Period Pains — Free SCA Practice Case

Character Overview: You are Julia Kowalska, a 16 year old in your first term at a sixth form college, studying A levels in Art, Sociology and Spanish. You live with your mum Ewa, a school cook, and your dad Marek, a bus driver. Your sister Natalia, 27, lives in Nottingham. Natalia has a womb condition that took years to find: told her pain was normal, found at a keyhole operation at 23, and now she is at a fertility clinic because she cannot get pregnant. You never say the medical name of Natalia's condition. You call it "what Natalia's got", and if asked its name you say it is a long name you never say properly. If the doctor says the name, you recognise it at once ("yeah, that's it").

Your periods have become more and more painful and you have missed college. You booked this call yourself and are ringing from an empty art studio. Your mum offered to come, but you wanted to do this alone. You have a girlfriend, Ruby, who is 16 and in your art class; your parents do not know and you will tell them in your own time. You are bright, polite and a little guarded, and speak like a teenager ("like", "basically", "literally"). Underneath, you are frightened that you have what Natalia has and that nobody will take you seriously.

Opening Sentence: "Thanks for calling me back. It's my periods. The pain's so bad I've already had two days off college and I've only been there a month. Paracetamol does next to nothing. And I really don't want to just be told it's normal."

History if Asked (Data Gathering Phase)

• ●What the pain is like: "Really strong cramps, low down in the middle of my tummy. It goes into my lower back and the tops of my legs."
• ●When it comes: "It starts the evening before I come on, and the first two days are the worst. By the third day it's calmed down." Eight out of ten on day one: "I can't sit in a lesson with it."
• ●When it started: "My periods started at 11. They started hurting about a year later, but it's got properly bad this last year." No pain at other times.
• ●The periods: "Regular, every 28 to 30 days, about five days. The first two are heavy, I change my pad every three or four hours, but I don't flood and there aren't big clots." No bleeding between periods. Last period two weeks ago.
• ●What she has taken: "Just paracetamol. Two of the 500s when it gets bad, maybe twice on the worst day. It takes the edge off for like an hour." Never ibuprofen: "Mum says it's bad for your stomach, so we've only ever had paracetamol in the house." Nothing else.

Ideas, Concerns, Expectations

Gating note: Julia does not raise any of the following herself, apart from the opening line. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, what she was hoping for, or why she does not want to be told it is normal.

• ●Ideas: She thinks she has the same thing as Natalia. "It started exactly like mine, at my age, and everyone kept saying it was just bad periods."
• ●Concerns: Being dismissed as Natalia was. "They told her it was normal for years. Years. She was on the pill and everything and nobody checked properly, and by the operation it was everywhere." If the doctor explores further, her voice wobbles: "She's having fertility treatment now because she can't get pregnant. I'm scared that's going to be me."
• ●Expectations: "I want someone to actually check. Natalia had that keyhole test. Can I have that, or at least a scan? And I need something that works before my next period."

If Asked: Medical History and Medications

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

• ●Health and medicines: "I'm never really ill. No asthma, stomach problems, kidney problems or easy bruising. No regular medicines or allergies. I don't really get headaches, never flashing lights."
• ●Smoking, alcohol and drugs: "No smoking. A couple of drinks at a party. No drugs."
• ●Family history of period problems: "My sister Natalia's got something. She's 27. Really bad periods from my age, they kept saying it was normal, then they found it at a keyhole operation when she was 23. She's had another since, and now she's at a fertility clinic." If asked what it is called: "It's a long name, I never say it right. It's a womb thing." If the doctor says the name: "Yeah, that's it. That's what she's got." Her mum says her own periods were fine and feels bad about Natalia.
• ●Other family history: "Nobody's had a clot."

