Condoms: advising on the options

Key practice points:

• If external (male) condoms are used correctly on every occasion of sexual intercourse over a year the rate of pregnancy is approximately 2%; however, typical use results in a yearly rate of pregnancy of 13%
• If used correctly, all types of condoms are effective at preventing transmission of most STIs, including HIV, syphilis, gonorrhoea, chlamydia and hepatitis B
• Condoms should be routinely and widely offered in primary care to ensure equitable access
• A variety of external latex condoms are fully subsidised in New Zealand
• Latex-free condoms are available, but not subsidised; however, these products should only be necessary in a small number of people with latex allergy (approximately 4% of the general population)
• Internal (female) condoms are available, but not subsidised; there is an approximately 5% rate of pregnancy with correct use on every occasion of sexual intercourse over a year, however, typical usage results in a yearly pregnancy rate of 21%

The benefits of regular condom use

The first external (male) condoms were developed in the 16th century to slow the spread of syphilis.¹ Originally these were bespoke and made from linen or animal gut,¹ but in the twentieth century mass production resulted in a variety of condom sizes, shapes, colours, flavours and thicknesses. The majority of external condoms are constructed from latex, although they may be made from other materials including polyurethane, polyisoprene and nitrile.²

Recommend condoms widely to prevent the spread of STIs

Condoms are the only method of contraception that protects against sexually transmitted infections (STIs). They are often used in combination with another contraceptive, to prevent STI transmission and to further reduce the risk of an unintended pregnancy.

The advantages and disadvantages of external condoms:²

The effectiveness of external condoms

Pregnancy occurs in approximately 2% of females when external condoms are used correctly as the sole form of contraception during every occasion of sexual intercourse over one year.² However, condoms are often not used consistently or correctly, therefore typical usage results in 13% of females becoming pregnant each year that condoms are used.²

Condoms substantially reduce the risk of STI transmission occurring through discharge to or from the penile urethra during vaginal or anal sex, e.g. HIV, gonorrhoea, chlamydia and hepatitis B.² Dermal and oral transmission of STIs, e.g. herpes and human papillomavirus (HPV), is reduced, but not eliminated through the regular use of condoms as they may not cover all infectious areas.²

Recommending the most appropriate condom

Ensuring consistent and correct use are the most important considerations when providing patients with condoms. All subsidised condoms available in New Zealand are made from latex and are pre-lubricated. There are differences in the width, thickness, length and shape of subsidised condoms and some patients may require guidance on these issues (Table 1). Condoms made from isoprene (for people with latex allergy – see below) and textured condoms are available over-the-counter from a variety of retail outlets and online stores but are not subsidised.

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Table 1: Selection guide for fully-subsidised condoms in New Zealand

Advising patients on the size and type of condom

The 56 mm condoms are the most commonly prescribed size in New Zealand.³ However, due to variations in penile size,⁴ this width of condom may not be appropriate for all. The length and thickness of some brands of condom does vary slightly, however, this is unlikely to be a significant issue for fit or protection in most cases.

Offer patients a selection to try first

All fully subsidised condoms in New Zealand are also available on Practitioner’s Supply Order (PSO). It is recommended that a selection of condoms be available in the practice and offered the first time a prescription for condoms is provided. The prescription can be written with a default option but with instructions for another width or brand of condom to be dispensed if the patient wishes, following discussion with a pharmacist, e.g. “as specified or directed by patient preference”. Filling the prescription can be delayed until the preferred condom size has been determined. If a previous prescription for condoms has been provided, ask if the fit was appropriate.

N.B. Prescription condom dispensing is currently limited to 72 condoms every 90 days due to a global supply shortage.

Additional lubrication is not routinely required with condom use

All subsidised condoms in New Zealand are pre-lubricated; there are no separate lubricant products for use with condoms that are subsidised. There is insufficient evidence to recommend the routine use of extra lubrication for vaginal intercourse.⁵ However, additional lubrication may be helpful where there is a history of condom breakage or irritation.⁵ There is some evidence to suggest that extra lubrication may help to reduce the risk of condom breakage during anal intercourse.⁵

Water-based, e.g. K-Y Jelly, or silicone-based, e.g. Durex Perfect Glide, lubricants should be used if additional lubrication of latex condoms is required.⁵ Oil-based lubricants, e.g. petroleum gel (Vaseline) should not be used with latex condoms as they increase the risk that the condom will break.⁵ Lubricating substances such as cooking or coconut oil or body moisturisers should not be used with condoms.²

The frequent use of spermicidal condoms is not recommended

There is no evidence that condoms with added spermicide provide any additional protection against pregnancy or STIs than non-spermicidal condoms.⁵ Nonoxynol-9, a surfactant that disrupts cell membranes, is the most common spermicide.⁵ The use of condoms lubricated with nonoxynol-9 is not recommended as excessive use, i.e. several times a day, increases the risk of urinary tract infections (UTIs) and vaginal or anal irritation which may increase the risk of HIV infection.² However, using condoms with nonoxynol-9 is preferable to not using condoms at all.

