Weight Loss — Free SCA Practice Case
Young woman struggling with weight loss
Station Timer
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
Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Full Name
Sophie Taylor
Age
26 years
Consultation Type
VideoAge
26
Reason for Encounter
"Patient wants to discuss weight loss options. She feels she has tried every diet without success. Recent routine bloods were taken by the healthcare assistant last week to rule out thyroid issues."
Medical Records
- ●PMH: Nil significant.
- ●Medications: None.
- ●Allergies: NKDA.
Recent Notes (Blood Results Received)
- ●TSH: 2.1 mU/L (Normal)
- ●HbA1c: 40 mmol/mol (Normal, but upper end)
- ●Serum Testosterone: 3.2 nmol/L (Raised)
- ●SHBG: 22 nmol/L (Low)
- ●LH: 14 IU/L / FSH: 5 IU/L (Raised LH:FSH ratio)
- ●Ultrasound Pelvis: Not yet performed.
- ●BMI: 34 kg/m²
Patient Script
For the friend playing the patient role
Character Overview: You are Sophie. You are deeply frustrated, demoralized, and carrying a heavy burden of shame regarding your body. You have tried Keto, intermittent fasting, and calorie counting, but the weight refuses to budge. You saw the "abnormal" hormone flags on your NHS app yesterday. You Googled the results and instantly realized they point to Polycystic Ovary Syndrome (PCOS). This sent you into a panic because you read that PCOS causes permanent infertility. You are getting married next year and desperately want to start a family immediately after. Furthermore, you are hiding a deeply embarrassing symptom: thick, dark hair on your chin and neck that you spend 30 minutes plucking every morning. You will not volunteer the facial hair or your terror of infertility unless the doctor creates a safe, non-judgmental space and specifically asks about other symptoms or your future worries.
Consultation Flow & Responses:
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The Opening
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If the doctor asks an open question: "Hi Doctor. I'm here because I just don't know what to do anymore. I restrict my calories, I go to the gym, but I cannot lose weight. My BMI is 34 and I feel like a failure. I saw my blood tests on the app and it said my testosterone is high. Is there a magic pill to fix my metabolism?"
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Data Gathering (The Layers)
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Layer 1: The Weight & Diet Struggle:
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"I've tried everything. Slimming World, fasting, cutting out carbs. I might lose half a stone, but it comes straight back on even when I'm eating healthily."
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"I do binge sometimes out of frustration, but mostly I am really strict."
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Layer 2: Menstrual History (The Diagnostic Clue):
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If asked about her periods: "They've never been regular. I probably only get three or four periods a year. I haven't been on the pill since I was 20."
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"I just thought I was lucky not having them every month, but now I'm worrying that's part of the hormone problem."
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Layer 3: The Shame (Hyperandrogenism):
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If the doctor gently asks about acne, hair loss, or excess body hair: You look away, visibly embarrassed. "I get horrible cystic spots on my jawline. And... I have to pluck thick dark hairs off my chin every single morning. It makes me feel so unfeminine. Is that because of the testosterone?"
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Layer 4: ICE & The Core Revelation (The Infertility Terror) - ONLY REVEAL IF ASKED:
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If the doctor asks: "What are you most worried these results might mean?" or "What did you read online?"
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Reaction (The Reveal): You start to cry. "I Googled high testosterone and missed periods, and everything says it's PCOS. Every forum I read says women with PCOS are barren and can never have babies. I'm getting married next year and we want kids straight away. Am I infertile, Doctor? Is that why my body is broken?"
ICE — Ideas, Concerns, Expectations
(Actor guidance: Do not volunteer any of this unprompted. These responses surface only when the candidate directly explores the patient's perspective through open or targeted questioning.)
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Ideas: You believe the high testosterone and missed periods mean you have PCOS — you read about it on Google and NHS forums yesterday after seeing the flagged results on your NHS app. You think PCOS is the reason your body "won't cooperate" with diets, and that there is something fundamentally wrong with your metabolism that willpower alone cannot fix.
