm the diagnosis and guide treatment.

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Q3: How would you manage Sophie’s menstrual symptoms and anaemia?

1. Menstrual Management

• First-line: Combined oral contraceptive pill (COCP) for cycle regulation
• Alternative: Levonorgestrel IUD (Mirena) for long-term bleeding control
• Non-hormonal: Tranexamic acid, NSAIDs for heavy bleeding if contraception not desired

2. Anaemia Treatment

• Oral iron supplementation (100-200 mg elemental iron daily)
• Dietary advice – increase iron-rich foods (red meat, leafy greens)

3. Addressing Fertility Concerns

• Reassure that cycle regulation improves future fertility
• If PCOS suspected – may need ovulation induction when planning pregnancy

Sophie’s treatment plan should align with her symptom control needs and reproductive goals.

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Q4: When would you refer Sophie to a specialist?

1. Gynaecology Referral

• Severe anaemia requiring transfusion
• Suspected endometriosis with persistent pelvic pain
• Failed medical management (persistent irregular/heavy bleeding)

2. Endocrinology Referral

• PCOS with severe insulin resistance
• Pituitary disorder (elevated prolactin, abnormal hormonal results)

A referral ensures appropriate management for underlying gynaecological or endocrine conditions.

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Q5: What lifestyle and preventive measures would you recommend?

1. Diet and Exercise

• Regular physical activity – improves insulin sensitivity, hormonal balance
• Balanced diet – reduce processed foods, increase whole grains and proteins
• Weight management – if PCOS suspected, aim for 5-10% weight reduction

2. Menstrual Tracking and Education

• Use apps or diaries to track cycle patterns
• Recognise signs of worsening anaemia (fatigue, dizziness)

3. Mental Health and Well-being

• Address emotional impact of menstrual disorders
• Encourage stress reduction strategies (yoga, mindfulness)

A holistic approach supports long-term menstrual health and well-being.

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SUMMARY OF A COMPETENT ANSWER

• Thoroughly assesses menstrual history to identify potential causes
• Orders appropriate blood tests and pelvic ultrasound as needed
• Provides medical and non-medical treatment for bleeding and anaemia
• Recognises when specialist referral is warranted
• Discusses lifestyle interventions for long-term cycle regulation

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PITFALLS

• Not considering hormonal causes such as PCOS or thyroid dysfunction
• Delaying iron therapy despite documented anaemia
• Failing to address Sophie’s fertility concerns
• Overlooking lifestyle modifications as part of management
• Not recognising the need for specialist referral when conservative measures fail

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REFERENCES

• RACGP Guidelines on Heavy Menstrual Bleeding
• Australian Commission on Safety and Quality in Health Care on Heavy Menstrual Bleeding Clinical Care Standard
• Therapeutic Guidelines on Gynaecology (Menstrual Disorders)
• Jean Hailes for Women’s Health on Heavy and Irregular Periods

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Uses sensitive and patient-centred communication when discussing menstrual health.
1.3 Explains investigations and management options in a clear and supportive manner.

2. Clinical Information Gathering and Interpretation

2.1 Conducts a thorough menstrual and reproductive history.
2.3 Identifies red flags requiring further investigation (e.g., anaemia, endometrial pathology).

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between common causes of menstrual irregularities.
3.3 Determines when imaging and specialist referral are warranted.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides appropriate pharmacological and non-pharmacological management options.
4.4 Develops an individualised management plan based on the patient’s symptoms and goals.

5. Preventive and Population Health

5.1 Discusses the impact of lifestyle, nutrition, and stress on menstrual health.

6. Professionalism

6.2 Provides culturally sensitive and non-judgmental care.

7. General Practice Systems and Regulatory Requirements

7.1 Orders investigations appropriately and ensures follow-up of abnormal results.

8. Procedural Skills

8.2 Performs pelvic examinations when indicated.

9. Managing Uncertainty

9.1 Recognises when to initiate empirical treatment versus awaiting diagnostic confirmation.

10. Identifying and Managing the Patient with Significant Illness

10.2 Identifies complications such as anaemia or underlying gynaecological pathology.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD