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Simple steps from INTRA to successfully counsel women about intrauterine contraception (IUC) in under 7 minutes.
Aims of this section:
- Guided six-step discussion with women to help them reach an informed decision where IUC is actively considered as a contraceptive option
- Increase the number of HCPs proactively integrating IUC as part of routine contraceptive care in a way that women can easily understand
- Demonstrate (video) it is possible to have a simple, short, & very effective counselling session about IUC in under 7 minutes
- Formation of the INTRA group and its ongoing work is supported by Bayer Return to content
The global INTRA group is a panel of independent physicians with an expert interest in intrauterine contraception.*
An introduction to INTRA
The Global INTRA group identified six key steps, which they believe form the basis of an effective counselling session about IUC.
Every step includes a short explanation, example questions and an estimated time recommendation.
If you would like to learn more, click here to access the downloads at the bottom of the page.
In this step, HCPs should:
Understand what a woman wants from her contraception
Establish her goals in the coming years
Discover what previous methods of contraception she has used including the pros and cons
Step 1 - Starting the conversation
To establish a women’s contraceptive needs:
Form questions that match a woman’s goals and needs, for example:
‘Do you have any plans to get pregnant?
If yes, how soon?’
‘How important is it for you not to be pregnant right now?’
-
Understand her experience of different methods:
‘What contraception do you use now (if any)?
What have you used before (if any)?’
‘How happy are/were you with those methods?
What did you like most about your previous/current method?
What did you like least?’
In this step, HCPs should:
Use a women’s contraceptive needs to link to LARC (if appropriate)
Increase a woman’s awareness and knowledge of LARC
Introduce IUC as a method of LARC
Bear in mind that a woman’s contraceptive needs change through her life – LARC may be an option in the future if it isn’t right now
Step 2 - Linking to LARC
Encourage HCPs to continue to ask a woman about her contraception as her needs change throughout her reproductive life1
Use simple linking phrases to increase awareness and knowledge about LARC using her established contraceptive needs:
Contraception options have a
range of levels of effectiveness
– one of the most effective
and reversible methods is
intrauterine contraception…
IUC is more than
99% effective in
the first year2
- Merki-Feld GS et al. Eur J Contracept Reprod Health Care. 2018:183-193. Return to content
- Trussell J. Contraceptive failure in the United States. Contraception 2011;83:397−404. Return to content
Step 2 - Introducing IUC
-
Once interest in a long-acting method of contraception is confirmed, introduce IUC as a potential method:
‘There are many myths associated with intrauterine
contraception, let me tell you some of the real facts which
may help…’
‘You seem quite knowledgeable about intrauterine
contraception, is there something that has stopped you
considering it as an option in the past?’
‘You mentioned you have heavy periods, one benefit of
some types of intrauterine contraception can be reduced
bleeding or for your periods to stop altogether.’
In this step, HCPs should:
Discuss the potential benefits of IUC, linking back to her contraceptive needs
Discuss non-contraceptive benefits of some IUC methods in eligible women
Use extra time to compare benefits to other methods
Step 3 - Discussing the benefits of IUC
- NHS. Intrauterine system (IUS) - Your contraception guide [online]. Updated 22 February 2018. Available from: https://www.nhs.uk/conditions/contraception/ius-intrauterine-system/ [Last accessed: December 2021]. Return to content
- NICE clinical guideline [CG30]. Long-acting reversible contraception [online]. Updated July 2019. Available from: https://www.nice.org.uk/guidance/cg30 [Last accessed: December 2021]. Return to content
- Brant AR. Curr Obstet Gynecol Rep (2017) 6:109–117 Return to content
- Carr BR, et al. Return of fertility in nulliparous and parous women after levonorgestrel 52 mg intrauterine system discontinuation [ASRM abstract O-104]. Fertil Steril. 2018;110(45 suppl):e46. Return to content
Step 3 - Extra time?
- In certain cases, you may find that you have a little more time available with your patient. If so, consider discussing:
- The effectiveness of IUC compared to oral contraceptives and/or other methods
- The effect of some IUC methods on menstrual blood loss in women experiencing heavy menstrual bleeding
In this step, HCPs should:
Build clinical knowledge to dispel common misperceptions around IUC
Put risks and side effects into perspective in relation to other methods and pregnancy itself
Feel confident in addressing these with a woman to reassure her
Step 4 - Background Reading - Common barriers and myths
- Many HCPs have misconceptions about IUC which results in them not proactively discussing or offering it as part of their contraceptive discussion
- To dispel many of the common barriers and myths, the Global INTRA Group have developed a review paper published in EJC.
