ℹ️ This is the case information for the doctor.
Name
Jessica Williams
Age
21
Address
Flat 2, 18 Willowmere Close, Bristol
Social history
• Third-year undergraduate student in English at the University of Bristol; exams are in three months.
• Lives in private student accommodation with three friends.
• Started seeing a new boyfriend within the last few months.
• Drinks socially, around 5–6 units per week.
• Non-smoker.
• No recreational drug use.
• Stays in regular contact with family and has a close group of friends.
Past history
• Migraines without aura, visual symptoms or neurological symptoms, typically 2–3 times per year.
• Menorrhagia since menarche.
• No surgeries or hospital admissions.
• No history of blood clots, DVT, PE, hypertension, stroke or heart problems.
Investigation results
Readings from registration 6 weeks prior
• BMI: 26 kg/m².
• Blood pressure: 110/76 mmHg.
• Pulse rate and other observations: Normal.
Medication
• No regular prescription medication.
Booking note
Request to discuss going on the pill
ℹ️ This is the information for the person role playing the patient.
Name
Jessica Williams
Age
21
Address
Flat 2, 18 Willowmere Close, Bristol
Social history
• Third-year undergraduate student in English at the University of Bristol; exams are in three months.
• Lives in private student accommodation with three friends.
• Started seeing a new boyfriend within the last few months.
• Drinks socially, around 5–6 units per week.
• Non-smoker.
• No recreational drug use.
• Stays in regular contact with family and has a close group of friends.
Past history
• Migraines without aura, visual symptoms or neurological symptoms, typically 2–3 times per year.
• Menorrhagia since menarche.
• No surgeries or hospital admissions.
• No history of blood clots, DVT, PE, hypertension, stroke or heart problems.
Medication
• No regular prescription medication.
I’d like to talk about going on the pill, please.
• Periods occur every 4 weeks and last 6–7 days.
• Periods are very heavy.
• During the first few days she has to change pads every hour.
• She sometimes leaks through clothes or sheets at night.
• She is worried her periods will interfere with upcoming exams and holiday plans.
Provide these naturally during the conversation or if the doctor asks how this is affecting you:
• Pleasant and open, but slightly anxious about periods interfering with daily life.
• Wants practical help and hopes the problem can be sorted today.
• May feel embarrassed discussing leaking and heavy bleeding but engages if the doctor is empathetic.
• Engages well if the clinician listens, acknowledges the impact of heavy periods and explores her contraception needs.
• Becomes grateful and receptive when given clear, reassuring advice. She may ask about how the pill works, missed-pill advice, safety and side effects.
• If the doctor is dismissive or reluctant to prescribe without explanation, she becomes withdrawn and disappointed and may say: “I really hoped I could sort this today…”
• If told she cannot have the COCP because of migraines without a clear explanation, she asks about alternatives but is disappointed.
• If reassured that migraine without aura is being assessed differently from migraine with aura, she is receptive but wants to understand the safety implications.
• If the plan clearly addresses both contraception and heavy periods, she is grateful and wants to understand how to take the pill, whether she needs condoms initially or for STI protection, what to do if she misses a pill, what warning symptoms to look for and when review will happen.
ℹ️ To mark data gathering & diagnosis select from the descriptors below.
Positive descriptors
Negative descriptors
Data gathering is systematic and targeted, ensuring patient safety:
• Begins with open questions to explore Jessica’s reasons for requesting the pill, her heavy periods, contraception needs, concerns and expectations.
• Progresses to focused questions about menstrual history, migraine characteristics, medication use, contraceptive history and COCP contraindications.
Data gathering is systematic and targeted, ensuring patient safety:
• Fails to clarify Jessica’s main priorities or jumps between unrelated topics without a clear structure.
• Omits focused questions about migraine characteristics, menstrual pattern, medication use or contraceptive history.
Uses existing information and considers the wider context:
• Integrates available information including previous tranexamic acid use, BMI, blood pressure, non-smoking status and migraine history.
• Explores Jessica’s student lifestyle, exams, new relationship, holiday plans and how heavy bleeding affects daily life.
Uses existing information and considers the wider context:
• Ignores relevant available information such as previous tranexamic acid use, BMI, blood pressure, non-smoking status or migraine history.
• Fails to ask about the impact of periods on university life, exams, holidays, relationships or wellbeing.
Establishes the presence or absence of relevant red flags:
• Checks migraine safety features, including aura, visual symptoms, focal neurological symptoms and triptan use.
• Screens for COCP contraindications and red flags including VTE history, smoking, hypertension, unexplained vaginal bleeding, intermenstrual bleeding, postcoital bleeding and anaemia symptoms.