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Concerns: Your deepest fear is that you are infertile and will never be able to have children. This is devastating because you are getting married next year and having a family soon after is central to your life plan. Beneath that, you carry daily shame about the facial hair — you are terrified your fiancé will eventually notice, or that it will get worse. You also worry that doctors dismiss you as lazy and don't take your weight struggles seriously.
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Expectations: You want the doctor to explain what the blood results actually mean in plain language, to take your weight struggle seriously rather than just telling you to eat less, and to offer something practical — whether that is medication, a referral, or a clear plan — that gives you hope. You also want honest reassurance about whether you can still have children.
If Asked — Medical History and Medications
(Actor guidance: Sophie has no significant past medical history and takes no regular medications. The following responses are for when the candidate asks about specific items from the medical records.)
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If asked about past medical history: "No, I've never really been unwell. No operations, no hospital stays, nothing like that."
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If asked about regular medications: "I don't take anything prescribed. I take a multivitamin sometimes but not every day."
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If asked about allergies: "No, no allergies to anything that I know of."
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If asked about the blood results generally: "I saw them on the app yesterday. The testosterone was flagged as high and there was something about a ratio being off. The thyroid one was normal, which is good I suppose, but I don't really understand the rest."
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If asked about the HbA1c result: "The nurse said something about my sugar levels being okay but 'worth keeping an eye on.' I didn't think much of it at the time. Should I be worried about diabetes as well?"
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If asked about the TSH result: "That one was normal, wasn't it? I was half hoping it would be my thyroid because at least that's treatable and would explain why I can't lose weight."
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If asked about the testosterone or LH/FSH results: "Those were the ones flagged red on the app. I didn't really understand the numbers but when I Googled high testosterone in women, everything pointed to PCOS."
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If asked about the pelvic ultrasound: "No, I haven't had one yet. Nobody's mentioned it. Should I be having one?"
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If asked about contraception history: "I was on the combined pill from about 16 to 20 to help with my skin. My periods were regular on it. Once I came off it, they went all over the place but I just assumed that was normal."
Social History and Lifestyle Impact
(Actor guidance: Volunteer lifestyle impact naturally during conversation, particularly when discussing the weight struggle or emotional burden. Do not deliver as a monologue.)
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Occupation / daily life context: You work as a marketing coordinator at a small firm in town. It's a desk job, Monday to Friday. You go to the gym three or four times a week — a mix of classes and the treadmill — and you track your calories using an app. Your fiancé Tom is supportive but doesn't fully understand why the weight won't shift despite how hard you try.
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Lifestyle impact of the condition:
- ●"I set my alarm for 5:45 every morning just so I have time to pluck my chin and cover the shadow with makeup before Tom wakes up. I'm terrified he'll see it one day and be disgusted."
- ●"I dread work socials because everyone comments on what I'm eating. I had a salad at the Christmas do and someone still said 'oh, being good are we?' as if I'm not trying every single day."
- ●"The gym is becoming pointless — I'm doing everything right and the scales don't move. I've started cancelling sessions because what's the point? It makes me feel worse, not better."
- ●"I cry most evenings scrolling through Instagram seeing girls my age in bikinis or announcing pregnancies. I feel like my body is broken and I'm the only one."
If Asked — Associated Symptoms
(Actor guidance: Respond only when the candidate directly asks about specific symptoms. Keep answers natural and brief.)
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If asked about mood or mental health: "I've been really low, honestly. I cry a lot and I don't feel like myself. I wouldn't say I'm depressed exactly, but I'm not happy. It's all tied up with how I look and feel about my body."
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If asked about sleep: "Sleep is okay mostly. I sometimes lie awake worrying about things, but once I'm off, I'm off. I don't snore or anything like that."
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If asked about fatigue or tiredness: "I am tired a lot actually, but I put that down to the early mornings and the gym. I don't know if it's something separate."
