Cases/People with Long-term Conditions Including Cancer

Epilepsy On Lamotrigine Asking About the Combined Pill — Free SCA Practice Case

Woman with epilepsy on lamotrigine asking about the combined pill

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

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Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Ffion Maddocks

Age

24 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. Routine appointment booked by the patient.

Reason for Encounter

"I'd like to start the combined pill, please."

Medical Records

●PMH: Generalised epilepsy, diagnosed at 14. Last seizure recorded 3 years ago. Epilepsy nurse review 5 months ago: BP 112/70, BMI 22.
●Medications: Lamotrigine 150 mg twice daily, repeat. No contraception recorded.
●Allergies: NKDA.
●Social: Works as an estate agency administrator and drives to work. Non smoker.

Patient Script

For the friend playing the patient role

Character Overview: You are Ffion Maddocks, a 24 year old estate agency administrator in a market town. You drive 20 minutes to work every day, rent a one bedroom flat on your own, and have been seeing your partner Ieuan, a physiotherapy assistant, for four months. You have had epilepsy since you were 14 and take lamotrigine. You have been fit free for three years and you are proud of it, and a little superstitious about it. Ieuan does not like condoms and has asked you to go on the pill. Your friend Mared, who takes the pill and "knows someone with epilepsy", told you it can bring fits back, so you are anxious. You are friendly, chatty and sensible, you speak in plain everyday terms, and you get quiet and a bit tearful if the talk turns to losing your driving licence or your independence.

Opening Sentence: "Hello, doctor. I'd like to go on the combined pill, please. My boyfriend would like me to, but I've got epilepsy and my friend says the pill can bring the fits back, so I wanted to check first."

History if Asked (Data Gathering Phase)

●Your epilepsy: "I was 14 when I had my first fit, in a PE lesson at school. I collapsed, went stiff and shook, and woke up in hospital. They did a brain trace and said it was generalised epilepsy, and I've been on lamotrigine ever since. I think they said the fits involve the whole brain, not one spot."
●Last seizure: "Three years ago, in my last year at university. I'd been up for two nights finishing an essay, I'd been drinking, and I'd skipped some tablets. Nothing since, not even a funny turn."
●What the fits are like: "I only get the big ones, with the stiffening and shaking. I've never had jerks in the morning or staring spells that I know of."
●Your tablets: "Lamotrigine, 150 milligrams in the morning and 150 at night. I take it every day with my breakfast and when I brush my teeth at night. I might forget one dose a month, but I take it as soon as I remember."
●Epilepsy follow up: "I see the epilepsy nurse once a year. The last time was about five months ago. She checked my blood pressure and weight, and said everything was fine. I haven't seen a neurologist for a couple of years."
●Triggers: "Lack of sleep and too much alcohol. I have a few drinks on a Saturday, no more than that now."
●Side effects of lamotrigine: "None. I've never had a rash, and I'm not dizzy or double sighted."
●Driving: "I drive to work, and I'm allowed to because I've been fit free so long. It would be awful to lose that. I'd have to give up my job, because there's no bus."

Ideas, Concerns, Expectations

Gating note: Ffion does not raise any of the following unless the doctor asks what she is thinking, what is worrying her, or what she was hoping for. The opening sentence already mentions the friend and the fits, but the details only come out when asked.

●Ideas: She thinks the pill is the normal, easy option that "everyone is on". She has half heard that the hormones in the pill upset the brain and can start fits, but she does not know how. "Mared said her cousin had a fit after starting the pill. I don't know if that's true."
●Concerns: Her biggest fear is having a fit and losing her licence and her job. She also worries about getting pregnant while taking her tablets, because she has read that epilepsy tablets can harm a baby. "I'd hate to put all this at risk just for something that's meant to be simple."
●Expectations: She expected a prescription for the combined pill today, and was ready to be told to come in for a blood pressure check. She is open to other methods. "If the pill isn't right, I don't mind. I just don't want condoms forever, and Ieuan really doesn't like them."

If Asked: Contraception and Sexual History

Gating note: Ffion answers each of these plainly when the doctor asks about it.

