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Reversible Contraception

Reversibility is an extremely important consideration for young adults when they choose a contraceptive
method, because most people either plan to have children or at least want to keep their options open until they
are older.

Oral Contraceptives: The Pill

About a century ago, a researcher noted that ovulation does not occur during pregnancy. Further research
revealed the hormonal mechanism: During pregnancy, the corpus luteum secretes progesterone and estrogen in
amounts high enough to suppress ovulation. Oral contraceptives (OCs), or birth control pills, prevent
ovulation by mimicking the hormonal activity of the corpus luteum. The active ingredients in OCs are estrogen
and progestins, laboratory-made compounds that are closely related to progesterone. Today, OCs are the most
widely used form of contraception among unmarried women and are second only to sterilization among married
women.

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In addition to preventing ovulation, the birth control pill has other backup contraceptive effects. It inhibits the
movement of sperm by thickening the cervical mucus, alters the rate of ovum transport by means of its hormonal
effects on the oviducts, and may prevent implantation by changing the lining of the uterus, in the unlikely event
that a fertilized ovum reaches that area.

The most common type of OC is the combination pill. Each one-month packet contains a three-week supply of
pills that combine varying types and amounts of estrogen and progestin. Some packets also include a one-week
supply of inactive pills to be taken following the hormone pills; others simply instruct the woman to take no pills
at all for one week before starting the next cycle. During the week in which no hormones are taken, a light
menstrual period occurs. Many different types of combination pills are available.

Advantages

OCs are very effective in preventing pregnancy. Nearly all unplanned pregnancies result because the pills were
not taken as directed. The pill is relatively simple to use and does not hinder sexual spontaneity. Most women
also enjoy the predictable regularity of periods, as well as the decrease in cramps and blood loss. For young
women, the reversibility of the pill is especially important; fertilitythe ability to reproducereturns after the
pill is discontinued (although not always immediately).

Medical advantages include a decreased incidence of benign breast disease, iron-deficiency anemia, pelvic
inflammatory disease (PID), ectopic pregnancy, colon and rectal cancer, endometrial cancer (in the lining of the
uterus), and ovarian cancer. Women who have never used the pill are twice as likely to develop endometrial or
ovarian cancer as those who have taken it for at least five years.

Disadvantages

Although OCs lower the risk of PID, they do not protect against HIV infection or other STIs in the lower
reproductive tract. OCs have been associated with increased cervical chlamydia. Regular condom use is
recommended for an OC user, unless she is in a long-term, mutually monogamous relationship with an
uninfected partner.

The hormones in birth control pills influence all tissues of the body and can lead to a variety of disturbances.
Symptoms of early pregnancymorning nausea and swollen breasts, for examplemay appear during the first
few months of OC use. They usually disappear by the fourth cycle. Other side effects include depression,
nervousness, changes in sex drive, dizziness, generalized headaches, migraine, bleeding between periods, and
changes in the lining of the walls of the vagina, with an increase in clear or white vaginal discharge. Melasma, or
mask of pregnancy, sometimes occurs, causing brown pigmentation to appear on the face. Acne may develop
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or worsen but, in most women, using the pill causes acne to clear up, and it is sometimes prescribed for that
purpose.

Serious side effects have been reported in a small number of women. These include blood clots, stroke, and heart
attack, concentrated mostly in older women who smoke or have a history of circulatory disease. Recent studies
have shown no increased risk of stroke or heart attack for healthy, young, non-smoking women on lower-dosage
pills. OC users may be slightly more prone to high blood pressure, blood clots in the legs and arms, and benign
liver tumours that may rupture and bleed.

OC use is associated with little, if any, increase in breast cancer and a slight increase in cervical cancer;
however, earlier detection and other variables, such as number of sexual partners, may account for much of this
increase. The link between OC use and cervical cancer appears to pertain primarily to women infected with
human papillomavirus, an STI.

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Birth control pills are not recommended for women with a history of blood clots (or a close family member with
unexplained blood clots at an early age), heart disease or stroke, migraines with changes in vision, any form of
cancer or liver tumour, or impaired liver function. Women with certain other health conditions or behaviours,
including migraines without changes in vision, high blood pressure, cigarette smoking, and sickle-cell disease,
require close monitoring.

Reversible hormonal contraceptives are available in several forms. Shown here are a variety of birth control pill
options.
Effectiveness

OC effectiveness varies substantially because it depends so much on individual factors. If taken exactly as
directed, the failure rate is extremely low (0.3 percent). However, among average users, lapses, such as
forgetting to take a pill, do occur, and a typical first-year failure rate is 8.7 percent. The continuation rate for
OCs also varies; the average rate is 68 percent after one year.

