Woman of 45 with 2 Years of Heavy Periods — Free SCA Practice Case

Character Overview: You are Fiona, a 45-year-old office manager. You are worn down and frustrated — two years of heavy, unpredictable periods have taken over your life, and you are tired all the time. You have finally come to get it sorted and you want action. You are cooperative and will engage, but you want to feel taken seriously rather than fobbed off with "it's your age."

Opening Sentence: "Hi Doctor. For about two years now my periods have been really heavy — I'm flooding through pads and tampons, passing clots, and I dread going out during them. I'm shattered all the time. I've put up with it long enough — I want to know what can be done."

History if Asked (Data Gathering Phase)

• ●The bleeding: "Heavy — I'm changing protection every hour or two on the worst days, doubling up, flooding onto my clothes and bedding. Big clots. It lasts seven or eight days."
• ●The cycle: "Fairly regular, every four weeks or so, but the bleeding itself has got heavier and heavier over the two years."
• ●Impact: "I plan my life around it — I've missed work, avoided going out, ruined clothes. I'm drained and my energy's rock bottom."
• ●Anaemia symptoms: "I'm tired all the time, a bit breathless on the stairs, and people say I look pale."
• ●Other bleeding: "No bleeding between periods, and none after sex."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores her perspective.

• ●Ideas: Fiona assumes it is "just her age / the change starting" and has put up with it, but she is no longer willing to. She has not thought about what might be causing it. "I figured it's my age, the menopause starting, and you just have to grin and bear it — but I can't anymore."
• ●Concerns: She is worried about how much it is affecting her life and energy, and — when gently explored — has a background fear that heavy bleeding "could be something sinister." "Mostly it's the exhaustion and my life being on hold. But there's a niggle at the back of my mind — could it be something serious, cancer even?"
• ●Expectations: She wants effective treatment and to feel heard, not dismissed. "I want something that actually works, and I don't want to be told it's just my age and sent away."

If Asked — Medical History and Medications

The patient confirms these details only when directly asked.

• ●Obstetric/gynae history: "Two children, normal births. Smears up to date and normal. No previous gynae problems."
• ●Contraception: "Not using any at the moment. My husband and I aren't planning any more children."
• ●PCOS/hormonal features: "My cycles have always been regular. No excess hair or acne."
• ●Bleeding disorder history: "No, I don't bruise easily, and I didn't have heavy bleeding as a teenager — this is new over the last couple of years."
• ●Family history: "No family history of womb or bowel cancer that I know of."

Social History and Lifestyle Impact

Fiona is an office manager. She lives with her husband and two teenage children.

• ●Weight: "I've put weight on over the last few years — my BMI's about 31, I was told. I know I could lose some."
• ●Work: "Office job. The flooding at work is mortifying — I've had accidents."
• ●Smoking/alcohol: "Non-smoker. A couple of glasses of wine at the weekend."
• ●Mood/energy: "The tiredness is really getting me down. I've no energy for anything."

If Asked — Red-Flag Screen

The patient answers these only when directly asked.

• ●If asked about intermenstrual bleeding: "No, no bleeding between periods."
• ●If asked about postcoital bleeding: "No, no bleeding after sex."
• ●If asked about pelvic pain, pressure, or bloating: "Some dragging heaviness low down during my periods, but no severe pain, and no bloating or pressure otherwise."
• ●If asked about unintentional weight loss: "No — if anything I've gained weight."
• ●If asked about postmenopausal-type bleeding: "No, I'm still having regular periods."
• ●If asked about symptoms of anaemia (fatigue, breathlessness, palpitations, dizziness): "Yes — tired all the time, breathless on stairs, occasional palpitations."
• ●If asked about cervical screening: "Up to date and normal."

Responses to Management (The Negotiation Phase)

• ●If the Doctor recommends the intrauterine system (hormonal coil) as first-line: "A coil? I thought that was just for contraception. How does that help heavy periods?" (The tested point is explaining the levonorgestrel intrauterine system as the first-line treatment for heavy menstrual bleeding, where appropriate.)
• ●If the Doctor recommends blood tests and an internal scan: "Why do I need a scan and blood tests? Can't you just give me something?" (The tested point is explaining the need for a full blood count and, given her age and BMI, assessment for endometrial pathology.)
• ●If the Doctor raises her weight and endometrial risk: "What's my weight got to do with my periods?" (The tested point is explaining the link between raised BMI, hormones, and the lining of the womb — sensitively.)
• ●If the Doctor addresses the "it's just my age" belief: "So it's not just the menopause starting? I assumed I had to put up with it."
• ●If the Doctor safety-nets: "What would mean I need to be seen more urgently?"