Contraception Counseling OSCE - IUD/Coil Discussion

Case Overview

• Age/Sex: 29-year-old female
• Occupation: Office administrator
• Setting: Primary care / family planning clinic
• Chief complaint: "I want to talk about contraception — I'm thinking about getting a coil."

Patient Script

Who I Am

I'm 29, work full time in an office, and I've been feeling pretty stressed with work lately.

What Brings Me In

I want a long-term contraception option — I've heard about the coil and want to know if it's right for me.

My Story

I've been thinking about changing my contraception for a while. I stopped the combined pill about a year ago because I got headaches and felt a bit down, and since then we've been using condoms most of the time. Over the last 2 years I've noticed my periods have been a bit heavier than before, and my cramps are sometimes worse. About 3 days ago I had a bit of urinary frequency and burning and the GP gave me antibiotics for a suspected UTI — that cleared up quickly. I had chlamydia about 5 years ago which was treated and I had no problems afterward. My last period started 12 days ago. I don't have children and I'd like to avoid pregnancy for the next 2–3 years, maybe start trying after that. I've been reading online and friends mentioned the coil (IUD) — I'm a bit worried about pain with insertion, whether it will make my periods worse, and whether it will affect my chance of getting pregnant later.

My Medical Background

• Past medical history: generally healthy; tension-type headaches occasionally
• Gynaecology/sexual: nulliparous; chlamydia treated 5 years ago
• Medications: none regularly
• Allergies: none known
• Social: non-smoker, drinks social alcohol, works long hours; monogamous relationship
• Family history: mother with breast cancer at 62 (no close early-onset breast cancer)

What I Think & Worry About

• I think the coil might be the best long-term option for me.
• I'm worried it will hurt a lot to have it put in.
• I'm worried it might stop me getting pregnant in future or make my periods worse.

If You Ask Me About Other Symptoms...

• Vaginal discharge: "No unusual discharge — nothing offensive or heavy."
• Fever/weight loss/night sweats: "No."
• Abdominal/pelvic pain: "I get cramps with my period, but no ongoing pelvic pain now."
• Recent infections: "Like I said, I had a UTI symptom and antibiotics 3 days ago and it got better."
• Sexual partners/STI risk: "I'm in a monogamous relationship and we both get tested sometimes — I had chlamydia years ago and it was treated."
• Desire for pregnancy: "Not now — maybe in a few years."
• Previous contraception side effects: "With the pill I had headaches and felt low sometimes, which is why I stopped."

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Clinical Summary

Examination

• General: alert, well, not feverish
• Vitals: BP 118/74 mmHg, HR 72/min, Temp 36.8°C
• Abdomen: soft, non-tender, no guarding
• Speculum: cervix appears normal, no mucopurulent discharge
• Bimanual: uterus small, mobile, non-tender; no cervical motion tenderness; adnexa not tender

Investigations

• Urine pregnancy test (urine hCG): <5 mIU/mL (negative)
• Urine dipstick: nitrite negative, leukocyte esterase negative (no evidence of ongoing UTI)
• Full blood count: Hb 138 g/L (normal) (no significant anaemia despite heavier menses)
• Cervical/urine NAAT for chlamydia/gonorrhoea: negative (screening performed)
• (If indicated) Transvaginal ultrasound: normal uterine cavity, no fibroids or structural abnormality

Diagnosis

• Primary: Suitable candidate for an intrauterine device (IUD) — likely a levonorgestrel-releasing IUD favored given history of heavier menstrual bleeding and desire for long-acting reversible contraception.

  • Evidence: patient desires LARC, negative pregnancy test, negative STI screen, normal pelvic exam, heavy menses that may improve with levonorgestrel IUD.

• Differentials / alternative options with reasoning:

  • Copper IUD: effective LARC but may worsen menstrual bleeding — less suitable given her heavier periods.
  • Progestogen-only implant or depot injection: LARC options, but depot may have systemic effects (weight/mood) and implant may be acceptable — discuss pros/cons with patient.
  • Combined oral contraceptive pill: effective but she had headaches and mood symptoms on the combined pill previously; also less convenient and not LARC.
  • Contraceptive sterilization: not appropriate given desire for future fertility.

Management

• Counseling:

  • Discuss both types of IUD: levonorgestrel IUD (reduces menstrual bleeding and cramps; licensed durations vary by device) versus copper IUD (non-hormonal but may increase bleeding/cramps).
  • Explain insertion procedure, likely discomfort/cramping during insertion, local analgesia/NSAIDs can be offered, and that most women tolerate it well.
  • Explain immediate and long-term side effects (spotting, changes in bleeding pattern, possible transient pelvic pain, rare risk of perforation or expulsion).
  • Reassure that fertility usually returns quickly after removal.
  • Discuss that IUDs do not protect against STIs; condoms advised for STI prevention.

• Pre-insertion checks and practical steps:

  • Confirm negative pregnancy test on the day of insertion (done).
  • Ensure STI screen is negative (done); if STI had been positive or signs of PID present, treat and delay insertion until resolved.
  • Given LMP was 12 days ago, counsel that if levonorgestrel IUD is inserted now she should use additional barrier contraception for 7 days after insertion (or follow local guideline); if insertion timed during menses, no additional contraception is needed.
  • Offer analgesia (NSAID premedication) and discuss options for local analgesia or cervical block if needed.
  • Arrange insertion appointment with consent and provide written information and contact details for complications.
  • Arrange follow-up at 4–6 weeks (or after the next menses) to check strings and address concerns.

• Warning signs to advise patient to seek urgent care:

  • Severe pelvic pain or fever (possible infection/perforation)
  • Heavy bleeding far more than usual
  • Missing IUD strings or suspected expulsion

Key Learning Points

• Check pregnancy status and screen for STIs before IUD insertion; active pelvic infection is a contraindication to immediate insertion.
• Levonorgestrel IUDs often reduce menstrual blood loss and are a good option for patients with heavier periods; copper IUDs may worsen bleeding.
• Counsel patients about what to expect during insertion, need for backup contraception depending on timing of insertion, and signs of complications (fever, severe pain, heavy bleeding, missing strings).