Source: Zieman, M., Hatcher, R., Cwiak, C., Darney, P., Creinin, M., & Stosur, H. (2007). A pocket guide to managing contraception, 2007-2009. Tiger, GA: Bridging the Gap Foundation.

FAMs involve several techniques to identify high risk fertile days. The following discussion includes the most common techniques and some promising techniques for the future.

Natural family planning (NFP) provides contraception by using methods that rely on avoidance of intercourse during fertile periods. NFP methods are the only contraceptive practices acceptable to the Roman Catholic Church. NFP methods combine charting signs and symptoms of the menstrual cycle with the use of abstinence during fertile periods. Signs and symptoms most commonly used are menstrual bleeding, cervical mucus, and basal body temperature (see later discussions) (Jennings & Arevalo, 2007).

The human ovum can be fertilized no later than 16 to 24 hours after ovulation. Motile sperm have been recovered from the uterus and the oviducts as long as 60 hours after coitus. However, their ability to fertilize the ovum probably lasts no longer than 24 to 48 hours. Pregnancy is unlikely to occur if a couple abstains from intercourse for 4 days before and for 3 or 4 days after ovulation (fertile period). Unprotected intercourse on the other days of the cycle (safe period) should not result in pregnancy. However, this method presents two principal problems: (1) The exact time of ovulation cannot be predicted accurately, and (2) some couples have difficulty exercising restraint for several days before and after ovulation. Women with irregular menstrual periods have the greatest risk of failure with this form of contraception.

Calendar rhythm method.

Practice of the calendar rhythm method is based on the number of days in each cycle counting from the first day of menses. With this method, the woman determines the fertile period after accurately recording the lengths of menstrual cycles for 6 months. The beginning of the fertile period is estimated by subtracting 18 days from the length of the shortest cycle. The end of the fertile period is determined by subtracting 11 days from the length of the longest cycle (Jennings & Arevalo, 2007). If the shortest cycle is 24 days and longest is 30 days, you apply the formula as follows:

Shortest cycle: 24−18=sixth day

Longest cycle: 30−11=nineteenth day

To prevent conception the couple would abstain during the fertile period—days 6 through 19. If the woman has very regular cycles of 28 days each, the fertile days would be as follows:

Shortest cycle: 28−18=tenth day

Longest cycle: 28−11=seventeenth day

To prevent pregnancy, the couple abstains from day 10 through 17 because ovulation occurs on day 14 plus or minus 2 days.

Standard days method.

The Standard Days Method (SDM) is essentially a modified form of the calendar rhythm method that has a fixed number of days of fertility for each cycle—that is, days 8 to 19. The woman can purchase a CycleBeads necklace—a color-coded string of beads—as a concrete tool to track fertility (Fig. 4-2). Day 1 of the menstrual flow is the first day to begin the counting. Women who use this device avoid unprotected intercourse on days 8 to 19 (white beads on CycleBeads necklace). Although this method is useful to women whose cycles are 26 to 32 days long, it is unreliable to those who have longer or shorter cycles (CycleBeads, 2007). The typical failure rate for the SDM is 14% during the first year of use (Jennings & Arevalo, 2007).

Fig. 4-2 CycleBeads. Red bead marks the first day of the menstrual cycle. White beads mark days that are likely to be fertile days; therefore unprotected intercourse should be avoided. Brown beads are days when pregnancy is unlikely and unprotected intercourse is permitted. (Courtesy Dee Lowdermilk, Chapel Hill, NC.)

TwoDay method of family planning.

Based on monitoring and the recording of cervical secretions, the TwoDay Algorithm is used to identify the fertile window (Jennings & Arevalo, 2007). It appears to be simpler to teach, learn, and use than current natural methods. The woman needs to ask two questions each day: (1) “Did I note secretions today?” and (2) “Did I note secretions yesterday?” If the answer is yes to either question, she should avoid coitus or use a backup method of birth control. If the answer is no to both questions, her probability of getting pregnant is very low (Germano & Jennings, 2006).

Critical Thinking Exercise: Patient Teachning: Contraception

Ovulation method.

