Patient education: Barrier methods of birth control (Beyond the Basics)
- Andrew M Kaunitz, MD
Andrew M Kaunitz, MD
- Professor and Associate Chairman
- Department of Obstetrics and Gynecology
- University of Florida College of Medicine-Jacksonville
BARRIER BIRTH CONTROL OVERVIEW
Barrier methods of birth control physically block or otherwise prevent sperm from entering the uterus and reaching the egg for fertilization. Barrier contraceptives include the condom, diaphragm, and cervical cap. These methods:
●Have fewer side effects than hormonal contraceptives
●Offer effective protection against certain sexually transmitted diseases (STDs)
●Are available without a prescription (condom and spermicides)
Spermicides (contraceptive creams or gels) are chemical substances that destroy sperm. They are available over the counter and are typically recommended in combination with some barrier contraceptives to maximize the contraceptive effect (see 'Spermicide' below).
This topic discusses barrier methods of birth control, including the condom, diaphragm, cervical cap, sponge, and spermicides. A discussion of hormonal and long-term birth control methods is available separately. (See "Patient education: Hormonal methods of birth control (Beyond the Basics)" and "Patient education: Long-acting methods of birth control (Beyond the Basics)".) An overview of all birth control methods is also available. (See "Patient education: Birth control; which method is right for me? (Beyond the Basics)".)
CHOOSING A BIRTH CONTROL METHOD
It can be difficult to decide which birth control method is best due to the variety of options available. The best method is one that will be used consistently, is acceptable to the woman and her partner, and which does not cause bothersome side effects. Other factors to consider include:
●Duration of action
●Reversibility and time to return of fertility
●Effect on uterine bleeding
●Frequency of side effects and adverse events
●Protection against sexually transmitted diseases
No method of contraception is perfect. Each woman must balance the advantages of each method against the disadvantages and decide which method she prefers. A list of questions that are useful for defining a person's preferences are provided in the table (table 1).
Emergency contraception (EC, also known as postcoital contraception or the morning-after pill) refers to the use of drugs to prevent pregnancy in women who have had recent unprotected intercourse (including sexual assault), or who have had a failure of another method of contraception (eg, broken condom). Since barrier methods can have high failure rates in couples during typical use, it is recommended that couples choosing these methods have a supply of emergency contraceptive available at home to use if needed (condom breakage, forgot to use method). Emergency contraception is discussed in detail in a separate topic (see "Patient education: Emergency contraception (morning after pill) (Beyond the Basics)").
Male condom — Male condoms are a thin, flexible sheath or cover that is placed over the penis to prevent semen from entering the partner's body during sexual intercourse. To help ensure optimal effectiveness and protection, people who use condoms must carefully follow instructions for their use.
Spermicidal condoms (those that are packaged with spermicide applied to the condom) are no more effective and expire faster than condoms without spermicide, and therefore are not recommended.
When used properly, condoms can also reduce the risk of sexually transmitted infections such as HIV. Studies have found the following:
●There is a decreased risk of gonorrhea, chlamydia, trichomonas, syphilis, HIV, and HPV (human papillomavirus, which can cause genital warts and cervical cancer) in women whose male partner consistently uses condoms. (See "Patient education: Genital warts in women (Beyond the Basics)" and "Patient education: Cervical cancer screening (Beyond the Basics)" and "Patient education: Testing for HIV (Beyond the Basics)".)
●In a study of HIV-negative women whose only risk for infection was a stable relationship with an HIV-infected man, none of the women who consistently used condoms became infected.
●Regular use of latex condoms appears to decrease the risk of HIV infection by about 69 percent.
Oil-based lubricants (eg, suntan oil, petroleum jelly, whipped cream) should not be used with latex condoms because this can cause breakage of the condom. Water-based lubricants are safe (eg, K-Y, Astroglide).
Most condoms are made of latex, which can be a problem for people who have an allergy or sensitivity to latex. Polyurethane condoms are available as an alternative to latex. Animal skin condoms (eg, lambskin) are not recommended when there is a risk of HIV infection because they do not effectively prevent transmission of HIV.
When couples use condoms perfectly, only two women will become pregnant during the first year of use. However, with typical use, 18 women out of 100 will become pregnant.
Female condom — The female condom is worn by a woman to prevent semen from entering the vagina. It is a sheath made of nitrile and is prelubricated with a silicone-based lubricant. There is a soft, flexible ring at each end (picture 1). The edges of the ring at the closed end of the sheath are squeezed together and then inserted as far as possible into the vagina; upon release, the ring will open to hold the condom in place. The ring at the open end of the sheath remains outside the vulva, resting against the labia. The patient should check to make sure the condom is not twisted.
When couples use female condoms perfectly, only five women will become pregnant during the first year of use. However, with typical use, 21 women out of 100 will become pregnant.
The diaphragm or cervical cap is placed over the cervix before intercourse. Pregnancy is prevented by blocking sperm from entering the uterus and killing sperm with the spermicide (see 'Spermicide' below). Both require fitting by a trained clinician, and the fit should be checked after childbirth and weight loss or gain of more than 10 pounds (4.5 kilograms). A new diaphragm, called Caya, does not need to be fitted as it comes in one size for everyone to use.
Both devices can decrease the risk of certain sexually transmitted diseases and infections, including gonorrhea, chlamydia, and pelvic inflammatory disease. However, the diaphragm and cervical cap are less effective than condoms in preventing the spread of HIV infection. Diaphragms and cervical caps are not recommended for women at high risk for HIV, who are HIV infected, or who have AIDS as they do not appear to prevent transmission of the virus.