Establishes the presence or absence of relevant red flags:
• Does not ask about migraine aura, visual symptoms or focal neurological symptoms.
• Misses screening for COCP contraindications or heavy bleeding red flags such as intermenstrual bleeding, postcoital bleeding or anaemia symptoms.
Explores sexual and reproductive context sensitively:
• Clarifies current contraception, condom use, new partner context, pregnancy risk and need for contraception that is reliable and acceptable to Jessica.
• Considers STI risk and safe-sex needs without making assumptions or causing embarrassment.
Explores sexual and reproductive context sensitively:
• Avoids asking about contraception, pregnancy risk, condom use, new partner context or STI considerations.
• Uses judgemental or insensitive questioning that discourages Jessica from discussing sexual health.
Collects information to contextualise heavy menstrual bleeding:
• Explores duration, regularity, severity, flooding, impact, previous treatment and associated symptoms.
• Considers possible secondary causes by asking about pelvic pain, abnormal bleeding, anaemia symptoms, relevant medication and family history where appropriate.
Collects information to contextualise heavy menstrual bleeding:
• Does not clarify the severity, duration, regularity, impact or previous management of the heavy bleeding.
• Fails to consider possible secondary causes or symptoms that would require a different approach.
Clarifies ideas, concerns and expectations:
• Elicits Jessica’s belief that the pill may make periods lighter and regular, her preference for Microgynon, her pregnancy concerns and her worries about side effects.
• Checks what she hopes to achieve today before moving into management.
Clarifies ideas, concerns and expectations:
• Does not explore Jessica’s reasons for wanting Microgynon, her worries about pregnancy or side effects, or what she wants from the consultation.
• Moves straight to prescribing or refusing the pill without understanding her agenda.
ℹ️ To mark clinical management & medical complexity select from the descriptors below.
Positive descriptors
Negative descriptors
Offers safe and appropriate management options:
• Explains the role of COCP for contraception and potentially lighter, more predictable periods, while also discussing alternatives such as POP, LARC, condoms and treatments for heavy bleeding.
• Weighs options against Jessica’s clinical profile, lifestyle and preference for an immediate method.
Offers safe and appropriate management options:
• Focuses only on Microgynon or only on condoms without discussing other relevant contraception or heavy bleeding options.
• Omits alternatives such as POP, LARC or non-hormonal management for heavy bleeding when discussing choices.
Prescribes safely considering contraceptive suitability:
• Checks suitability for COCP using relevant factors supplied in the case: age, blood pressure, BMI, smoking status, migraine history, personal thromboembolic/cardiovascular history and family history concerns.
• Avoids prescribing until migraine features and other key contraindications have been clarified.
Prescribes safely considering contraceptive suitability:
• Prescribes COCP without clarifying migraine aura, blood pressure, BMI, smoking status or thromboembolic risk.
• Dismisses migraine, breast cancer family history concerns or other contraindication screening without explanation.
Empowers self-care and independence:
• Provides practical education about pill-taking, missed-pill advice, side effects, breakthrough bleeding and warning symptoms.
• Encourages self-monitoring of periods, migraines and side effects.
Empowers self-care and independence:
• Simply prescribes without explaining how to take the pill, what side effects to expect or what to do if a pill is missed.
• Gives no advice about monitoring migraines, bleeding or complications.
Arranges appropriate follow-up and safety-netting:
• Agrees a review plan to assess bleeding, side effects, blood pressure and migraine control after starting treatment.
• Gives clear urgent safety-netting for new aura, neurological symptoms, severe headache, chest pain, breathlessness or leg swelling.
Arranges appropriate follow-up and safety-netting:
• Provides a prescription without review arrangements or safety-netting.
• Fails to advise what to do if she develops aura, neurological symptoms, chest pain, breathlessness, leg swelling or worsening bleeding.
Practises holistically and promotes sexual health:
• Addresses STI prevention, condom use, safe sex and sexual health screening where appropriate.
• Recognises the effect of heavy periods on exams, confidence, holidays and emotional wellbeing.
Practises holistically and promotes sexual health:
• Focuses solely on pregnancy prevention and ignores STI protection, condom use, emotional impact or exam-related concerns.
• Does not acknowledge Jessica’s embarrassment, stress or anxiety about leaking and contraception reliability.
Tailors management to Jessica’s circumstances, priorities and preferences:
• Responds to Jessica’s wish for something she can start promptly while discussing future options such as LARC.
• Discusses her preference for Microgynon while explaining that safety, suitability and correct use are more important than matching her friend’s brand.
Tailors management to Jessica’s circumstances, priorities and preferences:
• Rigidly prescribes or withholds the pill without involving Jessica in the decision.