The cervical mucus ovulation-detection method (also called the Billings method and the Creighton model ovulation method) requires that the woman recognize and interpret the cyclic changes in the amount and consistency of cervical mucus that characterize her own unique pattern of changes (see Patient Instructions for Self-Management box). The cervical mucus that accompanies ovulation is necessary for viability and motility of sperm. It alters the pH environment, neutralizing the acidity, to be more compatible for sperm survival. Without adequate cervical mucus, coitus does not result in conception. Women check the quantity and character of mucus on the vulva or introitus with fingers or tissue paper each day for several months to learn the cycle. To ensure an accurate assessment of changes the cervical mucus should be free from semen, contraceptive gels or foams, and blood or discharge from vaginal infections for at least one full cycle. Other factors that create difficulty in identifying mucus changes include douches and vaginal deodorants, being in the sexually aroused state (which thins the mucus), and taking medications such as antihistamines (which dry up the mucus). Intercourse is considered safe without restriction beginning 4 days after the last day of wet, clear, slippery mucus (postovulation) (Jennings & Arevalo, 2007).

Patient Instructions for Self-Management

Cervical Mucus Characteristics

Setting the Stage

• Show charts of menstrual cycle along with changes in the cervical mucus.

• Have the woman practice with raw egg white.

• Supply her with a basal body temperature (BBT) log and graph if she does not already have one.

• Explain that assessment of cervical mucus characteristics is best when mucus is not mixed with semen, contraceptive jellies or foams, or discharge from infections. Tell her to refrain from douching before the assessment.

Content Related to Cervical Mucus

• Explain to the woman (couple) how cervical mucus changes throughout the menstrual cycle.

a. Postmenstrual mucus: scant

b. Preovulation mucus: cloudy, yellow or white, sticky

c. Ovulation mucus: clear, wet, sticky, slippery

d. Postovulation fertile mucus: thick, cloudy, sticky

e. Postovulation, postfertile mucus: scant

• Right before ovulation, the watery, thin, clear mucus becomes more abundant and thick (Fig. A). It feels similar to a lubricant and can be stretched 5+ cm between the thumb and forefinger; this quality of mucus is called spinnbarkeit (Fig. B), and its presence indicates the period of maximal fertility. Sperm deposited in this type of mucus can survive until ovulation occurs.

Assessment Technique

• Stress that good handwashing is imperative to begin and end all self-assessment.

• Start observation from last day of menstrual flow.

• Assess cervical mucus several times a day for several cycles. Mucus can be obtained from vaginal opening; reaching into the vagina to the cervix is unnecessary.

• Record the findings on the same record on which the BBT is entered.

Symptothermal method.

The symptothermal method is a tool that the woman uses to gain fertility awareness as she tracks the physiologic and psychologic symptoms that mark the phases of her cycle. This method combines at least two methods, usually cervical mucus changes with basal body temperature (BBT), in addition to heightened awareness of secondary, cycle phase-related symptoms. Secondary symptoms include increased libido, midcycle spotting, mittelschmerz, pelvic fullness or tenderness, and vulvar fullness. The woman learns to palpate her cervix to assess for changes in texture, position, and dilation, which indicate ovulation. During the preovulatory and ovulatory periods the cervix softens, opens, rises in the vagina, and is more moist. During the postovulatory period the cervix drops, becomes firm, and closes. The woman notes the days on which coitus, changes in routine, illness, and so on have occurred (Fig. 4-3). Calendar calculations and cervical mucus changes help to estimate the onset of the fertile period, and changes in cervical mucus or the BBT help to estimate its end (see Patient Instructions for Self-Management: Assessing Basal Body Temperature).

Fig. 4-3 Example of a completed symptothermal chart. Note basal temperature shows drop and sharp rise at time of ovulation.

Patient Instructions for Self-Management

Basal Body Temperature (BBT)

• Take your BBT using a special calibrated thermometer every morning at the same time before you get out of bed.

• You may take your BBT orally, vaginally, or rectally, but always use the same site.

• Record your temperature daily on a graph and connect the dots (see Fig. 4-3).

• You may see a slight drop in temperature (0.05° C) about the time of ovulation but many women will not experience this change.

• Your temperature likely will rise 0.4° C to 0.8° C around the time of ovulation and stay elevated until just before the next menses.

• Avoid intercourse until 3 days of higher temperatures occur after 6 days of lower than baseline temperatures.

• Infection, fatigue, less than 3 hours sleep per night, awakening late, and anxiety may cause temperature fluctuations, altering the expected pattern.

• Jet lag, alcohol and antipyretic medications taken the evening before, or sleeping in a heated waterbed also must be noted on the chart because each factor affects the BBT.

Source:

Jennings, V., Arevalo, M. Fertility awareness-based methods. In Hatcher R., et al, eds.: Contraceptive technology, 19th ed., New York: Ardent Media, 2007.

Home predictor test kits for ovulation.

