The Eighteen Months She Called Normal

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The Eighteen Months She Called Normal

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CANDIDATE’S NOTES (Video Consultation)

Rosalind Hale, 34, female

Reason for contact (booked by reception): “heavy periods – wants to discuss”

Allergies: nil known

(Video consultation.)

ROLE PLAYER BRIEF

THE CARD

Who you are: Rosalind Hale, 34, teaching assistant with a Reception class. Two children, 6 and 4. Calling from your kitchen at lunchtime.
Your opening words, exactly: “Hiya – sorry, I feel a bit daft even ringing about this. It’s just my periods, really. They’ve got a bit heavier.”
What you want from today: something to stop you flooding at your sister’s wedding. You are a bridesmaid; it is in six weeks and your period is due that day. You have counted.
What you are not volunteering: how bad the bleeding actually is, and that you are frightened it is womb cancer.
How you feel as it starts: brisk, apologetic, playing it down. You half expect to be told it’s normal for your age.

VOLUNTEER ONCE – bring both in yourself, early, as soon as the doctor gives you an opening. Do not repeat them once picked up.

“I nearly cancelled, honestly. You’ve got proper poorly people to see.”
“I had to walk out of my class the other week.”

IF ASKED

If the doctor asks about…	Say…
ICE (Ideas, Concerns and Expectations) – what you think it is, what worries you, what you want today
what you think is going on	“I just assumed this is what happens once you’re in your thirties and you’ve had two.”
what worries you (open question only)	“The wedding. I’m a bridesmaid, and I’ve worked it out – I’m due on the day of it.”
your deeper worry	not volunteered – released only as the direction notes describe
what you want today	“Something that works by then. And I suppose I’d like to know it’s nothing.”
The bleeding
how long this has gone on	“About eighteen months. It’s crept up. It wasn’t like this before.”
whether your periods are heavy	“They’re not that bad, really. I mean they’re heavy, but everyone says that, don’t they?”
how long they last, how often	“Six or seven days, same as always. Every four weeks, regular as anything.”
your worst day, hour by hour – how often you change, whether you double up, whether you’re up in the night	“Second and third day, I’m changing every hour, hour and a half. I use a tampon and a pad together – I have to. I’ve bled through onto my trousers at school twice; the second time I sent a child to the office for a spare cardigan to tie round my waist. And I’m up twice in the night, sometimes three times. There’s a towel on the bed.”
clots, and what you’ve given up	“Big ones on the bad days, like a ten-pence piece. I don’t take the kids swimming then. I’ve made excuses to my sister twice.”
your last period, and your first	“Started a fortnight ago, finished a week back.” / “I was thirteen. Normal for twenty years – that’s the thing.”
Checks the doctor may run
bleeding between periods, or after sex	“No. Never.”
pain	“First-day cramps, that’s all. Paracetamol sorts it.”
pressure, bloating, swelling, a lump, weight loss, waterworks, bowels	“No. My weight’s the same.”
tiredness, breathlessness, dizziness, faintness, sore tongue	“I’m shattered all the time – worst the week after. But I’ve got a six-year-old and a four-year-old.” Everything else: no.
feeling the cold, dry skin, constipation, your neck, your hair	“No, nothing like that. I’m always too hot if anything, running about after them.”
your smear	“Up to date – about eighteen months ago, and normal. I got the letter.”
bruising, nosebleeds, family bleeding, bleeding after childbirth or dental work	“No, nothing like that. Both births were fine.”
partners, and whether you’ve ever had an infection down below	“Just my partner – eleven years, it’s only ever been the two of us. No, never anything like that, and nothing now.”
medication and allergies	“Nothing regular. Just paracetamol for the first day, and I take something for my hay fever when the pollen’s bad – one of those antihistamine ones you get from the chemist.” No allergies.
what the hay fever tablets are	“It’s the one-a-day tablets you just buy over the counter. I only take them for about two months a year, when the pollen’s bad. I’m not on anything at the moment.”
pregnancies, contraception, more children	“Two, both normal deliveries.” / “Condoms. We’re not planning any more – but I don’t want anything permanent, and I’ve never fancied being on hormones.”
smoking, driving	Never smoked. You drive the school run, ten minutes.
work	“Teaching assistant, Reception. Half eight till half three, term time, plus after-school club two days.”
anything else about your day-to-day life	Answer from the everyday layer in the direction notes.
what you think about a coil, if one is mentioned	“A girl at work had one and said it was agony going in. And doesn’t it make you put weight on?”
being seen in person, if the doctor offers	Not keen at first: *“I can’t just take a day off in term time – they’d have to get cover for my class, and I’d need to give notice.”* You agree once told a coil cannot be fitted without examining you first and offered a workable time: *“Right – if it’s before school starts, or the last bit of the afternoon, I can sort that. Just not the middle of the day.”*
Findings
how you look	Well. A bit tired round the eyes, not pale. Talking in full sentences.
what you can measure at home	Bathroom scales and a thermometer. You know your height. No blood pressure machine, no finger monitor, no urine sticks.
anything needing the doctor’s hands or instruments	“I can’t really see that myself.” / “I haven’t got one of those.”

YOUR TWO QUESTIONS – ask both, in these words, unless the doctor has already answered them.

“If I go for the coil, will my periods be sorted by the wedding? That’s six weeks.”
“A girl at work said hers fell out and she didn’t know for ages. How would I know if that happened to me?”

SIMULATION & DIRECTION NOTES (for the AI patient; role-players may skim)

VOICE DELIVERY – on the AI platform and in most peer practice this case is voice-only: asked about anything visible, read the “how you look” line aloud as what the doctor would see; lines marked video colour are skipped; nothing visual is performed or marked.

Persona and manner. Warm, quick, self-deprecating, at a normal volume throughout. You start fast and light – sentences run into each other, you laugh at the end of them, you apologise twice in the first minute. The minimising is audible: “just”, “only”, “a bit” before everything, and answers trailing off into “…but it’s fine.” Asked something concrete and given room, the pace drops and the laughing stops – that is the real account arriving. Before “I had to walk out of my class” there is a small break. Video colour: you glance at the clock; a half-eaten sandwich goes down as the call starts.

Speaking register. Plain everyday words; never medical terms, never a diagnosis. A partial lay account first, detail only on the specific follow-up. No tidy chronology.

The everyday layer, for ordinary questions the table misses. Home: you, your partner and the two children; he leaves early, so you do the school runs, the tea and the shopping, and your mum has them one afternoon a week. Food: family cooking, a lot of pasta and chicken, not much red meat, cereal on the run. Drink: two glasses of wine at weekends, not every week. No drugs. Exercise: nothing formal – on your feet with the class, and the school walk. None of it changes the decision.

The sexual-history question. Answer plainly, no offence taken. If the doctor explains why: “No, that makes sense.” If asked coldly, answer anyway, briefly.

The gated discriminator. Discriminating fact – the true volume and impact: hourly changing on two days, doubling up, bleeding through clothes at work, up two or three times a night, activities abandoned.

Decoy – “they’re not that bad, really”, the honest and non-discriminating answer to heaviness as a label; a question about duration gets a true, unremarkable number. Neither is a lie; neither holds what the doctor needs.

Unlock – being asked to count something. Not sympathy, not a summary, not “tell me more about the bleeding”. Never volunteered, never in the notes, never in medical language.

The deeper worry, and what releases it. You are frightened this is womb cancer; a woman in the school office was diagnosed with it last year. You will not raise it to a direct question, to reassurance, or to “is there anything else?” You raise it in one place only: after the doctor has summarised your account back to you and left a gap. Into that gap, lightly, looking away: “It’s not something serious though, is it? Only a woman at work was diagnosed with womb cancer last year.” If no summary comes, or every pause is filled, the fear is never spoken.

The hormone reservation. “I’ve never fancied being on hormones” is a real position, not a throwaway. If the doctor never comes back to it, you go along with the plan but stay slightly flat. If the doctor picks it up – asks what puts you off hormones, or explains that this one works mostly where it sits – you engage properly: “Oh. I didn’t know that. That’s different, then.”

Good versus poor consultation. Listened to, given room, asked for numbers: you warm up, stop apologising, give the full picture and engage with the choice. Rushed or run as a checklist: you stay in “it’s not that bad”, the wedding never comes up, you agree to whatever is suggested. Given a flat “no, it’s not cancer”: you go quiet, say “no, no, that’s fine”, and stop contributing. Told what you are having: “if you think so”, and you never raise your worry about the coil.

