Cases/Gynaecology and Breast

Woman Still Bleeding Four Months After Her Hormonal Coil Was Fitted — Free SCA Practice Case

Woman still bleeding four months after her hormonal coil was fitted

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

Try 5 free cases

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

Patient Profile

Full Name

Tanvi Shah

Age

38 years

Consultation Type

Video

Age

Situation

Video Consultation. Routine appointment booked by the patient.

Reason for Encounter

"Coil fitted 4 months ago for heavy periods. Bleeding on and off most days since. Would like it removed."

Medical Records

●PMH: Heavy menstrual bleeding. One vaginal delivery, 11 years ago.
●Medications: Levonorgestrel 52 mg intrauterine system, inserted 4 months ago, threads trimmed to 3 cm. Tranexamic acid last year, stopped.
●Allergies: NKDA.
●Social: Police community support officer. Non smoker.

Recent Notes

●5 months ago: BP 118/74, BMI 24.6. Hb 124 g/L, ferritin 41. Chlamydia and gonorrhoea swab negative. Cervical screening October 2024, HPV not detected.

Patient Script

For the friend playing the patient role

Character Overview: You are Tanvi Shah, a 38 year old police community support officer. Most shifts are eight to ten hours on foot patrol around the town centre, in uniform and a stab vest, with few toilets. You separated from your husband two years ago and live with your daughter Anya, 11, whose dad has her every other weekend. About three months ago you started seeing Kieran, a joiner, and it is going well. You fly to Tenerife together a week on Saturday for your first holiday.

Your periods have been heavy since Anya was born eleven years ago, and they got worse through your thirties. Tranexamic acid tablets only took the edge off, so four months ago a GP at the practice fitted a hormonal coil. Since the first fortnight you have had spotting or light bleeding on most days. You booked this call to ask for the coil to come out this week. You are practical, a bit blunt and fed up, but not rude. Your voice goes quieter and a little embarrassed when sex or Kieran comes up.

Opening Sentence: "Hi, thanks for calling. I had the hormonal coil put in four months ago for my heavy periods, and I've been bleeding on and off nearly every day since. I've given it a fair go and I've had enough. I'd like it out, this week if possible."

History if Asked (Data Gathering Phase)

●The bleeding now: "It's mostly spotting. Brownish, sometimes pinky red. I wear a liner every day and change it two or three times on a shift. A couple of days a month it's a bit more, like the start of a light period, and I'll use a pad. No clots, and I've never soaked through. It's the fact it never stops that gets me."
●Her periods before the coil (if asked): "Every four weeks, about a week long, and the first four days were awful. They've been heavy ever since Anya was born and got worse through my thirties. Clots, a tampon and a pad together, up in the night to change. So this is less blood, I'll give it that. It's just there all the time."
●How it has changed since the fitting: "A proper period with cramps for the first couple of weeks. Since then it's been the spotting, maybe a bit less than the first month. I haven't had a clean week since it went in."
●What she was told at the fitting (if asked): "It might be all over the place for a few months. I thought she meant a few weeks."
●The threads (if asked whether she has checked them): "I tried once, a couple of weeks ago. I couldn't find anything, but I don't really know what I'm feeling for."
●Pain: "Cramps for the first fortnight. Now just the odd twinge low down."

Ideas, Concerns, Expectations

Gating note: Tanvi does not raise any of the following herself. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, or what she was hoping for.

●Ideas: She thinks her body simply does not get on with the coil, and that once it is out the bleeding will stop. "I reckon my body just doesn't like it. Like it's fighting it. Take it out and it'll stop, won't it?"
●Concerns: Her main worry is Kieran and the holiday. "I've only been seeing someone for three months. It's early days, and I'm bleeding all the time. I've been making excuses, to be honest. We're going away a week on Saturday, our first holiday together, and I don't want to spend it worrying about that." If asked what she made of not finding the threads, or whether anything else is worrying her, a quieter worry comes out: "When I couldn't feel the threads I did wonder if it had moved. A woman I work with had one go through her womb, and she had to have an operation to get it out. That's been in the back of my mind."
●Expectations: She expected to have it taken out this week. "I just assumed I could book in and have it out before we go. It's a two minute job, isn't it?"

