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11/13/24, 8\:18 PM Guide | IUS counselling

IUS counselling

Table of contents

Introduction

Contraceptive counselling often features in OSCEs, and it’s important to be familiar with the various methods of
contraception available.
This article focuses on counselling patients about the intrauterine system (also referred to as the IUS or hormonal coil),
including the common questions patients ask, the information you'll be expected to give and how best to structure the
consultation.
Patients will often refer to the IUS as the Mirena coil. Mirena is a common brand of IUS. Other brands (e.g. Levosert) are
available with variable hormone content and lifespan.
For the purposes of this OSCE guide, we will focus on the Mirena brand of IUS being used for contraception.

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Explain the reason for the consultation\:
t h a t c o r r e c t ?”
.
“ I u n d e r s t a n d y o u a r e i n t e r e s t e d i n u s i n g t h e i n t r a u t e r i n e s y s t e m f o r c o n t r a c e p t i o n . I s
It is important to establish a good rapport and an open line of communication with the patient early in the consultation\:
h a v e a n y q u e s t i o n s a t a n y p o i n t , o r i f s o m e t h i n g i s n o t c l e a r , p l e a s e f e e l f r e e t o i n t e r r u p t a n d a s k m e .
”
“ I f y o u
Make sure to check the patient’s understanding at regular intervals throughout the consultation and provide opportunities to
ask questions (this is often referred to as ‘chunking and checking’).

Ideas, concerns and expectations

A key component of contraceptive counselling involves exploring a patient’s ideas, concerns and expectations (often referred
to as ICE).
In a contraceptive consultation, it is important to explore ICE, as many patients will have researched or have prior experience
with contraceptive methods. This will help you tailor the consultation and the advice you give regarding speci
important to identify any patient concerns and expectations early in the consultation, as this may a
method and subsequent contraceptive e
It can sometimes be challenging to use the ICE structure in a way that sounds natural in your contraceptive consultation, but
we have provided some examples for each of the three areas below.

Ideas

Explore what the patient currently understands about the IUS\:
“ H a v e y o u h e a r d o f t h e I U S / M i r e n a / h o r m o n a l c o i l ?”
“ W h a t d o y o u a l r e a d y k n o w a b o u t t h e I U S / M i r e n a / h o r m o n a l c o i l ?”
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Concerns

Ask if the patient has any concerns about the IUS\:
“ I s t h e r e a n y t h i n g t h a t w o r r i e s y o u a b o u t t h e I U S / M i r e n a / h o r m o n a l c o i l o r h a v i n g i t

Expectations

Explore the patient’s expectations of the IUS\:
" W h a t f a c t o r s i n
" W h a t a r e y o u h o p i n g t h e I U S / M i r e n a / h o r m o n a l c o i l c a n d o f o r y o u ?"
" A r e y o u h o p i n g t h e I U S / M i r e n a / h o r m o n a l c o i l w o u l d h e l p w i t h h e a v y p e r i o d s ?"

Eligibility

Before starting any method of contraception, it is vital to check the patient's eligibility and for any contraindications.
The Faculty of Sexual and Reproductive Health (FSRH) produce the UK Medical Eligibility Criteria for Contraceptive Use
(UKMEC) which guides clinicians on the safety of di
characteristics and medical co-morbidities\:
UKMEC 1\: no restriction
UKMEC 2\: bene
UKMEC 3\: theoretical or proven risk generally outweighs the bene
UKMEC 4\: contra-indicated

UKMEC 4 criteria

UKMEC 4 criteria for the IUS include\:
Current breast cancer
Postpartum or post-abortion sepsis
Active pelvic in
Symptomatic chlamydial infection
Current gonorrhoea infection
Unexplained vaginal bleeding (suspicious for a serious cause, before assessment has occurred)
Gestational trophoblastic disease with persistently elevated hCG levels or malignant disease
Cervical cancer (awaiting treatment)
Endometrial cancer
Pelvic tuberculosis

UKMEC 3 criteria

UKMEC 3 criteria for the IUS include\:
Past breast cancer
Severe decompensated cirrhosis
Benign hepatocellular adenoma
Malignant hepatocellular carcinoma
48 hours to \<4 weeks postpartum
Complicated organ transplant (rejection, failure)
Long QT syndrome
Previous radical trachelectomy
Uterine
HIV infection (\<CD4 \<200)
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What is the IUS?

