SIMULATED PATIENT (ROLE-PLAYER) BRIEF

Persona and manner. Bethan Prichard, 34, primary school teacher, alone in your empty classroom on your free period. Worn out and slightly short-fused at first: clipped sentences, you answer only what is asked, a small audible sigh in the first minute, an edge of “I’ve just got on with it for a year and a half”. Once the doctor takes you seriously rather than briskly, your pace slows, the edge goes, and by the end you sound relieved and a bit emotional. Normal, steady volume throughout. If the doctor comments on how you look, people at work keep telling you that you look grey.

Speaking register. Everyday words only – “flooding”, “going through”, “accidents”. No medical terms; never name a treatment. Partial account first; detail only when asked something specific.

Opening statement (verbatim). “Right – sorry, I’ve only got twenty minutes before the bell. My periods have got really heavy and I honestly can’t keep going like this.”

History to give if asked

• Bleeding: heavier since your second baby 18 months ago, steadily worse. Cycle 28 days, regular as clockwork, bleeding six or seven days. Days two and three are the bad ones: a super tampon and a pad together, both soaked in about an hour and a half. Lumps the size of a 50p. Up twice in the night to change. Wrung out for a couple of days after.
• Last period: started 9 days ago, finished 3 days ago.
• Impact: two accidents at work – bled through onto your chair and your trousers. You are lead teacher on a three-day residential in three weeks. Next period due in about 19 days, so your two worst days land on the first days of the trip.
• Tried so far: only supermarket painkillers. If asked what and how much: ibuprofen, the 200s, two at a time, three times a day at most; paracetamol, the 500s, two at a time, four times at most – both only on the two bad days. Give strengths only if asked directly. Nothing on prescription, ever.
• Red flags – all ABSENT, confirm clearly if asked: no bleeding between periods; no bleeding after sex; no pain beyond ordinary period cramps; no dragging, pressure or fullness; no bloating or swollen tummy; no weight loss; no lump you can feel.
• Anaemia: tired, more than two small children explains; light-headed standing up on the heavy days. No breathlessness at rest, no sore tongue, no craving odd things, no palpitations.
• Other: periods normal until 18 months ago. No bruising or nosebleeds; no bleeding problems or gynaecological cancer in the family. Smear up to date. Not breastfeeding – stopped at about 10 months. Never had a migraine, and never a headache with flashing lights, zigzags or blind spots before it. No clots in your legs or lungs, none in the family. Nobody has told you your blood pressure was a problem, and you cannot check it at home.
• Contraception: condoms, every time, always. You and your partner think you have finished having children but have not made it final.

Lifestyle. Never smoked. Two or three glasses of wine at the weekend, none in the week. No recreational drugs. Drives, no problems. Eats reasonably; no exercise beyond chasing children. Teaches a Year 2 class of thirty and cannot leave them to go to the toilet.

Household. Partner and two children, 4 and 2. Your partner does mornings and nursery drop-off; you do teatime and bedtime. You both cook and shop.

ICE (Ideas, Concerns and Expectations).

Ideas: “I assumed this is just what happens once you’ve had kids”; you half-expect to be told to put up with it.

Concerns: the humiliation, carried by the cue below rather than stated.

Expectations: something that will actually stop it, and something to get you through the trip. You have never heard of a coil for heavy periods.

Cues. (1) “I’ve had two accidents at work” – say it flatly, then pause two seconds. (2) “I’ve got the residential in three weeks.” (3) If still not picked up: “I’ve had to sort of rearrange how I dress for work.” Drop each once; never explain them.

Hidden agenda and reveal rule. Content: it happened while you were sitting on the carpet reading to your class, and a child asked what was on your trousers. You now wear dark trousers every single day and keep a spare pair in your desk drawer. The thought of it happening on the residential, sharing a bathroom with colleagues and thirty children, frightens you.

Reveal rule – strict: disclose ONLY if the doctor validates or normalises what you have already said – names how hard that must be, or says many women find work the hardest part. A question does not unlock it. Asked “how is this affecting you?” or “what’s worrying you most?”, answer flatly: “It’s fine. I manage.” If they move on, do not raise it again, and stay clipped for the rest of the consultation.

Gated clinical discriminator. None – no clinical discriminator in this case.

Findings you can give if asked

• On camera: tired and washed out; alert, comfortable, breathing normally, full sentences. If asked, hold your hands up – and if they cannot be seen, or there is no camera, describe them: “The palms look pale to me. Not pink like they used to be.” Nothing else to see.
• Audible: normal speech, no breathlessness, no distress until the disclosure.
• At home: NO blood pressure machine, NO thermometer, NO oxygen monitor, NO scales you would trust. Nothing to measure with.
• You cannot give anything needing a doctor’s hands or instruments: “I don’t have one of those at home”, or “I can’t really see that myself.”

