Copper Intrauterine Devices

Case Study 2

Gloria is a 23-year-old nulliparous woman who has been in a serious relationship for the past six months. She and her boyfriend have recently agreed to be monogamous. They have decided to get tested for sexually transmitted infections, including HIV. Gloria is currently on the Pill and used to have somewhat irregular periods, before taking COCs. She is considering switching to an IUD, and has come to the clinic with her boyfriend to learn more about the method. She is otherwise healthy.

Question Set A

During your initial meeting, Gloria asks how effective the IUD is and how long it lasts. She says she wants to use an IUD because she is currently using the Pill and does not always remember to take it. She also says it gives her headaches and causes mood swings. She wants a method that doesn’t require her to do anything, and that lasts for several years, at least, because she does not want to have children for at least four or five years. However, she tells you that she heard the IUD works by aborting a fertilized egg. She has also heard that IUD insertion can be very painful and that it can cause a lot of cramping and heavy bleeding during menstruation, and she is concerned about these things.

  1. How effective is the copper IUD compared to other methods? How long does it keep working?
  2. How does a copper IUD work?
  3. How would you respond to Gloria’s concerns about the IUD causing abortion, pain during insertion, and heavy bleeding with cramps?
  4. What other information or counseling would you provide Gloria and her boyfriend?

Question Set B

After you provide information and counseling, Gloria and her boyfriend decide to use an IUD. You screen her for eligibility. Gloria’s period started 10 days ago. Her boyfriend says that he has had another sexual partner in the past three months, but as of two months ago, he and Gloria are having sexual intercourse only with each other. Gloria has not used condoms with her boyfriend, and he did not use condoms with his previous sexual partner. However, neither Gloria nor her boyfriend reports any symptoms of current STIs.

  1. What screening tool(s) would you select to screen for medical eligibility for a copper IUD?
  2. Does her boyfriend’s history of having another sexual partner in the past three months affect Gloria’s eligibility for a copper IUD?
  3. Is Gloria eligible to have a copper IUD inserted at this time? Why or why not?
  4. What plan of action would you recommend, and why?
  5. What other information and counseling would you provide Gloria and her boyfriend, given their particular situation?

Question Set C

Gloria and her boyfriend tested positive for gonorrhea. (However, they both tested negative for HIV.) They both completed the treatment regimen that you gave them on Gloria’s first return visit, they have used condoms, as instructed, and Gloria has taken COCs consistently. Gloria has confirmed that she would still like to start using an IUD and has now returned to have the IUD inserted. Before inserting the IUD, you provide pre-insertion counseling.

  1. What tool(s) would you use to help conduct this counseling session?
  2. How can you help Gloria anticipate possible side effects and prepare to manage them?
  3. What type of medical exam does Gloria require before having the IUD inserted?
  4. What should you tell Gloria about the insertion procedure and what to expect?

Facilitator Note: For Question Set D, choose Option 1 or Option 2

Question Set D: Option 1

Three months later, Gloria returns to the clinic and says that she had a lot of cramping and heavy bleeding during her first three periods, as she had expected based on the pre-insertion counseling. She also says that she checked the strings, and felt them after each menses, but could not feel them after her third menses, which ended seven days ago. She didn’t notice anything coming out, but because her menses were very heavy, she didn’t take time to inspect every pad. She is concerned that the IUD has been expelled or has gone into her abdomen. She and her boyfriend have continued to use condoms.

  1. Is it likely that the IUD has been expelled? Why or why not?
  2. What is your plan of action?
  3. If the IUD has been expelled, is Gloria eligible to have another one inserted at this time? Why or why not?
  4. If Gloria decides to have another IUD inserted (and she is eligible), what tests or medical examinations would you need to perform?

Question Set D: Option 2

It is now six months since Gloria had the IUD inserted. During a visit three months ago, Gloria had complained of heavy bleeding and cramping during menses. She was also concerned about IUD expulsion. You confirmed that the IUD is still in place and reassured her about the side effects. You gave her NSAIDs for managing her discomfort and reminded her about the warning signs of complications. Today she has returned to the clinic and complains about having low abdominal pain and pain during sex. She has checked the strings after each menses since her last visit and has felt them each time. She and her boyfriend have used condoms most of the time, but not every time. During the counseling session, Gloria reveals that her boyfriend had a brief affair with a previous girlfriend who had returned to their community. He confessed to her and apologized.

