Menstrual disorders in adolescents — OSCE: heavy menstrual bleeding assessment and plan

Station objectives

1. Establish a confidential adolescent frame with conditional confidentiality. [1]
2. Take an objective menstrual history using FIGO descriptors and practical volume prompts. [2] [5]
3. Justify a focused work-up including pregnancy test, full blood count, ferritin, and von Willebrand screening. [3] [4]
4. Agree a shared, mechanism-based management plan with iron treatment and follow-up. [3]

Candidate brief

You are the paediatric doctor in adolescent clinic. You have 12 minutes. A 14-year-old, 18 months post-menarche, reports flooding, clots, menses lasting 9 to 10 days, fatigue, and missed school. Her mother is present and says heavy periods "run in the family." Examiners score process, safety, partnership language and the clinical accuracy of the work-up. [1] [3]

Station tasks

1. Confidential frame. Greet the young person, set a joint agenda, create time alone, and state conditional confidentiality with its limits. [1]

2. Menstrual history in FIGO terms. Ask cycle length, days of bleeding, flooding, clots, soaks per hour, and impact on school and sport. Describe the pattern as heavy and prolonged bleeding. Ask whether bleeding has been heavy from the very first period and about bruising, epistaxis and family history. [2] [5]

3. Work-up rationale. Justify: pregnancy test, full blood count and ferritin (anaemia, iron deficiency), TSH, prolactin, free testosterone (endocrine gates), and a coagulation screen with a von Willebrand panel because about one in five adolescents referred for HMB has an underlying bleeding disorder. Reserve pelvic ultrasound for suspected structural cause. [3] [4]

4. Shared plan. Treat iron deficiency with oral iron and recheck at about 3 months; offer combined hormonal contraception (or the 52 mg levonorgestrel intrauterine system) for cycle control, with tranexamic acid during menses if hormonal therapy is declined or contraindicated; arrange follow-up; address school attendance; document sensitively. [3]

Marking anchors

Clear pass: secures time alone and conditional confidentiality; describes bleeding in FIGO terms; justifies von Willebrand screening with the correct prevalence; agrees a mechanism-based plan with iron treatment and follow-up; uses non-judgemental, partnership language. [1] [3] [4] Borderline: good rapport but vague work-up rationale, missed iron treatment, or unclear follow-up. Fail: no private time; no pregnancy test; classifies bleeding as "normal for teenagers"; ignores anaemia; parent answers every sensitive question. [1] [3]

Debrief pearls

• The cycle is a vital sign; abnormal means investigate. [1]
• Heavy bleeding from menarche → screen von Willebrand disease. [4]
• Always treat iron deficiency alongside the bleeding. [3]
• Confidentiality and the pregnancy test go together. [1]