• Clinical science

Nonhormonal contraception

Abstract

Nonhormonal contraceptive methods are a birth-control option for individuals who do not tolerate or wish to avoid the use of hormones. These methods include behavioural methods, barrier methods, spermicides, and surgical sterilization. Behavioural methods, such as coitus interruptus, periodic abstinence, and lactational amenorrhea are inexpensive and readily available, but are associated with a high failure rate because of poor compliance and unreliability. Condoms are the only contraceptive method that additionally prevents sexually transmitted infections, including HIV. Surgical sterilization techniques and copper intrauterine devices have the lowest failure rate with regular use. Other non-hormonal contraceptive methods discussed in this learning card include the vaginal douche method, diaphragm, cervical cap, and spermicides.

Overview

All contraceptive methods listed below have the benefit of avoiding adverse effects associated with hormone use.

Effectiveness of nonhormonal contraceptive methods

  • Failure rate with typical use: refers to the number out of every 100 women who become pregnant within the first year of typical use of the method of contraception.
  • Pearl index (PI): the number of unintended pregnancies in 100 women per year with perfect use of the method of contraception. The PI is the most common measure of contraceptive efficacy used in clinical studies.
Overview of nonhormonal contraceptive method
Method Failure rate with typical use (based on CDC data) Pros Cons
Behavioral methods
Lactational amenorrhea
  • ∼ 2%
  • Reversible
  • Inexpensive
Coitus interruptus
  • ∼ 22%
  • Reversible
  • Inexpensive
  • Readily available
  • No side effects
Fertility-awareness based methods
  • ∼ 24%
  • Reversible
  • Inexpensive
  • Readily available
  • No side effects
Vaginal douche
  • No data available
  • None
Intrauterine device
Nonhormonal copper device
  • ∼ 1%
Barrier methods
Diaphragm
  • ∼ 12%
  • Reversible
Condom
  • High risk for poor compliance .
  • Risk of incorrect use and complications thereof
  • Female condom: difficult placement
Sponge
  • ∼ 12% (nulliparous)
  • ∼ 24% (parous)
  • Reversible
  • Does not require professional fitting
Spermicides
  • ∼ 28%
  • Reversible
Cervical cap
  • ∼ 20–40%
  • Reversible
Surgical sterilization
Vasectomy
  • ∼ 0.15%
  • Permanent contraception
Female sterilization
  • ∼ 0.5%
  • Permanent contraception

References:[1][2][3]

Behavioural methods

For the pros and cons of individual contraception methods see overview of nonhormonal contraceptive methods above.

Coitus interruptus

Fertility-awareness based methods

  • Description: avoiding sexual intercourse during the ovulation period
  • Calendar method: The fertility period is estimated by documenting the timing of ovulation
    • Based on 3 points: (i) an egg can be fertilized for ∼ 24 hours after ovulation; (ii) the lifespan of sperm is 48 hours following ejaculation; and (iii) ovulation occurs 12–16 days before onset of the next menses.
    • Fertilization can occur anytime from 3 days before to 1 day after ovulation.
    • The fertility period is calculated after recording 6 menstrual cycles
  • Cervical mucus method: The fertility period is estimated by evaluating the abundance and consistency of cervical mucus throughout the cycle.
    • During the days leading to ovulation, cervical mucus becomes stringy and elastic, thick, and abundant.
    • Conception is more probable up to 4 days after cervical mucus reaches its maximum abundance and elasticity; intercourse should be avoided during this time.
    • Contraindicated in breastfeeding women < 6 weeks postpartum, non-breastfeeding women < 4 weeks postpartum, and in women with irregular menstrual cycles
  • Basal body temperature method: The body temperature is measured throughout the cycle. Ovulation triggers an increase in basal body temperature, thus indicating the fertility period.
  • Symptothermal method: including a combination of the basal body temperature method and the cervical mucus method

Vaginal douche

  • Unreliable method of contraception, although still practiced by over 20% of women in the US. Not a recommended form of contraception, but many women in the US still have this misconception
  • Risk of promoting unintentional pregnancy by pushing semen into the cervical canal
  • Method: The vagina is flushed with water or other products immediately after male ejaculation during intercourse in an attempt to theoretically flush semen out

Lactational amenorrhea

References:[1][4][5][3][6]

Barrier methods

For the pros and cons of individual contraception methods see overview of nonhormonal contraceptive methods above.

Condom

  • Description
    • A thin sheath that is placed over the shaft of the penis (male condom) or in the vaginal canal (female condom) prior to sexual intercourse
    • Acts as a physical barrier between penile, vaginal, and/or anal secretions
  • Contraindication: latex allergy for latex condoms
  • Complications: unintentional pregnancy or infection due to breakage (usually related to incorrect use)

Diaphragm (contraceptive)

  • Description
    • Dome-shaped latex, metal, or plastic device that holds spermicide
    • Placed into the anterior and posterior fornix of the vagina prior to sexual intercourse; must be kept in place for 6 hours after intercourse
    • Prevents passage of semen into the cervix
  • Contraindications: cervical anomalies or abnormalities (e.g., infection, malignancy), spermicide or latex allergy
  • Complication: toxic shock syndrome

Cervical cap

  • Description
    • Cup shaped latex, metal, or plastic device that holds spermicide
    • Placed over the base of the cervix; inserted up to ∼ 8 hours before sexual intercourse and must be removed after 48 hours
    • Prevents passage of semen into the cervical canal
  • Contraindications: cervical anomalies or abnormalities, spermicide or latex allergy
  • Complication: toxic shock syndrome, cervical erosion (resulting in spotting)

Intrauterine device (nonhormonal copper device)

Sponge

  • Description
    • Foam disk containing spermicidal fluid; activated by moistening with tap water and gently squeezing before inserting into the vagina
    • Inserted up to 24 hours before intercourse; should not be worn > 30 hours
    • Prevents entry of semen into the cervix and has spermicidal effects
  • Contraindications: similar to diaphragm
  • Complication: vaginal irrigation, toxic shock syndrome (rare)

Spermicide

  • Description
    • Foams or jellies that are inserted into the vagina prior to sexual intercourse
    • The active ingredient disrupts surface membranes → spermicidal effect
  • Contraindication: spermicide allergy
  • Complication: vaginal irritation

References:[4][5]

Surgical sterilization

For the pros and cons of individual contraception methods see overview of nonhormonal contraceptive methods above.

Female sterilization

  • Description: surgical interruption of the fallopian tubes
  • Methods
    • Tubal ligation with or without partial salpingectomy
    • Partial destruction of oviduct with electrocoagulation
    • Clipping or banding of the fallopian tubes
  • Can be performed under local or general anaesthesia

Vasectomy

  • Description: bilateral tubal ligation and partial destruction/removal of the vas deferens
  • Can be performed under local anaesthesia
  • Complications

References:[3]