All of the preceding methods discussed estimate the occurrence and approximate timing of ovulation, but none of these methods can prove ovulation is occurring (Fig. 4-4). The urine predictor test for ovulation detects the sudden surge of luteinizing hormone (LH) that occurs approximately 12 to 24 hours before ovulation. Unlike BBT, illness, emotional upset, or physical activity do not affect the test. For home use, a test kit contains sufficient material for several days of testing during each cycle. An easy-to-read color change indicates a positive response or an LH surge. Directions for use of urine predictor test kits vary with the manufacturer. Saliva predictor tests for ovulation use dried, nonfoamy saliva as a tool to show fertility patterns. More research is needed to determine the efficacy of use of these tests for pregnancy prevention.

Fig. 4-4 Examples of ovulation prediction tests. (Courtesy Shannon Perry, Phoenix, AZ.)

An electronic hormonal fertility-monitoring device, the ClearBlue Early Fertility Monitor (CEFM), is a handheld device that uses test strips to measure urinary metabolites of estrogen and LH. The monitor provides the user with low, high, and peak fertility readings. The CEFM method incorporates the use of the monitor as an aid to learning NFP and fertility awareness. It continues to be investigated for its effectiveness in helping couples prevent pregnancy (Fehring, Schneider, Raviele, & Barron, 2007).

Community Activity

Contact the local obstetrics offices, health departments, school nurses, or clinics to obtain information related to family planning services in your community. Identify location, hours, access, and fee schedules for insured and uninsured patients. Are local, state, and federal funds available? Describe how health teaching is provided. What methods of contraception are available? What services provide Plan B as a back up? How are requests for Plan B managed if patients are not 18 years of age?

Barrier methods

Barrier contraceptives have gained in popularity not only as a contraceptive method, but also as a protective measure against the spread of STIs, such as human papillomavirus and herpes simplex virus (HSV). Some male condoms and female vaginal methods provide a physical barrier to several STIs, and some male condoms provide protection against HIV (Cates & Raymond, 2007; Warner, & Steiner, 2007). Spermicides serve as chemical barriers against the sperm.

Spermicides.

Spermicides work by reducing the sperm’s mobility; the chemicals attack the sperm flagella and body, thereby preventing the sperm from reaching the cervical os. Nonoxynol-9 (N-9), the most commonly used spermicidal chemical in the United States, is a surfactant that destroys the sperm cell membrane. However, data suggest that frequent use (more than two times a day) of N-9, or use as a lubricant during anal intercourse, may increase the transmission of HIV and can cause lesions (Cates & Raymond, 2007). Women with high risk behaviors that increase their likelihood of contracting HIV and other STIs need to avoid the use of spermicidal products containing N-9, including lubricated condoms, diaphragms, and cervical caps to which N-9 is added (WHO, 2004). Intravaginal spermicides are marketed and sold without a prescription as foams, tablets, suppositories, creams, films, and gels (Fig. 4-5). Preloaded, single-dose applicators small enough to be carried in a small purse are available. Effectiveness of spermicides depends on consistent and accurate use. Caution patients against misunderstanding terms: Contraceptive gel differs from fruit jelly, and cosmetics or hair products containing the nonspermicidal forms of nonoxynol are not adequate substitutes. The spermicide should be inserted high into the vagina so that it makes contact with the cervix. Some spermicides should be inserted at least 15 minutes before, but no longer than 1 hour before, sexual intercourse. Spermicide needs to be reapplied for each additional act of intercourse, even if using a barrier method. Studies have shown varying effectiveness rates for spermicidal use alone. The typical failure rate for spermicide use alone is 29% (Trussell, 2007).

Condoms.

The male condom is a thin, stretchable sheath that covers the penis before genital, oral, or anal contact and is removed after the penis is withdrawn from the partner’s orifice after ejaculation (Fig. 4-6, A). Condoms are made of latex rubber, polyurethane (strong, thin plastic), or natural membranes (animal tissue). In addition to providing a physical barrier for sperm, nonspermicidal latex condoms also provide a barrier for STIs (particularly gonorrhea, chlamydia, and trichomoniasis) and HIV transmission. Condoms lubricated with N-9 are not recommended for preventing STIs or HIV (Centers for Disease Control and Prevention, 2006). Latex condoms will break down with oil-based lubricants and should be used only with water-based or silicone lubricants (Warner, & Steiner, 2007). Because of the growing number of people with latex allergies, condom manufacturers have begun using polyurethane, which is thinner and stronger than latex. Research is ongoing to determine the effectiveness of polyurethane condoms to protect against STIs and HIV.