Social History and Lifestyle Impact

• ●College and impact: "I've had two days off already this term. My tutor's flagged my attendance, and they take money off my bursary, which pays for my bus pass, for days that aren't authorised. Last summer I had a GCSE exam on the first day of my period and I could hardly think."
• ●Mood (if asked): "Really fed up when it comes, a bit teary on the first day. The rest of the month I'm fine." No thoughts of self harm.
• ●Relationship (if asked): Asked about a boyfriend, she says "No, no boyfriend," pauses, and adds nothing if the doctor moves on. If asked openly whether she is seeing anyone, or the pause is followed up: "Um. Yeah. I've got a girlfriend, Ruby. She's in my art class, she's 16 as well. We've been together about three months." Then, quietly: "My mum and dad don't know yet. I'm going to tell them when I'm ready."
• ●Sex (if asked): "We haven't, like, done anything like that. And I've never been with a boy, so I can't be pregnant, if that's what you're asking." She feels safe: "She's lovely."
• ●Texts, letters and who can see her record (if asked): "I think the surgery's texts go to Mum's phone, the number you've got from when I was little. I've got my own NHS App now, that's how I booked this. Mum used to be able to book stuff for me, but that stopped at sixteen. Letters come to the house and Mum opens the post."

If Asked: Associated Symptoms

Gating note: Julia answers briefly. The following are all negative: pain or bleeding when opening her bowels, urinary symptoms, unusual discharge, fever, sudden severe pain on one side ("It's always in the middle, and it builds up"), fainting, and weight or appetite change.

• ●Nausea, bowels and tiredness: "I feel sick on the first day but I haven't been sick. I go a bit looser, it doesn't hurt. I'm wiped out on the first two days." Weight about the same, quite small.

Responses to Management (The Negotiation Phase)

• ●If the doctor calls it normal period pain before showing her worry is taken seriously, or says a condition like Natalia's is possible:
  • ●Reaction: If brushed off, hurt and guarded: "That's literally what they said to Natalia." She stays short until her sister's experience is acknowledged: "Okay. Thank you. That's all I wanted." If told a condition like Natalia's is being considered: "Thank you. So how do you find out if I've got it?"
• ●If the doctor recommends ibuprofen or another anti inflammatory, or suggests codeine:
  • ●Reaction: Surprised. "I thought ibuprofen was just for headaches. Mum says it's bad for your stomach." Once it is explained: "So do I start it the night before? Do I have to eat first?" About codeine: "Natalia says it made her constipated, which made the pain worse."
• ●If the doctor offers hormonal treatment, or says she must wait for a diagnosis first:
  • ●Reaction: About the combined pill: "If I'm on the pill, won't my mum and dad think I've got a boyfriend?" Then: "And Natalia was on the pill for years and they still said it was nothing. Won't it just cover it up?" Once both are answered she is open: "Could I take it so I don't really get periods at all? That would be amazing." She would rather start both now but accepts painkillers first if the reason is explained. If told hormones will damage her fertility, or she must wait: "So what am I meant to do until then?"
• ●If the doctor explains she can consent to her own treatment, says her mum must be told, or asks about involving others:
  • ●Reaction: Relieved at consent: "Even though I'm sixteen? Okay, good." Then: "The surgery texts go to my mum's phone. Would she get a text about the scan?" Reassured if offered her own number on the record: "Use my number. Letters I can sort, Mum knows it's my periods. It's just the other stuff." If told her mum must be told: "I'm sixteen. I thought I could sort this out myself." Asked about support: "Mum can know it's about my periods. I just don't want the Ruby thing coming up, that's mine to tell."
• ●If the doctor arranges an examination, a scan or a referral, or talks about fertility:
  • ●Reaction: Anxious: "Do I have to have an internal? I really don't want that." Relieved if it would be her tummy, blood pressure and weight. About a referral: "Thank you, that's what I wanted. Would they do the keyhole thing?" If the plan is review in three months and referral only if not better: "That's three more lots of missing college," though she accepts it with treatment now and a clear point for referral. About fertility: "If I have got it, does that mean I can't have kids?" An honest answer that promises nothing steadies her.
• ●If the doctor suggests a diary, gives safety netting or offers help with college:
  • ●Reaction: "Can I use an app? I track my period already." Vague safety netting such as "come back if it gets worse": "It's already really bad every month. What would actually mean I need to go to A&E?" Offered help with college: "My tutor said if there's a medical reason they can authorise it. That would really help." Asked to check anything herself on the call: "Can I just come in?"