Laura Churchill, The Copper IUD for Emergency Contraception

The Copper IUD for
Emergency Contraception
Laura Churchill, MS, FNP-BC
Deputy Director of Public Health/
Clinical Services
Greene County Public Health/Family Planning
Disclosure
The following people have no relevant financial, professional or personal
relationships to disclose:
Faculty:
Laura Churchill, MS FNP-BC
CME/CNE Program Planner(s):
Robert Cohen, MD (CME Programs)
Melanie Steilen, RN, BSN, ACRN (CNE Programs)
Iris Stendig-Raskin, MSN, CRNP, WHNP-BC (CNE Programs)
CME/CNE Program Reviewer(s):
Robert Cohen, MD (CME Programs)
Iris Stendig-Raskin, MSN, CRNP, WHNP-BC (CNE Programs)
There are no commercial supporters of this activity.
Disclaimer
The manufacturers of Paragard IUD do not
list the use of a copper IUD for emergency
contraception in their labeling, as such the
IUD will be referred to as the copper IUD
While this is off label use, it is
recommended and promoted as an option
for emergency contraception by the CDC,
WHO, OPA, ACOG, and many health care
organizations
Objectives
As a result of this training, participants will be
able to:
Identify who is an appropriate candidate for a
copper IUD for emergency contraception, and
promote the use in a clinic/office setting
Apply counseling strategies for women choosing
the copper IUD as emergency contraception for
immediate and long term use
Interpret and manage side effects of the copper
IUD
Contraceptive Emergency
Any woman or man in your office seeking
emergency contraception (EC) is having a
contraceptive emergency visit
This is an excellent opportunity to educate
and promote the most effective method of
emergency contraception
Why a Copper IUD?
It is 99% effective
It provides long-acting contraception for 1012 years
It contains no hormones
There is no weight dependence
There are very few contraindications
Teens and women will chose this method if
they are offered it!
Emergency Contraceptive
Options
Failure rates
Plan B
Ulipristal
Copper IUD
0.6-3.1%
0.9-2.1%
< 0.1%
BMI-related
failure rates
5.8% failure with
BMI> 30
2.6% failure with
BMI> 30
Not weight-related
Drug
interactions
Reduced
effectiveness with
rifampin,
anticonvulsants
Reduced
effectiveness with
rifampin,
anticonvulsants
No drug
interactions
Accessibility
Over the counter
By prescription
By office visit only
Source: Cleland K, et al., Clinical Obstetrics and Gynecology, 2014
Selected Practice Recommendations
for Contraceptive Use
The copper IUD can be inserted within 5
days of the first act of unprotected sexual
intercourse as an emergency contraceptive
When the day of ovulation can be
estimated, the copper IUD can be inserted
beyond 5 days after sexual intercourse, as
long as insertion does not occur > 5 days
after ovulation
Source: CDC. MMWR, 2013.
Rates of Pregnancy:
Oral LNG vs. Copper IUD
542 women provided with EC at a Utah
family planning clinic
215 chose the copper IUD
327 chose oral LNG
One year later:
Copper IUD pregnancy rates: 6.5%
Oral LNG pregnancy rates: 12.2%
64% of IUD users had their IUD one year later
Source: Turok D, et al. Contraception, 2014.
How To Be Reasonably Certain
a Woman Is Not Pregnant
A health-care provider can be reasonably certain a woman is
not pregnant if she has no symptoms or signs of pregnancy,
and
Meets any one of the following criteria:
Is ≤ 7 days after the start of normal menses
Has not had sexual intercourse since the start of last normal
menses
Has been correctly and consistently using a reliable method
of contraception
Is ≤7 days after spontaneous or induced abortion
Is within 4 weeks postpartum
Is fully or nearly fully breastfeeding (exclusively
breastfeeding or the vast majority [≥85%] of feeds are
breastfeeds), amenorrheic, and < 6 months postpartum
Source: CDC. MMWR, 2013.
Contraindications to Use
Pregnancy known
Current pelvic inflammatory disease (PID)
Current purulent cervicitis
Active gonorrhea
Active chlamydia
Uterus sounds to less than 6cm
Source: Cleland K, et al., Clinical Obstetrics and Gynecology. 2014
Greene County Family
Planning’s Experience
Greene County Family Planning received a $12,500
grant from NFPRHA to pilot the use of copper IUDs
as EC from October 2013 to April 2014
Prior to 2013, did not offer this EC option
Campaign named “Plan C”
Advertised with billboards, a Facebook page, and YouTube
video ads promoting the use
Health educator promoted “Plan C” in schools and
community presentations
Billboard Ad
YouTube Video
you-tube video ad-copperiud.mp4
Results of Pilot Study
During the data collection period, 23% of
women (17 of 71) seeking EC chose the
copper IUD
Advertising also led to a 54% increase in
non-EC clients choosing the copper IUD as
their contraceptive method
We continue to offer this EC option
Best Practice
All staff need to be on board, from the
receptionist to clinicians
Be consistent with “most effective method”
message
Conduct teen outreach and education–they
do well with insertion
Flexible scheduling a must
Clinician buy-in a must
Harper C, et al. Obstetrics and Gynecology. 2012.
