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Spermicides appeal to many women seeking contraception. In countries
where they are available, obtaining them usually does not require a
prescription or a provider's help. Using them is easy and sometimes can be
done without a sexual partner's knowledge.
They can be used only when needed. And while they damage or kill sperm
and may have minor localized side effects, spermicides have no effect on
various systems throughout a woman's body. Finally, they come in different
formulations, giving women a variety of choices: films, suppositories,
gels, foams, creams or tablets.
However, spermicides used alone are among the least effective of modern
contraceptives in preventing pregnancy. Pregnancy rates in typical use are
about 26 percent in the first year.1 Thus, spermicides are more
appropriate for women who cannot use other contraceptive methods or choose
not to, and for women willing to risk an unintended pregnancy. Spermicide
users should be informed about the use of emergency contraception as a
backup, in case a spermicide was not used or was used incorrectly.
Furthermore, women should not expect sizable protection against
sexually transmitted diseases, or STDs. Nonoxynol-9 (N-9) appears to
provide modest protection against the bacterial STDs gonorrhea and
chlamydia, but studies are inconclusive about whether it protects against
viral STDs, including HIV. In fact, repeated use can irritate the vaginal
lining, possibly increasing susceptibility to HIV. Research is under way
to determine further the protection against disease provided by various
existing spermicidal products, including those with benzalkonium chloride
and octoxynol-9.
Determining effectiveness
How well do spermicides protect against pregnancy?
N-9 products have been available for more than 40 years, and rigorous
clinical contraceptive testing of effectiveness was not required for
their original approval by the U.S. Food and Drug Administration (FDA)
in 1980. A 26 percent pregnancy rate during the first year of typical
use reflects findings from studies that are difficult to compare and
vary widely, with reported first-year typical pregnancy rates ranging
from 0.3 percent to 37 percent.2
Pregnancy rates estimated for the first year of typical use, based on
six-month data, were even higher in a recent FHI five-country study
involving about 750 women. This study calculated annual pregnancy rates
of 40 percent and 44 percent, respectively, among women using a
spermicidal film containing a medium dose (72 mg) of N-9 and foaming
tablets containing a high dose (100 mg) of N-9.3 When no
contraception is used, about 85 percent of sexually active women become
pregnant within a year.4
Contraceptive effectiveness of N-9 spermicides in various doses and
formulations is the focus of a large study in the United States being
conducted by FHI. This randomized, controlled trial of safety,
contraceptive effectiveness, acceptability and consistency of use of
various N-9 products will involve 1,800 women. The FDA has recommended
that spermicide manufacturers be required to conduct full-scale clinical
studies of products already on the market, but is awaiting results from
the FHI study before making a decision.
Despite continuing attempts by researchers to provide more accurate
pregnancy rates for spermicide effectiveness, FHI epidemiologist Dr.
Markus Steiner emphasizes that these rates can be misleading. Rather
than relying on such pregnancy rates, providers and clients should
recognize that the effectiveness of spermicides — like other barrier
methods — largely depends upon whether they are used correctly and
consistently, he says.5 In general, spermicides are the least
effective of contraceptive methods because people tend to use them
incorrectly or inconsistently during typical use. Just how effective
spermicides are during correct and consistent use (or perfect use) is
difficult to measure because it requires participants to provide
accurate and truthful information throughout a clinical effectiveness
study.
Correct spermicide use as a contraceptive entails using spermicide
each time intercourse occurs; placing the substance correctly in the
vagina (on or near the cervix) no longer than one hour before
intercourse; allowing adequate time for the spermicide to dissolve and
disperse; using another application of spermicide if more than one hour
has passed between insertion and intercourse; and not douching until at
least six hours after sexual intercourse.
Because spermicides are often purchased at pharmacies or provided by
community-based distribution, informing clients about their
effectiveness and correct use can be challenging.
Use with other barrier methods
Whether using spermicides with other barrier methods increases
contraceptive effectiveness is debatable. Widely varying results may
reflect, as FHI's Dr. Steiner emphasizes, whether clients are using the
methods correctly and consistently.
Using spermicide with cervical caps appears to improve somewhat the
contraceptive effectiveness of the caps. One-year pregnancy rates for
women using cervical caps with spermicide range from 5 percent to 21
percent, according to various studies.6 One-year pregnancy
rates for typical use of cervical caps alone range from 20 percent for
nulliparous women to 40 percent for parous women.
