CCE-CE-049

CASE INFORMATION

Case ID: CCE-GYN-009
Case Name: Emily Dawson
Age: 35
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: X99 – Menstrual problem NOS

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Establishes rapport and engages the patient
1.2 Explores the patient’s concerns, ideas, and expectations
1.3 Provides clear and structured explanations about diagnosis, prognosis, and management
2. Clinical Information Gathering and Interpretation2.1 Takes a focused menstrual and reproductive history
2.2 Identifies red flags and risk factors for underlying gynaecological pathology
3. Diagnosis, Decision-Making and Reasoning3.1 Differentiates between common causes of menstrual irregularities (e.g., PCOS, fibroids, thyroid dysfunction)
3.2 Identifies when further investigations or specialist referral is required
4. Clinical Management and Therapeutic Reasoning4.1 Provides evidence-based management options, including medical and lifestyle interventions
4.2 Addresses symptom control, fertility concerns, and long-term health implications
5. Preventive and Population Health5.1 Provides education on menstrual health and lifestyle modifications
5.2 Encourages screening for related conditions, including anaemia, metabolic syndrome, and reproductive health issues
6. Professionalism6.1 Demonstrates empathy and a patient-centred approach to gynaecological concerns
7. General Practice Systems and Regulatory Requirements7.1 Ensures appropriate follow-up and referrals to specialists where indicated
8. Procedural Skills8.1 Performs or arranges relevant investigations, including blood tests and pelvic ultrasound
9. Managing Uncertainty9.1 Recognises when menstrual irregularities require urgent escalation (e.g., endometrial pathology, abnormal bleeding)
10. Identifying and Managing the Patient with Significant Illness10.1 Identifies and appropriately manages conditions such as heavy menstrual bleeding, PCOS, and endometriosis

CASE FEATURES

  • Need for appropriate investigations and evidence-based management
  • Irregular and heavy menstrual bleeding impacting daily life
  • Concerns about underlying pathology (e.g., fibroids, PCOS, hormonal imbalance)
  • Potential anaemia and associated fatigue
  • Fertility considerations and impact on quality of life

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face to face.

You are not required to perform an examination.

A patient record summary is provided for your information.

Perform the following tasks:

  1. Take an appropriate history.
  2. Outline the differential diagnosis and key investigations required.
  3. Address the patient’s concerns.
  4. Develop a safe and patient-centred management plan.

SCENARIO

Emily Dawson, a 35-year-old teacher, presents with irregular and heavy menstrual bleeding over the past six months. She reports periods lasting 8–10 days with heavy flow, passing clots, and requiring frequent pad changes. She feels fatigued and lightheaded during her period and is worried about whether this is normal or if something is wrong.


PATIENT RECORD SUMMARY

Patient Details

Name: Emily Dawson
Age: 35
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • None known

Medications

  • Nil regular medications

Past History

  • No known gynaecological conditions
  • No history of thyroid disease or bleeding disorders

Social History

  • Works as a teacher, active job but high stress

Family History

  • Mother had fibroids and heavy periods
  • No family history of clotting disorders or gynaecological cancers

Smoking

  • Non-smoker

Alcohol

  • Drinks 1–2 glasses of wine per week

Vaccination and Preventative Activities

  • Up to date with cervical screening test (last done 2 years ago, normal)

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.


SCRIPT FOR ROLE-PLAYER

Opening Line

“Doctor, my periods have been really heavy and all over the place lately. I don’t know what’s going on, and I’m starting to worry.”


General Information

Emily Dawson is a 35-year-old teacher who presents with irregular and heavy menstrual bleeding over the past six months. She describes her cycles as previously regular (28–30 days) and lasting 4–5 days, but now they are unpredictable, lasting up to 10 days with very heavy bleeding and clotting.

She has no known history of gynaecological issues but is worried that something is wrong. She has noticed fatigue and occasional dizziness during her periods and wonders if she is losing too much blood.


Specific Information

(To be revealed only when asked)

Background Information

She is sexually active with her long-term partner and was planning to try for a pregnancy in the next year. This has increased her anxiety about her cycles, as she is unsure if this could affect her fertility.

She does not use hormonal contraception and has no history of sexually transmitted infections (STIs).

Her main concerns are:

  • “Why are my periods suddenly so heavy and irregular?”
  • “Do I need any tests or scans?”
  • “Could this affect my ability to get pregnant?”
  • “Are there any treatments that could help?”

