1. Pre-service Education on FP and AYSRH
Session II, Topic 8 IUDs
Copper T 380A

2. IUDs: Key Points for Providers and Clients
Copper IUD
5/25/2012
Small plastic device inserted through the vagina and cervix into the uterus.
Works mainly by stopping sperm and egg from meeting.
Requires no user action.
Requires a clinically trained provider to properly insert and remove.
Most women can use IUDs, including women who have never been pregnant.
Very effective
Very effective, with little to remember.
A woman can soon become pregnant when IUD is taken out.
Long acting
Long acting – up to 12 years – depending on type of device.
Can be removed whenever woman wants.
For older women: should be removed 1 year after last menstrual period (menopause).
Adapted from WHO’s Decision-making tool for family planning clients and providers.
Ask the students:
What are IUDs? <allow students to answer>.
What are some qualities of IUDs that are unique to this method? <allow students to answer>.
Explain:
IUDs are small plastic devices inserted through the vagina and cervix into the uterus.
The key points to remember about IUDs include:
They are small devices that fit inside the womb
Are very effective (more than 99 percent effective) in preventing pregnancy
Are long acting and easily reversible. IUDs can work up to 12 years (depending on type) and can be easily removed by a provider whenever the woman wants. Return to fertility occurs very soon after an IUD is removed. It has also been shown that the IUD can be used by women who have never had a baby without having any negative effect on their future fertility.
Are very safe; they might increase menstrual bleeding or cramps; and they do not provide protection against STIs or HIV and AIDS.

3. IUDs: Key Points for Providers and Clients
Copper IUD
5/25/2012
Very safe
Copper-bearing IUDs act locally on the reproductive tract and have no systemic effects. For this reason, copper IUDs can be used safely by breastfeeding women and by women who cannot use hormonal contraceptives.
IUDs do not:
Leave the womb and move around the body.
Get in the way during intercourse, although sometimes the man may feel the strings.
Rust inside the body, even after many years.
Some women have side-effects
Side-effects usually get better after first 3 months.
Side-effects include increase in menstrual bleeding or cramps.
No protection against STIS or HIV/AIDS
For STI/HIV and AIDS protection, also use condoms.
Adapted from WHO’s Decision-making tool for family planning clients and providers.

4. Copper IUDs
Copper IUDs have a small plastic frame with copper sleeves or wire around it
TCu-380A, “Copper T” is most widely used copper IUD
Multiload 375 is another copper IUD commonly available in some countries
Copper T-380A
Ask the students:
What are the types of IUDs in use today? <allow students to respond>.
How do they differ? <allow students to answer and add to the students’ responses as needed; probe for the following>
Explain:
Today, the most commonly inserted IUDs are copper-bearing IUDs. The most commonly used copper-bearing IUD is a small, T-shaped plastic frame with copper sleeves or wire around it.
In the late 1960s, researchers found that adding copper to the plastic frames made IUDs more effective than earlier devices. The copper released into the uterine cavity increases the contraceptive efficacy of the IUD.
They are safe, highly effective and long-acting contraceptive methods. IUDs remain effective for up to 12 years, depending on the type of the device.
The TCu-380A, or “Copper T,” is the most widely used copper IUD in the world.
The Multiload 375 is another copper-bearing IUD that is commonly available in some countries.
Hormonal IUDs are another type of IUD currently in use. However, in most countries, the availability of hormonal IUDs is very limited because of their much higher cost compared to copper IUDs.
Hormonal IUDs and copper IUDs have very different mechanisms of action and medical eligibility criteria.
This session does not cover hormonal IUDs. Instead, the remainder of this module will focus on the Copper T IUD.
Note to facilitator: Introduce the types of copper IUDs available in the country. The Copper T 380A and the Multiload 375 (if this is available) will most likely be registered under different names in different countries.
Multiload 375

5. Effectiveness of IUDs
In this progression of effectiveness, where would you place copper intrauterine devices (IUDs)?
Implants
Male Sterilization
Female Sterilization
Progestin-only Injectables
Combined Oral Contraceptives
Male Condoms
Standard Days Method
Female Condoms
Spermicides
More effective
Copper IUDs
Ask the students:
Where would you put IUDs on this list? <after students respond, click the mouse to reveal the answer>
Inform:
The list on this slide categorizes contraceptive methods from most effective to least effective as commonly used. In this list, spermicides are the least effective method and the most effective methods are contraceptive implants, sterilization and IUDs.
Conclude by emphasizing that IUDs would be in the top tier of methods, as they are a very effective method of contraception. Only implants and male and female sterilization are more effective than IUDs.
Less effective

