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A clinician’s guide to condoms, spermicides, microbicides, and lubricants

Apart from abstinence, the proper use of a new latex condom during every act of sexual intercourse is currently the most effective method of preventing sexually transmitted infections, including HIV.

Patricia R. Jennings, DrPH, PA-C; Laura Bachmann, MD, MPH

Patricia Jennings is Associate Professor, Division of Physician Assistant Studies, and Laura Bachmann is Assistant Professor, Division of Infectious Disease, both at the University of Alabama, Birmingham. The authors have indicated no relationships to disclose relating to the content of this article.

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A 55-year-old man finds himself single after being in a mutually monogamous relationship for 20 years. In order to prepare himself for future sexual relationships, he goes to the local drugstore to purchase condoms. Once in the store, however, he becomes alarmed at the number and types of condoms available. He sees four shelves in front of him, all containing condoms. There are lubricated and nonlubricated condoms. There are spermicidal and nonspermicidal condoms. There are colored, flavored, studded, ribbed, latex, natural skin, and polyurethane condoms. Also within view are boxes of female condoms. Now totally perplexed, he leaves the drugstore and makes an appointment with his primary care practitioner, a physician assistant. As the PA enters the examination room, the man exclaims, “Please help me choose a condom. I’m so confused!”

His response is understandable, of course. The variety of condoms available today can be bewildering, even for primary care practitioners. To help clarify matters, this article describes the important differences among male condoms, female condoms, microbicides, spermicides, and lubricants.

Male latex condoms

Male condoms are currently made from three materials: latex, polyurethane, and natural animal skin. Latex condoms are made from natural rubber that is extremely elastic and can stretch to fit almost any size (see Figure 1).

The most reliable way for patients to avoid transmitting or contracting a sexually transmitted infection (STI) is to abstain from sex (oral, vaginal, and anal sex) or to be in a long-term, mutually monogamous relationship with an uninfected partner. For patients who choose not to abstain, who continue to have sex with multiple partners, or who have an infected partner, condom use is the most effective way to reduce the risk of STIs.

Several cross-sectional and case-control studies have shown that when used consistently and correctly, male latex condoms are effective in preventing the sexual transmission of HIV infection and can reduce the risk for other STIs.¹ A recent review indicated that consistent use of male latex condoms resulted in an 80% reduction in the incidence of HIV infection.² Additionally, prospective studies published since June 2000 show that condom use is associated with statistically significant protection of men and women against several other types of STIs, including chlamydia, gonorrhea, herpes simplex virus type 2 infection, and syphilis.³

Failure to use a condom correctly and consistently, rather than potential defects of the condom itself, is considered to be the major barrier to condom effectiveness. Many incidents of condom breakage and leakage are associated with improper handling or inappropriate use of lubricants.⁴ For instance, patients frequently ask if “doubling up” (using two condoms) confers additional protection against disease. This practice is not recommended, however, as the friction between the two condoms can lead to an increase in breakage. If lubricant is used between the two layers to reduce friction, an increase in slippage occurs.

Since 1976, condoms have been regulated under the Medical Device Amendments to the Federal Food, Drug, and Cosmetic Act. In 1987, the FDA sent a letter to all US condom manufacturers, importers, and repackagers recommending proper labeling of male latex condoms to include adequate instructions for usage.

Male latex condoms come in various types, including extra thin, extra sensitive, extra large, extra strength, form-fitting, extra head room, ribbed, studded, and spiraled. In addition, male latex condoms may have additives such as lubricants, spermicidal agents, flavors, and dyes. Patients should know that they need to be cautious about additives, not just because they may weaken the condom, but also because they may cause a contact dermatitis. While the variety of condoms available is confusing, the important point to remember about those just discussed is that all are made of latex and thus are regulated by the FDA.

Educating patients about how to use a condom is essential. Note the following important points:

A condom should be used before the expiration date.
The condom should be opened in a manner that will not tear it and placed on an erect penis before any genital contact with the partner occurs.
Enough room should be left at the tip of the condom to allow for ejaculate collection; this can be ensured by pinching the tip and then rolling the condom down the shaft of the penis.
If the condom is inadvertently put on upside down, that condom should not be turned over and reapplied. Instead, it should be thrown away to avoid exposing the partner to fluid from the penis that might have gotten on the condom when it was put on incorrectly.
To remove a condom, the patient should hold it firmly against the base of the penis, withdrawing the penis while it is still erect in order to prevent slippage. The condom should then be removed from the penis and disposed of wrapped in tissue in a trash can (so that children, animals, and others do not come into contact with the condom or its fluid content). It may be helpful to educate patients that flushing condoms down the toilet adversely affects municipal sewage treatment facilities and is potentially harmful to septic systems.
Condoms should be stored in a cool, dry place. Keeping condoms in a vehicle may subject them to temperatures high enough to accelerate their decomposition.

