Intrauterine System (Mirena) Counselling – OSCE guide

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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 theΒ 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 theΒ IUSΒ as theΒ Mirena coil.Β 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 IUSΒ being used forΒ contraception.Β 


Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including yourΒ nameΒ andΒ role.

Confirm the patient’sΒ nameΒ andΒ date of birth.

Explain theΒ reasonΒ for the consultation:Β β€œI understand you are interested in using the intrauterine system for contraception. Is that correct?”.

It is important to establish a goodΒ rapportΒ and anΒ open line of communicationΒ with the patient early in the consultation:Β β€œIf you have any questions at any point, or if something is not clear, please feel free to interrupt and ask me.”

Make sure toΒ check the patient’s understandingΒ at regular intervals throughout the consultation andΒ provide opportunities to ask questionsΒ (this is often referred to as β€˜chunking and checking’).

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Ideas, concerns and expectations

A key component of contraceptive counselling involves exploring a patient’s ideas,Β concernsΒ andΒ expectationsΒ (often referred to as ICE).

In aΒ 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 patientΒ 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 currentlyΒ understands about the IUS:

  • β€œHave you heard of the IUS/Mirena/hormonal coil?”
  • β€œWhat do you already know about the IUS/Mirena/hormonal coil?”

Concerns

Ask if the patient has anyΒ concerns about the IUS:

  • β€œIs there anything that worries you about the IUS/Mirena/hormonal coil or having it fitted?”

Expectations

Explore the patient’sΒ expectations of the IUS:

  • “What factors influenced your decision to opt for the IUS/Mirena/hormonal coil?”
  • “What are you hoping the IUS/Mirena/hormonal coil can do for you?”
  • “Are you hoping the IUS/Mirena/hormonal coil would help with heavy periods?”

What is the IUS?

UsingΒ patient-friendly language, explain that the IUS is a form ofΒ long-acting reversible contraception, meaning the patient does not need to remember to take it every day. The IUS is aΒ small plastic device inserted into theΒ uterus and releases a hormone called levonorgestrelΒ (a progestogen).

Explain that the IUS requires a short procedure in clinic to fit and remove it. Once inserted, it can last up to 5 years (depending on the IUS brand and hormonal content).Β 

Example

“The IUS is a small plastic device that sits inside your womb and releases a hormone to prevent you from becoming pregnant. It is highly effective, and you do not need to remember to take it every day. It can last up to 5 years, depending on the type of IUS fitted.Β 

“As the device sits in the womb, it requires a small procedure in clinic to fit and remove it”


How effective is the IUS?

When counselling patients regarding contraception, it is very important to explain how effectiveΒ any method is and highlight any factors which may impact efficacy.Β 

Explain that the IUS isΒ highly effective at preventing pregnancy (>99% effective).Β 

Example

“The IUS is a very effective method of contraception, which is over 99% effective at preventing pregnancy. This means less than 1 in 100 women using the IUS will become pregnant in one year.”


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

“As we’ve discussed, the IUS is a very effective method of contraception. It works in three main ways. Firstly, it thins the lining of your womb to prevent a fertilised egg from implanting. It also thickens the mucus in the neck of your womb (cervix) to prevent sperm from entering the womb and reaching an egg. Lastly, in some cases, it can prevent you from ovulating and releasing an egg from your ovaries.”


Advantages and disadvantages of the IUS

When discussing contraceptive options, it is important to give the patientΒ enough informationΒ to make anΒ informed decisionΒ and direct them to reputable sources of further information.Β 

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: β€œNext, I’d like to talk about some of the additional benefits of having the IUS and some of the potential disadvantages. Is that ok?.”

Advantages of the IUS

Advantages of the IUS include:

  • Very effective
  • ‘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 effect profiles due to the differing amounts of hormones between devices.Β 

Example

“The IUS is a very effective form of contraception. It is a ‘fit and forget’ method, so you don’t have to remember to take it every day. The IUS is often used to help women who experience heavy or painful menstrual bleeding, the IUS can thin and lighten your periods. In some women, periods will stop all together.

