Lecture 9 Over the Counter Reproductive Health Care Peterson

SPERMICIDES, FILMS AND CONTRACEPTIVE SPONGE:

SPERMICIDE: N-9 SPERMICIDES:
• Chemical agent that kills or immobilizes sperm • MOA: acts as a surfactant which destroys sperm cell membrane by
• Spermicidal agent incorporated into vehicle allowing for dispersal and altering lipid layer so that spermatozoon becomes permeable and swells,
retention of spermicide in vagina where it acts as both a physical and with breakage of plasma and acrosomal membranes
chemical barrier to sperm motility o Minimum effective dose: 100 mg N-9
o Failure rate : 18 – 28%
SPERMICIDAL AGENTS: • May also increase genital irritation or cause epithelial disruption leading
• Spermicidal active ingredients commonly used: to easier transmission of HIV and other STIs
o Noxynol-9 (N-9) • Associated with ↑ risk of E. coli UTIs due to alteration of vaginal flora
o Lactic acid
o Menfegol CONTRACEPTIVE FILM – VCF:
• Formulated in a safe, inert vehicle consisting of ≥ 1 suitable thickening • MOA: physical and chemical barrier to sperm
agents, humectants, buffering agents, preservatives & water o N-9 in film base that dissolves at body temp to form gel barrier
o Failure rate: 6 – 28%
SPERMICIDE INDICATIONS: • Effective after 15 mins and up to 3 hours after insertion
• Suitable contraceptive for women unable/unwilling to use hormonal or o Additional film required for each act of intercourse
IUD methods • Available on pharmacy shelves and online
• Dual protection with other methods of contraception as important
contributor to efficacy of contraceptive devices (sponge, male condom, CONTRACEPTIVE SPONGE – TODAY:
diaphragm and cervical cap) • Small, one-size-fits-all, disposable, polyurethane foam device intended
to fit over the cervix impregnated with a spermicidal agent
SPERMICIDE CONTRAINDICATIONS: o MOA: contraceptive action primarily provided by the
Absolute • High risk for HIV spermicide impregnated in the sponge, augmented by its ability
Relative • Allergy to spermicidal agent to absorb and trap sperm
• History of TSS o Failure rate: 9-12% in nulliparous; 20-24% in parous women
• HIV positive or AIDs diagnosis • Effective for multiple acts of intercourse over 24-hour period
• Use of antiretroviral therapy o May be forgotten and left in place = toxic shock potential
Not • Women uncomfortable touching their genitals • Available on pharmacy shelves & internet
recommended • Women with personal/medical need for highly
for: effective contraception
• N-9: women with chronic UTIs LACTIC ACID SPERMICIDES – CONTRAGEL, CAYA GEL:
• Sponge/film: women with abnormal vaginal • MOA: some evidence that lactic acid reduces pH of vagina, reducing
anatomy, physical disabilities or neurological sperm motility
impairment which limits ability to insert or o Marketed as a green, natural, alternative to N-9 spermicides
remove the device ▪ Less irritating than N-9
• Sponge: within 6 weeks of delivery, miscarriage o Failure rates: ??
or abortion • Compatible with latex, polyurethane and silicon devices

MALE CONDOMS:
MALE CONDOMS: AVAILABILITY:
MOA: • Physical barrier • Non-prescription – various brands
o Prevents passage of sperm • Various shapes, sizes, textures, colors, lubrications
o Decreases contact with semen, bodily fluids & genital lesions • Various materials including: latex, polyisoprene,
INDICATIONS: • Prevention of pregnancy – ideally dual protection polyurethane, tactylon, lambskin
• Prevention of transmission of STIs and cervical dysplasia • Optimal fitting requires trying variety of condoms
EFFECTIVENESS: • Contraceptive failure rate: 3 – 14% o Online condom sizing charts available
• STI transmission failure rate: variable