Response to a face-to-face offer.

Classification: OPTIONAL.

Obstacle: school hours – no classroom cover, you would lose a half-day.

You agree if given a specific reason it must be in person (the device has to be fitted, and they need to examine you first) and help with timing.

Push-back (verbatim): “Can we not sort it out now? I can’t just get cover for my class – I’d have to take a half-day, and I’ve only just used one.”

Agreement (verbatim): “Right – if it’s the actual fitting then obviously I’ll come in. Is there anything after three?”

Patient questions (locked – ask any not already answered).

1. “If it takes six months to work, what am I supposed to do about the trip?”
2. “Will it stop me getting pregnant as well, or do we still need to use something?” Satisfied only by all three: it is a contraceptive; not working as one straight away; unless it goes in during the first five days of a period, condoms for seven days after.
3. “One of the other teachers had a coil put in and said it was the worst pain of her life. Is that what I’m signing up for?” A generalisation – “everyone’s different”, “most people are fine” – does not satisfy you. Say flatly: “That’s more or less what she said her doctor told her.” You settle only when told what will actually be offered for the pain on the day, and that you can ask them to stop.

Also asked every run: “What does it actually look like? I can’t picture it.” Ask when the device is first described; accept a description if it cannot be shown.

Flexible extras: “Can I have it taken out if I hate it?” “Will it make me put on weight?”

Patient-described items. None – every item on this record is named.

Actor latitude.

LOCKED: all clinical facts above (timeline, cycle, product use, the 19-day and 21-day intervals, the present-and-absent red flags, the migraine, clot and blood-pressure negatives, family history, contraception); the over-the-counter strengths and daily patterns; the hidden-agenda content and its validation-only reveal rule; the ICE positions; the OPTIONAL classification and the agree trigger; the three locked questions and the satisfaction rules on 2 and 3; the show-me-the-device ask; the palm-description line; the verbatim opening, push-back and agreement lines.

FLEXIBLE: wording of answers; how much edge is in the first minute; the order secondary details emerge; character-consistent detail about school and the children; how you phrase resistance to coming in.

Tone: a tired teacher on her free period, not a script-reader – the locked facts protect what is being tested, everything else should sound like you.

PART A – MARKING GUIDE

The SCA is marked holistically by a trained examiner against the standard of a newly qualified, independent GP. The indicators and anchors below are training aids that approximate that judgement – not a checklist where each item earns a mark, and timings are pacing guides, not thresholds.

Working diagnosis: heavy menstrual bleeding with no identified pathology – regular, cyclical, no red flags, low risk of fibroids, cavity or endometrial abnormality or adenomyosis, so treatment may begin without investigating the cause. Note the precise meaning: no cause has been excluded by investigation; the risk has been assessed as low enough on history that investigation is not required first, and a physical examination is still mandatory before any device is fitted.

Differentials excluded on history: fibroids or adenomyosis (no pressure symptoms, no significant period pain, no palpable mass); polyps or endometrial pathology (no intermenstrual or postcoital bleeding, no risk factors); a clotting disorder (began 18 months ago, not from her first periods, no personal or family history); thyroid disease (no features, and testing is not indicated without them); iron deficiency anaemia as a complication rather than a cause.

The single “must not miss”: committing her to a device without completing the red-flag sweep and without arranging a full blood count. Unevaluated bleeding is a reason not to fit an intrauterine system; a negative sweep is what makes fitting safe. The blood count runs alongside the decision, and its result is seen before the fitting.

Data Gathering & Diagnosis

Positives

• Opens openly and lets her run – the timeline, the products and the accidents come unprompted if she is not interrupted.
• Quantifies the bleeding: duration, regularity, flooding, clots, two products at once, night changes, days per month.
• One signposted red-flag sweep – bleeding between periods, after sex, pelvic pain or pressure, bloating, weight loss, a lump – with the negatives stated back.
• Screens for anaemia symptoms specifically, not just “are you tired”.
• Uses the record aloud rather than asking as if it were blank: the clear smear 18 months ago, condoms since her second baby.
• Drug history reaches what she buys herself, and quantifies it – which drug, what strength, how many, how often, how many days.

Negatives

• Never establishes how heavy “heavy” actually is – no products, no clots, no night changes.
• Red-flag sweep omitted, or partial in a way that would change the plan.
• Re-asks the smear or the contraception as though the record were blank.
• Accepts “I take painkillers” without finding out what – or finds out what without finding out how much.
• Settles on “postnatal change” and stops gathering while plan-changing questions are unasked.