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If asked about hair thinning or hair loss on the scalp: "Now you mention it, my hair does seem thinner than it used to be. I lose a lot in the shower. I thought it was just my shampoo but maybe not."
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If asked about skin darkening (acanthosis nigricans): "No, I haven't noticed any dark patches on my skin, nothing like that."
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If asked about skin tags: "No, I don't think I have any skin tags."
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If asked about pelvic pain or abdominal pain: "No, I don't get any pain down there. No cramping or anything."
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If asked about changes in libido: "I haven't really noticed a change, no. It's more that I feel so unattractive that I don't always want to be intimate, but that's a confidence thing, not a physical thing."
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If asked about galactorrhoea (breast discharge): "No, nothing like that at all."
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If asked about visual disturbances or headaches: "No, my vision is fine and I don't get bad headaches."
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If asked about voice deepening: "No, my voice hasn't changed."
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If asked about increased muscle bulk: "No, nothing like that. If anything I struggle to build muscle at the gym."
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If asked about smoking: "No, I've never smoked."
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If asked about alcohol: "I'll have a few drinks on a weekend with friends, maybe a bottle of wine over Friday and Saturday, but nothing during the week."
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If asked about recreational drugs: "No, never."
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If asked about family history of PCOS, diabetes, or hormonal problems: "My mum is type 2 diabetic and she's always struggled with her weight too. My older sister has irregular periods but she's never been diagnosed with anything. I don't know about PCOS specifically in the family."
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If asked about diet in more detail: "On a good day I'll have porridge for breakfast, a chicken salad for lunch, and something like salmon and vegetables for dinner. I track it on MyFitnessPal and I'm usually around 1,400 to 1,500 calories. But then I'll have a bad day where I just lose control and eat everything in sight — crisps, chocolate, toast — and I feel disgusting afterwards."
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If asked about exercise in more detail: "I go to the gym three or four times a week. I do a spin class, some weights, or just the treadmill for 40 minutes. I've been doing this for over a year and I've barely lost anything. My friend started the same routine and dropped two stone."
Negotiation & Collaborative Management Plan
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If the Doctor just says "Eat less and move more" or focuses purely on BMI:
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Reaction: Defensive and shut down. "You're just like every other doctor. You think I'm lazy and secretly eating cakes. I told you, I am trying!" (Testing the doctor's awareness of weight stigma and PCOS insulin resistance).
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If the Doctor diagnoses PCOS but ignores the emotional impact of the fertility fear:
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Reaction: "So I do have it. But what about babies? Am I ever going to be a mum?"
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If the Doctor suggests the Combined Pill (COCP) to regulate periods and help the hair:
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Reaction: "Will that help the chin hair? Because that's ruining my confidence. But if I take the pill, won't that delay me getting pregnant after the wedding?" (Doctor must explain it manages symptoms now, and they can stop it when ready to conceive).
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If the Doctor mentions weight loss medications (GLP-1s/Orlistat) or Tier 3 Weight Management:
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Reaction: "I've read about those injections. Would I be allowed them? I just need something to help my body actually respond to the diets I'm doing."
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Safety Netting / Follow-up
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If the Doctor sets a plan to prescribe the COCP, arrange an ultrasound, and review in a month:
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Reaction: "Okay. I feel a lot better knowing I'm not totally barren. I'll start the pill to protect my womb, and we can talk about the weight management referral next time."
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Diagnosing PCOS — Rotterdam Criteria
A diagnosis of PCOS requires two out of three Rotterdam criteria, after excluding other causes of hyperandrogenism and oligo-ovulation:
- ●Oligo-ovulation or anovulation — fewer than 8 periods per year, or cycles shorter than 21 or longer than 35 days.
- ●Clinical or biochemical hyperandrogenism — hirsutism, cystic acne, scalp hair thinning, or raised serum testosterone (with low SHBG and raised LH:FSH ratio, as seen here).
