OBGYN Contraception Osce

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What is contraception?
Prevention of pregnancy using methods of birth control (contraceptive methods).
Facts on contraception
Most users wish to use methods which are comfortable, affordable and effective in preventing pregnancy
and sexually transmitted diseases.
Contraceptive usage in the local context is widely discussed and available among married couples.
Information on contraception is important for teenagers today since there is an increasing number of
them who are sexually-active.
Teenagers are encouraged to obtain advice from adults or health providers before deciding on the method
of contraception that is most suitable for them.
There are two major groups of contraceptive methods:
Non-hormonal
Hormonal
Non-hormonal contraceptive methods

These methods do not use hormones and do not change a woman’;s menstrual cycle. Except for
abstinence, they prevent pregnancy in one of several ways: by creating a “barrier” against sperm,
interrupting sperm movement, or creating a hostile (unfriendly) environment for sperm.
1. Abstinence
What it is : The act of not having any form of sex, either oral, vaginal, or anal
How it works : Since there is no sexual intercourse, pregnancy is not possible. This is the most effective
form of contraception (100% effectiveness)
Benefits : For teenagers who have not been sexually-active – for whatever reasons, they should be
encouraged to practice this method, since it is the most effective contraceptive in the world. These
teenagers do not have to face any consequences or complications from intercourse, and they can avoid
unplanned pregnancy and/or sexually transmitted diseases
Drawbacks : It can be hard to abstain especially with pressures from friends or partners. Teenagers
require a strong determination to deal with sexual desire, which can be hard to deal with. Even if
teenagers practice abstinence, they still need a good understanding on other methods of contraceptive
as well
2. Method: Coitus Interrupts (aka “withdrawal” or “pulling out”)
What it is : Withdrawal of penis from vagina before ejaculation
How it works : Since there is no ejaculation inside the vagina, there will be no sperm entering the vagina
Benefits : Can be used readily especially when no other method is available
Drawbacks : Needs a lot of self-control in male partners. Risk of pregnancy is increased if the male
ejaculates as he is pulling out or right outside the vaginal opening. May interfere with sexual pleasure for
both couple. Does not protect from sexually transmitted diseases
3. Barrier method
Male condom
Female condom
Spermicidal
Diaphragm and cervical cap
Male condom
What it is : A latex or rubber sheath that covers the penis and collects semen
How it works : Prevents sperm from entering the vagina, thus preventing pregnancy. Also limits the
risk of sexually transmitted diseases
Benefits : It is cheap, easy to use, and can prevent unplanned pregnancy and protect against most –
but not all – sexually transmitted diseases. Easily available in drugstores or convenient stores and
does not require medical personnel to prescribe. This method is quite popular and well-accepted
among teenagers
Drawbacks : To be effective, it must be applied on erected penis before penetration happens.

Occasionally, it can tear or slip off during removal
Female condom
What it is : A plastic (polyurethane) sheath with flexible rings at each end, inserted into the vagina
How it works : It functions as a cover in the vaginal canal. The ring at the closed end holds the sheath
inside; the ring at the open end stays outside the vaginal opening. It collects semen before, during,
and after ejaculation, thus preventing sperm from entering the vagina
Benefits : Besides preventing pregnancy, it also protects against most, but not all sexually transmitted
diseases. It allows women to share responsibility in preventing infection
Drawbacks : Needs practice to insert it correctly. The outside ring may slip into the vagina during
intercourse. May also cause discomfort and vaginal irritation. It is not as easily available as male
condom and not popular among teenagers
Spermicidal
Can be in the form of foaming tablet, film, jelly or cream
It is inserted inside the vagina before sexual intercourse
It works by killing the sperm or making the sperm unable to move towards the egg
It is simple to use but not as effective in preventing pregnancy
It provides protection against some sexually transmitted diseases but not really known against HIV
Diaphragm and cervical cap
They are soft rubber cups to be inserted inside the vagina that covers the cervix
The cervical cap is smaller in size
They work by blocking the sperm from entering the uterus and tubes
A doctor need to be consulted to determine the right size and clients need to learn and practice how
to use them at first
A spermicidal is usually added to give better protection
They can be inserted a few hours before sex
It can protect against some sexual transmitted disease but may cause increase incidence of urinary
tract infection
They need to washed and cleaned after use and requires careful storage
4. Intrauterine contraceptive device (IUCD)
What it is : A small “T” – shaped object that is inserted through the cervix and placed within the cavity of
the uterus. A small string hangs down from the IUCD into the upper part of the vagina and it can be felt
by the woman. It can be attached with copper or hormonal rod
How it works : It occupies the uterine cavity for years ( three to five years) and decreases the lifespan
and movement of the sperm. With a hormonal rod added to the device, it changes the lining of the
uterus to prevent a fertilized ovum (egg) from implanting (attaching itself) to the uterine wall
Benefits : Requires no daily attention, immediately effective, and long lasting for years
Drawbacks : Insertion and removal require trained medical personnel in clinic setting. Does not protect
against sexually transmitted diseases. Also can cause menstrual problems such as menstrual cramps
and heavy flow. It is not recommended to teenagers
Hormonal contraceptive methods
These methods use hormones to prevent ovulation (release of an ovum from the ovary). They also work by
making it difficult for sperm and ovum to join.
1. Birth control pills (aka ‘The Pills’)
What it is : A contraceptive taken orally is usually made from two types of hormones (estrogen and
progestin)
How it works : A woman takes a pill every day at about the same time for 21 days and then stops for
seven days, so she gets her period. The pills stop the release of ovum (ovulation), this preventing
pregnancy
Benefits : Besides preventing pregnancy effectively, it also makes a woman’s period to become more
regular and shorter in duration, reduces menstrual symptoms such as cramps and bloating. It may also
reduce mild acne
Drawbacks : Users have to remember to take the pill every day, otherwise it will not prevent pregnancy
and can cause irregular bleeding. It does not protect against sexually transmitted diseases. Minor side
effects such as headache may occur
2. Depo-provera injection
What it is : A hormonal (progestin) injection into the muscles (intramuscular) that a woman gets every
three months (four times a year)
How it works : An injection is given either in the arm or upper buttocks/lower back at any time during the
first five days of a woman’s period. After the initial shot, a shot is given every 11 to 13 weeks. The
hormone thickens the mucus at the uterine opening, making it difficult for sperms to pass through. It
also causes the lining of the uterus to thin out, preventing pregnancy to happen
Benefits : It prevents pregnancy for three months at a time. It is very private, immediately effective, and
slowly reduces menstrual flow and may stop periods altogether
Drawbacks : It does not protect against sexually transmitted diseases. May also cause irregular periods
or spotting, slight weight gain, possible decrease in bone density, and side effects do not wear off until
12 to 14 weeks after a woman stops getting the injection
3. Hormonal implant
What it is : An implant containing hormone (progestin) inserted beneath the skin over the inner side of
the forearm
How it works : It releases small amount of hormone over three or five years to prevent ovulation, thicken
the mucus at the uterine opening and thin out the uterine lining
Benefits : It prevents pregnancy over years, the user does not have to remember taking pills every day
Drawbacks : It requires trained medical personnel to insert. It is so quite expensive, with irregular
spotting being the commonest side-effect. It is not usually recommended for teenagers
4. Hormonal patch
What it is : A thin, beige, smooth patch that contains both hormones – progestin and estrogen. A woman
puts the patch on her upper shoulder, buttock, abdomen, or upper arm once a week for three weeks.
During the fourth week, no patch is used so as to trigger menstruation
How it works : Hormones are released into the body, preventing the release of ovum (ovulation)
Benefits : Easy to use and non-invasive
Drawbacks : Does not protect against sexually transmitted diseases. Side effects can include nausea,
breast tenderness, and headaches
5. Hormonal ring
What it is : A flexible, ring-shaped hormone contraceptive that is two inches in diameter and inserted
into the vagina once a month
How it works : It contains estrogen and progestin, which prevent the ovaries from releasing eggs. A
woman keeps the ring inside her vagina for 21 days and then removes it, so her body can menstruate for
seven days. After that, she inserts a new ring to begin the cycle again
Benefits : Provides month-long protection against pregnancy. No daily pill taking, only have to remember
to place a new ring in once a month
Drawbacks: May feel uncomfortable to insert at first and irritation in the vagina and cervix can occur.
Does not protect against sexually transmitted diseases. There may also be increased discharge, and the
ring may slide out and need to be reinserted
Emergency contraception aka ‘the morning-after pills’)
What it is :
Contraceptive methods that prevents pregnancy after unprotected vaginal intercourse – for instance, if
birth control (like a condom) is not used, or in the case of rape.
Two forms of emergency contraception:
1. Hormone-based emergency contraceptive pills (ECPs), also known as “the morning-after pill,”
ECPs are divided into two groups : either a combination of estrogen and progestin, or progestin-only.
They can be taken up to 120 hours (five days after unprotected intercourse, but work best when taken
within 72 hours (three days)
2. Intrauterine contraceptive device (IUCD)
The copper intrauterine device (IUCD) can be inserted within five days of unprotected intercourse and
removed after the next menstrual period or remain inside for three or five years, providing long-term
pregnancy prevention.
How it works : For ECPs, a woman takes one dose right away and another 12 hours later. If she is already
pregnant, ECPs will not affect the pregnancy. The hormones act to prevent ovulation, fertilization, or
implantation of a fertilized egg The IUCD inserted within five days of unprotected intercourse, will
prevent implantation
Benefits : Can prevent unplanned pregnancy after unprotected intercourse and reduce the overall
number of unplanned pregnancies and abortions
Drawbacks : It does not protect against sexually transmitted diseases. ECPs can cause side effects like
nausea, breast tenderness, irregular bleeding, and headaches. The IUCD is not suitable for women who
have more than one partner and are at risk for sexually transmitted diseases, since insertion of the
device can lead to pelvic infection
Combined Oral Contraceptive Pill (COCP) Counselling
– OSCE Guide
geekymedics.com/combined-oral-contraceptive-pill-counselling/
Rachel Mason
Contraceptive counselling often features in OSCEs and it’s therefore important to

