INTRODUCTION — Contraception or birth control is the use of a medication, device, or method to prevent pregnancy. Such devices or techniques, known as contraceptives, work to: Prevent ovulation, the release of eggs from a woman's ovary Prevent sperm from getting into the uterus and fallopian tubes (where fertilization of the egg normally occurs) Prevent implantation of the embryo (fertilized egg) into the uterine lining (endometrium)
Most women of reproductive age in the United States use some form of contraception. However, unintended pregnancy is still a common problem in this country. Almost one-half of pregnancies are estimated to be unintended.
This topic is an overview of all methods of birth control. More detailed discussions of hormonal, long-term, and barrier birth control methods are available separately. (See "Patient information: Long-term methods of birth control" and see "Patient information: Barrier methods of birth control" and see "Patient information: Hormonal methods of birth control").
EFFECTIVENESS OF CONTRACEPTION — Most contraceptive methods are quite effective if used properly. However, the actual effectiveness of a method can differ from "perfect use" effectiveness (show table 1A-1B). Contraceptives fail for a number of reasons, including improper use, failure to follow treatment recommendations, or failure of the medication, device, or method itself.
Certain contraceptives, such as intrauterine devices (IUDs) and injectable contraceptives, have a low risk of failure (pregnancy). This is because compliance (using the method correctly or taking the medication on a regular basis) is not a major factor. (See "Patient information: Long-term methods of birth control").
Oral contraceptives (birth control pills) have a low pregnancy rate if they are taken properly (ie, pills are taken every day). However, the actual pregnancy rate is much higher because many women forget to take the pill every day. (See "Patient information: Hormonal methods of birth control").
Other contraceptive methods such as the condom, diaphragm/cervical cap, and spermicides can be very effective if used properly. However, these methods are also associated with higher "actual" pregnancy rates because of incorrect or inconsistent use. (See "Patient information: Barrier methods of birth control").
Overall, contraceptive methods that are designed for use at or near the occurrence of intercourse (eg, the condom, diaphragm) are generally less effective than contraceptive methods that are unrelated to the occurrence of sexual activity (eg, intrauterine device, oral contraceptives).
Women who are at risk of pregnancy and are using birth control should also have a supply of emergency contraceptive pills on hand (See "Emergency contraception" below).
CHOOSING A METHOD — It can be difficult to decide which birth control method is best due to the variety of options available. The best method is one that will be used consistently, is acceptable to the woman and her partner, and does not cause bothersome side effects. Other factors to consider include: Efficacy Convenience Duration of action Reversibility and time to return of fertility Effect on uterine bleeding Frequency of side effects and adverse events Affordability Protection against sexually transmitted diseases
No method of contraception is perfect. Each woman must balance the advantages of each method against the disadvantages and then choose the most effective method that she feels she will be able to use consistently and correctly. A list of questions that are useful for defining a person's preferences are provided in the table (show table 2).
EMERGENCY CONTRACEPTION — Emergency contraception (EC, also known as postcoital contraception or the morning-after pill) refers to the use of drugs to prevent pregnancy in women who have had recent unprotected intercourse (including sexual assault), or who have had a failure of another method of contraception (eg, broken condom). As many as 30 percent of women will become pregnant after a single unprotected act of sex that occurs near the time of ovulation. Use of EC significantly reduces the chance of pregnancy, but pregnancy may still occur.
Experts are uncertain about how EC prevents pregnancy. Since these drugs are taken within hours of intercourse and implantation does not occur until approximately five to seven days after ovulation, use of EC does not interrupt pregnancy (the United States Federal policy is that a woman is considered pregnant once a conceptus has implanted; however, some consider pregnancy to begin at conception).
Several options are available for EC (show table 3 and show table 4). Plan B is a pill pack that contains two 0.75 mg tablets of levonorgestrel, both of which should be taken as soon as possible after unprotected sex. It is also acceptable to take one pill as soon as possible, followed by the second pill 12 hours later (this is the instruction given by the manufacturer). The cost is approximately $40. The Plan B regimen is more effective and better tolerated than regimens using oral contraceptive pills that contain estrogen (eg, Ovral two tablets twelve hours apart or Lo/Ovral four tablets 12 hours apart).