CONDOM TYPES:
LATEX: • Manufactured from natural latex rubber; 0.3 – 0.8 mm thickness
• Offered in variety of colors, shapes, sizes, widths, lengths, textures and lubrication
• CANNOT be used by those sensitive/allergy to latex OR with oil-based lubricants
• Offer BEST protection against pregnancy
POLYISOPRENE: • Manufactured from latex that has been put through a process to remove latex allergens
o Fewer medical events than latex condoms
o Transmits more heat, allowing more sensitivity
• Similar to latex in terms of preventing pregnancy & transmission of STIs (no published data)
• Cannot be used with oil-based lubricants
POLYURETHANE: • May offer better physical properties than latex condoms:
o Similar to polyisoprene in terms of warm feel; can be formulated to feel thinner than actually are; less constricting fit
o More resistant to deterioration; compatible with oil-based lubricants BUT higher slippage and breakage rates than latex
o Can be used by those sensitive or allergic to latex
o More expensive
LAMBSKIN: • Made from lamb’s intestine; cannot be used by those with lanolin sensitivity
• Not recommended because of lack of protection against STIs transmitted by viral organisms
o Lab tests have shown passage of HIV, hepatitis B & HSV through small pores on surface of lambskin condoms
Lecture 9
MALE CONDOMS (CONTINUED):
COMMON CAUSES OF CONDOM FAILURE:
1. Slippage rates: between 0.90 – 1.28%
• Associated with use of lubricants:
o ↑ rates in vaginal intercourse
o ↓ anal in vaginal intercourse
2. Breakage rates: between 2.8 – 3.42%
• Rough handling
• Lengthy/intense intercourse
• Use of oil-based lubricants
• Incorrect storage and usage after expiry date
• Failure to leave space or remove air at tip
• Concurrent use of alcohol and/or drugs
3. Late application or early removal
4. Inconsistent use; non-use; re-use
5. Applying condom inside out
Over the Counter Reproductive Health Care
ADVANTAGES VS. DISADVANTAGES:
Advantages
• Protection against STIs
• ↓ likelihood of infertility or
cervical neoplasia by ↓ risk of STIs
• Up to 80% reduction in HIV
transmission when used correctly
or consistently
• Relatively inexpensive
• Widely available and accessible
• More/less stimulation –
premature ejaculation
• No prescription required
• Convenient/portable/discreet
• Low incidence of side effects
• Enhances other contraceptive
methods
Peterson
Disadvantages
• May break or slip
• Requires motivation & responsibility to use
• Interrupts intercourse – must be put on the
penis before any genital contact
• Loss of spontaneity
• Potential latex allergy and lanolin sensitivity
to lambskin condoms
• Decreased sensation
• May interfere with maintenance of erection
• Awareness of presence
• May have unpleasant taste
• Less protection against HSV or HPV
• Must withdraw promptly after ejaculation
• Can be used only once
• N-9 lubricated condoms increase risk of E.
coli and UTIs + transmission of HIV and STIs

FEMALE CONDOMS:
FEMALE CONDOMS: TYPES OF FEMALE CONDOMS:
MOA: • Physical barrier • FC1 – original female condom (polyurethane)
o A soft, loose, fitting sheath which acts as an intravaginal • FC2 – 2nd generation female condom (nitrile rubber)
barrier to semen and bodily fluids o More cost-effective
INDICATIONS: • Prevention of pregnancy o Efficient manufacturing process
• Prevention of transmission of STIs o No seam in the condom
EFFECTIVENESS: • Contraceptive failure rate: 5 – 21% o Softer material that is quitter during use
• STI transmission failure rate: variable (as much as male condom) o Thicker and less tear resistant

ADVANTAGES VS. DISADVANTAGES: REALITY FEMALE CONDOM:

Advantages
• Protects against pregnancy about
as well as a male condom
• Decreased risk of STIs
• Less likely to cause allergic
reaction vs. male latex condom
• Less likely to break or tear than
latex male condom
• Does not deteriorate on exposure
to oil-based lubricants
• 1. Breakage rates: 0.5 – 2.1%
No prescription required
• Shared responsibility with partners
• A woman can place it
autonomously and has full control
of effectiveness
• Adjusts well to anatomy of vagina
• Less disruptive than male condom
– can be inserted ahead of time
(up t o 8 hours prior)
• Withstands storage better than
latex – shelf-life up to 5 years
Disadvantages • Soft, thin sheath with 2 flexible rings; one unattached
• Should be used only once ring at one end (closed) and slightly larger, attached
• Costs $3-5 per condom ring at opposite end (open) of condom
• Availability issues o Inner ring is inserted into vagina & placed over
• Insertion and removal difficulties – need cervix to anchor it in place in vagina
to practice insertion and use device o Outer ring rests outside vagina & keeps condom
several times before confident with use from being pushed inside vagina during use
• Higher slippage rates than male condom
• Outer ring is somewhat cumbersome
COMMON CAUSES OF CONDOM FAILURE:
• Aesthetically unacceptable to some
• Pain during intercourse – inner ring may
cause some discomfort during coitus 2. Slippage rates: 5.1 – 6.13%
• Does not provide complete protection 3. Invagination (outer ring gets pushed in)
against all STIs 4. Misdirection (penis misses condom)
• Higher failure rate than male condom
• Polyurethane product makes crackling
and popping noise during intercourse
(noise with FC1 condom)

DIAPHRAGM AND CAPS:

DIAPHRAGM: A soft shallow silicone dome-shaped contraceptive device with either an encased flexible steel or nylon rim around its edge
Milex Wide-Seal Diaphragm SILCS Caya Diaphragm
• Flexible steel rim (arching & omniflex rim styles) + silicone dome • Nylon rim + silicone dome
o Wide rim provides increased suction and seal • Available in one size (67 mm)
• Available in eight sizes (60-95 mm) • No fitting necessary – fits most women (sized between 65-80
• Pelvic exam and fitting required by trained clinician mm for traditional diaphragm)
• Yearly replacement recommended • Replace every 2 years
CERVICAL CAP: • FemCap available online; 22, 26, 30 mm sizes (sizing based on obstetrical history)
• Replace yearly
MOA: Contraceptive devices designed to be used in conjunction with spermicidal gel providing both physical & chemical barrier to spermatozoa
INDICATIONS: • Prevention of pregnancy
• Well suited for women who do not wish to use hormonal contraception for personal or medical reasons
• Caps often used by women who cannot use a diaphragm
EFFECTIVENESS: • Diaphragm failure rate: 6-12% (N-9); 12 – 23.6% (N9 or acid buffering)
• Cap failure rate: nulliparous 14%, parous 29%
Lecture 9 Over the Counter Reproductive Health Care Peterson

DIAPHRAGM AND CAPS (CONTINUED):

CONTRAINDICATIONS AND CAUTIONS: DIAPHRAGM ADVANTAGES VS. DISADVANTAGES:
DIAPHRAGMS • Known hypersensitivity to silicon Advantages Disadvantages
& CAPS: • History of toxic shock syndrome (TSS) • Ability to insert device • Must be used with spermicide
• Use within 6 weeks of childbirth just before intercourse (most effective)
DIAPHRAGMS • Uterine prolapse, rectocele or cystocele or up to 30-60 min • Refitting is required after
• Acute or chronic – recurrent UTIs prior may allow more pregnancy, abortion, miscarriage,
• Refit required after childbirth, 2nd trimester spontaneity pelvic surgery, or significant
abortion, genital surgery or weight gain/loss > 10 lbs • Rarely causes weight loss/gain (10-20 lbs)
CAYA • Women previously fit with diaphragm sizes > 60 mm discomfort and reduced • Proper insertion requires practice
DIAPHRAGM or > 85 mm pleasure during • Some require fitting by trained
intercourse clinician
• Convenient for women • Showering after intercourse is
CAPS DISADVANTAGES VS. DISADVANTAGES: only requiring safe but bathing is not – may
Advantages Disadvantages contraceptive on an wash away spermicide
• Smaller and generally • Does not protect against occasional basis • If multiple acts of intercourse
more comfortable than a transmission of STIs or HIV occur during a 6-hour period,
diaphragm • More difficult to insert than must re-apply spermicide before
• Requires less spermicide diaphragm each act
than a diaphragm • Bacteria may grow inside the cap – • May increase risk of persistent UTI
• Inexpensive and re-usable TSS – pressure on bladder can change
• May be left in place for up • Unpleasant odor if used for longer size or rim type
to 48 hours than 48 hours • May increase risk of Toxic Shock
• Higher failure rate than diaphragm Syndrome (TSS)
• Less effective in nulliparous • Odor if left in place longer than
women recommended
• Potential allergic rxn to material

