(Published September 2004)

Screening and Counseling Patients

Goals for Providers

There are a number of goals that providers need to consider during the process of screening and counseling patients for intrauterine contraception (IUC) use. They include reviewing the range of contraceptive options with their patients, promoting the successful use of the chosen method, allowing time for questions, and providing written materials in the language and literacy level their patients require.

Candidates for Intrauterine Contraception

In the past, overly restrictive protocols for selecting IUC candidates prevented many women from accessing this form of contraception. Appropriate candidates potentially include all women of reproductive age who are seeking a long-term, highly effective contraceptive method. IUC is especially suited for women who are at low risk for sexually transmitted infections because they are in a mutually monogamous relationship or because their partners correctly and consistently use condoms, those seeking a convenient method, or those considering sterilization.

There are few absolute contraindications to IUC use. Table 4 lists conditions designated as category 4 according to the medical eligibility criteria that the WHO has established for contraceptive use.¹ Conditions assigned to category 4 are those that represent an unacceptable health risk if the contraceptive method is used. For complete information about relative contraindications, see the WHO criteria, available at: http://www.who.int/reproductive-health/publications/mec/index.htm.
In helping women choose between the IUC devices available in the United States, providers should consider that the copper-T IUD can be left in place five years longer than the LNG IUS and that it may be preferred by women who do not want to use a hormone-releasing IUD. The LNG IUS is better suited for women with menorrhagia or those who would find amenorrhea an advantage.

TABLE 4. Contraindications to Intrauterine Contraception Use, According to the World Health Organization¹
Category 4 Condition*	Comments
Pregnancy
Puerperal sepsis
Use immediately after septic abortion
Distorted uterine cavity
Unexplained vaginal bleeding	For initiation; continuation of IUC is designated category 2
Malignant trophoblastic disease
Cervical cancer (awaiting treatment)	For initiation; continuation of IUC is designated category 2
Endometrial cancer	For initiation; continuation of IUC is designated category 2
Breast disease (current)	For LNG IUS only
Uterine fibroids that distort uterine cavity
Pelvic inflammatory disease (current or within past three months)	For initiation; continuation of IUC is designated category 3
STIs (current or within past three months) including purulent cervicitis
Known pelvic tuberculosis	For initiation; continuation of IUC is designated category 3
*Category descriptions: Category 1: A condition for which there is no restriction for the use of the contraceptive method. Category 2: A condition where the advantages of using the method generally outweigh the theoretical or proven risks. Category 3: A condition where the theoretical or proven risks usually outweigh the advantages of using the method. Category 4: A condition that represents an unacceptable health risk if the contraceptive method is used.

TABLE 5. Myths About Intrauterine Contraception

Effectiveness
Mechanisms of action
Description of devices
Insertion and removal procedures
Possible adverse events, including
menstrual changes
Possible complications
Instructions for checking string, follow-up visits, and warning signs
Noncontraceptive benefits

Counseling Topics

Providers need to counsel women who are considering IUC to ensure they have sufficient and accurate information to make an informed choice. Providers need to ask patients about their current understanding and dispel any myths they may have about IUC or other forms of contraception. Providers should discuss the topics listed in Table 5, and then ask patients if they have any additional questions.

Reference

1. World Health Organization. Improving Acess to Quality Care in Family Planning: Medical Eligibility Criteria for Contraceptive Use. 2nd ed. Geneva: WHO, 2000.