Contraceptive Skin Patch

The contraceptive skin patch, Ortho Evra, is a thin, 4.5 centimetre by 4.5 centimetre patch that slowly releases
an estrogen and a progestin into the bloodstream. The contraceptive patch prevents pregnancy in the same way
as combination OCs, following a similar schedule. Each patch is worn continuously for one week and is replaced
on the same day of the week for three consecutive weeks. The fourth week is patch free, allowing a woman to
have her menstrual period.

The patch can be worn on the upper outer arm, abdomen, buttocks, or upper torso (excluding the breasts); it is
designed to stick to skin even during bathing or swimming. If a patch should fall off for more than a day, it is
advisable to start a new four-week cycle of patches and use a backup method of contraception for the first week.

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Patches should be discarded according to the manufacturer's directions to avoid leakage of hormones into the
environment.

Advantages

With both perfect and typical use, the patch is as effective as OCs in preventing pregnancy. Compliance seems to
be higher with the patch than with OCs, probably because the patch requires weekly instead of daily action.
Medical benefits are likely to be comparable to those of OCs.

Disadvantages

With patch use, additional measures must be taken to protect against STIs. Minor side effects are similar to those
of OCs, although breast discomfort may be more common in patch users. Some women also experience skin
irritation around the patch. More serious complications are thought to be similar to those of OCs, including an
increased risk of side effects among women who smoke. However, because Ortho Evra exposes users to higher
doses of estrogen than most OCs, patch use may further increase the risk of blood clots and other adverse
effects.

Effectiveness

With perfect use, the patch's failure rate is very low (0.3 percent) in the first year of use. The typical failure rate
is assumed to be lower than the pill's 8.7 percent, because consistent use is better among patch users. The
product appears to be less effective when used by women weighing more than 90 kilograms.

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Vaginal Contraceptive Ring

The NuvaRing is a vaginal ring that is moulded with a mixture of progestin and estrogen. The five-centimetre
ring slowly releases hormones and maintains blood hormone levels comparable to those found with OC use; it
prevents pregnancy in the same way as OCs. A woman inserts the ring anytime during the first five days of her
menstrual period and leaves it in place for three weeks. During the fourth week, which is ring-free, her next
menstrual period occurs. A new ring is then inserted. Rings should be discarded according to the manufacturer's
directions to avoid leakage of hormones into the environment.

Backup contraception must be used for the first seven days of the first ring use or if the ring has been removed
for more than three hours during use. A diaphragm is not recommended as a backup contraceptive with the
NuvaRing because the ring may interfere with the placement of a diaphragm. Diaphragm use is discussed later
in this chapter.

Advantages

The NuvaRing offers one month of protection with no daily or weekly action required. It does not require a
fitting by a clinician, and exact placement in the vagina is not critical as it is with a diaphragm. Medical benefits
are probably similar to those of OCs.

Disadvantages

The NuvaRing gives no protection against STIs. Side effects are roughly comparable to those seen with OC use,
except for a lower incidence of nausea and vomiting. Other side effects may include vaginal discharge, vaginitis,
and vaginal irritation. Medical risks also are similar to those found with OC use.

Effectiveness

As with the pill and patch, the perfect use failure rate is around 0.3 percent and the typical use failure rate is
likely to be lower than the pill's 8.7 percent.

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Contraceptive Implant

Contraceptive implants are placed under the skin of the upper arm and deliver a small but steady dose of
progestin (a synthetic progesterone) over a period of years.

The progestins in implants have several contraceptive effects. They cause hormonal shifts that may inhibit
ovulation and affect development of the uterine lining. The hormones also thicken the cervical mucus, inhibiting
the movement of sperm. Finally, they may slow the transport of the egg through the fallopian tubes.
Contraceptive implants are best suited for women who want continuous and long-term protection against
pregnancy.

Advantages

Contraceptive implants are highly effective. After insertion of the implants, no further action is required;
contraceptive effects are quickly reversed on removal. Because implants, unlike the combination pill, contain no
estrogen, they carry a lower risk of certain side effects, such as blood clots and other cardiovascular
complications. In addition, the progestin is released at a steady rate, in smaller quantities than are found in oral
contraceptives. The thickened cervical mucus resulting from implant use has a protective effect against PID.

Only trained health professionals can insert a contraceptive implant.