6. IUDs: Mechanism of Action
Prevents fertilization by:
Impairing the viability of the sperm
Interfering with movement of the sperm
Explaining How IUDs Work
Brainstorming (10 min.)
The purpose of this activity is to keep students focused on how they translate technical information into concepts that their clients can understand.
For women who are interested in this method, how will you explain how IUDs work?
Brainstorming instructions:
Ask students to brainstorm ideas about how to explain how IUDs work to prevent pregnancy, using simple language the client will understand.
For example, “The IUD works mainly from stopping the sperm and egg from meeting.”
Source: Ortiz, 1996

7. Copper IUDs: Characteristics
Safe and highly effective
Require no user action
Long-acting (up to 12 years)
Rapid return to fertility
No systemic effects
Have health benefits
Trained provider needed to insert and remove
Require pelvic exam
Possible pain or discomfort during insertion
Have potential side effects
Complications are rare, but may occur
Do not protect against STIs/HIV
See Session Plan for Work Group Activity
Use Slide 7 to present the characteristics of IUDs (including advantages and limitations).
Remind students that women with similar characteristics in similar situations may have very different reasons for making method choices. When counseling women, it is important to help clients consider how these method characteristics fit into their lifestyles and reproductive health goals and desires.
Award a token prize to the team with the most thorough lists.
As you review the next few slides in the presentation, refer to the lists that the students developed.
Source: CCP and WHO, 2011.

8. Copper IUDs: Health Benefits
IUDs are known to:
Prevent risks of pregnancy
Reduce risk of ectopic pregnancy
Rate in IUD users is 12 in 10,000 (2 in 10,000 for Copper T380A)
Rate in women using no contraception is 65 in 10,000
Help protect against endometrial cancer
Explain:
In addition to the benefit of preventing unwanted pregnancy and therefore preventing the risks associated with pregnancy, IUD-use has some significant non- contraceptive health benefits. IUDs are known to reduce risk of ectopic pregnancy. The ectopic pregnancy rate in IUD users is only 12 in 10,000 (2 in 10,000 for the Copper T), compared to 65 in 10,000 for women using no contraception.
However, on a very rare occasion when an IUD fails, 6-8 out of 100 pregnancies resulting from a failed IUD are ectopic.
IUDs have also been shown to help protect against endometrial cancer.

9. Possible Side-Effects
Copper IUD
If a woman chooses this method, she may have some side-effects. They are not usually signs of illness.
After insertion:
Other common side-effects:
Some cramps for several days
Longer and heavier periods
Bleeding or spotting between periods
Some spotting for a few weeks
Adapted from WHO’s Decision-making tool for family planning clients and providers.
Remind students that as with many contraceptive methods, there are some side effects associated with IUDs that are not harmful but may be unpleasant.
Women’s preferences for certain methods are often related to side effects. Ask the students: What side effects of IUDs, have you heard about?
As we have acknowledged, some women who take IUDs experience certain side effects. IUD users commonly experience the following side effects:
Heavier and/or prolonged menstrual bleeding
Increased menstrual cramping
Spotting between periods. Spotting or irregular bleeding is more common immediately following IUD insertion.
Typically, these side effects will become less pronounced within the first 3–6 months of use.
Providers need to reassure the woman that these side effects do not indicate a serious medical problem. Increased cramping can be alleviated by taking ibuprofen, paracetamol, or other pain reliever—except aspirin—as needed. (Aspirin should not be taken because it slows clotting)
Because these side effects may have an important impact on users’ experience with an IUD, they should
More cramps or pain during periods
May get less after a few months

