The recommendation grades (A to C, Good Practice Point) are defined at the end of the "Major Recommendations" field.
Assessing Which Women Can Use Female Barrier Methods
Medical Eligibility Criteria for Contraceptive Use
Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS)
- The use of a diaphragm, cervical cap or contraceptive sponge (all with nonoxynol-9) by women who have HIV or AIDS, or who are at high risk of HIV infection, is not generally recommended (Grade C).
- The consistent and correct use of female condoms may reduce the risk of HIV transmission (Good Practice Point).
Sensitivity to Latex Proteins
- Women with sensitivity to latex proteins can use a silicone diaphragm or cervical cap or a polyurethane female condom (Grade C).
Toxic Shock Syndrome
- For women with a history of toxic shock syndrome the use of a diaphragm, cervical cap or contraceptive sponge is not generally recommended (Grade C).
- Women with a history of toxic shock syndrome may use a female condom (Grade C).
- A diaphragm, cervical cap or contraceptive sponge should not be left in situ longer than recommended by the manufacturer (Good Practice Point).
Other Conditions That May Need to Be Considered Individually When Counselling About the Use of Female Barrier Methods
- Women considering use of a diaphragm or cervical cap should be assessed individually to determine if use is appropriate for them (Good Practice Point).
How Effective Are Female Barrier Methods at Preventing Pregnancy?
Diaphragms and Cervical Caps
- When used consistently and correctly and with spermicide, diaphragm and cervical caps are estimated to be between 92% and 96% effective at preventing pregnancy (Grade C).
Female Condoms
- When used consistently and correctly, female condoms are 95% effective at preventing pregnancy (Grade C).
Contraceptive Sponge
- When used consistently and correctly, the contraceptive sponge is estimated to be between 80% and 90% effective (Grade C).
Is the Contraceptive Efficacy of a Diaphragm or Cervical Cap Increased with Use of Spermicide?
- Women using a diaphragm should be advised to use it with spermicide (Grade B).
- Women using a cervical cap should be advised to use it with spermicide (Good Practice Point).
Do Female Barrier Methods Provide Any Protection Against Sexually Transmitted Infections (STIs)?
Female Condo
- In general, evidence supports the use of female condoms to reduce the risk of STIs. However, even with consistent and correct use, transmission may occur and male condoms provide better protection (Grade C).
Diaphragm, Cervical Caps and Contraceptive Sponge
- In general there is little evidence to support the use of a diaphragm or cervical cap (with spermicide) or a contraceptive sponge to reduce the risk of STIs (Grade C).
- There is limited evidence that a diaphragm may reduce the risk of cervical intra-epithelial neoplasia (CIN) (Grade C).
What Should Health Professionals Assess at the Initial Fitting and Follow-Up of Women Using a Diaphragm or Cervical Cap?
Clinical History Taking
- A medical history (including a sexual history) should be taken from women considering the use of a diaphragm or cervical cap (Good Practice Point).
- An individual assessment of STI risk should inform decisions about the appropriateness of diaphragm and cervical cap use, the need for use of male condoms in addition if STI risk is higher, and appropriate testing for STIs (Good Practice Point).
Vaginal Examination at Initial Visit and Follow-Up
- A vaginal examination by a competent health professional at initial fitting and follow-up is mandatory to ensure the safe and effective use of a diaphragm or cervical cap (Grade C).
- Women having a vaginal examination for fitting a diaphragm or cervical cap should be offered a chaperone and this should be documented in the case notes (Grade C).
- As a minimum, health professionals should be competent in counselling about the correct use of the method, choosing the most appropriate method and ensuring that the cervix is covered (Good Practice Point).
- After the initial fitting, all women should be asked to re-attend the clinic for review after using the diaphragm or cervical cap as a secondary method of contraception (Good Practice Point).
- At first follow-up, the health professional should check the woman can insert the diaphragm or cervical cap correctly to cover the cervix; that the method used is the correct size; that the woman is comfortable while using the method for the duration of its use, including during intercourse; and that she can tolerate the use of spermicide (Good Practice Point).
Emergency Contraception
- Health professionals should consider the advance provision of emergency hormonal contraception to women who use a diaphragm or cervical cap (Grade C).
What Information Should Be Given to Women on the Use of a Diaphragm or Cervical Cap?
Information About Correct Use (i.e., Insertion and Removal, Use of Spermicide and Need for Emergency Contraception)
Note: Detailed instructions for women on use of a diaphragm or cervical cap are included in Box 2 of the original guideline document.
- A diaphragm or cervical cap can be inserted with spermicide any time before intercourse but additional spermicide should be applied if sex is to take place and the method has been in situ for >3 hours or if sex is repeated with the method in place (Grade C).
- Women using a diaphragm or cervical cap should be informed that the method must be left in place for at least 6 hours after the last episode of intercourse (Grade C).
- Latex diaphragms and cervical caps can remain in place for a maximum of 30 hours but women should refer to the patient information leaflet for recommended duration of use for specific diaphragms and cervical caps (Grade C).
- Women using a diaphragm or cervical cap should be advised in what circumstances emergency contraception may be indicated (such as if a diaphragm or cervical cap is dislodged during sex or removed within 6 hours of sex) (Good Practice Point).
Factors That May Influence Contraceptive Efficacy
- Women should be advised to check the diaphragm or cervical cap regularly for tears, holes or cracks (Grade C).
- Oil-based products can damage latex and women should be advised to avoid their use when using latex diaphragms or cervical caps (Grade C).
- Women should be advised to follow the manufacturers' instructions regarding cleaning and caring for a diaphragm or cervical cap (Good Practice Point).
- Women using diaphragms can be advised that there is no evidence that colour changes or a small change in outer ring shape has an effect on contraceptive efficacy (Good Practice Point).
- There is no evidence that inserting the diaphragm dome up or dome down influences efficacy; however, the woman should check that the diaphragm covers the cervix after insertion (Good Practice Point).
When Should Women Attend for Advice
- Women using a diaphragm or cervical cap should be advised to attend for a contraceptive review if they have any problems with the method, if they have lost or gained over 3 kg (7 lb) in weight, or if they have had any pregnancy (Grade C).
Definitions:
Grades of Recommendations
A: Evidence based on randomised controlled trials (RCTs)
B: Evidence based on other robust experimental or observational studies
C: Evidence is limited but the advice relies on expert opinion and has the endorsement of respected authorities
Good Practice Point: Where no evidence exists but where best practice is based on the clinical experience of the Multidisciplinary Group