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Disadvantages

Like the pill, an implant provides no protection against HIV infection and STIs in the lower reproductive tract.
Although the implants are barely visible, their appearance may bother some women. Only specially trained
practitioners can insert or remove the implants, and removal is sometimes difficult.

The most common side effects of contraceptive implants are menstrual irregularities, including longer menstrual
periods, spotting between periods, or no bleeding at all. The menstrual cycle usually becomes more regular after
one year of use. Less common side effects include headaches, weight gain, breast tenderness, nausea, acne, and
mood swings. Cautions and more serious health concerns are similar to those associated with oral contraceptives
but are less common.

Effectiveness

The overall failure rate is estimated at about 0.1 percent.

Injectable Contraceptives

Hormonal contraceptive injections were developed in the 1960s and are currently being used in at least 80
countries throughout the world. The first injectable contraceptive approved for use in Canada was Depo-Provera,
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which uses long-acting progestins. Injected into the arm or buttocks, Depo-Provera is usually given every 12
weeks, although it actually provides effective contraception for a few weeks beyond that. As another progestin-
only contraceptive, it prevents pregnancy in the same ways as implants.

Advantages

Injectable contraceptives are highly effective and require little action on the part of the user. Because the
injections leave no trace and involve no ongoing supplies, injectables allow women almost total privacy in their
decision to use contraception. Depo-Provera has no estrogen-related side effects; it requires only periodic
injections rather than the minor surgical procedures of implant insertion and removal.

Disadvantages

Injectable contraceptives provide no protection against HIV infection and STIs in the lower reproductive tract. A
woman must visit a health care facility every three months to receive the injections. The side effects of Depo-
Provera are similar to those of implants; menstrual irregularities are the most common, and after one year of
using Depo-Provera many women have no menstrual bleeding at all. Weight gain is a common side effect. After
discontinuing the use of Depo-Provera, women may experience temporary infertility for up to 12 months.

Reasons for not using Depo-Provera are similar to those for not using implants. Extended use of Depo-Provera is
associated with decreased bone density, a risk factor for osteoporosis (see Chapter 5); women who use Depo-
Provera are advised to do weight-bearing exercise and take 1000 milligrams of calcium daily. Women are
advised to use Depo-Provera as a long-term contraceptive (longer than two years, for example) only if other
methods are inadequate. Studies have found that bone density rebounds when use of Depo-Provera stops.

Effectiveness

The perfect use failure rate is 0.3 percent for Depo-Provera. With typical use, the failure rate increases to 6.7
percent in the first year of use. The one-year continuation rate for Depo-Provera is about 56 percent.

Emergency Contraception

Emergency contraception refers to postcoital methodsthose used after unprotected sexual intercourse. An
emergency contraceptive may be appropriate if a regularly used method has failed (for example, if a condom
breaks) or if unprotected sex has occurred. Sometimes called the morning-after pill, emergency contraceptives
are designed only for emergency use and should not be relied on as a regular birth control method.

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Until recently the most frequently used emergency contraceptive was a two-dose regimen of certain oral
contraceptives. Researchers are still uncertain precisely how OCs work as emergency contraceptives. Opponents
of their use argue that if they act by preventing implantation of a fertilized egg, they may actually be
abortifacients; however, recent evidence indicates that prevention of implantation is not their primary mode of
action. Postcoital pills appear to work primarily by inhibiting or delaying ovulation and by altering the transport
of sperm or eggs; they do not affect a fertilized egg already implanted in the uterus.

Plan B is a newer product specifically designed for emergency contraception. It is available over the counter in
Canada and contains two progestin-only pills. The first pill should be taken as soon as possible (no more than
120 hours) after inadequately protected sex. The second pill should be taken 12 hours after the first. Both pills
may be taken together in a single dose with little change in effectiveness or side effects. If taken within 24 hours
after intercourse, Plan B may prevent as many as 95 percent of expected pregnancies. Overall, Plan B reduces
pregnancy risk by about 89 percent. It is most effective if initiated in the first 12 hours. Possible side effects are
similar to those associated with the OC regimen and can include nausea, stomach pain, headache, dizziness, and
breast tenderness.

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Easy access to emergency contraception is important because the sooner the drug is taken, the more effective it
is. Some clinicians advise women to keep a package of emergency contraception on hand in case their regular
contraception method fails. Research has found that ready access to emergency contraception does not lead to an
increase in unprotected intercourse, unintended pregnancies, or STIs.

