Counselling patients

Step 1 - Starting the conversation

To establish a women’s contraceptive needs:

1. 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?’
   

2. 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?’

Step 2 - Linking to LARC

1. Encourage HCPs to continue to ask a woman about her contraception as her needs change throughout her reproductive life
2. 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 being intrauterine contraception…
• IUC is more than 99% effective in the first year

Step 2 - Introducing IUC

1. 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.’

Step 3 - Discussing the benefits of IUC

1. Discuss the key potential benefits of IUC with the woman:

• Highly effective
• Cost-effective
• No need for daily, weekly or monthly administration
• Potential non-contraceptive benefits
• Reversible

2. Supporting information is provided for HCPs
3. This step includes discussion points for extra time

Step 3 - Extra time?

1. 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

Step 4 - Background Reading - Common barriers and myths

1. Many HCPs have misconceptions about IUC which results in them not proactively discussing or offering it as part of their contraceptive discussion
2. 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

3. 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

1. 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 IUC

Step 4 - Explain risks and side-effects 

1. 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?

1. 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 cost
• Almost 60% of women chose IUC
• 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.

Step 5 - Use clinical experience and be honest when addressing concerns

1. Share your knowledge and clinical experience to support her decision to use IUC
2. 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?’

3. 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

1. 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)

Step 6 - Provide reassurance

1. 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.
• STI screening can be performed on the same day as counselling 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 severe
• 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

1. 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 effects
• If the woman does experience side effects she should contact her healthcare professional immediately including pain, fever, unusual
  discharge, or severe bleeding
• It is important to note that cervical screening is independent of IUC placement and not a pre-requisite