Calibration anchor

• Clear Pass: Open question, narrative allowed to run to its end. Bleeding quantified in her own terms. Red-flag sweep delivered as one signposted sweep, negatives stated back. Record used aloud at least twice. Over-the-counter drugs found and dosed.
• Pass: Open question used but cut short. Bleeding quantified, in less detail. Sweep completed as a list. Record referenced once. Over-the-counter drugs found on a second attempt and named, if not quantified.
• Fail: Closed questions from the outset. Bleeding never quantified. Sweep incomplete. Notes ignored, so the smear or contraception is asked from scratch.
• Clear Fail: No structure. Moves to a plan without establishing severity or excluding red flags. Contradicts the record.

Clinical Management & Medical Complexity

Positives

• Offers a levonorgestrel-releasing intrauterine system (LNG-IUS) as the first treatment – with alternatives, not as an instruction.
• All three counselling points: the bleeding pattern will change, especially over the first few cycles and possibly beyond six months; give it at least six cycles; the brand matters, because the products differ in what they are licensed for and how long they last.
• Names the brand. The Medicines and Healthcare products Regulatory Agency (MHRA) advises these systems are always prescribed by brand name – the products differ in indications, duration and introducer.
• Full blood count alongside the decision, with the reason, and the result seen before the fitting.
• Solves the three-week problem: tranexamic acid 1 g three times a day for up to four days from the start of bleeding, licensed for heavy periods and hers to take on the trip – while being honest that the device will not have worked by then.
• Fitting is in person, examination first, pregnancy excluded beforehand.
• Contraception answered in full: it is a contraceptive; not immediately; condoms for 7 days after fitting unless fitted within the first 5 days of a period.
• Aftercare, not one line of it: about 1 in 20 expelled, most often in the first few months; thread check within 4–6 weeks then monthly or after a period; condoms until checked if she cannot feel them.
• Consent on more than one risk: perforation around 1 in 1,000 fittings; pelvic infection, likeliest in the first three weeks; ectopic pregnancy, with the symptoms to act on.
• Both follow-ups arranged – thread check at 4–6 weeks, review of effect at 6–8 weeks.
• Face-to-face (OPTIONAL): Positive – offers to bring her in with a specific reason (the fitting, and the examination before it), works round the school day, safety-nets the interval. Closing remotely with the fitting booked and a safety-net is equally a pass. Negative – a vague “just to check you over” with no stated reason, or ending remotely with no safety-net and no arrangements.

Negatives

• “Coil” prescribed generically, no brand, no acknowledgement that the brands differ.
• Promises rapid improvement, or omits the early bleeding pattern – the erratic phase arrives before the benefit, and an unwarned woman stops too soon.
• No blood count, or a blood count made a precondition of treatment.
• The trip never addressed, so the plan does not touch the thing she came about.
• Offers something not indicated at this stage; or keeps her ibuprofen going and adds a second anti-inflammatory.
• Tranexamic acid without the dose, the four-day limit or the “start when the bleeding starts” instruction.
• Leaves her believing the device is contraception from the moment it goes in.
• Consents her on perforation alone and calls that consent.

Safe alternative approaches – none of these is a fail

• Tranexamic acid alone, 1 g three times a day for up to four days per period, as treatment rather than bridge – listed where the device is declined. Safe if the device stays on the table and the blood count is arranged.
• Mefenamic acid 500 mg three times a day, licensed for heavy periods – provided she stops her own ibuprofen. Two anti-inflammatories together are avoided; running them alongside each other is a fail, not an alternative. Examiner note: national guidance attaches a general off-label note to anti-inflammatories here, so a candidate who mentions off-label use is not wrong.
• Cyclical oral norethisterone 5 mg three times a day, day 5 to day 26 – off-label for this indication, less effective than the device, defensible if chosen with her. Instead of the device, never alongside it: two progestogens are not run together. It is not a contraceptive, so her condoms continue; birth defects have been reported with non-contraceptive use, and a candidate who says so is doing it right.
• Combined hormonal contraception – a nationally listed option where the device is declined, and offering it is not a fail. It cannot be started on this call: it needs a blood pressure and a safety screen she cannot supply from home, so a candidate offering it should say the screen comes first – that is the mark, not the choice. Offered alongside tranexamic acid the two carry an additive clotting caution, and a candidate who notices that is doing well. Detailed counselling for this option is not what this case examines.
• Deferring the decision to the face-to-face appointment, so she can see the device and be examined, with the trip covered meanwhile – defensible where she is undecided, provided the blood count is arranged today.