be familiar with the various types of contraception available. This article focuses on
counselling patients about the combined oral contraceptive pill (COCP), including
the common questions patients ask, the answers you’ll be expected to articulate and
how best to structure the consultation.
Download the COCP counselling PDF OSCE checklist, or use our interactive OSCE
checklist. You might also be interested in our other contraception counselling guides.
Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
Check the patient’s understanding of the types of contraception available.
Explore the reasons why the patient wants the COCP.
Ideas, concerns and expectations

It is important to explore the patient’s ideas, concerns and expectations early in the
consultation, as you may need to correct any misconceptions about the COCP and
address the patient’s concerns. When exploring concerns, it is important to do so in a
sensitive and honest manner.
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It’s also important to clarify the patient’s expectations of the COCP because if these
are unrealistic, other forms of contraception may be better able to meet their needs.
Ideas
Explore what the patient currently understands about the COCP:
“Have you heard of the combined oral contraceptive pill?”

“What do you already know about the combined oral contraceptive pill?”
Concerns
Ask if the patient has any concerns about the COCP:
“Is there anything that worries you about the combined oral contraceptive pill?”
Expectations
Explore the patient’s expectations of the COCP:
“What are you hoping the combined oral contraceptive pill can do for you?”
“Why do you think the combined oral contraceptive pill is the best choice for
you?”
What is the combined contraceptive pill?

Using patient-friendly language, explain that the combined pill contains both
oestrogen and progesterone. Explain that there are a number of different types of
combined pills available.
“The combined contraceptive pill is what many people refer to as ‘the pill’. It is a pill
that contains two hormones – progesterone and oestrogen. These hormones are
similar to the natural hormones produced by your ovaries.” ¹
What are the different types of pill available?

Explain to the patient that there are three main types of combined pills:
The monophasic 21-day pill is the most common type of combined pill. Each
pill has the same amount of hormone in it and the monophasic pill is taken for 21
days followed by a 7-day break. ¹
The phasic 21-day pill: each pill contains a different amount of hormone and
therefore the pills must be taken in the correct order. The phasic pill is taken for
21 days followed by a 7-day break. ¹
The everyday pill: there are 21 pills containing hormones and 7 placebo pills.
Pills are taken for 28 days without a break in between packs. ¹
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How does the combined pill work?
Explain to the patient that the pill prevents conception by inhibiting ovulation,
thickening cervical mucus and thinning the endometrium to prevent
implantation of the blastocyst. ²
“The pill prevents you from getting pregnant by stopping your ovaries from
producing an egg every month.”
“It also works by thickening the mucus around your cervix which stops sperm from
entering your womb.”
“It can also make the lining of your womb thinner, which makes it less likely that a
fertilised egg would be able to implant in the womb.”
How effective is the combined pill?

Patients understandably want to know how effective contraception is and this is often
a major factor in their decision as to which type of contraception they want to use. As a
result, it’s useful to know some basic statistics on efficacy. However, if you’re
unsure, signpost the patient to a reliable source and don’t guess!
Explain to the patient that the effectiveness of the pill depends on compliance. However,
if the pill is used correctly, it is 99% effective. ¹
“If you take the combined pill at the appropriate time each day and don’t miss pills, it
is 99% effective at preventing pregnancy.”
Pros and cons of the combined pill

Always give patients as much information as possible so that they can make an informed
decision. It is useful to do this by discussing the pros and cons of the combined pill.
“If it is okay with you, I’d like to tell you about the benefits and disadvantages of the
pill, then hopefully you will then have enough information to make a decision.”
Advantages of the COCP
Non-invasive method
“Taking the pill does not require an invasive procedure like some other forms of
contraception.”
Effective contraception
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“The combined pill is 99% effective when taken correctly.”
Problems associated with periods improve
“Your periods may become more regular, lighter and less painful.”
Controls timing of periods
“You can run the pill packets back-to-back if you want to control the timing of your
period for holidays or certain events.”
Improves acne
“In some people, the pill can improve acne.”
Reduces symptoms of premenstrual syndrome
“The pill may help reduce symptoms of premenstrual syndrome.”
Cancer risk
“The pill reduces the risk of ovarian, uterine and colon cancer.”
Disadvantages of the COCP
Side effects
“To start off with, you may experience some side effects such as a headache, nausea,
mood changes or breast tenderness.” ¹
Breakthrough bleeding
“Especially in the first few months, you might experience bleeding on the days you are
taking the pill. This is called breakthrough bleeding.”
Protection from STIs
“Unfortunately, the COCP does not protect you from sexually transmitted infections
(STIs). Barrier contraception (e.g. condoms) is the only form of contraception to
provide protection from STIs.”
User dependent
“This contraceptive method relies on you remembering to take it daily. Sometimes it is

helpful to set a reminder on your phone or in your diary.”
Risks of the combined pill

