Station 23 · Heavy periods

Candidates: do not open until you have consulted.

Persona and manner

• Sandra Kelly, 44, a supervisor on a supermarket shop floor; direct, tired, embarrassed by the bleeding and determined to sort it; you have read about HRT online and about your mother's breast cancer.
• You are open if the doctor is matter-of-fact; you bristle if told to lose weight or stop smoking before anything else is offered.

Opening line (verbatim)

• “My periods have gone mad — heavy, every three weeks, and I'm flooding through everything at work. I'm getting hot flushes as well. I need something to stop the bleeding. I'm not keen on HRT though, my mum had breast cancer.”

The story

• “For about a year the periods have been heavier and closer. Now it's every three weeks, seven or eight days, and on the worst two days I'm changing a super tampon and a pad every hour. Clots the size of a two-pence piece.”
• “I've had to go home from work twice. I keep a spare uniform in my locker.”
• If asked: no bleeding between periods; no bleeding after sex; no pelvic pain beyond cramps; some pressure in the lower abdomen and needing to pass water more often.
• Flushes: five or six a day, and night sweats that wake you two or three times a week; sleep broken; irritable; “my memory's gone”; low mood on bad days but not depressed; libido “not interested”.
• If asked: no vaginal dryness yet; no urinary infections.
• Tired; breathless carrying boxes at work, which is new. No chest pain.
• Your mother had breast cancer at 67, treated with surgery and tablets; alive and well. No ovarian or bowel cancer in the family. No clots in the family; no clots yourself.
• You smoke ten a day; alcohol a bottle of wine over the weekend. Not pregnant: your partner had a vasectomy.
• If asked what you know about HRT: “It gives you breast cancer, doesn't it? And it's all through the papers.” You would consider it “if the risk was small and I understood it”. If asked about a coil: “I had one years ago and it was awful.” You would consider it if the reason was explained.

Ideas, concerns and expectations

• Idea: “It's the change, isn't it. And I'm anaemic, the nurse said.”
• Concern: Breast cancer like your mum if you take HRT; being told it is your weight; losing your job.
• Expectation: Something to stop the bleeding, this month.

Impact

• Work: twelve-hour shifts; the flooding; the spare uniform; two early finishes; your manager has noticed.
• Home: your partner is kind but you are too tired to talk; the night sweats wake him too.
• Driving and money: fine while you are working.

Red flags

• Present: Iron-deficiency anaemia with exertional breathlessness; pressure symptoms and urinary frequency that raise the question of fibroids; a first-degree relative with breast cancer that shapes the HRT conversation.
• Absent: No intermenstrual or post-coital bleeding; no post-menopausal bleeding (she is still menstruating); no weight loss; no pelvic mass known.
• Absent: No personal or family history of venous thromboembolism; no migraine with aura.

Hidden facts and their triggers

• The pressure in the lower abdomen and the urinary frequency — released only if asked about pressure symptoms or the bladder
• The breathlessness carrying boxes — released only if asked about exertion or breathing
• That she would consider HRT if the risk was small and she understood it — released only if the doctor asks what would change her mind, after exploring what she has read
• That she had a coil years ago and found it awful — released only if a coil is raised
• That her manager has noticed — released only if asked about work

Behaviour

• Minute 1: “I'm not keen on HRT though, my mum had breast cancer.”
• Minute 4, if told to lose weight or stop smoking before anything else: “I came about the bleeding.”
• Minute 7, if a coil is proposed without the reason: “I had one years ago and it was awful.”
• If the doctor takes the bleeding seriously, explains the anaemia and treats it, examines or arranges examination and a scan because of the pressure symptoms, offers a treatment for the bleeding now and explains the coil as the best long-term option with why, talks about the flushes and the HRT question in numbers that include your mother, and plans a review: engaged. “So the coil would sort the bleeding and I could still have HRT later?” and “What's the actual risk, with my mum?”
• If the doctor prescribes tranexamic acid and iron and nothing else: “Thanks.” Leave.
• If the doctor says HRT is out of the question because of your mother: “That's what I thought.” Withdraw.
• If the doctor dismisses the flushes as not the problem today: “They're half the problem.”

Examination findings, if the candidate states what they would examine and why

• If the candidate explains and asks: blood pressure 126/82; BMI 29; pale conjunctivae; abdomen: a firm, non-tender mass arising from the pelvis to about 12 weeks' size; a pelvic examination, with consent, finds an enlarged, irregular uterus and no adnexal mass; the cervix looks normal.

Domain grades — with the key facts that earn a clear pass at this station

Global rating (recorded, not added to the total): ☐ Fail ☐ Bare Fail ☐ Bare Pass ☐ Pass

The domain grades (RCGP descriptors): CP clear pass — above the standard of a newly qualified, independent GP · P pass — sufficiently demonstrated at the standard · F fail — insufficiently demonstrated at the standard · CF clear fail — clearly demonstrated below the standard.

