Female barrier methods of contraception

Female barrier methods of contraception include caps, diaphragms and condoms. The contraceptive sponge is no longer available in the UK.

Caps and diaphragms form a physical barrier, preventing entrance of sperm to the cervix. They also provide a reservoir for spermicide.

How common are female barrier methods of contraception? (Epidemiology)

Very few women in the UK use diaphragms, caps, or female condoms. Statistics published by the Health and Social Care Information Centre (HSCIC) in 2014 regarding methods prescribed by community contraceptive clinics at first contact suggest that in the 2013-2014 year 0.1% of women used female condoms.¹ In this report diaphragms and caps do not have enough usage to make their own statistic, being part of the 2.4% "other methods" category, which also includes emergency contraception, the vaginal ring and natural methods.

Their popularity as forms of contraception has declined with the availability of more effective methods. However, they still offer options to those who are unable to use other forms through personal preference or contra-indications, or for those who desire a female-controlled form of contraception.

Indications

They are potentially suitable for use by most women, as they are non-hormonal forms of contraception. However, the relatively high failure rate should be taken into consideration.

Diaphragms²

Diaphragms are thin, dome-shaped devices made of latex or silicone. Diaphragms should lie diagonally between the posterior fornix and behind the pubic bone. They are held in place by the vaginal muscles, the tension of the ring, and the pubic bone.

• Coil spring diaphragms have a soft, flexible rim. They are made from latex or silicone and are suitable for women with a normal pelvis and deep pelvic arch. The sizes range from 60–90 mm in increments of 5 mm.

• Arcing diaphragms have a firm rim and are easier to insert. They are silicone-based and are useful for women with poor vaginal muscular support and those in whom the length or position of the cervix makes fitting a coil spring diaphragm more difficult. The sizes range from 60–90 mm in increments of 5 mm.

• Caya® is a one-size diaphragm designed to fit most women (about 80%). It is silicone-based with a flexible rim and grip dimples to help with insertion, and a removal dome to help with the removal. It is available online and over-the-counter. The Faculty of Sexual and Reproductive Healthcare (FSRH) advises that Caya® will not be suitable for all women and some women may still require assistance from a health professional to ensure correct fitting prior to use.

Caps²

Cervical caps are smaller than diaphragms. They fit directly over the cervix and are held in place by suction and by support from the vaginal wall. They are an alternative for women who do not want to (or cannot) use a diaphragm, and they may fit better than a diaphragm in women with poor muscle tone or prolapse.

FemCap® is currently the only cervical cap available in the UK. It is available in 22, 26, and 30 mm sizes. It must be left in place for 6-8 hours after intercourse and may be left in place for up to 48 hours.

Spermicide^{2 3}

Spermicides provide a chemical barrier to sperm and must be used with diaphragms and cervical caps. Gygel® vaginal cream is the only prescribable spermicide currently available in the UK, and contains nonoxinol-9 (N-9). N-9 is a surfactant that disrupts cell membranes.

Epithelial disruption in the vagina and rectum has been identified with N-9 use in studies. Repeated and high-dose use of N-9 is associated with an increased risk of genital lesions, which may increase the risk of HIV acquisition/transmission. The use of condoms lubricated with N-9 is therefore not recommended.

There is no evidence that condoms lubricated with spermicide provide additional protection against pregnancy or sexually transmitted infections (STIs) compared with condoms lubricated with a non-spermicidal lubricant.

Female condom²

Femidom® is currently the only female condom available in the UK and is only available in one size. It is a loose-fitting polyurethane sheath pre-lubricated with dimethicone, an odourless, non-spermicidal lubricant.

The closed end of the condom has a polyurethane ring that is placed inside the vagina. The condom then lines the vagina, and the opening of the condom (which also has a polyurethane ring) lies just outside the vagina.

Contraceptive efficacy²

Female condom:

• When used consistently and correctly, the female condom can be up to 95% effective at preventing pregnancy (5% of women will conceive within the first year of use due to method failure).

• When used typically, 21% of women will conceive within the first year of use due to method failure or user failure.

Diaphragm:

• When used consistently and correctly, 6% of women will conceive within the first year of use due to method failure.

• When used typically, 12% of women will conceive within the first year of use due to method failure or user failure.

Cervical cap:

• In parous women:

  • When used consistently and correctly, 20% of women will conceive within the first year of use due to method failure.

  • When used typically, 24% of women will conceive within the first year of use due to method failure or user failure.

• In nulliparous women:

  • When used consistently and correctly, 9% of women will conceive within the first year of use due to method failure.

  • When used typically, 12% of women will conceive within the first year of use due to method failure or user failure.

Prevention of sexually transmitted infections (STIs)²

• Consistent and correct use of the female condom is recommended to reduce the risk of transmission of C. trachomatis, N. gonorrhoea, T. vaginalis and genital HPV.

• Consistent and correct use of female condoms may be advised to help reduce the risk of transmission of HIV, syphilis and HSV (during symptomatic episodes of HSV, avoidance of vaginal, anal, and oral sex may be advisable). Transmission of HSV can still occur by viral shedding even when there are no symptoms.

• There is little evidence that diaphragms and cervical caps reduce the risk of transmission of sexually transmitted infections, including HIV, or the development of cervical intraepithelial neoplasia (CIN).