Face-to-face. REQUIRED, conditionally – only if you choose the coil; push back once, then agree, as the table sets out. You do not agree to an unexplained “I think we should see you”, nor if no workable time is offered.

The tablets you can and cannot name. The hay fever tablets: you cannot name them and never could; the closure line above is locked. Paracetamol is different – you can name it, and mention it only under pain or a direct question.

Non-speaking presence. None – you are alone; the children are at school and nursery.

Actor latitude.

LOCKED (must not vary across runs): every clinical fact in the IF ASKED table above, exactly as written. The deeper worry and its reveal trigger. The hormone reservation and its two responses. The decoy and the unlock. The closure line for the hay fever tablets. The three ICE positions. The face-to-face classification and the agree-trigger, with its verbatim push-back and agreement lines. Both patient questions, in their exact words. The verbatim opening line. Both cue drops – each offered at least once per run, wording flexible. The good-versus-poor response policy above.
FLEXIBLE: exact wording of ordinary answers; how strongly the apologising and minimising come across; the order in which secondary details arrive; character-consistent small talk about the class, the children and the wedding.
Tone note: sound like a real person, not a script-reader. The locked facts protect what is tested; the flexibility makes it real.

PART A – MARKING GUIDE

The SCA (Simulated Consultation Assessment) 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.

DATA GATHERING AND DIAGNOSIS

Positive indicators	Negative indicators
· Opens broadly, lets her account run, picks up “walk out of my class”. · Counts the bleeding – changes per hour, doubling up, night changes, clothes soaked. · Screens the required list and both clotting limbs, then summarises. · Uses the record – confirms the allergy status aloud, not cold.	· Accepts “they’re not that bad, really” and counts nothing. · Runs a closed checklist from minute one; the screen or summary is missing. · Asks for the allergy status cold, as if the record were blank.

Positive indicators

Negative indicators

· Opens broadly, lets her account run, picks up “walk out of my class”.

· Counts the bleeding – changes per hour, doubling up, night changes, clothes soaked.

· Screens the required list and both clotting limbs, then summarises.

· Uses the record – confirms the allergy status aloud, not cold.

· Accepts “they’re not that bad, really” and counts nothing.

· Runs a closed checklist from minute one; the screen or summary is missing.

· Asks for the allergy status cold, as if the record were blank.

Calibration

Clear Pass – Pass, plus the discriminator below, done in the room.

Pass – Opens broadly, hears her out. Asks her to quantify the bleeding rather than taking the label, so the hourly changing, the doubling up and the night changes are on the table. Completes the screen, summarises, and the fear surfaces.

– PASS STANDARD –

Fail – Takes “they’re not that bad, really” as the answer. Nothing is counted, so there is no evidence the bleeding meets the threshold for treatment. Screen partial; no summary.

Clear Fail – Closed questions from minute one, no impact history, red flags omitted.

CLINICAL MANAGEMENT AND MEDICAL COMPLEXITY

Positive indicators	Negative indicators
· Arranges the blood count alongside treatment, and says what happens if it’s low. · Explains why no scan or camera test; offers the menu with numbers. · Names the three-to-six-month settling against her six-week deadline, and the six-cycle rule. · Counsels brand, contraception, perforation, threads, infection and pregnancy before consent; takes the sexual history; books the examination.	· Announces the coil as “the treatment”, or lets her choose it believing it works by the wedding. · Gives the perforation warnings and stops – no infection or pregnancy limb. · Plans the fitting with no examination or infection-risk question, or omits the blood count.

Positive indicators

Negative indicators

· Arranges the blood count alongside treatment, and says what happens if it’s low.

· Explains why no scan or camera test; offers the menu with numbers.

· Names the three-to-six-month settling against her six-week deadline, and the six-cycle rule.

· Counsels brand, contraception, perforation, threads, infection and pregnancy before consent; takes the sexual history; books the examination.

· Announces the coil as “the treatment”, or lets her choose it believing it works by the wedding.

· Gives the perforation warnings and stops – no infection or pregnancy limb.

· Plans the fitting with no examination or infection-risk question, or omits the blood count.

Calibration

Clear Pass – Pass, plus the discriminator below, done in the room.

Pass – Says why no imaging is needed and arranges the blood count alongside treatment. Lays out the options, not one. Delivers the whole consent bundle – bleeding change over three to six months, six cycles, brand, contraception, perforation, threads, a net carrying infection and pregnancy – and completes the three-limb assessment.

– PASS STANDARD –

Fail – Recommends the coil correctly but thinly. The consent counselling is incomplete – bleeding change, perforation, the infection and pregnancy limbs, or the pre-fitting examination is missing – so she agrees to a procedure she has not been told about. Blood count omitted or used to delay.

Clear Fail – Refers with nothing tried, or fits with no examination.

RELATING TO OTHERS

Positive indicators	Negative indicators
· Answers her apology by naming what she just described. · Uses her own words – the class, the wedding – in the explanation. · Responds to the womb-cancer fear before explaining anything else. · Asks what puts her off a coil and off hormones, then checks understanding by what she says back, not “does that make sense?”.	· Reassures flatly – “it’s not cancer” – without asking what prompted it. · Delivers the counselling in one block; treats the wedding as trivial. · Hands her the list and leaves her to choose, without weighing it against what she told him.

Positive indicators

Negative indicators

· Answers her apology by naming what she just described.

· Uses her own words – the class, the wedding – in the explanation.

· Responds to the womb-cancer fear before explaining anything else.

· Asks what puts her off a coil and off hormones, then checks understanding by what she says back, not “does that make sense?”.

· Reassures flatly – “it’s not cancer” – without asking what prompted it.

· Delivers the counselling in one block; treats the wedding as trivial.

· Hands her the list and leaves her to choose, without weighing it against what she told him.

Calibration

Clear Pass – Pass, plus the discriminator below, done in the room.

Pass – Hears the apology and the cue, answers both. When the fear arrives, takes it first – asks about the woman at work, then explains what does and does not point that way – rather than answering with a bare no. The coil hesitation is asked about.

– PASS STANDARD –

Fail – Polite and organised, but the consultation is the doctor’s. The fear is closed down rather than opened up; the hesitation is answered with more facts about the coil. She agrees without engaging.

Clear Fail – Apology, cue and fear unremarked; the plan is announced.

CLEAR PASS DISCRIMINATOR

Pass candidates counsel the three-to-six-month settling and the six-cycle rule while explaining the coil. Clear Pass candidates do it before she chooses, set it against her own six-week deadline, say plainly that the wedding week could be messier rather than better, and plan for that week.

MOMENT CALIBRATION TABLE

Moment	Failing version	Passing version	Clear Pass version
The first two minutes	Interrupts the apology with closed questions	Lets her account run; picks up “walk out of my class”	Answers the apology by naming what she described
How heavy it actually is	Accepts “they’re not that bad, really”	Asks her to count changes, doubling up, night changes	Also asks what she has given up
The summary, and what follows	No summary; the fear is never spoken	Summarises, pauses, hears the cancer worry	Asks about the woman at work before explaining
Options, and deciding	Names the coil as the treatment and moves on	Gives the menu with numbers; asks what matters to her	Sets three-to-six months against her six weeks first
Fitting, and closing	Books a fitting with no examination	Completes the pre-fitting assessment; gives device, infection and pregnancy advice	She says all three groups back in her own words

SIMULATION MARKING & CLINICAL REFERENCE (for the AI grader; markers may skim)

CASE ESSENTIALS

Data gathering.
Working diagnosis:	heavy menstrual bleeding, no identified pathology, possible iron deficiency anaemia.
Must exclude – the required screen:	bleeding between periods or after sex; pelvic pain or pressure; abdominal swelling or a lump; weight loss; smear overdue or abnormal; anaemia symptoms; and the thyroid negatives that justify not testing. Any positive and the route is the same – examine and investigate rather than treat blind, using the suspected-cancer pathway where cancer is suspected.
Alternatives:	four forks – fibroids, adenomyosis, polyp or endometrial pathology, clotting disorder – each with its own investigation below.
Must-not-miss:	she carries none of the four risk factors for endometrial pathology, and that absence, actively established, is what makes treating without investigating safe.
Clinical management.
Investigations:	full blood count (FBC) in every woman with heavy menstrual bleeding, alongside treatment rather than before it – and no imaging here, since nothing in her history raises a cavity, endometrial, fibroid or adenomyosis cause.
First-line:	a levonorgestrel-releasing intrauterine system (LNG-IUS) – indications, and the four alternatives if it is declined or unsuitable, below.
The assessment a fitting requires, all three limbs:	examination; pregnancy excluded; and a sexual history for infection risk, testing offered as appropriate – the excess pelvic-infection risk in the first three weeks runs through existing infection.
Face-to-face:	REQUIRED, conditionally – only because she chooses the coil; she pushes back once, then agrees to a clinical reason plus a workable time.
Must-not-miss:	the LNG-IUS is the one route needing all three limbs before fitting.