10. Copper IUDs: Counseling about Side Effects
Before insertion, describe common side effects:
Heavier and/or prolonged menstrual bleeding
Menstrual cramping
Spotting between periods
Explain that side effects:
Are not signs of illness
Usually become less within the first 3–6 months
Encourage to come back with questions or concerns
If client cannot tolerate side effects, treatment or discontinuation may be necessary
Thorough counseling is the best way to help women manage the side effects associated with IUDs.
When women know what to expect, there is less change that they will want to discontinue use.
Before insertion, describe common side effects.
Explain side effects:
A woman who is considering using an IUD should be counseled that she may experience these side effects, and that they are not signs of disease or health problems.
Providers need to reassure the woman that cramping can be alleviated by taking ibuprofen, paracetamol, or other pain reliever–except aspiring–as needed.
For the majority of women, these side effects will become less pronounced within the first 3-6 months of use.
Encourage to come back with questions or concerns:
After IUD insertion, the practitioner should tell a client to come back if she has any questions or concerns.
Ongoing counseling and reassurance should be provided if needed.
If the user continues to be concerned or if she finds the side effects unacceptable, it may be necessary to remove the IUD.

11. Who Can and Cannot Use the IUD
Copper IUD
Most women can safely use the IUD
But usually cannot use IUD if :
May be pregnant
Gave birth recently (more than 2 days ago)
Unusual vaginal bleeding recently
At high risk for STIs
Infection or problem in female organs
Adapted from WHO
Use slide to explain that most women can safely use the IUD as mentioned in the previous slide.

12. When clinical judgment is available
WHO’s Medical Eligibility Criteria
Categories for IUDs, Hormonal and Barrier Methods
Category
Description
When clinical judgment is available 1
No restriction for use
Use the method under any circumstances 2
Benefits generally outweigh risks
Generally use the method 3
Risks usually outweigh benefits
Use of method not usually recommended, unless other methods are not available/acceptable 4
Unacceptable health risk
Method not to be used
Use slide 12 to review the categories of medical eligibility.
Show slide 13. Explain that in situations where clinical judgment is limited, the four-category classification framework can be simplified into two categories. When simplified for these situations, categories 1 and 2 indicate that the method can be used, while categories 3 and 4 indicate that the woman is not medically eligible to use the method.
Use Slide 14: to identify medical eligibility criteria included in category 1 and 2.
Use slide 15 to identify medical eligibility criteria included in category 3 and 4.
Source: WHO, 2010.

13. With Limited Clinical Judgment
WHO’s Medical Eligibility Criteria
Categories for IUDs, When Only Limited Clinical Judgment is Available
Category
With Limited Clinical Judgment 1
Use the method 2 3
Do not use the method 4
Source: WHO, 2010.

14. Conditions (selected examples)
Category 1 and 2 Examples (not inclusive): Who Can Use Copper IUDs
WHO Category
Conditions (selected examples)
Category 1
≥20 years, cervical ectopy, uterine fibroids without distortion of the uterine cavity, irregular bleeding without heavy bleeding, <48 hours postpartum, 4 weeks to < 6 weeks postpartum
Category 2
Menarche to <20 years, nulliparous, heavy or prolonged bleeding, severe dysmenorrhea, anemia
Source: WHO, 2010.

15. Conditions (selected examples)
Category 3 and 4 Examples (not inclusive): Who Should Not Use Copper IUDs
WHO Category
Conditions (selected examples)
Category 3
48 hours to <4 weeks postpartum, ovarian cancer/if initiating use, high individual risk of STI/ if initiating use
Category 4
Pregnancy, unexplained vaginal bleeding (prior to evaluation), current PID or cervical infection, endometrial or cervical cancer/if initiating use
Source: WHO, 2010.