If Asked: Medical History and Medications

Gating note: Tanvi answers each plainly when asked.

●General health and medicines: "I'm fit and well, just the periods. Nothing regular, paracetamol now and then. I had the tranexamic acid last year but it only took the edge off, so I stopped it. No allergies."
●Pregnancies and plans: "Just Anya, a normal delivery, eleven years ago. I'm not starting again, which is partly why the coil appealed." If asked whether she could be pregnant: "I wouldn't have thought so, not with the coil. I haven't done a test."
●Cervical screening and swab: "A smear about two years ago, no HPV. The swab before the coil was clear."
●Contraception before: "The combined pill in my twenties. It suited me, I just forgot it."
●Risk factors for the pill (if asked): Never smoked. No migraines, just the odd headache after a long shift. No blood clots, in herself or her family. No bruising or bleeding problems. Mum has diabetes."
●Sexual partners: Her voice drops a little. "Just Kieran, about three months. Before that there was nobody for a long time, not since I split from my husband."
●Condoms and last sex: "We did at first. Then I told him I had the coil, so we stopped. I didn't think we needed them. Not for about ten days now, because I keep putting him off with the bleeding."
●Whether Kieran has been checked: "I don't know. I've never asked him. He's not like that, though."

Social History and Lifestyle Impact

●Work and impact: "I'm on my feet all day in the uniform and the vest. Finding a loo means asking in a café or walking back to the station. I keep spare liners in my vest pocket. I can't remember the last day I didn't have to think about it. I've stopped going to boxercise."
●Home and mood: Kieran stays over some weekends when Anya is at her dad's. "Fed up with it. I'm not down, just fed up." A cider if they go out.

If Asked: Associated Symptoms

Gating note: Answers are brief and natural. The following are all negative: fever or feeling unwell, vaginal discharge, smell or itching, pain during sex, pain low on one side, shoulder tip pain, feeling faint, dizziness, breathlessness, feeling something hard or the coil coming out ("Kieran's never said he can feel anything either"), changes in passing water or bowels, weight change. She has more energy than when the periods were heavy.

●If asked about bleeding after sex: "Now you mention it, a couple of times there's been a bit more the next morning. I put it down to the coil." If asked whether it happened before the coil: "No, never. It's only been since the coil went in."

Responses to Management (The Negotiation Phase)

●
If the doctor explains that bleeding is common in the first months and usually settles, or recommends giving it six months:
- ●Reaction: Sceptical. "Everyone says it settles. When, though? I've done four months." If told that the heavy periods have already gone: "I suppose they have." If six months is suggested with no mention of the holiday: "We fly a week on Saturday. What am I meant to do in the meantime?"
●
If the doctor asks to see her in person for an examination and tests, or asks her to feel for the threads on camera:
- ●Reaction: Declines to examine herself on a video call. "I'm not doing that on video, sorry. Can someone just have a look in person? Can't they take it out at the same appointment, if I still want it out?" Relieved once it is arranged: "Good. At least someone will check it's where it should be. I'm off on Thursday and Friday."
●
If the doctor explains why a new partner matters, suggests an infection swab or pregnancy test, or advises condoms:
- ●Reaction: Defensive at first. "You're not saying Kieran's given me something? He's not like that." Once told that infection often causes no symptoms and testing is routine with a new partner: "Fair enough. I'd rather know. Does he need testing as well? How do I bring that up with him?" Pregnancy test: "With the coil? Fine, I'd be amazed." Condoms: "Even with the coil in?" She accepts once she understands why.
●
If the doctor offers the combined pill alongside the coil, or tablets for the heavier days:
- ●Reaction: Interested but surprised. "The pill as well as the coil? Is that allowed? Would it work in time for the holiday?" For tablets: "The tranexamic didn't do much last time. Is this different?"
●
If the doctor agrees to take it out, or explains the week before removal and what she would use afterwards:
- ●Reaction: Relieved, then practical. "So can it be before we go?" If told her heavy periods are likely to return: "Oh. So I could end up with a proper heavy one while we're away? I hadn't thought of that." She may decide to keep it for now, or still want it out with a plan for her periods. On avoiding sex or using condoms for a week before: "We haven't for ten days anyway, so condoms until then is fine?" On contraception afterwards: "I hadn't got that far. Condoms, or the pill again, if I can remember it."
●
If the doctor gives vague safety netting, explains what happens if the bleeding carries on, or responds to her worry that the coil has moved:
- ●Reaction: Vague safety netting: "Worse how? Which things would mean dropping everything and getting seen, especially when I'm away?" If bleeding carries on: "What if it's still like this after six months?" She settles when she hears a clear next step, such as a scan or a specialist opinion. On the coil moving: "So it's not likely? What would I notice if it had?" She settles with an honest answer and the plan to check it in person.