Menstrual and Gynaecological History

  • Prior to six months ago: Regular cycles (28–30 days), moderate bleeding lasting 4–5 days.
  • Currently: Periods every 21–45 days, lasting 8–10 days, with heavier bleeding, clotting, and cramping.
  • Flow is significantly heavier, requiring changing pads every 1–2 hours on heavy days.
  • Experiences fatigue and occasional dizziness during her periods.
  • No significant pelvic pain outside of menstruation.
  • No history of endometriosis, PCOS, or uterine abnormalities.

Sexual and Contraceptive History

  • Not using hormonal contraception.
  • Uses condoms for contraception.
  • Sexually active with a long-term partner, no concerns about STIs.
  • No previous pregnancies or miscarriages.

Family History and Risk Factors

  • Mother had fibroids and heavy periods before menopause.
  • No family history of endometrial cancer, PCOS, or clotting disorders.
  • No history of thyroid disease.

Concerns About Fertility and Health

  • Worried about whether this will affect her chances of getting pregnant.
  • Concerned that she may have fibroids, PCOS, or another gynaecological condition.
  • Anxious about whether she needs blood tests or an ultrasound.
  • Wants to know if there are treatments that can help her cycles return to normal.

Emotional Cues

Emily is worried but open to discussion. She seeks reassurance and clear guidance.

  • Concerned about the severity of her symptoms: “Is it normal to have such heavy periods at my age?”
  • Worried about fertility: “Will this make it harder for me to get pregnant?”
  • Anxious about diagnosis: “Could this be something serious like cancer?”
  • Seeking guidance on treatment options: “Are there ways to regulate my periods?”

If the candidate is reassuring and informative, she will engage positively. If the candidate is vague or dismissive, she may become frustrated or push for unnecessary tests.


Questions for the Candidate

Emily will ask some of the following questions, especially if the doctor does not address them directly:

  1. “What could be causing my periods to change like this?”
  2. “Do I need blood tests or a scan?”
  3. “Could this be fibroids, PCOS, or something more serious?”
  4. “Is this related to stress or my lifestyle?”
  5. “How will this affect my ability to get pregnant?”
  6. “Are there treatments that can help regulate my cycles?”
  7. “Will I need to go on the pill, or are there other options?”
  8. “What if this doesn’t improve—what are the next steps?”

Expected Reactions Based on Candidate Performance

If the candidate provides a clear explanation and structured plan:

  • Emily will be reassured and engaged in her management plan.
  • She will accept recommendations for investigations and treatment options.
  • She may say, “That makes sense. I feel better knowing there are ways to manage this.”

If the candidate is vague or dismissive:

  • Emily may appear frustrated or push for unnecessary tests.
  • She might say, “But why has this suddenly changed? Are you sure it’s nothing serious?”

If the candidate does not address fertility concerns:

  • Emily may say, “So, does this mean I won’t be able to have kids?”
  • She might seem distressed or uncertain about next steps.

Key Takeaways for the Candidate

  • Elicit a comprehensive menstrual history, including cycle changes, flow, and symptoms.
  • Consider possible causes, including fibroids, PCOS, endometrial pathology, thyroid dysfunction, and hormonal changes.
  • Arrange appropriate investigations, including:
    • Pelvic ultrasound (assess endometrial thickness, fibroids, ovarian abnormalities).
    • Blood tests (full blood count, iron studies, thyroid function, reproductive hormones).
  • Discuss treatment options, including:
    • Medical management (tranexamic acid, NSAIDs, hormonal therapy).
    • Lifestyle modifications (iron-rich diet, stress management).
  • Address fertility concerns and provide reassurance about management options.
  • Ensure follow-up, particularly if symptoms persist or worsen.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including menstrual patterns, symptom burden, and impact on daily life.

The competent candidate should:

  • Elicit a detailed menstrual history, including cycle length, duration, heaviness of flow, clot size, pain, and associated symptoms.
  • Assess functional impact, including fatigue, dizziness, interference with work, social activities, and quality of life.
  • Screen for red flags, such as sudden change in cycle, post-coital bleeding, intermenstrual bleeding, or severe pain.
  • Gather reproductive history, including contraceptive use, pregnancy plans, and history of infertility or miscarriages.
  • Assess risk factors for underlying pathology, such as family history of fibroids or PCOS, thyroid dysfunction, and clotting disorders.

Task 2: Identify potential underlying causes and recommend appropriate investigations.