16. IUD Use by Women with HIV and AIDS
WHO Eligibility Criteria
Condition
Category
Initiate
Continue
HIV-infected 2
AIDS (without ARVs) 3
ARV therapy
(clinically well)
Women who are at risk of HIV can safely have the IUD inserted.
Women who have HIV clinical disease that is mild or with no symptoms can safely have the IUD inserted (WHO stage 1 or 2). This includes women who are doing well on ART.
Women who have HIV clinical disease that is severe or advanced (AIDS) should not have the IUD inserted (WHO stage 3 or 4).
Ask students: Let us take a closer look at the conditions and categories pertaining to clients with HIV or AIDs.
Use slide to present the following:
The medical eligibility criteria state that women with HIV can generally initiate and continue to use an IUD. HIV is classified as a Category 2 condition. This chart shows the specific WHO recommendations.
An IUD can be provided to a woman with HIV if she has no symptoms of AIDS.
A woman who develops AIDS while using an IUD can continue to use the device.
A woman with AIDS who is doing clinically well on ARV therapy (meaning that the symptoms of AIDS are controlled by the ARVs) can both initiate and continue IUD use.
While IUD users who develop AIDS can continue using the method, IUD initiation is generally not recommended in women who already have AIDS. The WHO determined that IUD initiation in such women should be classified as a Category 3 conditions because of the theoretical risk that advanced immunosuppression could increase the risk of IUD-related complications unless a woman is on ARV therapy.
While the IUD offers highly effective protection from pregnancy, it does not guard against STI and HIV transmission. As with other methods, providers who counsel sexually active HIV-positive clients about their contraceptive options should always encourage condom use in addition to the IUD.
Source: WHO, 2010.

17. IUD Use by Women with HIV and AIDS (Continued)
WHO Eligibility Criteria
Condition
Category
Initiate
Continue
HIV-infected 2
AIDS (without ARVs) 3
ARV therapy
(clinically well)
If a woman becomes infected with HIV or her HIV clinical disease becomes severe or advanced while she has an IUD in place, it does not need to be removed.
IUD users with HIV clinical disease that is severe or advanced should be monitored for pelvic inflammatory disease.
Urge women to use condoms along with the IUD. Used consistently and correctly, condoms help prevent transmission of HIV and other STIs.
Source: WHO, 2010.

18. IUD Use by Postpartum Women
Women less than 48 hours postpartum can have copper IUD inserted
Women 48 hours to 4 weeks postpartum generally should not initiate IUDs
No restrictions starting at 4 weeks postpartum
Women with puerperal sepsis should not have IUD inserted
WHO Eligibility Criteria
Characteristic/ Condition
Category
<48 hours 1
48 hours to <4 weeks 3
≥4 weeks
Puerperal sepsis 4
Ask students: Let us take a closer look at the conditions and categories pertaining to postpartum clients.
Use slide to present the following:
Women who are less than 48 hours postpartum may generally initiate the copper IUD.
Women who are more than 48 hours but less than 4 weeks postpartum generally should not have an IUD inserted because of the increased risk of expulsion.
Women who are 4 or more weeks postpartum may start using an IUD without restrictions.
Postpartum women who have puerperal sepsis should not initiate IUD use until they are infection free.
Note to Instructor: Consider using this slide if the students will be offering services to postpartum clients. It provides a concise overview of medical eligibility issues related to IUD use by these clients.
Source: WHO, 2010.

19. When to Insert an IUD
Copper IUD
IUD can be inserted in first 2 days after you give birth.
Insertion after childbirth:
Can insert within 48 hours after birth. Special training needed.
Between 48 hours and 4 weeks after birth, delay insertion. Offer condoms or another method if she is not fully breastfeeding.
Can insert after 4 weeks after birth. Must be reasonably certain she is not pregnant.
You can start any day of the menstrual cycle if we can be sure you aren’t pregnant.
If menstrual bleeding started in last 12 days, can insert IUD now.
If menstrual bleeding started more than 12 days ago, can insert IUD now if reasonably certain she is not pregnant. No need to wait for next menstrual period.
Adapted from WHO
See Session Plan for Experiential Learning Exercise and Case Study
See Session Plan to discuss the timing pf IUD insertion

20. When to insert an IUD (continued)
Copper IUD
Copper IUD
IUD can be inserted if fully or nearly fully breastfeeding less than 6 months after giving birth.
An IUD can be inserted anytime from 4 weeks to 6 months after giving birth and menstruation has not returned.
IUD can be inserted after an abortion or miscarriage.
Can be inserted immediately or within 12 days after a first- or second-trimester abortion or miscarriage and if no infection is present. No need for a backup method.
IUD insertion after second-trimester abortion or miscarriage requires specific training. If not specifically trained, delay insertion until at least 4 weeks after miscarriage or abortion.
If infection, insert after infection has been treated and cured.
IUD can be inserted if switching from another method.
Can be inserted immediately, if she has been using the method consistently and correctly or if it is otherwise reasonably certain she is not pregnant.
Adapted from WHO
See Session Plan to continue discussion on timing of IUD insertion