Addresses HCP misconceptions regarding:
The risk of PID, infertility and ectopic pregnancy
The difficulty and risks of insertion of IUCs
The mechanism of action
- Further barriers to the use of IUC covered in this review paper include:
Health system barriers include
Pharmaceutical guidelines
Lack of understanding of the value/
cost effectiveness of IUCs
The number of trained providers
User barriers include:
Lack of awareness and
understanding of IUC
Fear of IUC, particularly pain on insertion
Cost of IUC
- Black K et al. Eur J Contracept Reprod Health Care; 2012: 17(5): 340-50) Return to content
Step 4 - Addressing ‘user’ barriers
- Women also have a number of misconceptions about IUC which may need to be addressed within a consultation:
Pain on insertion has been shown to be lower than often feared:
A study of 117 women found that 62% of women taking part felt no more than ‘period pain’ during insertion of IUC1
- Brockmeyer A, et al. Experience of IUD/IUS insertions and clinical performance in nulliparous women–a pilot study. Eur J Contracept Reprod Health Care. 2008 Sep;13(3):248-54. doi: 10.1080/02699200802253706. Return to content
Step 4 - Putting risks and side-effects into perspective
- Any method of contraception has risks and side effects. Helping a woman make an informed choice about IUC involves an appropriate discussion of these, using your clinical knowledge and experience.
For example:
- Risk of ectopic pregnancy
- Perforation
- Expulsion
- Infection
- Changes to her monthly bleeding pattern
‘The most common side effects can be headaches and abdominal pains but not all women experience these. Just be aware that having an IUC won’t protect you against STIs so as you would with the pill, you’ll need to use a condom if you think you might be at risk.’
Step 4 - Extra time?
- If possible, this theme can be expanded upon by discussing the CHOICE study:
- Over 9,000 adolescents and women at risk of unintended pregnancy were offered a choice of all reversible methods of contraception at no cost1
- Almost 60% of women chose IUC2
- Where LARC methods were compared with oral contraceptive pills: (OCPs) IUC had higher continuation rates than OCPs (86% vs 55%) and higher satisfaction rates than OCPs (80% vs 54%) at one year.
- Birgisson NE. J Womens Health (Larchmt). 2015 May 1; 24(5): 349–353. Return to content
- PCWHF. 10 Top Tips for Intrauterine Contraception (IUC) [online]. Updated November 2019. Available from: https://pcwhf.co.uk/wp-content/uploads/2019/01/PCWHF-10-Tips-IUC.pdf [Last accessed: December 2021]. Return to content
- Peipert J, et al. Obstet Gynecol, 2011;117:1105–13. Return to content
In this step, HCPs should:
Use clinical experience to support a woman in deciding whether to use IUC – referring back to her initial contraceptive needs
Offer personal experience
Address any further concerns a woman may have openly and honestly
Step 5 - Use clinical experience and be honest when addressing concerns
- Share your knowledge and clinical experience to support her decision to use IUC
- Bear in mind that IUC won’t be the right choice for every woman
‘Based on what you’ve told me these are the most
effective options to suit your needs – which of these do
you think would suit you best?’
- Include risks and potential side effects into your counselling
‘For most women, placement can cause a little pain, a bit
like period pain, which quickly passes.’
Step 5 - Offer personal experience
- If pertinent, personal disclosure has been found to be useful at this time:
‘In our practice we have a large number of women using
this method.’
‘Amongst the patients I see, there are many who opt for an IUC.’
‘Many of the women who work here use IUC.’
(If you and your colleagues are comfortable)
In this step, HCPs should:
Offer guidance to confirm a woman’s choice of IUC
Answer any final questions
Explain that insertion can take place within 7 days of the onset of menstruation. This is to ensure she is not pregnant. If Mirena® (52mg levonorgestrel) is inserted more than 7 days since menstruation, abstinence or barrier contraception is recommended for 7 days1
Run through final formalities ahead of insertion
Step 6 - Provide reassurance
- Offer guidance to confirm a woman’s choice of IUC including:
IUC placement is done within 7 days of menstruation, and the IUC can be replaced at any time in the cycle.1
STI screening can be performed on the same day as placement and, if the screen comes back positive, the infection can be treated prior to insertion. Mirena® must be removed if the woman experiences recurrent endometritis or pelvic infection, or if an acute infection is severe2
If she has any concerns following placement, she can return to discuss these with you at any time or call the clinic
- Mirena® Summary of Product Characteristics. Return to content
- Mirena® Product Monograph Return to content
Step 6 - Ahead of insertion
- Before proceeding with IUC insertion, ensure that:
You meet your local requirements for informed consent at the time when the woman returns for the device to be inserted. When gaining this consent, remind her of the potential risks and side effects1
If the woman does experience side effects she should contact her healthcare professional immediately including pain, fever, unusual discharge, or severe bleeding2
It is important to note that cervical screening is independent of IUC placement and not a pre-requisite2
- Johnson BA. Insertion and removal of intrauterine devices, American Family Physician. January (2005). Return to content
- Mirena® Product Monograph Return to content
Latest content
PP-PF-WHC-GB-1335 September 2023
Reporting adverse events and quality complaints
Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Bayer plc.
If you want to report an adverse event or quality complaint, reports can be directed to: Tel: 01182063500 or email: pvuk@bayer.com
Further information is available on the “contact” tab at www.bayer.co.uk.
