Nonhormonal contraception

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 behavioral methods, barrier methods, spermicides, and surgical sterilization. Behavioral 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 nonhormonal contraceptive methods discussed in this article include the vaginal douche method, diaphragm, cervical cap, and spermicides.

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: 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.

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

Coitus interruptus

• Also known as the withdrawal method
• Method: The penis is withdrawn from the vagina before ejaculation.

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/elastic, thick, and abundant due to an increase in progesterone.
  • 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. The increase in progesterone concentration after 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

• Amenorrhea is induced by exclusively breastfeeding for up to 6 months immediately postpartum
• Method
  • Suckling at the breast → ↑ prolactin and ↓ gonadotropin-releasing hormone → suppression of ovulation
    • FSH levels are normal/high → follicle growth; however, ↓ LH leads to inhibited follicular maturation and the absent LH surge prevents ovulation ^[3]

References:^[1][2]

Nonhormonal copper device

• Description
  • A T-shaped device wrapped in copper wire that is inserted into the uterus
  • Approved for 10 years of continuous use; may be effective for longer
• Mechanism of action: altered tubal motility; and a sterile inflammatory reaction of the endometrium → spermicidal effect and prevention of implantation
• Indications
  • Emergency contraception (most effective type)
  • Long-acting contraception
  • Contraception in patients with contraindications for estrogen-based contraceptives
• Contraindications
  • Uterine abnormalities (i.e. bleeding, malignancy, infection, abnormal anatomy)
  • Cervical infections
  • Known or suspected pregnancy
  • Menorrhagia
  • Dysmenorrhea
  • Copper hypersensitivity
• Complications
  • Menorrhagia
  • Dysmenorrhea
  • Uterine perforation
  • Ectopic pregnancy
  • Pelvic inflammatory disease ^[4]

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 (use for ≥ 24 hours is not recommended)

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)

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: cervical anomalies or abnormalities, spermicide allergy
• Complication: vaginal irritation, 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]

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 neuraxial or general anesthesia

Vasectomy

• Description: division and removal of a section of the vas deferens
• Can be performed under local anesthesia
• Complications
  • Hematoma
  • Surgical site infection
  • Sperm granulomas: a collection of sperm due to leakage from the vas deferens into the surrounding interstitium
  • Postvasectomy pain syndrome
    • A condition characterized by a chronic, dull, aching pain in the testes in patients who have had a vasectomy
    • Caused by the accumulation of testicular fluid in the epididymis
  • Failure
    • Patients should be counseled about potential post-vasectomy pregnancies (approx. 1 in 2,000 cases)
    • Follow-up sperm sample test at three months after surgery to verify azoospermia

References:^[2]