How to use tailored regimens of combined hormonal contraceptive pills

Ask an expert: Contraception in primary care

Sophia is 25 and was started three months ago on a combined hormonal contraceptive (CHC) pill containing ethinylestradiol with levonorgestrel. In general Sophia is happy with this contraception, but she is getting mild headaches during her seven day break, and finds that she can’t handle stress at work as well in that week. You consider her for a tailored regimen to see if this might help, and discuss options with her. 

What kind of tailored regimen could she try?  How would you explain this to her?

Check your answer in our updated module Ask an expert: Contraception in primary care.  There are brand new questions relating to last month’s clinical guideline update from the FSRH on Combined Hormonal Contraception, which places more emphasis on offering continuous or extended CHC regimens. The module will help you identify practice-changing points in this guideline, and answer questions on contraception more generally.

"Excellent and practical module with problems that one encounters in GP practice! Thank you!"

How can I identify patients at high risk of diabetes?

Screening for cervical cancer

One of your patients is a 48 year old accountant of Nigerian heritage. He recently attended a new patient check and had a risk score calculated for his risk of diabetes. It gave him a 25% chance of developing diabetes in the next 10 years. He had a blood test and his HbA1c has come back as 46 mmol/mol. He does not have any symptoms of type 2 diabetes.

What would be the most appropriate next step?

Check your answer in our module Step by step: preventing diabetes in high risk patients, which offers a guide to the diagnosis and management of impaired glucose regulation, and evidence on interventions that can help prevent the progression to diabetes.

"Very clear summary. Very helpful as this is quite a complicated area with many factors influencing management"

"Very useful clarification for GPs"

How can we increase the uptake of cervical screening?

Screening for cervical cancer

Carol is 28 years old. She has a routine cervical screening test and cytology shows changes consistent with moderate dyskaryosis. When should you repeat the test, or does she need referral for colposcopy?

Check your answer in our updated module: Screening for cervical cancer. It covers how to advise women who are worried about cervical cancer or have questions about the NHS cervical screening programme.

Recent reports in the media suggest that cervical screening coverage in England is now at a 21 year low, with 71.4% of eligible women screened adequately in 2017-18. [Cervical screening programme 2017-18] Therefore, it is important to be able to guide women who may be concerned about screening, and know how best to manage any abnormalities that come up.  The module has had some great feedback:

“Very well-written and answers all relevant questions regarding cervical screening”

“This module was interesting and I actually enjoyed doing it. It did not seem like an effort - it was well illustrated, instructive, and contained very useful information, communicated in a very accessible way”

Recognising sepsis in primary care

Guideline focus: Recognition and management of sepsis in primary care

A 72 year old man comes to see you complaining of fever and a headache for the last two days. His daughter reports that he has been “muddled” from time to time during this period. He has not vomited, has no cough, and is passing urine normally. He has type 2 diabetes and hypertension for which he takes metformin and amlodipine respectively.

On examination he is alert and well oriented, his temperature is 37.0°C, respiratory rate 22 breaths per minute, heart rate 95 beats per minute, and blood pressure 110/78 mmHg. His blood glucose is 8.2 mmol/L. He has a large ulcer on his right shin which is discharging pus. The rest of his clinical examination is unremarkable.

What is his risk of severe illness or death from sepsis? How important is the relative’s account of confusion if he is now well orientated?

Check your answers in our new module, Guideline focus: Recognition and management of sepsis in primary care.  It provides practical tips and case scenarios to help improve early recognition of patients who are at risk of sepsis, which GPs have already found useful:

“An excellent module, with a lot of very detailed, specific information”

"Straightforward and useful, more aware of the the NEWS2 scoring criteria."

Anorexia nervosa in adolescence: how easily can you identify this?

Anorexia nervosa in childhood and adolescence: recognition and initial management in primary care

Amy, a 13 year old girl, is brought in by her mother to see you. Amy’s mother explains her concern that Amy has been missing breakfast and not eating as much dinner as usual. She has been very focused on her competitive running, she has lost weight, and her clothes are a bit loose. Amy says she is not concerned about her weight, she just does not feel hungry sometimes, but admits she is keen to do well in an upcoming running competition and has been training harder than usual. 

On examination, you find that her observations are all within the normal range for her age. You note that she is slim but not cachectic, she is between the 9th and 25th centile for BMI for girls her age. She has no signs of dehydration.

How concerned should you be about Amy at this stage? What kind of investigations might be appropriate, and what “red flags” should you be looking out for? Should you speak to Amy on her own?

Check your answers in our new module on Anorexia nervosa in childhood and adolescence: recognition and initial management in primary care. This module guides you through Amy’s case, with advice on recognising anorexia nervosa, identifying red flags, and knowing when to refer.

GPs who have already taken this module have said:

“Very informative and easy to understand."

"Very clear protocol for how to investigate monitor and treat in primary care"

A dry chronic cough: what treatment options can you suggest?

You see a 47 year old non-smoker who is suffering from a dry chronic cough that has been bothering her for several months. There are no red flags, her chest x ray and spirometry results were normal, and she is not taking any regular medication. She says the constant coughing is driving her mad and irritating her colleagues at work, and she is desperate for you to do something to help control it. 

What treatment options are available in primary care for relieving a chronic cough that has no easily identifiable cause? Does any one option have a stronger evidence base than others? Which approach would you suggest trying first in this patient’s case?  

