Female Barrier Methods of Contraception

These include caps, diaphragms, condoms and the contraceptive sponge.
Caps and diaphragms form a physical barrier, preventing entrance of sperm to the cervix.¹ They also provide a reservoir for spermicide.
Their popularity as forms of contraception have declined with the availability of more effective methods. However, they still offer options to those who are unable to use other forms through personal preference or contraindications, or for those who desire a female-controlled form of contraception. 1% women aged 16-49 use diaphragms or caps;² 3% of women over 40.³

Indications

They are potentially suitable for use by most women, as they are non-hormonal forms of contraception. However, the relatively high failure rate should be taken into consideration.

Diaphragms are thin, dome-shaped devices made of latex or silicone and range in size between 55 and 100mm. Diaphragms should lie diagonally between the posterior fornix and behind the pubic bone. They come in 3 styles:

• Flat spring - these are firm and are suitable for women with normal vaginal musculature and particularly those with a shallow arch behind the symphysis.
• Coil spring - these have a softer spring and may feel more comfortable. They are suitable for women with a normal pelvis and deep pelvic arch.
• Arcing spring - these fold at two points making them easiest to insert. They are useful for women with poor vaginal muscle tone or those with a retroverted uterus.

Caps are smaller than diaphragms and sit directly over the cervix held by suction. In the UK, they tend to be reserved for women who have had problems with the diaphragm.

Rubber caps include

• Cervical cap - thimble-like and fits directly over the cervix. The cervix needs to have straight, parallel sides and point along the long axis of the vagina. Sizes 22-31mm
• Vault cap - this adheres to the vaginal wall and is suitable where there is a flattish cervix. Sizes 55-75mm
• Vimule - similar to the vault cap but has elongated dome so fits a longer cervix. Sizes 42, 48 and 54mm

Silicone caps include

• Oves cap - can be used for a 48 hour period and are disposable.
  They are not prescribable on a FP10 so a woman should buy a fitting pack from a chemist and then see her health professional to assess sizing before buying the correct size on a regular basis.
• FemCap - can be used for 3 days in total.

Available as Femidom®.
This is a loose-fitting polyurethane sheath with two flexible polyurethane rings one at either end. It sits in the vagina. At the closed end of the tube the ring is not fixed but helps make insertion easier. It also acts as an internal anchor. At the open end the flexible ring lies outside the vagina. It is lubricated with non-spermicidal lubricant. No fitting is required.

Instructions for use

Never re-use a female condom.⁴ Always check expiry date.

• Take care not to damage with nails or jewellery when removing from packet.
• It may be inserted any time before sex, but must always be in position before the penis touches the genital area.
• In a comfortable position e.g. squatting or one leg up on a chair, hold the closed end of the condom and squeeze the ring between thumb and middle finger.
• Using the other hand to open the labia, push the ring as high into the vagina as possible.
• Place the middle finger into the open end of the condom and try to feel the inner ring. Push it high into the vagina.
• Make sure the outer ring is lying close to the vulva. It is advisable to guide the penis into the condom, to avoid slipping between condom and vagina.

To remove the condom, twist the outer ring (to trap semen inside) and pull gently.

This is available as Today®. It is made of polyurethane and is 6 cm in diameter and 1.5 cm thick. It is impregnated with nonoxynol-9 spermicide. No fitting is required. Maximum recommended duration of use is 30 hours.

• It is fitted into the vagina prior to sexual intercourse and works by occluding the cervix, releasing spermicide, and absorbing semen.
• The sponge needs to have water applied to activate the spermicide.
• It is inserted into the vagina by hand. There is an indentation on one side which helps to place it against the cervix.
• There is a loop that makes removal easier.
• The sponge may be inserted up to 24 hours before sex and removed any time after 6 hours.

• With barrier methods efficacy is largely user-dependent, the keys to success being good fitting, patient education and motivation.¹
• When used according to instructions (with spermicide), diaphragms have a first year failure rate of 4-8% and caps 9-26%.
• Parity increases the risk of failure with women who use the cap.
• A comparison of 2 types of cap to the diaphragm showed the Prentif cap (similar design to Oves cap) to be comparable to the diaphragm in preventing pregnancy but the Femcap is thought to be less effective.⁵
• The use of spermicide is advocated with these methods although a Cochrane review failed to prove its contraceptive contribution.⁶
• First-year probability of failure during perfect use is 11-12% for the sponge, rising to 17% during typical use. Higher rates of failure seen in parous women.⁷
• Typical use first year failure rates are 15% for the female condom.⁸ Perfect use first year failure rate is around 5%, showing it can be highly effective.