Intrauterine devices, discussed in the next section, can also be used for emergency contraception: If inserted
within five days of unprotected intercourse, they are even more effective than OCs. However, because their use
is more complicated, they are not used nearly as frequently.

The Intrauterine Device (IUD)

The intrauterine device (IUD) is a small device placed in the uterus as a contraceptive. There are two types of
IUDs in Canada, and they are effective for about five years.

Researchers do not know exactly how IUDs prevent pregnancy. Current evidence suggests that they work
primarily by preventing fertilization. IUDs may cause biochemical changes in the uterus and affect the
movement of sperm and eggs; although less likely, they may also interfere with implantation of fertilized eggs.
Some IUDs slowly release very small amounts of hormones, which impede fertilization or implantation.

An IUD must be inserted and removed by a trained professional. It can be inserted at any time during the
menstrual cycle, as long as the woman is not pregnant. The device is threaded into a sterile inserter, which is
introduced through the cervix; a plunger pushes the IUD into the uterus. The threads protruding from the cervix
are trimmed so that only 2.54 centimetres remain in the upper vagina.

Advantages

Intrauterine devices are highly reliable and are simple and convenient to use, requiring no attention except for a
periodic check of the string position. They do not require the woman to anticipate or interrupt sexual activity.
According to researchers, IUD use reduces the risk of developing endometrial cancer by as much as 40 percent.
Usually IUDs have only localized side effects, and in the absence of complications they are considered a fully
reversible contraceptive. In most cases, fertility is restored as soon as the IUD is removed. The risks of ectopic
pregnancy and uterine cancer are both decreased with IUD use.

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Disadvantages

Most side effects of IUD use are limited to the genital tract. Heavy menstrual flow and bleeding and spotting
between periods may occur, although with some IUDs menstrual periods tend to become shorter and lighter over
time. Another side effect is pain, particularly uterine cramps and backache, which seem to occur most often in
women who have never been pregnant. Spontaneous expulsion of the IUD happens to 56 percent of women
within the first year, most commonly during the first months after insertion. The older the woman is and the
more children she has had, the less likely she is to expel the device. In about 1 of 1000 insertions, the IUD
punctures the wall of the uterus and may migrate into the abdominal cavity.

A serious but rare complication of IUD use is pelvic inflammatory disease (PID). Most pelvic infections among
IUD users occur shortly after insertion, are relatively mild, and can be treated successfully with antibiotics.
However, early and adequate treatment is criticala lingering infection can lead to tubal scarring and
subsequent infertility.

Some physicians advise against the use of IUDs by young women who have never been pregnant because of the
increased incidence of side effects in this group and the risk of infection with the possibility of subsequent
infertility.

IUDs are not recommended for women of any age who are at high risk for STIs. They are also unsuitable for
women with suspected pregnancy, large tumours of the uterus or other anatomical abnormalities, irregular or

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unexplained bleeding, or rheumatic heart disease. No evidence has been found linking IUD use to an increased
risk of cancer. IUDs offer no protection against STIs.

Early IUD danger signals are abdominal pain, fever, chills, foul-smelling vaginal discharge, irregular menstrual
periods, and other unusual vaginal bleeding. A change in string length should also be noted. An annual checkup
is important and should include a Pap test and a blood check for anemia if menstrual flow has increased.

Effectiveness

The typical failure rate of IUDs during the first year of use is 0.10.6 percent. Effectiveness can be increased by
periodically checking to see that the device is in place and by using a backup method for the first few months
after IUD insertion. If pregnancy occurs, the IUD should be removed to safeguard the health of the woman and
to maintain the pregnancy. The continuation rate of IUDs is about 80 percent after one year of use.

Male Condoms

Video: Condom Stories

Click here to view a transcript of this video

The male condom is a thin sheath designed to cover the penis during sexual intercourse. Most brands available
in Canada are made of latex, although condoms made of polyurethane are also now available. Condoms prevent
sperm from entering the vagina and provide protection against disease. Condoms are the most widely used
barrier method and the third most popular of all contraceptive methods used in North America, after the pill and
female sterilization.

Condom sales have increased dramatically in recent years, primarily because they are the only method that
provides substantial protection against HIV infection as well as some protection against other STIs. At least one-
third of all male condoms are bought by women.

