Nonhormonal Contraception

Nonhormonal contraception does not affect the reproductive hormones in women. Nonhormonal contraception includes physiological methods, barrier methods, surgical methods, or the use of a copper intrauterine device. Each method has a different mechanism and extent of efficiency in preventing pregnancy. It is important to note that most physiologic methods are associated with high failure rates. On the other hand, surgical methods are permanent and highly effective.

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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
Effectiveness of hormonal and non-hormonal contraception

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  • The penis is completely withdrawn from the vagina prior to ejaculation.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
Unrolled male condom nonhormonal contraception

An unrolled male condom

Image: “An unrolled male condom” by Béa. License: Public Domain

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
Contraceptive_diaphragm

A contraceptive diaphragm

Image: “A contraceptive diaphragm” by Axefan2. License: Public Domain

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
Copper intrauterine device

An example of a copper intrauterine device

Image: “IUD contraception” by Sarang. License: Public Domain

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)

References

  1. 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
  2. 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
  3. 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
  4. 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
  5. 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
  6. Warner, L., et al. (2021). External (formerly male) condoms. UpToDate. Retrieved August 3, 2021, from https://www.uptodate.com/contents/external-formerly-male-condoms
  7. Hoke, T., et al. (2020). Female condoms. UpToDate. Retrieved August 3, 2021, from https://www.uptodate.com/contents/female-condoms
  8. 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
  9. 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
  10. Viera, A.J. (2021). Vasectomy. UpToDate. Retrieved August 21, 2021, from https://www.uptodate.com/contents/vasectomy

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