Case Study #1
A 19 year-old female in rehab for one month for
heroin addiction walks in seeking EC with her
male partner of 5 years
She has a history of 3 terminations in the past 3
years and does not use any regular method
You have no labs or history and she will be
returning to her county of residence after rehab
Their last act of unprotected sex was 4 days ago
Her last period started two weeks ago
Which EC do you advise?
Discussion Case Study #1
At high-risk for repeat unintended
pregnancy
Currently mid-cycle
Obtain Chlamydia and gonorrhea testing at
time of insertion
Advise to return to clinic in one month for a
recheck, or two weeks if her period does
not come when it should
Source: Turok D, et al. Human Reproduction, 2013.
Case Study #2
15 year-old presents to teen walk-in clinic
requesting a copper IUD for EC
She was seen by the nurse one day ago
for Plan B and returned today for a more
effective method
Her last period was 31 days ago
Her unprotected sex was 3 days ago
She is brand new to the clinic and has
never had a pelvic exam
Discussion Case Study #2
Pregnancy test negative
Cultures for Chlamydia and gonorrhea
taken at the time of insertion
Counseled about pain and discomfort and
what to expect during her first pelvic exam
Given 600mg ibuprofen and a granola bar
prior to insertion
Framing the message
Long-term use of the method is promoted
Discuss of side effects of the copper IUD
Let the client know you will work with her to
manage the side effects
For teens whose parents monitor their
menses, the copper IUD is a good choice
Side Effects: Normal
Heavier menses typical in the first few months
Increased cramping may occur initially
Advise using a non-steroidal anti-inflammatory at
the onset of menses once every 6-8 hours with
food
Offer Lysteda, if patient desires
Check for Chlamydia and rule-out pregnancy if
irregular bleeding or no bleeding occurs
Side Effects: Abnormal
Bleeding that occurs for more than 10 days per
cycle and is new
Post-coital bleeding
Pain with intercourse
Fever, vaginal discharge, and pelvic pain
Bleeding heavier than one pad per hour for more
than 8 hours
Management
of Complications
Pelvic and bi-manual exam
STI cultures
Pelvic ultrasound with transvaginal views
Consider and counsel for another method
or LARC, if side effects not tolerable
Case Study #3
19 year-old female who received a copper
IUD for EC
6 months later, is reporting bleeding from 714 days with each menses and cramping
Not currently using condoms
The nurse prescribed two months of lowdose combined oral contraceptive pills
How do you advise this client?
Case #3 Follow-up
Chlamydia discovered and treated
Pregnancy was ruled-out
She did not remember to take the
combined oral contraceptive pills
Contraceptive counseling revealed she
liked the IUD as a method, but not the
bleeding
Her copper IUD was removed and a
Mirena IUD inserted at the same time
Case Study #4
16 year-old presents 10 months postinsertion of a copper IUD for EC
complaining of vaginal discharge
Reports her menses come once month and
last for 7 days
Her last menstrual period was 28 days ago
Diagnosed with vaginal candidiasis
You do not see her IUD strings upon exam
How do you proceed?
Case Study #4 Follow-up
Pregnancy test in office is negative
Patient advised to use condoms for all
intercourse until placement confirmed
Pelvic ultrasound was done and confirmed
a normally placed IUD present
Client is advised she is safe from
pregnancy, but condoms still advised for
STI prevention
Case Study #5
16 year-old client last seen 3 months ago for a
positive pregnancy test
Her exam was suspicious for Chlamydia, her test came
back equivocal, and she was treated presumptively
She had a surgical termination 2 months ago and has
had no follow-up
Her last period started one week ago
She is not using any method of contraception and
had unprotected sex yesterday
She would like a copper IUD
How would you proceed ?
Case Study #5 Follow-up
Her vaginal exam and wet mount today are
abnormal and suspicious for Chlamydia again
The risk of PID with IUD insertion is discussed
Nexplanon is offered, but she wants 10 years
Plan:
She and her partner (with her today) are both treated with
azithromycin 1 gm, and instructed not to have sex for 7
days
She wants an IUD, but opts to have the NP place a
vaginal ring today
She is scheduled to return in two weeks for a copper IUD
Both receive condom/lubricant demonstration from the
health educator at the same time
Conclusion
The Copper IUD is a highly effective
method of emergency contraception
Promoting awareness of it and offering it as
an option is a game changer
Be brave!
Thank you!
Laura Churchill
[email protected]

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