DescriptionAn in-depth report on the birth control options available to women.
Alternative NamesDiaphragm; Norplant; Oral Contraception; Tubal Ligation
Spermicidal and Barrier Contraception
Barrier contraceptives are devices that provide a mechanical barrier between the sperm and the egg. Examples of barrier contraceptives include the male condom, female condom, and the diaphragm. [For a description of the male condom, see Box Male Condom.] Barrier devices are the only contraceptive methods that can help prevent sexually transmitted diseases (STDs).
Spermicides are sperm-killing substances available as foams, creams, or gels, and are often used in female contraception with barrier and other devices. Spermicides are usually available without a prescription or medical examination.
The active ingredient in US-made spermicides is usually nonoxynol-9, which attacks the surface of the sperm cell. Nonoxynol-9, however, does not provide any additional protection against sexually-transmitted diseases. In fact, research now suggests that frequent use may cause vaginal injuries and actually increase the risk for HIV transmission in women. In addition, use of a spermicide with a barrier device also poses a two- to three-fold risk for a urinary tract infection in women, regardless of whether the device is a condom or diaphragm. Spermicides are no longer recommended with male condoms. Some experts question their use with the diaphragm, suggesting that they may not even add much protection against pregnancies. A major analysis of current research found only one study that reported enhanced protection, but it had limitations.
In general, spermicides may be an appropriate choice for women who have intercourse only once in a while, or need backup protection against pregnancy (for instance, if they forget to take their birth control pills). Spermicides should not be used alone as the primary method of birth control. Nor should they be used to prevent sexually transmitted diseases.
The diaphragm, which is generally used with a spermicidal cream, foam, or gel, is a small dome-shaped latex cup with a flexible ring that fits over the cervix. The cup acts as a physical barrier against the entry of sperm into the uterus. The spermicide provides added chemical protection. (Of note: some evidence suggests that spermicide does not add any additional protection, but more studies are needed to confirm this. Current spermicides, in any case, do not protect against sexually transmitted infections.)
There are three basic rim designs.
Diaphragms come in different sizes and require a fitting by a trained health care provider. The health care provider also advises and prescribes the correct size of diaphragm for the user. Some women will need to be refitted with a different-sized diaphragm after pregnancy, abdominal or pelvic surgery, or weight loss or gain of 10 pounds or more. As a general rule, diaphragms should be replaced every one to two years.
Although the diaphragm has a relatively high failure rate, even with perfect use, it is considered a good choice for women whose health or lifestyle prevents them from using more effective hormonal contraceptives. Certain conditions of the vagina and uterus, a history of toxic shock syndrome, or a history of recurrent urinary tract infections, may disqualify a woman from using the device. The diaphragm should not be used if either partner is allergic to latex or spermicides.
Using and Inserting the Diaphragm. The diaphragm can be placed in the vagina up to one hour before intercourse and can be used even when a woman is menstruating. The following are general guidelines for insertion:
Advantages of the Diaphragm. The diaphragm can be carried in a purse, can be inserted up to an hour before intercourse begins, and usually cannot be felt by either partner. It appears to protect against cervical gonorrhea, Chlamydia, and trichomoniasis, although more research is needed to confirm this. It does not provide protection against sexually-transmitted infections in areas other than the cervix.
Disadvantages and Complications of the Diaphragm. Some disadvantages or complications are as follows:
The cervical cap (Prentif, FemCap) is a thimble-shaped latex cup that fits over the cervix and is always used with a spermicidal cream or gel. It is like the diaphragm, but smaller, and is available in only four sizes. The cap is sold by prescription and requires a pelvic examination, Pap test, and fitting by a health care provider.
Insertion and Use of the Cervical Cap. After a small amount of spermicide is placed in the cap, the device is inserted by hand. As in diaphragm use, instruction and practice is required. The cap must be kept in the vagina for eight hours after the final act of intercourse. Caps wear out and should be replaced every one to two years. A refitting may also be needed when a woman experiences certain changes in her health or physical status.