- ●Polycystic ovarian morphology on ultrasound — ≥20 follicles in at least one ovary (updated ESHRE 2023 threshold), or increased ovarian volume >10 mL.
Sophie already meets criterion 1 (3–4 periods per year) and criterion 2 (biochemical hyperandrogenism plus clinical hirsutism). The pelvic ultrasound should still be arranged to complete the diagnostic picture, but the diagnosis is clinically supportable without it. Do not delay management pending the ultrasound.
Differential Diagnosis — What Else Must Be Excluded
Before accepting PCOS as the working diagnosis, briefly screen for other causes of raised testosterone and oligo-ovulation:
- ●Hyperprolactinaemia / prolactinoma — ask about galactorrhoea, headaches, and visual field disturbance. Serum prolactin should be checked if these are present.
- ●Thyroid dysfunction — TSH is normal here (2.1 mU/L), effectively excluding this.
- ●Congenital adrenal hyperplasia (CAH) — consider if virilisation is severe or onset was rapid; 17-hydroxyprogesterone level can be measured if suspected.
- ●Androgen-secreting tumour — rare but important to consider if testosterone is markedly elevated (typically >5 nmol/L), symptoms developed rapidly, or virilisation is pronounced (voice deepening, significant clitoromegaly). Absent in this case.
- ●Cushing's syndrome — consider if there are additional features (central obesity with striae, proximal myopathy, easy bruising, hypertension).
In Sophie's case, the clinical picture — gradual onset, the triad of oligo-ovulation, biochemical hyperandrogenism, and BMI 34 — is highly consistent with PCOS. The negative screens above appropriately de-prioritise rarer differentials.
Insulin Resistance — Why Weight Loss Is Harder
Up to 70% of women with PCOS have peripheral insulin resistance, irrespective of BMI.
- ●Compensatory hyperinsulinaemia directly stimulates ovarian theca cells to produce excess androgens and suppresses hepatic SHBG synthesis, increasing free (active) testosterone.
- ●This mechanism makes weight gain easier and weight loss substantially harder than in women without PCOS — not a failure of effort or willpower.
- ●Sophie's HbA1c of 40 mmol/mol (upper end of normal), BMI of 34, and maternal type 2 diabetes combine to place her at meaningful cardiometabolic risk. This is the physiological context for her weight struggle and must be explained clearly.
Investigations
- ●Pelvic ultrasound — arrange to complete Rotterdam workup and assess for polycystic ovarian morphology. Reassure the patient this is routine.
- ●Fasting lipid profile — PCOS is independently associated with dyslipidaemia (raised triglycerides, low HDL). Check at diagnosis.
- ●Repeat HbA1c in 12 months — Sophie's borderline result (40 mmol/mol) in the context of PCOS, BMI 34, and maternal T2DM warrants annual monitoring for progression to impaired fasting glucose or type 2 diabetes.
- ●Blood pressure — measure at baseline and monitor annually given cardiometabolic risk profile.
- ●Note: serum prolactin and 17-hydroxyprogesterone are only indicated if the clinical picture raises suspicion of hyperprolactinaemia or CAH respectively — not routinely required when the diagnosis is straightforward.
Endometrial Protection
Women with PCOS who have fewer than four periods per year are at significantly increased risk of endometrial hyperplasia and endometrial carcinoma due to chronic unopposed oestrogen stimulation of an anovulatory endometrium.
A withdrawal bleed must be induced at least every 3–4 months. Options:
- ●Combined oral contraceptive pill (COCP) — first-line where the patient also wants symptom management (hirsutism, acne, cycle regulation). Preferred option for Sophie.
- ●Cyclical progestogen — e.g., medroxyprogesterone acetate 10 mg daily for 14 days every 3 months, or norethisterone 5 mg daily for 10–14 days. Use if the COCP is contraindicated or declined.
- ●Levonorgestrel intrauterine system (LNG-IUS / Mirena) — provides continuous endometrial protection; suitable if contraception is the primary aim and systemic effects of COCP are undesirable.