Nausea and vomiting are the major side effects of the estrogen-containing regimen. A medication to reduce nausea and vomiting can be taken one hour before the first dose. Nausea and vomiting is less common with the levonorgestrel method. However, if levonorgestrel is vomited within one hour of taking it, a medication to prevent nausea can be taken, followed by a repeat of the EC dose.
EC is most effective when taken as soon as possible after intercourse. However, studies have shown that it is somewhat effective for up to 120 hours (five days) after intercourse, and may be started up to that time if necessary. After five days, insertion of a copper intrauterine device (IUD) is considered the best way to prevent pregnancy. (See "Patient information: Long-term methods of birth control").
A risk of pregnancy still exists if the woman has unprotected intercourse after EC pills have been taken. Therefore, another method of contraception (eg, condoms) should be used for the rest of the cycle. A second dose of EC may be used if a second episode of unprotected intercourse occurs anytime after the first dose.
A woman who is sexually active and does not want to become pregnant can consider purchasing EC before it is needed. This would eliminate any delay in taking the first dose. In the United States, EC is approved as an over the counter medication for individuals (men or women) age 18 and older; proof of age (a government issued ID) is required. Younger patients still require a prescription. Plan B is only available at sites with a licensed pharmacist.
ORAL CONTRACEPTIVES — Most oral contraceptives, also referred to as "the pill," contain a combination of female hormones, estrogen and progestin (a progesterone-like medication). A list of available pills is shown in the table (show table 5). A full discussion of hormonal birth control methods is available separately. (See "Patient information: Hormonal methods of birth control").
The combination pill reduces the risk of pregnancy by: Preventing ovulation Keeping the mucus in the cervix thick and impenetrable to sperm Keeping the lining of the uterus thin
Other non-contraceptive benefits of the pill include a reduction in: Menstrual cramps or pain (dysmenorrhea) Ovarian cancer Cancer of the endometrium (uterine lining) Acne Iron-deficiency anemia (a low blood count due to low iron levels)
Efficacy — When taken properly, OCs are a very effective form of contraception. Although the failure rate is less than one percent when pills are taken perfectly (same time every day, no missed pills), the actual failure rate is 8 percent due primarily to missed pills or failure to restart the pill after the seven-day pill-free interval (show table 1A-1B).
Missed pills are a common cause of contraceptive failure. In general, an active pill should be taken as soon as possible after a pill has been missed. Back-up contraception should be used for seven days if more than two pills are missed.
Side effects — Side effects of the pill include: Nausea, breast tenderness, bloating, and mood changes, which typically improve after two to three months. Breakthrough bleeding or spotting. This is particularly common during the first few months of taking oral contraceptives. Forgetting a pill can also cause breakthrough bleeding.
Women taking the pill should notify their healthcare provider if they experience abdominal pain, chest pain, severe headaches, eye problems, or severe leg pain, as these could be symptoms of several serious conditions including heart attack, blood clot, stroke, liver, and gallbladder disease.
Progestin only pills — Some pills contain only progestin (called the mini-pill), which is useful for women who cannot or should not take estrogen. This includes women who are breastfeeding or who have aggravation of migraines or high blood pressure with combination contraceptive pills. Progestin only pills (or mini-pills) are as effective as combination pills when taken at the same time every day, but there is a slightly higher failure rate of the mini pill if the woman is more than three hours late in taking it. A backup method of birth control should be used for seven days if a pill is forgotten or taken more that three hours late.
INJECTABLE CONTRACEPTION — The only injectable contraceptive currently available in the United States is medroxyprogesterone acetate or DMPA (Depo-Provera®). DMPA is injected deep into a muscle, such as the buttock or upper arm, once every three months. A preparation that is given subcutaneously (under the skin) is also available. A full discussion of hormonal birth control methods is available separately. (See "Patient information: Hormonal methods of birth control").
DMPA prevents ovulation and alters the cervical mucus, making the cervix impenetrable to sperm. DMPA also thins the uterine lining. Women who receive their first DMPA injection more than seven days after their menstrual period should use a second form of contraception (eg, condoms) for seven days. DMPA is very effective, with a failure (pregnancy) rate of less than one percent (show table 1A-1B).
Side effects — The most common side effects of DMPA are irregular or prolonged bleeding and spotting, particularly during early therapy. Up to 50 percent of women completely stop having menstrual periods (amenorrhea) after one year of DMPA use. Menses generally return within six months of the last DMPA injection.
