Cases/Gynaecology and Breast

Woman Told Her Ultrasound Scan Shows Fibroids — Free SCA Practice Case

Woman told her ultrasound scan shows fibroids

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Priya Sharma

Age

35 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. The patient has booked a call to discuss the results of a pelvic ultrasound.

Reason for Encounter

"Hi Doctor, I've come to discuss my scan results — I had it done because of my heavy periods."

Medical Records

●PMH: Iron-deficiency anaemia secondary to heavy menstrual bleeding.
●Medications: Ferrous sulfate 200 mg OD (recently stopped by patient). Microgynon 30 — stopped 9 months ago (to try to conceive).
●Allergies: NKDA. Cervical screening up to date and normal.
●Recent notes (2 weeks ago): Heavy menstrual bleeding since stopping the combined pill 9 months ago. Microcytic anaemia, Hb 109 g/L. Pelvic examination unremarkable, no masses. Ferrous sulfate started; pelvic ultrasound requested.
●Pelvic ultrasound report: Enlarged uterus with multiple intramural and subserosal fibroids; largest posterior fibroid 4.2 cm. Endometrial thickness normal for cycle phase. Both ovaries normal. No adnexal mass or free fluid. Conclusion: multiple uterine fibroids, largest 4.2 cm; clinical correlation advised.

Patient Script

For the friend playing the patient role

Character Overview: You are Priya, a 35-year-old solicitor. You are articulate and organised, and you have come to understand your scan and get a plan. Your heavy periods have returned since you stopped the pill to try for a baby, and they are affecting your life and your energy. You are worried about two things above all: getting the bleeding under control, and whether this will stop you getting pregnant. You are cooperative and want clear answers.

Opening Sentence: "Hi Doctor. I'm calling about my scan results. I had it because my periods have been really heavy since I came off the pill — my husband and I are trying for a baby. I'd like to understand what the scan showed and what we do about it."

History if Asked (Data Gathering Phase)

●The bleeding: "Really heavy — flooding, changing protection every couple of hours on the worst days, lasting about a week. It came back about seven months ago, after I'd been off the pill a couple of months. It was well controlled on the pill before that."
●Pattern and pain: "My cycle's regular, every 28 days. It's not especially painful — it's the amount of bleeding that's the problem."
●Trying to conceive: "We've been trying for about nine months, since I stopped the pill. Nothing yet, which is starting to worry me — and now these fibroids."
●Impact: "I've had to take time off work with the bleeding and the tiredness. It's really wearing me down."
●Iron tablets: "I stopped the iron tablets a couple of weeks ago — they were making me really constipated. I didn't know what to do instead."

ICE — Ideas, Concerns, Expectations

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

●Ideas: Priya is not sure what is causing the heavy bleeding and does not really know what fibroids are or whether they are dangerous. "I don't really know what fibroids are, if I'm honest. Are they serious? Are they something to worry about?"
●Concerns: Her two dominant concerns are getting the bleeding controlled and, above all, whether the fibroids will stop her conceiving. There is also a quieter worry that anything growing in the womb "could be cancer." "The bleeding is exhausting, but the thing that really frightens me is whether this means I can't have a baby. And — is there any chance it's something sinister?"
●Expectations: She wants the scan explained, the cause of the bleeding clarified, treatment recommended, and advice on the iron tablets. "I want to understand the scan, get the bleeding sorted, know what it means for having a baby, and know what to do about the iron tablets."

If Asked — Medical History and Medications

The patient confirms these details only when directly asked.

●Gynae history: "Never been pregnant. Smears up to date and normal. No pain or bleeding with sex."
●Contraception: "Not using anything now — we're trying to conceive."
●Family history: "My sister had similar heavy periods and was told she had fibroids too."
●Iron tablets: "Ferrous sulfate once a day, but the constipation was awful so I stopped."
●Allergies: "None."

Social History and Lifestyle Impact

Priya is a solicitor. She lives with her husband. They are trying to conceive.

●Work: "Full-time solicitor, demanding job. The heavy days and the tiredness have meant time off, which I hate."
●Lifestyle: "I don't smoke or drink. I try to eat well."
●Impact: "It's affecting work, my energy, and it's hanging over the whole trying-for-a-baby thing."

If Asked — Red-Flag and Pressure-Symptom Screen

The patient answers these only when directly asked.

