As I delved into the world of non-hormonal contraceptives, I couldn’t help but wonder – ‘There is so much information available out there. Do women in India take the time to educate themselves thoroughly about their options or is that responsibility left solely upon their doctors?’ Honestly speaking, I myself have never had a comprehensive discussion with a gynecologist about ALL the options available out there and the best choice for me. It may not be possible to cover the literature on all contraceptive means during a standard gynecological consultation. Is there even time for that in busy outpatient departments (OPDs) and clinics in India? In my personal experience, the doctor usually discusses one or two options before taking a call and making a prescription. This could mean that a more suitable selection for you may be left out. That is why, it is all the more imperative for women in India to take charge of their sexual health.
In addition to at least knowing the basics about different contraceptive means available, it is also important to know one’s priorities. Would you rather prefer a contraceptive method that provides the best efficacy rate against pregnancy or is it more important for you to find the least painful method? Other considerations include:
- Do you prefer long-term methods where you use the contraceptive once and then forget about it for a few years? Or do you prefer a daily or weekly schedule?
- Do you want something that helps with periods?
- Do you want something that is discreet and easy to keep to yourself?
- Do you prefer non-hormonal methods?
- Do you want protection against STIs?
- Do you want something that does not reduce sexual pleasure?
- Do you want access to contraception without a prescription or the services of a doctor?
- Do you have a history of migraines and other health conditions that could exclude you from using certain contraceptives?
- Do you have a sexual history of multiple partners?
- Is budget an important consideration for you?
- Do you want to bear a child in the near future?
You might decide that one or more of the above factors matter to you while you don’t really care too much about the others. Knowing what you value most will allow you to have more meaningful discussions with your doctor. There, with those two caveats off my chest, let’s now take a look at the non-hormonal contraceptive space.
Spermicides
Spermicides are chemicals that kill sperm and also block the cervix thus preventing the sperm from reaching the egg. They are available in various forms such as foams, creams and jellies. Spermicides need to be inserted deep into the vagina prior to sex and are best used in conjunction with other contraceptive methods for higher efficacy. There is a whopping 30% chance of conceiving if spermicides are used by themselves. Spermicides are easily available over the counter and are low cost but do not provide any protection against STIs. Furthermore, they may cause irritation of the tissue of the vagina, vulva, penis or anus.
Diaphragm and Cervical Cap
The diaphragm is a rubber dome that is inserted into the vagina over the cervix while the cervical cap is a smaller version of this type of barrier contraception. Both block the opening of the uterus thus preventing the sperm from joining the egg. There are numerous types and sizes of diaphragms available on the market. It requires a doctor’s visit to correctly fit a diaphragm/cap and to learn how to use them, as wearing them properly can be tricky and requires practice. Both the products require the use of spermicide which is filled into the cup and around the rim. Both products have to be left in for six hours after the last time you have sex. However, a diaphragm must be removed within 24 hours of insertion whereas a cervical cap can be removed up to 48 hours post insertion. Reuse of the products within the 6-hour window requires additional use of spermicide deep within the vagina without removal of the products.
The diaphragm and cervical cap are both 88% effective, low cost and reusable for up to 2 years. They however cannot be used during periods and offer no protection against STIs. It is interesting to note that while some gynecologists report that in their personal experience, diaphragms are more popular amongst sex workers, others recently report a comeback in the popularity of diaphragms amongst women in general.
FemCap is the only brand of cervical cap approved in the US whereas Caya is a new diaphragm made out of silicone (instead of latex) for comfort and durability with a newer design for easy insertion and removal.
Today Sponge
This is a small, donut shaped foam sponge soaked with spermicide which is placed against the cervix and it has a nylon thread attached to it which makes it easier to remove (unlike the diaphragm and the cap). The Today Sponge is available over the counter, is low cost ($15 for 3), and is the only sponge FDA approved in the USA. While it is not easily available even in the US and difficult to find in India, I still include it here for your holistic information. It can be worn up to 24 hours before sex but needs to be left inside for at least 6 hours after the last time you have sex. In real life, it is difficult to use the sponge perfectly and requires practice, so efficacy rates vary from 88% for women that have never given birth and 76% for women who have given birth. Interestingly, some people report that using the sponge is messy due to the liquid whereas others report that the sponge soaks up the wetness of the vagina leading to dryness. The sponge does not protect against STIs and one needs to be aware of its side effects can include sensitivity and irritation to Nonoxynol-9, the ingredient in the sponge’s spermicide which can also increase your risk for HIV and other STDs, and a higher risk for toxic shock syndrome, which is rare. It is also not as easily available. as well.