Whether use of a spermicide with a diaphragm increases or even
decreases the contraceptive effectiveness of the diaphragm is unknown.
In various studies, 12-month pregnancy rates have ranged from 10 percent
to 21 percent for women using a diaphragm with spermicide.7 A
12-month pregnancy rate for typical use of the diaphragm alone ranges
from 1 percent to 29 percent.
Typical use of a diaphragm without spermicide may actually provide
more effective contraception than diaphragm use with a spermicide. The
messiness, cost, and inconvenience of using spermicide with a diaphragm
can discourage consistent diaphragm use. In addition, researchers have
speculated that continuous use of a diaphragm would be less
inconvenient, and perhaps more consistent, than the traditional use of
diaphragms, with insertion occurring just before intercourse and removal
recommended within 24 hours.
Two studies involving a total of 1,670 users, in which diaphragms
were worn continuously (up to one year in one study and up to four years
in the other) show excellent contraceptive protection rates. Using
diaphragms continuously without spermicides resulted in pregnancy rates
of 3 percent and 1 percent a year, respectively.8 However, an
FHI-sponsored study conducted among 110 women by the London-based
Margaret Pyke Centre of a continuously used diaphragm over 12 months
without spermicide found a 24 percent annual pregnancy rate.9
In all three studies, diaphragms were briefly removed for cleaning each
day at least six hours after intercourse, then immediately reinserted.
Other studies have found that use of a diaphragm in the traditional
way — with spermicide and with insertion just before intercourse — is
associated with lower pregnancy rates than continuous use of a diaphragm
without spermicide. However, no significant difference has been
demonstrated.10 In general, no differences in discontinuation
due to medical reasons have been observed between the two modes of
diaphragm use.
Continuous use of a diaphragm without spermicide is considered an
experimental method and is not recommended for general use.
Whether the use of spermicide with condoms should be promoted also
has been the subject of debate and investigation. Concerns have focused
on whether promoting spermicide use with condoms might reduce condom
use.
One FHI study looked at how spermicide availability affected male
condom use among three groups of Colombian prostitutes. The first group
used condoms only, the second group used spermicides with condoms, and
the third group was assigned to use spermicide as a backup if a condom
was not used. All participants were instructed to use a condom at every
act of intercourse. Researchers found that half of women in the
condom-only group — and nearly 40 percent of women in the spermicide
and condom group — reported using condoms for every act of intercourse.
However, fewer than 5 percent used condoms among the women assigned to
use spermicide as a backup when condoms were not used. "The lower
level of consistent condom use reported among this group is of
programmatic concern," concluded the study's authors. "Sex
workers may be less motivated to negotiate condom use if spermicides are
presented as an option to potential customers."11
Use of spermicides with female condoms is possible, but no studies
have been conducted comparing the effectiveness of female condom use
alone versus female condom use with spermicides. (The lubricant that is
supplied with female condoms is not spermicidal.)
The spermicide used in contraceptive sponges is considered to be the
primary means of pregnancy prevention. Consequently, sponges are not
used without spermicides.
Health effects
The most common problem associated with spermicide use is skin
irritation of the female or male genitalia. Usually irritation is
temporary, and stops when spermicide use is discontinued. Persistent use
of spermicides can also disrupt the vaginal lining.
Use of N-9 spermicide also appears to increase a woman's risk of
urinary tract infection (UTI), characterized by painful, urgent or more
frequent than normal urination. Increased risk of UTI has been found in
women using diaphragms with spermicide,12 in women using
spermicide-coated condoms,13 and in women using spermicide
alone.14 Spermicides appear to change the normal vaginal
environment. These changes allow microorganisms such as Escherichia
coli — the most common cause of UTI — to thrive and attach to the
mucous membrane of the vagina more easily.15
Notably, more frequent use of diaphragms with spermicide and of
spermicide-coated condoms has been strongly associated with increased
risk of UTI among sexually active young women participating in two U.S.
studies.16 Whether more frequent use of spermicide alone also
increases UTI risk requires further research.
Guidelines are not available to help providers counsel clients about
their risk of UTI as it relates to frequent spermicide use.