Advantages⁴

• No serious side-effects.

• Female-controlled.

• May be a useful choice where fertility is reduced (eg, breast-feeding, perimenopause).

• More independent of intercourse than condoms, allowing greater sexual spontaneity (caps and diaphragms).

• No loss of sensation (caps and diaphragms).

• Diaphragms and caps may be preferred to female condoms as female-controlled barrier methods, as there is less perceived interference with sexual pleasure.

Disadvantages⁴

• Less effective than other methods.

• Requires motivation and careful use.

• Requires some forward planning and confidence examining one's genitals.

• Must be used with spermicide which can make it messy and cause irritation or allergy.

• The female condom is noisy.

• Diaphragms and caps require fitting on at least an annual basis and education from a trained health professional.

• May increase risk of urinary tract infections (UTIs) - mostly with diaphragms.

Contra-indications^{2 5}

These are taken from the UK medical eligibility criteria (UKMEC) based on the World Health Organization (WHO) criteria. There are no absolute contra-indications (UKMEC category 4), and all conditions are UKMEC category 1 (no restriction) for female condoms. The following are UKMEC category 3 for diaphragms and caps, meaning usually the risk outweighs the benefits:

• The patient is known to have, or is at high risk of, HIV/AIDS. This is because there is evidence that repeated high-dose use of the spermicide nonoxynol-9 is associated with increased risk of genital lesions, which may increase the risk of acquiring HIV. (These are UKMEC 3 due to the risk associated with the spermicide and therefore the restriction applies to diaphragms and caps. However, the consistent and correct use of female condoms may reduce the risk of HIV transmission.)

• History of toxic shock syndrome.

• Latex allergy (consider a silicone device). These women can use a silicone diaphragm or cervical cap, or a polyurethane female condom.

• Spermicide allergy.

Additional cautions include:

• Anatomical constraints - inadequate retropubic ledge, or uterovaginal prolapse. However, cervical/vault caps may be possible. Also, markedly anteverted cervix or septate vagina, or severe obesity.

• Woman unable to insert or remove the device.

• Cervical cancer or cervical intraepithelial neoplasia (applies to caps only).

• Do not fit diaphragms/caps until six weeks postnatal to allow anatomy to be restored to normal.

Fitting and follow-up: caps and diaphragms²

Initial visit

• Counsel fully to check the method is acceptable to the woman and that she is fully informed regarding risks/benefits, and provide reinforcing written information.

• Pelvic examination to assess suitability. The bowel and bladder should be emptied prior to fitting. Ideally, caps should be fitted mid-cycle.

• Select a size for a practice device (for a diaphragm, this should approximate the distance from behind the cervix to the pelvic arch).

• Start with the largest size that is comfortable. Check that the device does not fall out when the woman ambulates or performs a Valsalva manoeuvre.

• Teach the woman how to remove and insert the device. It is important that the woman should be aware of what her cervix feels like and how to check that the device fully covers the cervix when in the correct position.

• To insert a diaphragm, put your index finger on top of the diaphragm and squeeze it between your thumb and other fingers. Slide the diaphragm into the vagina in a downwards and posterior fashion. Some women find it easier to squat and others to lie down for insertion.

• To insert a cap, squeeze the sides of the cap together and hold between the thumb and first two fingers, allowing it to "suction" neatly over the cervix.

• The woman goes home with a practice device. She must be aware not to rely on it for contraception until after the second visit.

Second visit

The woman should return with the device in situ to enable the positioning and size of the device to be checked. Any problems the woman has encountered fitting it should be fully explored.

Give specific instructions:

• Insert the device before sexual intercourse.

• Always use with spermicide.

• Use a total of 10 cm cream or jelly or one pessary (allowing 10 minutes to dissolve fully).

• Spermicide is only active for one to three hours, so if intercourse continues for longer than this time, or is repeated after this time, re-insert spermicide.

• Leave the device for at least six hours following sexual intercourse, but for no more than 30 hours (up to 48 hours for the cap).

• After removing the device, wash it in warm water and soap if required and dry before putting it away.

• Never use with oil-based products (eg, antifungal formulations, oestrogen creams, emulsifying ointment, Vaseline®, and massage oils), as these can cause the latex to decay more rapidly.

• Check for puckering and holes - if present, the device should be replaced urgently.

Monitoring

Follow-up should be on an annual basis since devices should be replaced at that interval (unless there is earlier evidence of damage):

• Any weight change of more than 3 kg should prompt a review.

• Fitting should also be checked after childbirth (at least six weeks postpartum), termination or miscarriage.

Reasons for women discontinuing use of diaphragms include:

• Difficulty with removal and insertion.

• Perception that leaving the diaphragm in the vagina after sex is "dirty".

• Desire for a more reliable form of contraception.

Complications

• Difficulty with insertion:
  

  • Try a different size.

  • Try an arching spring diaphragm.

  • Try an applicator.

• Recurrent UTIs:
  

  • Advise women to empty the bladder before and after intercourse.

  • Try a smaller size or coil spring diaphragm.

  • Change to a vault or cervical cap.

• Vaginal soreness:
  

  • Check size.

  • Treat any infection.

  • Try an alternative spermicide.

  • Consider rubber allergy.

• Partner feeling the device:
  

  • Check size.

  • Change to a coil spring device.

  • Change to a vault or cervical cap.