21. What Will Happen When You Get Your IUD
Steps:
Pelvic examination
Cleaning the vagina and cervix
Placing IUD in the womb through the cervix   
May hurt at insertion
Please tell us if it hurts
Rest as long as you like afterwards
May have cramps for several days after insertion
Adapted from WHO
In addition to providing information on the characteristics of IUDs, including side effects; accessing the client’s eligibility; and addressing misconceptions or questions that a client may have about IUDs, what are some other key counseling topics related to IUDs? <students brainstorm; write the answers on a flip chart>
In addition to the topics we have already discussed, it is imperative that during counseling about IUDs providers:
Explain the procedure used to insert (or remove) the IUD, using illustrations if possible, including the length of time it takes to complete the procedure, who will perform it, and that the woman may experience some pain and cramping, briefly. (We will discuss how to explain the procedure on the next slide).
Provide post-insertion instructions so that a client knows what to expect in the first few days (some cramping and spotting) and when to return to the clinic if something does not seem right. We will review these instructions in more detail later.
Explain how long the IUDs protect against pregnancy and help women remember when they should come back to have IUD removed or replaced. All clients should be given the following information:
The type of IUD (such as Copper T)
Date of insertion
Month and year when the IUD will need to be removed/replaced
Where to go in case of questions or problems (a reminder card can be useful for this purpose)
Finally, the provider should advise a client about circumstances that require her to return (which are described in more detail later in the presentation).
Afterwards: you can check your IUD from time to time if you want.

22. Explaining the IUD Insertion Procedure
You may feel discomfort, like heavy menstrual cramps.
The provider:
Performs a pelvic examination
Cleans the cervix and vagina with an antiseptic
Inserts a small rod into the uterus to measure the depth of the uterus
Inserts the IUD through the vagina and into the uterus using a small applicator
A client who has chosen to use an IUD needs to know what will happen during insertion.
A provider should describe the procedure simply and with just enough detail so the client will know what to expect. For example, the provider could 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. It has two thin strings attached, which hang down into the vagina. These strings make it easy for provider to remove an IUD. If you want, you may also touch the strings to check each month after your menstrual period that the IUD is still in place and that you are still protected from getting pregnant.”
“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.”
The provider could add more details to describe the procedure, such as:
“Before inserting the IUD, I will clean the cervix and vagina with an antiseptic. Next, I will insert a small rod into the uterus to measure the length of your uterus. Then I will use a thin 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 way into the vagina. After the insertion, you will rest.”
“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.”
After the insertion, you will rest.

23. Post-Insertion Instructions
Tell client to expect cramping and spotting for a few days
If client wants to check strings, teach her how:
Use clean hands
Check after menses
If convenient for client, schedule follow-up visit for 3–6 weeks
Counsel to return immediately if there are any signs of complications.
Ask students: Providing post-insertion instructions is an important element of counseling for IUD use. What information or instructions should you give clients after IUD insertion? <allow for several responses>
Tell the client to expect cramping and spotting or light bleeding for a few days, in addition to common side effect.
If a client wants to be able to check the strings, teach her how.
Make sure that she knows to wash her hands thoroughly before inserting her fingers into her vagina.
If she is unwilling or unable to check with her hand, she can inspect the pads she uses during menses for possibly expulsion of the IUD.
A woman may want to check for strings after each menses, especially during the first six months, since this is when the chance of the IUD being expelled is higher.
If the strings are missing the client should start using a backup method and visit her provider as soon as possible.
If it is convenient for the client, schedule a return visit with the client 3-6 weeks after insertion to check for presence and length of the IUD strings and to check for signs of infection. This visit is not mandatory. She does not need to return to the clinic again, unless she experiences problems or has concerns.
A client should return to the clinic immediately if she experiences any signs of possible complications.
Source: CCP and WHO, 2011; WHO, 2004, updated 2008.