In most studies, the failure rate (number of pregnancies) was higher for users of the diaphragm or cervical cap compared to hormonal methods of birth control (eg, the birth control pill).
When couples use the diaphragm perfectly, only six women will become pregnant during the first year of use. However, with typical use, 12 women out of 100 will become pregnant.
Diaphragm — The diaphragm is a soft dome-shaped cup made of latex rubber or silicone with a flexible rim. Before intercourse, the hollow of the dome is partially filled with a spermicidal cream or jelly and then the diaphragm is inserted deep into the vagina and positioned so that it fits over the cervix (picture 2). It must be left in place for six to eight hours after sexual intercourse, and then should be removed. If the woman has sex more than once during this time, an additional dose of spermicide should be inserted into the vagina.
Precautions — Most women can use the diaphragm; however; it is not a good method for those who have an allergy/sensitivity to latex, silicone, or spermicides; significant pelvic relaxation (uterine prolapse, cystocele, rectocele, poor vaginal tone); frequent urinary tract infections; HIV infection or are at high risk for acquiring HIV; or have difficulty with the insertion process. Women with a history of toxic shock syndrome should not use a diaphragm.
Cervical cap — The cervical cap is available in latex (the Prentif cap) or silicone rubber (FemCap) in multiple sizes. Similar to the diaphragm, it is partially filled with spermicide and placed over the cervix. It can remain in place for up to 48 hours.
OTHER BARRIER METHODS
The contraceptive sponge blocks sperm from entering the uterus and contains a spermicide to kill sperm. It can be purchased without a prescription.
Sponge — The Today sponge is a 2-inch wide circular disk that is 3/4 of an inch thick and attached to a loop that is used for removal. It contains a spermicide, and is moistened with tap water before insertion deep in the vagina.
The sponge can be left in place and used repeatedly for up to 24 hours.
When women with no previous births use the sponge perfectly, 9 will become pregnant during the first year of use. With typical use, 12 women out of 100 will become pregnant. The failure rate is higher in women with previous births.
Spermicides are chemical substances that destroy sperm. They are available in most pharmacies without a prescription. Spermicides are available in a variety of forms including gel, foam, cream, film, suppository, and tablet.
Spermicides may be used alone, but are more effective when used in combination with a condom, diaphragm, or cervical cap. Effectiveness is reduced if the patient does not wait long enough for the spermicide to disperse before having intercourse, if intercourse is delayed for more than one hour after administration, or if a repeat dose is not applied before each additional act of intercourse.
Local irritation of the vagina is not uncommon with spermicide use, and spermicide-coated condoms are associated with an increased risk of urinary tract infection in the female partner. In the United States, the only spermicide available is nonoxynol-9; use of this spermicide alone is not effective in preventing transmission of sexually transmitted infections, including HIV.
When couples use a spermicide alone perfectly, 18 women will become pregnant during the first year of use. With typical use, 28 women out of 100 will become pregnant.
WHERE TO GET MORE INFORMATION
Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Choosing birth control (The Basics)
Patient education: Vasectomy (The Basics)
Patient education: Screening for sexually transmitted infections (The Basics)
Patient education: Syphilis (The Basics)
Patient education: Urethritis (The Basics)
Patient education: Hormonal birth control (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Hormonal methods of birth control (Beyond the Basics)
Patient education: Long-acting methods of birth control (Beyond the Basics)
Patient education: Birth control; which method is right for me? (Beyond the Basics)
Patient education: Emergency contraception (morning after pill) (Beyond the Basics)
Patient education: Genital warts in women (Beyond the Basics)
Patient education: Cervical cancer screening (Beyond the Basics)
Patient education: Testing for HIV (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Intrauterine contraception: Devices, candidates, and selection
Contraception: Overview of issues specific to adolescents
Depot medroxyprogesterone acetate for contraception
Fertility awareness-based methods of pregnancy prevention
Hormonal contraception for suppression of menstruation
Diaphragm, cervical cap, and sponge
Contraceptive counseling and selection
Overview of the use of estrogen-progestin contraceptives
Progestin-only pills (POPs) for contraception
Risks and side effects associated with estrogen-progestin contraceptives
The following organizations also provide reliable health information.
●National Library of Medicine
●National Institute of Child Health and Human Development (NICHD)
Toll-free: (800) 370-2943
●National Women's Health Resource Center (NWHRC)
Toll-free: (877) 986-9472
●Planned Parenthood Federation of America
Phone: (212) 541-7800
●The Hormone Foundation
- Fu H, Darroch JE, Haas T, Ranjit N. Contraceptive failure rates: new estimates from the 1995 National Survey of Family Growth. Fam Plann Perspect 1999; 31:56.
- Steiner MJ, Dominik R, Rountree RW, et al. Contraceptive effectiveness of a polyurethane condom and a latex condom: a randomized controlled trial. Obstet Gynecol 2003; 101:539.
- Gallo MF, Grimes DA, Schulz KF. Non-latex versus latex male condoms for contraception. Cochrane Database Syst Rev 2003; :CD003550.
- Gallo MF, Grimes DA, Schulz KF. Cervical cap versus diaphragm for contraception. Cochrane Database Syst Rev 2002; :CD003551.
- Kuyoh MA, Toroitich-Ruto C, Grimes DA, et al. Sponge versus diaphragm for contraception. Cochrane Database Syst Rev 2002; :CD003172.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.