Nonlatex condoms

Two brands of male nonlatex condoms are available in the United States: the Avanti condom and the Trojan Supra condom (see Figure 2). Both are made of polyurethane, a material that is nonallergenic, odorless, transparent, and not easily broken down by oil-based lubricants. Polyurethane and latex condoms provide equivalent levels of contraceptive protection. However, the polyurethane male condom has a higher frequency of breakage and slippage, suggesting that this condom may provide less protection against STIs than does the latex condom.⁵

Styrene ethylene butylene styrene (SEBS), a synthetic material known commercially as Tactylon, is similar to latex but does not initiate an allergic response in people with known allergies to latex. In clinical trials, breakage rates for various SEBS condoms, ranging from 4.2% to 8%, were higher than the rates for male latex condoms, and therefore SEBS condoms are not recommended.⁶

The female condom is a soft, loose-fitting polyurethane tube that lines the vagina (see Figure 3). It has a soft ring on each end, with one end closed and the other end open. Directions for insertion and removal of the female condom are printed on the package.

The female condom has been used by both men and women for anal intercourse; however, this use is considered off label by the FDA.

More than 10 years have passed since the female condom became available in the United States, and
it remains the only female-initiated means of preventing both pregnancy and STIs.⁷ Randomized controlled trials provide evidence that during vaginal intercourse, female condoms confer as much protection against STIs as male condoms.⁸ Estimates of contraceptive efficacy are in the same range as those of other barrier methods, with contraceptive failure rates ranging from 0.8% to 9.5%.⁷ However, user satisfaction with the female condom is lower than anticipated. Cost is also an issue. Female condoms cost an average of $3.00 each and are available in a package of three. Efforts to lower the cost are being considered as the higher price of the female condom has been identified as a barrier to its sustained use.⁷

Research demonstrating efficacy in STI prevention utilizing the female condom for anal intercourse is needed before recommending this use to patients. Female condoms nevertheless remain an important option, especially when heterosexually acquired HIV infection rates are soaring globally. There is reliable evidence that effective promotion of the female condom is possible, especially if educational programs are directed at both the patient and the provider.⁷

South Africa is one of the few countries where a national family planning program has played a role in introducing the female condom. It was introduced in 1998 through family planning clinics and community-based programs in order to broaden its acceptance. Preliminary findings indicate that South Africans view the female condom as an acceptable barrier method.⁹

Natural skin condoms made from the intestine’s
of animals were one of the first forms of birth control. They remain on the market today to be utilized by mutually monogamous, uninfected couples to prevent pregnancy. Natural skin condoms do not protect against transmission of HIV and other sexually transmitted diseases. Some patients report increased sensation when using natural skin condoms compared to that with latex condoms.

Microbicides and spermicides

Microbicides are defined as antimicrobial products that can be applied topically to prevent transmission of HIV and other STIs. Spermicides kill or disable sperm so that they cannot cause pregnancy. The terms microbicide and spermicide are not synonymous, although one product currently on the market—Nonoxynol-9 (nonylphenoxypolyethoxyethanol [N-9])—acts as both. N-9 was the first microbicide to be clinically evaluated.

Spermicides come in many different forms—foam, jelly, cream, film, and suppositories. Recent evidence has indicated that vaginal spermicides containing N-9 are not effective in preventing cervical gonorrhea, chlamydia, or HIV infection.¹ In fact, frequent use of spermicides containing N-9 has been associated with microulcerations, which may be associated with an increased risk of HIV transmission. Although similar studies have not been conducted with men who have sex with men, N-9 has been found to damage the cells lining the rectum, providing a portal of entry for HIV and other sexually transmitted pathogens. Therefore, purchase of any condom lubricated with N-9 for the purposes of preventing STI transmission is not recommended.¹

The majority of microbicide products are currently in preclinical development, with 18 products being evaluated in clinical research studies. The six microbicide products that are the furthest along in the development process are carrageenans (Carraguard), naphthalene sulfonate (PRO 2000), acidifying gel (BufferGel), C31G (SAVVY), dextrin-2-sulfate (Emmelle), and cellulose sulfate (Ushercell).⁸

Lubricants

Lubricants are moistening substances that are used to make sexual activity more comfortable and pleasurable. Water-based lubrication is important for the proper use of the male latex condom. Different types of water-based lubricants are commercially available and include gels and liquid. Products include K-Y Jelly, Astroglide, and Aqua Lube. Oil-based lubricants can break down latex and cause the condom to tear. Thus, products containing substances such as petroleum jelly, baby oil, or mineral oil should not be used as lubrication with latex condoms. Silicone-based lubricants such as Wet, Frixion, Vielle, and O’My are waterproof and will not harm latex. Silicone-based lubricants will harm other objects made from silicon, however, such as some sexual enhancement devices (sex toys).

