Guidelines 2016 – Barrier Methods of Contraception

Guidelines 2016 – Barrier Methods of Contraception
Guidelines for Nurse Practitioners in Gynecologic Settings 2016

■ DIAPHRAGM

I. DEFINITION/MECHANISM OF ACTION
a diaphragm is a soft latex or silicone dome with a flexible rim that is placed in the vagina to cover the cervix. it serves as both a mechanical barrier and a receptacle for (contraceptive) spermicidal cream or jelly, which must be used to ensure effectiveness.
II. EFFECTIVENESS AND BENEFITS
a. Method: 97% effectiveness rate
B. User: 80% to 85% effectiveness rate
C. May be inserted up to 4 hours prior to intercourse
d. after intercourse must be left in place for at least 6 hours
e. May have some protective effects against transmission of certain sex- ually transmitted infections (stis)
f. effective form of contraception for women who have infrequent inter- course or for whom there are contraindications for other methods
III. SIDE EFFECTS AND COMPLICATIONS
a. allergic reaction of patient or her partner to latex, silicone, or spermi- cidal agents (a variety exists)
B. inability to achieve satisfactory fitting
C. inability of patient to learn the correct insertion and/or removal technique
d. Use may be associated with an increased incidence of urinary tract infection because of upward pressure of the rim of the diaphragm against the urethra
e. pelvic discomfort, cramps, pressure on the bladder or rectum can occur if
1. diaphragm is too large
2. patient has chronic constipation
f. toxic shock syndrome: severe cases occurring immediately after use have been reported in diaphragm users during menses (although these appear to be related to damage to vaginal walls during scanty flow by tampon use rather than diaphragm use per se).
g. foul-smelling vaginal discharge may occur if the diaphragm is left in too long.
IV. TYPES (REPRESENTATIVE OF SEVERAL MANUFACTURERS)
a. arcing spring
1. sturdy rim with firm spring strength (spiral, coiled spring, silicone)
2. firm construction allows diaphragm to be kept in place despite rec- tocele, cystocele, mild pelvic relaxation, and uterine retroversion.
3. folds in an arc shape

B. Coil spring
1. spring in rim is spiral, coiled, and sturdy.
2. Best suited for women with good vaginal tone and no uterine displacement
3. folds flat for insertion
C. new variations
1. the Caya diaphragm is made of silicone and has an arcing spring; a finger cup is molded on one end for easy removal. one size fits all and does not require a fitting process.
2. the duet disposable diaphragm is made of dipped polyurethane, prefilled with Buffer gel. (Buffer gel is currently in clinical trials as a spermicide and microbicide.)

V. FITTING FOR TRADITIONAL DIAPHRAGMS
a. Most diaphragms available in sizes ranging from 50 or 55 mm to 95 or 100 mm (available sizes in 5-mm gradations)
B. fit should be snug between the posterior fornix, pubic symphy- sis, and lateral vaginal walls but should cause no pressure or discomfort.
C. the patient may review and sign an informed consent form (see Appendix A).
d. after a diaphragm has been fitted, instructions have been given, and the patient has demonstrated her ability to insert and remove it, she may be given an appointment for a follow-up visit in 1 week. during this week, the patient is instructed to practice wearing the diaphragm at least for 8-hour intervals. (in many settings, the 1-week follow-up may be unrealistic, so diaphragm fitting and use will be taught at one visit, and the patient is given the prescription or kit.) it is helpful for the patient to be given a phone number and a schedule to call about any concerns or problems.
e. at the optional follow-up appointment
1. diaphragm is checked for fit and proper insertion
2. instructions are again reviewed and patient is given an opportu- nity to ask questions
f. if the previous criteria are met, patient is then given a prescription for a diaphragm.
g. yearly diaphragm check is recommended, but patient should return for recheck sooner if
1. the diaphragm does not seem to fit well or can be displaced; this can occur with weight gain or loss of more than 15 pounds (6.8 kg).
2. the woman has any pelvic surgery.
3. the woman has a miscarriage or an abortion or wishes to resume using diaphragm after giving birth.
4. the woman is having problems with use.

Appendix A may be photocopied and used as an informational handout on the diaphragm as well as a consent form for your patients.
See Bibliographies.

■ FEMCAP

I. DEFINITION/MECHANISM OF ACTION
the contraceptive femCap is a prescription-only contraceptive device used to hold spermicide and to provide a partial barrier to sperm when placed over the cervix.