Calibration anchor

• Clear Pass: Names the brand and says why the brand matters. All three counselling points, including that the early bleeding may last beyond six months. Blood count arranged alongside the decision, result to be seen before the fitting. The trip solved with a named drug, dose, timing and limit. Contraception answered in full, including the 7-day rule. Expulsion named and the thread check taught, with what to do if the threads cannot be felt.
• Pass: Device offered as first treatment with the six-cycle advice and the change in bleeding pattern. Blood count arranged. Brand named but not explained. The trip acknowledged, with or without a prescription she accepts. Contraception answered at least in outline, including that it is not immediate.
• Fail: Device offered generically with no brand and no bleeding-pattern counselling; or blood count omitted; or the trip never addressed; or she is left believing the device protects her from the day it goes in.
• Clear Fail: An option offered as first-line that appears nowhere in national guidance for heavy menstrual bleeding; or a device recommended without the red-flag sweep having been done.

Relating to Others

Positives

• Responds to “I’ve had two accidents at work” by validating or normalising it rather than asking another question – this is the only thing that opens the disclosure.
• Once she discloses, names the feeling without minimising: acknowledges the humiliation of it happening in front of her class.
• Quotes her own words back – “dark trousers every day”, “wrung out” – rather than paraphrasing.
• Addresses her idea directly: this is not simply what happens after children, and it is treatable.
• Offers genuine choice, including doing nothing, and checks what matters most to her before recommending.
• Answers the insertion-pain question with substance, not reassurance: most fittings are mildly to moderately uncomfortable but it varies; pain relief options are discussed and offered before the day, she can be sent elsewhere if what she wants is not available here, and she can ask the fitter to stop.
• Checks understanding at the point of the aftercare and the tranexamic acid instructions, not only at the end.

Negatives

• Moves straight from the accidents to the next question – the disclosure never happens and the consultation stays transactional.
• Asks “how is it affecting you?” and accepts “it’s fine, I manage” at face value.
• Dismissive reassurance – “it’s very common, lots of women get this” – used to close the topic.
• Answers the pain question with a generalisation and moves on.
• Delivers the device as a decision already made.

Calibration anchor

• Clear Pass: Picks up the accidents cue the first time it is offered and validates rather than questions, so the disclosure comes. Names the humiliation in her own words. Explains the device in plain language and checks she has followed it. She audibly softens.
• Pass: Picks up the cue on a later drop, or after the disclosure has nearly passed. Names the impact in her own terms and lets her finish before moving on. Explanation clear, understanding checked once, at the end.
• Fail: Cue missed entirely. Explanation delivered in device language (“intrauterine system”, “progestogen”) without adaptation. She stays clipped.
• Clear Fail: Talks over her. Plan announced without her preference sought. Distress in the room unacknowledged.

Clear Pass discriminator

Clear Pass candidates tell Bethan, before she asks, that the device will not have started working by the residential, and hand her something licensed that will get her through those three days – and they meet “I’ve had two accidents at work” with validation rather than a follow-up question, which is the only key that opens the dark-trousers disclosure. Pass candidates counsel the device accurately and she agrees to it; Clear Pass candidates leave her feeling understood, covered for the trip she actually rang about, and knowing when the device starts protecting her and how to tell whether it is still in place.

Moment calibration table

PART B – MODEL CONSULTATION & MANAGEMENT

History hinges

GP: “Thanks for making time in your free period. Tell me about what’s been happening with your periods.”

Bethan: “They’ve just got heavier and heavier since I had my second. The middle two days I’m going through a super tampon and a pad together in about an hour and a half. I’m up twice in the night. And I’ve had two accidents at work.”

GP: (pause) “Two accidents at work – Bethan, that’s a horrible thing to be carrying around, and you’ve been managing it on your own for a year and a half.”

Bethan: (pause, voice changes) “It happened while I was sitting on the carpet reading to them. One of the children asked what was on my trousers. I wear dark trousers every day now. I’ve got a spare pair in my drawer.”

GP: “Thank you for telling me that. Can I ask some quicker questions to check nothing else is going on? I’ve got your notes here, so I won’t make you repeat things.”

(Focused history, red-flag sweep, anaemia screen, and a drug history that reaches the strength and daily pattern of anything she buys herself.)

GP: “So: regular as clockwork, six or seven days, two really heavy days, nothing in between and nothing after sex. Your smear 18 months ago was clear, and the notes say condoms since your second baby – still right? And the thing at the front of your mind is the residential in three weeks.”

Bethan: “Still condoms, yes. And yes – it’s the trip.”

Explanation, and her ideas

GP: “What you’re describing is heavy periods with nothing abnormal behind them – the commonest picture there is. There’s no magic number; the test is whether it’s interfering with your life, and yours plainly is.”

Bethan: “I’d sort of assumed this is just what happens once you’ve had kids.”

GP: “It’s common after babies – but common isn’t the same as untreatable, and it isn’t something you’ve caused. And I’m not going to give you a plan that ignores the residential, because that’s clearly the thing keeping you awake.”

