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You are an FY1 doing a placement in a GP surgery. Your next patient is Angie O’Plasty, a 35-year-old woman complaining of painful periods. She was treated with the combined oral contraceptive pill for dysmenorrhoea in her 20s but has no other significant past medical history. She has come to see you today, as she is worried that there is something going on that has caused her to be unable to have children.

Please take a history from Angie and perform a relevant examination, ensuring that you address Angie’s concerns.

You are Angie O’Plasty, a 35-year-old lady. You live with your husband, Arthur. You have been suffering from painful periods your whole life, but these have recently become much worse. You have been trying for a baby for the last two years but so far haven’t been able to conceive a child.

HPC: You have had painful periods for as long as you can remember, but during your teenage years you chose to put up with this as you thought it was normal. In the last six months, your periods have become much more painful than before, rendering you virtually unable to do anything. You choose to lie in bed all day rather than facing going out as the pain is crippling.

The pain starts just a few days before your period begins, and becomes much worse over the course of the period, settling down as it finishes. The pain occurs in your lower tummy but you can’t pinpoint a particular area that is worse. It is a severe cramping pain that comes in waves. It sometimes goes to your back and to the tops of your legs. In between periods you have a dull ache felt in your lower abdomen on most days; this is tolerable but very uncomfortable.

You also get pain during sex that feels like it’s coming from right inside your pelvis. You haven’t noticed any pain on going to the toilet to pass urine or to open your bowels and you’ve noticed no changes in your urine or stools. You haven’t been going to the toilet more frequently and you haven’t had to rush to the toilet.

You’ve noticed a bit of bleeding between periods over the last few months, but there is no bleeding after sex. You’ve always had heavy periods, so you can’t tell if this has changed.

You feel really tired all the time. You spend a lot of time in bed, and although you are usually a very sociable person, you are seeing your friends less and less as you’d prefer to stay at home instead. You and Arthur have been keen to start a family for a while now. Despite trying every trick in the book for two years, you haven’t been able to conceive a child. Arthur has had tests in the last few months that have shown his side of things is normal.

ICE: The main thing worrying you is your inability to conceive. Most of your friends have now had babies of their own and you feel like you’re losing out and falling behind your friends, unable to share in their joy because of your own jealousy. This has been made worse by the fact that Arthur’s tests came back normal and so you feel guilty as you feel like you are the problem, and you’re holding Arthur back from having a child.

You are very anxious about the worsening pain. You think that there is something inside your tummy that is causing the pain and also making you infertile. You’ve never really thought about the problems you’ve had with periods until now, and you are convinced that there is a link between the period pain and the inability to conceive.

You have become anxious about going to work as being surrounded by children makes you upset.

If you feel able to open up to the doctor, you can tell them that you have been googling your symptoms on the internet and you are worried that this could be cancer, and that you’re going to die and leave Arthur without not only a child, but a wife also. You haven’t discussed your appointment today with Arthur.

You really want answers to your problems, and someone to listen to, as you’ve isolated yourself from your friends and distanced yourself from Arthur.

Past Obstetric/Gynae History: Your last menstrual period finished 4 days ago. You started your periods quite early at age 9. They were irregular to begin with and became regular by age 12 but even then your cycles were only 22 days long. Your periods have always been heavy and painful, and when you were 22 you began taking the combined oral contraceptive pill aiming to alleviate the pain. This worked for some time and you did not have any issues, but the pains began to start again when you came off the pill at age 32 to try and conceive.

Your last smear was two years ago, and it was normal. You have never had an abnormal smear and you’ve always attended your appointments. You have never been pregnant.

PMH: None significant

DH: Paracetamol No allergies

FH: Your mother suffered from painful periods and you also had an episode of her coughing up blood

SH: You live with your husband Arthur in a beautiful detached house in the countryside. You work as a school teacher in a primary school where you teach Year 1 (5-6 year olds). You would never touch a cigarette. You haven’t drank in 2 years as you’re worried it may affect your chances of conceiving.

The candidate should be able to take a good history of the pain that Angie is having and how this is impacting on her life. They should also be able to elicit and explore Angie’s concerns regarding fertility and diagnosis. An abdominal exam would be an appropriate exam in this case.

Differential Diagnosis:

My differential diagnosis would include gynaecological causes of abdominal pain such as endometriosis or pelvic inflammatory disease, or torsion of an ovarian cyst. Given the patient’s long history of dysmenorrhoea, alleviated by the oral contraceptive pill, the patient’s age and her inability to conceive, endometriosis would be high on my list of differential diagnoses. Due to the chronic nature of this pain, acute causes of abdominal pain such as an ectopic pregnancy or appendicitis and other surgical emergencies can be ruled out, although endometriosis can also mimic these conditions.


• What is endometriosis? • How could we investigate Angie’s problems further? • Can you describe the management of endometriosis? • What are some complications of endometriosis: • Are there any ‘red flags’ in Angie’s history that would concern you? • What is menorrhagia? How much bleeding is classified as menorrhagia? • What health care professionals would be involved with Angie’s care?