Uterine fibroids — structured oral station (12 minutes)

Opening prompt — "Classify her fibroids and tell me which one is driving the bleeding"

Model response: ^[2][3]

• "The submucosal fibroid projecting into the cavity with a small intramural component is FIGO type 1 — submucosal, less than 50 per cent intramural. The others are intramural, type 4."
• "FIGO type, not size, predicts the symptom. The type 1 submucosal fibroid is the one most likely driving her heavy bleeding — it distorts the endometrial venules and the myometrium over it cannot contract to clamp them. The intramural fibroids are more likely contributing to her bulk and girth."^[2][3]

Probe 1 — "What is your initial workup?"

• "Exclude pregnancy first. Confirm uterine origin on bimanual exam; saline-infusion sonography to map the cavity component; FBC and ferritin — she is likely iron deficient; and a coagulation and von Willebrand panel if bleeding has been heavy since menarche."^[1][3]

Probe 2 — "Her ferritin is 8. How does that change your plan?"

• "She has iron-deficiency anaemia from chronic heavy bleeding. I replete iron (oral or intravenous), and I can use a short course of medical therapy to stop the bleeding and shrink the fibroids ahead of any surgery — that improves her operative safety and reduces transfusion."^[1]

Probe 3 — "Walk me through your medical options"

• "Tranexamic acid and NSAIDs first for cyclic control; the levonorgestrel intrauterine system — the most effective non-surgical option; a GnRH analogue with add-back for short-term volume reduction; or the modern oral GnRH antagonist relugolix combination (relugolix 40 mg plus oestradiol 1 mg plus norethindrone acetate 0.5 mg once daily), which avoids the flare and the separate add-back."^[1][5]

Probe 4 — "Her friend took ulipristal acetate. Would you?"

• "Ulipristal works — PEARL showed around 90 per cent bleeding control — but the EMA restricted it after reports of serious liver injury, including transplants. It is now second-line and short-course: baseline and on-treatment liver function tests, contraindicated in pre-existing liver disease, and not recommended in women seeking fertility. I would not choose it first-line for this family-incomplete woman."^[4]

Probe 5 — "She is frightened she will need a hysterectomy and lose her fertility. What do you say?"

This is a scored communication domain — demonstrate it out loud: ^[1]

• Move to her eye level, acknowledge the fear, and give the structure: "There are uterus-sparing options that fit your goal of preserving fertility. The submucosal fibroid can be removed through the cervix with a camera (hysteroscopic myomectomy), and we treat the bleeding medically first. A hysterectomy is not on the table for you unless everything else fails, and I will explain every option as we go."
• Offer a clear plan, a timeline, and a named contact between visits.^[1]