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 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Tanvi, 38, has had spotting on most days for four months since a 52 mg levonorgestrel intrauterine system (LNG IUS) was fitted for heavy periods, and wants it out this week. The skill is to see that a new partner, bleeding after sex and threads she cannot feel need an in person check, and to help her choose between keeping the coil and removal with the facts.
●Model answer: acknowledge the request and the holiday; explain the usual time course; arrange a face to face appointment within about a week for a speculum examination, a vulvovaginal swab and a pregnancy test; advise condoms until the coil is confirmed in place; offer a plan if she keeps it and a safe removal plan if she does not, including what her periods will do; review and a specific safety net.
●Acceptable alternatives: the same assessment through a sexual health clinic; removal at the same appointment once the threads are seen; keeping the coil with a planned review, a combined pill trial, or both.

What Bleeding to Expect After an LNG IUS for Heavy Periods

●Most of the fall in blood loss happens in the first 3 months, and in one cohort 92% no longer reported heavy bleeding at 6 months (College of Sexual and Reproductive Healthcare, CoSRH).
●Irregular bleeding and spotting are the commonest early effects. Bleeding or spotting days fall from about 36 in the first 90 days to about 19 in the second and about 12 in the last 90 days of the first year, and by a year about 80% report much lighter bleeding.
●NICE NG88 (Heavy menstrual bleeding) says to explain that bleeding changes are expected, particularly in the first few cycles and possibly beyond 6 months, and that it is advisable to wait at least 6 cycles to see the benefit.
●Tanvi's heavy bleeding has already gone. At 4 months her spotting is within the expected range, but other features mean it needs checking.

When Bleeding on a Coil Needs an Examination

●NICE Clinical Knowledge Summaries (CKS) and CoSRH support a speculum examination for persistent bleeding beyond the first 3 to 6 months of an LNG IUS, a new symptom, bleeding after sex, pain, cervical screening that is not up to date, or when the woman asks.
●Tanvi has four triggers: more than 3 months of bleeding, a new partner since the fitting, bleeding after sex and threads she could not find. None can be assessed on video, so she needs to be seen in person within about a week. It is not an emergency, but she flies a week on Saturday.

Excluding Infection and Pregnancy

●A woman with problematic bleeding at risk of a sexually transmitted infection (a new partner, under 25, or more than one partner in a year) should be tested for chlamydia as a minimum. One vulvovaginal swab, which can be self taken, tests for chlamydia and gonorrhoea. About 70% of women with chlamydia have no symptoms. A full new partner screen adds HIV and syphilis blood tests.
●CKS advises a pregnancy test for unscheduled bleeding on an LNG IUS. Pregnancy with a coil in place is very rare, but more likely to be ectopic, so a positive test needs the early pregnancy pathway.
●If chlamydia is found: doxycycline 100 mg twice daily for 7 days (CKS), the partner treated too, and no sex until both have completed treatment (7 days after azithromycin, the second line choice). Doxycycline causes sensitivity to sunlight, which matters before a holiday. The coil can usually stay in (UKMEC 2025, category 2).

Threads, Expulsion, Malposition and Perforation

●Many women cannot feel their threads, but until the coil is shown to be in place its effectiveness cannot be guaranteed (CKS). Exclude pregnancy and examine. If the threads are not seen, arrange an ultrasound to locate the device, advise condoms or no sex meanwhile, and consider emergency contraception after recent unprotected sex.
●A correctly placed coil is left alone. A device outside the uterus needs gynaecology referral for laparoscopic removal. A coil found displaced or missing prompts emergency contraception to be considered and a pregnancy test 3 weeks after the last unprotected sex (CoSRH).
●Expulsion affects about 1 in 20 users, most often in the first year. A low lying device may cause prolonged bleeding and is usually removed and replaced.
●Perforation is rare, about 1 to 2 in 1000 insertions. Lost threads, pain or a change in bleeding can point to it, and visible threads do not fully exclude it. Serious harm is uncommon.