Advantages

Condoms are easy to purchase and are available without prescription or medical supervision. In addition to being
free of medical side effects (other than occasional allergic reactions), latex condoms help protect against STIs. A
recent study determined that condoms may also protect women from human papilloma virus (HPV), which
causes cervical cancer. Condoms made of polyurethane are appropriate for people who are allergic to latex.
However, they are more likely to slip or break than latex condoms and therefore may give less protection against
STIs and pregnancy. (Lambskin condoms permit the passage of HIV and other disease-causing organisms, so
they can be used only for pregnancy prevention, not the prevention of STIs.) Except for abstinence, correct and
consistent use of latex male condoms offers the most reliable available protection against the transmission of
HIV. (See Figure 11.6 for the proper way to use a condom.)

Click here for a description of Figure 11.6 Use of the Male Condom.

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FIGURE 11.6
FIGURE 11.6 Use of the Male Condom(a) Check the expiration date and check to see that the package is intact.
Put the condom on before any genital contact. If uncircumcised, pull back the foreskin. Cover the head of the
penis with the condom. Leave some space at the tip for ejaculate, but gently press out any air. This will reduce
the risk of breakage. (b) Unroll the condom so that the entire erect penis is covered all the way to the base. If
needed, you may generously apply a water-based or silicone lubricant to the outside of the condom before
penetration. Do not use oil-based lubricants. To prevent slippage, hold the condom at the base of the penis when
withdrawing. (c) After ejaculation occurs, withdraw the penis before it gets soft. Hold onto the condom to
prevent slippage. Throw the condom away.

Source: McKinley Health Center, University of Illinois at Urbana-Champaign. 2004. How to Use a Condom and
Spermicidal Jelly for Intercourse,
http://www.mckinley.illinois.edu/handouts/condom_spermicidal_jelly/condom_spermicidal_jelly.html (retrieved
July 22, 2015).
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Disadvantages

The two most common complaints about condoms are that they diminish sensation and interfere with
spontaneity. Although some people find these drawbacks serious, others consider them only minor
disadvantages. Many couples learn to creatively integrate condom use into their sexual practices. Indeed, it can
be a way to improve communication and share responsibility in a relationship.

Effectiveness

In actual use, the failure rate of condoms varies considerably. First-year rates among typical users average about
17.4 percent. With perfect use, the first-year failure rate is about 2 percent. At least some pregnancies happen
because the condom is carelessly removed after ejaculation. Some may also occur because of breakage or
slippage, which may happen 12 times in every 100 instances of use for latex condoms and up to 10 times in
every 100 instances for polyurethane condoms. Breakage is more common among inexperienced users. Other
contributing factors include poorly fitting condoms, insufficient lubrication, excessively vigorous sex, and
improper storage (because heat destroys rubber, latex condoms should not be stored for long periods in a wallet
or a car's glove compartment). To help ensure quality, condoms should not be used past their expiration date or
more than five years past their date of manufacture (two years for those with spermicide).

If a condom breaks or is carelessly removed, the risk of pregnancy can be reduced somewhat by the immediate
use of a vaginal spermicide. Some clinicians recommend keeping emergency contraceptive pills on hand. If the
emergency contraceptive Plan B is taken within one hour of inadequately protected sex, the failure rate is only
about 0.14 percent. The most common cause of pregnancy with condom users is taking a chancethat is,
occasionally not using a condom at allor waiting to use it until after preejaculate fluid (which may contain
some sperm) has already entered the vagina.

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Female Condoms

A female condom is a latex or polyurethane pouch that can be inserted into a woman's vagina. Although the
female condom is preferred in certain situations because it requires less participation on the part of the male
partner, its overall popularity remains far below that of the male condom.

The female condom currently available is a disposable device that comes in one size and consists of a soft,
loose-fitting polyurethane sheath with two flexible rings (see Figure 11.7). The ring at the closed end is inserted
into the vagina and placed at the cervix, much like a diaphragm. The ring at the open end remains outside the
vagina. The walls of the condom protect the inside of the vagina.

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Click here for a description of Figure 11.7 The Female Condom Properly Positioned.

FIGURE 11.7
FIGURE 11.7 The Female Condom Properly Positioned

The directions that accompany the condom should be followed closely. It can be inserted up to eight hours
before intercourse and should be used with the supplied lubricant or a spermicide to prevent penile irritation. As
with male condoms, users need to take care not to tear the condom during insertion or removal. Following
intercourse, the woman should remove the condom immediately, before standing up. By twisting and squeezing
the outer ring, she can prevent the spilling of semen. A new condom should be used for each act of sexual
intercourse. A female condom should not be used with a male condom because when the two are used together
slippage is more likely to occur.