What earns each mark – and what doesn’t

Behaviour	Credit when	Do not credit
Quantifies the bleeding	Any ask for a number, frequency or given-up activity	“Heavy”; “how bad is it?”; a summary
Screens what changes the route	Covered however phrased; either clotting limb asked	A closed “any other symptoms?”
Summarises, leaves a gap	A summary then silence she can speak into	A summary talked straight through
Uses the record	Allergy status confirmed aloud before anything is offered	Asked cold, as if unknown
Treats without investigating, tests in parallel	The screen was completed and the reasoning from it voiced or implied; treatment started anyway	“You don’t need a scan”, no basis; the conclusion reached without the screen; the test used to delay
Names the menu	Genuinely offered, in any order	Listed after she agrees
Counsels the bleeding-pattern change	Both the change and the wait are given	“It’ll settle down”
Completes the pre-fitting assessment and counsels it	A brand or the rule; the sexual-history question; warning signs covering device, infection and pregnancy; threads; an appointment with its purpose	“Whatever we’ve got”; “pop in when you can”; perforation given alone as the whole net; a fitting arranged with infection risk never asked about
Takes the fear, then the hesitation	Each explored before it is answered, and answered honestly	A flat denial, however kind; “that’s a myth”

Paraphrases are credited; grading never depends on keywords, and a safe route is never failed for differing from the model.

SAFE ALTERNATIVE APPROACHES – do not fail these

Tranexamic acid instead, concluded remotely with no examination – where she declines the coil or prefers something she controls.
Combined hormonal contraception or cyclical oral progestogen – where she prefers a tablet and the eligibility screen is done; the combined route needs a blood pressure, so it cannot start on this call.
Norethisterone to postpone the period for the wedding – a licensed regimen, dose below. Credit it where the clot history is clean and the clot warning signs are given.
Do not stack tranexamic acid on an oestrogen-containing method or a high-dose cyclical progestogen without a stated reason, a short defined course and the clot warning signs.

None is a pass or fail in itself; what is marked is how safely it is applied, explained, negotiated, followed up and safety-netted.

Face-to-face – the working

The condition is the treatment chosen: with no related symptoms a tablet route may be concluded remotely with a safety-net, and that is not an under-call. Fail only where a fitting is planned without the three-limb assessment, or attendance demanded with no reason and no workable time.

CLINICAL REFERENCE
Investigations
The four forks, and what each calls for: pressure or a palpable uterus → fibroids → pelvic ultrasound; period pain or a bulky tender uterus → adenomyosis → transvaginal ultrasound; persistent bleeding between periods → polyp or endometrial pathology → outpatient hysteroscopy; heavy since her first period plus a personal or family bleeding history → clotting disorder → clotting tests. Risk factors for endometrial pathology: persistent intermenstrual or irregular bleeding; infrequent heavy bleeding with obesity or polycystic ovary syndrome; tamoxifen; treatment already unsuccessful.
First-line where there is no identified pathology, fibroids under 3 cm not distorting the cavity, or suspected or diagnosed adenomyosis: a levonorgestrel-releasing intrauterine system. If it is declined or unsuitable: tranexamic acid, an anti-inflammatory, combined hormonal contraception, or cyclical oral progestogen.
Arranged: full blood count, for iron deficiency anaemia, alongside treatment rather than before it. If it shows iron deficiency anaemia, that is treated with oral iron and the count rechecked – the regimen, the recheck interval and the referral threshold are not this case’s teaching point, and no marking turns on them. Dietary iron is an adjunct and not a treatment: dietary deficiency is rarely a cause on its own in adults. Not arranged, and why: female hormone testing (not carried out in heavy menstrual bleeding); thyroid function testing (not carried out unless other signs or symptoms of thyroid disease are present – she is asked and has none: no cold intolerance, dry skin, constipation, goitre or hair change); clotting tests (the two-limb rule is not met: her bleeding was normal for twenty years and there is no personal or family bleeding history); pelvic ultrasound (for a uterus palpable abdominally, a suspected pelvic mass, or examination that is inconclusive or difficult – none applies); outpatient hysteroscopy (where the history suggests submucosal fibroids, polyps or endometrial pathology – she has neither persistent bleeding between periods nor any endometrial-pathology risk factor); measurement of blood loss (not used to diagnose); routine serum ferritin (not part of the routine work-up in this pathway). No marking in this case turns on ferritin either way.
Remote access and recall: she books a blood test at the surgery, which can be done at the same visit as the examination and fitting. Results are back within about a week; the requesting GP reviews them and the practice contacts her if anything needs acting on. Interim safety-net, in the wording the case uses throughout: “Ring the surgery if you start bleeding between periods or after sex, or get new pain or pressure in your tummy. Ring the same day if you feel faint, breathless or dizzy.” Treatment goes ahead regardless of the blood result.
Who may fit it. Only a clinician holding the Letter of Competence in Intrauterine Techniques, or equivalent recognised competence. Naming that, or saying “one of our nurses who fits these”, is credited; it is never required.
Prescription detail
Drug	Levonorgestrel-releasing intrauterine system, prescribed by brand as Mirena
Dose, formulation, route	One system containing levonorgestrel 52 mg, releasing approximately 20 micrograms daily during the first year; by intra-uterine administration
Frequency / duration	Single fitting. Effective for 5 years in heavy menstrual bleeding and 8 years for contraception; remove or replace sooner if heavy bleeding returns, and no later than 8 years after fitting
How to take	Fitted only by a clinician trained in this device, after physical examination, exclusion of pregnancy, and a sexual history taken to assess infection risk with testing offered as appropriate. Fit within 5 days of the start of a period, or at any other time if it is reasonably certain she is not pregnant and not at risk of conception; if fitted outside that 5-day window, additional contraceptive precautions for at least 7 days
Key warnings & cautions for THIS patient	Checked against her record: allergies nil known; no pelvic infection, cervicitis, cervical dysplasia, uterine or cervical cancer, liver disease or breast cancer; no current or past sexually transmitted infection and no risk factors for one, established by asking; her bleeding is regular and characterised, not undiagnosed irregular bleeding; not pregnant, not breastfeeding, and not within 36 weeks of a delivery – so neither of the two main perforation risk factors applies. MHRA (Medicines and Healthcare products Regulatory Agency) – brand-name prescribing: this must be prescribed by brand name, because products differ in indication, licensed duration and introducer. MHRA – uterine perforation: the warning signs must be given before fitting; perforation occurs in about 1 in every 1,000 fittings. Expulsion risk is higher in women fitted for heavy bleeding, so thread-checking at 4 to 6 weeks, then monthly or after each period, is specifically indicated here. Bleeding will be irregular or prolonged for the first 3 to 6 months, and she waits 6 cycles before judging it. Chosen over a 52 mg system licensed for only 3 years in this indication because her treatment is intended to be long term. Insertion may precipitate a vasovagal faint and cramping, so she is told to allow herself a little time afterwards. The post-fitting safety-net has three groups: the device – severe pelvic pain worse than period cramps; pain or heavy bleeding continuing more than a few weeks; a sudden change in periods; pain during sex; threads she cannot feel – ring us, and condoms until the position is confirmed. Infection – same day for a temperature, a change in discharge, or feeling unwell with pain; the excess risk is highest in the first three weeks. Pregnancy – very unlikely, but if it happens it is more likely to be ectopic, so lower abdominal pain with a missed or unusual period means a pregnancy test and a call, at any time, including once periods have settled or stopped
Post-fitting clinician check. Not required routinely. What is required of everyone is thread self-checking at 4 to 6 weeks, then monthly or after each period, with review on any concern. A candidate who arranges a 4-to-6-week check is credited and never penalised. The three-week review in this case is arranged for the wedding, not as a device check.
Not appropriate in this case: specialist referral – she is at the start of the pathway, nothing has been tried, and there is no red flag, pelvic mass or fibroid to suspect; referral belongs where treatment has been unsuccessful, is declined, or symptoms are severe.
Numbers for the shared decision, per 100 people treated: intrauterine system – blood loss down by about 80 to 95%, 65 to 85 satisfied, 10 to 50 report periods stopping altogether; tranexamic acid – down by about 40 to 60%, 35 to 60 satisfied; combined pill – about 35 to 45%; anti-inflammatory tablets – about 20 to 60%; doing nothing – about 5%. Intrauterine system harms: the device comes loose or out in about 5 per 100; bleeding, or bleeding between periods, in 15 to 55 per 100, most likely in the first 6 months; about half of people on any hormone treatment report effects such as breast tenderness, bloating, mood change or reduced sex drive.
Mefenamic acid 500 mg three times daily, started on the first day of heavy bleeding, is the anti-inflammatory option. Its licensed indication for menorrhagia is qualified “when other pelvic pathology has been ruled out” – which is not this patient, who is being treated without investigation – so the use here is off-label and is explained to her as such. It can cause drowsiness and dizziness; she drives, and may be taking a sedating over-the-counter antihistamine. Tranexamic acid 1 g three times daily for up to 4 days, started only once bleeding has begun and not exceeding 4 g in 24 hours, is the licensed non-hormonal option. Cyclical norethisterone 5 mg three times daily from day 5 to day 26 – menorrhagia is a licensed indication for this product, but at a different regimen (5 mg three times daily for 10 days, then twice daily on days 19 to 26 for two cycles); the day 5–26 cyclical course is off-label and is explained as such. The same product carries a licensed regimen for postponing a period – 5 mg three times daily, started three days before it is due.
Signposting material: the NHS website page on heavy periods, and the NHS England decision support tool Making a decision about managing heavy periods, which sets out these numbers in the same form for her to read at home.

