So-called mini-pils are progestin-only contraceptives that are taken daily. hese contraceptives have not achieved widespread popularity and are used by only 0.4 percent of reproductive-aged American women (Hall, 2012). Unlike COCs, they do not reliably inhibit ovulation. Rather, their efectiveness depends more on cervical mucus thickening and endometrial atrophy. Because mucus changes are not sustained longer than 24 hours, mini-pills should be taken at the same time every day to be maximally efective. If a progestin-only pill is taken even 4 hours late, a supplemental form of contraception must be used for the next 48 hours. Progestin-only pills are contraindicated in women with known breast cancer or pregnancy. Other cautions are listed in Table 38-2.
For many years, male and female condoms, vaginal diaphragms, and periodic abstinence have been used for contraception with variable success (see Table 38-2). When used properly, condoms
FIGURE 38-6 FC2 Female Condom insertion and positioning. A. diaphragm. B. The inner ring is pushed inward with an index finger.
provide considerable but not absolute protection against a broad range of sexually transmitted diseases, including HIV (Eaton, 2014). Contraceptive eicacy of the male condom is enhanced appreciably by a reservoir tip and probably by the addition of a spermicide. Such agents, as well as those used for lubrication, should be water-based because oil-based products degrade latex condoms and diaphragms.
For individuals sensitive to latex, condoms made from lamb intestines are efective, but they do not provide infection protection. Fortunately, nonallergenic condoms have been developed that are made of polyurethane or of synthetic elastomers. Polyurethane condoms are efective against STDs but have a higher breakage and slippage rate compared with latex condoms (Gallo, 2012a).
The only female condom available in the United States is marketed as the FC2 Female Condom. It is a synthetic nitrile sheath with one lexible polyurethane ring at each end. Its open ring remains outside the vagina, whereas its closed internal ring is fitted under the symphysis like a diaphragm (Fig. 38-6). The female condom can be used with both water-based and oilbased lubricants. Male condoms should not be used concurrently because simultaneous use may cause friction that leads to condom slipping, tearing, and displacement. Following use, the female condom outer ring should be twisted to seal the condom so that no semen spills. As an added value, the female condom may ofer some protection against STDs (Minnis, 2005).
The diaphragm consists of a circular latex dome of variable diameter supported by a circumferential latex-covered metal spring. It is efective when used in combination with spermicidal
The inner ring is squeezed for insertion. The sheath is inserted similarly to a jelly or cream. The spermicide is applied into the dome cup and along the device rim. The diaphragm is then positioned so that the cup faces the cervix and that the cervix, vaginal fornices, and anterior vaginal wall are partitioned efectively from the remainder of the vagina and the penis. In this fashion, the centrally placed spermicide is held against the cervix. When appropriately positioned, one rim is lodged deep in the posterior vaginal fornix, and the opposite rim its behind the inner surface of the symphysis and immediately below the urethra (Fig. 38-7). If a diaphragm is too small, it will not remain in place. If it is too large, it is uncomfortable when forced into position. A coexistent cystocele or uterine prolapse typically leads to instability and expulsion. Because size and spring flexibility must be individualized, the diaphragm is itted by
FIGURE 38-7 A diaphragm in place creates a physical barrier between the vagina and cervix.