Using patient-friendly language, explain that the IUS is a form of long-acting reversible contraception, meaning the patient
does not need to remember to take it every day. The IUS is a small plastic device inserted into the uterus and releases a
hormone called levonorgestrel (a progestogen).
Explain that the IUS requires a short procedure in clinic to
on the IUS brand and hormonal content).
Example
" T h e I U S i s a s m a l l p l a s t i c d e v i c e t h a t s i t s i n s i d e y o u r w o m b a n d r e l e a s e s a h o r m o n e t o p r e v e n t y o u f r o m b e c o m i n g
p r e g n a n t . I t i s h i g h l y e
o n t h e t y p e o f I U S
" A s t h e d e v i c e s i t s i n t h e w o m b , i t r e q u i r e s a s m a l l p r o c e d u r e i n c l i n i c t o

How e

When counselling patients regarding contraception, it is very important to explain how e
any factors which may impact e
Explain that the IUS is highly e
Example
" T h e I U S i s a v e r y e
t h a n 1 i n 1 0 0 w o m e n u s i n g t h e I U S w i l l b e c o m e p r e g n a n t i n o n e y e a r .
"

How does the IUS work?

Explain to the patient that the release of the hormone (a progestogen) from the IUS causes thinning of the endometrium (to
prevent implantation of a fertilised egg), thickening of the cervical mucus (to prevent sperm entering the uterus) and, in some
cases, will prevent ovulation.
Example
" A s w e' v e d i s c u s s e d , t h e I U S i s a v e r y e
l i n i n g o f y o u r w o m b t o p r e v e n t a f e r t i l i s e d e gg f r o m i m p l a n t i n g . I t a l s o t h i c k e n s t h e m u c u s i n t h e n e c k o f y o u r w o m b
( c e r v i x ) t o p r e v e n t s p e r m f r o m e n t e r i n g t h e w o m b a n d r e a c h i n g a n e g g. L a s t l y , i n s o m e c a s e s , i t c a n p r e v e n t y o u f r o m
o v u l a t i n g a n d r e l e a s i n g a n e g g f r o m y o u r o v a r i e s .
"

Pros and cons of the IUS

When discussing contraceptive options, it is important to give the patient enough information to make an informed
decision and direct them to reputable sources of further information.
When explaining potential advantages and disadvantages, you should consider the patient's ideas, concerns and
expectations (identi
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Signposting is important to help you structure the consultation\:
h a v i n g t h e I U S a n d s o m e o f t h e p o t e n t i a l d i s a d v a n t a g e s . “ N e x t , I s t h a t o k ? .
”
I' d l i k e t o t a l k a b o u t s o m e o f t h e a d d i t i o n a l b e n e

Advantages of the IUS

Advantages of the IUS include\:
Very e
'Fit and forget'
- no requirement to take a daily pill or attend regular appointments
Often used to help with heavy menstrual bleeding
Easily reversible (once removed, fertility returns instantly)
Provides localised hormones (less systemic absorption compared to other hormonal contraception)
Safe in breastfeeding
Can be used as part of HRT (if relevant)
Note\: The brand of IUS used may impact bleeding patterns and side e
between devices.
Example
" T h e I U S i s a v e r y e
e v e r y d a y . T h e I U S i s o f t e n u s e d t o h e l p w o m e n w h o e x p e r i e n c e h e a v y o r p a i n f u l m e n s t r u a l b l e e d i n g, t h e I U S c a n t h i n
a n d l i g h t e n y o u r p e r i o d s . I n s o m e w o m e n , p e r i o d s w i l l s t o p a l l t o ge t h e r .
T h e I U S i s e a s i l y r e v e r s i b l e , s o y o u r f e r t i l i t y w i l l r e t u r n a s s o o n a s w e r e m o v e t h e d e v i c e . A s t h e c o i l i s i n s e r t e d i n t h e
w o m b , i t p r o v i d e s l o c a l i s e d h o r m o n e r e l e a s e t o t h e w o m b . T h e r e f o r e , t h e r e a r e f e w e r e
w h e n b r e a s t f e e d i n g .
"

