Barrier methods include mechanical barriers such as male and female condoms, the female diaphragm and cervical cap, and chemical barriers such as spermicidal products. Nonprescription barrier contraceptives are an important contraceptive option because of their wide availability, relative ease of use, and acceptably high efficacy when used correctly and consistently. While the contraceptive efficacies of the various barrier methods when used alone are comparable to each other (typically about twenty pregnancies per one hundred women per year), their use in combination adds significantly to their effectiveness. In addition, male latex condoms and female vaginal sheaths, when used consistently and correctly, provide a high degree of protection against both the acquisition and the transmission of a number of sexually transmitted pathogens, including gonorrhea, chlamydia, syphilis, and some viral pathogens, including hepatitis B virus and HIV (human immunodeficiency virus), the virus that causes AIDS (acquired immunodeficiency syndrome). Spermicidal products, in addition to their contraceptive effect, have in vitro microbicidal properties and appear to provide some protection against gonorrhea and chlamydia. Nonprescription barrier contraceptives include male latex and animal membrane condoms; female polyurethane vaginal sheaths; the contraceptive sponge; and spermicidal films, foams, jellies, creams, and suppositories. Contraindications include allergy to latex rubber (in the case of male condoms, diaphragm, or cervical cap), a history of significant skin irritation with acute or chronic exposure to spermicides, and inability to understand instructions for use.
The contraceptive diaphragm is a dome-shaped latex device that serves as a mechanical barrier against the cervix and also holds a spermicidal preparation in place within the vagina. The diaphragm is one of the oldest barrier methods of the modern era, and has retained its popularity because of its nonhormonal nature, ease of use, and reasonable efficacy. It may be an appropriate method of contraception for women who prefer an intercourse-related nonhormonal method of contraception; desire a barrier method that can provide continuous protection over twenty-four hours; and feel that the diaphragm is less noticeable during intercourse than other barrier methods. The diaphragm should fit comfortably with the anterior (front) rim tucked behind the pubic bone in front and the posterior (back) rim seated deep in the vagina and behind the cervix, so that the cervix is covered by the dome of the diaphragm. The largest, most comfortable diaphragm that fits well should be chosen. Use of a backup method of contraception until the return visit, or until the patient is sure that the diaphragm is staying in place during intercourse, should be advised.
No attempt should be made to use the diaphragm if the woman cannot be fitted with the device due to physical characteristics of the vagina, cervix, or uterus that interfere with proper placement, or if the proper size diaphragm is not available. Other contraindications include a recent history of frequent lower urinary tract infections (e.g., cystitis), especially if associated with prior diaphragm use; less than three months since cervical surgery; less than two weeks since mid-trimester abortion or less than six weeks postpartum (after delivery of a child); allergy to rubber or to all spermicides; inability to understand instructions for use; and inability to insert, remove, and care for the device correctly.
The cervical cap is a thimble-shaped latex device that fits over the cervix and stays in place by mild suction. When used with a spermicide, it is a reliable barrier method of contraception that can be used continuously for up to forty-eight hours. In use in European countries since the 1930s, it was approved by the FDA for contraceptive use in the United States in 1988. The efficacy of the cervical cap in preventing pregnancy is similar to that of the diaphragm in nulliparous women, although the failure rate of the cap is greater in parous women.
The Prentif Cavity Rim Cervical Cap® is the only cap currently approved by the FDA. It is available in four sizes: 22-, 25-, 28-, and 31-mm internal diameter. Because cervix size may vary considerably, these sizes fit approximately 70—75 percent of women. The cap may be an appropriate choice for women who have experienced frequent urinary tract infections, especially if they occurred in association with the contraceptive diaphragm. Because there is less pressure on the urethra and bladder, the cap may be more comfortable than a diaphragm and less likely to predispose the user to a lower urinary tract infection.
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