Procedure

Class

Rationale

A

• Bimanual and speculum exams are mandatory before IUD use, to rule out contraindications: pregnancy, pelvic inflammatory disease (PID) and endocervical infection, and to determine uterine position in order to avoid perforation.
• If the woman is pregnant, presence of the IUD will lead to spontaneous abortion (miscarriage) in about half of all pregnancies, and there is significant risk of septic abortion¹.
• If a purulent endocervical discharge is present, at the time the IUD is inserted through the cervical canal, bacteria in the canal may be introduced into the sterile uterine cavity and lead to PID¹. The woman and her partner(s) must be treated before considering IUD insertion.

C

• IUD use does not affect blood pressure².
• Screening for high blood pressure is part of optimal preventive health care.

C

• For all women of reproductive age or beyond, a breast exam is recommended for optimal health care.
• IUD use does not cause (nor increase the risk of) breast cancer.

A

• Assessment of STD risk by personal history and socio-demographic risk factors is an important method of identifying women at risk of PID.
• Assessment of STD risk permits empiric therapy of client and presumptive treatment of partner.

B

• Assessment of STD risk by personal history and socio-demographic risk factors may be the most practical method of identifying women at risk for PID. The speculum and bimanual exam may also detect some STDs. Although STD lab tests may not be practical or affordable in many settings, in some cases it may be reasonable to supplement screening by history and physical exam with certain lab tests, especially where the client or the provider is concerned that the client may be of risk for STDs (clients with current signs or symptoms of STDs are not eligible for IUDs). When feasible, negative test results provide reassurance to corroborate the woman's history. It is important to try to avoid the imposition of additional visits in weighing the value of such tests.
• For those clients with a personal history or with socio-demographic risk factors which suggest high risk, the client who still makes an informed choice of an IUD must understand she may have an STD without any signs or symptoms.

C

• Cervical cancer screening is indicated for women at risk of cervical carcinoma, and is recommended for optimal preventive health care for women of reproductive age or beyond (particularly women at risk of STDs).

NOTE: Cervical cancer screening is advised for optimal preventive care for all women at risk of cervical cancer (e.g., smokers, women with partners having multiple partners, women with young age at first intercourse, etc.). All women at risk should ideally have access to a practical method of cervical cancer screening, treatment and follow up.

• IUD insertions and continued IUD use have no known relation to the risk of acquiring cervical carcinoma ³.

D

• General counseling:

- efficacy

- common side effects

- correct use of method

- signs and symptoms for which to return to the clinic

- STD protection (when/as appropriate)

A

• Accurate client education is essential for maximum quality of family planning services.
• Appropriate counseling about common contraceptive side effects at the time of method selection can lead to improved client satisfaction and contraceptive continuation⁴.

• Counseling concerning change in menses, including increased bleeding with copper- bearing IUDs.

A

• As in pre-method choice counseling, the women should be informed that menses are normally heavier with the IUD and intermenstrual bleeding may occur, particularly post insertion. Inert IUDs approximately double normal menstrual blood loss and copper IUDs may increase it by 50%, which may be clinically significant for women who are already anemic. The more progestin an IUD releases, the more effectively it decreases menstrual blood loss ⁵.

• High risk behavior

• Women at risk should be counseled on high risk behavior for contracting STDs and potential complications from IUD use. Women should be instructed to return to the clinic for: abdominal pain, pain with intercourse, abnormal vaginal discharge or pelvic pain, especially with fever, or if the IUD string is missing or appears to be longer or shorter or if the client is not pleased with the method.

• Counseling about condom use for women who, under certain circumstances, might become at high risk for STDs.

• When condoms are used as a back-up method, counseling should be given to increase correct use and compliance.
• Condoms offer the greatest potential for preventing STD spread among persons at risk for STDs.

• Counseling sessions providing skill training may increase the rate of condom use.