The last week I’ve been busy with my regular day-to-day activities, and on top of it all had a paper to write for my Men’s and Women’s Health course at CCNM. The topic that I chose was looking at the main active ingredient in SPERMICIDES, Nonoxynol-9 and its effects as a contraceptive and STI (sexually transmitted infection) preventative. The paper is quite long, so I’ve only posted the main ideas. For my complete report please contact me.
Is Nonoxynol-9 a Safe and Effective Spermicide and Preventative
for Sexually Transmitted Infections?
There are approximately 62 million U.S. women within their childbearing years and 43 million of them sexually active and not wanting to become pregnant (Guttmacher Institute, 2010). About 62% of reproductive-age women are currently using a contraceptive with over half choosing non-permanent methods, including hormonal approaches, intrauterine devices, and condoms (Guttmacher Institute, 2010). Refer to Table 1 for a list of common contraception methods (Centers for Disease Control and Prevention, 2010).
Currently, the only method of contraception for heterosexual intercourse that also protects against STIs is male condoms (Centers for Disease Control and Prevention, 2010). Male condoms are very effective, low in cost, and do not require prescriptions however, they require the cooperation of the male partner. Crosby et al. (2006), reports that loss of male penis erection during intercourse due to the use of condoms can contribute to risky sexual behaviours (including unprotected sex), which could potentially expose partners to STIs. There is a global need for female-controlled contraceptives that act safe and effectively to prevent sexually transmitted infections while maintaining sensitivity during intercourse.
What are Spermicides and Nonoxynol-9?
Nonoxynol-9 (N-9) is a typical non-ionic surfactant and spermicidal agent that has been under investigation for its potential use as a microbicide (Iyer & Poddar, 2008). Spermicidal agents are locally acting non-hormonal contraceptives that pass specific screening processes for efficacy and safety (Batista & Ramalho-Santos, 2009). Spermicides must rapidly kill or immobilize sperm on contact or render sperm incapable of fertilizing an oocyte while evading adverse effects on viable embryos or foetuses (Batista & Ramalho-Santos, 2009). N-9 is the most frequently used spermicide to date and comes in a variety of different forms: creams, films, gels, pessaries, tablets, jellies, suppositories, foams, and condom lubricants (Iyer & Poddar, 2008). Table 2 displays a list of common over-the-counter contraceptives containing Nonoxynol-9.
Nonoxynol-9 is an effective contraceptive option with local-acting mechanisms, insignificant systemic effects or risks, easy over-the-counter accessibility, and complete female-control (Iyer & Poddar, 2008 and Harwood et al., 2008). Not only is the product effective, but it is also easy and comfortable to use. An acceptability trial found that of 1389 women using spermicides, 43% reported they liked it “very much” and 40% liked it “somewhat”, while only 3% “hated” it (Raymond et al., 2005). Initially, N-9 was thought to decrease transmission of certain STIs as well as act as a contraceptive, but it is now evident that the membrane disruption potential to sperm and microbes also affects the vaginal endothelium to increase the risk of STIs at high doses (Harwood et al., 2008). The mechanism of action in vivo is unclear, however reports show a dose-dependency for transient disruption and inflammation to the vaginal endothelium increasing incidences of STI and HIV infections (Schreiber et al., 2006 and Jain et al., 2010). In 2008, the FDA issued a warning stating N-9 products “do not protect against sexually transmitted diseases and HIV/AIDS” (Bowers, 2008). In some cases, N-9 can induce allergic contact dermatitis, photosensitizing reactions, genital irritation (in both females and males), inhibit commensal vaginal Lactobacilli thereby increasing the risk of opportunistic infections, and can cause deep epithelial disruptions (Iyer & Poddar, 2008 and Harwood et al., 2008).