Disadvantages of the IUS

Potential disadvantages of the IUS include\:
Irregular bleeding (particularly in the
Does not protect against sexually transmitted infections
Requires a procedure to
1/20 risk of expulsion of the device (highest in
May not prevent ovulation (therefore, may not help with premenstrual syndrome symptoms)
Ectopic pregnancy\: whilst the chance of pregnancy is extremely low, if users were to become pregnant with the device in
situ there is an increased risk of ectopic pregnancy
Side e
Example
" A s w e' v e d i s c u s s e d , t h e I U S w o r k s b y t h i n n i n g t h e l i n i n g o f y o u r w o m b . D u r i n g t h i s p e r i o d , y o u m a y e x p e r i e n c e h e a v y
i r r e g u l a r b l e e d i n g d u r i n g t h e
"
a n d
" O n l y c o n d o m s w i l l p r o t e c t a g a i n s t s e x u a l l y t r a n s m i t t e d i n f e c t i o n s . T h e r e f o r e , w e w o u l d a d v i s e u s i n g c o n d o m s a l o n gs i d e
t h e I U S .
"
" T h e I U S r e q u i r e s a s h o r t p r o c e d u r e t o
"
a s t h e r e a r e a f e w t h i n gs y o u
" A f t e r
e x p u l s i o n , a n d t h e r i s k i s h i g h e s t i n t h e
( t h r e a d s ) , w h i c h h a n g i n t h e v a g i n a . W e e n c o u r a g e y o u t o s e l f -e x a m i n e t o c h e c k t h e t h r e a d s a r e s t i l l p r e s e n t , i n d i c a t i n g
t h e I U S i s s t i l l p r e s e n t .
"
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" N o t e v e r y u s e r w i l l s t o p o v u l a t i n g w i t h t h i s m e t h o d , t h e r e f o r e , i f y o u n o r m a l l y e x p e r i e n c e p r e m e n s t r u a l s y m p t o m s ( P M S ) ,
t h e s e m a y c o n t i n u e . A l t h o u g h t h e c h a n c e s o f g e t t i n g p r e g n a n t a r e v e r y s m a l l , i f y o u w e r e t o b e c o m e p r e g n a n t w i t h t h e
I U S , y o u r c h a n c e o f h a v i n g a p r e g n a n c y d e v e l o p i n g o u t s i d e t h e w o m b ( a n e c t o p i c p r e gn a n c y ) w o u l d b e h i g h e r .
T h e r e f o r e , i f y o u b e c o m e p r e g n a n t , i t i s i m p o r t a n t t o s e e k m e d i c a l a d v i c e .
"
" S o m e w o m e n m a y e x p e r i e n c e s i d e e