PART B – MODEL CONSULTATION & MANAGEMENT

(Video. Minute markers are pacing guides, never read aloud.)

HISTORY HINGES – from 0:00

0:00 – GP: “Hello Rosalind. Tell me what’s brought you along today.”

Rosalind: “Hiya – sorry, I feel a bit daft even ringing. It’s just my periods, really. They’ve got a bit heavier. I nearly cancelled, honestly – you’ve got proper poorly people to see.” (the candidate says nothing and lets her carry on) “It’s crept up over about eighteen months. And I had to walk out of my class the other week.”

0:35 – GP: “You walked out of your class. Tell me about that.”

Rosalind: “I’d bled through onto my trousers. I sent a child to the office for a spare cardigan to tie round my waist.”

0:50 – GP: “Sending a child out for something to tie round your waist – that’s a lot to manage mid-lesson. Take me through your second day, hour by hour: how often are you changing, and are you using two things at once?”

Rosalind: “Every hour, hour and a half. Tampon and a pad together – I have to. And up twice in the night, sometimes three.”

1:20 – GP: “That’s what I needed. Now some other symptoms, because they change what I’d advise.”

(the focused and red-flag questions follow here, about seventy seconds of brisk screening – set out in the golden questions)

2:35 – GP: “Let me say this back. Eighteen months of heavier periods, still four-weekly, still six or seven days. On the two bad days, changing hourly, doubling up, up twice a night, bled through at work. Nothing in between, nothing after sex, smear clear. You’re worn out – and your sister’s wedding is six weeks away, on the day your period’s due.”

(then stops talking)

Rosalind: (after a moment, glancing away) “It’s not something serious though, is it? Only a woman at work was diagnosed with womb cancer last year.”

RESPONDING TO HER IDEAS, CONCERNS AND EXPECTATIONS – from 3:15

3:15 – GP: “Tell me about the woman at work – what happened to her?”

Rosalind: “She’s in the office. She’d been bleeding in between for months and left it. She’s alright now. But it frightened me.”

GP: “I can see why. What makes me worry about the lining of the womb is bleeding between periods, bleeding after sex, or bleeding after periods have stopped. The first is what happened to her. You have none of them – regular cycle, same length as always, smear clear. What’s changed is the amount, and on its own that doesn’t point that way.”

Rosalind: “Right. That’s – that’s good, actually.”

GP: “You’d assumed this was your thirties, after two children. Periods do change – but changing hourly and up twice a night isn’t the change I’d expect, and isn’t something to put up with.”

EXPLAINING THE CONDITION – from 4:05

4:05 – GP: “For about half the women with this there’s nothing single to find. The lining builds up and comes away each month, and in some people it bleeds more than it used to. Nothing damaged, nothing growing. It’s worth treating for what it costs you – up in the night, out of your class, no swimming with the children.”

GP: “One blood test alongside whatever we decide – a full blood count, to see whether losing this much has left you short of iron. If it has, that’s treated with iron and rechecked; food helps, but food alone won’t put it back. No scan, no camera test – those are for when the history points inside the womb, and yours doesn’t.”

Rosalind: “So no scan at all?”

GP: “Not for you. And this is the bit to remember: ring the surgery if you start bleeding between periods or after sex, or get new pain or pressure in your tummy. Ring the same day if you feel faint, breathless or dizzy.”

THE MANAGEMENT PLAN – from 5:10

5:10 – GP: “Five things we could do, and the numbers differ a lot. Doing nothing barely shifts it. Anti-inflammatory tablets during your period, twenty to sixty per cent less. Tranexamic acid, also just during your period, forty to sixty – and it works on the period you take it in. The combined pill, thirty-five to forty-five. The hormone coil is strongest by a long way: eighty to ninety-five per cent less bleeding, and between one in ten and one in two women stop having periods. That’s the one I’d recommend.”

Rosalind: “A girl at work had one and said it was agony going in. And doesn’t it make you put weight on?”

GP: “Both worth asking. Putting it in is uncomfortable for most, painful for some – painkillers beforehand help, and whoever fits it talks you through it. Weight gain is on the list: about half of women on any hormone treatment notice something – sore breasts, bloating, a dip in mood.”

GP: “And you said you’d never fancied hormones. This one sits in the womb and works mostly there – the dose in your bloodstream is a fraction of a pill’s, and it comes out whenever you want it out. It’s also contraception, for eight years; only condoms protect against infection, which on what you’ve told me isn’t a worry.”

Rosalind: “Oh. I didn’t know that. That’s different, then.”

6:30 – GP: “Before you choose, the timing. The coil takes three to six months to settle, and in those months the bleeding is unpredictable – spotting for days, or a longer bleed than usual. Give it six cycles before you judge it; that’s the rule, and people give up at three. Your sister’s wedding is six weeks away. It will not have settled, and that week could be messier rather than better.”

Rosalind: “So if I go for the coil, my periods won’t be sorted by the wedding? That’s six weeks.”

GP: “No. Which leaves two questions with different answers: what fixes the next eighteen months, and what gets you through that one day. Which first?”

Rosalind: “The eighteen months, put like that. The wedding’s one day and I’ve had this since before the little one started nursery. But can we do something about the wedding too?”

GP: “Yes. We fit it as soon as we can and I see you three weeks later – the week before the wedding. We’ll know how it’s settling, and if that week still worries you there’s the tablet that works on the period you take it in. We decide then, not guess now.”

7:45 – GP: “Two checks before you agree. We’ve no allergies recorded – still right? And before a coil I ask everyone: have you or your partner had other partners, or any infection down below? The extra infection risk in the first weeks runs through an infection already there.”

Rosalind: “No, nothing. Never reacted to anything. And it’s just been the two of us for eleven years – nothing like that, ever.”

GP: “Then nothing I’d test for on that basis – say if you’d rather anyway. These are prescribed by name; they aren’t interchangeable. Yours is Mirena, licensed for heavy periods, five years for that. Putting one in can, rarely, make a small hole in the wall of the womb – about one in a thousand fittings.”

Rosalind: “A girl at work said hers fell out and she didn’t know for ages. How would I know if that happened to me?”