Immobilization of Sperm by Nonoxynol-9
When I begin clinical practice in May, 2012, I would not recommend Nonoxynol-9 as an independent contraceptive if either partner was positive for STIs or if the patient was averse to becoming pregnant. I would recommend its use in conjunction to male condoms to ensure the greatest contraception and prevention of possible STIs. If the patient was in a monogamous relationship with both partners negative for STIs and was impartial to becoming pregnant, N-9 would be a suitable spermicide in any form at a low dose, 50-150mg per day. There are a number of over-the-counter N-9 products available (Table 2) with an average efficacy of 94% as a contraceptive (Iyer & Poddar, 2008). N-9 is a safe product when used correctly, however if the patient reported genital irritation or signs of infection I would have them discontinue the product and follow-up with a pelvic exam and relevant tests for early detection of possible abnormalities. I found this topic clinically relevant for the importance of designing a female-controlled product that acts effectively as a spermicide and microbicide without damaging the vaginal endothelium or desensitizing the genitals during intercourse.
TABLE 1 – Common Methods of Contraception and their Failure Rates (%)
Method Typical Use Perfect Use Benefits Risks/Disadvantages COMBINED HORMONAL Oral 8 0.3 Intercourse-independent; rapid reversibility; daily, weekly, or monthly dosing options; decreased risk for dysmenorrhea, rheumatoid arthritis, iron-deficiency anemia, ovarian and uterine cancers, ovarian cysts, acne, ectopic pregnancy, benign breast disorders Thromboembolic phenomena, cerebrovascular accident, hypertension, worsening migraines, nausea, weight gain, breast tenderness, breakthrough bleeding, amenorrhea, depression; not a barrier to STI Transdermal 8 0.3 Vaginal ring 8 0.3 PROGESTIN ONLY DMPA 3 0.3 Intercourse-independent; can be used while breast-feeding; no estrogen; decreased risk for ovarian/endometrial cancer; no drug interactions; pill and implant have rapid reversibility Menstrual irregularity/amenorrhea, weight gain, reversible osteopenia, mood changes, breast tenderness, headaches; not a barrier to STI; DMPA delays return to fertility Progestin pill 8 0.03 Implant 0.05 0.05 INTRA-UTERINE DEVICE Copper T380A 0.8 0.6 Decreased ectopic pregnancy; intercourse-independent, rapidly reversible, discreet Practitioner placement/removal required; no STI protection; may increase Actinomycescolonization, or infection; increased menstrual bleeding and cramping (CopperT380A only); expulsion, perforation, or embedment Levonorgestrel IUS 0.1 0.1 BARRIER Male condom 15 2 No major risks; low cost, non-prescription; male involved; protects against STI and cervical cancer Decreased sensation; use with each act of coitus; requires male cooperation Diaphragm with contraceptive cream or jelly 16 6 Most effective female barrier method; reduced risk for STI; may be placed in anticipation; single insertion for multiple acts of intercourse Professional fitting and prescription only; requires motivation, preparation, and access; messy; allergies, increased risk for UTI, small risk for toxic shock syndrome Female condom 21 5 May be inserted up to 8 hr before coitus Complex and difficult to place; low efficacy; lack of STI reduction evidence; expensive; use with each act of coitus; associated noise WITHDRAWAL 27 4 NO METHOD 85
Centers for Disease Control and Prevention: Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion. US Medical Eligibility Criteria for Contraceptive Use, 2010, 4th ed. May 2010; 89.
Note: DMPA, Depomedroxyprogesterone acetate; PID, pelvic inflammatory disease; STI, sexually transmitted infection; UTI, urinary tract infection.
TABLE 2 – Common Over-the-Counter Products Containing Nonoxynol-9
Advantage 24 LakePharmaceuticals Gel Conceptrol Ortho Pharmaceuticals Gel Delfen Ortho Pharmaceuticals Foam Sermicid WhitehallPharmaceuticals Suppository VCF Apothecus Pharmaceuticals Film Today Bliss Pharmaceuticals
Gynol Ortho Options Gel
(Iyer & Poddar, 2008)
I personally found this topic is really interesting and I hope you all enjoy (I apologize for the technical terminology, please message me if you need further clarification). For the full report please email me at AlisonChen.ND@gmail.com. Have any questions or comments? Please share in the comment section below or email me for private questions.
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