Advantages

For many women, the greatest advantage of the female condom is the control it gives them over contraception
and STI prevention. (Partner cooperation is still important, however.) Female condoms can be inserted before
sexual activity and are thus less disruptive than male condoms. Because the outer part of the condom covers the
area around the vaginal opening as well as the base of the penis during intercourse, it offers potentially better
protection against genital warts or herpes. The polyurethane pouch can be used by people who are allergic to
latex. And because polyurethane is thin and pliable, little loss of sensation occurs.

When used correctly, the female condom should theoretically provide protection against HIV transmission and
STIs comparable to that of the latex male condom. However, in research involving typical users, the female
condom was less effective in preventing both pregnancy and STIs. With careful instruction and practice,
effectiveness can be improved.

Disadvantages

As with the traditional condom, interference with spontaneity is likely to be a common complaint. The outer
ring, which hangs visibly outside the vagina, may be bothersome during foreplay; if so, couples may choose to
put the device in just before intercourse. During coitus, both partners must take care that the penis is inserted
into the pouch, not outside it, and that the device does not slip inside the vagina. Female condoms, like male
condoms, are made for one-time use. A single female condom costs about four times as much as a single male
condom.

Effectiveness
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The typical first-year failure rate of the female condom is 27 percent. For women who follow instructions
carefully and consistently, the failure rate is considerably lowerabout 5 percent. Although the female condom
rarely breaks during use, slippage occurs in nearly one in ten users. The risk of being exposed to semen is higher
if the relationship is new or short-term, if intercourse is very active, and if there is a large disparity between
vagina and penis sizes. Having Plan B available as a backup contraceptive is recommended.

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The Diaphragm with Spermicide

Before oral contraceptives were introduced, about 25 percent of all North American couples who used any form
of contraception relied on the diaphragm. Many diaphragm users switched to the pill or IUDs, but the
diaphragm offers advantages that are important to some couples.

The diaphragm is a dome-shaped cup of thin rubber stretched over a collapsible metal ring. When correctly used
with spermicidal cream or jelly, the diaphragm covers the cervix, blocking sperm from entering the uterus.

Diaphragms are available only by prescription. Because of individual anatomical differences among women, a
diaphragm must be carefully fitted by a trained clinician to ensure both comfort and effectiveness. The fitting
should be checked with each routine annual medical examination, as well as after childbirth, abortion, or a
weight change of more than 4.5 kilograms.

The woman spreads spermicidal jelly or cream on the diaphragm before inserting it and checking its placement
(see Figure 11.8). If more than six hours elapse between the time of insertion and the time of intercourse,
additional spermicide must be applied. The diaphragm must be left in place for at least six hours after the last act
of coitus to give the spermicide enough time to kill all the sperm. With repeated intercourse, a condom should be
used for additional protection.

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Click here for a description of Figure 11.8 Use of the Diaphragm.

FIGURE 11.8
FIGURE 11.8 Use of the DiaphragmWash your hands with soap and water before inserting the diaphragm. It can
be inserted while squatting, lying down, or standing with one foot raised. (a) Place about 15 millilitres (a
tablespoon) of spermicidal jelly or cream in the concave side of the diaphragm, and spread it around the inside
of the diaphragm and around the rim. (b) Squeeze the diaphragm into a long, narrow shape between the thumb
and forefinger. Insert it into the vagina, and push it up along the back wall of the vagina as far as it will go. (c)
Check its position to make sure the cervix is completely covered and that the front rim of the diaphragm is
tucked behind the pubic bone.

To remove the diaphragm, the woman simply hooks the front rim down from the pubic bone with one finger and
pulls it out. She should wash it with mild soap and water, rinse it, pat it dry, and then examine it for holes or
cracks. Defects would most likely develop near the rim and can be spotted by looking at the diaphragm in front
of a bright light. After inspecting the diaphragm, she should store it in its case.

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Advantages

Diaphragm use is less intrusive than male condom use because a diaphragm can be inserted up to six hours
before intercourse. Its use can be limited to times of sexual activity only, and it allows for immediate and total
reversibility. The diaphragm is free of medical side effects (other than rare allergic reactions).

When used along with spermicidal jelly or cream, it offers significant protection against gonorrhea and possibly
chlamydia, STIs that are transmitted only by semen and for which the cervix is the sole site of entry. Diaphragm
use can also protect the cervix from semen infected with the human papillomavirus, which causes cervical
cancer. However, the diaphragm is unlikely to protect against STIs that can be transmitted through vaginal or
vulvar surfaces (in addition to the cervix), including HIV infection, genital herpes, and syphilis.

