Cases/Gynaecology and Breast

Young Woman Wishing to Discuss Borderline Cervical Smear Result — Free SCA Practice Case

Young woman wishing to discuss borderline cervical smear result

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

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Sophie Miller

Age

26 years

Consultation Type

Video

Age

26 (DOB: 12/04/1999)

Situation

Telephone or Video Consultation.

Reason for Encounter

"Patient received her first cervical screening (smear) letter today. She is highly anxious about the results and wants a doctor to explain it."

Medical Records

●PMH: Nil significant.
●Medications: Microgynon 30 (Combined Oral Contraceptive Pill).
●Allergies: NKDA.

Recent Notes

●2 Weeks Ago: Routine first cervical screening test performed by the practice nurse.
●Lab Result (Received today): HPV Primary Screening: High-Risk HPV (HR-HPV) POSITIVE. Cytology: Borderline squamous changes.
●Action taken by lab: Direct referral made to routine Colposcopy (appointment letter to follow in the post).

Patient Script

For the friend playing the patient role

Character Overview: You are Sophie. You are tearful, panicked, and angry. You opened the NHS letter this morning and saw the words "Abnormal", "HPV Positive", and "Colposcopy Clinic". You have spent the last two hours Googling these terms. You are convinced you have cervical cancer. You are also furious because you think HPV is a sexually transmitted infection, and since you have been in a monogamous relationship with your boyfriend for 3 years, you assume he has been cheating on you.

Opening Sentence: "Hi Doctor. I got my smear letter this morning and I haven't stopped crying. It says my cells are borderline abnormal and I have an STI called HPV. They are sending me to a hospital clinic. Do I have cancer? And how did I get an STI? I've been with Mark for three years!"

History if Asked (Data Gathering Phase)

●
Current Symptoms (Red Flag Screen):
- ●"No, I don't have any bleeding between my periods."
- ●"No bleeding after sex."
- ●"No pain during sex or strange discharge."
- ●(These negative answers are crucial for the doctor to confidently reassure her that cancer is highly unlikely).
●
The Boyfriend / HPV Timeline:
- ●"Mark is the only person I've slept with for the last three years. Before him, I had a couple of boyfriends at university. But I was tested for Chlamydia and Gonorrhoea at a clinic two years ago and I was all clear! So Mark must have given this to me recently, right?"
●
The Letter:
- ●"The letter mentions a 'Colposcopy'. Google says they cut a piece of your cervix out. Will that mean I can't have babies?"

ICE — Ideas, Concerns, Expectations

(Actor guidance: Sophie does not volunteer these unprompted. These surface only when the candidate directly explores her perspective.)

●
Ideas: Sophie believes the HPV result means she has an STI that her boyfriend must have given her recently. She has Googled "borderline abnormal cells" and is now convinced this means early-stage cervical cancer. She does not understand that HPV can be dormant for years or that borderline changes are not cancer.
●
Concerns: Her two dominant fears are tightly linked — first, that she has cervical cancer and may die or lose her fertility; second, that Mark has been unfaithful. Beneath the anger is deep hurt and a fear that her relationship is over. She is also frightened about the colposcopy procedure itself — Google has shown her images of biopsies and she is dreading pain.
●
Expectations: She wants a doctor who will be straight with her — tell her clearly whether she has cancer, explain what the colposcopy actually involves in plain language, and help her understand how she got HPV so she knows whether she can trust Mark. She wants to leave the consultation feeling less frightened and with a plan she can understand.

If Asked — Medical History and Medications

(Actor guidance: Sophie confirms the following only if directly asked by the candidate. She does not raise these unprompted.)

●
Microgynon 30 (Combined Oral Contraceptive Pill): "Yes, I'm on the pill — Microgynon. I've been on it since I was about 19. I take it every day and I've never really had any problems with it. My periods are regular and light."
●
Past Medical History: "No, I've never really had anything. I've always been healthy — I've never been in hospital or had any operations or anything like that."
●
Allergies: "No, no allergies to anything."
●
Previous Cervical Screening: "This was my first one. I got the invite when I turned 25 but I put it off for a few months because I was nervous. I wish I hadn't bothered now — I didn't feel like this before I had it done."
●
Previous STI Testing: "I went to a sexual health clinic about two years ago — they tested me for Chlamydia and Gonorrhoea and both came back clear. I didn't know HPV was a thing they could test for separately."

Social History and Lifestyle Impact

(Actor guidance: Sophie shares this naturally in conversation when the candidate asks about her life or how she's coping. It should not be delivered as a monologue.)

