Heavy menstrual bleeding — structured oral station (12 minutes)

Opening prompt — "Define HMB and tell me what has changed about the definition."

Model response: ^[1][2]

• "The modern definition (NICE NG88 1.1.1) is excessive menstrual blood loss that interferes with the woman's quality of life, regardless of the absolute amount."
• "The classical definition, Hallberg 1966, was menstrual blood loss of 80 mL or more per cycle measured by the alkali-haematin method. Above that threshold, iron-deficiency anaemia became measurably more common."
• "The 80 mL number is now a historical and epidemiological anchor — we no longer collect or measure menstrual blood in clinic; the woman's quality of life is the threshold."^[1][2]

Probe 1 — "She has a 12-week palpable uterus. How does that change your investigation pathway?"

• "A palpable uterus or a pelvic mass is an indication for pelvic ultrasound (NICE NG88 1.3.12). I would image her uterus to map the size, number and location of any fibroids, because that determines whether she fits the LNG-IUS pathway or needs specialist referral."
• "I would also do a full blood count and iron studies — her ferritin is likely low given 8 months of heavy bleeding."^[2]

Probe 2 — "Her ultrasound shows three fibroids, the largest 4.5 cm, intramural and not distorting the cavity. What now?"

• "Fibroids 3 cm or larger are a trigger for specialist referral (NICE NG88 1.5.8). This woman's largest fibroid is 4.5 cm, so she needs gynaecology referral for additional investigations and discussion of treatment options."
• "While she waits for definitive treatment, I can offer tranexamic acid and/or NSAIDs as a bridge (NICE NG88 1.5.9). I would be cautious about the LNG-IUS here — pharmacological effectiveness may be limited when fibroids are substantially greater than 3 cm (1.5.15)."^[2]

Probe 3 — "She asks whether she can just have 'a pill' rather than surgery. How do you counsel her?"

• Communication domain — demonstrate it out loud: ^[2][3]
• "I would move to her eye level, acknowledge her preference, and explain that the pill (tranexamic acid or NSAIDs) is a reasonable first bridge while we plan definitive treatment — but that her fibroids may limit how well a pill alone works."
• "I would lay out the options clearly: medical bridging, the LNG-IUS, second-generation endometrial ablation, myomectomy (which preserves fertility), uterine artery embolisation, and hysterectomy as the definitive cure. I would ask about her fertility wishes and her priorities."

Probe 4 — "A colleague suggests a blind Pipelle biopsy to check the endometrium. Do you agree?"

• "No. NICE NG88 1.3.11 explicitly recommends against blind endometrial biopsy. If I am sampling the endometrium, I should be in the cavity looking at it — outpatient hysteroscopy with directed biopsy. The indications in this woman would be persistent IMB or endometrial pathology risk factors (1.3.10); with simple HMB and a fibroid, the threshold is higher."
• "Dilatation and curettage alone is also out as a diagnostic tool (1.3.18) and as a treatment (1.5.23)."^[2]

Probe 5 — "How would your first-line choice differ if she were 19 with no fibroids and no examination findings?"

• "In a 19-year-old with simple HMB and no related symptoms, I would offer the LNG-IUS first-line (NICE NG88 1.5.2), and I would screen for a bleeding disorder if she had HMB since menarche plus a positive family history (1.2.7). I would not routinely image or biopsy — NICE NG88 1.3.1 allows treatment without investigation in a low-risk woman."
• "Anovulation and bleeding disorders predominate in adolescents; invasive investigation is not first-line."^[2]