Nonhormonal Contraception

Overview

Classification

Nonhormonal contraception can be classified into:

• Physiologic methods:
  • Withdrawal/coitus interruptus
  • Periodic abstinence:
    • Rhythm method
    • Basal body temperature method
    • Cervical mucus method
  • Lactational amenorrhea
  • Abstinence from all sexual activity
• Barrier methods:
  • Condom (male or female)
  • Spermicide
  • Contraceptive sponge
  • Diaphragm
  • Cervical cap
• Copper intrauterine device
• Surgical methods:
  • Tubal ligation
  • Vasectomy

Choice of contraception

• Individuals may desire nonhormonal contraceptive methods owing to:
  • Accessibility of some methods
  • Desire for a “backup” method to hormonal contraception
  • Low risk of systemic effects (e.g., venous thromboembolism, hormonal effects)
• Choice of the nonhormonal contraceptive may depend upon:
  • Ease of access and use
  • Affordability
  • Efficacy rate
  • Reversibility or permanence
  • Prevention of STIs

Physiologic Methods

Withdrawal/coitus interruptus

• A traditional method that has been in use for centuries
• The penis is completely withdrawn from the vagina prior to ejaculation.
• Prevents fertilization by preventing the sperm from reaching the egg
• High failure rate

Periodic abstinence

Rhythm method (calendar method)

• Based on the woman’s menstrual cycle
• The cycle has to be regular.
• Awareness of fertile and infertile phases is important.
• Associated with a high failure rate

Basal body temperature method

• Based on an ↑ in body temperature at rest (by 0.3–0.5 degrees) during and after ovulation
• Associated with a high failure rate

Cervical mucus method

• Based on cervical mucus changes observed during ovulation due to estrogen changes
• Before ovulation, the mucus is:
  • Increased
  • Thinner
  • Clearer
  • Stretchy
• High failure rate

Lactational amenorrhea

• Mechanism:
  • Prolactin is secreted to stimulate the production of breast milk.
  • Effects: 
    • ↓ Gonadotropin-releasing hormone
    • Delay in ovulation
• Only viable for women:
  • Who are exclusively breastfeeding (frequently day and night)
  • Within the 1st 6 months postpartum
  • Who have not seen a return of their menstrual period

Barrier Methods

Condoms

Mechanism:

• Creates a physical barrier between the male and female genitalia and secretions
• Effects:
  • Protects against pregnancy
  • ↓ STI risk, including HIV
  • Protects against HPV infections → ↓ risk of cervical neoplasia

Male condom:

• Only reversible male contraceptive method (except for withdrawal)
• Use:
  • A thin (usually latex) tube with a reservoir at the tip and a base ring
  • Applied to an erect penis before penetration
• Advantages:
  • Does not affect fertility
  • Protection from STIs
  • Easily accessible
  • Inexpensive
  • Minimal side effects
• Disadvantages:
  • Latex allergy is a contraindication.
  • Potential ↓ in sensitivity
  • Some individuals may have difficulty finding a proper fit.
  • Slippage or breakage can occur.
• Pregnancy rate at 1 year:
  • 2% with perfect use
  • 18% with typical use (inconsistent use)

Female condom:

• Use:
  • A pouch with an inner and an outer ring
  • The inner ring is inserted into the vagina. The outer ring remains outside and covers the perineum.
  • Should be used no more than 8 hours before intercourse
• Advantages:
  • Does not affect fertility
  • Protection from STIs
  • Does not require medical evaluation or special fitting
  • Minimal side effects
  • Offers protection to women whose partners refuse to use a male condom
• Disadvantages:
  • Allergy to nitrile is a contraindication.
  • Not as readily available as male condoms
  • May be difficult to insert and remove properly
  • Possibility of:
    • Semen to spill when removing
    • Breakage
    • Slippage
• Pregnancy rate at 1 year:
  • 5% with perfect use
  • 21% with typical use

Spermicides

• Mechanism:
  • Most spermicides contain nonoxynol-9
  • Provide a chemical barrier by killing or immobilizing sperm cells
• Use:
  • Can be in the form of foams, creams, and suppositories
  • Should be placed in the vagina at least 10‒30 minutes (no more than 1 hour) before sexual intercourse
• Advantages:
  • Does not require a prescription
  • Easy to use
  • Does not affect fertility
• Disadvantages:
  • Should be used with other barrier methods due to limited efficacy
  • Does not protect against STIs
  • May cause vaginal irritation → ↑ risk for HIV infection
• Pregnancy rate:
  • 19% with perfect use
  • 28% with typical use

Contraceptive sponge

• Mechanism:
  • Foam disk impregnated with nonoxynol-9
  • Acts as both a barrier device and spermicidal agent
• Use:
  • Moisten with water before insertion into the vagina → activates spermicide
  • Should cover the cervix
  • Can be inserted up to 24 hours before intercourse
  • Should be left in place for ≥ 6 hours after intercourse
• Advantages:
  • Available without a prescription or special fitting
  • Does not affect fertility
• Disadvantages:
  • Less effective than other barrier methods
  • Can cause vaginal irritation or dryness → ↑ risk of HIV transmission
  • May be difficult to remove (can break apart during removal)
  • Associated with ↑ risk of toxic shock syndrome (rare)
• Pregnancy rate:
  • 12% for nulliparous women
  • 24% for multiparous women