●Current method: "Condoms, every time. We have never had sex without one. I've never used any other contraception."
●Last period: "About two weeks ago. They are regular, every 28 days, lasting four to five days, moderate, with a bit of cramping on the first day. No bleeding between periods or after sex, and no pain."
●Chance of pregnancy: "No, no chance. No split condoms or anything like that."
●Partners and infections: "Ieuan is my only partner for the last year. I've never had a sexual health check. I've had no discharge, pain or sores. I'd be happy to be tested."
●Plans for a family: "Not for a few years. I'd like children by about 30. I haven't thought about what my tablets mean for that. I just assumed I'd have to come off them."
●Preferences: "I'd like something I don't have to think about every day. I'm worried about having a coil, because I've heard it hurts, and I don't like the idea of needles."

If Asked: Medical History and Medications

Gating note: Ffion answers each of these plainly when the doctor asks about it.

●Other medicines: "Only lamotrigine. No vitamins, no herbal things, no St John's wort, nothing from the chemist."
●Allergies: "None."
●Blood pressure, clots or migraine: "My blood pressure is normal, the nurse said 112 over 70. I've never had a clot. I don't get migraines or visual disturbances. Headaches are rare."
●Smoking and vaping: "I've never smoked or vaped."
●Weight: "Around 60 kilos. The nurse said it was healthy."
●Family history: "No clots, strokes or breast cancer in the family that I know of. My mum has a thyroid problem."
●Other conditions: "No liver, kidney or heart trouble. I had my cervical screening last year and it was normal."
●Mood: "Fine. I've been happy since meeting Ieuan."

Social History and Lifestyle Impact

●Work and home: Estate agency administrator, with a 20 minute drive each way. Lives alone in a rented flat, a short drive from her parents.
●Alcohol: About 8 units on a Saturday night. Never during the week.
●Sleep: Seven to eight hours most nights and she guards it. She gets anxious if a night out runs late.
●Ieuan: Supportive generally, but he finds condoms uncomfortable and has said it would be "easier" if she were on the pill. He does not know much about her epilepsy, and she is nervous about telling him the pill may not suit her. He would not pressure her if she said no.
●Availability: Can come to the surgery at the end of the day or on her day off on Fridays.
●Telephone: If asked to check her blood pressure or examine her, she says she can come in; she has no home monitor.

If Asked: Epilepsy Safety and Other Questions

Gating note: Ffion answers only what is asked, and everything else is negative.

●If asked whether she has told the epilepsy team about wanting contraception: "No. I wasn't sure it was their job. Should I?"
●If asked about taking tablets at the same time or missed doses: "Once a month, at most."
●If asked about dizziness, double vision, unsteadiness or sickness with her tablets: "No, never."
●If asked about other seizure types, auras or warnings: "No warning at all. They just happen."
●If asked whether she has been told what her tablets mean for the pill before: "No. Nobody has ever said anything."

Responses to Management (The Negotiation Phase)

●
If the doctor explains that the combined pill can lower her lamotrigine level and may not be advised:
- ●Reaction: Surprised and a little worried. "So Mared was right, then. Does the pill cause fits?" She accepts the explanation if it is given simply: it is the lamotrigine level that matters rather than the pill damaging the brain. "So the pill itself is fine, it's what it does to my tablets? Does my tablet affect the pill, too?" Then she asks, "What do I do about Ieuan? He's expecting me to be on it."
●
If the doctor suggests a coil, implant or injection:
- ●Reaction: Cautious. "Does the coil hurt? And will it make my periods heavy?" About the implant: "Is that the one in the arm? Does it need a needle?" About the injection: "Do I have to keep coming back for it?" She becomes interested once told that these methods work for years and do not interfere with her tablets. "Could I have that done here? How long would I have to wait?"
●
If the doctor suggests a progestogen only pill:
- ●Reaction: Hopeful, then practical. "Would that work with my tablets? Would I still need condoms?" If told she would need to keep using condoms: "Then it's not much different from now, is it?" She says she would still choose it for the time being if the doctor explains why it is sensible while she waits for the coil.
●
If the doctor says the combined pill can still be an option and explains how it would be supervised:
- ●Reaction: Interested but wary. "Would you put my lamotrigine up? Who decides that, you or the nurse?" Once told that her epilepsy team and blood levels would be involved: "I'd rather do that than have a fit. But I'd have to get the dose right before I started, wouldn't I?"
●
If the doctor mentions the epilepsy team, or her medication in future pregnancy:
- ●Reaction: Relieved. "I didn't think I was allowed to ask them." Asked about pregnancy: "Nobody told me I could keep taking it. I thought I'd have to stop." If told not to stop tablets without advice: "That's a huge relief."
●
If the doctor gives safety netting or summarises the plan:
- ●Reaction: Wants specifics. "What would I look out for, exactly? What counts as a warning sign?" She repeats the plan back accurately if it is clear. If the advice is vague: "But how would I know if it's the tablets?" She asks if she can stay on condoms until she has been seen.