Some male latex condoms are prelubricated with a water-based lubricant, in which case the package will be clearly labeled “lubricated condom.” If the lubricant is spermicidal, the package will be labeled “latex condom with spermicide,” “latex condom with Nonoxynol-9,” or “latex condom with spermicide, N-9.” As previously mentioned, the use of condoms prelubricated with N-9 is not recommended.¹

Additional water-based lubrication may be added to both prelubricated and nonlubricated condoms, and ample use of lubrication is advised. Inadequate lubrication while using a condom may result in irritation and discomfort during sexual activity; in addition, the friction created while using a condom with insufficient lubrication may cause the condom to break.

Numerous lubricant products contain flavorings or a “warming” chemical. The biological safety of these additives is being researched, but the cytotoxic effects of colorants and flavorings on the cells lining the vagina, cervix, and anal mucosa are currently unknown.¹⁰ Until more is known about the safety of additives, flavored lubricants and flavored condoms should be utilized for oral intercourse only.

Some “warming” lubricants warm on contact, and others contain ginseng or hemp, which may produce a tingly feeling during the sexual encounter. Patients should check the label to assess whether such a lubricant is safe for use with condoms, spermicidal agents, and other forms of birth control (diaphragms, rings). Condoms that come with lubricants already on them are generally safe to use.

Conclusion

For sexually active patients who are not in a mutually monogamous relationship with an uninfected partner, using a new latex condom during every act of anal, oral, or vaginal sex is currently the most effective method of preventing STIs, including HIV infection.^1,3 Use of a generous amount of a water-based lubricant can decrease the friction created by a male latex condom, increasing comfort and reducing the risk of condom breakage. Persons allergic to latex can utilize male or female condoms made from polyurethane or SEBS/Tactylon, although studies have shown that these condoms have increased rates of slippage and breakage compared to those of male latex condoms. Condoms containing the spermicide N-9 are not recommended, as N-9-associated irritation and mucosal breakdown may increase the transmission risk for certain STIs, including HIV infection. Products containing flavoring and coloring additives should be further tested with the possible additive or synergistic effects noted, as these may affect the health of the user.

REFERENCES

1.
Sexually transmitted diseases treatment guidelines 2002. MMWR Recomm Rep. 2002;51(RR-6):1-78.

2.
Cayley WE Jr. Effectiveness of condoms in reducing heterosexual transmission of HIV. Am Fam Physician. 2004;70(7)1268-1269.

3.
Holmes KK, Levine R, Weaver M. Effectiveness of condoms in preventing sexually transmitted infections. Bull World Health Organ. 2004;82(6):454-461.

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Eng TR, Butler WT, eds. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: The National Academies Press; 1997:146.

5.
Frezieres RG, Walsh TL, Nelson AL, et al. Evaluation of the efficacy of a polyurethane condom: results from a randomized, controlled clinical trial. Fam Plann Perspect. 1999;31(2):81-87.

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Walsh TL, Frezieres RG, Peacock K, et al. Evaluation of the efficacy of a nonlatex condom: results from a randomized, controlled clinical trial. Perspect Sex Reprod Health. 2003;35(2)79-86.

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Hoffman S, Mantell J, Exner T, Stein Z. The future of the female condom. Int Fam Plan Perspect. 2004;30(3)139-145.

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Minnis A, Padian N. Effectiveness of female controlled barrier methods in preventing sexually transmitted infections and HIV: current evidence and future research directions. Sex Transm Infect. 2005:81(3):193-200.

9.
Family Health International. FHI research briefs on the female condom—No. 6: female condom introduction in South Africa. Available at: http://www.fhi.org/en/RH/Pubs/Briefs/fcbriefs/southafrica.htm. Accessed October 27, 2005.

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Motsoane NA, Bester MJ, Pretorius E, Becker PJ. An in vitro study of biological safety of condoms and their additives. Hum Exp Toxicol. 2003;22(12):659-664.