• Ignores her need for an immediate, practical option before exams and holidays or dismisses her interest in future LARC discussion.
ℹ️ To mark relating to others select from the descriptors below.
Positive descriptors
Negative descriptors
Communicates in a person-centred way:
• Greets Jessica warmly, acknowledges her anxiety about heavy periods and exams, and validates the embarrassment and stress caused by leaking.
• Adapts the discussion to her student context and desire for convenience and control.
Communicates in a person-centred way:
• Gives generic information about the pill without exploring why the issue matters to Jessica.
• Ignores cues about exam stress, embarrassment or anxiety about leaking.
Ensures informed consent through clear explanation:
• Explains risks, benefits, alternatives and uncertainties in clear language.
• Checks Jessica understands the relevance of migraine history, possible family history concerns and what to do if symptoms change.
Ensures informed consent through clear explanation:
• Issues or refuses COCP without discussing risks, benefits, alternatives or the relevance of migraine history.
• Fails to check Jessica’s understanding before agreeing a plan.
Works collaboratively around what matters to the patient:
• Co-creates a plan that addresses both contraception and heavy periods.
• Explores her preference for Microgynon while checking whether other safe options would meet her goals.
Works collaboratively around what matters to the patient:
• Imposes a management plan without exploring Jessica’s preferences, concerns or wish for an immediate solution.
• Dismisses her request for Microgynon without explaining equivalent options or safety considerations.
Adapts communication to Jessica’s reactions and understanding:
• Uses jargon-free explanations about COCP, migraine aura, side effects and warning symptoms.
• Offers written information or repeats information in a different way if Jessica looks confused or concerned.
Adapts communication to Jessica’s reactions and understanding:
• Uses jargon about oestrogen, UKMEC, cardiovascular risk or migraine aura without explanation.
• Repeats information rigidly without checking understanding or responding to Jessica’s cues.
Demonstrates empathy and willingness to help:
• Acknowledges the impact of heavy bleeding on confidence, social life, holidays and exam preparation.
• Offers reassurance and practical support while maintaining clinical safety.
Demonstrates empathy and willingness to help:
• Minimises the emotional impact of leaking or worries about pregnancy.
• Appears dismissive, rushed or reluctant to help, causing Jessica to withdraw.
Works appropriately with the wider healthcare team:
• Explains the potential role of the practice nurse, sexual health services, pharmacist or university health service for contraception advice, blood pressure checks, STI screening, emergency contraception or follow-up.
• Clarifies how Jessica can access help if problems arise.
Works appropriately with the wider healthcare team:
• Does not explain who Jessica can contact for follow-up, sexual health advice, prescription queries or urgent concerns.
• Undermines or ignores the potential contribution of practice nurses, pharmacists, sexual health services or university health services.
ℹ️ Insights from the examiner
Case at a glance
Jessica Williams is a 21-year-old university student requesting the combined oral contraceptive pill (COCP).
She has two linked agendas:
Jessica has migraine without aura, normal blood pressure and a BMI of 26 kg/m². No personal history of VTE, stroke, hypertension or heart disease is provided.
The consultation should assess whether the COCP is safe and suitable, clarify the nature and impact of the heavy bleeding, discuss alternative contraceptive and menstrual-management options, and agree a practical plan.
GP trainee performance focus
A strong GP trainee should demonstrate that they can:
What this case is testing
Patient priorities and concerns
Jessica’s priorities include:
Central challenge
The central challenge is to avoid both:
The clinician needs to combine a safe contraceptive assessment with Jessica’s practical wish for an immediate option that may improve her heavy bleeding.
Must-not-miss issue or diagnosis
The must-not-miss issue is prescribing the COCP when it is unsafe, particularly if Jessica’s migraines include aura or neurological symptoms, or if there are other contraindications such as VTE risk, cardiovascular disease, unexplained bleeding or pregnancy risk.
Red flags or high-risk features
features requiring clarification include:
Common GP trainee pitfalls
What good looks like
A strong consultation is safe, practical and responsive to Jessica’s priorities. The trainee recognises her wish for prompt help, completes targeted safety screening, explains options clearly and agrees a plan that fits exams, holidays and her new relationship.
“The pill could help both with contraception and with making your bleeding lighter and more predictable. Before we decide, I need to check a few things to make sure it’s safe, particularly the type of migraine you get and any history of clots.”
Learner checkpoint
Have I addressed both contraception and heavy bleeding, while completing COCP safety screening before prescribing?
Start with an open question
Begin with an open invitation that allows Jessica to explain her priorities.
“Can you tell me a bit more about what’s made you think about the pill now?”
This helps clarify whether her main priority is:
Time-efficient data gathering
Use Jessica’s agenda to guide focused questions. Avoid a scattergun approach.