●
Occupation / daily life context: Sophie works as a primary school teaching assistant. She lives with her boyfriend Mark in a rented flat. They have been together for three years and have recently been talking about getting engaged.
●
Lifestyle impact of the condition: "I couldn't go into work today — I just sat in the car park crying and then drove home. I haven't told Mark yet because I'm so angry with him. I can't even look at him right now. I was supposed to be going to my friend's birthday dinner tonight but there's no way I can face people — I feel dirty, like there's something wrong with me. I haven't eaten anything all day. I just keep going back to Google and every time I read something it makes me feel worse."

If Asked — Associated Symptoms

(Actor guidance: Sophie answers these only if directly asked by the candidate. Keep answers brief and natural.)

●
If asked about any lumps or swellings in the groin or elsewhere: "No, nothing like that."
●
If asked about unexplained weight loss: "No, my weight's been normal — no changes."
●
If asked about fatigue or feeling generally unwell: "I mean I'm exhausted today but that's because I've been crying all morning. Before this letter, I felt completely fine."
●
If asked about lower abdominal or pelvic pain: "No, no pain down there at all."
●
If asked about changes in bowel habit: "No, everything's been normal."
●
If asked about urinary symptoms: "No, nothing like that — no burning or anything."
●
If asked about any skin changes, rashes, or warts: "No, I haven't noticed anything like that."
●
If asked about heavy or irregular periods: "No, my periods have been really regular on the pill — light and predictable."
●
If asked about smoking: "No, I've never smoked."
●
If asked about alcohol: "Just socially — maybe a couple of glasses of wine at the weekend, nothing heavy."
●
If asked about family history of cervical cancer or gynaecological cancers: "No, not that I know of. My mum and my nan are both fine."
●
If asked about previous HPV vaccination: "I think I had the jab at school — the one they give you in Year 8? I can't really remember, but I'm pretty sure I did. I thought that was supposed to stop all this."

Responses to Management (The Negotiation Phase)

●
If the Doctor explains that HPV can lie dormant for years:
- ●Reaction: Huge sigh of relief. "Wait, really? So it can hide in your body? So Mark might not have cheated? Oh my god, that makes me feel so much better. I was going to pack my bags tonight."
●
If the Doctor says 'Borderline means early cancer':
- ●Reaction: Hysterical. "I knew it! Am I going to die? I'm only 26!" (Note: This is a clinical failure. Borderline means mild dyskaryosis/cellular changes, NOT cancer).
●
If the Doctor explains Colposcopy simply (magnifying glass and a dye):
- ●Reaction: Calming down. "Okay, so it's just a closer look. Does it hurt? Will they definitely take a biopsy?"
●
If the Doctor focuses purely on the medical science and ignores her relationship fears:
- ●Reaction: Frustrated. "Yes, fine, cells and viruses, but what about my boyfriend? How do I explain this to him?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 2: Clinical Management and Medical Complexity

0 / 28 indicators checked+0−0

Positive (0/14)

Negative (0/14)

Domain 3: Relating to Others

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Clinical Learning Points

Primary HPV Screening — The Current UK Pathway

●Since 2019, the UK uses HPV Primary Screening for all cervical samples.
●The lab first tests for High-Risk Human Papillomavirus (HR-HPV). If HPV negative, the patient returns to routine recall (every 3 or 5 years) with no cytology performed — her cancer risk over the next 5 years is statistically negligible.
●If HPV positive, the same sample is examined for cytology (cellular changes/dyskaryosis).
●Sophie is HPV positive with borderline squamous changes (low-grade dyskaryosis) — the screening system has worked exactly as designed by detecting a minor change early.

Understanding Borderline Changes — Not Cancer

●Borderline (also called borderline nuclear abnormality) means very minor changes to the surface cells of the cervix caused by HPV irritation. It is not cancer, and it is not pre-cancer.
●Any patient who is HPV positive with any grade of cytological change — borderline, mild, moderate, or severe — is referred directly to colposcopy.
●Timeline: Borderline/mild changes require routine colposcopy (typically within 6 weeks). Moderate/severe changes require urgent colposcopy (within 2 weeks, 2-week wait pathway).
●The most likely outcome for borderline changes in a young woman is that the immune system clears HPV and the cells return to normal — treatment is not inevitable.

HPV — Prevalence, Latency, and Transmission

●Prevalence: Approximately 80% of sexually active adults will acquire HPV at some point in their lives. It is transmitted via skin-to-skin genital contact, not solely penetrative intercourse — condoms reduce but do not eliminate transmission risk.
●Latency (clinically critical): HPV can remain dormant in the basal epithelial cells for months, years, or even decades before becoming detectable. A positive result now does not indicate recent acquisition or infidelity.
●Clearance: In most immunocompetent young women, the immune system clears the virus within 12–24 months without any treatment.
●HPV should be framed as an extremely common virus — not as a traditional STI with the associated stigma — when communicating with patients.