Treating the Spotting if She Keeps the Coil

●Bleeding often settles without treatment, so reassurance with a planned review is a legitimate plan.
●CoSRH suggests a 3 month trial of a combined oral contraceptive pill for medically eligible women with problematic bleeding on intrauterine contraception. It can be taken in the usual way or continuously without a pill free interval, which is off label. Bleeding may return when the pill stops.
●Eligibility is checked against UKMEC 2025: migraine with aura is category 4; a first degree relative with venous thromboembolism is category 3. Tanvi is a non smoker without migraine, with no personal or family history of clots, BP 118/74 and BMI 24.6, so she is eligible.

If She Chooses Removal, and Her Heavy Periods Afterwards

●Removal is her decision. The clinician makes sure she decides with the facts: that spotting usually settles, and that removal is likely to bring back the heavy periods the coil treated.
●CoSRH: if pregnancy is not wanted, avoid unprotected sex for 7 days before removal. If there has been unprotected sex in that week, ideally defer removal; otherwise consider emergency contraception and a pregnancy test 21 days after the last unprotected sex.
●Plan contraception first. A combined pill can be started at any time when switching from an LNG IUS if pregnancy is reasonably excluded, with condoms for 7 days; starting it at least 7 days before removal avoids the gap (CKS). Fertility returns quickly.
●Removal needs the threads to be seen. If they cannot be, the coil is located by ultrasound first, so the in person appointment is where removal is carried out, not a promise made by video.
●NG88 options if the coil is declined or removed: tranexamic acid (1 g three times a day for up to 4 days from the start of bleeding, maximum 4 g a day) or an NSAID such as mefenamic acid 500 mg three times a day; combined hormonal contraception; cyclical oral progestogens (not contraceptive); or a progestogen only method. Tranexamic acid only partly helped her, so the combined pill is the obvious alternative if eligible. Referral follows if treatment fails.

The Cervix, Follow Up and Safety Netting

●Cervical screening is not a diagnostic test. If it is up to date, a new screen is not needed for bleeding; looking at the cervix is what matters. Tanvi tested HPV negative in October 2024, and from July 2025 the recall after a negative test at 25 to 49 is 5 years, so she is not due under either interval.
●If the cervix looks suspicious of cancer, NICE NG12 advises a suspected cancer pathway referral. It triggers on the appearance of the cervix, not on bleeding after sex alone, which is why the speculum examination is the step that matters.
●Review around 6 months after the fitting, at the end of a pill trial, or after removal. If bleeding persists beyond 6 months, despite treatment, or with new symptoms: pelvic ultrasound and gynaecology referral, for example for hysteroscopy.
●Same day assessment: lower abdominal pain with fever or offensive discharge; one sided pelvic pain, shoulder tip pain, fainting or a positive pregnancy test (999 if she collapses). Prompt review, with condoms meanwhile, if she feels the hard part of the coil. The same applies in Tenerife.

Common Mistakes in This Station

●Removing the coil on request without explaining that heavy periods are likely to return, or without a plan for the week before and contraception after.
●Refusing removal, or insisting she must wait 6 months, rather than letting her decide with the facts.
●Putting the spotting down to the coil on video without an examination, an infection swab and a pregnancy test, despite a new partner, bleeding after sex and unfelt threads.
●Repeating cervical screening that is not due, instead of looking at the cervix.
●Not taking a sexual history, or asking about Kieran in a way that sounds like an accusation.
●Telling her the coil protects her when its position is unknown.
●Starting the combined pill without checking eligibility, or presenting tranexamic acid or an NSAID as a cure for daily spotting.
●Giving no review date and no next step, and safety netting with "come back if it gets worse".

Mapped to the RCGP curriculum topic: Gynaecology and Breast.

← Back to Free SCA Practice Cases