Disadvantages

Diaphragms must always be used with a spermicide, so a woman must keep both of these somewhat bulky
supplies with her whenever she anticipates sexual activity. Diaphragms require extra attention, since they must
be cleaned and stored with care to preserve their effectiveness. Some women cannot wear a diaphragm because
of their vaginal or uterine anatomy. In other women, diaphragm use can cause an increase in bladder infections
and may need to be discontinued if repeated infections occur.

Diaphragms have also been associated with a slightly increased risk of toxic shock syndrome (TSS), an
occasionally fatal bacterial infection. To reduce the risk of TSS, a woman should wash her hands carefully with
soap and water before inserting or removing the diaphragm, should not use the diaphragm during menstruation
or when abnormal vaginal discharge is present, and should never leave the device in place for more than 24
hours.

Effectiveness

The diaphragm's effectiveness depends mainly on whether it is used properly. In actual practice, women rarely
use it correctly every time they have intercourse. With perfect use, the failure rate is about 6 percent. Typical
failure rates are 16 percent during the first year of use. The main causes of failure are incorrect insertion,
inconsistent use, and inaccurate fitting. Sometimes, too, the vaginal walls expand during sexual stimulation,
causing the diaphragm to be dislodged. If a diaphragm slips during intercourse, a woman may choose to use
emergency contraception.

QUICK STATS

17% of Canadian university students have experienced unprotected sex when drinking alcohol.

National College Health Assessment II, 2013

Lea's Shield

Lea's Shield is a one-size-fits-all diaphragm-like device, available by prescription. Made of silicone rubber, it
can be used by women who are allergic to latex, and it is not damaged by petroleum-based products. The shield
has a valve that allows the flow of air and fluids from the cervix as well as a loop that aids in insertion and
removal. The device may be inserted at any time before intercourse, but should be left in place for eight hours
after last intercourse; it can be worn for up to 48 hours. Like the diaphragm, it must be used with spermicide.
Studies completed thus far have reported advantages, disadvantages, and failure rates similar to those of the
diaphragm.

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FemCap

FemCap, another barrier device, is a small flexible cup that fits snugly over the cervix and is held in place by
suction. This cervical cap is a clear silicone cup with a brim around the dome to hold spermicide and trap sperm
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and a removal strap over the dome. It comes in three sizes and must be fitted by a trained clinician. It is used like
a diaphragm, with a small amount of spermicide placed in the cup and on the brim before insertion.

Advantages

Advantages of the cervical cap are similar to those associated with diaphragm use and include partial STI
protection. It is an alternative for women who cannot use a diaphragm because of anatomical reasons or
recurrent urinary tract infections. Because the cap fits tightly, it does not require backup condom use with
repeated intercourse. It may be left in place for up to 48 hours.

Disadvantages

Along with most of the disadvantages associated with the diaphragm, difficulty with insertion and removal is
more common for cervical cap users. Because there may be a slightly increased risk of TSS with prolonged use,
the cap should not be left in place for more than 48 hours.

Effectiveness

Studies indicate that the average failure rate for the cervical cap is 16 percent for women who have never had a
child and 32 percent for women who have had a child. Failure rates drop significantly with perfect use.

The Contraceptive Sponge

The sponge is a round, absorbent device about five centimetres in diameter with a polyester loop on one side
(for removal) and a concave dimple on the other side, which helps it fit snugly over the cervix. The sponge is
made of polyurethane and is presaturated with the same spermicide that is used in contraceptive creams and
foams. The spermicide is activated when moistened with a small amount of water just before insertion. The
sponge, which can be used only once, acts as a barrier, as a spermicide, and as a seminal fluid absorbent.

Advantages

The sponge offers advantages similar to those of the diaphragm and cervical cap, including partial protection
against some STIs. In addition, sponges can be obtained without a prescription or professional fitting, and they
may be safely left in place for 24 hours without the addition of spermicide for repeated intercourse.

Disadvantages

Reported disadvantages include difficulty with removal and an unpleasant odour if the sponge is left in place for
more than 18 hours. Allergic reactions, such as irritation of the vagina, are more common with the sponge than
with other spermicide products, probably because the overall dose contained in each sponge is significantly
higher than that used with other methods. (A sponge contains 1 gram of spermicide compared with the 60100
milligrams present in one application of other spermicidal products.) If irritation of the vaginal lining occurs, the
risk of yeast infections and STIs (including HIV) may increase.