  1. What is the likely cause of Gloria’s symptoms?
  2. Does she need to have the IUD removed, why or why not?
  3. What is your plan of action?
  4. What other counseling and advice would you offer, and why?

Case Study 2—Answer Key

Knowledge and Skills Objectives Addressed by IUDs Case Study 2
1.Describe the characteristics of IUDs in a manner that clients can understand
2.Demonstrate the ability to:
  1. Screen clients for medical eligibility for the copper IUD
  2. Explain insertion and follow-up procedures to clients
  3. Explain when to return to the clinic
  4. Address common concerns, misconceptions, and myths
  5. Conduct follow-up for clients using copper IUDs in a way that enhances continuing satisfaction and acceptance
3.Describe when to initiate use of the copper IUD
4.Explain how to manage side effects of the copper IUD
6.Identify clients in need of referral for IUD-related complications

Answers to Question Set A

  1. How effective is the copper IUD compared with other methods? How long does it keep working?

(Using Comparing Effectiveness of Family Planning Methods, show Gloria how copper IUDs match up with other contraceptive methods.) The copper IUD is one of the most effective methods of contraception available—more than 99 percent effective. It is also the most long-lasting reversible method, effective for at least 12 years.

  1. How does a copper IUD work?

The copper IUD works primarily by preventing fertilization. The IUD releases small amounts of copper, which damages sperm, reducing the ability of sperm to move and preventing the sperm from meeting the egg.

  1. How would you respond to Gloria’s concerns about IUDs causing abortion, pain during insertion, and heavy bleeding with cramps?

Using visual aids, such as a client counseling tool, reassure Gloria that a copper IUD works mainly by preventing the sperm from meeting the egg. If sperm can’t unite with an egg, there is no pregnancy to interrupt.

Regarding pain during insertion: Show her a sample IUD and let her hold it in her hand. Explain that the IUD is placed through the opening to the uterus (cervix) and into the uterine cavity (womb) using an inserter tube. She may feel some discomfort or mild pain, briefly, during the insertion. Most women don’t think it is painful, and say that it is like heavy menstrual cramps. She can take an analgesic, like ibuprofen, before the procedure, to help with any discomfort.

Regarding cramping and pain during menses: Describe that, during the first few months after insertion, the uterus is adjusting to the device, so it is common for women to have more cramping and pain during menses, and heavier and longer menstruation. They may also have some spotting and cramping between periods. But these effects usually become less with time, after the first 3–6 months of use, and many women don’t experience these side effects at all.

  1. What other information or counseling would you provide Gloria and her boyfriend?

Tell her that a pelvic exam is required before she can begin using an IUD. Ask whether there are any other contraceptive options she has considered that would be acceptable to her. If so, tell her about these, if she is interested. Ask about her current COC use and encourage her to use COCs correctly while she is considering another method. Remind her that she needs to use a backup method if she misses three or more pills in a row. Suggest ways that will help her to remember to take the Pill until she begins using another method. Advise condoms as a backup method and for STI protection. Make sure she understands the information you gave her, especially about IUD side effects.

Answers to Question Set B

  1. What screening tool(s) would you select to screen for medical eligibility for IUDs?

The Checklist for Screening Clients Who Want to Initiate Use of the Copper IUD, the WHO Medical Eligibility Criteria Wheel for Contraceptive Use, or the Quick Reference Chart for the WHO Medical Eligibility Criteria for Contraceptive Use.

  1. Does her boyfriend’s history of having another sexual partner within the past three months affect her eligibility for IUDs? Why or why not?

Yes. Questions 10-13 on the checklist assess risk of STI infection. Because Gloria would answer yes to question 11, she is at high risk of having an STI.

  1. Is Gloria eligible to have an IUD inserted at this time? Why or why not?

No. Because she is at high risk of having an STI, she should not have an IUD inserted unless chlamydia and/or gonorrhea infection can be ruled out or unless other methods are unavailable or inaccessible to her.

  1. What plan of action would you recommend, and why?

Because Gloria is unhappy with COCs, and wants a long-lasting, reversible method without hormones, there appears to be no other acceptable and appropriate contraceptive choice for her. Recommend testing her and her boyfriend for STIs, including HIV, and providing treatment, if needed, then inserting an IUD after the end of the treatment period. If testing is not available, treat her for both gonorrhea and chlamydia presumptively prior to insertion. She should be advised to use condoms consistently, at least until treatment is completed and the IUD is inserted.