●If asked about intermenstrual bleeding: "No, no bleeding between periods."
●If asked about postcoital bleeding or pain with sex: "No, none of that."
●If asked about pressure symptoms (urinary frequency/urgency, bloating, constipation from pressure): "Not really — no urinary problems or bloating that I've noticed."
●If asked about anaemia symptoms (dizziness, breathlessness, palpitations, chest pain): "I do feel tired, and occasionally light-headed, but no chest pain or racing heart."
●If asked about weight loss or feeling generally unwell: "No weight loss, I feel well apart from the tiredness."
●If asked about difficulty conceiving duration: "About nine months of trying."

Responses to Management (The Negotiation Phase)

●If the Doctor explains fibroids are benign growths causing the heavy bleeding: "So fibroids aren't cancer? They're causing the heavy bleeding? Can they be got rid of?" (The tested point is explaining the benign nature of fibroids and correlating them with her symptoms, reassuring her about cancer.)
●If the Doctor recommends gynaecology referral: "Do I need to see a specialist? Why can't it just be sorted here?" (The tested point is explaining the referral criteria — fibroid over 3 cm and fertility concerns — and what the specialist can offer.)
●If the Doctor offers tranexamic acid in the meantime: "Is that safe while we're trying for a baby? What does it do?" (The tested point is offering a non-hormonal option that does not prevent conception, and explaining it — recognising hormonal treatments are unsuitable while trying to conceive.)
●If the Doctor advises restarting iron: "But the iron tablets constipated me so badly. What am I supposed to do?"
●If the Doctor addresses the fertility worry: "Will the fibroids stop me getting pregnant? Is that why it's not happening?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Uterine Fibroids

●Fibroids (leiomyomas) are benign smooth-muscle growths of the uterus. They are very common, often asymptomatic, and a frequent cause of heavy menstrual bleeding, and can cause pressure symptoms (urinary, bowel) and, depending on location, affect fertility.
●They are classified by location: submucosal (into the cavity — most likely to affect bleeding and fertility), intramural (within the wall), and subserosal (on the outer surface).

Explaining an Imaging Result and Correlating with Symptoms

●An ultrasound finding must be correlated clinically: fibroids explain heavy bleeding, but the management depends on the symptoms, size, location, and the woman's priorities (here, fertility) — not on the scan alone.
●Reassure about the benign nature while remaining accurate (rapid or postmenopausal growth would prompt different, urgent assessment).

Referral Criteria for Fibroids

●Refer to gynaecology if fibroids are >3 cm, submucosal, distorting the uterine cavity, causing pressure symptoms, associated with fertility concerns or subfertility, or where symptoms cannot be controlled in primary care.
●Postmenopausal growth of fibroids raises concern for other pathology and warrants urgent referral.

Treatment Spectrum

●Options range from watchful waiting (small, asymptomatic fibroids) through medical treatment to procedures.
●Medical: non-hormonal (tranexamic acid, NSAIDs) and hormonal (LNG-IUS, combined pill, progestogens) — but hormonal options are unsuitable when trying to conceive.
●Procedural/surgical: myomectomy (removes fibroids, preserves fertility), uterine artery embolisation, and hysterectomy (definitive, ends fertility) — chosen with the specialist according to symptoms, size, and fertility wishes.

Fibroids and Fertility

●Fibroids can affect fertility depending on type and location — submucosal fibroids and those distorting the cavity are most relevant. Specialist assessment guides whether treatment (e.g. myomectomy) would help.

Managing Iron-Deficiency Anaemia and Iron Intolerance

●Fibroid-related heavy bleeding commonly causes iron-deficiency anaemia. Treat with oral iron, and manage the common side effect of constipation by alternate-day dosing (which is as effective and better tolerated), taking iron with orange juice/food, or adding a laxative — rather than stopping treatment.

Tranexamic Acid

●Tranexamic acid is a non-hormonal antifibrinolytic that reduces menstrual blood loss and does not prevent conception, making it suitable while trying to conceive. Counsel on the small venous thromboembolism risk and when to seek help.

Common Candidate Mistakes in This Case

●Offering a hormonal treatment while she is trying to conceive: prescribing the pill or a coil, which would prevent the pregnancy she wants.
●Not referring despite clear criteria: missing that a fibroid >3 cm with fertility concerns warrants gynaecology referral.
●Ignoring the iron-tablet problem: failing to address the constipation that made her stop iron, leaving her anaemia untreated.
●Not addressing the fertility fear: focusing on the bleeding and neglecting her central concern about conceiving.
●Poor result-explanation: failing to reassure clearly that fibroids are benign, leaving a cancer fear unaddressed.

Free MRCGP SCA practice case for GP registrars covering Woman Told Her Ultrasound Scan Shows Fibroids — Gynaecology and Breast. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

← Back to Free SCA Practice Cases