Male Condoms
The male condom provides a barrier by collecting the sperm during ejaculation and preventing it from entering the vagina altogether. The male condom is rolled on from the tip to the base of the erect penis, with a small pouch like space left at the tip to collect the semen. Male condoms come in different sizes and it is important to obtain the right fit to prevent semen from accidentally entering the vagina via leakage. A variety of flavoured, glow in the dark and textured condoms are also available in different materials such as latex, polyurethane, silicone and even natural animal membrane. It is important to state here that it is alright for women to have a preference – for example, some women enjoy ribbed condoms while some experience pain while using them, and prefer a smoother texture. What you prefer to use can be decided mutually between you and your partner.
Condoms have expiry dates and must be used well within these dates to maintain their efficacy which is about 82%. The major advantage of condoms is that they prevent STDs and STIs. They are also low cost and available to buy over the counter. The usual complaint with condoms of course is a dulling of sensation and potential interruption to the ‘mood’.
Female Condoms
Female condoms (also known as internal condoms) come in just one size and consist of a long pouch made out of nitrile with flexible rings at either end to help with insertion. Nitrile is thinner but stronger than latex and also does not cause allergies that sometimes are experienced by people sensitive to latex. It doesn’t exactly look pretty with the open end of the condom actually hanging an inch outside your vagina. However, women have reported feeling like they have an element of control because of it and studies confirm the same. The female condom can be inserted into the vagina up to eight hours before having sex so it doesn’t ‘kill the mood’ during the act. The female condom is costlier than male condoms and less effective at 79%. However, it does offer protection against STIs although there is still debate around whether it is less effective (see here and here) or more effective (see here) than male condoms. Gynecologists say that this could be due to incorrect usage due to inadequate education. Female condoms require practice to be inserted properly and it is advisable to have a doctor ensure that you are correcting using it. They are usually easier to use if women already use tampons.
It is thought-provoking that while there are hundreds of condoms that have been FDA approved, only two female condoms, creatively branded FC1 (now defunct) & FC2 by the company Veru, have been FDA approved. In the USA, FC2 is covered with no out-of-pocket costs by most insurances when obtained with a prescription – this could be a reason that the female condom is not very popular. Imagine having to get a prescription every time a male had to use a condom! And even then, not all pharmacies carry them. This very interesting short video on why female condoms are so hard to find mentioning how Amazon has 76 pages of options for male condoms, caused me to do a quick search in India where I only found 2 types of female condoms – Cupid Angel & Velvet – both made from latex. The FC2 model was not available online. It is incredibly heartening however to see some of the government’s initiatives and collaboration with the Female Health Company and NGOs to make female condoms more accessible to women in India at the low cost of INR 5. There is most definitely an urgent need for better access and education about female condoms. I mean, imagine a world where you can go to the Durex website and actually browse through and buy a variety of female condoms instead of just coming across a single, lonely blog entry on their website when searching for female condoms with the polite and non-committal sentiment – “it is really wonderful to know that there’s another option that lets woman be in control.” That is wonderful, but I wonder what it would take you and other condom companies to enthusiastically add them to your product list and make them widely available?
Click here to continue on to the final part of this series – Part III – for interesting facts and stories about non-hormonal pills, IUDs, tubal ligations and non-hormonal emergency contraception (coming soon).
Disclaimer : This information is educational and should not be construed as medical advice. Please consult your doctor before making any dietary changes or adding supplements.
ProactiveForHer is a digital clinic for women, offering accessible, personalised, and confidential healthcare solutions. We offer out-patient care, diagnostic services and programs for various health concerns of Indian women, across their lifetime - from puberty to pregnancy to menopause.