Starting the combined pill — counselling and missed-pill rules

PLAB 2 & PRES 3 · prescribing / women's health · medium · 10 minutes

Candidate brief

You are an FY2 doctor in a GP surgery. Miss Sophie Laurent, 21, a university student, has asked to start "the pill". She has never used hormonal contraception. Her observations: BP 118/74 mmHg, BMI 24. She is in a relationship of 8 months and currently uses condoms, inconsistently. Please assess her suitability for the combined oral contraceptive pill and counsel her on starting it, including what to do if she misses a pill.

What examiners look for

Contraception counselling is prescribing under cross-examination: the safety lies in the screening history (aura, clots, pressure, interactions — including the herbal bottle she did not think to mention), and the effectiveness lies in the missed-pill teaching. A technically perfect explanation of a pill she takes badly protects nobody. Ask about the cousin properly. "Blood clot on the pill" can mean an unprovoked VTE in a first-degree relative (a real caution) or a provoked clot after a cast and a long flight in a cousin (reassuring) — the candidate who fails to ask leaves the patient's biggest fear untouched, whatever prescription they write. St John's wort is the interaction that walks into GP surgeries unannounced: bought online, "natural", mood-related, and capable of quietly switching the pill off. The medicines history that stops at prescribed drugs is only half a history — in contraception, sexual health and psychiatry alike. Missed pills have a grammar: one is forgiven (take it, carry on), two resets the clock (condoms for seven days), and the WEEK decides the danger — week 1 risks the pill-free interval behind it (emergency contraception territory), week 3 abolishes the break ahead of it. Teach it as that sentence and she will remember it at 1 a.m. in student halls, which is when it will be needed. Calibrate risk in absolute numbers or do not quote it at all: a VTE risk of "about 5–7 in 10,000 women per year on this pill, against 2 in 10,000 off it — and pregnancy carries a higher risk than either" lets a psychology student make a rational decision; "it can cause clots" makes an anxious one. And note what she actually gained today: contraception she controls, the heavy painful week of every month addressed, an emergency-contraception scare made unlikely to recur, an STI screen offered, and a mood remedy gently replaced with an open door. That is what good prescribing consultations are for.

Guideline references

Practise this station

Role-play it with an AI patient and get feedback against the full marking scheme. Create a free account — 3 stations per month free.