Fig. 4-6 A, Mechanical barriers. From the top left corner clockwise: female condom, male condom, cervical cap, diaphragm. B, Contraceptive sponge. (A, Courtesy Dee Lowdermilk, Chapel Hill, NC.; B, courtesy Allendale Pharmaceuticals, Inc., Allendale, NJ.)

Nursing Alert

Question all persons about the potential for latex allergy. Latex condom use is contraindicated for people with latex sensitivity.

A small percentage of condoms are made from the lamb cecum (natural skin). Natural skin condoms do not provide the same protection against STIs and HIV infection as latex condoms. Natural skin condoms contain small pores that could allow passage of viruses such as hepatitis B, HSV, and HIV. Condoms need to be discarded after each single use. They are available without a prescription.

A functional difference in condom shape is the presence or absence of a sperm-reservoir tip (see Fig. 4-6, A). To enhance vaginal stimulation, some condoms are contoured and rippled or have ribbed or roughened surfaces. Thinner construction increases heat transmission and sensitivity; a variety of colors and flavors increases condoms’ acceptability and attractiveness (Trussell, 2007). A wet jelly or dry powder lubricates some condoms. Typical failure rate in the first year of male condom use is 15% (Trussell). To prevent unintended pregnancy and the spread of STIs, individuals must use condoms consistently and correctly. You can use instructions, such as those listed in Box 4-2, for patient teaching.

BOX 4-2 Male Condoms

Mechanism of Action

A sheath is applied over the erect penis before insertion or loss of preejaculatory drops of semen. Used correctly, condoms prevent sperm from entering the cervix. Spermicide-coated condoms cause ejaculated sperm to be immobilized rapidly, thus increasing contraceptive effectiveness.

Failure Rate

• Typical users, 15%

• Correct and consistent users, 2%

• Premalignant changes in cervix prevented or ameliorated in women whose partners use condoms

• Method of male nonsurgical contraception

Disadvantages

• Lovemaking must be interrupted to apply the sheath.

• Sensation may be altered.

• If condom is used improperly, spillage of sperm can result in pregnancy.

• Condoms may occasionally tear during intercourse.

Protection Against Sexually Transmitted Infections (STIs)

If a condom is used throughout the act of intercourse and no unprotected contact occurs with female genitals, a latex rubber condom, which is impermeable to viruses, can act as a protective measure against STIs.

Nursing Considerations

Teach men to do the following:

• Use a new condom (check expiration date) for each act of sexual intercourse or other acts between partners that involve contact with the penis.

• Place the condom after the penis is erect and before intimate contact.

• Place the condom on head of penis (Fig. A) and unroll it all the way to the base (Fig. B).

• Leave an empty space at the tip (Fig. A); remove any air remaining in the tip by gently pressing air out toward the base of the penis.

• If a lubricant is desired, use water-based products such as K-Y lubricating jelly. Do not use petroleum-based products because they can cause the condom to break.

• After ejaculation, carefully withdraw the still-erect penis from the vagina, holding onto condom rim; remove and discard the condom.

• Store unused condoms in a cool, dry place.

• Do not use condoms that are sticky, brittle, or obviously damaged.

The female condom is a lubricated vaginal sheath made of polyurethane and has flexible rings at both ends (see Fig. 4-6, A). The closed end of the pouch is inserted into the vagina and is anchored around the cervix, and the open ring covers the labia. Women whose partner will not wear a male condom can use this as a protective mechanical barrier. Rewetting drops or oil- or water-based lubricants help decrease the distracting noise that is produced while penile thrusting occurs. The female condom is available in one size, intended for single use only, and is sold over the counter. Individuals should not use male condoms with the female condom, because the friction from both sheaths can increase the likelihood of either or both tearing (Female Health Company, 2008). Typical failure rate in the first year of female condom use is 21% (Trussell, 2007).

Diaphragms, cervical caps, and sponges.

Diaphragms, cervical caps, and shields are soft latex or silicone barriers that cover the cervix and prevent the sperm from migrating to fertilize the ovum. These barriers are used with spermicidal jelly or cream as an additional method to prevent pregnancy.

Diaphragms.

