Many GPs provide contraceptive advice to youngsters who have recently become sexually active or who are considering starting sexual relationships. In the UK, the median age of first sexual intercourse is 17 years for women aged 25-44 years and 16 for women aged 16-24 years. For men, this is 17 years for those aged between 20 and 44 years and 16 for those aged between 16 and 19. Over the last 10 years there has been an increase in the proportion of women having intercourse before the age of 16 years, whereas the proportion of men having intercourse before 16 has remained fairly constant for all ages. For 16-19 year olds, just under a third of men and a quarter of women report having had intercourse before the age of 16. The time between first sexual experience and first intercourse is 4 years for men and 3 years for women (i.e. age of first sexual experience is 13 years for men and 14 years for women). A number of studies have documented an association between early age at first intercourse and early menarche, early school leaving age, family disruption, and poor educational attainment. A recent large behavioral study in the UK found that just under a third of sexually active young women who left school at age 16 years with no qualifications had a child at age 17 years or younger. Young people who leave school later and with qualifications are less likely to have early intercourse, more likely to use contraception at first sex, be sexually competent and less likely to become pregnant.
Reassuringly, there has been an increase in condom use in the UK over the past 10 years with approximately three quarters of men and women reporting using a condom at first intercourse. There has also been a decrease in those using no contraception at first intercourse (approximately 10% of men and women under the age of 24 years). The UK has one of the highest teenage conception rates in Western Europe, with just over one-half of pregnancies in under 16-year-olds ending in termination.
These data emphasize the importance of providing the young and sexually active with easy access to contraception. The opportunity should also be taken to discuss other sexual health matters, in particular how to avoid acquiring sexually transmitted infections. This chapter looks at the issue of contraception and STIs in a little more detail.
Laboratory studies have shown that latex condoms are effective mechanical barriers against hepatitis B virus, HIV, cytomegalovirus, herpes simplex virus, and Chlamydia.
Epidemiological studies have shown that correct and consistent use of condoms protect against gonorrhea, NGU, and HIV infection. There are conflicting data regarding protection from HPV infection, however, consistent condom use appears to offer some protection against genital warts, high grde CIN and cervical cancer and has also been found to produce higher rates of cervical HPV clearance and CIN regression. To be protective the condom must cover that part of the genital tract which is infected or likely to become infected, for example the cervix in the female and the urethra in the male. Protection is less likely for infections that may affect the vulva and perineum or the epithelium beyond the penile shaft, for example genital herpes and HPV infection.
There are a few points worth emphasizing. First, condoms must be used correctly, that is placed on to the penis before genital contact and unrolled fully to cover as much of the penis as possible. Teated condoms should have the air squeezed from the end as they are unrolled. Many youngsters do not know how to use a condom, particularly when they are being used for the first time. Condom manufacturers are usually happy to provide plastic demonstration models. These should be considered essential equipment for all GP surgeries and clinics that provide contraceptive or sexual health advice.
Condoms do occasionally split or slip off the penis during intercourse. Individuals who are particularly prone to these mishaps should check that they are fully unrolling the condom and that fingernails are not damaging the latex. In addition, some nonwater-based lubricants and various vaginal preparations may damage latex and therefore should not be used in conjunction with either the condom or the diaphragm. The preparations include baby oil, petroleum jelly, Vaseline, 2% clindamycin cream, Ecostatin, Fungilin, Gyno-Daktarin, Gyno-Pevaryl, Monistat, Nizoral, Nystatin cream, Ortho Dienoestrol, Ortho Gynest, Premarin,
Sultrin, Witepsol-based suppositories, hair conditioner, skin softener, bath oil, massage oil, body oil, suntan oil, lipstick, cooking oil, margarine, butter, salad cream, cream, and ice cream!
A tremendous effort has been put into condom marketing in recent years and the larger manufacturers now provide a wide range of shapes, colors, and flavors. Apparently mint and Pina Colada flavored condoms are particularly well accepted. Occasionally low standard condoms find their way on to the market and for this reason, in the UK, only brands which display the British Standards "Kite Mark" should be used.