Management plan

a) Shared decision-making

GP: “There are a few routes, and it’s genuinely your choice – including doing nothing. There are tablets you take only during your period, and there’s a small device that sits inside the womb and works continuously. The device reduces the bleeding the most, but it takes months rather than weeks. Shall I take you through it?”

Bethan: “Go on then. What does it actually look like? I can’t picture it.”

GP: “I’ll show you – it’s about the length of your thumb.” (holds thumb and forefinger up to the camera) “A small T-shaped device that a doctor or nurse puts inside the womb. It releases a tiny dose of hormone into the lining, so the lining doesn’t build up as much and there’s much less to shed. Most women’s bleeding drops a long way; for some it stops.”

b) Investigations

SPOKEN

GP: “One blood test – a full blood count, to see whether all this bleeding has left you short of iron. We don’t wait for it to make the plan; it runs alongside. The one thing I do want is the result back before the coil goes in, because people can feel faint during the fitting and I’d rather know your blood count first. Phlebotomy any morning, no appointment, and I’ll ring you either way.”

GP: “And before it goes in we need to be sure you’re not pregnant, so there’s a quick urine test on the day.”

UNSPOKEN – investigation detail (not read aloud)

• Full blood count is indicated in every woman with heavy menstrual bleeding, carried out in parallel with any treatment offered. Treatment and the treatment decision are not delayed for it; the fitting appointment is sequenced after the result, which is a procedural precaution and not an investigation-before-treatment step.
• Compare against her count from two years ago, haemoglobin 131 g/L. A fall dates the anaemia to the 18 months of heavy bleeding and needs no separate explanation; a normal count reassures without changing the plan.
• The cause of her bleeding has not been established. It has been risk-stratified as low on history, which is what permits treatment without investigating the cause, and the pre-fitting bimanual examination is the second half of that safeguard. “No identified pathology” is not “pathology excluded”.
• Pregnancy exclusion is required before fitting. She meets the “reasonably certain not pregnant” criterion through consistent, correct condom use; a urine test on the day is still appropriate given the change in her bleeding pattern.
• A brief sexual history is taken at the fitting appointment. She is at low risk – one partner, condoms every time – so screening is offered rather than required, and can be done on the day.
• The fitting is booked after the residential, so she is not in the first days post-insertion while she is away.
• Deliberately not done: ferritin (not routine in heavy menstrual bleeding); female hormone testing (not indicated); thyroid function (not indicated without thyroid features); pelvic ultrasound or hysteroscopy (no intermenstrual or postcoital bleeding, no pressure symptoms, no significant period pain, no palpable mass, no endometrial risk factors, so treatment may start without investigating the cause); coagulation testing (bleeding began 18 months ago, not from menarche, with no personal or family history).
• Results and recall: she is contacted with the result; iron replacement started if deficient, with a repeat full blood count at 2–4 weeks to confirm she is responding; anaemia failing to respond with other causes excluded is a referral trigger.

c) Non-drug

GP: “Keep the ibuprofen going for the cramps exactly as you are – at that dose it’s safe, and it takes a bit off the bleeding as well. Don’t add a second anti-inflammatory on top of it; two together do harm rather than good.”

d) Medication

SPOKEN

GP: “Two things I really want you to hear about the coil. First, your bleeding will be unpredictable at the start – spotting, or bleeding on and off – and that’s expected, particularly over the first few cycles, and it can last beyond six months. Second: give it at least six cycles before you judge it.”

Bethan: “Six months. Right. And will it stop me getting pregnant as well, or do we still need to use something?”

GP: “It does – it’s a very effective contraceptive as well. But not straight away. If it goes in during the first five days of a period you’re covered from that moment; any other time, condoms for seven days after. I’ll tell you which applies on the day.”

GP: “One thing about living with it. It has two fine threads at the top of the vagina, and I want you to be able to find them – once in the first four to six weeks, then monthly or after a period. About one in twenty of these devices comes out on its own, most often in the first few months, and heavy bleeding and a body mass index over 25 both nudge that up a little.”

GP: “So what would you do if you couldn’t feel them?”

Bethan: “Ring you, I suppose.”

GP: “Ring us, yes – and go back to condoms until we’ve checked it, because if it’s moved we can’t promise it’s working.”

GP: “Now, the trip – and I’ll be straight with you, the coil won’t have got going by then. So I’d like to give you tranexamic acid to take with you. Only when you’re bleeding: two 500 mg tablets – 1 g – three times a day, starting the day the bleeding starts, for up to four days. Three doses a day is your dose; don’t go above it without speaking to us. It’s licensed for heavy periods and it cuts the flow substantially. Enough for three periods, then we’ll review.”

GP: “Stop it and ring us if your vision changes – colours looking different, or blurring. Rare, but it means stop.”