Managing Hyperandrogenism — Hirsutism and Acne
- ●First-line: The COCP suppresses ovarian androgen production and increases SHBG, reducing free testosterone. Pills containing anti-androgenic progestogens (e.g., co-cyprindiol / Dianette, or drospirenone-containing preparations such as Yasmin) provide the greatest benefit for hirsutism and acne.
- ●Co-cyprindiol carries a higher VTE risk than standard COCPs and is licensed specifically for severe acne and hirsutism refractory to other treatments; use of a standard COCP or drospirenone-containing pill is often preferred as first-line, particularly in patients with a BMI of 34 where VTE risk is already elevated.
- ●Hair growth cycles are long: set realistic expectations — at least 6 months of treatment before significant reduction in hirsutism is seen.
- ●Adjuncts: Topical eflornithine cream (Vaniqa) reduces facial hair growth and can be used alongside the COCP. Physical methods (laser hair removal, electrolysis) are effective but not NHS-funded for PCOS hirsutism. For acne: topical retinoids, benzoyl peroxide, or referral to dermatology if severe.
Weight Management
- ●Generic lifestyle advice alone ('eat less, move more') is insufficient and inappropriate for a patient with PCOS-related insulin resistance. It risks reinforcing weight stigma.
- ●5–10% body weight loss can restore spontaneous ovulation in many women with PCOS and improves all metabolic parameters.
- ●Dietary approach: reduced refined carbohydrate and glycaemic load diet is more effective than calorie restriction alone in PCOS, as it directly targets hyperinsulinaemia. Strength training improves insulin sensitivity beyond aerobic exercise.
- ●Structured support: refer to a Tier 2 or Tier 3 weight management service — do not rely on self-directed effort alone.
- ●GLP-1 receptor agonists (e.g., semaglutide / Wegovy): indicated where BMI ≥30 with a comorbidity (PCOS qualifies). Particularly beneficial in PCOS due to direct insulin-sensitising effects. Subject to local commissioning arrangements and specialist initiation via Tier 3 in most areas.
- ●Metformin: consider as an adjunct in PCOS with insulin resistance and metabolic risk — especially where HbA1c is borderline, BMI is elevated, and there is a family history of type 2 diabetes (all three apply to Sophie). Improves cycle regularity, supports modest weight reduction, and may reduce long-term diabetes risk. Not first-line for hirsutism. Prescribe off-label in PCOS; discuss with patient.
Fertility in PCOS — Correcting the Myth
PCOS does not cause permanent infertility. This is a pervasive and harmful misconception that must be addressed explicitly and empathetically.
- ●PCOS causes unpredictable ovulation, not absent ovulation for life. Many women with PCOS conceive spontaneously, particularly after weight optimisation.
- ●When Sophie is ready to conceive, if spontaneous ovulation does not occur, ovulation induction is highly effective:
- ●Letrozole (aromatase inhibitor) — first-line per NICE NG156 (2023). Higher live birth rates than clomifene with lower risk of multiple pregnancy.
- ●Clomifene citrate — second-line alternative.
- ●Gonadotrophin injections — used in specialist fertility settings if oral agents fail.
- ●IVF — reserved for cases where ovulation induction fails or there are additional fertility factors.
- ●Optimising BMI before conception substantially improves ovulation induction success rates, reduces miscarriage risk, and improves pregnancy outcomes. This is a strong, guideline-supported reason to address weight now.
Pre-conception Advice
Begin this conversation proactively — Sophie is getting married next year and wants to conceive soon after:
- ●Folic acid: Start 5 mg daily (not the standard 400 mcg) where BMI ≥30, per NICE guidance on neural tube defect prevention. Ideally begin at least one month before stopping contraception.
- ●Stop the COCP when ready to conceive. Ovulation typically returns within 1–3 months of stopping, though it may take longer in PCOS.