GP: “Coming out is commoner in women fitted for heavy bleeding – about five in a hundred. Two threads sit high up inside where you can feel them: check at four to six weeks, then monthly.”

GP: “So – three groups to ring us about. The device: severe pelvic pain, worse than period cramps; pain or bleeding going on more than a few weeks; a sudden change in your periods; pain during sex; threads you can’t feel. Ring, and condoms until we’ve checked it.”

Rosalind: “Right. Threads. I can do that.”

GP: “Infection next, highest in the first three weeks: a temperature, a change in your discharge, or feeling unwell with pain. Which of those is a same-day call?”

Rosalind: “A temperature. Or feeling ill with the pain.”

GP: “All three are. And pregnancy – very unlikely with this in, but if it happened it’s likelier to be in the wrong place. Lower tummy pain with a missed or odd period means a test and a ring, even after your periods settle or stop.”

9:45 – GP: “Then why I can’t simply book the fitting. It can’t be done without examining you first, and we need to be certain you’re not pregnant. So this needs you in the surgery.”

Rosalind: “I can’t just take a day off in term time – they’d have to get cover for my class, and I’d need to give notice.”

GP: “Then we won’t use a school day. We run appointments from eight, and a last slot in the afternoon. It’s best done in the first days of a period, and yours is due in about a fortnight – so an early slot that week, blood at the same visit. Give yourself time afterwards: some people feel faint or crampy, and you’ll be driving.”

Rosalind: “Right – if it’s before school starts, or the last bit of the afternoon, I can sort that. Just not the middle of the day.”

10:40 – GP: “Meanwhile, get iron into what you already eat – red meat, fish, lentils, beans, dark green veg, eggs. And I’ll send the NHS leaflet: the same numbers side by side, to read tonight. Nothing is fixed until it’s fitted.”

THE CLOSE – from 10:55

10:55 – GP: “So: blood test and fitting at one appointment, before school or at day’s end, in the first days of your next period. Review three weeks later, the week before the wedding. Meanwhile – between-period or after-sex bleeding, new pain or pressure: ring. Faint, breathless or dizzy: same day. Now tell me what you’d ring about once the coil is in.”

Rosalind: “Bad pain, worse than cramps. Bleeding that keeps going for weeks. Periods suddenly heavy again. Pain when we have sex. Threads I can’t feel – and condoms till it’s checked. Then same day for a temperature or a change in discharge.”

GP: “And the third group?”

Rosalind: “A test if I get tummy pain with a period that’s late or odd – because it’d be likelier to be in the wrong place.”

GP: “Perfect. I’ll see you the week before the wedding.”

PART C – GOLDEN HISTORY-TAKING QUESTIONS

“Tell me what’s been happening with your periods.”
“You said you walked out of your class – tell me about that.”
“Take me through your second day, hour by hour: how often are you changing, are you doubling up, are you up in the night?”
“Have you bled through onto clothes or the bed – and what have you stopped doing?”
“Do you ever bleed between periods, or after sex?” (a polyp or the lining of the womb – it moves her to investigate-first)
“Any pain, pressure or bloating in your tummy, or any swelling?” (separates fibroids or adenomyosis from no-cause-found bleeding)
“Heavy right from your first period – and does anyone in the family bruise or bleed easily?” (the two-part pattern pointing to a clotting disorder)
“More tired than usual, breathless or dizzy on the stairs – and feeling the cold, dry skin, constipation?” (anaemia; and the thyroid negatives that justify not testing)
“When was your last smear, and what did the letter say? And we’ve nothing down for allergies – still right?” (record checks, made before anything is offered)
“What did you think was causing it?”
“What made you book today, and what were you hoping for?”
“What contraception are you using, and are any more children planned? And before I offer a coil: have you or your partner had other partners, or any infection down below?” (the answers change which treatments are open, and infection risk is asked before any fitting)

PART D – MANAGEMENT SUMMARY

Establish volume by behaviour, never the word “heavy” – changes per hour, doubling up, night changes, flooding, activities dropped.
Screen the required list, including the thyroid negatives; any positive and she is examined and investigated.
Arrange a full blood count alongside treatment; say why no imaging is needed. Treat iron deficiency anaemia with iron if the count shows it – food is an adjunct, not treatment.
Offer the menu with its figures and elicit her priorities – the system takes off most, 80–95%. Set the three-to-six-month settling against her six-week deadline before she chooses, and plan for that week. Signpost the NHS page and decision tool.
Start tranexamic acid if she declines it – 1 g three times daily, up to 4 days from the start of bleeding, max 4 g daily; no examination needed.
Assess before any fitting, three limbs: examination; pregnancy excluded; sexual history for infection risk, testing offered as appropriate. Arrange it within 5 days of a period, with time afterwards; review at three weeks.
Prescribe by brand once allergy status is confirmed; counsel before consent: also contraception; unpredictable bleeding for 3 to 6 months, 6 cycles before judging it; perforation about 1 in 1,000; thread checks at 4 to 6 weeks, then monthly.
Safety-net after fitting, three groups.
Device – severe pelvic pain, bleeding beyond a few weeks, sudden change in periods, pain during sex, threads not felt: ring, condoms until checked.
Infection – same day for temperature, changed discharge or feeling unwell with pain.
Pregnancy – lower abdominal pain with a missed or odd period: test and ring; ectopic is likelier with a device in.
Safety-net meanwhile: ring for bleeding between periods or after sex, or new pain or pressure; same day for faint, breathless or dizzy.

AT A GLANCE

Heavy menstrual bleeding is defined by its effect on quality of life, not by millilitres. First-line with no identified pathology, fibroids under 3 cm not distorting the cavity, or suspected or diagnosed adenomyosis: the levonorgestrel-releasing intrauterine system. If declined or unsuitable: tranexamic acid, an anti-inflammatory, combined hormonal contraception, or cyclical progestogen.

PART E – CASE VARIATIONS

She asks for “just the pill instead”

Changed fact(s): She declines the coil and asks for the combined pill.

The candidate needs to: Treat it as a listed option, then run the eligibility screen: migraine with aura, personal or family clot history, smoking, weight, height. She answers cleanly and gives both.

Management pivot: It cannot start on this call: blood pressure decides eligibility and cannot be taken down a camera, so the appointment becomes a blood pressure check. 160/100 and above rules it out outright; 140–159 or 90–99, or hypertension already treated, also means she should not use it while safer options are open. Clot risk: about 2 to 4 leg clots per 10,000 women a year without the pill, about 5 to 12 on it, highest in the first months and after a break of a month or more.

What remains unchanged: The blood count, the screen, the no-investigation decision, the safety-net – and the six-week problem the pill will not fix.

Teaching point: A request does not shorten the screen behind it – and this threshold has two bands, not one.

She also bleeds between periods

Changed fact(s): She also reports light mid-cycle bleeding, two or three days, these last months.

The candidate needs to: Characterise it – months, days, every cycle – and see that the plan’s ground has gone.

Management pivot: She no longer qualifies for treatment without investigation, and a related symptom means examination before anything is arranged: abdomen, speculum to see the cervix, bimanual. Bleeding between periods points to a submucosal fibroid, polyp or endometrial pathology, so the investigation is outpatient hysteroscopy, not a scan – alternatives discussed, oral pain relief first; declined, hysteroscopy under anaesthesia; declined again, pelvic ultrasound with its limits. She now meets the biopsy criteria, and the coil is deferred, not abandoned. Tranexamic acid is not the first reach for the wedding here: its labelling bars use in irregular bleeding until the cause is established. Offer an anti-inflammatory instead, or wait for the hysteroscopy.

What remains unchanged: The blood count, the impact history, her fear about the woman at work, the wedding deadline. Re-check the screen.

Teaching point: One extra symptom moves her from the treat-now limb to the investigate-first limb – and examination comes before investigation, not instead.

She wants tranexamic acid as well as the pill

Changed fact(s): Established on the combined pill above, she asks for tranexamic acid for the wedding.

The candidate needs to: Recognise these are not a free combination, and ask again about clot risk – personal or family history, immobility, surgery, a long flight.