Candidacy for the Cervical Cap. Because of the restricted range of available sizes, about one woman in five will not be able to be fitted for the cap. The cap is not widely used, and some women, particularly those who live in sparsely populated areas, may not have access to health care professionals who are trained in fitting this device. Other conditions that can preclude cap use include the following:
Advantages of the Cervical Cap. Among women who have never given birth, the caps failure rate, at least with Prentif cervical cap, is similar to that of the diaphragm. (The FemCap appears to have a higher failure rate.) The cap in general is also similar to the diaphragm in terms of cost, ease of use, protection against STDs, and also the potential for latex or spermicidal allergies. But unlike the diaphragm, the cap can safely remain in the vagina for up to 48 hours (twice the time limit for a diaphragm), so it can be inserted well in advance of intercourse. The cap is rarely associated with urinary tract infections, and no documented cases of toxic shock syndrome have been reported.
Disadvantages of the Cervical Cap. The following are disadvantages of the cervical cap.
The female condom (e.g., Reality, Femidom) is a lubricated, loose-fitting pouch that lines the vagina. It is designed to create a physical barrier against sperm and sexually transmitted diseases by surrounding the penis during intercourse. The failure rate for the female condom is about the same as for the diaphragm and cervical cap. It is available without a prescription but may be hard to find.
Use and Insertion of the Female Condom. The female condom is about three inches wide and six to seven inches long (larger than a male condom), with a flexible ring at both ends. Current products are made of polyurethane.
The insertion process may seem daunting at first but becomes much easier with practice:
The female condom should be removed in the following circumstances:
The female condom may be the best option for women at risk for sexually transmitted diseases and who are not certain that their male partner will use a condom. There are virtually no obstacles against its use except a negative psychological perception. It is not completely fail-proof against pregnancy or sexually transmitted diseases.
Advantages of the Female Condom. In one study, 75% of the women preferred the female to the male condom. Many men also find it more appealing than the latex male condom. The female condom has a number of advantages over the male condom:
Disadvantages and Complications of the Female Condom. Compliance rates are low for many reasons. About 25% of women have difficulty on the first attempt at self-insertion. Some women are distressed by self-insertion. The inner ring may be uncomfortable for some women (in which case it can be removed). Some couples complain that the female condom is unpleasant to look at and can be noisy during intercourse. Without sufficient lubrication, it can also be pushed out of place by the penis. Using more lubricant can help keep the female condom in place and reduce the noise. Female condoms are also expensive (about $3.00 each) and some women wash them out and reuse them to save money. (In such cases, they should be disinfected first and then washed carefully.) Repeated washings can increase the risk for damage and holes. It is not known how many rewashings are safe.
The sponge (Protectaid, Today) is a disposable form of barrier contraception. It is made of soft polyurethane, is round in shape, and fits over the cervix like a diaphragm, but is smaller and easily portable. In the US, the Today sponge was very popular for ten years but was discontinued in 1994 after a few reports of toxic shock syndrome. It is now available in Canada and is expected to be back on the US market in late 2003 or early 2004. Of note, the Today sponge contains ten times the amount of the spermicide, nonoxynol-9, than other products, and there is some evidence that this spermicide may even increase the risk for HIV. The Protectaid sponge is currently available in Canada. It contains a mix of three spermicides (nonoxynol-9, sodium cholate and benzal konium chloride). There have been few studies on the Canadian device.
Use and Insertion. To use the sponge, the woman first wets it with water, then inserts it into the vagina with a finger, using a cord loop attachment. It can be inserted up to six hours before intercourse and should be left in place for at least six hours following intercourse. The sponge provides protection for up to 12 hours. It should not be left in for more than 30 hours from time of insertion.
The sponge should not be used during menstruation, after childbirth, miscarriage, or termination of pregnancy, or by women with a history of toxic shock syndrome.
Advantages. Because the sponge is not felt during intercourse and can be inserted up to six hours before intercourse, it encourages spontaneity. It appears to protect against cervical gonorrhea and Chlamydia.
Disadvantages. Failure rates (about 10%) are higher than with the diaphragm. There is a very small risk for toxic shock using the sponge, as there is for other barrier methods of contraception. People who are allergic to spermicides should not use the sponge. The sponge does not protect against HIV or sexually transmitted diseases outside the cervix. It increases the risk for candidiasis (yeast infection).
The Lea shield is made of silicone and its cup-shaped bowl completely surrounds the cervix without resting on it. The shield, therefore, does not need to be fitted, and manufacturers showed results equal to the diaphragm and cap when used with spermicide. Its advantages are as follows: