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Miss Fever is a 17 year old girl presenting to her GP with menstrual symptoms.

Please take a history and carry out the relevant examination for this lady. You will then be asked to present your differential diagnosis and discuss aspects of this lady’s case.

You are a 17 year old girl called Scarlett, who has come to her GP alone due to problems with your periods.

HPC: You suspect your periods have always been on the heavy side, but you’ve never known any different. You bleed for 5 days out of a regular 28-day cycle, and this hasn’t changed. You usually have to change your sanitary pads every couple of hours, and occasionally have to ‘double up’ due to flooding. This has been the same since you first started your periods, aged 11. Your periods are extremely painful (7/10), to the extent that you have to miss school/college when you’re on. The pain is crampy in nature and feels like it’s just below and behind your belly button. You take Feminax and use a hot water bottle for this and it helps somewhat, though the pain never really goes away completely. The pain starts a few days before your period starts, and lasts until the end of your period. You often feel nauseous and faint due to the pain, though you haven’t actually vomited or lost consciousness to date. If specifically asked, you don’t suffer from chest pain/shortness of breath, although you are very tired and people have noted you look paler than your brother. You have no bladder/bowel symptoms.

PMH: None. FH: No history of any gynaecological problems. DH: Feminax Ultra (naproxen) when you’re on your period. No allergies. SH: You are a student at your local sixth form college, and live with your parents and brother. You do not smoke and do not drink. You have never been sexually active. You have recently had some feedback from your teachers that you are missing too much college, and they are worried about your progress, especially with your AS exams coming up soon. You have a part time job pulling pints in a local pub.

ICE: You suspect you’re being a bit of a wimp, as none of your friends take time off school for their periods. One of your friends, Katie, has started on the ‘mini pill’ and doesn’t have any periods any more; you wonder if this might be possible for you. You’re worried you’ll do badly in your exams as you regularly miss time from school due to the period pains.

Please observe the student take a history from this patient. Ideally they should perform a gynaecological examination, including speculum and bimanual palpation, on a manikin. Their differential diagnosis should sound like the following:

“My differential diagnosis would firstly include endometriosis, due to the cyclical nature of her symptoms, dysmenorrhoea and menorrhagia. Secondly, I would like to exclude any myometrial pathology such as fibroids, and finally exclude the possibility of any pelvic or uterine infection.”

Topics for discussion: • What investigations would you undertake in the GP setting for this lady, and what investigations would you refer her for? • What are some of the medical treatment options for her endometriosis? • What are some of the surgical/definitive treatment options for her endometriosis? • Where are some sites that endometriosis can affect, and what are some of the complications of this? (Looking for bowel/adhesions, ovary/chocolate cyst, lung/haemoptysis)