Check your answers in our recently updated module on chronic cough in primary care. The module covers common causes that can be easily addressed. It also outlines a pragmatic “trials of treatment” approach for patients in whom no obvious cause for the cough can be identified. Other GPs have given it great reviews:

“Informative, up to date, practical, relevant and realistic.”

“Great module, will be invaluable in consultations.”

Heart failure guideline changes: key points for GPs

What combination of drugs is now recommended by NICE as the first line option for a patient with a new diagnosis of heart failure with reduced ejection fraction? How should you adjust your approach to management when a patient’s renal function declines significantly after you titrate up their heart failure medications? What’s the role of NT-proBNP testing for diagnosis of suspected heart failure in a patient with a history of myocardial infarction?

These questions cover just some of the key practice changing points for GPs from the recent update of the NICE guideline on diagnosis and management of heart failure, and you can get up to speed with all the changes with our updated set of modules on this important primary care topic:

Ask an expert: Chronic heart failure
Consultant cardiologist Dr Abdallah Al-Mohammad advises on tricky clinical scenarios and queries submitted by GP users.
“An excellent module with a lot of practical day to day tips.”

Step by step: A guide to diagnosing heart failure
When to suspect the diagnosis, how to rule out important differentials, which tests to request and when to refer.
“So well explained.”

Step by step: A guide to managing heart failure in primary care
Drugs to prescribe and those to avoid, treatment options for patients with refractory symptoms, monitoring treatment and when to seek specialist advice.
“Great module with thought provoking cases.”

How long should this patient continue taking a bisphosphonate?

Clinical pointers OsteoporosisYou see Mary, who is 64 years old. She started taking alendronic acid for primary prevention of fragility fracture three months ago, when her FRAX 10-year risk score indicated that she was at high risk, and a DXA scan confirmed a diagnosis of osteoporosis. She is also taking vitamin D supplements. She has tried unsuccessfully to give up smoking, and has a strong family history of osteoporosis. She is here to review her medication and get the results of serum calcium blood tests, which are normal. She is not suffering from any concerning side effects, but wants to know whether she will need to take a bisphosphonate for the rest of her life.

What factors do you need to consider in weighing up the risks and benefits of long-term bisphosphonate treatment? How does this judgement vary for different bisphosphonates?

 Check your answers in our recently updated module Clinical pointers: Osteoporosis – prevention and management in primary care. The module offers practical tips on fracture risk assessment, indications for DXA scanning, the use of bone-sparing medication for primary and secondary prevention and how to ensure patients with osteoporosis are vitamin D and calcium replete. Other GPs are finding it very helpful:

“Great module, learned a lot of things doing this one.”

“A brilliant, informative module on a confusing topic.”

Tired all the time: how would you manage this patient?

A 56 year old woman comes to see you complaining of feeling tired all the time. She is otherwise well, and has no other symptoms of hypothyroidism. On examination she is clinically euthyroid, with no evidence of goitre. She does not take any drugs known to affect thyroid function. As her symptoms have persisted for some time, you request a set of screening investigations including thyroid function tests (TFTs). The results are as follows:

  • TSH: 8.1 mU/L (normal range 0.4 mU/L to 4.5 mU/L)
  • Free T4: 12.1 pmol/L (9.0 pmol/L to 25.0 pmol/L)
  • Free T3: 5.3 pmol/L (3.5 pmol/L to 7.8 pmol/L)

All of the other screening investigations are normal. How should you interpret these TFT results, and how should you manage this patient? Check your answers in our new Step by step module on Diagnosing thyroid dysfunction in primary care.  It will refresh your knowledge on when (and when not) to request thyroid function tests, the recommended primary care follow up for patients with subclinical hypothyroidism and hyperthyroidism, and how to identify and manage thyroid dysfunction in pregnancy. The module is already proving very popular with other GPs:

“Wow. One of the best modules I have ever read.”

What step-up treatment does this asthma patient need?

You see Mia, a 28-year-old woman who was diagnosed with asthma two years ago. She is taking a short-acting beta agonist as required as well as regular twice-a-day use of a combination beclometasone/formoterol inhaler containing a low dose of the inhaled corticosteroid. She has had no improvement in her symptoms since starting the combination inhaler. You have rechecked her diagnosis, checked her inhaler technique and confirmed her concordance with treatment. You conclude that her asthma medication needs stepping up - what would be the most appropriate next step?

Check your answer- and find out how and why the BTS/SIGN and NICE guidelines would recommend different approaches for this patient - in our newly updated module on Managing chronic asthma in adults. You'll earn 2 hours of CPD credits as you work through patient cases that you might see in everyday primary care.

You might also want to take our other recently updated asthma modules to ensure you are up to speed on all aspects of diagnosis and management:

Guideline focus: Asthma diagnosis in adults and children
"Succinct but very useful for daily practice."

Ask an expert: Management of chronic asthma in children in primary care
"Excellent, clear, directive expert advice. Has cleared a lot of lingering doubts. I highly recommend this module."

Step by step: How to manage acute asthma in adults in primary care
"This module is an absolute must for every GP."

Step by step: How to manage acute asthma and wheezing in children in primary care
"An extraordinary, brilliant module, worth repeating more than one time."