24. Complications of IUDs
Potential complications of IUDs include perforations, pelvic inflammatory disease (PID), and expulsions.
Biases in early research overstated risks of PID.
Most research since the 1980s has concluded that serious complications are rare with modern IUDs.
Ask students: Among your friends or other students, what concerns do you hear about serious complications of IUD use? <allow students to respond; click mouse to reveal first bullet>
Most concerns about the safety of IUDs are rooted in earlier IUD experiences and research.
Several biases in early research overstated risks of PID.
Most research since the 1980s demonstrates that serious complications are area with modern IUDs.
Potential complications of IUDs include:
Perforations
PID
Expulsions
Perforations are associated almost exclusively with the insertion procedure. The woman’s uterus or cervix can be perforated when an IUD is inserted.
Although perforations are rare, it is a potentially serious event if it does occur. According to the WHO, rates of perforation at the time of insertion are about 1 in 1,000.
The risk of perforation is directly linked to the skill and experience of the provider. Carefully following the instructions for IUD insertion reduces the risk of perforation the uterus. The risk of perforation does not vary by timing of insertion.

25. Complications of IUDs, continued
Risk
Linked to
Reduced through/by
Perforation
Very low, 1 in 1,000 insertions
Skill and experience of provider
Supervised training
PID
Between 1 and 2 in 600 (depending on STI prevalence)
Mostly due to presence of cervical infections at time of insertion
Screening women for risk of STIs; not inserting in women with current STIs; adherence to infection prevention procedures
Expulsion
Provider’s skill; age and parity of woman; time since insertion; timing of insertion

26. Signs of Possible IUD Complications
Advise client to return immediately in case of:
Bleeding and severe abdominal cramping within a few days post-insertion perforation
Irregular bleeding or pain every cycle partial expulsion, perforation
During counseling, providers need to discuss the signs of possible IUD complications and advise the client to return immediately if any of the following signs or symptoms appear:
Bleeding or severe abdominal cramping during the first few days after insertion– this could indicate that the uterus or cervix may have been perforated when the IUD was inserted.
Irregular bleeding or pain in every cycle–this could indicate an IUD dislocation, partial expulsion, or perforation.
Fever and chills, unusual vaginal discharge, or lower abdominal pain – this could indicate an infection, which is a concern especially during the first month after the IUD is inserted. This is when PID, although rare, is most likely to develop.
Missing IUD strings or a missed menstrual period – these could indicate IUD expulsion and pregnancy, either uterine or ectopic.
Fever, unusual vaginal discharge, low abdominal pain infection
Missing IUD strings, missed period expulsion, pregnancy
Source: CCP and WHO, 2011.

27. Explain Removal Procedure to Client
IUD removal is quick and usually quite painless.
The provider:
Inserts a speculum to see the cervix and IUD strings.
Cleans the cervix and vagina with an antiseptic.
Asks the woman to take slow, deep breaths, and tell the provider if she feels pain during the procedure.
Using forceps, pulls the IUD strings slowly and gently until the IUD is completely out of uterus.
Prior to removal, a provider should describe to the lcient what will happen during the removal procedure. Providers hould explain that IUD removal is quick, and usually quite painless.
The simplified description is: <ask students to take turns reading the steps aloud>
The provider inserts a speculum to see the cervix and IUD strings.
The provider carefully cleans the cervix and vagina with an antiseptic solution.
The provider asks the woman to take slow, deep breaths and to relax. The woman should say if she feels pain during the procedure.
Using narrow forceps, the provider pulls the IUD strings slowly and gently until the IUD is completely out of the uterus.
Another IUD may be inserted immediately, if desired.
Providers must not refuse or delay when a woman asks to have her IUD removed, whatever her reason, whether it is personal or medical. All staff must understand and agree that she must not be pressured or forced to continue using the IUD.
If a woman is finding side effects difficult to tolerate, first discuss the problems she is having. See if she would rather try to manage the problem or to have the IUD removed immediately.
Removing an IUD is usually simple. It can be done any time of the month. Removal may be easier during monthly bleeding, when the cervix is naturally softened. In cases of uterine perforation or if removal is not easy, refer the woman to an experienced clinical who can use an appropriate removal technique.
Source: CCP and WHO, 2011.