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Domain 2: Clinical Management and Medical Complexity

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Ffion is 24, has been free of seizures for three years on lamotrigine, and asks for the combined pill because her partner prefers it. The station tests whether the candidate spots a two way drug interaction and finds a method that protects both her seizure control and her contraception, while respecting what she wants.
●The model plan has six parts. Take an epilepsy and contraceptive history. Screen for other contraindications and interacting medicines. Explain that oestrogen lowers lamotrigine levels and lamotrigine may weaken some contraceptives. Offer methods that avoid the problem, led by an intrauterine system or copper intrauterine device. Provide interim protection with condoms, with a progestogen only pill if she wants a tablet. Keep lamotrigine unchanged, inform her epilepsy team, and give specific safety netting.
●Acceptable alternatives: the implant or progestogen injection as her long acting choice, a progestogen only pill with condoms, or, if she still wants the combined pill after an informed discussion, starting it with epilepsy team agreement, lamotrigine dose review, level monitoring and condoms. All of these are guideline supported and none is marked as a fail provided the interaction is explained and the epilepsy team is involved.

What the Interaction Actually Is

●Her friend is partly right but for the wrong reason. The pill does not directly provoke seizures. Oestrogen speeds the breakdown of lamotrigine, so levels can fall substantially, and a lower level may allow seizures to return.
●Lamotrigine is not a classical liver enzyme inducer, unlike carbamazepine, phenytoin, oxcarbazepine, phenobarbital, primidone and topiramate, so the usual enzyme inducer advice does not apply. The effect runs both ways. The BNF notes that combined hormonal contraceptives alter lamotrigine exposure and that lamotrigine might decrease their efficacy.
●In a cyclical pill regimen, lamotrigine levels may rise during the hormone free week and fall again once the pill restarts, so toxicity symptoms such as dizziness, double vision, unsteadiness and nausea can appear in the pill free week. Stopping the combined pill can also raise lamotrigine levels, so the dose may need reducing again.

What the Guidance Says

●BNF treatment summary on contraceptive interactions: lamotrigine could reduce the efficacy of combined hormonal contraceptives, so additional reliable use of condoms is recommended. Combined hormonal contraceptives can reduce lamotrigine concentrations and hence seizure control. If a combined method is unavoidable, consider increasing the lamotrigine dose and monitoring concentrations, and a continuous regimen with no hormone free interval can be used to avoid cyclical swings (unlicensed use).
●For progestogen only pills, the same source says lamotrigine could reduce efficacy, so condoms are recommended in addition. Desogestrel might increase lamotrigine concentrations, evidence for other progestogen only pills is lacking, and patients should be vigilant for lamotrigine toxicity on starting.
●The BNF interactions list for lamotrigine records effects on the implant and drospirenone as theoretical or predicted, while the section on injectable contraception does not mention lamotrigine.
●UK Medical Eligibility Criteria (UKMEC): combined hormonal methods are category 3 for a woman taking lamotrigine (risks usually outweigh benefits), while progestogen only methods and intrauterine devices are category 1. NICE NG217 says to be aware that oestrogen containing contraceptives can impair the effectiveness of lamotrigine, and that the antiseizure medicine and contraception should be reviewed together.

