Dysmenorrhoea and heavy menstrual bleeding — branching viva

Station opening

Examiner: "A 15-year-old presents with painful periods that began about a year after menarche. Define dysmenorrhoea and tell me why primary dysmenorrhoea begins at that point and not at the first period." [1]

Strong candidate (must-hit)

• Defines dysmenorrhoea as cyclic pelvic pain with menstruation. Explains that primary dysmenorrhoea begins only once ovulatory cycles establish, typically 6 to 12 months after menarche, because the secretory-phase progesterone of an ovulatory cycle primes the endometrium to synthesise prostaglandins (PGF2α, PGE2) and leukotrienes — the mediators that drive myometrial contraction, vasoconstriction and uterine ischaemia. The very first, anovulatory periods carry a smaller prostaglandin load, so they are often painless. [1] [6]

Weak candidate

• "It is period pain, and it starts from the first period." [1]

Branch A — The management ladder

Examiner: "She has tried some ibuprofen with partial relief. Take me through the stepwise management." [6]

Strong

• First-line is an NSAID at the onset of menses — ibuprofen 400 to 600 mg or naproxen 250 to 500 mg, with food, for 2 to 3 days of bleeding — because NSAIDs block prostaglandin synthesis and are more effective than placebo (Marjoribanks 2010, Cochrane). Second, add the combined oral contraceptive if the NSAID is inadequate or contraception is desired, assessed over three cycles at an adequate dose (Wong 2009, Cochrane, supports the oral contraceptive for primary dysmenorrhoea). Third, review adherence and reconsider a secondary cause. Fourth, refer for pelvic ultrasound and gynaecology. Emphasises that NSAIDs work best started at onset, before the prostaglandin cascade has run. [6]

Weak

• "Give paracetamol, and if it does not work refer to gynaecology." [6]

Branch B — The heavy-from-menarche adolescent

Examiner: "Now a 13-year-old with heavy bleeding from her very first period. She bruises easily and her mother had a hysterectomy for menorrhagia. What is your concern, and what do you do?" [4]

Strong

• The concern is a bleeding disorder — von Willebrand disease is the commonest inherited bleeding disorder in females, and heavy menstrual bleeding from menarche is its most common presentation. Orders a bleeding-disease screen: von Willebrand factor antigen and activity (ristocetin cofactor), factor VIII, with blood-group-aware interpretation, and a platelet count and platelet function screen. Notes the timing caveat that von Willebrand factor levels fall during active bleeding, so a level drawn during heavy bleeding is interpreted in context and repeated when stable. Sends a full blood count and ferritin, and starts medical therapy while the screen returns. Involves haematology when a disorder is confirmed. [4]

Weak

• "It is just heavy puberty bleeding — put her on the pill and see her in six months." [4]

Branch C — The breakthrough-pain trap

Examiner: "A 16-year-old's pain has not responded to an NSAID and three cycles of the combined oral contraceptive. It is non-cyclic, with dyspareunia and dyschezia. What now?" [1]

Strong

• This is secondary dysmenorrhoea until proven otherwise; in the adolescent endometriosis is the leading cause and carries a long diagnostic delay. Arranges pelvic ultrasound and gynaecology referral. Explains that empirical hormonal suppression (the combined oral contraceptive or a progestogen) is first-line for suspected endometriosis in the adolescent, and laparoscopy is reserved for refractory disease. Does not simply switch preparations or continue to reassure. [1]

Weak

• "Switch to a different pill and reassess in three more cycles." [1]

Branch D — Acute severe bleeding

Examiner: "A 14-year-old presents with acute severe heavy menstrual bleeding, presyncope, heart rate 110, haemoglobin 68 g/L. She is sexually active. What is your immediate management?" [4]

Strong

• Establishes intravenous access and resuscitates with isotonic fluids while sending a full blood count, group-and-hold and coagulation. Starts a hormonal taper regimen (combined oral contraceptive or oral progestogen) plus tranexamic acid 1 g three times daily. Does a pregnancy test and a sexually transmitted infection screen because she is sexually active. Transfuses if she remains unstable or critically anaemic, and refers to paediatric gynaecology and haematology. Notes that dilatation and curettage is rarely indicated in the adolescent, and that the levonorgestrel intrauterine system is a long-term option, not the acute step. [4]

Weak

• "Give oral tranexamic acid and discharge with outpatient follow-up." [4]

Branch E — The FIGO classification

Examiner: "Apply the FIGO classification to the causes of adolescent heavy menstrual bleeding. Which arm dominates, and why?" [3]

Strong

• Reproduces PALM-COEIN: the structural PALM arm (Polyp, Adenomyosis, Leiomyoma, Malignancy) and the non-structural COEIN arm (Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not otherwise classified). States that in the adolescent the COEIN arm dominates, because the immature hypothalamic–pituitary–ovarian axis produces anovulatory cycles and coagulopathy is over-represented. The structural PALM causes are rare and are pursued only when the picture is atypical or persistent. [3] [4]

Weak

• "The classification is for older women; it does not really apply to adolescents." [3]

Close

Examiner: "Summarise your approach to the adolescent with dysmenorrhoea and heavy menstrual bleeding in one sentence." [1]

Strong

• "Assess the young person alone with confidentiality framed; split dysmenorrhoea into primary — prostaglandin-driven, beginning after ovulatory cycles establish — and secondary — endometriosis until proven otherwise when NSAIDs and the combined oral contraceptive fail; classify heavy menstrual bleeding with FIGO PALM-COEIN, where the COEIN arm of anovulation and coagulopathy dominates; screen for a bleeding disorder when bleeding is heavy from menarche; and run the NSAID-to-combined-oral-contraceptive ladder for pain and the NSAID-or-tranexamic-acid-to-hormonal-to-levonorgestrel-IUS ladder for bleeding, with iron repletion and follow-up at three cycles." [1] [4]