LUBRICANTS:
PERSONAL LUBRICANTS:
• Used during intercourse to:
o Reduce friction with genital/anal tissue
o Increase comfort and pleasure during sexual intercourse
o Relieves vaginal dryness associated with:
▪ Certain medications
▪ Low estrogen levels during peri-menopause, menopause, post-partum period, breastfeeding, and immediately following menses
▪ Sexual dysfunction
• Types of lubricants: water, silicon, oil

FORMULATION: WATER-BASED FORMULATION: SILICONE

• Most are made up of one or more of the following ingredients:
o Hydrophilic polymers
o Humectants (glycols)
o Viscosity modifiers (cellulose)
o Moisturizers (cellulose, glycols)
o Preservatives (parabens, sorbates, phenoxyethanol, benzoic acid)
o pH balancing agent
• Many water based lubricants are hyperosmolar causing fluid loss from
vaginal and rectal cells resulting in fragility and damage to the epithelium,
potentially increasing the risk of transmission of STIs and HIV
o Glycerin, glycerol and glycol containing products implicated
• Alternative to water-based lubricants
• Chemically inert and water resistant
• More expensive than water-based lubricants
• Common ingredients: cyclomethicone, dimethicone, silicone,
dimethicone copolyol – all silicone liquids that combine together to
create inert silicone lubricant
FORMULATION: OIL-BASED – NOT RECOMMENDED
• Petroleum-based and other oils destroy latex upon contact (some
condoms, historically some diaphragms, and protective coatings
around some IUDs)
• Oils can be irritating, difficult to remove and can coat inside of
vagina/rectum providing a breeding ground for pathogenic bacteria

ADVANTAGES VS. DISADVANTAGES:

Lubricant Advantages Disadvantages
Water-based • Relatively low cost • Tendency to dry out during use, requiring constant reapplication
• Easily washes away with water • Incompatible with sexual activity occurring in water
• Most widely available on market • Potential for hyperosmolar products to disrupt vaginal/rectal epithelium and
increase risk of STI transmission
Silicone-based • Ideal for using in or under water • May leave an oily residue on skin/fabric
• Constant reapplication not necessary • More expensive
• Available in a variety of consistencies • Not all silicon products compatible with latex - * check label
Lecture 9 Over the Counter Reproductive Health Care Peterson

FERTILITY AWARENESS METHODS (FAM) OF CONTRACEPTION:

• Rely on an understanding of the physiology of the menstrual cycle and the timing of ovulation to schedule intercourse in order to prevent a pregnancy
• Can be also used to maximize the potential for conception
• Several FAM including Standard Days, Calendar Days, Sympto-thermal, Cervical Mucus, Two Day and Basal Body Temperature methods

BASAL BODY TEMPERATURE METHOD:

• Measure temperature daily to detect an increase of 0.2 – 0.6o C over 3 days (stays elevated till beginning of next cycle)
o When ovulation occurs, progesterone is released which causes this rise in temperature
• Use a basal thermometer which detects smaller fluctuations than a regular thermometer
• Helps predict window of next cycle (won’t help in the same cycle)