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,
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 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
Advantages |
Disadvantages |
- Protect effectively against many STIs
- Do not affect fertility
- Do not cause hormonal-related adverse effects
- May result in sex lasting longer, due to decreased sensitivity
- Provide foetal protection against STIs, if used during pregnancy
|
- Need to be stored in an easily accessible location
- Breakage or slippage may occur requiring emergency contraception
- Incorrect use may result in pregnancy
- May be uncomfortable if an inappropriate size is used
- The sensation of sex may be dulled
- Latex-free condoms (not subsidised) are required if either partner has a latex allergy
|
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
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.
Table 1: Selection guide for fully-subsidised condoms in New Zealand
Condom width |
Brand |
Thickness |
Length |
Additional features |
49 mm |
Shield 49 |
0.065 mm |
Information not available |
- |
53 mm |
Shield Blue |
0.065 mm |
Information not available |
- |
Gold Knight |
0.065 mm |
180 mm |
Strawberry or chocolate flavoured lubricant |
56 mm |
Gold Knight |
0.065 mm |
180 mm |
- |
Durex Extra Safe |
0.08 mm |
190-195 mm |
Slightly thicker with extra lubricant |
Durex Confidence |
0.065 mm |
|
“Shaped”* |
60 mm |
Shield XL |
0.065 mm |
Information not available |
|
* The manufacturer claims the design makes it easier to apply and more comfortable to wear
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, 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
Advantages |
Disadvantages |
- The female partner controls the use of the condom
- They can be inserted up to eight hours prior to sex
- They have a soft, moist texture that feels more “natural” than latex and does not dull the sensation of sex
- Water, silicone or oil-based lubricants can be safely used with latex-free condoms
- They do not need to be removed immediately after ejaculation
- The outer ring may provide additional stimulation
|
- Not subsidised in New Zealand
- Less effective at preventing pregnancy than external condoms
- More often used incorrectly than external condoms
- Slippage may occur requiring emergency contraception
- Insertion may need to be practiced
- May be uncomfortable for some people
|
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
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Acknowledgement:
Thank you to Dr Beth Messenger, National Medical Advisor, Family Planning New Zealand for expert review of this article
N.B. Expert reviewers are not responsible for the final content of the article.
References
- Cecil M, Nelson AL, Trussell J, et al. If the condom doesn’t fit, you must resize it. Contraception 2010;82:489–90. http://dx.doi.org/10.1016/j.contraception.2010.06.007
- World Health Organization Department of Reproductive Health and, Research (WHO/RHR) and Johns Hopkins Bloomberg School
of Public Health/Center, for Communication Programs (CCP). Family Planning: a global handbook for providers (2018 update).
2018.
- PHARMAC. Requests for proposals - supply of condoms and water-based lubricant. 2018. Available from: http://www.pharmac.govt.nz/assets/RFP-2018-05-16-condoms.pdf (Accessed
Jan, 2019)
- Herbenick D, Reece M, Schick V, et al. Erect penile length and circumference dimensions of 1,661 sexually active men
in the United States. J Sex Med 2014;11:93–101. http://dx.doi.org/10.1111/jsm.12244
- Faculty of Sexual and Reproductive Healthcare. Barrier methods for contraception and STI prevention. 2015. Available
from: http://www.fsrh.org/standards-and-guidance/documents/ceuguidancebarriermethodscontraceptionsdi (Accessed
Feb, 2019).
- Golombok S, Harding R, Sheldon J. An evaluation of a thicker versus a standard condom with gay men. AIDS 2001;15:245–50.
- Wu M, McIntosh J, Liu J. Current prevalence rate of latex allergy: Why it remains a problem? J Occup Health 2016;58:138–44. http://dx.doi.org/10.1539/joh.15-0275-RA
- Multichem NZ Ltd. New Zealand data sheet. 2018. Available from: http://www.medsafe.govt.nz/profs/datasheet/c/Clomazolcrmvagcrm.pdf (Accessed
Jan, 2019)
- Mylan New Zealand Ltd. New Zealand data sheet: MICREME. 2017. Available from: http://www.medsafe.govt.nz/profs/datasheet/m/Micremevagcrm.pdf (Accessed
Jan, 2019)
- Pharmacy Retailing (NZ) Limited. New Zealand data sheet: NILSTAT. 2013. Available from: http://www.medsafe.govt.nz/profs/datasheet/n/nilstatcapdrpowdtabcrointvagcr.pdf (Accessed
Jan, 2019)
- Faculty of Sexual and Reproductive Healthcare. Emergency contraception. 2017. Available from: http://www.fsrh.org/documents/ceu-clinical-guidance-emergency-contraception-march-2017 (Accessed
Jan, 2019)
- Family Planning. Internal condoms. Available from: http://www.familyplanning.org.nz/advice/contraception/internal-condoms (Accessed
Jan, 2019)