  1. What other information and counseling would you provide Gloria and her boyfriend, given their particular situation?

Advise them to use condoms each time they have sex, to protect against infection (or reinfection) with STIs, including HIV. Make sure that Gloria is willing to continue using COCs in addition to condoms, until STIs can be ruled out or resolved and the IUD inserted.

Answers to Question Set C

  1. What tool(s) would you use to help conduct this counseling session?

An IUD that Gloria can hold, and a model of a uterus, if available, showing how the IUD sits in the uterus. A picture of the instruments that will be used, or the instruments themselves. Also, a counseling tool, with pictures, that describes the insertion procedure in simple terms, if this is available.

  1. How can you help Gloria anticipate possible side effects and prepare to manage them?

Review with her the common side effects of IUDs that you discussed in a previous visit, and ask her if she has any questions and concerns about these. Discuss ways she can manage any discomfort, and respond to any other questions she may have.

  1. What type of medical exam does Gloria require before having the IUD inserted?

A pelvic examination (bimanual and speculum).

  1. What should you tell Gloria about the insertion procedure and what to expect?

Describe the procedure simply, with just enough detail so Gloria will know what to expect. For example, you may describe the procedure in this way:

“The IUD is placed in the uterus through the vagina and the opening of the uterus, using a small applicator. Inserting the IUD is simple. You may feel uncomfortable for a few minutes. Most women, however, say that it is not too painful and compare the feeling to having heavy menstrual cramps. Before I insert the IUD, I will need to ask you some questions about your medical history, and perform a pelvic examination to make sure the IUD is right for you.”

You could add more details to describe the procedure, such as:

Before inserting the IUD, I will clean the cervix and vagina with a special antiseptic. Next, I will insert a small rod into the uterus to measure the length of your uterus.

Then I will use an inserter tube to insert the IUD through the cervix, or opening of the uterus, and place it into the uterus. I will cut the strings on the IUD so they hang just a little ways into the vagina. After the insertion, you will rest.

The strings are also used to remove the IUD. Removing the IUD takes only a few minutes and is usually not painful. When you want the IUD removed, it must be done by a doctor or trained health worker.

Answers to Question Set D: Option 1

  1. Is it likely that the IUD has been expelled? Why or why not?

It is possible that the IUD has been expelled, since Gloria cannot feel the strings, and she could feel them after her first two menses. It could have come out during menstruation and she did not notice. The risk of expulsion is highest during the first three months following insertion, especially in women who have not yet given birth. It is also possible that the strings may be pulled up into the cervix, where she can’t feel them.

  1. What is your plan of action?

Perform a speculum exam to check for the strings in her cervix using thin forceps. If you cannot find them, refer her for ultrasound or x-ray to assess whether the IUD has perforated the uterus and moved to the abdominal cavity or was expelled.

  1. If the IUD has been expelled, is Gloria eligible to have another one inserted at this time? Why or why not?

Yes, after it is confirmed that the IUD is indeed was expelled.

  1. If Gloria decides to have another IUD inserted (and she is eligible), what tests or medical examinations would you need to perform?

A pelvic exam is required before IUD insertion or reinsertion. You would also need to use the screening checklist to confirm that Gloria is not pregnant and not at high risk for STIs. Because she and her boyfriend have continued to use condoms, she should not be considered at risk of STIs and pregnancy.

Answers to Question Set D: Option 2

  1. What is the likely cause of Gloria’s symptoms?

PID, or pelvic inflammatory disease, caused by the presence of gonorrhea or chlamydia.

  1. Does she need to have the IUD removed, why or why not?

No. Pelvic inflammatory disease is a WHO MEC Category 4 for insertion, but a Category 2 for continuation. PID can be treated with IUD in place.

  1. What is your plan of action?

Provide antibiotics to treat the PID. Because PID may be caused by either gonorrhea or chlamydia infection, it would be appropriate to treat for both infections at this point (even if testing is available, you don’t want to waste time waiting for test results). Advise her to avoid sex until treatment is completed and recommend that her partner be treated as well. Explain where her partner should go for treatment and offer referral as appropriate. Make a follow-up appointment according to national guidelines.

  1. What other counseling and advice would you offer, and why?

Tell her that PID is a complication of STIs, such as gonorrhea or chlamydia. PID may lead to infertility (inability to have children) and even be life threatening if not treated on time. She should continue to use condoms to prevent future infection and possible PID.

Note: The recommendations provided in the Answer Key comply with the guidance in Family Planning: A Global Handbook for Providers (2011 update). If national guidelines are available and provide guidance on these topics, participants should follow the recommendations in the national guidelines.

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