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Heavy menstrual bleeding — RACGP Fellowship MCQ

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HardWomen's health and O&GHeavy menstrual bleedingRACGP Fellowship

A 49‑year‑old woman presents with heavy regular periods and fatigue. Pregnancy test is negative, haemoglobin is 96 g/L and ferritin is low. Pelvic examination is normal and she has no intermenstrual bleeding. What is the most appropriate investigation?

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Correct answer: A — Transvaginal pelvic ultrasound and assessment for iron deficiency management

In Australian primary care practice for heavy menstrual bleeding without red‑flag symptoms and with a normal pelvic exam, current guidance recommends transvaginal ultrasound as the next investigation to assess for structural causes (e.g. fibroids, adenomyosis) and concurrently treat iron deficiency anaemia. Serum CA‑125 is non‑specific and not part of first‑line evaluation. Hysterectomy is a treatment, not an investigation, and only considered after failed medical and less invasive management. Cervical screening is important but does not evaluate causes of heavy bleeding. Delaying investigation until menopause risks ongoing anaemia and missed treatable pathology.

Reference: RACGP management of HMB guidance 2021 (Transvaginal ultrasound) and RACGP women's health unit 580 2021, https://www1.racgp.org.au/getattachment/a5cc67f1-8280-44f8-82ea-21be8419a718/Management-of-heavy-menstrual-bleeding-in-Australi.aspx