The RCGP grades each domain CF, F, P or CP and weights clinical management and medical complexity against the other two domains; the examination's maximum is 126 over twelve cases, which is 10.5 per case. The RCGP does not publish the mark each grade carries. MD Acumen's training sheet uses CF 0 · F 1 · P 2 · CP 3, with clinical management weighted ×1.5 (0 · 1.5 · 3 · 4.5), so that a case is marked out of 10.5 and a twelve-case circuit out of 126. A P in all three domains is 7.0; MD Acumen treats that line as the training standard for a case. The examination's pass mark is set by borderline regression for each diet and is published in the RCGP's diet summary reports; it is not a fixed fraction of 126.

Weighting rationale, in the RCGP's words: “To reflect the capability coverage within the clinical management and medical complexity domain this is weighted in comparison to the other two domains.”

Written to the standard of a newly qualified independent GP; the clear-pass row describes practice above that standard. It is a debriefing aid, not a checklist: the grade is a judgement that the essentials, the italic key facts on the mark sheet, were done well, at the patient's pace and in plain language. MD Acumen training standard; the RCGP does not publish case mark sheets.

Where candidates lose this station

• Leading with weight and smoking, so that she says “I came about the bleeding” and the consultation is spent recovering (statement R5)
• Prescribing tranexamic acid and iron and nothing else, with no examination or scan despite the pressure symptoms (statement C3)
• Ruling out HRT because her mother had breast cancer, without the numbers, so that she says “That's what I thought” and withdraws (statement C7)

What the examiner is listening for in the last four minutes

By 8:00 the working diagnosis should have been stated: heavy bleeding in the perimenopause with iron-deficiency anaemia and probable fibroids, with the flushes alongside. The examiner is listening for: iron with a repeat count and tranexamic acid from this cycle; the examination and the scan with their purpose; the coil explained as the first-line long-term treatment and why it is not the coil she remembers; the HRT risk in numbers that include her mother, and the choice left with her; a safety-net for flooding, faintness and breathlessness; the review with the scan and the count; and her own words on what she will do this month.

The ten statements below are postulated: the feedback an examiner would most likely attach at this station, chosen from the RCGP's standardised list of 26 feedback statements that applies to every SCA case and spans the three marking domains (Data Gathering and Diagnosis; Clinical Management and Medical Complexity; Relating to Others). They are a prediction from the case content, its complexity and the marks that matter, not an examiner's record: any statement on the full list can be attached to any case, and feedback plays no part in the mark. Record the statements that applied in the practice log.

The full list of 26 statements, with the generic meaning of each, is on the exam and the mark scheme.

Points of fact the examiner should have to hand

Each statement is drawn from the named guideline, in its current version, with the date it was checked. The examiner marks against these facts; the candidate is not expected to quote them.