Thicker condoms are unlikely to provide better protection against STIs

Limited evidence suggests that using a thicker condom does not reduce the risk of a condom breaking. A study involving 283 male couples in England found that the failure rate for condoms 0.074 mm thick was 2.5%, compared to a failure rate of 2.3% for condoms 0.112 mm thick.⁶ The majority of the subsidised condoms in New Zealand are 0.065 mm thick, however, the Durex Extra Safe brand is 0.08 mm thick and can be prescribed if there is a history of condom breakage.

Latex allergy is uncommon and non-latex condoms are generally not indicated

Condoms users may report dermal adverse reactions involving irritation of the penis or vagina or redness, rash and/or swelling of the groin or thighs.² Mild symptoms may be avoided by using a water or silicone-based lubricant to reduce friction and irritation, or by trialling another brand of condom.² When discussing potential adverse reactions to condoms, consider if the symptoms may be caused by a STI and whether a sexual health check is appropriate.

Most people with latex allergy will already be aware of an allergy through previous reactions, e.g. when using latex gloves or dressings or inflating a balloon.² Severe latex allergy, e.g. systemic urticaria, dizziness, difficulty breathing or loss of consciousness, is extremely rare.³ The worldwide prevalence of latex allergy of any severity is estimated to be 4% in the general population, with higher rates in groups who are regularly exposed, e.g. health workers who wear latex gloves.⁷ Latex allergy can be managed by using non-latex external condoms or internal condoms (see below); neither of these options are currently subsidised.

Non-latex condoms are indicated while using vaginal creams for fungal infections

Latex condoms should not be used at the same time as vaginal creams for fungal infections, e.g. clotrimazole, miconazole and nystatin, as the condom may be degraded by ingredients in the base of the cream.^8–10 Abstinence from sex or the use of non-latex condoms can be recommended while using these creams.

Correct use is essential for condoms to be effective

Key points to cover when discussing the correct use of condoms include:

• Checking the expiry date
• Inspecting the packet carefully for tears and opening it carefully
• Applying the condom correctly, e.g. checking it is the right way up before applying

Detailed instructions on the correct use of condoms are provided with product packaging and Family Planning has instructions available from: www.familyplanning.org.nz/advice/contraception/condoms

N.B. Condoms should not be flushed down the toilet. Latex condoms degrade naturally in landfill.

Provide advice on what to do if a condom fails

Emergency contraception can be administered up to five days after experiencing condom failure. Treatment options that are fully subsidised include:¹¹

• A copper intra-uterine device which is the most effective method and can be used up to five days after unprotected sex
• The oral emergency contraceptive pill (levonorgestrel) is the most convenient method, however, this is only effective within three days of unprotected sex and may be less effective in patients weighing over 70 kg or with a body mass index greater than 26 kg/m²

A sexual health check should be undertaken following condom failure if there is a possibility of STI exposure.⁵

Further information on emergency contraception is available from: “Contraception: which option for which patient”

Internal condoms

Internal condoms, also referred to as female condoms, are thin pouches that are inserted into the vagina prior to sexual intercourse. The condom is held loosely in the vagina by a closed flexible ring at one end while an open ring at the other end allows for penile insertion. Internal condoms are “one size fits all” and the products available in New Zealand are generally made from a nitrile polymer and are latex-free.¹² Their use has been promoted among sex workers in some countries with high rates of HIV infection as a female-controlled, alternative form of barrier contraception.

Internal condoms are currently not subsidised in New Zealand and are less accessible than external condoms. They can be purchased from the Family Planning website or a limited number of retail outlets and online stores.

The advantages and disadvantages of internal condoms:²

Internal condoms are less effective at preventing pregnancy than external condoms

Pregnancy occurs in approximately 5% of females when internal condoms are used correctly as the sole form of contraception during every occasion of sexual intercourse over a year, compared to 2% with external condoms.² However, internal condoms may not be used consistently or correctly, therefore typical usage results in 21% of females becoming pregnant each year that condoms are used, compared to 13% for external condoms.²

Data on STI prevention is limited

Internal condoms reduce the risk of contracting STIs, including HIV.² However, due to a lack of studies it is not possible to directly compare the effectiveness of internal condoms and external condoms for STI prevention.

Using internal condoms correctly

Internal condoms are relatively easy to use, although it is recommended that patients practice the technique before they are used for the first time.² External condoms should not be used at the same time as internal condoms.⁵

Problems encountered with the use of internal condoms may include discomfort following insertion, which may be resolved by tucking the inner ring behind the pubic bone, and noise from friction during use which can be resolved with lubrication.²

Detailed instructions of the use of internal condoms are available on page 264 of the World Health Organisation family planning handbook, available from: www.fphandbook.org/sites/default/files/global-handbook-2018-full-web_0.pdf

Information is also available from New Zealand Family Planning: www.familyplanning.org.nz/advice/contraception/internal-condoms