The IUS is easily reversible, so your fertility will return as soon as we remove the device. As the coil is inserted in the womb, it provides localised hormone release to the womb. Therefore, there are fewer effects on the whole body. It is safe when breastfeeding.”

Disadvantages of the IUS

Potential disadvantages of the IUS include:

  • Irregular bleeding (particularly in the first 6 months of use)
  • Does not protect against sexually transmitted infections
  • Requires a procedure to fit and remove (associated small risk of infection and uterine perforation)
  • 1/20 risk of expulsion of the device (highest in first 6 months following fitting)
  • 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 effects: acne, headaches and breast tenderness
Example

“As we’ve discussed, the IUS works by thinning the lining of your womb. During this period, you may experience heavy irregular bleeding during the first few months of use. Once it has done the job, the IUS keeps your womb lining thin, and at this point, most women experience either no bleeding or spotting.”

“Only condoms will protect against sexually transmitted infections. Therefore, we would advise using condoms alongside the IUS.”

“The IUS requires a short procedure to fit and remove the device. 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 IUS 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 thin strings (threads), which hang in the vagina. We encourage you to self-examine to check the threads are still present, indicating the IUS is still present.

“Not every user will stop ovulating with this method, therefore, if you normally experience premenstrual symptoms (PMS), these may continue. Although the chances of getting pregnant are very small, if you were to become pregnant with the IUS, 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.”

“Some women may experience side effects including acne, headaches and breast tenderness with the IUS”


How is the IUS fitted and removed?

Insertion of an IUS

Inserting an IUS requires a trained fitter. It involves a bimanual examination, inserting a speculum and passing the IUS into the uterus through the cervical canal. Patients may have anxietiesΒ about having an IUS fitted. It is important to explore their ideas andΒ concerns regarding the procedure.Β 

Risks of IUS insertion include:

  • Pain
  • Bleeding
  • Infection
  • Perforation of the uterus

In nearly all cases, an IUS can be fitted in a community setting using local anaesthetic. Before an IUS can be inserted, you must ensure there is no risk of pregnancy. A routine pregnancy test may be indicated.Β 

Once fitted, the IUS can take up toΒ one week to be reliable for contraception, depending on cycle timings and any other contraception they may be using.Β 

UsingΒ patient-friendly language, explain the procedure for fitting an IUS and address any patient concerns.Β 

Example

“As we’ve discussed, the IUS requires a short procedure to insert the device into the uterus. This 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 IUS is inserted, the threads are trimmed, and the speculum is removed.”

“An uncomplicated insertion normally takes between 10 – 15 minutes. It may take up to 7 days before the IUS is reliable for contraception, depending on when in your cycle you have it fitted or if you are using another method of contraception alongside. The fitter will be able to advise you when you can rely on this method for contraception.”

Analgesia

All patients should be offered analgesia when an intrauterine device (IUS or copper coil) 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.Β 

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.Β 


Aftercare

Checking threads

Explain to the patient they will need to check the IUS threads once the IUS 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 IUS has not been expelled.

Safety netting

Patients should be informed to seek medical advice if:

  • They are unable to feel their threads on examination
  • Ongoing pain after fitting or they develop new pain
  • An unexpected or unwanted change in their bleeding pattern
  • Vaginal discharge
  • A change to their medical history
Example

“To check the threads and that your IUS is present, insert a finger into your vagina as far up as you can to feel something 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 IUS is.

If you cannot feel the threads, 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 or new pain, unexpected or unwanted change in bleeding pattern, any vaginal discharge or a change in your medical history please seek medical advice.”


Closing the consultation

Close the consultation by summarising what you have discussed. This allows you to emphasise theΒ key pointsΒ of the consultation.

Ask the patient if they have anyΒ further questionsΒ orΒ concernsΒ that haven’t been addressed.

If the patient is not currently using contraception, offer bridging contraceptionΒ to prevent pregnancy whilst awaiting the insertion of the IUS.

Finally,Β thank the patientΒ for their time and offer them aΒ leaflet summarising the key information related to the IUS (e.g. Sexwise IUS leaflet).

DisposeΒ ofΒ PPEΒ appropriately andΒ wash your hands.


References

  • FSRH. Intrauterine Contraception. 2019. Available from: [LINK]

 

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