How is the IUS

Insertion of an IUS

Inserting an IUS requires a trained
uterus through the cervical canal. Patients may have anxieties about having an IUS
and concerns regarding the procedure.
Risks of IUS insertion include\:
Pain
Bleeding
Infection
Perforation of the uterus
In nearly all cases, an IUS can be
must ensure there is no risk of pregnancy. A routine pregnancy test may be indicated.
Once
contraception they may be using.
Using patient-friendly language, explain the procedure for
Example
" A s w e' v e d i s c u s s e d , t h e I U S r e q u i r e s a s h o r t p r o c e d u r e t o i n s e r t t h e d e v i c e i n t o t h e u t e r u s . T h i s i n v o l v e s a n i n i t i a l i n t e r n a l
e x a m i n a t i o n ( u s i n g 2
c l i n i c i a n w i l l i n s e r t a s p e c u l u m t o v i s u a l i s e t h e c e r v i x ( t h e e n t r a n c e t o y o u r w o m b ) . A t t h i s p o i n t , p a i n r e l i e f ( l o c a l
a n a e s t h e t i c ) c a n b e a p p l i e d t o t h e c e r v i x o r i n s e r t e d i n t o t h e w o m b . A d e v i c e i s p l a c e d o n y o u r c e r v i x t o k e e p i t s t i l l f o r t h e
n e x t p a r t o f t h e p r o c e d u r e . A s m a l l m e a s u r i n g i n s t r u m e n t i s i n s e r t e d t o m e a s u r e t h e l e n gt h o f t h e w o m b . T h e I U S i s
i n s e r t e d , t h e t h r e a d s a r e t r i m m e d , a n d t h e s p e c u l u m i s r e m o v e d .
"
" A n u n c o m p l i c a t e d i n s e r t i o n n o r m a l l y t a k e s b e t w e e n 1 0 - 1 5 m i n u t e s . I t m a y t a k e u p t o 7 d a y s b e f o r e t h e I U S i s r e l i a b l e f o r
c o n t r a c e p t i o n , d e p e n d i n g o n w h e n i n y o u r c y c l e y o u h a v e i t
a l o n g s i d e . T h e
"

Analgesia

All patients should be o
include\:
An intracervical block (using local anaesthetic)
Local anaesthetic spray to the cervix
Insertion of anaesthetic gel into the uterus
Simple analgesia (paracetamol/ibuprofen)\: patients are advised to take simple analgesia before and after the procedure
It is important the user feels in control during the

Removal of an IUS

The IUS is removed during a short procedure, which is less invasive than the IUS insertion. A speculum is inserted to visualise
the cervix and threads, the threads can be pulled to remove the IUS from the uterus.
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Aftercare

Checking threads

Explain to the patient they will need to check the IUS threads once the IUS has been
uncomfortable with self-examination and checking threads. It may be appropriate to arrange a follow-up speculum
examination after

Safety netting

Patients should be informed to seek medical advice if\:
They are unable to feel their threads on examination
Ongoing pain after
An unexpected or unwanted change in their bleeding pattern
Vaginal discharge
A change to their medical history
Example
" T o c h e c k t h e t h r e a d s a n d t h a t y o u r I U S i s p r e s e n t , i n s e r t a
l i k e t h e t i p o f y o u r n o s e ; y o u r c e r v i x . Y o u s h o u l d b e a b l e t o f e e l t h e t h r e a d s ( o r t h r e a d - t h e y c a n s t i c k t o ge t h e r ) a r o u n d
y o u r c e r v i x . D o n o t p u l l t h e m , a s l o n g a s t h e y' r e t h e r e , y o u k n o w t h e I U S i s .
I f y o u c a n n o t f e e l t h e t h r e a d s , b o o k a n a p p o i n t m e n t f o r a c l i n i c i a n t o p e r f o r m a s p e c u l u m e x a m i n a t i o n t o c h e c k a n d u s e
a n a l t e r n a t i v e m e t h o d o f c o n t r a c e p t i o n w h i l s t w a i t i n g f o r t h i s . A d d i t i o n a l l y i f y o u e x p e r i e n c e o n go i n g p a i n a f t e r
n e w p a i n , u n e x p e c t e d o r u n w a n t e d c h a n g e i n b l e e d i n g p a t t e r n , a n y v a g i n a l d i s c h a r ge o r a c h a n ge i n y o u r m e d i c a l h i s t o r y
p l e a s e s e e k m e d i c a l a d v i c e .
"

Closing the consultation

Close the consultation by summarising what you have discussed. This allows you to emphasise the key points of the
consultation.
Ask the patient if they have any further questions or concerns that haven’t been addressed.
If the patient is not currently using contraception, o
insertion of the IUS.
Finally, thank the patient for their time and o
Sexwise IUS lea).
Dispose of PPE appropriately and wash your hands.

References

FSRH. Intrauterine Contraception. 2019. Available from\: [LINK]
Source\: geekymedics.com
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