Because the sponge has also been associated with toxic shock syndrome, the same precautions must be taken as
described for diaphragm use. A sponge user should be especially alert for symptoms of TSS when the sponge
has been difficult to remove or was not removed intact.

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Effectiveness

The typical effectiveness of the sponge is the same as the diaphragm (16 percent failure rate during the first year
of use) for women who have never experienced childbirth. For women who have had a child, however, sponges
are significantly less effective than diaphragms. One possible explanation is that the sponge's size may be
insufficient to adequately cover the cervix after childbirth. To ensure effectiveness, the user should carefully
check the expiration date on each sponge, as shelf life is limited.
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Vaginal Spermicides

Spermicidal compounds developed for use with a diaphragm have been adapted for use without a diaphragm by
combining them with a bulky base. Foams, creams, jellies, suppositories, and films are all available. Foam is
sold in an aerosol bottle or a metal container with an applicator that fits on the nozzle. Creams and jellies are
sold in tubes with an applicator that can be screwed onto the opening of the tube.

Foams, creams, and jellies must be placed deep in the vagina near the cervical entrance and must be inserted no
more than 60 minutes before intercourse. After an hour, their effectiveness is drastically reduced, and a new dose
must be inserted. Another application is also required before each repeated act of coitus. If the woman wants to
douche, she should wait for at least six hours after the last intercourse to make sure that there has been time for
the spermicide to kill all the sperm; douching is not recommended, however, because it can irritate vaginal tissue
and increase the risk of various infections.

The spermicidal suppository is small and easily inserted like a tampon. Because body heat is needed to dissolve
and activate the suppository, it is important to wait at least 15 minutes after insertion before having intercourse.
The suppository's spermicidal effects are limited in time, and coitus should take place within one hour of
insertion. A new suppository is required for every act of intercourse.

Vaginal contraceptive film (VCF) is a paper-thin five centimetre by five centimetre film that contains
spermicide. It is folded over one or two fingers and placed high in the vagina, as close to the cervix as possible.
In about 15 minutes the film dissolves into a spermicidal gel that is effective for up to one hour. A new film must
be inserted for each act of intercourse.

Advantages

The use of vaginal spermicides is relatively simple and can be limited to times of sexual activity. They are
readily available in most drugstores and do not require a prescription or a pelvic examination. Spermicides allow
for complete and immediate reversibility, and the only medical side effects are occasional allergic reactions.
Vaginal spermicides may provide limited protection against some STIs but should never be used instead of
condoms for reliable protection.

Disadvantages

When used alone, vaginal spermicides must be inserted shortly before intercourse, so their use may be seen as an
annoying disruption. Some women find the slight increase in vaginal fluids after spermicide use unpleasant.
Spermicides can alter the balance of bacteria in the vagina. Because this may increase the occurrence of yeast
infections and urinary tract infections, women who are especially prone to these infections may want to avoid
spermicides. Also, this method does not protect against gonorrhea, chlamydia, or HIV. Overuse of spermicides
can irritate vaginal tissues; if this occurs, the risk of HIV transmission may increase.

Effectiveness

The effectiveness rates of vaginal spermicides vary widely, depending partly on how consistently and carefully
instructions are followed. The typical failure rate is about 29 percent during the first year of use. Foam is
probably the most effective form of spermicide, because its effervescent mass forms a denser and more evenly
distributed barrier to the cervical opening. Creams and jellies provide only minimal protection unless used with a
diaphragm or cervical cap.

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QUESTIONS FOR CRITICAL THINKING AND REFLECTION

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What are the most important factors influencing your personal decisions about contraception? List these factors
in order of their priority to you, and determine whether you have given each factor full consideration in choosing
a contraceptive method.

Video: Viewpoints of Teens on Contraception Use

Click here to view a transcript of this video

Video: Teenage Pregnancy

Click here to view a transcript of this video

Spermicide is generally recommended only in combination with other barrier methods or as a backup to other
contraceptives. Plan B provides a better backup than spermicides, however.

Whatever your needs, circumstances, or beliefs, do make a choice about contraception. Not choosing anything is
the one method known not to work. This is an area in which taking charge of your health has immediate and
profound implications for your future. The method you choose today won't necessarily be the one you will want
to use your whole life, or even next year. But it should be one that works for you right now.

Even with the vast array of contraceptive options available to Canadians, unwanted pregnancies do occur for
various reasons. When this happens, abortion may need to be considered.

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