28. Counseling and reassurance are key
Managing IUD Side Effects or Complications: Heavy, Prolonged or Irregular Bleeding
Counseling and reassurance are key
Problem
Action/Management
Heavy or prolonged bleeding
Reassure client that this is common and not harmful, usually diminishes after few months
For short-term relief offer 5-day course of tranexamic acid or NSAIDs (not aspirin)
Provide iron tablets
Irregular bleeding
Reassure client
For short-term relief offer ibuprofen or indomethacin 2 times daily after meals for 5 days
Ask students: What is the most important thing that you can do for women who experience side effects? <students brainstorm; accept responses from several students>
Let us compare your responses with the slide. <click the mouse to reveal the answer>
As we have discussed, the best way to reduce the anxiety some women feel when they experience side effects is to provide detailed information about possible side effects during counseling, before the client makes a decision to use the IUD. If side effects occur, the first step is to address the client’s concerns through a follow-up counseling.
Recommended management for heavy or prolonged menstrual bleeding are as follows:
Reassure the client that some women using IUDs experience heavy or prolonged bleeding. It is generally not harmful and usually becomes less or stops after the first several months of use.
For modest, short-term relief she can try (one at a time): Tranexamic acid (1500 mg three times daily for three days, then 1000 mg once a day for two days beginning when bleeding starts; ibuprofen (400 mg) or indomethacin (25 mg) two times daily after meals for five days.
Other NSAIDs may be prescribed. Do not prescribe aspirin.
Provide iron tablets and recommend a diet high in iron when high iron-content foods are available. Give examples of locally available food with high-iron content.
Recommended management for irregular bleeding are as follows:
Reassure the client.
For short-term relief, she can try ibuprofen (400 mg) or indomethacin (25 mg) two times daily after meals for five days.
Source: CCP and WHO, 2011.

29. Managing IUD Side Effects or Complications: Cramping and Mild Pain
Counseling and reassurance are key
Problem
Action/Management
Cramping and mild pain
She can expect cramping and pain in first 1–2 days after insertion
Reassure client that this is common in first 3–6 months, not harmful, usually decreases over time
Suggest ibuprofen, other pain reliever (not aspirin if she also has heavy bleeding)
If cramping continues, occurs outside of menstruation, evaluate, treat or refer
If cramping is severe but no underlying condition, discuss removing the IUD
When a client reports cramping and pain:
Inform her she can expect some cramping and pain for the first day or two after insertion.
Reassure her that cramping is also common in the first three to six months after insertion, particularly during menses. Generally, this is not harmful and decreases over time.
Suggest ibuprofen ( mg) or other pain reliever. If there is heavy bleeding, aspirin should not be prescribed because it inhibits clotting and thus can increase bleeding.
If cramping continues and occurs outside of monthly bleeding, evaluate for underlying health conditions, treat, and refer. If no underlying conditions are found but cramping continues and client finds it unacceptable, discuss removing the IUD.
Source: CCP and WHO, 2011.

30. Rule out PID, ectopic pregnancy or perforation.
Managing IUD Side Effects or Complications: Severe Pain in Lower Abdomen (Rare)
Rule out PID, ectopic pregnancy or perforation.
If PID is suspected, treat with appropriate antibiotics for gonorrhea, chlamydia and anaerobic bacterial infection. There is no need to remove the IUD.
If ectopic pregnancy is suspected, refer immediately.
When a client reports severe pain in her lower abdomen:
Do abdominal and pelvic examinations to rule out PID, ectopic pregnancy, or perforation.
If a pelvic exam is not possible, suspect PID if she has a combination of the following signs and symptoms in additional to abdominal pain:
Unusual vaginal discharge
Fever or chills
Pain during sex or urination
Bleeding after sex or between monthly bleeding
Nausea and vomiting
A tender pelvic mass
Pain when the abdomen is gently pressed or when gently pressed and then suddenly released
If PID is suspected, treat with appropriate antibiotics for gonorrhea, chlamydia, and anaerobic bacterial infection or refer for treatment. There is no need to remove the IUD.
Suspect ectopic pregnancy if she has a combination of these signs or symptoms:
Unusual abdominal pain or tenderness
Abnormal vaginal bleeding or not monthly bleeding–especially if this is a change from her usual bleeding pattern
Light-headedness or dizziness
Fainting
If ectopic pregnancy or other serious health condition is suspected, refer at once.
Source: CCP and WHO, 2011.