Choosing the Method

●Intrauterine system or copper intrauterine device: not affected by lamotrigine, so these are the most reliable and are the usual first choice. They are not oral, need a face to face fit, and may cause cramps; the intrauterine system typically lightens periods, while the copper device may make them heavier.
●Progestogen injection: not affected by enzyme inducers, though a regular return visit is needed. Implant: effective and long acting, with a theoretical lamotrigine interaction listed by the BNF, so it is reasonable with counselling but not marked as an interaction free method.
●Progestogen only pill: acceptable as an interim or ongoing method, but condoms should be added, and she should be told to watch for lamotrigine toxicity, particularly with desogestrel.
●Combined pill: possible only as an exception, with epilepsy team involvement, a plan for lamotrigine dose and monitoring, and condoms. It is not first line. Patches and vaginal rings also contain oestrogen and are no better.

Epilepsy Team and Lamotrigine

●She should keep taking lamotrigine exactly as prescribed. Stopping it or changing the dose herself is dangerous. Any adjustment around hormonal contraception belongs to the epilepsy team.
●Inform her epilepsy nurse or neurologist about whichever method she chooses, so that levels can be monitored if she starts or stops any oestrogen containing method. She did not know she was allowed to contact them, so tell her she should.
●If seizures recur, she must stop driving straight away and tell the DVLA; for a car licence she could reapply once she had been seizure free for at least a year. She drives to work and lives alone, so a recurrence would cost her independence and employment. That is a concrete reason to avoid any change that threatens her control, and it explains why she is so anxious about the pill.
●Explaining the problem well matters as much as choosing the method. Say that the pill does not harm the brain, that the issue is the level of her tablet, and that she has several good options, so she hears the news as a choice and not as a refusal.

Emergency Contraception and Infection Risk

●Lamotrigine is not in the list of enzyme inducers that affect emergency hormonal contraception in the BNF summary, so standard advice applies if a condom fails; the copper intrauterine device remains the most effective emergency method.
●A new partner and no sexual health screening to date makes condoms and screening appropriate whatever hormonal method she uses. This does not need to be a long discussion in a 12 minute call, but a brief offer is expected.

Planning for Pregnancy

●She wants children in about six years and thinks she must stop her tablets. She should be told she should not stop lamotrigine, and that planning with the epilepsy team beforehand allows safe dosing and folic acid advice. Monitoring of lamotrigine levels before, during and after pregnancy is standard in BNF pregnancy guidance, because levels change.
●The aim is to avoid unplanned pregnancy on antiepileptic medicine while she plans. Reliable contraception now, followed by a planned conversation with the epilepsy team before she tries to conceive, serves her best. Valproate and its pregnancy prevention programme do not apply here because she takes lamotrigine.
●Do not give doses of folic acid or advice on conception from memory in the consultation; say that the epilepsy team will advise on this, and that she should contact them when she starts to plan.

Consulting by Telephone

●A telephone consultation is enough to take the history, explain the issue and agree a method. There is no need to ask her to check her own blood pressure on the phone; it was normal at the epilepsy review and is not needed for intrauterine or progestogen methods.
●If a coil or implant is chosen, arrange a face to face visit and bridge with condoms. If she wants a progestogen only pill in the meantime, it can be prescribed remotely with the caveats above.

Common Mistakes in This Station

●Prescribing the combined pill without mentioning lamotrigine, or telling her the pill is safe in epilepsy.
●Stating that the pill itself causes seizures, rather than explaining the effect on lamotrigine levels.
●Advising her to stop or increase lamotrigine without involving the epilepsy team.
●Offering a progestogen only pill and no condoms, or leaving her unprotected while waiting for a coil.
●Ignoring her partner's views or her fear of needles and coils.
●Forgetting infection risk, pregnancy plans or the epilepsy team.
●Using terms such as enzyme induction without explaining them.

Mapped to the RCGP curriculum topic: People with Long-term Conditions Including Cancer.

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