Counselling patients
Straight to the point: talking IUC
The following section is an introduction to the INTRA initiative which provides simple steps to successfully counselling women about intrauterine contraception (IUC) in under 7 minutes.
The global INTRA group is a panel of independent physicians with an expert interest in intrauterine contraception.*
Aims of this section:
-
Guide 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 (by 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 Healthcare.
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
1
Establish her contraceptive needs
45 seconds
2
Introduce long-acting reversible contraception (LARC)
30 seconds
3
Communicate the potential benefits of IUC
90 seconds
4
Provide reassurance and address her concerns
90 seconds
5
Help her decide
60 seconds
6
Confirm her choice and schedule placement (if choice was IUC)
60 seconds
In this step, HCPs should:
-
Understand what a woman wants from her contraception
-
Discover what previous methods of contraception she has used including the pros and cons
-
Establish her goals in the coming years
Step 1 - Starting the conversation
To establish a woman’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 woman’s contraceptive needs to link to LARC (if appropriate)
-
Introduce IUC as a method of LARC
-
Increase a woman’s awareness and knowledge 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.
- Trussell J. Contraceptive failure in the United States. Contraception 2011;83:397−404.
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 mentioned you have heavy periods, one benefit of some types of intrauterine contraception can be reduced bleeding or for your periods to stop altogether’
‘You seem quite knowledgeable about intrauterine contraception, is there something that has stopped you considering it as an option in the past?’
In this step, HCPs should:
-
Discuss the potential benefits of IUC, linking back to her contraceptive needs
-
Use extra time to compare benefits to other methods
-
Discuss non-contraceptive benefits of some IUC methods
Step 3 - Discussing the benefits of IUC
Discuss the key potential benefits of IUC with the woman:
Supporting information is provided for HCPs
This step includes discussion points for extra time
- 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: November 2019].
- NICE clinical guideline [CG30]. Long-acting reversible contraception [online]. Updated July 2019. Available from: https://www.nice.org.uk/guidance/cg30 [Last accessed: September 2019].
- Brant AR. Curr Obstet Gynecol Rep (2017) 6:109–117
- 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.
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
-
Feel confident in addressing these with a woman to reassure her
-
Put risks and side effects into perspective in relation to other methods and pregnancy itself
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 discussion1
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
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.
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
60% of women chose IUC2
Where LARC methods were compared with oral contraceptive pills (OCPs): IUC had higher continuation rates (86%) and higher satisfaction rates (80%) at one year, than OCPs3
- Birgisson NE. J Womens Health (Larchmt). 2015 May 1; 24(5): 349–353.
- 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: November 2019].
- Peipert J, et al. Obstet Gynecol, 2011;117:1105–13.
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
-
Address any further concerns a woman may have openly and honestly
-
Offer personal experience
Step 5 - Use clinical experience & 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
-
Explain that insertion can take place within 7 days of the onset of menstruation. This is to ensure she is not pregnant. If Mirena is inserted more than 7 days since menstruation, abstinence or barrier contraception is recommended for 7 days1
-
Answer any final questions
-
Run through final formalities ahead of insertion
Step 6 - Provide reassurance
Offer guidance to confirm a woman’s choice of IUC including:
IUC placement can be performed at any time during her menstrual cycle provided there is absolutely no risk that she is pregnant1
STI screening can be performed on the same day as placement and, if the screen comes back positive, the infection can be treated with the device/system in situ. 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
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 prerequisite2
Effective IUC counselling – video demonstration
These videos demonstrate that it is possible to have a simple, short, & very effective counselling session about IUC in under 7 minutes.
Counselling on Long-Acting Reversible Contraception (LARC)
To support contraceptive counselling in the UK, the Bayer Women’s Health team have developed virtual reality technology to help deliver LARC counselling to patients. The LARC VR programme offers virtual reality and interactive content to help women understand the different options available when considering Long Acting Reversible Contraceptives.
If you would like to learn more, or are interested in using LARC VR patient counselling in your practice, please submit a request via the contact a rep page
Downloads
Counselling booklet
16 page, A5 booklet entitled Straight to the Point: talking IUC
Aim: to assist HCPs when counselling women about IUC in under 7 minutes
Guides HCPs through a simple, brief, six step discussion
Developed by the Global INTRA Group, the contents reflect the evidence-based opinion of its members
This symbol represents the estimated time allowance for each section of the counselling booklet
This symbol represents any extra time allowance for each section of the counselling booklet
Counselling checklist
A one page A4 summary of the key topics, including the most important questions
Follows the same six key themes for discussion, as advised by the global INTRA group
Aim: to act as a quick reference during a consultation, to ensure the relevant topics have been covered without needing to refer to the full booklet