It is important to explain the risks of taking the pill so that the patient is aware and can
make an informed decision.
Venous thromboembolism
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“There is a small increase in the risk of developing clots in your legs and lungs. There
is also a small increase in the risk of having a heart attack or a stroke”
“If you have had any of these conditions in the past, then you should not use the pill.”
“The risk of developing these conditions is increased if you smoke regularly, have a
high BMI or if you are immobile for a long period of time.”
Breast cancer
“Research has shown that there is a small increased risk of breast cancer compared to
people who are taking non-hormonal contraception.”
“The risk reduces with time after stopping the pill.”
Cervical cancer
“Research has also shown that there is a small increased risk of developing cervical
cancer with longer use of the combined oral contraceptive.”
Contraindications of the combined pill ²

A patient cannot take the pill if they:
are pregnant
are a smoker and over 35 years old
are over 35 years old and stopped smoking less than one year ago
have a BMI of greater than 35kg/m 2
suffer from migraine with aura
are breastfeeding up to 6 weeks
have cardiovascular and venous thromboembolism risk factors
have a family history of breast cancer
Starting the pill and missed pills

This section of the consultation can be quite confusing for the patient. It is therefore
important to explain this in a patient-friendly manner, check understanding at
regular intervals and invite questions at the end.
Starting the pill

“You can start the pill at any time if you are sure you are not pregnant. You will need
to use condoms for the first seven days of taking the pill.” ¹
Missed pills
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One pill missed
If one pill is missed or a new pack is started one day late: “Take the missed pill
straight away and continue taking the rest of the pack as normal. Emergency
contraception is not required.”
Two or more pills missed
If two or more pills missed or a new pack is started two or more days late: “Take the
most recent pill you missed straight away and leave any of the pills you missed before
then. Use condoms or abstain from sex for the next 7 days. If you have had sex in the
previous seven days you need to seek advice for emergency contraception.”
What to do with the rest of the pack after a missed pill
If seven or more pills left in the pack: “If there are seven or more pills left, then you
should finish the pack and have the usual 7-day break.”
If there are less than seven pills left in the pack: “If there are less than seven pills left
in the pack then the pack should be finished and a new pack should be started the next
day. This means taking the pills back to back.”
Closing the consultation

Summarise the key points back to the patient.
Ask the patient if they have any further questions or concerns that haven’t been
addressed.
Throughout the consultation you should check the patient’s understanding

at regular intervals, using phrases such as “Can you just repeat back to me what
we’ve just discussed regarding…”.
It may also be useful to direct the patient to any websites or leaflets with further
information.
Offer the patient time to consider their decision.
Encourage the patient to use condoms if they are not currently using contraception.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Common patient questions
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Below are some common questions that patients may have regarding the contraceptive
pill. Sometimes, in an OSCE situation, they may ask you one or two questions at the end
of your consultation. Having a good answer can be helpful in demonstrating to the
examiner that you have a good understanding of the topic.
What happens if I’m sick or have diarrhoea?

If the patient is sick within two hours of taking the pill then they will need to take
another one if they are feeling better.
If a patient has severe diarrhoea for more than 24 hours, they will need to take
the pill as if they missed a pill and follow the instructions discussed above. This
should continue until the diarrhoea is no longer severe.
Which common medicines affect the efficacy of the pill?

Explain to the patient that they should tell you what medicines they are currently
taking.
“Some medicines such as some epilepsy medication, HIV medication and St John’s
Wort can reduce the levels of contraceptive hormones and therefore reduce the
effectiveness of the contraception. You should always check when you start taking a
new medication if it will interact with your pill.”
Is it harmful to miss a withdrawal bleed?

It is not dangerous for a patient to miss their withdrawal bleed, also known as taking
pills back to back. However, it is important to remind the patient that they may still get
some bleeding or spotting.
What should the patient do if they want to try and become pregnant?
Patients are usually advised to stop taking the pill at the end of a pack and wait until
after their first natural period before trying to become pregnant. Don’t forget to advise
the patient on pre-pregnancy care such as folic acid and smoking cessation.
What should the patient do if they want to stop taking the pill?
Patients are usually advised to stop taking the pill at the end of a pack. However, if they
cannot wait it is important to offer information about other contraception to prevent
pregnancy.
Is it dangerous to take the pill for a long time?

Other than the risks mentioned above, it is not dangerous to take the pill for a long time.
This is because the hormones do not build up in the body. Furthermore, there is no
evidence to show that taking the pill affects fertility.
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References
1. Fpa.org.uk. (2018). The Combined Pill- Your Guide. Available at: [ LINK].
2. Harding, M. (2014). Combined Oral Contraceptive Pill (First Prescription) COCP.
Patient.info. Available at: [LINK].
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Contraceptive Implant Counselling – OSCE Guide
geekymedics.com/contraceptive-implant-counselling-osce-guide/
Rachel Mason
Contraceptive counselling often features in OSCEs and it’s therefore important to be

familiar with the various types of contraception available. This article focuses on
counselling patients about the contraceptive implant (also referred to as simply “the
implant”) including the common questions patients ask, the answers you’ll be expected
to articulate and how best to structure the consultation.
Download the contraceptive implant counselling PDF OSCE checklist, or use our
interactive OSCE checklist. You might also be interested in our other contraception
counselling guides.

Explore the reasons why the patient wants the contraceptive implant.

consultation, as you may need to correct any misconceptions about the implant and
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It’s also important to clarify the patient’s expectations of the implant because if these
are unrealistic, other forms of contraception may be better able to meet their needs.
Ideas
Explore what the patient currently understands about the implant:
“Have you heard of the contraceptive implant?”

“What do you already know about the contraceptive implant?”
Concerns
Ask if the patient has any concerns about the implant:
“Is there anything that worries you about the contraceptive implant?”
Expectations
Explore the patient’s expectations of the implant:
“What are you hoping the implant can do for you?”

“Why do you think the implant is the best choice for you?”
What is the implant?

Using patient-friendly language, explain that the implant is a flexible, plastic rod
that is placed subdermally in the upper part of the arm. ¹
“The implant is a small plastic rod that sits just under the skin in the upper part of the
arm, it is a long-acting reversible method of contraception and can be effective for up
to 3 years.”
How does the implant work?

Explain that the implant primarily works by preventing ovulation, however, it also
thickens cervical mucus and thins the endometrium. ²
“The implant stops an egg from being released from your ovaries. It also thickens the
mucus in the neck of your womb and thins the lining of your womb. This can make it
difficult for sperm to reach an egg and make it less likely for your womb to accept a
fertilised egg.”
How effective is the implant?

