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OSCE question 5. |
Marks |
An eighteen year old nulliparous woman wishes to go on the Pill for the first time.
1. Name
a version of the Pill you might consider. Why would you consider it?
| Any “second generation”
Pill, i.e. containing 20 - 35mg.
oestrogen. The lower dose of oestrogen is linked to less risk. Avoid
“third generation” progestogens, e.g. desogestrel and gestodene,
unless there is good reason to do otherwise, although the current advice
is that they can be used after appropriate counselling – see MCQ8. |
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| The list is long! Pregnancy!
Arterial / venous thrombosis. Thrombophilia. Focal migraine. BP>
160/95. Stroke, coronary artery disease. Chronic liver disease,
cholestatic jaundice of pregnancy (I know she is nulliparous – this is a
general list), porphyria, breast cancer, previous severe oestrogen or
pregnancy induced disease e.g. haemolytic uraemic syndrome, recent molar
pregnancy, until HCG levels normal, abnormal genital tract bleeding.
Relative contraindications include smoking in women over 35, gross
obesity, sickle cell disease, diabetes, gallstones. Strong family history
of breast cancer, particularly if young age at onset. Crohn’s disease.
Epilepsy could be added as some of the drugs reduce the efficacy of the
Pill, but this can be overcome by giving a higher dose. (See MCQ7,
question 19 and MCQ10, question 26.) |
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3. List 3 non-contraceptive benefits
of the Pill. (A DRCOG examination favourite.)
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Reduction in menstrual loss and consequent anaemia. Reduced dysmenorrhoea. Regularisation of cycle lengths and abolition of the unpredictability of when bleeding will begin, with considerable social benefit for many women. Reduction in ovarian stimulation with resulting lower incidences of functional ovarian cysts and ovarian cancer. Less risk of endometrial cancer. Reduced pre-menstrual symptoms for some. There may be a reduced risk of fibroids and rheumatoid arthritis, but this is unproven, so would be unlikely to get a mark. |
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4. List four key pieces of advice you would include in counselling her.
| The risks and efficacy of
the Pill. Signs and symptoms of complications such as DVT. How to take the
Pill. (This can be a roleplay station with you faced with a patient who
has been fully counselled and a packet of the Pill, with instructions to
tell her how to take it.) Breakthrough bleeding. What to do about missed
Pills, diarrhoea & vomiting, antibiotics. To seek advice about
alternative contraception or pre-pregnancy counselling before stopping. |
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