GP: “And on consenting you for the fitting: in around 1 in 1,000 fittings the device makes a small hole in the womb; infection is uncommon and likeliest in the first three weeks; and a pregnancy with a coil in place needs checking early. I’ll tell you what to do about each in a moment.”

UNSPOKEN – PRESCRIPTION DETAIL TABLE

Not appropriate in this case: Kyleena and Jaydess – neither is licensed for heavy menstrual bleeding and neither is recommended for it, so prescribing “a coil” generically risks a device that will not treat her problem.

Recommended regimen for this patient: Mirena 20 micrograms/24 hours fitted at a booked in-person appointment once the full blood count is back, plus tranexamic acid 500 mg tablets, 1 g three times daily for up to four days from the start of bleeding, to cover the residential trip.

e) Follow-up

GP: “Two things afterwards: a quick check at four to six weeks that it’s sitting where it should – that’s a brief examination, and I’ll get you an after-school slot for that too. Then I’ll ring you at six to eight weeks about how the bleeding is settling. And if six cycles in it hasn’t given you what you want, come back – there are other options, we’re not stuck.”

f) Safety-netting

GP: “Before the fitting, ring us the same day if the bleeding gets worse than this, if you feel faint or actually pass out, or if you start bleeding between periods or after sex. After the fitting: severe pain worse than period cramps, unusual discharge or a temperature, or threads you can’t feel – get seen, don’t wait. And a period that’s late or unlike your usual one with one-sided tummy pain – do a pregnancy test and ring us. If any of that happens while you’re away with the school, use 111 rather than sitting on it.”

g) Health promotion

GP: “One thing while you’re here – the coil gives no protection against sexually transmitted infections. I say that to everyone, not because of anything you’ve said.”

h) Referral

GP: “We fit these here, so I’ll ask reception to book a fitting clinic once the blood test is back – after school or first thing, whichever suits. If our list is long I can send you to the community sexual health service instead; either way the prescriptions and the replacement stay with us.”

Bethan: “After three would be much easier.”

Close

GP: “So: blood test this week, fitting booked after school once that’s back, tranexamic acid in your bag for the trip, and condoms carrying on until I tell you on the day that you’re covered. Before you go back to your class – tell me how you’ll take the tranexamic acid, so I know I’ve explained it properly?”

Bethan: “Two tablets, three times a day, only from the day I actually start bleeding. Four days at the most. And stop it if my eyes go funny.”

GP: “Exactly right. And don’t judge the coil before six cycles. I’ll send you the leaflet on choosing between the options, and I’ll speak to you in six to eight weeks.”

PART C – GOLDEN HISTORY-TAKING QUESTIONS

1. “Tell me about what’s been happening with your periods.”
2. “You said you’ve had two accidents at work – that must have been horrible.” (validation, not a question – this is what opens the disclosure)
3. “On your worst day, what are you using, and how long before you have to change?”
4. “Are you getting up in the night to change?”
5. “Are you passing clots – and roughly what size?”
6. “Is your cycle regular, and how many days do you bleed for?”
7. “Can I check a few things – any bleeding between periods, or after sex? Any pain or pressure low down? Any bloating, or weight loss you can’t explain?”
8. “Are you more tired than you’d expect? Any dizziness, breathlessness, or sore tongue?”
9. “The notes say condoms since your second baby – still right? Any more children planned?”
10. “What do you take for it, including anything you buy yourself – which one, what strength, how many at a time and how often?”
11. “What were you hoping we might be able to do today?”
12. “You’ve got the residential in three weeks – what worries you most about it?”

PART D – NIGHT-BEFORE MANAGEMENT CHECKLIST

• Explanation [ ] – heavy periods, nothing abnormal behind them, treatable, not her fault
• ICE addressed [ ] – “not just what happens after kids”; the accidents validated, not questioned
• Investigations [ ] – full blood count now, alongside the decision; result seen before the fitting; pregnancy excluded on the day; no ferritin, hormones, thyroid or scan
• Medication + dose [ ] – levonorgestrel-releasing intrauterine system, named by brand; tranexamic acid 1 g three times daily, up to 4 days, from day 1 of bleeding
• Contraception [ ] – a contraceptive, but not immediately: condoms for 7 days after fitting unless fitted in the first 5 days of a period
• Aftercare [ ] – about 1 in 20 expelled (heavy bleeding, BMI over 25); thread check at 4–6 weeks then monthly; condoms until checked if absent
• Key safety warning [ ] – stop tranexamic acid for visual disturbance; after fitting, severe pain, absent threads, unusual discharge or temperature, or a late or odd period with one-sided pain
• Safety-net [ ] – same day for heavier bleeding, faintness, or new bleeding between periods or after sex; 111 while she is away
• Follow-up [ ] – thread check 4–6 weeks; review call 6–8 weeks; judge at 6 cycles
• Referral threshold [ ] – no improvement on treatment, or anaemia not responding
• Health promotion [ ] – no protection against sexually transmitted infections