Often patients want to know how effective contraception is, as this can help guide
their decision on which contraception to choose. As a result, it’s useful to know some
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basic statistics on efficacy. However, if you’re unsure, signpost the patient to a
reliable source and don’t guess!
“The implant 99% effective. Less than 1 implant user in 100 will get pregnant in one
year.”¹
Advantages and disadvantages of the implant

decision. It is useful to do this by discussing the pros and cons of choosing the
implant.
implant, then hopefully you will have enough information to make a decision.”
Advantages of the implant
Long term contraception
“The implant is a form of long-term contraception. It will remain effective for up to

three years from the date of insertion.”
Can be reversed easily
“As soon as the implant is removed, fertility should resume as normal.”
May make periods less heavy and painful
“The implant may help with heavy or painful periods.”
Safe to use when breastfeeding
“The implant is safe to use if you choose to breastfeed your baby.”
Disadvantages of the implant
Unpredictable periods
“Some people experience irregular periods, longer-lasting periods or no periods at

all.”
Possible temporary side effects
“You may experience some side effects such as headaches, breast tenderness and mood
changes. However, normally these last for no longer than a few months.” ¹
Acne
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“Some people find that they may develop acne or have worsening of their acne after
insertion of the implant.”
Small procedure required
“A simple procedure is required to insert and remove the implant. I will go on to

explain this later in the consultation.”
No protection from STIs
“Unfortunately, the implant does not protect you from sexually transmitted infections
(STIs). Barrier contraception (e.g. condoms) is the only form of contraception that
provides protection from STIs.”
Some risks of the implant
Infection
“There’s a small chance of getting an infection during the first few weeks after an
implant is put in. However, the healthcare professional will take the appropriate steps
to reduce the chance of an infection developing.”
Bruising and bleeding
“It is common to have a small amount of bleeding during the procedure and pressure
will be applied to minimise this.”
“You will most likely develop a bruise, which may be large and extend down your arm
as a result of small amounts of blood leaking under your skin. Although this might
look concerning, these bruises typically fade over the following week or so.”
Damage to local structures
“We carefully insert the implant in a location that isn’t close to any large blood vessels
or nerves. However, there is a very small possibility that some of your blood vessels,
nerves or muscles could be damaged during the procedure.”
Breast cancer
“There may be a slightly increased risk of developing breast cancer compared with
people who do not use hormonal contraception.” ¹
How is the implant fitted?

It is useful to explain the process of inserting an implant using a
before, during and after structure. This will also help you remember the key points
for each step.
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Before
“You can have the implant fitted at any time during your period.”
“Firstly, a trained healthcare professional will use a needle and syringe to administer
a small amount of local anaesthetic to numb the relevant area of your arm. This
means that the insertion of the implant itself should not hurt.”
“You will experience a stinging sensation when the local anaesthetic is injected, but
this should fade quickly.”
During
“The implant is the size of a matchstick. A nurse or doctor will insert the implant into
the skin. It should not take more than a few minutes.”
After
“After the procedure, the nurse or doctor will show you how to feel the implant to
make sure that it is in place. The area where the implant was inserted may be slightly
tender, bruised or swollen for a couple of days following the procedure.”
“It is important to try to keep this area clean for the next few days to help prevent
infection.”
“If the implant is inserted during the first five days of your period, you will be
protected immediately after. However, if it is inserted at any other time in your cycle,
you would need to use condoms for the next seven days.”
Removing the device

“The implant can be kept in for up to three years. If you decide you do not want it, a
trained healthcare professional can remove it.”
“Just like with the insertion, you’ll be given a local anaesthetic injection and a small
cut will be made in your arm. The implant will be removed through this. This should
only take a couple of minutes.”
“Occasionally, there can be some difficulty removing the implant. If this is the case,
you will be referred to a specialist centre to remove it with the assistance of an
ultrasound scan.”

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addressed.
Throughout the consultation you should check the patient’s understanding at

regular intervals, using phrases such as “Can you just repeat back to me what we’ve
just discussed regarding…”.
information.
Can medication impact the effectiveness of the implant?
The implant is effected by enzyme-inducing drugs such as:
Barbiturates
Carbamazepine
Phenytoin
Rifampicin
The patient’s medication history should be checked prior to being commenced on the
implant. The patient should also be told to make other clinicians aware of their implant,
before starting a new medication.
Will the implant still work if I have diarrhoea or vomiting?
The implant is not affected by vomiting or diarrhoea.
How will the implant affect my periods?
It is likely that the patient will experience changes to their menstrual cycle. Some people
experience irregular unpredictable periods or longer-lasting periods, whilst others find
that their periods stop completely.
References
1. FPA.org.uk. (2018). The Contraceptive Implant – Your Guide. [online]. Available
from: [LINK].
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2. FSRH Clinical Effectiveness Unit. (2014). FSRH Clinical Guidance: Progestogen-
only Implants [online]. Available from: [LINK].
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Copper Coil Counselling – OSCE Guide
geekymedics.com/copper-coil-counselling-osce-guide/
Rachel Mason

counselling patients about the copper coil (also known as the copper intrauterine
device) including the common questions patients ask, the answers you’ll be expected to
articulate and how best to structure the consultation.
Download the copper coil counselling PDF OSCE checklist, or use our interactive OSCE
checklist.

Explore the reasons why the patient wants the copper coil.
Patient’s ideas, concerns and expectations

consultation, as you may need to correct any misconceptions about the copper coil and
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It’s also important to clarify the patient’s expectations of the copper coil because if
these are unrealistic, other forms of contraception may be better able to meet their
needs.
Ideas
Explore what the patient currently understands about the copper coil:
“Have you heard of the copper coil?”

“What do you already know about the copper coil?”
Concerns
Ask if the patient has any concerns about the copper coil:
“Is there anything that worries you about the copper coil?”
Expectations
Explore the patient’s expectations of the copper coil:
“What are you hoping the copper coil can do for you?”
“Why do you think the copper coil is the best choice for you?”
What is the copper coil?

Using patient-friendly language, explain that the copper coil is a small plastic and
copper device that sits inside the uterus.¹There are two (or sometimes one) thread(s)
which pass through the cervix and lie in the vagina.
“The copper coil is a small plastic and copper T-shaped device that will sit inside your
womb. There are normally two threads attached to the device which pass through the
neck of the womb, these are important in allowing you to check that the coil is still in
place.”
How does the copper coil work?

Explain to the patient that the copper coil is spermicidal and the concentration of
copper in the mucus inhibits the motility of sperm. The copper coil can also be used as
emergency contraception. ²
“The copper coil works by preventing any sperm from surviving. The copper can
change the cervical mucus slightly, which stops sperm from reaching an egg.”
How effective is the copper coil?

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Often patients want to know how effective contraception is, as this can help guide their
decision on what contraception to choose. As a result, it’s useful to know some
basic statistics on efficacy. However, if you’re unsure, signpost the patient to a reliable
source and don’t guess!
“The copper coil is over 99% effective”
“Less than 1 copper coil user in 100 will get pregnant in one year”
“If 100 sexually active women don’t use any contraception, 80–90 will get pregnant in
a year.”
Pros and cons of the copper coil

decision. It is useful to do this by discussing the pros and cons of choosing the copper
coil.
copper coil, then hopefully you will have enough information to make a decision.”
Advantages of the copper coil
“The copper coil is 99% effective and will last for up to 10 years. One of the reasons
why it is so effective is that you do not need to remember to use it.”
Immediate contraception
“The copper coil works as soon as it is put in, this is why sometimes it can also be used
as emergency contraception.”
Easily reversed
“As soon as the copper coil is removed, fertility resumes as normal.”
No effect on other medication
“The copper coil will not have any effect on your other medications, this makes it a
good option if you are taking certain medications such as antiepileptic drugs.”
Breastfeeding
“The copper coil is safe to use if choose to breastfeed your baby.”
No hormonal content
“Unlike some other forms of contraception, there are no hormones in the copper coil.”
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Disadvantages of the copper coil
Heavier bleeding
“Your periods may be heavier, longer and more painful, especially in the first few
months.”
“Unfortunately, the coil does not protect you from sexually transmitted infections
Some risks of the copper coil
Expulsion of the coil
“Sometimes the coil can come out without you realising. If this does happen, we can
give you advice on what to do next, and we will teach you how to check that the coil is
still in place.”
The most likely time for this to happen is soon after insertion and/or during a period,
so we typically advise to check your coil is in place after each period, once a month.”
“If you were concerned the coil might be been expelled, you would need to use an
alternative method of contraception and seek review from your local GP or sexual
health service.”
Damage to the womb
“When you get the coil fitted there is a very small risk that the device might perforate
your uterus or cervix.”
“This is rare, occurring in around 2 in a 1000 copper coil insertions.”
“If this was to happen, you may have to undergo surgery to remove the device and
repair the perforation.”
Infection
“There’s a small chance of you getting an infection during the first few weeks after an
IUD is put in. You may be advised to have a check for sexually transmitted infections
before a coil is fitted or at the time it’s fitted.”
“If you were to develop an infection, you would likely notice some abdominal pain,
vaginal bleeding, fever and abnormal discharge. This can often be treated with a
course of antibiotics, however, in some cases, the coil may need to be removed.”
Ectopic pregnancy
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“The copper coil is a highly effective contraceptive method, however if you do fall
pregnant whilst using the copper coil, there is a high risk that the pregnancy may have
implanted outside of the womb, in the fallopian tubes, which is known as an ectopic
pregnancy.”
“Ectopic pregnancy is potentially life-threatening and therefore if you have a positive