Advantages

• No serious side-effects and female controlled.
• Good choice where fertility is reduced (eg breast feeding, peri-menopause).^9,10
• More independent of intercourse than condoms allowing greater sexual spontaneity.
• No loss of sensation.
• All barrier methods may offer some protection against cervical cancer, sexually transmitted infections (estimated 50-75% efficacy)¹¹ and pelvic inflammatory diseases when compared to oral contraceptive pills and intrauterine devices. This may be important in risk reduction approaches, particularly in the developing world where caps and diaphragms are methods within female control, more acceptable and less stigmatized compared to condom use.^12,13 However, they do not reliably protect against HIV and other STDs and are therefore not recommended for women at high risk in the UK. (See contraindications)
• Diaphragms and caps may be preferred to female condoms as female-controlled barrier methods as there is less perceived interference with sexual pleasure.

Disadvantages

• Less effective than other methods.^9,10
• Requires motivation and careful use.
• Requires some forward planning and confidence examining one's genitals.
• Must be used with spermicide which can make it messy, cause irritation or allergy.
• Female condom is noisy.
• Diaphragms and caps require fitting on at least an annual basis and education from trained health professional.
• May increase risk of UTIs (mostly with diaphragms).

These are taken from the UK medical eligibility criteria (based on the WHO criteria).¹⁴

• Patient is known to have, or is at high risk of HIV/AIDS; evidence of repeated high-dose use of the spermicide nonoxynol-9 is associated with increased risk of genital lesions, which may increase the risk of acquiring HIV. However, the consistent and correct use of female condoms may reduce the risk of HIV transmission.
• History of toxic shock syndrome.^9,10 The use of a diaphragm, cervical cap or contraceptive sponge is not generally recommended, but they may use a female condom.
• Acute vaginitis or concurrent pelvic infection; treat first.
• Woman unable to insert or remove device.
• Anatomical constraints - inadequate retropubic ledge or uterovaginal prolapse. However, cervical/vault caps may be possible. Also markedly anteverted cervix or septate vagina.
• Abnormal cervical smear or biopsy in last 12 weeks.
• Recurrent UTIs.
• Rubber allergy (consider silicone device). These women can use a silicone diaphragm or cervical cap or a polyurethane female condom.
• Spermicide allergy.

• Counsel fully to check method is acceptable to woman and that she is fully informed regarding risks/benefits and provide reinforcing written information.
• Pelvic examination to assess suitability. Bowel and bladder should be emptied prior to fitting. Ideally caps should be fitted mid-cycle.
• Select size for practice device (for diaphragm, this should approximate the distance from behind the cervix to the pelvic arch).
• Start with the largest size that is comfortable. Check that the device does not fall out when the woman ambulates or performs a Valsalva manoeuvre.
• Teach the woman how to remove and insert the device. It is important that the woman is aware of what her cervix feels like and how to check that the device fully covers the cervix when in correct position.
• To insert a diaphragm, put your index finger on top of the diaphragm and squeeze it between your thumb and other fingers. Slide the diaphragm into the vagina in a downwards and posterior fashion. Some women find it easier to squat and others to lie down for insertion.
• To insert a cap, squeeze the sides of the cap together and hold between thumb and first two fingers allowing to suction neatly over the cervix.
• The woman goes home with a practice device. She must be aware not to rely on it for contraception until after the second visit.

The woman should return with the device in situ to enable the positioning and size of the device to be checked. Any problems the woman has encountered any problems fitting it should be fully explored.
Give specific instructions:

• Insert the device before sexual intercourse
• Always use with spermicide
• Use a total of 10cm cream or jelly or 1 pessary (allowing 10 minutes to fully dissolve).
• Spermicide is only active for 3 hours so if intercourse continues for longer than 3 hours, reinsert spermicide
• Leave the device for at least 6 hours post sexual intercourse, but no more than 30 hours.
• After removing device, wash it in warm water and soap if required and dry before putting away.
• Never use with oil based products eg. antifungal formulations, oestrogen creams, emulsifying ointment, vaseline, massage oils as these can cause the latex to decay more rapidly.
• Check for puckering and holes - if present, the device should be replaced urgently.

Follow up should be on an annual basis since devices should be replaced at that interval (unless there is earlier evidence of damage).
Any weight change of more than 3kg should prompt a review.
Fitting should also be checked after childbirth (at least 6 weeks post-partum), termination or miscarriage.
Reasons for women discontinuing use of diaphragms include:

• Difficulty with removal and insertion.
• Perception that leaving the diaphragm in the vagina after sex is 'dirty'.
• Desire for a more reliable form of contraception.¹⁵

• Difficulty with insertion
  • Try a different size
  • Try an arching spring diaphragm
  • Try an applicator
• Recurrent UTIs
  • Advise women to empty bladder before and after intercourse.
  • Try a smaller size or coil spring diaphragm.
  • Change to vault or cervical cap.
• Vaginal soreness
  • Check size
  • Treat any infection
  • Try alternative spermicide
  • Consider rubber allergy
• Partner feeling device
  • Check size
  • Change to coil spring device
  • Change to vault or cervical cap