Management pivot: Tranexamic acid is used with care alongside a combined hormonal contraceptive, for the added clotting risk. The pair needs a stated reason, a short defined course, and the clot warning signs – a calf painful, swollen or hot; breathlessness; chest pain. If the profile is not clean, change the method rather than stack the two. The same caution covers any oestrogen-containing method and high-dose cyclical norethisterone, which carries its own thromboembolic signal.

What remains unchanged: The dose and rule do not move, nor the instruction to stop and ring if her colour vision changes.

Teaching point: Adding a drug to a working treatment is still a prescribing decision – against this patient’s clot risk, not the request.

PART F – WHY CANDIDATES FAIL THIS CASE

You take the label instead of the count. You ask whether her periods are heavy, she says “they’re not that bad, really”, and you write it down. Now you have a label instead of a picture, and nothing you have gathered tells you whether this woman meets the threshold for treatment at all, so every choice after it is a guess. Ask her to count: how often she changes on the second day, whether she doubles up, how many times she is up in the night. That is the data gathering this case is built on, and without it there is none.

You recommend instead of deciding together. You know the coil is first-line, so you say so, and the consultation turns into an instruction. She says “if you think so” and stops contributing, and the shared decision – which is where clinical management is really marked here – never happens. Give her the numbers for all of them, say which you would recommend and why, then ask what matters most to her.

You leave the timing out. You explain the coil well and say nothing about three to six months, because it undercuts the recommendation you have just made. Six weeks later she is flooding at her sister’s wedding with a device she agreed to on a false premise: your prescribing was safe, but it was not complete. Say it before she chooses – it will not have settled, that week could be worse rather than better, and here is what we will do about that week.

You consent her on half the bundle. You give the perforation warning, because that is the one everybody remembers, and stop there. You never ask about infection risk before arranging a fitting, never tell her the device is also her contraception, never mention the six cycles, and hand her a safety-net with no infection limb and no pregnancy limb – in a woman you have just told may stop having periods altogether, which is exactly the state in which an ectopic hides. Three limbs before the fitting, three groups afterwards.

You never summarise, so the fear never surfaces. The gap where she would have said “it’s not something serious though, is it?” never opens. You then explain heavy periods to a woman who came in frightened of womb cancer, and she leaves with the fear intact – the plainest way there is to lose marks for relating to the person in front of you. Say her account back to her, then stop talking.

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

Sources consulted in the preparation of MRCGP SCA Case 1 (heavy menstrual bleeding). Harvard (author–date) style.

Bayer plc (2023) Microgynon 30: summary of product characteristics. Text last revised 13 February 2023. Available at: https://www.medicines.org.uk/emc (Accessed: 25 August 2026).

Bayer plc (2026) Mirena 20 micrograms/24 hours intrauterine delivery system: summary of product characteristics. Text last revised 12 May 2026. Available at: https://www.medicines.org.uk/emc (Accessed: 25 August 2026).

Chemidex Pharma Ltd t/a Tarus Pharmaceuticals (2025) Mefenamic Acid 500 mg Tablets: summary of product characteristics. Text last revised 15 February 2025. Available at: https://www.medicines.org.uk/emc (Accessed: 25 August 2026).

Faculty of Sexual and Reproductive Healthcare (2019) FSRH clinical guideline: combined hormonal contraception. January 2019, amended October 2023. London: FSRH. Available at: https://www.fsrh.org (Accessed: 25 August 2026).

Faculty of Sexual and Reproductive Healthcare (2023) FSRH clinical guideline: intrauterine contraception. March 2023, amended January 2025. London: FSRH. Available at: https://www.fsrh.org (Accessed: 25 August 2026).

Faculty of Sexual and Reproductive Healthcare (2025) UK medical eligibility criteria for contraceptive use (UKMEC 2025): summary tables. London: FSRH. Available at: https://www.fsrh.org (Accessed: 25 August 2026).

Gedeon Richter Plc (2026) Levosert 20 micrograms/24 hours intrauterine delivery system: summary of product characteristics. Text last revised 13 April 2026. Available at: https://www.medicines.org.uk/emc (Accessed: 25 August 2026).

Joint Formulary Committee (2026a) ‘Contraceptives, hormonal’ [treatment summary], in British National Formulary. London: BMJ Group and Pharmaceutical Press. Available at: https://bnf.nice.org.uk (Accessed: 25 August 2026).

Joint Formulary Committee (2026b) ‘Ethinylestradiol with levonorgestrel’, in British National Formulary. London: BMJ Group and Pharmaceutical Press. Available at: https://bnf.nice.org.uk (Accessed: 25 August 2026).

Joint Formulary Committee (2026c) ‘Heavy menstrual bleeding’ [treatment summary], in British National Formulary. London: BMJ Group and Pharmaceutical Press. Available at: https://bnf.nice.org.uk (Accessed: 25 August 2026).

Joint Formulary Committee (2026d) ‘Levonorgestrel’, in British National Formulary. London: BMJ Group and Pharmaceutical Press. Available at: https://bnf.nice.org.uk (Accessed: 25 August 2026).

Joint Formulary Committee (2026e) ‘Mefenamic acid’, in British National Formulary. London: BMJ Group and Pharmaceutical Press. Available at: https://bnf.nice.org.uk (Accessed: 25 August 2026).

Joint Formulary Committee (2026f) ‘Tranexamic acid’, in British National Formulary. London: BMJ Group and Pharmaceutical Press. Available at: https://bnf.nice.org.uk (Accessed: 25 August 2026).

Medicines and Healthcare products Regulatory Agency (2014a) ‘Combined hormonal contraceptives and venous thromboembolism: review confirms risk is small’, Drug Safety Update, 7(7), A2. Published 11 December 2014. Available at: https://www.gov.uk/drug-safety-update (Accessed: 25 August 2026).

Medicines and Healthcare products Regulatory Agency (2014b) ‘Combined hormonal contraceptives: risk of venous thromboembolism’, Drug Safety Update, March 2014. Published 11 December 2014. Available at: https://www.gov.uk/drug-safety-update (Accessed: 25 August 2026).

Medicines and Healthcare products Regulatory Agency (2015) ‘Intrauterine contraception: uterine perforation – updated information on risk factors’, Drug Safety Update. Published 26 June 2015. Available at: https://www.gov.uk/drug-safety-update (Accessed: 25 August 2026).

Medicines and Healthcare products Regulatory Agency (2016) ‘Levonorgestrel-releasing intrauterine systems: prescribe by brand name’, Drug Safety Update. Published 21 January 2016. Available at: https://www.gov.uk/drug-safety-update (Accessed: 25 August 2026).

National Institute for Health and Care Excellence (2015) Suspected cancer: recognition and referral. NICE guideline NG12. Published 23 June 2015, last updated 15 April 2026. London: NICE. Available at: https://www.nice.org.uk/guidance/ng12 (Accessed: 25 August 2026).

National Institute for Health and Care Excellence (2018) Heavy menstrual bleeding: assessment and management. NICE guideline NG88. Published 14 March 2018, last updated 7 July 2026. London: NICE. Available at: https://www.nice.org.uk/guidance/ng88 (Accessed: 25 August 2026).

National Institute for Health and Care Excellence (2020) Heavy menstrual bleeding. Quality standard QS47. Last updated 16 October 2020. London: NICE. Available at: https://www.nice.org.uk/guidance/qs47 (Accessed: 25 August 2026).

NHS (2024) Heavy periods. Page last reviewed 19 September 2024. Available at: https://www.nhs.uk/conditions/heavy-periods/ (Accessed: 25 August 2026).

Royal College of General Practitioners (no date) Feedback statements for the SCA. London: RCGP. Available at: https://www.rcgp.org.uk (Accessed: 25 August 2026).

Royal College of General Practitioners (no date) Marking and results for the SCA. London: RCGP. Available at: https://www.rcgp.org.uk (Accessed: 25 August 2026).

Waymade plc t/a Sovereign Medical (2026) Tranexamic Acid 500 mg Tablets: summary of product characteristics. Text last revised 8 April 2026. Available at: https://www.medicines.org.uk/emc (Accessed: 25 August 2026).

Winton Centre for Risk and Evidence Communication and NHS England (2023) Making a decision about managing heavy periods. Last updated June 2023. Available at: https://www.england.nhs.uk/personalisedcare/shared-decision-making/decision-support-tools/ (Accessed: 25 August 2026).