pregnancy test whilst using the copper coil you need to see a doctor urgently, who will
assess you and arrange a scan to check the location of the pregnancy.”
“Your overall chance of having an ectopic pregnancy is still less than someone not
using contraception.”
How is the copper coil fitted?

It is useful to explain the process using a before, during and after structure. This will
also help you remember the key points for each step.
Before
“Before the copper coil is fitted, we need to be confident you are not pregnant and
therefore we would advise avoiding any unprotected sexual intercourse in the 2 weeks
prior to insertion. A urine pregnancy test may be performed, to check you are not
pregnant.”
“The coil can be fitted at any time in your menstrual cycle.”
“Ideally, you should take some paracetamol and ibuprofen around 1 hour before the
procedure, as this will help make things more comfortable.”
“A doctor or nurse will perform a bimanual vaginal examination, which involves

placing two fingers into your vagina and one hand on your tummy to assess the
position of the womb, which is important to know before inserting the device.”
During
“The nurse or doctor will insert a speculum into the vagina, to allow the neck of the
womb to be visualised.”
“You may then choose to have some local anaesthetic injected into the neck of the
womb, which can make the insertion process less uncomfortable.”
“A surgical instrument is then attached to control the position of the neck of the womb.
There can sometimes be some discomfort when this is attached.”
“A small plastic tube is then passed through the neck of the womb, to check the size of
the womb cavity, before being removed.”
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“The copper coil is then inserted using another thin plastic tube. Once the coil is inside
of the womb, the T-shaped arms open out to secure the device. As the copper coil
device is inserted through the neck of the womb, you may experience period-like
cramping.”
“The insertion device is then removed.”
“Finally, the two threads of the coil will be trimmed, so that they sit high up in the
vagina.”
“Overall the procedure should take around 5 minutes in total.”
After
“After the procedure, you may have painful cramps and light vaginal bleeding for the
next few hours, so we advise resting and using painkillers as needed.”
Follow-up
“As long as you are able to feel the threads yourself in a months time, you do not need
to come back for a review. If however, you are unable to feel them, you will need to
book an appointment.”
“The coil lasts for 10 years when used for contraception, so you would need to have the
device replaced or use an alternative method of contraception once the expiry date is
reached.”
Removing the device

“The copper coil can be removed at any time via a simple procedure. Should you want
to have the device removed, you need to make an appointment with your GP or local
sexual health clinic.”
“It is important to know that if you are planning to have the copper coil removed, you
will need to abstain from sex or use an alternative method of contraception for the
week prior to removal. This is because sperm can survive for several days in the
vagina and womb and therefore there is a theoretical risk of pregnancy after removal
of the device.”
How do I check the threads?

“A copper coil has one or two threads attached to the end that hang a little way down
from your womb into the top of your vagina. The nurse or doctor will tell you how
many threads there should be.”
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The patient should be shown how to check the copper IUD threads using a test
device, to allow them to get an idea of what the threads should feel like.
“We would advise checking you can feel your threads a few times in the first month
and that at regular intervals each month (e.g. after your period). If you were
concerned the coil might be been expelled (e.g. you can’t feel the threads), you would
need to use an alternative method of contraception and seek review from your local
GP or sexual health service.”

addressed.

information.
References
1. Fpa.org.uk. (2018). The Intrauterine Device- Your Guide. [online] Available at:
[LINK].
2. Loweth, M. (2014). Intrauterine Contraceptive Device (IUCD) Information Page.
[online] Patient.info. Available at: [LINK].
7/7
Mirena (IUS) Counselling – OSCE guide
geekymedics.com/mirena-ius-counselling-osce-guide/
Rachel Mason

counselling patients about the Mirena intrauterine system (also referred to as the
IUS, Mirena coil or hormonal coil), including the common questions patients ask, the
answers you’ll be expected to articulate and how best to structure the consultation.
There are several types of IUS available, each with varying levels of hormone and
lifespan, but for the purposes of this guide, we are focusing on the Mirena IUS.
Download the Mirena (IUS) counselling PDF OSCE checklist, or use our interactive
OSCE checklist.

Explore the reasons why the patient wants the Mirena IUS.

consultation, as you may need to correct any misconceptions about the Mirena IUS and
1/8
It’s also important to clarify the patient’s expectations of the Mirena IUS because if
these are unrealistic, other forms of contraception may be better able to meet their
needs.
Ideas
Explore what the patient currently understands about the Mirena IUS:
“Have you heard of the Mirena coil?”

“What do you already know about the Mirena coil?”
Concerns
Ask if the patient has any concerns about the Mirena IUS:
“Is there anything that worries you about the Mirena coil?”
Expectations
Explore the patient’s expectations of the Mirena IUS:
“What are you hoping the Mirena coil can do for you?”
“Why do you think the Mirena coil is the best choice for you?”
What is the Mirena IUS?

Using patient-friendly language, explain that the Mirena IUS is a small plastic
device that sits inside the uterus and releases a hormone called progestogen. There
are two threads which pass through the cervix and lie in the vagina.
“The Mirena coil is a small plastic T-shaped device that will sit inside your womb.”
“There are two threads attached to the device which pass through the neck of the
womb, these are important in allowing you to check that the device is still in place.”
How does the Mirena IUS work?

Explain to the patient that the Mirena IUS contains a small amount of progesterone
which causing thickening of mucus in the neck of the womb.¹This creates a plug
which stops sperm from getting through the neck of the womb to fertilize the egg.
Also, explain to the patient that the hormones make the lining of the womb much
thinner. This means that even if an egg was fertilized, the likelihood of it implanting
into the womb is very small.
2/8
“The Mirena coil releases a small amount of hormone into your womb. This causes the
mucus around the neck of the womb to thicken, making it difficult for sperm to pass
through and fertilise an egg.”
“In the unlikely event that sperm does get through this thickened mucus, the hormone
released by the Mirena coil also makes the lining of the womb really thin, so even if an
egg was fertilised, it would be very unlikely to implant.”
“In some people, it stops the ovaries releasing an egg (ovulation), but most people who
use an IUS continue to ovulate.”
How effective is the Mirena IUS?

