Contraception Counseling OSCE - Combined Pill Counseling

Case Overview

• Age/Sex: 24-year-old female
• Occupation: University student (undergraduate, final year)
• Setting: Primary care / student health clinic
• Chief complaint: "I want to discuss contraception"

Patient Script

Who I Am

I'm 24, a university student finishing my degree, and pretty stressed with exams right now.

What Brings Me In

I want to start contraception because I'm about to become sexually active with a new partner and I want something reliable and easy to use.

My Story

I've been thinking about contraception for a few weeks and finally booked this appointment because my exams start in two weeks and I don't want to worry about pregnancy. I have fairly regular periods—usually every 28 days—and my last period was 10 days ago. I've had some breakouts since starting university, so I heard the pill can help with acne and make periods lighter. I sometimes get tension headaches around exam time but they are just dull and there is no visual disturbance or aura. I don't smoke regularly—maybe a cigarette at parties a couple of times a month—and I occasionally vape. I take a daily multivitamin and sometimes use over-the-counter St John's wort for stress (started last month). I haven't been pregnant before and I had one STI screen at a sexual health clinic two years ago (it was negative). I had a wisdom tooth out last year and that was fine.

My Medical Background

• Past medical history: none significant
• Medications: multivitamin daily; St John's wort occasionally for stress
• Allergies: none known
• Social history: drinks alcohol socially (2–4 units, once or twice a week); occasional recreational vaping; single, about to start a sexual relationship
• Obstetric/Gyn history: menarche at 13, cycles ~28 days, mild dysmenorrhoea (Ibuprofen helps)
• Family history: mother alive, healthy; grandmother had breast cancer in her 60s

What I Think & Worry About

• I think the pill might help with acne and make my periods lighter.
• I'm worried about side effects and whether it's safe with the St John's wort I sometimes take.
• I expect the doctor to recommend something reliable I can manage around exams.

If You Ask Me About Other Symptoms...

• Headaches: "I get tension-type headaches before exams—no flashing lights or visual changes, and they last a few hours."
• Breathlessness/chest pain: "No, I haven't had shortness of breath or chest pain."
• Leg symptoms: "No calf pain or swelling."
• Breast symptoms: "No lumps or nipple discharge."
• Mood/mental health: "I feel anxious because of exams but no history of depression or mood swings that required treatment."
• Recent infections: "No abnormal vaginal discharge, no painful urination."
• Sexual history: "I'm not in a long-term relationship yet; I've had a few partners in the past year; last sexual encounter was protected and was about 3 weeks ago."
• Emergency contraception: "I didn't need emergency contraception recently."
• Prior contraception use: "I've used condoms before but never the pill."

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Clinical Summary

Examination

• General: alert, well woman, no acute distress
• BP: 116/72 mmHg
• Heart rate: 76 beats/min, regular
• Respiratory rate: 14/min
• Temperature: 36.7°C
• BMI: 22 kg/m2 (height 168 cm, weight 62 kg)
• Cardiorespiratory exam: chest clear, heart sounds normal, no murmurs
• Abdominal exam: soft, non-tender
• Neurological: no focal deficits; cranial nerves intact
• Breast exam: no masses or nipple discharge
• Peripheral vascular: no calf tenderness or unilateral swelling

Investigations

• Urine pregnancy test: negative (no evidence of pregnancy)
• Urinalysis: normal (no infection)
• STI screen: not done today (offer recommended)
• BP and BMI documented above (acceptable for combined hormonal contraception)

Diagnosis

Primary: Suitability for combined oral contraceptive pill (COCP) — patient is a healthy 24-year-old woman with regular cycles, negative pregnancy test, normal blood pressure and BMI, no history of migraine with aura, and no personal history of thromboembolism. Evidence: age <35, non-daily smoker, normal BP (116/72), BMI 22, no red-flag history.

Differentials/Alternatives:

• Progestogen-only pill (POP): suitable if contraindications to estrogen arise or if she prefers fewer systemic effects; considered if interactions with enzyme inducers are significant.
• Long-acting reversible contraception (e.g., IUD, implant): highly effective options to discuss if she prefers low-maintenance contraception.
• Barrier methods/condoms: useful for STI protection and as additional method during pill initiation or if she prefers non-hormonal methods.

Management

• Discuss options and obtain informed consent for COCP vs alternatives; patient education provided about benefits (pregnancy prevention, improvement in acne, reduced dysmenorrhoea) and risks (small increased risk of VTE, possible nausea, breast tenderness, mood changes).
• Address drug interactions: advise that St John's wort can reduce COCP effectiveness; recommend stopping St John's wort and consider alternative stress management or non-enzyme-inducing supplements before starting COCP. If she wishes to continue St John's wort, consider recommending a POP or LARC and counsel regarding additional barrier protection.
• Baseline checks completed: BP and BMI acceptable for COCP initiation today; pregnancy test negative — eligible to start.
• Start method: offer a "quick-start" (start active pill today with back-up condom for 7 days) or first-day start (start on first day of next period); discuss pros/cons and let patient choose. Provide prescription for a monophasic 21/7 or 28-day combined pill as appropriate to patient preference.
• Missed pill advice: provide clear instructions for missed pills and when to use emergency contraception.
• STI screening: offer full sexual health screen (chlamydia, gonorrhoea, HIV, syphilis) and vaccination review (HPV if indicated). Recommend condom use for STI prevention with new partners.
• Follow-up: arrange review in 3 months (or sooner if side effects) and BP check at 3 months and annually thereafter while on COCP.
• Provide urgent safety netting: advise to seek immediate care for signs of DVT (leg swelling/pain), pulmonary embolism (sudden chest pain, breathlessness), severe headache with visual disturbance, or jaundice.

Key Learning Points

• Assess suitability for combined oral contraceptives by reviewing age, smoking status, blood pressure, BMI, migraine history (particularly aura), and personal/family history of thrombosis.
• Enzyme-inducing drugs and some herbal preparations (e.g., St John's wort) reduce the effectiveness of combined hormonal contraception and should prompt consideration of alternatives or additional precautions.
• Always discuss STI risk and offer screening, explain start options (first-day vs quick-start) and provide clear missed-pill and safety-netting advice.