HPV Vaccination — What It Does and Does Not Cover

●The NHS school vaccination programme (currently Gardasil 9) protects against the most clinically significant high-risk strains, including HPV 16 and 18 (responsible for approximately 70% of cervical cancers), as well as low-risk strains 6 and 11 (genital warts).
●The vaccine does not cover all high-risk HPV strains. A vaccinated woman can still acquire other oncogenic strains — which is why cervical screening remains essential even in vaccinated individuals.
●Reinforce that vaccination has still provided significant protection and that screening is the complementary second line of defence.

Risk Factors for HPV Persistence and Progression

●
Most HPV infections clear spontaneously. Established risk factors for persistence and progression to higher-grade CIN or cervical cancer include:
- ●Smoking: A significant and modifiable risk factor. Smoking impairs local cervical immune surveillance, increasing the risk of HPV persistence and progression. Smoking cessation should be discussed and supported.
- ●Immunosuppression: HIV infection, long-term corticosteroids, or other immunocompromising conditions.
- ●Long-term combined oral contraceptive pill use: Long-term use (>5 years) in HPV-positive women is associated with a small increased risk of cervical abnormalities. Do not advise stopping the pill on this basis alone — benefits of reliable contraception and regular screening outweigh the risk.
- ●Multiple sexual partners / early sexual debut: Increases cumulative HPV exposure.
●Sophie is a non-smoker, which is a positive prognostic factor worth reinforcing.

Explaining Colposcopy — What the Patient Needs to Know

●Keep the explanation simple and de-medicalised: a colposcopy is a closer look at the cervix using a magnifying instrument on a stand, taking around 15–20 minutes, similar to a smear test. A dilute vinegar solution is applied to highlight any areas of change.
●Biopsy: A small punch biopsy may be taken if the colposcopist sees an area to examine further — but this is not guaranteed, and many colposcopies do not require one. If taken, it may cause brief discomfort but is not generally severely painful.
●Fertility: Colposcopy and punch biopsy have no impact on fertility. Even if treatment were required in future (e.g. LLETZ), the vast majority of women go on to have normal pregnancies.

Post-Colposcopy Pathways

●
Following colposcopy for borderline/low-grade changes, several outcomes are possible:
- ●No biopsy needed: return to test of cure smear at 12 months.
- ●Biopsy taken: results typically within 4–6 weeks; colposcopy clinic advises on next steps.
- ●CIN 1 confirmed: usually managed conservatively with surveillance, as the majority regress spontaneously.
- ●CIN 2/3 confirmed: treatment (usually LLETZ) recommended.
●Advise the patient that the appointment letter should arrive within approximately 2–4 weeks; if not received, contact the practice.

Safety-Netting

●
Advise return before the colposcopy appointment if any of the following develop:
- ●Post-coital bleeding (bleeding after sex)
- ●Intermenstrual bleeding (bleeding between periods)
- ●Persistent or new pelvic pain
- ●Unusual or offensive vaginal discharge
●The absence of all these symptoms is genuinely reassuring and makes serious pathology very unlikely.

Common Candidate Mistakes in This Case

●Conflating borderline changes with cancer or pre-cancer. Borderline changes are low-grade and most commonly resolve — implying they represent early cancer is a significant clinical error.
●Failing to explain HPV dormancy. Without this, Sophie will leave believing Mark has been unfaithful. This is the single most impactful communication point in the case.
●Ignoring the relationship fear. Candidates who address only the medical facts without addressing Sophie''s fear of infidelity will miss a key management indicator.
●Overstating biopsy certainty. Telling Sophie a biopsy will definitely be taken is inaccurate and creates unnecessary anxiety.
●Failing to safety-net specifically. Generic advice ("come back if worried") does not meet the marking scheme — specific symptoms must be named.
●Advising Sophie to stop the pill. Raising the OCP association without proper contextualisation — or advising cessation — is not supported by guidelines.

Signposting to Reliable Information

●Jo''s Cervical Cancer Trust (jostrust.org.uk) is the leading UK charity providing clear, trustworthy patient-facing information on HPV, colposcopy, and cervical screening — and operates a helpline.
●Recommend this specifically as an alternative to unfiltered internet searching, which demonstrably increased Sophie''s anxiety.
●The NHS also provides patient information at nhs.uk/conditions/cervical-screening.

Free MRCGP SCA practice case for GP registrars covering Young Woman Wishing to Discuss Borderline Cervical Smear Result — Gynaecology and Breast. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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