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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 copper intrauterine device (commonly referred to as the copper coil or Cu-IUD), including the common questions patients ask, the information you’ll be expected to give and how best to structure the consultation.
Opening the consultation
Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
Explain the reason for the consultation: “I understand you are interested in using the copper intrauterine device/copper coil for contraception. Is that correct?”.
It is important to establish a good rapport and an open line of communication with the patient early in the consultation: “If you have any questions at any point, or if something is not clear, please feel free to interrupt and ask me.”
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 specific methods. It is important to identify any patient concerns and expectations early in the consultation, as this may affect the tolerability of the method and subsequent contraceptive efficacy.
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 copper intrauterine device:
- “Have you heard of the copper intrauterine device/copper coil?”
- “What do you already know about the copper intrauterine device/copper coil?”
Concerns
Ask if the patient has any concerns about the copper intrauterine device:
- “Is there anything that worries you about the copper intrauterine device/copper coil?”
Expectations
Explore the patient’s expectations of the copper intrauterine device:
- “What factors have made you consider using the copper intrauterine device/copper coil?”
- “Why do you think the copper coil is the best choice for you?”
What is the copper coil?
Using patient-friendly language, explain that the copper intrauterine device is a form of long-acting reversible contraception (commonly referred to as LARC methods or ‘fit and forget’ methods).
The coil is a small plastic and copper device inserted into the uterus during a procedure in clinic. Its insertion is via an insertion tube, which passes through the cervix.
Depending on the amount of copper on the device, they can provide contraception for 5 – 10 years.
Example
“The copper coil is a small plastic and copper T-shaped device that will sit inside your womb and act to prevent pregnancy. It is highly effective, and you do not need to remember to take it every day. It can last up to 10 years, depending on the type of device that is fitted. As the device sits in the womb, it requires a small procedure in clinic to fit and remove it.”
How effective is the copper coil?
When counselling patients regarding contraception, it is very important to explain how effective any method is and highlight any factors which may impact efficacy.
Explain to the patient that the copper coil is over 99% effective at preventing pregnancy. The copper coil is effective immediately for contraception once fitted and can also be used as emergency contraception.
Example
“Less than 1 copper coil user in 100 will get pregnant in one year.”
“If 100 sexually active women don’t use any contraception, 80–90 will get pregnant in a year.”
How does the copper coil work?
Explain to the patient that the copper within the intrauterine device is spermicidal. The concentration of copper in the cervical mucus inhibits the motility of sperm into the womb, and the copper causes changes to the endometrium that can prevent implantation.
Example
“The copper coil works by preventing any sperm from surviving or reaching an egg. Even if a sperm were to reach an egg, the copper also causes changed to the womb lining that would make it more difficult for a pregnancy to implant and grow there.”
Advantages and disadvantages of the copper intrauterine device
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 (identified earlier in the consultation).
Signposting is important to help you structure the consultation: “Next, I’d like to talk about some of the additional benefits of having the copper coil and some of the potential disadvantages. Is that ok?.”
Advantages of the copper intrauterine device
Advantages of the copper intrauterine device include:
- Highly effective
- Immediately effective
- Long lasting (up to 10 years, depending on the type of device fitted)
- ‘Fit and forget’ – no requirement to take a daily pill or attend regular appointments.
- Easily reversible (once removed, fertility returns instantly)
- Does not contain hormones (may be an important factor for some users)
- No medication interactions
- Safe in breastfeeding
Example
“The copper coil begins working straight away as contraception, can last up to 10 years, and is 99% effective. One of the reasons why it is so effective is that you do not need to remember to use it. It does not contain any hormones, and for that reason does not interact with other medications you might need. As soon as the copper coil is removed, fertility resumes as normal.”
Disadvantages of the copper intrauterine device
Potential disadvantages of the copper intrauterine device include:
- Heavier and more painful periods
- Does not protect against sexually transmitted infections
- Requires a procedure to fit and remove (associated with a small risk of infection and uterine perforation)
- 1/20 risk of expulsion of the device (highest in first 3 months following fitting)
- Does not prevent ovulation (therefore, it would 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
Example
“Your periods may be heavier, longer and more painful than they were previously due to the effects of the copper within the device. Unfortunately, the coil does not protect you from sexually transmitted infections (STIs). Barrier contraception (e.g. condoms) are the only method of contraception to also provide protection from infections.”
“The copper intrauterine device requires a short procedure to fit and remove it. We’ll discuss this shortly, as there are a few things you need to be aware of.”
“After fitting, there is a small chance the copper coil could be expelled from the womb, coming out of the vagina. This is known as expulsion, and the risk is highest in the first 6 months after we fit the device. Attached to the device are some fine threads, which hang in the vagina. We encourage you to self-examine to check the threads are still present, indicating that the device is still present. If you had any concerns that the coil might have been expelled, you should not rely on it for contraception and seek a review from your local GP or sexual health service for ongoing support.”