"However, providers should alert clients using spermicides alone or
with other barrier methods to their increased risk of UTI," says
Elaine Murphy, senior program advisor at the U.S.-based Program for
Appropriate Technology in Health and cochair of a U. S. Agency for
International Development (USAID) committee on client-provider
interaction. "They should inform women of the signs and symptoms of
UTI and what to do if they experience such symptoms. Providers also
should be able to refer women with UTI for treatment. Women with
recurrent UTIs should be advised to consider using another form of
contraception besides spermicide."
Disruption of the vaginal environment also has been associated with
bacterial vaginosis. This common vaginal infection is considered a risk
factor for more serious pelvic and obstetric conditions. However,
evidence suggests that spermicide use decreases risk of bacterial
vaginosis. In the laboratory, various spermicides — including N-9,
benzalkonium chloride and menfegol — kill a variety of microorganisms
associated with bacterial vaginosis.17 In a study of some 180
women, 66 of whom used N-9 spermicide, a significantly reduced
prevalence of bacterial vaginosis was associated with spermicide use (15
percent), compared with those who were not using spermicide (31
percent).18 More research is needed to clarify this issue.
Use of N-9-impregnated sponges has been associated with vaginal yeast
infection due to overgrowth of Candida albicans.19
Data are conflicting about the association between spermicides used
alone and yeast vaginitis.20
Acceptability
Spermicides that people like to use and accept will be used more
consistently, making the contraceptive method more effective in typical
use. Should a spermicide also prove to protect against STDs
significantly, its acceptability would become even more critical.
Various studies are under way to assess the acceptability of
spermicidal products. Foam spermicide, for example, was found to be
excessively messy and produced too much lubrication in an FHI study
conducted in collaboration with researchers at University Teaching
Hospital in Lusaka, Zambia, among 114 women and 150 men attending an STD
clinic. Foam was less desirable than both suppositories and foaming
tablets.21
In another spermicide acceptability study conducted by FHI among 162
family planning clinic clients in Kenya, the Dominican Republic and
Mexico, women preferred contraceptive film over foaming tablets. Again,
the messiness and wetness associated with tablets were unacceptable to
many women.22
In focus group discussions, 77 low-income Mexican women said that
sperm-icides were the least bothersome of the barrier methods. But most
women felt that barrier methods, including spermicides, tended to
interrupt intimacy because they were inserted immediately prior to use.
The authors of the study noted that while female barrier methods can be
inserted immediately prior to use, "it appears that in this
community, the timing of intercourse is often difficult to anticipate,
and a man cannot be relied on to be patient while a woman prepares
herself."23
"The use of spermicides in Mexico is low," confirms Dr.
Susana Bassol, head of the Department of Biology of Reproduction, Centro
de Investigación Biomédica in Torreón, Mexico. "First,
spermicides are not distributed by family planning programs and they are
too expensive for most women to buy. Spermicides also are associated
with relatively high pregnancy rates. Providers recommend them only in
special cases, such as to women who are switching methods or
breastfeeding for a short time."
In Kenya, "there is a negative perception of spermicides by
clients who think they are messy, irritating, cause delays before sexual
intercourse, and have high failure rates," says Nester Theuri,
programme coordinator of the reproductive health department for Kenya's
family planning private sector. "Also, many women, especially rural
women, feel uncomfortable having to touch their reproductive parts in
order to use spermicides.
"Furthermore, there is lack of proper education about
spermicides. Health providers do not seem very keen to give spermicides
as a family planning method and so do not counsel clients properly about
them."
That spermicides are not used widely in Kenya is further explained by
their cost. Spermicides supplied through commercial sources are
expensive, particularly when women choose to combine them with another
method to protect themselves better against pregnancy or sexually
transmitted diseases.
The situation is similar in neighboring Uganda. "Not many women
— especially if they are married — use spermicides," says Allen
Nankunda, communication specialist with the Delivery of Improved
Services for Health Project, a joint project of the government of Uganda
and USAID. "Family planning clients tend to prefer methods that are
more long-term, easier to use and more effective. It is the unmarried
adolescents who are more likely to use spermicides."
In Nepal, spermicides have been available since 1983. However,
government health clinics do not supply them. And, while both vaginal
foaming tablets and films are available, their use is very low, says
Kamala Moktan of FHI, a registered nurse in that country.
— Kim Best
References
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