Female Condom The original female condom introduced in 1992 was a polyurethane vaginal pouch attached to a rim that partly covered the vulva. The recently FDA approved FC2 female condom is an improved version made from softer synthetic latex that does not require hand assembly during manufacture and is therefore less expensive (38). It is recommended for prevention of pregnancy and STDs, including HIV. Breakage may occur less often with the female condom than the male condom; slippage appears to be more common, especially for those new to its use (39). Exposure to seminal ﬂuid is slightly higher than with the male condom (40). Initial US trials showed a pregnancy rate of 15% in 6 months. Subsequent analysis found that with perfect use, the pregnancy rate may be only 2.6%. This rate is comparable to perfect use of the diaphragm and cervical cap, the other female barrier methods (41). As with the male condom, failure rates fall with increasing experience. Colposcopic studies of women using the female condom demonstrate no signs of trauma or change in the bacterial ﬂora (42).
Vaginal Spermicides Currently available vaginal spermicides combine a spermicidal chemical, either nonoxynol-9 (N9)or octoxynol, with a base of cream, jelly, aerosol foam, foaming tablet, film, suppository, or a polyurethane sponge. Nonoxynol-9 is a nonionic surface-active detergent that immobilizes sperm. Nonoxynol-9 spermicides alone appear considerably less effective in preventing pregnancy than condoms or diaphragms. Women using nonoxynol-9 spermicides frequently have higher rates of genital lesions than women not using spermicides. These lesions may increase their risk for STDs and HIV (43). In the same studies of serodiscordant couples in which condoms were proven effective in preventing transmission of HIV, nonoxynol-9 spermicides alone were not effective (34).
Concerns were raised about possible teratogenicity of spermicides. Nonoxynol-9 is not absorbed from the human vagina (44). Several large studies found no greater risk of miscarriage, birth defects, or low birth weight in spermicide users than in other women (45,46).
Nonoxynol-9 is toxic to the lactobacilli that normally colonize the vagina. Women who use spermicides regularly have increased vaginal colonization with the bacterium Escherichia coli and may be predisposed to E. coli bacteriuria after intercourse (47).
Vaginal Barriers At the beginning of the 20th century, four types of vaginal barriers were used in Europe: vaginal diaphragm, cervical cap, vault cap, and Vimule. Vaginal diaphragms, new varieties of cervical caps and the synthetic sponge are used in the United States. When used consistently, vaginal barriers can be reasonably effective. They are safe, and, as with condoms, they have the non-contraceptive benefit of relative protection from STDs, tubal infertility, and cervical neoplasia. A recent search for alternatives to condoms for HIV prevention in high-prevalence areas has rekindled interest in the other vaginal barriers (48).
Diaphragm The diaphragm consists of a circular spring covered with fine latex rubber (Fig. 10.3). There are several types of diaphragms, as determined by the spring rim: coil, ﬂat, or arcing. Coil-spring and ﬂat-spring diaphragms become a ﬂat oval when compressed for insertion. Arcing diaphragms form an arc or half moon when compressed; they are easiest to insert correctly. The practitioner must fit the diaphragm for the patient, and instruct her in its insertion and verify by examination that she can insert it correctly to cover the cervix and upper vagina. Spermicide is always prescribed for use with the diaphragm; whether this practice is necessary is not well studied.