CCE-CBD-221

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the possible causes of Emily’s symptoms, and how would you investigate them?

• Prompt: What are the most likely diagnoses based on her presentation?
• Prompt: What investigations are appropriate for menstrual irregularity and suspected PCOS?

Q2. How would you explain PCOS to the patient if confirmed?

• Prompt: What are the key features of PCOS?
• Prompt: How would you address Emily’s concerns about fertility and long-term health risks?

Q3. What are the management options for PCOS and menstrual irregularities?

• Prompt: What first-line treatments would you recommend?
• Prompt: How would management differ if she were not trying to conceive?

Q4. How would you approach contraception counselling if Emily decides to delay conception?

• Prompt: What are the pros and cons of different contraceptive options?
• Prompt: How would you discuss long-acting reversible contraception (LARC)?

Q5. What preventive health advice would you provide regarding Emily’s reproductive health?

• Prompt: What screening tests should be prioritised?
• Prompt: What lifestyle interventions would benefit her condition?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are the possible causes of Emily’s symptoms, and how would you investigate them?

Possible Causes of Symptoms

Emily presents with irregular, heavy, and painful periods, weight gain, acne, and infertility, suggesting several differential diagnoses:

• Polycystic Ovary Syndrome (PCOS) – Common in women with oligo/amenorrhoea, hyperandrogenism, and metabolic features.
• Hypothyroidism – Can cause menstrual irregularities, weight gain, and fatigue.
• Hyperprolactinaemia – May contribute to menstrual disturbances and infertility.
• Endometriosis – A potential cause of dysmenorrhoea and heavy bleeding.
• Perimenopause or Primary Ovarian Insufficiency – Less likely at age 29 but should be considered.

Investigations

Hormonal Tests:

• FSH, LH, oestradiol – Assess ovarian reserve.
• Testosterone, SHBG, DHEA-S – Evaluate for hyperandrogenism (PCOS).
• TSH and prolactin – Rule out thyroid dysfunction and hyperprolactinaemia.
• HbA1c and fasting insulin – Identify insulin resistance.

Pelvic Ultrasound:

• Assess ovarian morphology for PCOS features (≥12 follicles, ovarian volume >10 mL).
• Rule out structural abnormalities (e.g., fibroids, endometriomas).

Additional Tests:

• Cervical screening (overdue) and STI screening if indicated.
• Endometrial biopsy if concern for endometrial hyperplasia (e.g., prolonged amenorrhoea with heavy bleeding).

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Q2: How would you explain PCOS to the patient if confirmed?

Explanation of PCOS

• PCOS is a common hormonal condition affecting ovulation, metabolism, and androgen levels.
• It can lead to irregular periods, fertility issues, weight gain, and acne.
• It is not a disease but a syndrome, meaning it presents differently in different women.

Fertility Concerns

• Many women with PCOS can conceive naturally, but ovulation may be irregular.
• Lifestyle changes, weight management, and medications (e.g., letrozole, metformin) can improve fertility.
• Referral to a fertility specialist may be required if conception does not occur within 6-12 months.

Long-Term Health Risks

• Type 2 diabetes (due to insulin resistance).
• Endometrial hyperplasia (from prolonged unopposed oestrogen).
• Cardiovascular disease (from metabolic dysfunction).

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Q3: What are the management options for PCOS and menstrual irregularities?

Lifestyle Modifications

• Weight loss of 5-10% can improve ovulation and metabolic outcomes.
• Regular exercise and a low-GI diet help reduce insulin resistance.

Medical Management

• For menstrual regulation: Combined oral contraceptive pill (COCP) or cyclic progestins.
• For insulin resistance: Metformin may help, particularly in overweight patients.
• For hyperandrogenism: COCP + anti-androgens (e.g., spironolactone) if acne/hirsutism persists.
• For ovulation induction (if trying to conceive): Letrozole (first-line), clomiphene, or metformin.

Alternative Treatments

• Acupuncture and myo-inositol have emerging evidence in PCOS.

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Q4: How would you approach contraception counselling if Emily decides to delay conception?

Contraceptive Options

1. Combined Oral Contraceptive Pill (COCP)
   • Regulates periods, reduces acne, and protects endometrium.
   • Contraindicated if BMI ≥35 or smoking >35 years.
2. Long-Acting Reversible Contraceptives (LARC)
   • Mirena IUD: Controls bleeding, prevents endometrial hyperplasia.
   • Implanon: Effective but may cause irregular bleeding.
3. Progestin-Only Methods
   • Good for those at risk of venous thromboembolism (VTE).
4. Barrier Methods
   • Less effective but provide STI protection.

Counselling Approach

• Discuss pros and cons of each option.
• Consider metabolic risks when prescribing COCP.
• Offer cervical screening and discuss future fertility planning.

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Q5: What preventive health advice would you provide regarding Emily’s reproductive health?

Routine Screening

• Cervical screening test (overdue).
• STI screening (if indicated).
• Blood pressure and BMI monitoring.

Lifestyle Interventions

• Weight optimisation through diet and exercise.
• Smoking cessation and alcohol moderation.

Fertility Planning

• If delaying pregnancy, discuss ovarian reserve and future options.
• Encourage preconception care with folic acid supplementation.

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SUMMARY OF A COMPETENT ANSWER

• Recognises menstrual irregularities, infertility, and hyperandrogenism as key features of PCOS.
• Orders appropriate investigations, including hormonal tests and ultrasound.
• Explains PCOS clearly, addressing fertility concerns and long-term health risks.
• Provides a tailored management plan, considering lifestyle, medical therapy, and contraception.
• Emphasises preventive health measures, including cervical screening, weight management, and metabolic monitoring.

PITFALLS

• Failing to consider alternative diagnoses (e.g., hypothyroidism, endometriosis).
• Overlooking fertility concerns when discussing PCOS.
• Neglecting long-term metabolic risks (e.g., diabetes, cardiovascular disease).
• Inadequate contraception counselling, not discussing LARC options.
• Missing cervical screening and STI screening in routine reproductive care.

REFERENCES

• RACGP Guidelines on Heavy Menstrual Bleeding
• Australian Menopause Society on Management of Menstrual Disorders
• Better Health Channel on Iron Deficiency and Heavy Periods
• Jean Hailes for Women’s Health on PCOS and Fertility

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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 Establishes rapport and engages patient in discussion of sensitive issues.
1.2 Uses non-judgmental, patient-centred communication techniques.

2. Clinical Information Gathering and Interpretation

2.1 Elicits a thorough menstrual and reproductive health history.
2.2 Identifies possible causes of abnormal menstrual symptoms.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises common gynaecological conditions and their differentials.
3.2 Determines appropriate investigations.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides evidence-based management options for menstrual irregularities.
4.2 Discusses contraceptive choices considering patient preferences and medical suitability.

5. Preventive and Population Health

5.1 Provides cervical screening and preventive reproductive health advice.

6. Professionalism

6.1 Ensures culturally sensitive and ethical discussion of reproductive choices.

7. General Practice Systems and Regulatory Requirements

7.1 Understands contraceptive prescribing regulations, including LARC.

9. Managing Uncertainty

9.1 Recognises when referral to a specialist is required for further assessment.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies red flags for underlying serious pathology (e.g., endometrial pathology, PCOS, thyroid dysfunction).

Competency at Fellowship Level

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