The competent candidate should:

  • Consider differential diagnoses, including:
    • Fibroids (heavy, prolonged bleeding, pelvic pressure).
    • PCOS (irregular cycles, weight gain, acne, hirsutism).
    • Endometriosis (severe dysmenorrhoea, pelvic pain outside of menstruation).
    • Thyroid dysfunction (fatigue, weight changes, menstrual irregularities).
    • Bleeding disorders (family history of clotting issues, easy bruising).
  • Order relevant investigations, including:
    • Pelvic ultrasound (assess for fibroids, endometrial thickness, ovarian pathology).
    • Blood tests, such as:
      • Full blood count and iron studies (assess for anaemia).
      • Thyroid function tests (rule out thyroid-related menstrual dysfunction).
      • Serum progesterone or LH/FSH (if PCOS is suspected).
      • Coagulation studies (if there is a history suggestive of bleeding disorder).

Task 3: Provide an initial management plan, including symptom control and addressing patient concerns.

The competent candidate should:

  • Provide symptom relief, including:
    • NSAIDs (e.g., mefenamic acid) to reduce pain and bleeding.
    • Tranexamic acid for heavy menstrual bleeding.
    • Iron supplementation if anaemia is present.
  • Discuss hormonal treatment options, such as:
    • Combined oral contraceptive pill (regulates cycles, reduces bleeding).
    • Progestogen-only options (oral, depot, Mirena IUD) if oestrogen is contraindicated.
  • Address fertility concerns, explaining that most causes of heavy or irregular bleeding can be managed without affecting conception.
  • Provide lifestyle advice, including optimising diet, exercise, and stress management.

Task 4: Discuss further follow-up, including when specialist referral may be required.

The competent candidate should:

  • Arrange follow-up within 6–8 weeks to review symptoms and response to treatment.
  • Refer to a gynaecologist if:
    • Suspected fibroids, PCOS, or endometrial pathology requiring specialist intervention.
    • Severe or persistent symptoms despite medical management.
    • Fertility concerns requiring further assessment.
  • Ensure regular cervical screening and discuss preconception care if pregnancy is planned.

SUMMARY OF A COMPETENT ANSWER

  • Elicits a thorough menstrual and reproductive history, assessing symptoms and impact on daily life.
  • Considers and explains differential diagnoses, including fibroids, PCOS, thyroid dysfunction, and bleeding disorders.
  • Orders relevant investigations, including pelvic ultrasound and blood tests.
  • Provides a clear initial management plan, including medical and lifestyle interventions.
  • Addresses fertility concerns and reassures the patient.
  • Ensures appropriate follow-up and escalation if symptoms persist.

PITFALLS

  • Failing to explore full menstrual history, missing important details such as cycle regularity, clot size, or associated symptoms.
  • Overlooking red flags, such as intermenstrual bleeding, post-coital bleeding, or severe pain.
  • Delaying investigations, leading to missed diagnoses of fibroids or endometrial pathology.
  • Not addressing fertility concerns, leaving the patient anxious about future pregnancy prospects.
  • Providing a generic management plan, without considering individual patient preferences and contraindications.
  • Failing to arrange follow-up, leading to poor monitoring of treatment response.

REFERENCES


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 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations of healthcare and the full impact of their illness experience on their lives.
1.3 Provides clear and structured explanations about diagnosis, prognosis, and management.

2. Clinical Information Gathering and Interpretation

2.1 Takes a focused menstrual and reproductive history.
2.2 Identifies red flags and risk factors for underlying gynaecological pathology.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between common causes of menstrual irregularities (e.g., PCOS, fibroids, thyroid dysfunction).
3.2 Identifies when further investigations or specialist referral is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides evidence-based management options, including medical and lifestyle interventions.
4.2 Addresses symptom control, fertility concerns, and long-term health implications.

5. Preventive and Population Health

5.1 Provides education on menstrual health and lifestyle modifications.
5.2 Encourages screening for related conditions, including anaemia, metabolic syndrome, and reproductive health issues.

6. Professionalism

6.1 Demonstrates empathy and a patient-centred approach to gynaecological concerns.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate follow-up and referrals to specialists where indicated.

8. Procedural Skills

8.1 Performs or arranges relevant investigations, including blood tests and pelvic ultrasound.

9. Managing Uncertainty

9.1 Recognises when menstrual irregularities require urgent escalation (e.g., endometrial pathology, abnormal bleeding).

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies and appropriately manages conditions such as heavy menstrual bleeding, PCOS, and endometriosis.


Competency at Fellowship Level

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