Abnormal uterine bleeding — KFP-style written assessment

KFP 1 (10 marks)

A 43-year-old nurse reports two years of progressively heavy periods, now with clots flooding through protection on day 2–3, and fatigue. Cycles remain regular at 27 days. She is a non-smoker, BMI 29, takes no medication. Abdominal examination normal; speculum examination shows a healthy cervix; pregnancy test negative. Haemoglobin 104 g/L, MCV 72 fL, ferritin 8 ng/mL. ^{[3] [21]}

1. State the diagnosis using FIGO's current definition, and name the co-diagnosis her blood results establish. (2) ^[3]
2. Which investigations does NICE direct here, and which tests are explicitly avoided? (4) ^[21]
3. Outline first-line management including the iron plan. (4) ^{[21] [4]}

Model answers

1. Heavy menstrual bleeding by FIGO's impact-based definition: excessive menstrual blood loss interfering with quality of life regardless of measured volume. The bloods add iron-deficiency anaemia (Hb 104 g/L, microcytosis, ferritin 8 ng/mL) — a standard companion that changes treatment urgency but not the HMB label itself. ^[3]
2. Full blood count is already done — mandatory for all women with HMB. Because examination is normal and there are no related symptoms (no IMB, no pelvic pain or pressure), NICE permits starting pharmacological treatment without further investigation; if investigating anyway, hysteroscopy versus ultrasound is chosen by history and examination. Avoided tests: female hormone testing, thyroid testing without thyroid symptoms, blind endometrial biopsy, D&C as a diagnostic tool. Ferritin was appropriate given suspected deficiency. ^[21]
3. Offer an LNG-IUS as first treatment — she has no identified pathology — explaining expected bleeding change over initial cycles lasting possibly beyond six months, and waiting at least six cycles to judge benefit. Start oral iron concurrently for the deficiency, rechecking haemoglobin and ferritin to confirm repletion. If she declines the LNG-IUS, offer tranexamic acid and/or NSAIDs during menses (non-hormonal) or combined hormonal contraception/cyclical progestogens (hormonal). ^{[21] [4]}