II. EFFECTIVENESS AND BENEFITS
a. effectiveness depends on the parity of women due to the shape of the cervical os. the effective rate for nulliparous women in the first year is 91%, as opposed to 80% in parous women. With typical use within the first year, the effective rate is 80% in nulliparous women and 60% in parous women.
B. May be inserted before intercourse and left in place for up to 48 hours
C. additional spermicide not necessary for repeated intercourse
d. latex free
e. reusable for more than a year

III. SIDE EFFECTS AND DISADVANTAGES
a. Vaginal irritation from the device
B. Vaginal irritation from the spermicide used with the device
C. sensation of something in the vagina
d. requires a prescription and pelvic examination

IV. CONTRAINDICATIONS
a. allergy to spermicide
B. allergy to the material the device is made of
C. partner allergy to the device or spermicide
d. device expelled repeatedly during use
e. Cannot be used during menses
f. Known or suspected uterine or cervical cancer
g. history of toxic shock syndrome
h. Current infection of vagina or cervix, pelvic inflammatory disease (pid)
i. Cannot be used during postpartum or after an abortion for 6 weeks
J. adhesions between cervix and vaginal walls
K. third-degree uterine prolapse
l. Cut or tear in vagina or cervix noted on pelvic examination

V. TYPES
available in three sizes: 22 mm for women who have never been pregnant, 26 mm for women who have been pregnant, and 30 mm for women who have delivered a full-term infant vaginally

VI. FITTING
a. a pelvic examination is needed to rule out anatomical or pathologic contraindications and to evaluate size and position of cervix
B. select size based on the woman’s history and examination findings: small for nulligravidas; medium for those with history of abortion or cesarean section; large for women with one or more vaginal deliveries
C. follow up for any concerns or problems; annual examination
d. Website for femCap information: www.femcap.com

■ LEA’S SHIELD*

I. DEFINITION/MECHANISM OF ACTION
lea’s shield is a contraceptive device that is used to hold spermicide and to provide a partial barrier to sperm when placed over the cervix.
II. EFFECTIVENESS AND BENEFITS
a. 85% effective (limited data)
B. May be inserted before intercourse and left in place for up to 48 hours
C. latex free
d. reusable for more than a year
III. SIDE EFFECTS AND DISADVANTAGES
a. Vaginal irritation from the device
B. Vaginal irritation from the spermicide used with the device
C. sensation of something in the vagina
d. difficulty removing
e. requires prescription
IV. CONTRAINDICATIONS
a. allergy to spermicide
B. allergy to the material the device is made of
C. partner allergy to the device or spermicide
d. device expelled repeatedly during use
e. Cannot be used during menses
f. Known or suspected uterine or cervical cancer
g. history of toxic shock syndrome
h. Current infection of vagina or cervix, pid
i. Cannot be used during postpartum or after an abortion for 6 weeks
J. adhesions between cervix and vaginal walls
K. third-degree uterine prolapse

V. TYPES
a. available in one size

* discontinued in the United states

VI. FITTING
a. a pelvic examination is needed to rule out anatomical or pathologic contraindications and to evaluate size and position of cervix.
B. follow up for any concerns or problems; annual examination.

■ VAGINAL CONTRACEPTIVE SPONGE

I. DEFINITION/MECHANISM OF ACTION
the today vaginal contraceptive sponge looks like a small doughnut with a hollow area in the center. the hollow area fits over the cervix. the sponge measures about 1.75 in. (4.45 cm) in diameter. across the bottom is a string loop to provide for easy removal. the sponge is polyurethane and contains the spermicide nonoxynol-9. it provides a barrier between sperm and the cervix, traps sperm within the sponge, and releases spermicide to inactivate sperm for more than 24 hours. the today sponge is the only one available in the United states.*
II. EFFECTIVENESS AND BENEFITS
a. 89% to 90.8% effective
B. May be inserted before intercourse and left in place for up to 24 hours
C. latex free
d. over the counter
e. no need to add extra spermicide within 24 hours
III. SIDE EFFECTS AND DISADVANTAGES
a. Vaginal irritation from the sponge
B. Vaginal irritation from the spermicide in the sponge
C. sensation of something in the vagina
d. difficulty in removing
e. May be related to the development of toxic shock syndrome if not used as directed
f. frequent use of nonoxynol-9 can cause genital irritation and increase the risk of hiV and other stis.
IV. CONTRAINDICATIONS
a. allergy to spermicide
B. allergy to sponge material
C. partner allergy to sponge or spermicide
d. Cannot be used during menses
e. history of toxic shock syndrome
f. Current infection of vagina or cervix, pid

* Website: www.todaysponge.com; available online and over the counter in pharmacies

V. HOW TO USE

ContraCeptiVe sperMiCides and CondoMs 65

a. patient should read instructions carefully prior to using the sponge.
B. Can be left in place for up to 24 hours; offers protection for each act of intercourse
VI. FOLLOW-UP
follow up per the american College of obstetricians and gynecologists (aCog) Women’s health Care guidelines (2013)