31. Managing IUD Side Effects or Complications: Suspected Perforation
Stop procedure immediately, remove IUD
Observe vital signs for an hour; check for signs of bleeding
If rapid pulse, falling blood pressure, or increased pain: refer
Provide alternative contraception
Advise avoid sex for 2 weeks
Follow-up in a week or as needed
If you suspect the IUD has perforated the uterus, stop the insertion procedure immediately and remove the IUD. Observe the client carefully as follows:
Provide bed rest and check vital signs every five to 10 minutes for the first hour.
If client remains stable after an hour, check for signs of intra-abdominal bleeding and observe for several more hours. If she shows no signs or symptoms, she can be sent home, but should avoid sex for two weeks. Help her choose another contraceptive method.
If she has a rapid pulse and falling blood pressure, or new or increasing pain around the uterus, refer her for high level care.
If uterine perforation is suspected after insertion and is causing symptoms, refer the client for evaluation by a clinic an experienced at removing such IUDs.
Source: CCP and WHO, 2011.

32. Managing IUD Side Effects or Complications: Missing Strings
Determine risk of pregnancy
Perform pelvic exam, probe for strings in cervical canal
If cannot locate strings, consider X-ray or ultrasound, or refer
Give choice of another contraceptive method
Insert another IUD if expulsion is confirmed and
Woman is not pregnant
She still wants to use an IUD
In the case of missing IUD strings, the provider should ask the following questions:
Did the client see the IUD come out? If yes, when?
When did the client last feel the strings?
When did she have her last monthly period?
Does she have symptoms of pregnancy?
Has she used a backup method since she noticed the strings were missing?
Always start with minor and safe procedures.
Check for the strings in the folds of the cervical canal with forceps. About half of missing IUD strings can be found in the cervical canal. If the strings cannot be located in the cervical canal, either they have gone up into the uterus of the IUD has been expelled.
Rule out pregnancy before attempting more invasive procedures, including x-ray. Refer for evaluation and give the client a backup method to use, in case the IUD did not come out.
If expulsion is confirmed and the woman is not pregnant, insert another IUD if she still wants to use an IUD.
Source: CCP and WHO, 2011.

33. Managing IUD Side Effects or Complications: Suspected Pregnancy
Assess for pregnancy, including ectopic pregnancy
If the client is pregnant and wishes to continue the pregnancy:
Explain that using an IUD during pregnancy increases the risk of preterm delivery or miscarriage
If possible, remove the IUD
If not possible to remove, advise close follow-up for signs of septic miscarriage
In the case of suspected pregnancy, the provider should asses for pregnancy, including ectopic pregnancy.
An IUD in the uterus during pregnancy increases the risk of preterm delivery or miscarriage, including infected (septic) miscarriage during the first or second trimesters, which can be life-threatening.
If the client does wish to continue the pregnancy, advise her that it is best to remove the IUD. Explain the risks of pregnancy with the IUD in place. Early removal reduces risk although the removal procedure itself involves a small risk of miscarriage.
If the client agrees, gently remove the IUD or refer for removal. Explain that she should return if there are any signs of miscarriage. If she chooses to keep the IUD, her pregnancy should be followed closely by a healthcare provider and she should seek their attention if any signs of miscarriage develop.
If the IUD strings cannot be found in the cervical canal and the IUD cannot be safely retrieved, refer her for an ultra sound to determine whether the IUD is still in the uterus. If it is, or if ultrasound is not available, her pregnancy should be followed closely. She should seek care at once if she develops any signs of septic miscarriages.
See Session Plan for Roleplays
Source: CCP and WHO, 2011.

34. Copper IUDs: Summary Copper IUDs are:
Safe, highly effective, convenient, reversible, long lasting, cost-effective, easy to use, and appropriate for the majority of women.
Providers can ensure safety by:
Informative counseling
Careful screening
Appropriate infection prevention practices
Proper follow-up
Use Slide 34 for a summary of IUDs
Copper IUDs are:
Safe, highly effective, convenient, reversible, long lasting, cost-effective, easy to use, and appropriate for the majority of women.
Providers can ensure safety by:
Informative counseling
Careful screening
Appropriate infection prevention practices
Proper follow-up
See additional slide sets for IUD insertion and removal