The contraceptive diaphragm is a shallow, dome-shaped latex or silicone device with a flexible rim that covers the cervix (see Fig. 4-6, A). Three types of diaphragms are available: coil spring, arcing spring, and wide seal rim. Available in many sizes, the diaphragm should be the largest size the woman can wear without her being aware of its presence. All diaphragms require a prescription, but over-the-counter products are being researched (Cates & Raymond, 2007). Typical failure rate of the diaphragm combined with spermicide is 16% in the first year of use (Trussell, 2007). Effectiveness of the diaphragm is less when used without spermicide (Trussell). Women at high risk for HIV should avoid use of N-9 spermicides with the diaphragm (Cates & Raymond).

Inform the woman that she needs an annual gynecologic examination to assess the fit of the diaphragm. The woman should inspect the device before every use and replace it at least every 2 years. It will need to be refitted for a 20% weight fluctuation, after any abdominal or pelvic surgery, and after every term pregnancy and miscarriage or abortion that occurs after 14 weeks of gestation (Planned Parenthood, 2008). Because various types of diaphragms are on the market, use the package insert for teaching the woman how to use and care for the diaphragm (see Patient Instructions for Self-Management).

Patient Instructions for Self-Management

Use and Care of the Diaphragm

Inspection of the Diaphragm

You must inspect your diaphragm carefully before each use. The best way to perform this inspection is as follows:

• Hold the diaphragm up to a light source. Carefully stretch the diaphragm at the area of the rim, on all sides, making sure there are no holes. Remember, sharp fingernails can puncture the diaphragm.

• Another way to check for pinholes is to fill the diaphragm with water carefully. If any problem develops, you will see it immediately.

• A diaphragm that is puckered, especially near the rim, could mean thin spots.

• If you see any of these problems, do not use the diaphragm and consult your health care provider.

Preparation of the Diaphragm

Rinse off the cornstarch. Your diaphragm must always be used with a spermicidal lubricant to be effective. Pregnancy cannot be prevented effectively by the diaphragm alone.

Always empty your bladder before inserting the diaphragm. Place approximately 2 tsp of contraceptive jelly or contraceptive cream on the side of the diaphragm that will rest against the cervix (or whichever way you have been instructed). Spread it around to coat the surface and the rim. This measure aids in insertion and offers a more complete seal. Many women also spread some jelly or cream on the other side of the diaphragm (Fig. A).

Positions for Insertion of the Diaphragm

Squatting: Squatting is the most commonly used position, and most women find it satisfactory.

Leg-up method: Another position is to raise the left foot (if right hand is used for insertion) on a low stool, and, while in a bending position, insert the diaphragm.

Chair method: Another practical method for diaphragm insertion is to sit far forward on the edge of a chair.

Reclining: You may prefer to insert the diaphragm while in a semireclining position in bed.

Insertion of the Diaphragm

The diaphragm can be inserted up to 6 hours before intercourse. Hold the diaphragm between your thumb and fingers. The dome can be either up or down, as directed by your health care provider. Place your index finger on the outer rim of the compressed diaphragm (Fig. B).

Use the fingers of the other hand to spread the labia (lips of the vagina). This action will assist in guiding the diaphragm into place.

Insert the diaphragm into the vagina. Direct it inward and downward as far as it will go to the space behind and below the cervix (Fig. C).

Tuck the front of the rim of the diaphragm behind the pubic bone so that the rubber hugs the front wall of the vagina (Fig. D).

Feel for your cervix through the diaphragm to be certain it is properly placed and securely covered by the rubber dome (Fig. E).

General Information

Regardless of the time of the month, you must use your diaphragm every time intercourse takes place. Your diaphragm must be left in place for at least 6 hours after the last intercourse. If you remove your diaphragm before the 6-hour period, you will greatly increase your chance of becoming pregnant. If you have repeated acts of intercourse, you must add more spermicide for each act of intercourse.

Removal of the Diaphragm

The only proper way to remove the diaphragm is to insert your forefinger up and over the top side of the diaphragm and slightly to the side.

Next, turn the palm of your hand downward and backward, hooking the forefinger firmly on top of the inside of the upper rim of the diaphragm, breaking the suction.

Pull the diaphragm down and out. This technique prevents tearing the diaphragm with the fingernails. You should not remove the diaphragm by trying to catch the rim from below the dome (Fig. F).

Care of the Diaphragm

When using a vaginal diaphragm, avoid using oil-based products, such as certain body lubricants, mineral oil, baby oil, vaginal lubricants, or vaginitis preparations. These products can weaken the rubber.

A little care means longer wear for your diaphragm. After each use, wash the diaphragm in warm water and mild soap. Do not use detergent soaps, cold-cream soaps, deodorant soaps, and soaps containing oil products because they can weaken the rubber.