Diaphragm

• Mechanism:
  • A reusable, dome-shaped rubber cup with a flexible rim that fits over the:
    • Cervix
    • Upper and lateral wall of the vagina
  • Provides a physical barrier to sperm
• Types:
  • Conventional latex diaphragm:
    • Available in various sizes
    • Requires a medical visit and special fitting
    • Should be refitted after childbirth or weight changes
  • New single-size diaphragm:
    • Made of silicone
    • 1 size fits most.
    • Does not require a fitting
    • More durable
• Use:
  • Usually with a spermicide (applied before insertion)
  • Ideally, placed < 1 hour before intercourse
  • Should remain in place for 6‒8 hours (no more than 24 hours after intercourse)
• Advantages:
  • Does not affect fertility
  • Can be placed at a convenient time before intercourse
  • Durable and reusable (can last up to 2 years)
• Disadvantages:
  • Can be difficult to use properly
  • Requires a prescription
  • Does not prevent STIs
  • Should be avoided during menses due to the risk of infection
  • Can cause discomfort and vaginal irritation
  • May become dislodged
  • Associated with:
    • Urinary tract infections
    • ↑ Risk of toxic shock syndrome (rare)
• Pregnancy rate:
  • 6% with perfect use
  • 12% with typical use

Cervical cap

• Mechanism:
  • Resembles a diaphragm but is smaller and more rigid
  • Provides a barrier against sperm entering the cervix
• Use:
  • A spermicide should always be used.
  • Must be inserted before intercourse
  • Should remain in place for ≥ 6 hours after intercourse (no more than 48 hours)
• Advantages:
  • Does not affect fertility
  • Can be placed at a convenient time before intercourse
  • Durable and reusable (can last up to a year)
• Disadvantages:
  • Can be difficult to use properly
  • Requires a medical visit and fitting (should be refitted after childbirth)
  • Does not prevent STIs
  • Not to be used during menses
  • May cause vaginal irritation
  • Associated with urinary tract infections
• Pregnancy rate:
  • 13%‒16% for nulliparous women
  • 23%‒32% for multiparous women

Copper Intrauterine Device

Mechanism

• A T-shaped polyethylene device with a fine copper wire wound around the stem (and often the horizontal arms)
• Nonhormonal
• Causes local, sterile inflammation and releases small amounts of copper → affects sperm mobility and egg implantation

Use

• Inserted by a clinician
• STI testing is done just prior to insertion.
• Can remain in place for 10 years

Advantages

• Highly effective
• Provides long-term efficacy
• Convenient
• Does not affect fertility
• Minimal systemic effects
• Can be used as emergency contraception
• May be removed at any time

Disadvantages

• Requires a medical visit and placement
• Does not protect against STIs
• Side effects:
  • Heavy menstrual bleeding
  • Severe cramping

Contraindications

• Current STIs or pelvic inflammatory disease (PID)
• Anatomic abnormalities that distort the uterine cavity
• Unexplained vaginal bleeding
• Known cervical cancer or endometrial cancer
• Pregnancy
• Wilson disease or copper allergy

Complications

• Expulsion rates are < 5% within the 1st year after insertion.
• Uterine perforation
• Ectopic pregnancy
• ↑ Risk of PID

Pregnancy rate

• 0.5%‒0.8%
• Higher failure rate in younger women

Surgical Methods

Tubal ligation

Mechanism:

• Disrupts the patency of the fallopian tubes
• Can be accomplished surgically by:
  • Cutting and excising a segment of the fallopian tubes
  • Fallopian tube closure via:
    • Ligation
    • Fulguration
    • Various mechanical devices (plastic bands or rings, spring-loaded clips)
  • Complete removal of the fallopian tubes

Indications and contraindications:

• Indicated for women with a desire for permanent contraception (should be given extensive counseling)
• No absolute contraindications
• Risk factors for complications should be assessed:
  • Severe obesity
  • Prior abdominal surgery
  • Previous PID or abdominal infections
  • Comorbidities

Complications:

• Death: 1–2 per 100,000 women
• Hemorrhage or intestinal injuries: approximately 0.5% of women
• Failure of tubal occlusion: up to 5% of women
• Ectopic pregnancy: approximately 30% of pregnancies that occur after tubal occlusion

Vasectomy

Mechanism:

• Disrupts the patency of the vas deferens
• Can be accomplished surgically by:
  • Transection of the vas deferens
  • Ligation or fulguration of the ends

Indications and contraindications:

• Indicated for men with a desire for permanent contraception (should be given extensive counseling)
• Contraindications:
  • Scrotal hematoma
  • Infections

Complications:

• Hematoma (≤ 5%)
• Sperm granulomas (inflammatory response to sperm leakage)
• Epididymitis
• Post-vasectomy pain syndrome
• Spontaneous reanastomosis (usually occurs shortly after the procedure)