Couples who use male latex condoms correctly and consistently are protected from both
pregnancy and sexually transmitted diseases (STDs). However, because condoms are applied
by the user at the time of intercourse, they are generally not as effective as
contraceptives such as hormonal methods and intrauterine devices, which are not
coitus-related.
To help condom users prevent an unplanned pregnancy, some health officials recommend
emergency contraception (EC) as a backup method of family planning. EC, in the form of
oral contraceptives, can be given to condom users (or users of other barrier methods, such
as diaphragms or spermicides) as a precaution, to be used in the event of unprotected
intercourse or method failure. Such measures would likely improve access to and use of
emergency contraception, experts say.
"A user of the condom, diaphragm, sponge or spermicide could be given the correct
number of pills for emergency contraception along with instructions for their use,"
say draft guidelines developed for family planning providers by the Technical
Guidance/Competence Working Group, an international advisory panel organized by the U.S.
Agency for International Development (USAID). "Having emergency contraception readily
available in cases of slippage/breakage/non-use of barriers would decrease the risk of
unintended pregnancy."1
At a 1995 meeting of international experts, sponsored by the Rockefeller Foundation and
held in Bellagio, Italy, a consensus statement on emergency contraception recommended that
women who choose barrier methods or periodic abstinence as their contraceptive method
"should be informed about and, when appropriate, provided with emergency
contraceptives for future use."2
Using condoms as a primary means of contraception and emergency contraceptive pills
(ECPs) as a backup is a new approach to "dual-method" use. Previously, many
providers have recommended that couples use pills and condoms together - but with pills as
the primary means of pregnancy prevention and condoms for STD prevention.
Several studies are under way to determine the effect of giving ECPs to condom users
prior to immediate need.3 In one, FHI plans research on the
probability of pregnancy among condom users who receive counseling only, compared with
condom users who receive counseling and the emergency contraceptive method known as the
Yuzpe regimen (two elevated doses of combined oral contraceptives). The study will follow
two groups of women for three months, examining the consistency of condom use, frequency
of ECP use and method acceptability.
"Many people are beginning to recommend that all barrier method users should be
provided with emergency contraceptive pills in advance, to use in case they fail to use
the method or in case the method fails - for example, if the condom breaks," says Dr.
Elizabeth Raymond of FHI's clinical trials division. "However, some concern exists
that having ECPs at home could lead some women to use their barrier method less
consistently, possibly increasing their risk of pregnancy and STDs. The study will
evaluate and compare use of condoms in the two groups."
The World Health Organization (WHO) is also conducting a study of 3,000 people in
China, comparing those who use male condoms and those who use condoms with progestin-only
pills containing levonorgestrel as a backup. The Dean Terrace Family Planning Centre in
Edinburgh, Scotland is conducting a similar study of approximately 1,000 women whose
partners use condoms.
In South Africa, ECPs are being provided as backup contraception in three provinces --
Gauteng, North-West and Northern Province -- as part of a study to introduce dual-method
use. This study, conducted by the Baragwanath Hospital in Soweto with funding from WHO,
will provide information on user attitudes and practices, plus service delivery
requirements. South Africa recently approved sales of the emergency contraceptive pill
PC4, also marketed as Tetragynon.
In addition to research on service delivery, studies also are planned to learn more
about the mechanisms of action of ECPs, including a study by FHI. Currently, scientists
believe the pills may work by inhibiting ovulation, making the uterine lining less
receptive to implantation of the egg, and altering the speed at which the egg passes
through the fallopian tubes.4
Providing ECPs in advance of need could be especially beneficial to condom users, some
experts say. A study in New South Wales, Australia, found that 22 percent of women
requesting an abortion had been using condoms at the time of conception. Many women
reported a broken or slipped condom, caused by incorrect use.5
A separate study of women seeking abortion in England found that, of the 309 clients who
became pregnant while using condoms, 45 of them recognized condom failure, but only 20
people attempted to use emergency contraception.6
According to the USAID working group, providers who give clients ECPs prior to
unprotected intercourse should counsel clients about:
- how and when to use ECPs
- the potential complications resulting from ECP use (nausea, vomiting, irregular uterine
bleeding, breast tenderness)
- problems for which a woman should seek further treatment (lower abdominal pain, absence
of menses three weeks or more after ECPs are taken)
- what to do in case of ECP failure (virtually no risk for fetal development, but a woman
may need referrals for follow-up care).
Certain combined oral contraceptives, given in higher-than-usual doses, can be used as
emergency contraceptive pills. The Yuzpe method requires a woman to take an initial dose
containing 100 micrograms (mcg) of ethinyl estradiol and 1 milligram (mg) of norgestrel or
100 mcg of ethinyl estradiol and 0.5 mg of levonorgestrel within 72 hours of unprotected
sex. This should be followed by a second dose 12 hours later. In 1996, an advisory panel
of the U.S. Food and Drug Administration concluded that the following dosages of six
brands were known to work safely and effectively: two tablets per dose of the brand Ovral
or four pills per dose of the brands Lo/Ovral, Nordette, Levlen, Tri-Levlen or Triphasil
(yellow active pills only).
Emergency contraceptive pills are safe for use by any woman who has had unprotected
sexual intercourse, including women who cannot routinely use the pill due to health
problems, such as cardiovascular disease.7 Laboratory tests,
Pap smears, blood pressure and breast exams are not necessary.8
Certain progestin-only pills also may be used as an emergency contraceptive. Additional
studies are under way to determine effectiveness. Clients should take one dose, containing
0.75 mg of levonorgestrel within 48 hours of unprotected intercourse, followed by a second
dose 12 hours later.
Copper IUDs, inserted within five days of unprotected intercourse, also can be used as
an emergency contraceptive. However, because IUDs are not recommended for use by couples
at risk for STDs, this method would not be ideal for couples using condoms for STD
protection.
Emergency contraception can prevent nearly 75 percent of the pregnancies that would be
expected if emergency contraception had not been used.9
However, emergency contraception does not protect against STDs. For couples concerned
about transmission of STDs following unprotected intercourse, options are limited.
Combinations of antibiotics, given after unprotected sexual intercourse, may reduce a
woman's risk of infection from some bacterial STDs, and genital washing and medications
such as Protargol have shown some ability to prevent STDs among men. However, emergency
treatment of STDs typically is recommended for specific situations, such as treating rape
victims, and not for general use. No postcoital methods can prevent transmission of viral
STDs, such as HIV, the virus that causes AIDS.
-- Barbara Barnett
References
- Gaines M, ed. Recommendations for Updating Selected
Practices in Contraceptive Use. Volume II. Draft. July 1996.
- Consensus statement on emergency contraception. Contraception
1995; 52(4):211-12.
- Consortium for Emergency Contraception. Update on
Emergency Contraception. October 1996.
- Hatcher RA, Trussell J, Stewart F, et al. Emergency
Contraception: The Nation's Best Kept Secret. Atlanta: Bridging the Gap Communications
Inc., 1995.
- Weisberg E. Practical problems which women encounter
with available contraception in Australia. Aust N Z J Obstet Gynecol 1994; 34(3):
312-15.
- Bromham DR, Cartmill RS. Knowledge and use of secondary
contraception among patients requesting termination of pregnancy. BMJ 1993:
306(6877): 556-57.
- Improving Access to Quality Care in Family Planning:
Medical Eligibility Criteria for Contraceptive Use. Geneva: World Health Organization.
1996.
- Gaines.
- Trussell J, Ellertson C, Stewart F. The effectiveness of
the Yuzpe regimen of emergency contraception. Fam Plann Perspect 1996; 28: 58-64,
88.
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