Often patients want to know how effective contraception is, as this can help guide
their decision on what contraception to choose. As a result, it’s useful to know some
basic statistics on efficacy. However, if you’re unsure, signpost the patient to a
reliable source and don’t guess!
“The Mirena coil is over 99% effective. Less than one Mirena user in 100 will get
pregnant in one year.”
“If 100 sexually active women don’t use any contraception, 80–90 will get pregnant in
a year.”
Pros and cons of the Mirena IUS

decision. It is useful to do this by discussing the pros and cons of choosing the Mirena
IUS.
Mirena coil, then hopefully you will have enough information to make a decision.”
Advantages of the Mirena IUS
“The Mirena coil is 99% effective and will last for 5 years. One of the reasons it is so
effective is because you don’t need to remember to use it.”
“The Mirena coil can make your periods much lighter, shorter and sometimes less
painful. After 1 year, most women find that they only have a light spot once a month
and 1 in 5 women do not bleed at all.” ¹
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Easily reversible
“As soon as the Mirena coil is removed, fertility resumes as normal.”
Localised hormones
“Unlike the combined pill or mini-pill, the hormone released from the Mirena coil is
mainly contained within the womb, so less going around your body in your blood.
This means that the likelihood of hormonal side effects is reduced.”
Breastfeeding
“The Mirena coil is safe to use if you choose to breastfeed your baby.”
Cancer risk
“Unlike some other forms of contraception, there is no evidence that the Mirena coil
will increase your risk of cancer of the cervix, womb or ovaries.”
Not affected by other medications
“Because the Mirena coil acts locally, it does not depend on your ability to absorb
hormones through your digestive system, unlike oral contraceptives. As a result, it is
not affected by taking other medications.”
Disadvantages of the Mirena IUS
Irregular bleeding
“Especially in the first 3-6 months, irregular bleeding or spotting is common. Periods
usually become much lighter, however, they may still be irregular. Although this often
settles down, it can be quite bothersome for some people. ”
Side effects
“Some people may get side effects like acne, headaches and breast tenderness. These
usually get better after the first few months.”
No protection from STIs
“Unfortunately, the coil does not protect you from sexually transmitted infections
Some risks of the Mirena IUS
Infection
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“There’s a small chance of you getting an infection during the first few weeks after an
IUS is put in. You may be advised to have a check for sexually transmitted infections
before an IUS is fitted or at the time it’s fitted.”
“If you were to develop an infection, you would likely notice some abdominal pain,
vaginal bleeding, fever and abnormal discharge. This can often be treated with a
course of antibiotics, however, in some cases, the IUS may need to be removed.”
“After the first few weeks, your risk of infection returns to the same as someone
without a Mirena coil.”
Expulsion of the IUS
“Sometimes the coil can come out without you realising. If this does happen, we can
give you advice on what to do next, and we will teach you how to check that the coil is
still in place.”
“The most likely time for this to happen is soon after insertion and/or during a period,
so we typically advise to check your coil is in place after each period, once a month.”
“If you were concerned the coil might be been expelled, you would need to use an
alternative method of contraception and seek review from your local GP or sexual
health service.”
Damage to the womb
“When you get the coil fitted there is a very small risk that the device might perforate
your uterus or cervix. This is rare, occurring in around 2 in a 1000 Mirena coil
insertions.”
“It is most likely to occur in women who have recently given birth or are
breastfeeding.”
“If this was to happen, you may have to undergo surgery to remove the device and
repair the perforation.”
Ectopic pregnancy
“The Mirena coil is a highly effective contraceptive method, however if you do fall
pregnant whilst using the Mirena coil, there is a high risk that the pregnancy may
have implanted outside of the womb, in the fallopian tubes, which is known as an
ectopic pregnancy.”
“Ectopic pregnancy is potentially life-threatening and therefore if you have a positive

pregnancy test whilst using the Mirena coil you need to see a doctor urgently, who
will assess you and arrange a scan to check the location of the pregnancy.”
“Your overall chance of having an ectopic pregnancy is still less than someone not
using contraception.”
5/8
How is the Mirena IUS fitted?
It is useful to explain the process of Mirena IUS insertion by breaking it down into a
before, during and after structure. This will also help you remember the key points
for each step.
Before
“Before the Mirena coil is fitted, we need to be confident you are not pregnant and
therefore we would advise avoiding any unprotected sexual intercourse in the 2 weeks
prior to insertion. A urine pregnancy test may be performed, to check you are not
pregnant.”
“The coil can be fitted at any time in your menstrual cycle, but it is better to have it
fitted towards the end of your period, as insertion is often easier and you are unlikely
to be pregnant.”
“Ideally, you should take some paracetamol and ibuprofen around 1 hour before the
procedure, as this will help make things more comfortable.”
“A doctor or nurse will perform a bimanual vaginal examination, which involves

placing two fingers into your vagina and one hand on your tummy to assess the
position of the womb, which is important to know before inserting the device.”
During
“The nurse or doctor will insert a speculum into the vagina, to allow the neck of the
womb to be visualised.”
“You may then choose to have some local anaesthetic injected into the neck of the
womb, which can make the insertion process less uncomfortable.”
“A surgical instrument is then attached to control the position of the neck of the womb.
There can sometimes be some discomfort when this is attached.”
“A small plastic tube is then passed through the neck of the womb, to check the size of
the womb cavity, before being removed.”
“The Mirena coil is then inserted using another thin plastic tube. Once the Mirena is
inside of the womb, the T-shaped arms open out to secure the device. As the Mirena
device is inserted through the neck of the womb, you may experience period-like
cramping. The insertion device is then removed.”
“Finally, the two threads of the Mirena will be trimmed, so that they sit high up in the
vagina.”
“Overall the procedure should take around 5 minutes in total.”

6/8
After
“After the procedure, you may have painful cramps and light vaginal bleeding for the
next few hours, so we advise resting and using painkillers as needed.”
Follow-up
“As long as you are able to feel the threads yourself in a months time, you do not need
to come back for a review. If however, you are unable to feel them, you will need to
book an appointment.”
“The Mirena coil lasts for 5 years when used for contraception, so you would need to
have the device replaced or use an alternative method of contraception once the expiry
date is reached.”
Removing the device

“The Mirena coil can be removed at any time via a simple procedure. Should you want
to have the device removed, you need to make an appointment with your GP or local
sexual health clinic.”
“It is important to know that if you are planning to have the Mirena coil removed, you
will need to abstain from sex or use an alternative method of contraception for the
week prior to removal. This is because sperm can survive for several days in the
vagina and womb and therefore there is a theoretical risk of pregnancy after removal
of the device.”
How do I check the threads?

“A Mirena coil has two threads attached to the end that hang a little way down from
your womb into the top of your vagina.”
The patient should be shown how to check the Mirena IUS threads using a test
device, to allow them to get an idea of what the threads should feel like.
“We would advise checking you can feel your threads a few times in the first month
and that at regular intervals each month (e.g. after your period). If you were
concerned the coil might be been expelled (e.g. you can’t feel the threads), you would
need to use an alternative method of contraception and seek review from your local
GP or sexual health service.”

7/8
addressed.

information.
References
1. Harding, D. (2017). Intrauterine System. [online] Patient UK. Available from:
[LINK].
2. The Family Planning Association. Published May 2018. IUS (intrauterine system)
Patient Information Leaflet. Available from: [LINK].
8/8
Progesterone Depot Injection Counselling – OSCE
Guide
geekymedics.com/progesterone-depot-injection-counselling-osce-guide/
Rachel Mason

counselling patients about the progesterone depot injection including the common
questions patients ask, the answers you’ll be expected to articulate and how best to
structure the consultation.
Download the progesterone depot injection counselling PDF OSCE checklist, or use our
interactive OSCE checklist.

Explore the reasons why the patient wants the progesterone depot injection.

consultation, as you may need to correct any misconceptions about the progesterone
depot injection and address the patient’s concerns. When exploring concerns, it is
important to do so in a sensitive and honest manner.
1/6
It’s also important to clarify the patient’s expectations of the progesterone depot
injection because if these are unrealistic, other forms of contraception may be better
able to meet their needs.
Ideas
Explore what the patient currently understands about the progesterone depot
injection:
“Have you heard of the progesterone depot injection?”