Wockhardt UK Ltd (2024) Norethisterone 5 mg Tablets: summary of product characteristics. Text last revised 6 November 2024. Available at: https://www.medicines.org.uk/emc (Accessed: 25 August 2026).

EXAMPLE CONSULTATION EXCERPTS

Opening note for learner: After you’ve attempted this case, use these excerpts to learn how a passing candidate handles the moments that matter most. Each shows a weaker version and a stronger version of the same moment, so you can hear the difference. The point isn’t to memorise the wording – it’s to recognise the decision being made and learn to make it in your own voice.

How to use these excerpts:

Read both versions aloud.
Name what changed between the weak and strong versions before you read the explanation.
Cover the strong version. Try saying the same moment in your own words.
Use the “Try this yourself” prompt for active practice – ideally with a study partner playing the patient.

MOMENT 1 – “I nearly cancelled”

The setting: The first seconds of the video call. She has apologised for booking and played the problem down.

The decision: Whether to start asking questions now, or add nothing and let her whole first account finish.

What the marking scheme is rewarding: Opening broadly, letting her account run, picking up the cue about walking out of her class – and answering her apology by naming what she just described.

🔻 Borderline handling (what trainees often do):

GP: “Hello Rosalind. What can I do for you today?”

Rosalind: “Hiya – sorry, I feel a bit daft even ringing about this. It’s just my periods, really. They’ve got a bit heavier.”

GP: “Not daft at all. How long has that been going on?”

Rosalind: “About eighteen months, I suppose.”

GP: “And are they regular?”

Rosalind: “Yeah. Every four weeks, regular as anything.”

GP: “Any bleeding in between?”

Rosalind: “No, never.”

✅ Strong handling (what a passing candidate does):

GP: “Hello Rosalind. Tell me what’s brought you along today.”

Rosalind: “Hiya – sorry, I feel a bit daft even ringing about this. It’s just my periods, really. They’ve got a bit heavier. I nearly cancelled, honestly – you’ve got proper poorly people to see.”

GP: (says nothing, and waits)

Rosalind: “It’s crept up over about eighteen months. And I had to walk out of my class the other week.”

GP: “You walked out of your class. Tell me about that.”

Rosalind: “I’d bled through onto my trousers. I sent a child to the office for a spare cardigan to tie round my waist.”

GP: “You had to leave a Reception class and send a child to the office. That’s what you nearly cancelled about.”

Rosalind: (quieter) “Yeah. It wasn’t great.”

What changed:

The borderline opening asks for a complaint; the strong one asks for an account – and then nothing follows it until she stops talking.
The first follow-up in the borderline version lands after one sentence, so the class never comes up. The silence in the strong version is what produces it.
The apology is answered with her own facts – a Reception class, a child sent to the office – instead of a generic “not daft at all”.

The transferable principle: When a patient opens by minimising, the fastest route to the real story is to add nothing for a few seconds. Then answer the apology with the specifics they gave you, not with reassurance.

Phrase variants (three different ways to make the same move – choose what fits your voice):

“You had to leave a class and send a child to the office. That’s a reason to book, not a reason to apologise.”
“Eighteen months, and it’s now costing you your working day. I’m glad you rang.”
“Before we go further – you’ve told me two things that matter: eighteen months, and walking out of a lesson. Let’s start there.”

Try this yourself: Say her opening line out loud, then time five seconds of silence before you speak. Notice how long it feels. Then practise one sentence that answers her apology using only facts she has given you – no reassurance words at all.

Adoption note: Take one or two of these lines at most, and use them in real surgeries until they stop feeling borrowed. A phrase you’ve said fifty times in clinic is your voice; a phrase you read last night is a stock phrase, and the role-player will hear the difference.

MOMENT 2 – Turning “heavy” into a number

The setting: A minute in. She has described walking out of her class, and you now need to know how heavy this actually is.

The decision: Whether to take her word for the severity, or ask her to count something.

What the marking scheme is rewarding: Counting the bleeding – changes per hour, doubling up, night changes, clothes soaked – rather than accepting “they’re not that bad, really”.

🔻 Borderline handling (what trainees often do):

GP: “And are your periods heavy?”

Rosalind: “They’re not that bad, really. I mean they’re heavy, but everyone says that, don’t they?”

GP: “Okay. And how many days do they last?”

Rosalind: “Six or seven. Same as always.”

GP: “Any clots?”

Rosalind: “Some, on the bad days.”

GP: “Right. So they’ve got heavier, but the pattern’s the same. Shall we talk about what we can do?”

Rosalind: “Okay.”

✅ Strong handling (what a passing candidate does):

GP: “Take me through your second day, hour by hour. How often are you changing?”

Rosalind: “Every hour, hour and a half.”

GP: “One thing at a time, or two?”

Rosalind: “Tampon and a pad together – I have to.”

GP: “And at night?”

Rosalind: “Up twice, sometimes three times. There’s a towel on the bed.”

GP: “What have you stopped doing because of it?”

Rosalind: “I don’t take the kids swimming on those days. And I’ve made excuses to my sister twice.”

What changed:

The borderline version asks her to grade her own symptom. The strong version asks her to count things she can count.
Every strong question has exactly one answer – a number, a yes or no, an activity – so none of them can be met with “not that bad”.
The strong version finishes on what she has given up, which is the part that turns this from a variation into something worth treating.

The transferable principle: When a patient grades their own symptom, the adjective tells you about them, not about the symptom. Ask for something countable – how many, how often, what stopped – and let the numbers do the grading.

Phrase variants (three different ways to make the same move – choose what fits your voice):

“Talk me through your worst day. From when you wake up – how many changes?”
“What are you doing on those two days that you wouldn’t do on an ordinary day?”
“Think back two years, before this started. What’s different now that someone watching you would notice?”

Try this yourself: Take any symptom a patient might describe as “not too bad” – pain, breathlessness, tiredness. Write three questions that can only be answered with a number or a named activity. Say them aloud and cut any that could be answered “it’s fine”.

MOMENT 3 – The summary, and the gap after it

The setting: Around two and a half minutes. The history is done and you are about to start explaining.

The decision: Whether to run the summary straight into the plan, or stop talking – and then, if something surfaces, whether to reassure or to ask.

What the marking scheme is rewarding: Summarising and leaving a gap; responding to the womb-cancer fear before explaining anything else.

🔻 Borderline handling (what trainees often do):

GP: “Okay – so, heavier periods for eighteen months, still regular, nothing in between, smear up to date. So this is heavy menstrual bleeding, and the good news is there’s a lot we can do about it.”

Rosalind: “Right.”

GP: “There are tablets you take during your period, or something longer-term. Which sounds better to you?”

Rosalind: “I don’t know really. Whatever you think.”

✅ Strong handling (what a passing candidate does):

GP: “Let me say this back. Eighteen months of heavier periods, still four-weekly, still six or seven days. On the two bad days you’re changing hourly, doubling up, up twice a night, and you’ve bled through at work. Nothing in between, nothing after sex, smear clear. And your sister’s wedding is six weeks away, on the day your period’s due.”

GP: (stops talking, and lets the pause sit)

Rosalind: (after a moment, looking away from the camera) “It’s not something serious though, is it? Only a woman at work was diagnosed with womb cancer last year.”

GP: “Tell me about her – what happened?”

Rosalind: “She’s in the office. She’d been bleeding in between for months and left it. She’s alright now. But it frightened me.”

GP: “So that’s been sitting behind this since you booked. Nothing you’ve told me points that way, and here’s why. What worries me about the lining of the womb is bleeding between periods, bleeding after sex, or bleeding once periods have stopped for good.”

Rosalind: “And I’ve not had any of those.”

GP: “None of the three. That first one is what happened to her, and it’s why she was looked into. What’s changed for you is the amount, and on its own that doesn’t point that way.”

What changed:

The borderline summary is a bridge into the plan, so no gap opens and the worry is never spoken.
The strong version stops. The silence is what produces the question – and on video, she can see you waiting.
The borderline version would have reassured immediately. The strong one asks about the woman at work first, gives the answer plainly, then shows her the reasoning against her own three negatives.

The transferable principle: A summary is an invitation, not a conclusion. Deliver it, stop, and let the silence work – and when a fear surfaces, find out where it came from before you answer it.

