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
Comparison of the effectiveness of hormonal and nonhormonal contraceptives
Image by Lecturio.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- The penis is completely withdrawn from the vagina prior to ejaculation.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
An unrolled male condom
Image: “An unrolled male condom” by Béa. License: Public DomainSpermicides
- 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
- A reusable, dome-shaped rubber cup with a flexible rim that fits over the:
- 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
- Conventional latex diaphragm:
- 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
A contraceptive diaphragm
Image: “A contraceptive diaphragm” by Axefan2. License: Public DomainCervical 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
An example of a copper intrauterine device
Image: “IUD contraception” by Sarang. License: Public DomainUse
- 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)
References
- Casey, F.E. (2020). Barrier contraceptives. MSD Manual Professional Version. Retrieved August 3, 2021, from https://www.msdmanuals.com/professional/gynecology-and-obstetrics/family-planning/barrier-contraceptives
- Casey, F.E. (2020). Intrauterine devices (IUDs; IUD). MSD Manual Professional Version. Retrieved August 3, 2021, from https://www.msdmanuals.com/professional/gynecology-and-obstetrics/family-planning/intrauterine-device-iuds-iud
- Casey, F.E. (2020). Permanent contraception. MSD Manual Professional Version. Retrieved August 3, 2021, from https://www.msdmanuals.com/professional/gynecology-and-obstetrics/family-planning/permanent-contraception
- Casey, F.E. (2020). Fertility awareness-based methods of contraception. MSD Manual Professional Version. Retrieved August 21, 2021, from https://www.msdmanuals.com/professional/gynecology-and-obstetrics/family-planning/fertility-awareness%E2%80%92based-methods-of-contraception
- Bartz, D.A. (2020). Pericoital contraception: diaphragm, cervical cap, spermicides, and sponge. UpToDate. Retrieved August 3, 2021, from https://www.uptodate.com/contents/pericoital-contraception-diaphragm-cervical-cap-spermicides-and-sponge
- Warner, L., et al. (2021). External (formerly male) condoms. UpToDate. Retrieved August 3, 2021, from https://www.uptodate.com/contents/external-formerly-male-condoms
- Hoke, T., et al. (2020). Female condoms. UpToDate. Retrieved August 3, 2021, from https://www.uptodate.com/contents/female-condoms
- Madden, T. (2021). Intrauterine contraception: Background and device types. UpToDate. Retrieved August 21, 2021, from https://www.uptodate.com/contents/intrauterine-contraception-background-and-device-types
- Braaten, K.P., and Dutton, C. (2021). Overview of female permanent contraception. UpToDate. Retrieved August 21, 2021, from https://www.uptodate.com/contents/overview-of-female-permanent-contraception
- Viera, A.J. (2021). Vasectomy. UpToDate. Retrieved August 21, 2021, from https://www.uptodate.com/contents/vasectomy