PART E – CASE VARIATIONS

She declines the device. Tranexamic acid 1 g three times daily for up to four days per period becomes the treatment, not the bridge; or mefenamic acid 500 mg three times daily – but she must stop her own ibuprofen, as two anti-inflammatories are not run together. Combined hormonal contraception is also a listed option and offering it is not wrong, but it cannot be started on this call: it needs a blood pressure and a safety screen she cannot provide from home. Alongside tranexamic acid the two carry an additive clotting caution. Whichever is chosen, set a review – these are ongoing monthly treatments, not one-off scripts.

The blood count shows iron deficiency anaemia. One iron tablet once daily – ferrous fumarate 210 mg or ferrous sulfate 200 mg – for three months after the deficiency is corrected, with a repeat full blood count at 2–4 weeks to confirm she is responding. As a premenopausal woman under 50 who menstruates, with no colonic symptoms, no strong family history of gastrointestinal cancer and no anaemia persisting despite treatment, she needs no investigation before treatment starts. The fitting goes ahead, with the result known first and the fitter told.

Telephone rather than video. Appearance is unavailable and the device cannot be shown; anaemia symptoms must be asked explicitly and the explanation carry more descriptive work. The safety-net carries more too – spell out faintness, soaking through and the post-fitting triggers.

She wants another child within the year. The device is unsuitable for now. Tranexamic acid becomes the option of choice – and because it is only started once bleeding has begun, she cannot be pregnant when she takes it, which is what makes it appropriate. Anti-inflammatories carry a fertility caution with long-term use and are avoided in pregnancy, so they are deprioritised. Cyclical norethisterone is not the answer either: it is not a contraceptive, and birth defects have been reported with non-contraceptive use.

PART F – WHY CANDIDATES FAIL THIS CASE

• Trap: offering “a coil” with no brand → fails Clinical Management. These devices differ in what they are licensed for and how long they last, and two are not licensed for heavy bleeding at all. Fix: name the brand aloud and say why it matters.
• Trap: selling the device on how well it works and skipping the unpredictable early bleeding → fails Clinical Management. The erratic phase arrives before the benefit does, and an unwarned woman stops before the treatment has had a chance. Fix: say both – erratic at first, possibly beyond six months, and give it at least six cycles.
• Trap: counselling the device as a bleeding treatment and forgetting it is a contraceptive → fails Clinical Management. Her only contraception is condoms. Fix: answer all three parts – yes it is contraception, no it is not immediate, condoms for seven days unless it goes in during the first five days of a period.
• Trap: treating “1 in 1,000 for perforation” as the consent conversation → fails Clinical Management. About 1 in 20 devices is expelled; if she cannot find the threads and nobody taught her to look, she will not know. Fix: teach the thread check, and name expulsion, infection and ectopic pregnancy alongside perforation.
• Trap: answering “I’ve had two accidents at work” with another question → fails Relating to Others. She has a flat “it’s fine, I manage” scripted for exactly that. Fix: validate before you enquire.
• Trap: a textbook-perfect device plan that never mentions the residential → fails Clinical Management. She came about three specific days in three weeks. Fix: name the gap yourself and fill it with something licensed, dosed and timed.
• Trap: treating first and testing later, or testing first and treating later → fails Clinical Management. Fix: the blood count runs alongside the decision, neither delaying it nor omitted – and its result is back before anything goes inside the uterus.

PART G – REVISION CARD

Heavy periods – first-line treatment – Revision Card

Teacher, 18 months of flooding periods, leads a residential in three weeks – device counselling.

Diagnosis: Heavy menstrual bleeding, no identified pathology – risk-stratified low, not investigated.

Differentials: fibroids/adenomyosis; endometrial pathology; clotting disorder.

Must-ask history

1. “Tell me what’s been happening with your periods.”
2. “Two accidents at work – that must have been horrible.” (validate, don’t ask – this opens the disclosure)
3. “Worst day: what are you using, how long before you change, clots, night changes?”
4. “Cycle regular? Anything between periods or after sex? Pain, bloating, weight loss?”
5. “Tired, dizzy, breathless, sore tongue?”
6. “Still condoms? What do you buy – which, what strength, how much?”

Red flags to screen actively

Intermenstrual/postcoital bleeding · pelvic pain or pressure · bloating · weight loss · mass · faintness. All negative – the sweep permits fitting.

ICE (Ideas, Concerns and Expectations)

• Idea – normal after children → “It’s common after babies, but common isn’t the same as untreatable, and it isn’t something you’ve caused.”
• Concern – humiliation at bleeding through in class → “Two accidents at work – that’s a horrible thing to be carrying around, and you’ve been managing it on your own for a year and a half.”
• Expectation – a fix, plus cover for the trip → “I’m not going to give you a plan that ignores the residential.”