Phrase variants (three different ways to make the same move – choose what fits your voice):

“That’s what I’ve got. What have I missed?”
“Have I got that right? Take a moment – anything I’ve left out?”
(Summarise, then simply stop. No question at all – let the pause be the invitation.)

Try this yourself: Record yourself summarising this history, then stay silent for a full five seconds without ending on a question. Play it back and listen for the urge to fill it. Then practise the follow-up: one open question about the person she mentioned, before any reassurance.

MOMENT 4 – Five options, and the six weeks that don’t fit

The setting: Around five minutes. You have explained what is going on, and the options are about to go on the table.

The decision: Whether to name the best option and move on, or lay out the comparison, recommend with reasons, and say – before she commits – that what you are recommending will not have worked by the day she cares about.

What the marking scheme is rewarding: Offering the whole menu with its numbers; naming the three-to-six-month settling against her six-week deadline and the six-cycle rule; picking up what puts her off hormones.

🔻 Borderline handling (what trainees often do):

GP: “For heavy periods the most effective option by a long way is the hormone coil – eighty to ninety-five per cent less bleeding. I’d recommend that.”

Rosalind: “A girl at work had one and said it was agony going in. And doesn’t it make you put weight on?”

GP: “It can be uncomfortable, yes – painkillers beforehand help with that. And it does settle down over time.”

Rosalind: “Right.”

GP: “So shall I get you booked in for a fitting?”

Rosalind: “If you think so.”

✅ Strong handling (what a passing candidate does):

GP: “Five things we could do, and the numbers differ a lot. Doing nothing barely shifts it. Anti-inflammatory tablets during your period take off twenty to sixty per cent; tranexamic acid, also just during your period, forty to sixty; the combined pill, thirty-five to forty-five. The hormone coil takes off eighty to ninety-five, and between one in ten and one in two women stop having periods altogether.”

Rosalind: “A girl at work had one and said it was agony going in. And doesn’t it make you put weight on?”

GP: “Both worth asking. Putting it in is uncomfortable for most and painful for some – painkillers beforehand help. And weight gain is on the list: about half of women on any hormone treatment notice something, sore breasts, bloating, a dip in mood.”

Rosalind: (pause) “Hmm.”

GP: “You told me you’d never fancied being on hormones. This one sits in the womb and works mostly there, so the dose in your bloodstream is a fraction of a pill’s – and it comes out whenever you want it out. It’s still what I’d recommend, because it takes off the most.”

Rosalind: “Oh. I didn’t know that. That’s different, then.”

GP: “One thing before you choose, and for you it’s the important one. It takes three to six months to settle, and the bleeding is unpredictable in those months – give it six cycles before you judge it. Your sister’s wedding is six weeks away. It will not have settled, and that week could be messier rather than better.”

Rosalind: “So it won’t be sorted by the wedding? That’s six weeks.”

GP: “No. So let’s treat them as two problems rather than one: the coil for the next eighteen months, and a separate plan for that week – which we’ll make three weeks after it’s fitted, when we can see how it’s settling.”

What changed:

The borderline version offers one option; the strong version gives all five with their numbers, then recommends. The recommendation lands on a comparison instead of replacing it.
The borderline GP answers the pain half and lets the weight question go. The strong one answers both, then meets the objection underneath them – where the hormone actually goes, and that it is reversible.
“It does settle down over time” becomes three to six months, six cycles, and her six weeks – said before she chooses, not after.

The transferable principle: A recommendation you have to protect from a fact is not a shared decision. Give the comparison, recommend with your reason, then say the inconvenient thing out loud before the patient commits – and where two goals collide, split them into two problems with two plans.

Phrase variants (three different ways to make the same move – choose what fits your voice):

“Before you decide, there’s a catch in the timing you need to weigh up.”
“Let’s test this against your date. The wedding is six weeks away; this takes three to six months. Those two don’t meet.”
“There are two questions here with different answers: what fixes the next eighteen months, and what gets you through that one day.”

Try this yourself: Take a treatment you often recommend, and name the one fact about it you tend to leave until after the patient has agreed. Practise saying it aloud in the sentence before you ask them to decide. Notice whether your recommendation still stands up – it usually does.

MOMENT 5 – Asking the awkward question, and closing on her words

The setting: She has chosen the coil. The assessment, the safety advice and the appointment all sit in the last two minutes.

The decision: Whether to bundle the questions and deliver the safety advice as one block, or ask the intrusive question on its own with its reason, take the advice in named groups with a check inside it, and close on what she says back.

What the marking scheme is rewarding: Taking the sexual history and booking the examination; counselling the device, infection and pregnancy before consent; checking understanding by what she says back, not “does that make sense?”.

🔻 Borderline handling (what trainees often do):

GP: “Right, I’ll get you booked in for the fitting. Before you go – any allergies? And I do need to ask, do you or your partner have any other sexual partners?”

Rosalind: (pause) “Er – no. Just my partner.”

GP: “Fine. So, there’s a small risk of perforation, about one in a thousand, and there’s a chance of expulsion, so if you get severe pain or you can’t feel the threads, come back to us. Does that all make sense?”

Rosalind: “Yeah, I think so.”

GP: “Great. I’ll get that booked, then.”

Rosalind: “Okay.”

✅ Strong handling (what a passing candidate does):

GP: “One question I ask everyone before a coil, and I’ll tell you why first: the small extra risk of infection in the first few weeks after fitting runs through an infection that’s already there. So – have you or your partner had other partners, or any infection down below?”

Rosalind: “Just my partner – eleven years, it’s only ever been the two of us. No, never anything like that, and nothing now.”

GP: “Then nothing I’d test for on that basis – say if you’d rather anyway. Now, three groups of things to ring us about once it’s in, one at a time. First the device: putting one in can, rarely, make a small hole in the wall of the womb – about one in a thousand fittings. The signs are severe pelvic pain, worse than period cramps; bleeding going on more than a few weeks; a sudden change in your periods; pain during sex; or threads you can’t feel.”

Rosalind: “Right.”

GP: “Second, infection – that risk is highest in the first three weeks. A temperature, a change in your discharge, or feeling unwell with pain. Which of those is a same-day call?”

Rosalind: “A temperature. Or feeling ill with the pain.”

GP: “All three are, same day. And third, pregnancy – very unlikely with this in, but if it happened it’s more likely to be in the wrong place, so lower tummy pain with a missed or odd period means a test and a call. Tell me back the ones that need us the same day.”

Rosalind: “A temperature, a change in discharge, or feeling unwell with the pain.”

GP: “That’s the set. Blood test and fitting at the one appointment – before school or the last slot of the afternoon, in the first days of your next period. I’ll see you three weeks after that, the week before the wedding.”

What changed:

The borderline version asks the intrusive question cold, bundled behind an allergy check. The strong one gives the reason first, then asks it on its own, so she knows why it is being asked.
“Perforation” and “expulsion” become a small hole in the wall of the womb, and threads you can’t feel. Nothing technical is left unexplained in the same breath.
The safety advice goes from one block with a yes/no check, to three named groups with the check placed inside – a question she could get wrong, and did.
The borderline version ends on her “Okay”. The strong one ends with her saying the same-day triggers back, then the GP naming the appointment, the timing and the review.

The transferable principle: Dense safety information is delivered in named groups with the check inside it, not appended to the end – and the close proves understanding by what the patient says, not by what you asked. Where a question is intrusive, the reason comes before the question, not after it.

Phrase variants (three different ways to make the same move – choose what fits your voice):

“There’s one question I ask everyone before this, and it’s worth knowing why: [reason].”
“This next one is personal, and it changes what I do – so [reason]. Have you or your partner…”
“I’m going to ask about something private, because [reason]. Then I’ll tell you what happens next.”

Try this yourself: Take the safety advice from this case and split it aloud into three named groups. Put one check inside the middle group – a question with a wrong answer available – and finish by asking the patient to say back only the same-day items. Time it: it should run under ninety seconds.

One-line takeaway for this case: The marks here are won by saying the inconvenient thing before the patient chooses – the count she would rather not give, the fear she has not voiced, and the three months her wedding has not got.

Practice plan for this case:

Read through all moments aloud once, just to hear them.
Pick the moment you find hardest. Practise the strong version in your own words five times until it feels natural.
Find a study partner. Have them play the patient. Run the moment without looking at the transcript.
Record yourself. Listen back for the things that change between borderline and strong handling.