“What do you already know about the progesterone depot injection?”
Concerns
Ask if the patient has any concerns about the progesterone depot injection:
“Is there anything that worries you about the progesterone depot injection”
Expectations
Explore the patient’s expectations of the progesterone depot injection:
“What are you hoping the progesterone depot injection can do for you?”
“Why do you think the progesterone depot injection is the best choice for you?”
What is the progesterone depot injection?

Using patient-friendly language, explain that the progesterone depot injection contains
a hormone called progesterone.
“The progesterone depot injection contains a hormone called progesterone. This

hormone is almost exactly the same as the natural hormone that is produced by your
ovaries.” ¹
What types of depot injection are there?

The main types of depot injections available in the UK include:
Depo-Provera (most commonly used)

Sayana Press
How does the depot injection work?

Explain that the depot injection works by inhibiting ovulation, thickening cervical
mucus and thinning the lining of the endometrium, making it difficult for a
fertilised egg to implant. ²
2/6
“The depot injection works by preventing your ovaries from releasing an egg every
month. It also causes thickening of mucus at the entrance of your womb which stops
sperm from moving through it. Lastly, it thins the lining of your womb, so even if an
egg is fertilised, it would not be able to implant.”
How effective is the depot injection?

Patients understandably want to know how effective contraception is and this is often
a major factor in their decision as to which type of contraception they want to use. As a
The depot injection is 99% effective. ¹
“If you have your injections at the right time, then the depot injection is 99% effective.”
Pros and cons of the depot injection

decision. It is useful to do this by discussing the pros and cons of the progesterone
depot injection.
depot injection, then hopefully you will have enough information to make a decision.”
Advantages of the depot injection
Long-acting contraception
“The depot injection is a long-acting contraceptive method, this means that you don’t
have to think about contraception for as long as the injection lasts.”
“The depot injection is 99% effective when administered correctly.”
Not associated with ovarian cysts
“Unlike some other contraceptive methods, the depot injection is not associated with
ovarian cysts as it prevents ovulation.”
Less painful periods
“Your periods may become less painful.”
Useful if oestrogens can’t be taken
“The depot injection is useful if you can’t take oestrogen-containing contraceptives

3/6
such as the combined oral contraceptive pill.”
Safe during breastfeeding
“The depot injection will not harm your baby if you choose to breastfeed.”
Disadvantages of the depot injection
Side effects
acne, mood changes and breast tenderness.” ¹
Change in periods
“When you take the depot injection, your periods may change. You may experience
irregular, light or more frequent periods. There is also a chance that your periods may
last longer and become heavier.” ¹
“Unfortunately, the depot injection does not protect you from sexually transmitted
infections.”
Weight gain
“Depo-Provera and Sayana Press are associated with weight gain, especially if you
are under 18 or have a high BMI before starting the depot injections.”
Fertility
“After stopping the depot injection, there can be up to a one year delay before your
fertility returns and you are able to become pregnant.”
Risks of the depot injection

It is important to explain the risks of the depot injection so that the patient is aware and
can make an informed decision.
Osteoporosis
“Depo-Provera or Sayana Press may cause thinning of your bones. If you are at
higher risk of developing osteoporosis (long-term steroid use, family history of the
condition) then we would normally advise you to choose another type of
contraception.”
Breast cancer
“Research shows that there may be a very slight increase in the risk of breast cancer if
you use the depot injection.”
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Infection
“All injections come with a very small risk of infection. In most cases, this could be
easily treated with some antibiotics.”
Contraindications of the depot injection

A patient should not have the depot injection if they: 2
are pregnant
are thinking of becoming pregnant within the next year
have breast cancer
have severe cirrhosis
have liver tumours
have a history of severe arterial disease
have risk factors for osteoporosis
are experiencing unexplained vaginal bleeding
How is the depot injection administered?
Depo-Provera
“The Depo-Provera injection is administered into the muscle, often via your buttock or
the side of your thigh.”
Sayana Press
“Sayana Press is injected beneath the skin via the front of your thigh or abdomen.
Some women can be taught how to administer these injections themselves at home.”
Timing
Depo-Provera and Sayana Press injections are given once every 13 weeks.

addressed.

5/6
information.

Below are some common questions that patients may have regarding the depot
injection. Sometimes, in an OSCE situation, they may ask you one or two questions at
the end of your consultation. Having a good answer can demonstrate to the examiner
that you have a solid understanding of the topic.
When can the patient start using the contraceptive injection?

The patient can start using the injection at any time of their menstrual cycle as long as
they are not pregnant. However, if they start on any day other than the first five days of
their period, they would need to use condoms.
Patients are usually advised to omit further injections once they have decided they want
to get pregnant. There can be up to a one year delay between stopping the depot
injection and normal fertility resuming. Don’t forget to advise the patient on pre-
pregnancy care such as folic acid and smoking cessation.
Can the patient restart depot injections after having a baby?

Patients can restart the injection after having a baby. If the injection is started after day
21 advise them to use condoms for seven days.
References
1. Fpa.org.uk. (2018). Your guide to Contraceptive Injections [online] Available at:
[LINK].
2. Payne, J (2015). Progestogen-onlyI Injectable Contraceptives. Patient. [online]
Patient.info. Available at: [LINK].
6/6
Progesterone-only Pill (POP) Counselling – OSCE
guide
geekymedics.com/progesterone-only-pill-pop-counselling-osce-guide/
Rachel Mason

counselling patients about the progesterone-only pill (POP) including the common
questions patients ask, the answers you’ll be expected to articulate and how best to
structure the consultation.
Download the POP counselling PDF OSCE checklist, or use our interactive OSCE
checklist.

Explore the reasons why the patient wants the POP.

consultation, as you may need to correct any misconceptions about the POP and address
the patient’s concerns. When exploring concerns, it is important to do so in a
1/7
It’s also important to clarify the patient’s expectations of the POP because if these are
unrealistic, other forms of contraception may be better able to meet their needs.
Ideas
Explore what the patient currently understands about the POP:
“Have you heard of the progesterone-only pill?”

“What do you already know about the progesterone-only pill?”
Concerns
Ask if the patient has any concerns about the POP:
“Is there anything that worries you about the progesterone-only pill?”
Expectations
Explore the patient’s expectations of the POP:
“What are you hoping the progesterone-only pill can do for you?”
“Why do you think the progesterone-only pill is the best choice for you?”
What is the progesterone-only pill?

Using patient-friendly language, explain that the progesterone-only pill contains the
hormone progesterone. Explain that different POPs contain different types of
progesterone.
“The progesterone-only pill, sometimes called the mini-pill, is a type of contraceptive

pill that contains a hormone called progesterone. This hormone is almost exactly the
same as the natural hormone that is produced by your ovaries.” ¹
What are the different types of POP?

Explain to the patient that there are three main types of POP in the UK, each
containing different forms of progesterone:
Norethisterone
Levonorgestrel
Desogestrel
Levonorgestrel can also be used as emergency contraception.
How does the progesterone-only pill work?

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The POP prevents conception by inhibiting ovulation, thickening cervical mucus, and
thinning the endometrium to prevent implantation of the blastocyst. ²
“The main action of desogestrel is that it stops you from getting pregnant by stopping
your ovaries from producing an egg every month. Other types of POP will sometimes
stop you from producing an egg.”
“The POP also works by thickening the mucus around your cervix which stops sperm
from entering your womb.”
“The POP can also make the lining of your womb thinner which would prevent a
fertilised egg from being accepted.”
How effective is the progesterone-only pill?

