Non-Steroidal (Non-Hormonal) Contraceptives

1. Copper Intrauterine Device (Cu-IUD)

• Creates a local inflammatory/foreign body reaction in the uterus that is toxic to sperm
• Copper ions exert a direct spermatocidal effect, impairing sperm motility and function
• Alters uterine and tubal fluid, impeding sperm transport
• May impair fertilization and implantation

• Failure rate: ~0.8% typical use (as low as 0.6% perfect use)
• Cumulative 10-year pregnancy rate: ~1.7%
• Also the most effective form of emergency contraception if inserted within 120 hours of unprotected intercourse

• Immediately reversible (fertility returns promptly after removal)
• No hormonal side effects
• Suitable for women with contraindications to estrogen (e.g., migraine with aura, thrombophilia, cardiovascular disease)

• Increased menstrual bleeding and dysmenorrhea
• Risk of insertion-related complications: uterine perforation, expulsion, infection (highest in first month post-insertion, especially in women exposed to STIs)
• Contraindicated in unexplained uterine bleeding, uterine anomalies, active pelvic inflammatory disease
• Ganong's Review of Medical Physiology, 26e, p. 415
• Goldman-Cecil Medicine, 22e, Chapter 220

2. Barrier Methods

Male Condom (External Condom)

• One of the oldest known contraceptives; made of latex or polyurethane
• Typical use failure rate: ~18% per year
• Perfect use failure rate: ~2% (Ganong's: 3.6 failures per 100 woman-years)
• Only contraceptive method that also protects against STIs including HIV
• Polyurethane condoms are suitable for latex allergy and are less likely to rupture
• Easy to use, widely available, no prescription required

Female Condom (Internal Condom)

• Soft, loose-fitting polyurethane pouch with two flexible rings
• The inner (smaller) ring is inserted into the vagina; the outer (larger) ring remains outside
• Typical use failure rate: ~21%
• Can be inserted before sexual activity
• Less likely to rupture than latex male condoms
• Protects against HIV and STIs (both polyurethane and latex prevent viral transmission)

Diaphragm

• A soft latex or silicone dome inserted to cover the cervix before intercourse, used with spermicide
• Typical use failure rate: ~12% (Ganong's: 1.9 per 100 woman-years)
• Must remain in place for at least 6 hours after intercourse
• Requires fitting by a clinician
• Reusable; does not protect against STIs
• Risk: increased urinary tract infections; contraindicated with allergy to latex/spermicide

Cervical Cap and Sponge

• Cervical cap: fits over the cervix; used with spermicide; less effective in parous women
• Contraceptive sponge: soft foam device containing spermicide; inserted before intercourse
  • Failure rate: 24% in parous women, 12% in nulliparous women (typical use)
• Goldman-Cecil Medicine, 22e, Chapter 220
• Kaplan & Sadock's Comprehensive Textbook of Psychiatry, Table 30.1-6

3. Spermicides

• Typical use failure rate: ~28% (highest among all standard contraceptive methods)
• Ganong's: 11.9 per 100 woman-years
• More effective when combined with a barrier method (condom or diaphragm)

• A newer FDA-approved contraceptive vaginal gel containing L-lactic acid, citric acid, and potassium bitartrate
• Mechanism: maintains a low, spermicidal vaginal pH to inactivate sperm (sperm require an alkaline environment to survive)
• Associated with a 7-cycle pregnancy rate of ~18% in clinical trials (typical use)
• Used on-demand, applied immediately before each act of intercourse
• Provides an alternative for women who cannot use or prefer to avoid nonoxynol-9
• Goldman-Cecil Medicine, 22e (Spermicides section)

4. Fertility Awareness-Based Methods (FABMs)

• Calendar/rhythm method: Predicts fertile days based on past cycle length history
• Basal body temperature (BBT) method: Temperature rises ~0.2-0.5°C after ovulation (progesterone effect)
• Cervical mucus (Billings ovulation) method: Monitors changes in cervical secretions (thin, clear, stretchy "egg-white" mucus indicates ovulation)
• Symptothermal method: Combines BBT + cervical mucus monitoring (most reliable FABM)
• Standard Days Method (SDM): Avoids intercourse on days 8-19 of a 26-32 day cycle
• Lactational Amenorrhea Method (LAM): Exclusive breastfeeding suppresses ovulation; highly effective for the first 6 months postpartum if the woman is amenorrheic and exclusively breastfeeding (>98% effective under these conditions)

• Rhythm method: ~24% failure rate per year
• Ganong's: 15.5 per 100 woman-years
• Symptothermal method (perfect use): ~0.4-2% failure rate

• Pfenninger and Fowler's Procedures for Primary Care, 3e
• Ganong's Review of Medical Physiology, 26e

5. Surgical Sterilization (Permanent Methods)

• Vasectomy: occlusion or excision of the vas deferens; outpatient procedure; requires backup contraception for first 3 months until azoospermia confirmed
• Female sterilization: tubal ligation, fulguration, salpingectomy, or mechanical occlusion (clips/rings); laparoscopic or hysteroscopic approaches
• Cumulative failure: 1.31% at 5 years, 1.85% at 10 years (varies by technique; segmental resection has lowest rates)
• Goldman-Cecil Medicine, 22e
• Ganong's Review of Medical Physiology, 26e

6. Withdrawal (Coitus Interruptus)

• Man withdraws before ejaculation
• Typical use failure rate: ~22% (Ganong's: 6.7 per 100 woman-years)
• No side effects or devices needed
• Effectiveness is highly user-dependent; pre-ejaculatory fluid may contain sperm

Comparative Efficacy Summary

Key Points

• Non-hormonal contraceptives are preferred in women with contraindications to estrogen or progestins (e.g., thrombophilia, cardiovascular disease, estrogen-sensitive tumors, migraine with aura, breastfeeding)
• The copper IUD is the most effective non-hormonal reversible contraceptive and doubles as emergency contraception
• Condoms are the only method offering dual protection against both pregnancy and STIs
• Spermicide alone has the highest typical use failure rate and should ideally be combined with a barrier method
• Phexxi (L-lactic acid/citric acid/potassium bitartrate gel) is a new FDA-approved on-demand non-hormonal option
• The CDC Medical Eligibility Criteria (MEC) provides evidence-based guidance on contraceptive use for women with specific medical conditions (CDC MEC Guidelines)