What should be discussed with a patient before Copper T (intrauterine device) insertion?

Pre-Insertion Counseling for Copper T IUD

Before inserting a Copper T IUD, counsel patients using a person-centered approach that prioritizes shared decision-making, realistic pain expectations with specific management options, expected bleeding changes, safety profile including the low infection risk, and immediate effectiveness for contraception. 1

Essential Counseling Components

Procedure Information and Expectations

• Explain the procedure takes 5-10 minutes with additional time for counseling and aftercare, and can typically be completed in a single visit including any necessary STI or pregnancy screening 1

• Prepare patients for three distinct sensation points after speculum placement: (1) application of the cervical stabilization instrument, (2) uterine sounding, and (3) IUD placement through the cervix into the uterus 1

• Compare discomfort levels to familiar experiences like menstrual cramps, using a 0-10 scale, and acknowledge that while most patients report mild-to-moderate pain, nulliparous patients may experience higher pain scores (median 6.6-8.1/10) compared to multiparous patients (3.7/10) 1

• Reassure that the clinician will pause between each step and proceed only when the patient is ready, emphasizing patient control throughout the procedure 1

Pain Management Options

Offer specific pharmacological options to all patients, as analgesia should be discussed and made available regardless of perceived risk level 1:

• NSAIDs (most important): Naproxen 500-550 mg orally 1-2 hours before insertion (or 2 over-the-counter naproxen sodium = 440 mg), or ketorolac 20 mg orally 1-2 hours prior, or ibuprofen 800 mg 1-2 hours prior 1

• Always advise taking NSAIDs with food 1

• For patients with significant anxiety, discuss anxiolytic options (though these require someone to drive them home) 1

• For higher-risk patients (nulliparous, previous failed insertion, significant anxiety), discuss topical anesthetics or paracervical/intracervical blocks 1

Recommend nonpharmacological comfort measures including eating a light meal and drinking water beforehand, wearing comfortable clothing (separate top and bottom), and considering bringing a support person 1

Bleeding Pattern Changes

Counsel that unscheduled spotting, light bleeding, heavy bleeding, or prolonged bleeding are common during the first 3-6 months of Copper T use, are generally not harmful, and typically decrease with continued use 1:

• Unlike hormonal IUDs, the Copper T does not reduce menstrual bleeding and may increase it initially 1

• Heavy or prolonged menstrual bleeding is a common reason for discontinuation but can be managed with NSAIDs during bleeding days if needed 1

• Emphasize that these bleeding changes are not harmful and enhanced counseling about expected patterns reduces discontinuation rates 1

Safety and Efficacy Profile

Reassure patients that the Copper T IUD is extremely safe and highly effective with a failure rate of less than 1% 1, 2:

• The risk of pelvic infection occurs only during the first 20 days after insertion, not throughout use 1, 2

• Beyond 21 days, IUDs do not increase rates of STIs or pelvic inflammatory disease 1

• IUDs do not cause tubal infertility in nulliparous women, and fertility returns rapidly after removal 1

• If STI screening has been performed according to CDC guidelines, additional screening at insertion is not necessary; if not previously screened, screening can be done on insertion day without delaying the procedure 1

• If an STI is diagnosed after insertion, it can be treated with the IUD in place without removal 1

Timing and Immediate Effectiveness

Clarify that insertion can occur at any time in the menstrual cycle as long as pregnancy is reasonably excluded—there is no "best time" for placement 1:

• The patient does not need to be menstruating for insertion 1

• The Copper T is immediately effective for contraception after insertion with no need for backup contraception 1

• The Copper T can be used as emergency contraception up to 5 days after unprotected intercourse (or >5 days if within 5 days of ovulation) 1

Post-Procedure Expectations

Advise patients about post-insertion care and what to expect 1:

• Some discomfort or dizziness after placement is normal and usually resolves after brief rest 1

• Patients can decide whether to return to work/school or take time off 1

• Recommend continuing NSAIDs (naproxen 440-550 mg every 12 hours or ibuprofen 600-800 mg every 6-8 hours with food) for the first 24 hours post-procedure 1

Contraindications and When to Seek Care

Screen for absolute contraindications which are limited to current purulent cervicitis, active gonorrhea or chlamydia infection, current pelvic inflammatory disease, or other active pelvic infections 1:

• Past PID is NOT a contraindication 1

• HIV infection and immunosuppression are NOT contraindications 1

• Very high individual likelihood of STD exposure (e.g., partner with known gonorrhea) requires delaying insertion until testing and treatment 1

Instruct patients to seek care if they develop new-onset heavy or prolonged bleeding after initial months of use, as this may indicate IUD displacement, STI, pregnancy, or new uterine pathology (polyps, fibroids) 1

Duration of Use

Inform patients the Copper T380A is approved for 10 years of highly effective contraception 1, 2

Trauma-Informed Approach

Use trauma-informed care principles by screening for history of trauma before any pelvic procedure and using therapeutic language throughout 1:

• Avoid triggering language; use terms like "placement" instead of "insertion," "cervix holder" instead of "tenaculum," "measuring your uterus" instead of "sounding" 1

• Establish mutual trust and avoid minimizing pain, which can lead to feelings of betrayal 1