- ●Optimise weight before conception — even modest loss (5–10%) meaningfully improves outcomes.
- ●HbA1c and metabolic review — given Sophie's borderline HbA1c and cardiometabolic risk, a pre-conception metabolic check is appropriate when the time comes.
Referral Criteria
Refer to gynaecology or reproductive medicine if:
- ●Ovulation induction is required (fertility referral when ready to conceive and weight has been optimised).
- ●Diagnostic uncertainty persists after initial workup, or testosterone is markedly elevated raising concern for an androgen-secreting tumour.
- ●Symptoms of hyperandrogenism are severe and not responding to first-line COCP treatment.
Refer to endocrinology if:
- ●CAH, Cushing's syndrome, or adrenal pathology is suspected.
Refer to dermatology if:
- ●Acne is severe and unresponsive to primary care treatment.
Cardiometabolic Monitoring
PCOS is a long-term condition with significant cardiometabolic implications. Establish a monitoring plan at diagnosis:
- ●HbA1c annually — given borderline result and risk factors.
- ●Fasting lipid profile at baseline and periodically thereafter.
- ●Blood pressure annually.
- ●BMI and waist circumference at each review.
- ●Advise Sophie that reducing insulin resistance through weight management, dietary change, and physical activity is her most powerful long-term tool for reducing cardiovascular and diabetes risk.
Mental Health and Psychological Impact
PCOS is associated with significantly elevated rates of depression, anxiety, and disordered eating. The daily burden of hirsutism, weight gain, and fertility uncertainty compounds this.
- ●Screen proactively using PHQ-2 (or equivalent) — do not assume distress is purely reactive to today's consultation.
- ●Acknowledge the emotional weight of the diagnosis explicitly. Sophie's daily 5:45 a.m. plucking routine, social withdrawal, and evening crying represent a significant functional burden.
- ●Offer: acknowledgement and validation; self-referral to NHS Talking Therapies / IAPT; a safety-net follow-up for mental health specifically if symptoms are severe.
- ●Treating the underlying PCOS effectively (hirsutism, weight, cycle regulation) often improves mood significantly — this is worth communicating as a source of hope.
Safety Netting and Follow-up
- ●Review in 4–6 weeks to assess COCP tolerability, discuss pelvic ultrasound results, and revisit the weight management referral.
- ●Before starting the COCP in a patient with BMI 34, discuss VTE risk and advise her to seek urgent medical attention if she develops unilateral leg swelling, calf pain, or breathlessness.
- ●Advise her to return sooner if she experiences breakthrough bleeding (may indicate non-compliance or need to switch formulation), worsening mood, or any new symptoms.
- ●Confirm she understands when and how to stop the COCP when she is ready to conceive, and that this does not require a specialist appointment.
Common Candidate Mistakes in This Case
- ●Omitting the differential diagnosis screen. Failing to briefly exclude prolactinoma, CAH, and androgen-secreting tumour is a clear negative indicator — even if the clinical picture strongly suggests PCOS.
- ●Prescribing the COCP without addressing the fertility concern. Sophie will not engage with the prescription until she understands it will not permanently prevent her from having children. Failing to address this directly leaves her most important worry unresolved.
- ●Offering generic weight loss advice. Telling a patient with PCOS-related insulin resistance to 'eat less and move more' fails the consultation and triggers shutdown. The physiological barrier must be acknowledged before any management is discussed.
- ●Missing endometrial protection. With fewer than four periods per year, endometrial protection is not optional — omitting it is a patient safety failure.
- ●Using the wrong folic acid dose. Sophie's BMI of 34 requires 5 mg daily pre-conceptually, not the standard 400 mcg.
- ●Waiting for the ultrasound before making a diagnosis. The Rotterdam criteria are met biochemically and clinically. Withholding diagnosis and management pending the ultrasound unnecessarily delays treatment and leaves Sophie without explanation or reassurance.
Mapped to the RCGP curriculum topic: Metabolic Problems and Endocrinology.
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