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PIP: Vaginal sponges offer women control over protection against both pregnancy and sexually transmitted diseases (STDs), including HIV. Spermicide-impregnated sponges combine the actions of a physical barrier that blocks the cervix with a material that absorbs the ejaculate and a spermicide. Commercially available spermicides contain 1-5% of nonoxynol-9, shown to inhibit organisms responsible for gonorrhea, chlamydia, candidiasis, genital herpes, syphilis, trichomoniasis, and HIV. On the other hand, nonoxynol-9 is associated with a significantly higher risk of vaginal colonization with bacterial agents, ulcerative genital diseases, and vulvitis. A lower dose of nonoxynol-9 appears to avert vaginal irritation without compromising contraceptive efficacy. Use of chlorhexidene, a spermicide less irritating to mucosal cells than nonoxynol-9 but active against HIV in vivo and in vitro, is under investigation. Also promising are initial findings regarding the Protectaid contraceptive sponge with F-5 gel. Epidemiologic studies and clinical trials should provide quantitative estimates of the level of protection offered by barrier methods and identify the method that combines the highest protection, ease of use, and user acceptability.^ieng

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PIP: Concerns about the potential of nonoxynol-9 to irritate the vaginal mucosa have deterred the US Centers for Disease Control from endorsing use of this product for the prevention of sexually transmitted diseases (STDs), including HIV. To date, no manufacturers of over-the-counter spermicides have applied for product labeling changes. The US Food and Drug Administration recently held a joint committee meeting of four advisory panels aimed at encouraging spermicide manufacturers to submit clinical results pertaining to STD transmission. The committee concluded that, while manufacturers of over-the-counter spermicides may claim short-term protection against chlamydia and gonorrhea, the long-term safety of such products remains unclear. Needed are clinical trials that investigate the effects of spermicide-induced cervical and vaginal irritation on the risk of HIV transmission. The joint committee indicated that studies conducted in STD clinics and with commercial sex workers would be acceptable evidence. The National Institute of Allergy and Infectious Diseases soon will release the findings of a case-control study that used colposcopy to document the extent of epithelial erosion and other lesions associated with low doses of nonoxynol-9. Of continuing concern is the possibility that the labeling of spermicides as effective against STDs will reduce use of condoms, the most effective barrier to HIV transmission.^ieng

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PIP: The maintenance of vaginal flora is of major importance for users of hormonal contraceptives in order to exclude negative symptoms: discharge, dyspareunia, and itching. Genia 92 vaginal suppositories were employed in a study of their protective effect on the vaginal ecosystem. 47 women of reproductive age using hormonal contraception were enrolled in the investigation. The minimal duration of use of hormonal pills was 12 months. Monogamous sexual intercourse was confirmed in the anamnesis of the women studied. During the course of treatment, 10 pieces of Genia 92 vaginal suppositories were placed in the vagina every other day. The patients were followed-up by gynecological examinations twice during the study: before treatment and 30 days later. The following vaginal symptoms were noted on a 4-step scale of increasing severity (0, 1, 2, 3): 8, 21, 13, and 5 patients had discharge before treatment vs. 36, 8, 3, and 0 after treatment (30 days later), respectively. Skin reddening was noted in 7, 17, 12, and 11 women before and 39, 6, 2, and 0 women after treatment, respectively. Itching occurred in 16, 19, 10, and 2 patients before treatment and 41, 6, 0, and 0 patients after treatment, respectively. Pain was registered in 29, 12, 6, and 0 patients before treatment and 43, 4, 0, and 0 patients after treatment, respectively. Dyspareunia occurred in 21, 19, 5, and 2 women before treatment and 38, 6, 3, and 0 women after treatment, respectively. Each patient's pH was also determined before and after treatment and it was found that significant stabilization of the acidity was attained within a pH range of 4.50-4.32 after treatment. In 5 patients, pathogenic microorganisms were discovered during control examinations, most likely the result of infection. Thus, the suppositories exerted a beneficial effect on the vaginal flora of these women, thereby protecting epithelial tissue.^ieng

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Sexually transmitted diseases (STDs) are a major cause of ill health in women and their sexual partners and children. Contraceptive methods alter in various ways the risk of acquiring STD but assessment of the odds ratio is difficult due to the many confounding factors. Spermicides have been reported to kill a wide range of bacteria and viruses including HIV in vitro and to protect in vivo from infection by gonorrhoea, chlamydia and pelvic inflammatory disease (organisms unspecified). Spermicides will not cure pre-existing infections. Condoms and diaphragms will give some protection from bacterial and viral infections in all parts of the genital tract. Hormonal contraception and tubal ligation give protection to the upper genital tract but not the cervix. Carcinoma of the cervix follows the same pattern as STDs. The risk of pelvic infection in intrauterine device users is discussed in the chapter by Bromham (pp 100-123, this issue).

PIP: Spermicides kill a wide range of bacteria and viruses causing sexually transmitted diseases (STDs), including the human immunodeficiency virus (HIV) in vitro, and protect in vivo from infection by gonorrhoea, chlamydia, and pelvic inflammatory disease (PID). In the UK and the US, the most commonly used compound in spermicidal agents is the neutral surfactant nonoxynol-9. Although spermicides reduce the incidence of reinfection by some STDs, an in vivo virucidal action is not supported by convincing data. Among barrier methods, latex condoms provide an impervious barrier in vitro to most STD pathogens, including HIV. Natural condoms made of sheep intestinal membrane can allow passage of hepatitis B viral particles but not HIV in vitro. Several studies have shown protection against cervical gonorrhoea and PID among diaphragm users; however, diaphragm use has been associated with an increased rate of urinary infection and also bacterial vaginosis. It is conceivable that women using oral contraceptives (OCs) do not develop as much tubal damage as women not using OCs because of a modified immunological reaction. A study carried out in Europe showed a statistically significant protective effect against PID of the levonorgestrel-containing IUD as compared with the copper-containing Nova-T. A case/control study of 1028 women in Chicago in 1970 noted admission for PID during the following 7 years of only 1 woman who had been sterilized compared to 9 controls. A case/control study examining risk factors for cervical intraepithelial neoplasia (CIN) in 103 women with biopsy-confirmed CIN II or III did not find an increased risk with either OC or IUD use after adjusting for other known risk factors. After adjustment for age and education, the odds ratio for diaphragm use was .3 and the odds ratio for condom use was .5. Thus, hormonal contraception and tubal ligation give protection to the upper genital tract but not to the cervix.

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