A common reason given by men for not using condoms is decreased sensitivity and hence reduced sexual pleasure. A technique termed "gel charging" does appear to heighten the sexual experience for some men and therefore may help to encourage condom use. This involves placing a small amount (e.g. a teaspoonful) of lubricant or spermicidal gel into the end of a condom before placing onto the penis. Contoured and flared condoms apparently give the most effective results.
Less information is available regarding the diaphragm, but the small number of studies which have been performed do show that this form of contraception provides women with protection against gonorrhea and other cervical infections.
Diaphragm use does appear to increase the risk of urinary tract infection.
Nonoxynol-9 is a commonly used spermicide that also inhibits the growth of several sexually transmitted organisms. These include N. gonorrhoeae, C. trachomatis, T. pallidum, herpes simplex virus, cytomegalovirus, and HIV. It appears to have no action against HPV. Although many condoms are impregnated with spermicide, it is uncertain whether the amount present would be sufficient to kill these pathogens if the condom splits. There is also some concern that frequent use of nonoxynol-9 may produce vulvovaginal inflammation and possibly ulceration. These adverse reactions are of relevance to women having intercourse several times a day and are probably not applicable to the general sexually active population. Epidemiological studies on the use of spermicides have documented a protective effect against gonorrhea, trichomoniasis, and possibly Chlamydia and HIV. There appears to be no effect on bacterial vaginosis or candidiasis.
12.4 THE “FEMALE CONDOM”
The female condom, known in the UK as Femidom, is made from polyurethane. It has been shown in the laboratory to act as a complete barrier to cytomegalovirus, HIV, and to bacteriophages smaller than HIV and hepatitis B. The vaginal flora remains unchanged after repeated use and there is no evidence of an irritant effect on the vagina. A pregnancy rate of 2.6% during 6 months' use has been reported for "perfect users." Femidom is not acceptable to all women. It can be difficult to insert and occasionally the device can be pushed into the vagina or slip out. Hopefully, design modification will eventually resolve these problems. Unlike most male condoms, the lubricant on female condoms does not contain a spermicide.
12.5 INTRAUTERINE CONTRACEPTIVE DEVICE
The risk of PID among IUCD users has been generally overstated. There is a transient risk of developing infection at the time of or just after insertion that may be partly related to the degree of experience of the clinician fitting the device. PID affecting a women with an IUCD is often more severe clinically. Some studies have suggested a reduced risk of pelvic inflammatory disease amongst levonorgestrel-IUCD users compared with women using copper releasing devices.
12.6 HORMONAL CONTRACEPTIVES
Hormonal contraceptives have been shown to protect against PID and may reduce the degree of tubal inflammation if infection develops. Although some earlier studies did show an association between oral contraceptive use and chlamydial cervicitis, this has not been confirmed by more recent work. The use of injectable depot-medroxyprogesterone acetate has been reported to increase the risk of acquiring cervical chlamydial and gonococcal infection, possibly as a result of local immune suppression or by hormonally induced bacterial growth and persistence.
Chlamydia appears to be more frequently isolated from women with cervical ectopy, irrespective of the method of contraception used, probably owing to the organism preferentially infecting columnar epithelium rather than squamous epithelium.
12.7 IMPORTANT POINTS
(1) An ideal approach to contraception for the woman who is not in a steady relationship, or who may frequently change sexual partners, or who cannot guarantee the fidelity of her partner is to consider using both condoms and hormonal contraception.
The favored method of hormonal contraception is usually the oral contraceptive pill or a long acting reversible contraceptive. This approach provides optimal protection against STIs and pregnancy.
(2) All women starting oral or barrier contraception should receive information on emergency postcoital contraception. In particular, they need to know where emergency contraception is available and understand that it is appropriate to use "pills" up to 3 days and an IUCD up to 5 days after unprotected intercourse, although this may be extended and for IUCD use depends upon the time of ovulation. The term "morning after pill" gives the wrong message and should no longer be used. If unprotected intercourse was with a "new" partner, the possibility of acquiring a sexually transmitted infection should be discussed and referral to GU medicine advised. Women with a clinical suspicion or at risk for genital infection should ideally be screened for, in particular, Chlamydia, gonorrhea, and bacterial vaginosis and receive a course of tetracycline and metronidazole or co-amoxiclav prior to emergency IUCD insertion. Liaison with colleagues in GU medicine is to be recommended.