After washing, dry the diaphragm thoroughly. Remove all water and moisture with a towel. Then dust the diaphragm with cornstarch. Do not use scented talc, body powder, baby powder, or similar products because they can weaken the rubber.

To clean the introducer (if one is used), wash with mild soap and warm water, rinse, and dry thoroughly.

Place the diaphragm back in the plastic case for storage. Do not store it near a radiator or heat source or in a location that is exposed to light for an extended period.

Some women are reluctant to insert and remove the diaphragm. Although it can be inserted up to 6 hours before intercourse, a cold diaphragm and a cold gel temporarily reduce vaginal response to sexual stimulation if insertion of the diaphragm occurs immediately before intercourse. Some women or couples object to the messiness of the spermicide. These annoyances of diaphragm use, along with failure to insert the device once foreplay has begun, are the most common reasons for failures of this method. Side effects include irritation of tissues related to contact with spermicides. The diaphragm is not a good option for women with poor vaginal muscle tone or recurrent urinary tract infections. For proper placement, the diaphragm must rest behind the pubic symphysis and completely cover the cervix. To decrease the chance of exerting urethral pressure, the woman should empty her bladder before diaphragm insertion and immediately after intercourse. Diaphragms are contraindicated for women with pelvic relaxation (uterine prolapse) or a large cystocele. Women with a latex allergy should not use latex diaphragms.

Toxic shock syndrome (TSS), although reported in very small numbers, can occur in association with the use of the contraceptive diaphragm and cervical caps (Cates & Raymond, 2007). Instruct the woman about ways to reduce her risk for TSS. These measures include prompt removal of the diaphragm 6 to 8 hours after intercourse, not using the diaphragm or cervical caps during menses, and learning and watching for danger signs of TSS.

Nursing Alert

Be alert for signs of TSS in women who use a diaphragm or cervical cap as a contraceptive method. The most common signs include a sunburn-type rash, diarrhea, dizziness, faintness, weakness, sore throat, aching muscles and joints, sudden high fever, and vomiting (Planned Parenthood, 2008).

Cervical caps.

Three types of cervical caps are available. Two types come in varying sizes and one type is one size fits all. They are made of rubber or latex-free silicone and have soft domes and firm brims (see Fig. 4-6, A). The cap fits snugly around the base of the cervix close to the junction of the cervix and vaginal fornices. The cap should remain in place no less than 6 hours and not more than 48 hours at a time. It is left in place at least 6 hours after the last act of intercourse. The seal provides a physical barrier to sperm; spermicide inside the cap adds a chemical barrier. The extended period of wear may be an added convenience for women.

Spanish Guidelines: Contraception

Instructions for the actual insertion and use of the cervical cap closely resemble the instructions for the use of the contraceptive diaphragm. However, the cervical cap can be inserted hours before sexual intercourse without a need for additional spermicide later, and no additional spermicide is required for repeated acts of intercourse when the cap is used. In addition, the cervical cap requires less spermicide than the diaphragm when initially inserted. The angle of the uterus, the vaginal muscle tone, and the shape of the cervix may interfere with the cervical cap’s ease of fitting and use. Correct fitting requires time, effort, and skill from both the woman and the clinician. The woman must check the cap’s position before and after each act of intercourse (see Patient Instructions for Self-Management box).

Patient Instructions for Self-Management

Use of the Cervical Cap

• Push the cap up into the vagina until it covers the cervix.

• Press the rim against the cervix to create a seal.

• To remove, push the rim toward the right or left hip to loosen from the cervix, and then withdraw.

• The woman can assume several positions to insert the cervical cap. See the four positions shown for inserting the diaphragm.

Because of the potential risk of TSS associated with the use of the cervical cap, another form of birth control is recommended for use during menstrual bleeding and up to at least 6 weeks postpartum. Women should have the cap refitted after any gynecologic surgery or birth and after major weight losses or gains. Otherwise, the size should be checked at least once a year.

Women who are not good candidates for wearing the cervical cap include those with abnormal Papanicolaou (Pap) test results, those who cannot be fitted properly with the existing cap sizes, and those who find the insertion and removal of the device too difficult. Women with a history of TSS, vaginal or cervical infections, and those who experience allergic responses to the latex cap or spermicide are also not good candidates for cervical caps.

Contraceptive sponge.

The vaginal sponge is a small, round, polyurethane sponge that contains N-9 spermicide (see Fig. 4-6, B). It is designed to fit over the cervix (one size fits all). The side that is placed next to the cervix is concave for better fit. The opposite side has a woven polyester loop to be used for removal of the sponge.