Management – say this

• Face-to-face: OPTIONAL – offer it for the fitting and the examination before it, or conclude remotely with it booked.
• Explain: “Heavy periods with nothing abnormal behind them. There’s no magic number – the test is whether it’s interfering with your life.”
• Investigations: full blood count alongside the decision, not before it – result seen before the fitting (vasovagal risk). Pregnancy test on the day.
• Selected: levonorgestrel-releasing intrauterine system – Mirena 20 micrograms/24 hours. Brand name mandatory (Medicines and Healthcare products Regulatory Agency: products differ in indication, duration, introducer). Licensed 5 years for heavy bleeding, 8 years contraception. Counsel: erratic bleeding at first, maybe past 6 months; judge at 6 cycles; contraceptive but not immediately – condoms 7 days unless fitted in the first 5 days of a period; ~1 in 20 expelled – teach the thread check (4–6 weeks, then monthly; condoms until checked if absent); perforation ~1 in 1,000.
• Add-on: tranexamic acid 500 mg tablets – 1 g (two tablets) three times daily, from day 1 of bleeding, up to 4 days. Stop and ring for visual disturbance. The 4 g/24 h ceiling is a prescriber decision, not her headroom.
• AVOID: Kyleena, Jaydess – not licensed for heavy bleeding; no second anti-inflammatory beside her ibuprofen.
• Follow-up: thread check 4–6 weeks · review 6–8 weeks · judge at 6 cycles.

Safety-net – exact triggers

• Same-day GP or 111: heavier bleeding; faint or collapse; new bleeding between periods or after sex. After fitting – severe pain worse than cramps, unusual discharge or temperature, threads absent. Late or odd period with one-sided pain → pregnancy test and ring. On the trip: 111.
• Close (teach-back): “Tell me how you’ll take the tranexamic acid, so I know I’ve explained it properly?”

The pivot: A device is only as safe as its counselling – and it must solve what she rang about.

Clear Pass move: Say before she asks that the coil won’t work by the residential – and hand her something licensed for those three days.

Anchor phrase: “Let’s fix the periods properly, and get you through the trip while it’s working.”

Important Disclaimer

This MedDigest consultation is a fictional case, created for educational and revision purposes only. It should not be used for clinical decision-making or as a substitute for your own clinical judgment.

This content is an independent educational resource designed by MedDigest to illustrate clinical principles. It has not been produced, reviewed, or endorsed by NICE or the Royal College of General Practitioners.

Medicine is constantly evolving. For definitive recommendations, always refer to the latest official guidelines and your local clinical protocols.

MedDigest and its authors cannot accept responsibility for any loss or injury resulting from the use of the information contained herein.

References

The primary-care pathway in this case follows the relevant Clinical Knowledge Summaries topics. Those summaries are secondary sources; the underpinning guidance, formulary, regulatory and product references consulted directly in preparing this case are listed below.

Guidelines and standards

College of Sexual and Reproductive Healthcare (2025) UK medical eligibility criteria for contraceptive use (UKMEC 2025): summary tables. London: College of Sexual and Reproductive Healthcare. Available at: https://www.cosrh.org (Accessed: 3 August 2026).

Faculty of Sexual and Reproductive Healthcare (2019) FSRH guideline: combined hormonal contraception. Amended October 2023. London: Faculty of Sexual and Reproductive Healthcare. Also published in BMJ Sexual & Reproductive Health, 45(Suppl. 1). Available at: https://doi.org/10.1136/bmjsrh-2018-CHC (Accessed: 3 August 2026).

Faculty of Sexual and Reproductive Healthcare (2023) FSRH clinical guideline: intrauterine contraception. Amended January 2025. London: Faculty of Sexual and Reproductive Healthcare. Available at: https://www.fsrh.org (Accessed: 3 August 2026).

National Institute for Health and Care Excellence (2015) Suspected cancer: recognition and referral. NICE guideline NG12. London: National Institute for Health and Care Excellence. Available at: https://www.nice.org.uk/guidance/ng12 (Accessed: 3 August 2026).

National Institute for Health and Care Excellence (2018) Heavy menstrual bleeding: assessment and management. NICE guideline NG88. Last updated 7 July 2026. London: National Institute for Health and Care Excellence. Available at: https://www.nice.org.uk/guidance/ng88 (Accessed: 3 August 2026).

Royal College of General Practitioners (no date) Feedback statements for the SCA. Available at: https://www.rcgp.org.uk/mrcgp-exams/simulated-consultation-assessment/feedback-statements (Accessed: 4 August 2026).