“You will continue to produce an egg each month as normal with this method, therefore, if you normally experience premenstrual symptoms (PMS), these will likely continue. Although the chances of getting pregnant with the copper intrauterine device in situ are very small, if you were to become pregnant, your chance of having a pregnancy developing outside the womb (an ectopic pregnancy) would be higher. Therefore, if you become pregnant, it is important to seek medical advice. Your overall chance of having an ectopic pregnancy is still less than someone not using any contraception.”
How is the copper intrauterine device fitted and removed?
Insertion of a copper intrauterine device
A copper intrauterine device can be inserted anytime during the menstrual cycle. Inserting a copper intrauterine device requires a trained fitter. It involves a bimanual examination, inserting a speculum and passing the device into the uterus through the cervical canal. Patients may have anxieties about having a coil fitted. It is important to explore their ideas and concerns regarding the procedure.
Risks of insertion include:
- Pain
- Bleeding
- Infection
- Perforation of the uterus
In nearly all cases, an intrauterine device can be fitted in a community setting using local anaesthetic. The patient can also be advised to take some simple analgesia shortly before the procedure to help with their comfort. Before the device can be inserted, you must ensure there is no risk of pregnancy. A routine pregnancy test may be indicated.
Once fitted, the copper intrauterine device is immediately effective for contraception.
Using patient-friendly language, explain the procedure for fitting an intrauterine device and address any patient concerns.
Example
“As we’ve discussed, inserting a copper coil into the womb requires a short procedure. It is a good idea on the day to take some paracetamol and ibuprofen around 1 hour before your appointment to help make things more comfortable during the procedure.”
“The procedure involves an initial internal examination (using 2 fingers and a hand on the lower abdomen) to assess the position of the womb. Following this, the clinician will insert a speculum to visualise the cervix (the entrance to your womb). At this point, pain relief (local anaesthetic) can be applied to the cervix or inserted into the womb. A device is placed on your cervix to keep it still for the next part of the procedure. A small measuring instrument is inserted to measure the length of the womb. The copper coil is then inserted, the threads are trimmed, and the speculum is removed.”
“An uncomplicated insertion normally takes around 10 minutes. The copper intrauterine device is then immediately effective as contraception.”
Analgesia
All patients should be offered analgesia when an intrauterine device (copper intrauterine device or IUS) is inserted. Options for analgesia 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 fitting procedure, and that they feel able to stop the procedure at any time.
Removal of a copper intrauterine device
An intrauterine device is removed during a short procedure, which is less invasive than an insertion. A speculum is used to visualise the cervix and threads. The threads can be pulled to remove the device from the uterus.
Aftercare
Checking the threads
Explain to the patient they will need to check the threads of the IUD around 4-6 weeks after it has been fitted. Some patients may feel uncomfortable with self-examination and checking threads. It may be appropriate to arrange a follow-up speculum examination after fitting in this situation to check that the device has not been expelled.
Safety netting
Patients should be informed to seek medical advice if:
- They are unable to feel their threads on examination
- They experience ongoing pain after the fitting, or they develop new pain
- They experience an unexpected/ unwanted change in their bleeding pattern
- They experience unusual vaginal discharge or fever, which could indicate infection relating to the device
- There is a change to their medical history
Example
“To check the threads and that your copper coil is present, insert a finger into your vagina as far up as you can to feel something firm, like the tip of your nose; your cervix. You should be able to feel the threads (or thread – they can stick together) around your cervix. Do not pull them, as long as they’re there, you know the intrauterine device is in place.”
“If you cannot feel the threads, do not rely on the device for contraception, and book an appointment for a clinician to perform a speculum examination to check and use an alternative method of contraception whilst waiting for this. Additionally, if you experience ongoing pain after fitting, unexpected or unwanted change in your bleeding pattern, any unusual vaginal discharge, fever or a change in your medical history, then please seek medical advice.”
Closing the consultation
Close the consultation by summarising what you have discussed. This allows you to emphasise the key points of the consultation to ensure patient understanding.
Ask the patient if they have any further questions or concerns that haven’t been addressed.
If the patient is not currently using contraception, offer bridging contraception to prevent pregnancy whilst awaiting the insertion of the copper intrauterine device.
Finally, thank the patient for their time and offer them a leaflet summarising the key information related to the copper intrauterine device (e.g. Sexwise IUD leaflet).
Dispose of PPE appropriately and wash your hands.
Reviewer
Dr Ashley Jefferies
Community Sexual and Reproductive Health Registrar
References
- FSRH. Intrauterine Contraception. 2019. Available from: [LINK]