The woman moistens the sponge with water before insertion. It provides protection for up to 24 hours and for repeated instances of sexual intercourse. The sponge should be left in place for at least 6 hours after the last act of intercourse. Wearing longer than 24 to 30 hours may put the woman at risk for TSS (Cates & Raymond, 2007).

Failure rates for these barriers in the first year of use are 16% in nulliparas and 32% in multiparous women (Trussell, 2007).

Hormonal methods

More than 70 different contraceptive formulations are available in the United States today. Table 4-1 describes the general classes. Because of the wide variety of preparations available, the woman and nurse must read the package insert for information about specific products prescribed. Formulations include combined estrogen-progestin medications and progestational agents. The formulations are administered orally, transdermally, vaginally, by implantation, by injection, or via the intrauterine route.

TABLE 4-1

Hormonal Contraception

COMPOSITION	ROUTE OF ADMINISTRATION	DURATION OF EFFECT
Combination estrogen and progestin (synthetic estrogens and progestins in varying doses and formulations)	Oral	24 hours; extended cycle—12 weeks
	Transdermal	7 days
	Vaginal ring insertion	3 weeks
Progestin only:
Norethindrone, norgestrel	Oral	24 hours
Medroxyprogesterone acetate	Intramuscular injection; subcutaneous injection	3 months
Progestin; etonogestrel	Subdermal implant	Up to 3 years
Levonorgestrel	Intrauterine device	Up to 5 years

Combined estrogen-progestin contraceptives

Oral contraceptives.

The normal menstrual cycle is maintained by a feedback mechanism. The body secretes follicle-stimulating hormone (FSH) and LH in response to fluctuating levels of ovarian estrogen and progesterone. Regular ingestion of combined oral contraceptive pills (COCs) suppresses the action of the hypothalamus and anterior pituitary that inhibits production of FSH and LH; therefore follicles do not mature, suppressing ovulation.

Combined steroids induce other contraceptive effects. These substances alter maturation of the endometrium, making it a less favorable site for implantation. COCs also have a direct effect on the endometrium such that from 1 to 4 days after the last COC is taken the endometrium sloughs and bleeds as a result of hormone withdrawal. The withdrawal bleeding is usually less profuse than that of normal menstruation and may last only 2 to 3 days. Some women have no bleeding at all. The cervical mucus remains thick from the effect of the progestin (Nelson, 2007).

Cervical mucus under the effect of progesterone does not provide as suitable an environment for sperm penetration as does the thin, watery mucus at ovulation. The possible effect, if any, of altered tubal and uterine motility induced by COCs is not clear.

Monophasic pills provide fixed doses of estrogen and progestin. Multiphasic pills (e.g., biphasic and triphasic oral contraceptives) alter the amount of progestin and sometimes the amount of estrogen within each cycle. These preparations reduce the total dose of hormones in a single cycle without sacrificing contraceptive efficacy (Nelson, 2007). To maintain adequate hormonal levels for contraception and enhance compliance, women should take COCs at the same time each day.

Advantages.

Because taking the pill does not relate directly to the sexual act, its acceptability may be increased. Improvement in sexual response may occur once the possibility of pregnancy is not an issue. For some women, knowing when to expect the next menstrual flow is convenient.

Evidence of noncontraceptive benefits of oral contraceptives is based on studies of high-dose pills (50 mg of estrogen). Few data exist on noncontraceptive benefits of low-dose oral contraceptives (less than 35 mg of estrogen) (Nelson, 2007). The noncontraceptive health benefits of COCs include decreased menstrual blood loss and decreased iron-deficiency anemia, regulation of menorrhagia and irregular cycles, and reduced incidence of dysmenorrhea and premenstrual syndrome (PMS). Oral contraceptives also offer protection against endometrial cancer and ovarian cancer, reduce the incidence of benign breast disease, and improve acne. They also protect against the development of functional ovarian cysts and salpingitis and decrease the risk of ectopic pregnancy. Oral contraceptives are considered a safe option for nonsmoking women until menopause. Perimenopausal women can benefit from regular bleeding cycles, a regular hormonal pattern, and the noncontraceptive health benefits of oral contraceptives (Nelson).

Women taking COCs are examined before the medication is prescribed and yearly thereafter. The examination includes medical and family history, weight, blood pressure, general physical and pelvic examinations, and screening cervical cytologic analysis (Pap test). Consistent monitoring by the health care provider is valuable in the detection of non–contraception-related disorders as well so that providers can initiate timely treatment. Most health care providers assess the woman 3 months after she begins COCs to detect any complications.