Key areas to cover:
High-yield questions
Heavy menstrual bleeding
Clarify:
Contraception and pregnancy risk
Ask about:
Migraine assessment
Clarify whether Jessica experiences:
Also ask about:
COCP contraindication screening
Screen for:
Jessica’s normal blood pressure and non-smoking status are reassuring, but they do not replace a complete assessment.
Functional, psychosocial or contextual assessment
Jessica’s practical and emotional priorities include:
Validate these concerns.
“It makes sense that you’d want to avoid that happening during exams. Let’s look at what would help and what would be safe for you.”
Explore ideas, concerns and expectations
Explore her preference for Microgynon without dismissing it.
“You mentioned a friend has used Microgynon. Can you tell me what appeals to you about that option?”
Clarify:
Recognise and respond to cues
Jessica may feel embarrassed, time-pressured or disappointed if she senses caution without explanation.
Useful response:
“I can see this is affecting things that really matter to you, like exams and holidays. I’m not trying to delay things unnecessarily — I just want to make sure whichever option we choose is safe and practical.”
Useful consultation phrases
“Migraine without aura is different from migraine with aura. If you had visual or other neurological symptoms before a headache, that could change which contraceptives are safe.”
“Condoms still help protect against sexually transmitted infections, even if you use the pill for pregnancy prevention.”
“We shouldn’t choose a pill only because it suited a friend, but we can certainly discuss whether a similar option is safe and suitable for you.”
“Does that make sense so far, or is there anything you’d like me to go over again?”
Consultation flow and signposting
Summarising and checking understanding
Use a concise summary before moving into management.
“So your periods are regular but very heavy, you’re worried about leaks during exams, and you’d also like more reliable contraception than condoms. I also need to check the migraine safety points before we decide.”
Check:
Data gathering self-check
Before prescribing or agreeing a plan, the trainee should know:
Assessment domain mapping
Data gathering
Clinical management
Relating to others
Prioritised differential diagnosis or clinical reasoning
The working explanation is longstanding heavy menstrual bleeding with regular cycles and no supplied red flags. Primary heavy menstrual bleeding is suggested as the most likely explanation, provided further assessment does not identify concerning features.
However, avoid premature closure. Consider:
Clinical reasoning script
“The pill could be a good option because it may help with both contraception and making your bleeding lighter and more predictable. But we need to make sure it is safe for you first, especially because of your migraines and because some symptoms or clotting risks would change the safest choice.”
Red flags and risk assessment
Assess for:
Decision points
Key decisions include:
Management priority
The management priority is to agree a plan that is:
Management options
1. Combined oral contraceptive pill
The COCP may meet both of Jessica’s goals:
Discuss:
Microgynon or a similar low-dose COCP may be discussed, but the choice should be based on safe and effective prescribing rather than simply copying a friend’s prescription.
2. Progestogen-only pill
Discuss the POP as an alternative if:
Explain that bleeding patterns may differ from those associated with the COCP.
3. Long-acting reversible contraception
Introduce LARC options for future consideration, including:
These may be useful if Jessica later prefers a lower-maintenance method. Tailor the discussion to her current priorities without making her feel pressured to choose LARC immediately.
4. Condoms
Explain that condoms remain useful for:
5. Treatment for heavy bleeding
Discuss options such as:
Jessica has already tried tranexamic acid and would like another option, so explore:
6. Practical support
Offer:
Personalised plan
Link the plan to Jessica’s life:
Example phrase:
“Given your exams are coming up, it’s reasonable to prioritise something you can start promptly if it’s safe for you. We can also book a review and talk about longer-acting options later if you want something lower-maintenance.”
A personalised plan might include:
Shared decision-making
Discuss which option best fits Jessica’s:
Do not allow brand preference to replace safe contraceptive assessment, but do not ignore her wish for a prompt, practical option.
Safety-netting
Explain warning symptoms requiring urgent assessment, including symptoms suggestive of:
Provide clear advice about what Jessica should do if these symptoms occur.
Documentation points
Document:
Common unsafe management plans
Avoid:
Follow-up and coordination with other professionals
Arrange follow-up to review:
Learner checkpoint
Will the plan actually work for Jessica during exams, holidays and a new relationship?
Relevant guidance areas
This includes guidance and resources on:
NICE guidance
BNF references
RCGP and SCA resources
Relevant research or educational references
Key principles to remember
Transferable learning for future cases
In contraception consultations with an additional symptom agenda:
Supervisor or examiner lens
A supervisor or examiner is likely to look for:
Final learner takeaway
A COCP request is not just a prescription task: clarify the agenda, screen for safety, explain use clearly and tailor the plan to the patient’s real life.