1. Take a history of heavy menstrual bleeding covering the nature of the bleeding, related symptoms such as pressure symptoms and pelvic pain, intermenstrual and post-coital bleeding, and impact on quality of life; take a full blood count; offer a physical examination before investigation or treatment where there are related symptoms or a history suggesting structural pathology. NICE — NG88 Heavy menstrual bleeding: assessment and management, section 1.1, history and examination; section 1.2, laboratory tests, 2018, last updated May 2021, checked 10 Oct 2026
2. Offer a pelvic ultrasound as the first-line investigation when the uterus is palpable abdominally, there are pressure symptoms or a pelvic mass, or the history suggests structural pathology; consider hysteroscopy if the history suggests submucosal fibroids, polyps or endometrial pathology, including persistent intermenstrual bleeding or risk factors for endometrial disease. NICE — NG88 Heavy menstrual bleeding: assessment and management, section 1.3, investigations: imaging and hysteroscopy, 2018, last updated May 2021, checked 10 Oct 2026
3. Offer the levonorgestrel intrauterine system as first-line treatment for heavy menstrual bleeding with no identified pathology, fibroids under 3 cm or suspected adenomyosis; if declined or unsuitable, consider tranexamic acid or an NSAID, or the combined pill or cyclical oral progestogen; for fibroids of 3 cm or more, consider referral for further treatment options. NICE — NG88 Heavy menstrual bleeding: assessment and management, section 1.5, management, 2018, last updated May 2021, checked 10 Oct 2026
4. Oral iron (ferrous sulfate 200 mg daily or on alternate days) treats iron-deficiency anaemia; check the full blood count after two to four weeks and continue for three months after the haemoglobin normalises; the cause of the iron deficiency is treated alongside. NICE CKS — Anaemia, iron deficiency, management: treatment and monitoring, current online version, checked 10 Oct 2026
5. Diagnose perimenopause in a woman over 45 on vasomotor symptoms and irregular periods without laboratory tests; offer HRT for vasomotor symptoms after discussing the short-term and longer-term benefits and risks; a family history of breast cancer in one relative diagnosed over 50 is not a contraindication and the risk is discussed in absolute terms. NICE — NG23 Menopause: identification and management, section 1.2, diagnosis; section 1.4, managing short-term menopausal symptoms; section 1.6, breast cancer, 2015, last updated April 2026, checked 10 Oct 2026
6. The NICE discussion aid gives breast cancer in absolute numbers: of 1,000 women aged 50 to 59 not taking HRT, about 59 develop breast cancer over the next 20 years; with five years of oestrogen-only HRT about 69, and with five years of combined HRT about 79; the levonorgestrel intrauterine system can provide the progestogen component of HRT while treating the bleeding. NICE — NG23 Menopause: identification and management, discussion aid on HRT and breast cancer, table 2 and the patient discussion aid, November 2024 (within NG23 as updated April 2026), checked 10 Oct 2026
7. Transdermal rather than oral HRT is preferred for women at higher risk of venous thromboembolism, including those with a BMI over 30, and for women who smoke the thrombotic risk of oral oestrogen is a further reason to prefer the transdermal route. NICE — NG23 Menopause: identification and management, section 1.6, long-term benefits and risks: venous thromboembolism, 2015, last updated April 2026, checked 10 Oct 2026
8. Refer women on a suspected-cancer pathway for endometrial cancer if aged 55 and over with post-menopausal bleeding, and consider it under 55; consider a direct-access ultrasound for women aged 55 and over with unexplained vaginal discharge or visible haematuria with low haemoglobin, raised platelets or high glucose; in a menstruating woman of 44, persistent intermenstrual bleeding is the symptom that prompts endometrial assessment. NICE — NG12 Suspected cancer: recognition and referral, section 1.5, gynaecological cancers: endometrial, 2015, last updated 2025, checked 10 Oct 2026
9. A full blood count is taken for every woman with heavy menstrual bleeding; thyroid function only with thyroid symptoms, a coagulation screen only if bleeding has been heavy since menarche or there is a family history of a bleeding disorder; ferritin is not routine. Endometrial assessment by hysteroscopy or biopsy is arranged for persistent intermenstrual bleeding, for a woman aged 45 or over with treatment failure or ineffective treatment, or with risk factors for endometrial cancer such as obesity, diabetes or tamoxifen. NICE CKS — Menorrhagia (heavy menstrual bleeding), management: investigations; referral for endometrial assessment, current online version, checked 10 Oct 2026
10. Tranexamic acid for heavy menstrual bleeding: 1 g three times a day for up to four days, started when menstruation begins, increased if needed to a maximum of 4 g a day; it is taken only on bleeding days, does not regulate the cycle and is not a contraceptive. It is contraindicated with a history of venous or arterial thrombosis, a history of convulsions or severe renal impairment. BNF (NICE) — Tranexamic acid, indications and dose: menorrhagia; contra-indications; cautions, current BNF online, checked 10 Oct 2026
11. A woman with a uterus who takes HRT needs a progestogen. While she is still having periods, or within twelve months of her last period, the regimen is sequential (cyclical) combined HRT, with a monthly withdrawal bleed; continuous combined HRT, with no bleed, is for post-menopausal women (twelve months without a period, or aged 54 and over). HRT is not a contraceptive. Unscheduled bleeding is common in the first three months; bleeding that persists beyond them, or starts after a bleed-free interval, is investigated. NICE CKS — Menopause, management: choosing an HRT regimen; follow-up and unscheduled bleeding, current online version, checked 10 Oct 2026
12. The November 2024 update to NG23 recommends considering cognitive behavioural therapy, including digital CBT, for vasomotor symptoms, sleep disturbance and low mood or anxiety associated with the menopause, alongside HRT or as an alternative for a woman who does not want HRT or cannot take it. NG23 also states that HRT does not increase cardiovascular disease risk when started in women under 60. NICE — NG23 Menopause: identification and management, section 1.4, managing short-term menopausal symptoms: psychological interventions (2024 update); section 1.6, cardiovascular disease, 2015, last updated April 2026, checked 10 Oct 2026
13. The Gynaecology and breast health Topic Guide expects the GP to assess and manage heavy menstrual bleeding and menopausal symptoms in primary care, to prescribe HRT after an individualised discussion of benefits and risks that includes the family history, to recognise the indications for gynaecological referral and the suspected-cancer pathway, and to reach decisions with the woman that take account of her work and her preferences. RCGP — GP curriculum: Gynaecology and breast health, Topic Guide: menstrual disorders; the menopause and HRT; referral and cancer pathways, 2025 curriculum (Being a GP), checked 10 Oct 2026

Working references for this station

13 statements, 786 words. Every statement is signed by the Course Director before it is published; a station whose facts have changed since signature carries no signature line until it is signed again.

Record your three domain grades, your case total out of 10.5, your global rating, the RCGP feedback statements that applied, and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.

Record my marks and reflection for SCA-23