Oral hormonal contraceptives are initiated in three ways: (1) quick start—taking the first pill the same day as the clinic appointment and using a back-up method for 7 days, (2) first day start—taking the first pill on the first day of the menstrual cycle (menses), and (3) Sunday start—taking the first pill on the first Sunday after the start of their menstrual period (Nelson, 2007). Taken exactly as directed, COCs prevent ovulation, and pregnancy cannot occur; the overall effectiveness rate is almost 100%. Almost all failures (i.e., occurrence of pregnancy) are caused by omission of one or more pills during the regimen. The typical failure rate of COCs resulting from omission is 8% (Trussell, 2007).

COCs also can be taken using different patterns. Most are taken on a monthly cycle of 3 weeks of active pills followed by seven placebo pills. Some regimens now come with fewer placebo pills and more active pills, although research is still needed on the efficacy and safety of these regimens. Another pattern of use is the extended cycle—taking pills for longer times, which lessens the frequency of menstrual periods (i.e., withdrawal bleeding). The extended period can be short, such as for a special event like a vacation or honeymoon, or for more extended times. For example, a woman can take 2 months of active pills followed by seven placebo pills at the end of the second package or take a U.S. Food and Drug Administration (FDA)-approved extended-use pill. One such pill is levonorgestrel–ethinyl estradiol (Seasonale) that contains both estrogen and progestin, taken in 3-month cycles of 12 weeks of active pills followed by 1 week of inactive pills. Menstrual periods occur during the thirteenth week of the cycle. This active pill provides no protection from STIs, and risks are similar to those of COCs. Available only by prescription, women must take Seasonale on a daily schedule, regardless of the frequency of intercourse. Because users will have fewer menstrual flows, they should consider the possibility of pregnancy if they do not experience their thirteenth-week flow. Typical failure rate in the first year of Seasonale use is less than 5% (U.S. FDA, 2009).

Disadvantages and side effects.

Since hormonal contraceptives have come into use, the amount of estrogen and progestational agent contained in each tablet has been reduced considerably. This factor is important because adverse effects are, to a degree, dose related.

You need to screen women for medical conditions that preclude the use of oral contraceptives. Contraindications for COC use include a history or presence of thromboembolic disorders, cerebrovascular or coronary artery disease, valvular heart disease, breast cancer or other estrogen-dependent tumors, impaired liver function, and liver tumor. Women older than 35 years of age who smoke (more than 15 cigarettes per day), or those with severe hypertension or who have headaches with focal neurologic symptoms should not use COCs. Surgery with prolonged immobilization or any surgery on the legs and diabetes mellitus (of more than 20 years’ duration) with vascular disease also contraindicate COC use (Nelson, 2007).

Certain side effects of COCs are attributable to estrogen, progestin, or both. Serious adverse effects documented with high doses of estrogen and progesterone include stroke, myocardial infarction, thromboembolism, hypertension, gallbladder disease, and liver tumors. Common side effects of estrogen excess include nausea, breast tenderness, fluid retention, and chloasma. Side effects of estrogen deficiency include early spotting (days 1 to 14), hypomenorrhea, nervousness, and atrophic vaginitis leading to painful intercourse (dyspareunia). Side effects of progestin excess include increased appetite, tiredness, depression, breast tenderness, vaginal yeast infection, oily skin and scalp, hirsutism, and postpill amenorrhea. Side effects of progestin deficiency include late spotting and breakthrough bleeding (days 15 to 21), heavy flow with clots, and decreased breast size. One of the most common side effects of combined COCs is bleeding irregularities (Nelson, 2007).

In the presence of side effects, especially those that are bothersome to the woman, a different product, different drug content, or another method of contraception may be required. The “right” product for a woman contains the lowest dose of hormones that prevents ovulation and that has the fewest and least harmful side effects. Predicting the right dose for any particular woman is impossible. Issues to consider in prescribing oral contraceptives include history of oral contraceptive use, side effects during past use, menstrual history, and drug interactions (Nelson, 2007).

The following medications, when taken simultaneously with oral contraceptives, can reduce the effectiveness of contraceptives (Nelson, 2007).

• Anticonvulsants: barbiturates, oxcarbazepine, phenytoin, phenobarbital, felbamate, carbamazepine, primidone, and topiramate

• Systemic antifungals: griseofulvin

• Antituberculosis drugs: rifampicin and rifabutin