Patients understandably want to know how effective contraception is and this is often a
major factor in their decision as to which type of contraception they want to use. As a
Explain to the patient that the effectiveness of the pill depends on compliance. However,
if the POP is used correctly, it is 99% effective. ¹
“If you take the progesterone-only pill at the appropriate time each day and don’t
miss pills, it is 99% effective at preventing pregnancy.”
Pros and cons of the progesterone-only pill

decision. It is useful to do this by discussing the pros and cons of the POP.
pill, then hopefully you will have enough information to make a decision”
Advantages of the POP
Non-invasive method
“Taking the pill does not require an invasive procedure like some other forms of
contraception.”
“The pill is 99% effective when taken correctly.”
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“Your periods may become more regular, lighter and less painful.”
Useful if oestrogens can’t be taken
“The POP is useful if you can’t take oestrogen-containing medications such as the
combined oral contraceptive pill.”
Safe during breastfeeding
“The POP will not harm your baby if you choose to breastfeed.”
Disadvantages of the POP
Side effects
mood changes or breast tenderness.” ¹
Change in periods
“When you take the POP, your periods may change. You may experience irregular,
light or more frequent periods. Your periods could also stop completely.” ¹
“Unfortunately, the pill does not protect you from sexually transmitted infections.”
User dependent
“It is important that you remember to take the pill at the same time every day.
Sometimes it is helpful to set a reminder on your phone or in your diary.”
Risks of the POP

It is important to explain the risks of taking the pill so that the patient is aware and can
make an informed decision.
Ovarian cysts
“Sometimes women who use the POP may develop small cysts on their ovaries.”
“These cysts are not dangerous and often disappear without any treatment.”
Breast cancer
“Research has shown that there is a small increase in the risk of breast cancer
compared to people who are taking non-hormonal contraception.”
Contraindications of the POP ²
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A patient should not take the POP if they:
are pregnant
have breast cancer
have severe liver cirrhosis
have liver tumours
Starting the pill and missed pills

This section of the consultation can be quite confusing for the patient. It is therefore
important to explain this in a patient-friendly manner, check understanding at regular
intervals and invite questions at the end.
Starting the pill

“You can start the pill at any time if you are sure you are not pregnant. You will,
however, need to use condoms for the first seven days of taking the pill.” ¹
Missed pills
If one pill is missed or a new pack is started more than three hours* late ¹
“Take the missed pill straight away, if you have missed more than one pill, only take
one pill.”
“Take the next pill at the usual time you would take it, this might mean you have to
take two pills in one day. Don’t worry, this is not harmful.”
“Unfortunately, you are not protected from pregnancy and therefore you should use
condoms for the next two days. Continue to take your pills as you normally would.”
“If you have had sex in the same time period that you also missed your pill, you may
need to seek advice for emergency contraception.”
If one pill is missed less than three hours* late
“Take the pill as soon as you remember to take it and then take your next pill at the
usual time you would take it. You will then be protected from pregnancy.”
*12 hours if it is the desogestrel progesterone-only pill

addressed.
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Throughout the consultation you should check the patient’s understanding
at regular intervals, using phrases such as “Can you just repeat back to me what
we’ve just discussed regarding…”.
information.

Below are some common questions that patients may have regarding the progesterone-
only pill. Sometimes, in an OSCE situation, they may ask you one or two questions at
the end of your consultation. Having a good answer can be useful in demonstrating to
the examiner that you have a solid understanding of the topic.
What happens if the patient is sick or have diarrhoea?

If the patient is sick within two hours of taking the pill then they will need to take
another one if they are feeling better.
If a patient has severe diarrhoea for more than 24 hours, they will need to take the pill
as if they missed a pill and follow the instructions. This should continue until the
diarrhoea is no longer severe.
Which common medicines affect the efficacy of the pill?

Explain to the patient that they should make the person prescribing the pill aware of
what medications they are taking so the prescriber can identify any medications which
might affect the pill.
“Some medicines such as some epilepsy medication, HIV medication and St John’s
Wort can reduce the levels of contraceptive hormones and therefore reduce the
effectiveness of the contraception.”
Patients are usually advised to stop taking the pill at the end of a pack and wait until
after their first natural period before trying to become pregnant. Don’t forget to advise
the patient on pre-pregnancy care such as folic acid and smoking cessation.
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What should the patient do if they want to stop taking the pill?
Patients are usually advised to stop taking the pill at the end of a pack. However, if they
cannot wait, it is important to offer information about alternative contraception to
prevent pregnancy.
Can the patient take the POP after having a baby?

Patient’s can take the POP from any time after birth. If the POP is started after day 21,
advise them to use condoms for two days.
References
1. Fpa.org.uk. (2018). The Progesterone Only Pill- Your Guide. Available at: [ LINK].
2. Harding, M. (2014). Progestogen-only Contraceptive Pill. Patient.info. Available
at: [LINK].
7/7

OBGYN Contraception Osce

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39

Prevention of pregnancy using methods of birth control (contraceptive methods).

them who are sexually-active.

There are two major groups of contraceptive methods:

Non-hormonal contraceptive methods

form of contraception (100% effectiveness)

2. Method: Coitus Interrupts (aka “withdrawal” or “pulling out”)

What it is : Withdrawal of penis from vagina before ejaculation

Benefits : Can be used readily especially when no other method is available

Diaphragm and cervical cap

Drawbacks : To be effective, it must be applied on erected penis before penetration happens.

Can be in the form of foaming tablet, film, jelly or cream

It is inserted inside the vagina before sexual intercourse

It is simple to use but not as effective in preventing pregnancy

Diaphragm and cervical cap

The cervical cap is smaller in size

to use them at first

A spermicidal is usually added to give better protection

They can be inserted a few hours before sex

4. Intrauterine contraceptive device (IUCD)

by the woman. It can be attached with copper or hormonal rod

and heavy flow. It is not recommended to teenagers

Hormonal contraceptive methods

making it difficult for sperm and ovum to join.

1. Birth control pills (aka ‘The Pills’)

reduce mild acne

effects such as headache may occur

three months (four times a year)

slowly reduces menstrual flow and may stop periods altogether

12 to 14 weeks after a woman stops getting the injection

During the fourth week, no patch is used so as to trigger menstruation

Benefits : Easy to use and non-invasive

breast tenderness, and headaches

into the vagina once a month

to place a new ring in once a month

Emergency contraception aka ‘the morning-after pills’)

birth control (like a condom) is not used, or in the case of rape.

Two forms of emergency contraception:

within 72 hours (three days)

2. Intrauterine contraceptive device (IUCD)

number of unplanned pregnancies and abortions

Contraceptive counselling often features in OSCEs and it’s therefore important to

Opening the consultation

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Check the patient’s understanding of the types of contraception available.

Explore the reasons why the patient wants the COCP.

Ideas, concerns and expectations

“Have you heard of the combined oral contraceptive pill?”

What is the combined contraceptive pill?

What are the different types of pill available?

How effective is the combined pill?

Pros and cons of the combined pill

Advantages of the COCP

Problems associated with periods improve

Controls timing of periods

“In some people, the pill can improve acne.”

Reduces symptoms of premenstrual syndrome

“The pill may help reduce symptoms of premenstrual syndrome.”

Disadvantages of the COCP

Protection from STIs

“This contraceptive method relies on you remembering to take it daily. Sometimes it is