A full discussion of hormonal birth control methods is available separately. (See "Patient information: Hormonal methods of birth control").
TRANSDERMAL CONTRACEPTION (SKIN PATCHES) — Transdermal contraceptive patches contain estrogen and progestin, similar to oral contraceptives. The patch is as effective as oral contraceptives, and may be preferred by some women because it does not require daily dosing (show table 1A-1B). Ortho Evra is the only transdermal contraceptive available in the United States. Risks and effectiveness are similar to those of oral contraceptive pills. However, the patch appears to deliver a higher overall amount of estrogen than the pill. There is concern that this could increase the risk of blood clots, although this has not been proven.
The patch is worn for one week on the upper arm, shoulder, upper back, or hip. After one week, the old patch is removed and a new patch is applied; this is done for three weeks. During the fourth week, no patch is worn; the menstrual period occurs during this week.
VAGINAL RING — A flexible plastic vaginal ring (Nuvaring®) contains estrogen and a progestin, which is slowly absorbed through the vaginal tissues. This prevents pregnancy, similar to an oral contraceptive. It is worn inside the vagina for three weeks, followed by one week when no ring is used; the menstrual period occurs during this time. The ring is not noticeable, and it is easy for most women to insert and remove. It may be removed for up to three hours if desired, such as during intercourse, although it is not usually felt by the sexual partner. Risks and side effects are similar to those of oral contraceptives.
CONTRACEPTIVE IMPLANT — A single-rod progestin implant, Implanon, is available in the US and elsewhere. It provides three years of protection from pregnancy as progestin is slowly absorbed into the body. It is effective within 24 hours of insertion. Irregular bleeding is the most bothersome side effect. Fertility returns rapidly after removal of the rod.
BARRIER METHODS — This type of contraceptive physically blocks or otherwise prevents sperm from entering the uterus and reaching the egg for fertilization. Barrier contraceptives include the condom, diaphragm, and cervical cap. A full discussion of barrier methods of birth control is available separately. (See "Patient information: Barrier methods of birth control").
Male condom — The male condom is a thin, flexible sheath, or cover, placed over the penis to prevent semen from entering the vagina during sexual intercourse. To help ensure optimal effectiveness and protection, men who use condoms must carefully follow instructions for their use. Condoms are most effective when used with a vaginally-applied spermicide (see "Spermicide" below); use of the male condom and a vaginal spermicide is as effective as a hormonal method of contraception, and is more effective to prevent pregnancy than a condom alone. However, spermicidal condoms (those that are packaged with spermicide applied to the condom) are no more effective and expire faster than condoms without spermicide. Oil-based lubricants (eg, suntan oil, petroleum jelly, whipped cream) should not be used with latex condoms because this can cause breakage of the condom.
Many women who choose a contraceptive other than condoms also choose to use condoms to decrease their risk of acquiring a sexually transmitted disease.
Female condom — The female condom is worn by a woman to prevent semen from entering the vagina. It is a sheath made of polyurethane, and is prelubricated with a silicone-based lubricant. There is a soft, flexible ring at each end. The edges of the ring at the closed end of the sheath are squeezed together and then inserted as far as possible into the vagina; upon release, the ring will open to hold the condom in place. The ring at the open end of the sheath remains outside the vulva, resting against the labia. The woman should check to make sure the condom is not twisted.
Diaphragm/cervical cap — The diaphragm and cervical cap fit over the cervix, preventing sperm from entering the uterus. These devices are available in latex (the Prentif cap) or silicone rubber (FemCap) in multiple sizes, and require fitting by a clinician. These devices must be used with a spermicide and left in place for six to eight hours after sexual intercourse. The diaphragm must be removed after this period. However, the cervical cap can remain in place for up to 24 hours.
Spermicide — Spermicides are chemical substances that destroy sperm. They are available in most pharmacies without a prescription. Spermicides are available in a variety of forms including gel, foam, cream, film, suppository, and tablet.
INTRAUTERINE DEVICES (IUD) — IUDs are inserted by a healthcare provider through the vagina and cervix, into the uterus. Most are made of molded plastic and include an attached string that projects through the cervix into the vagina, enabling a woman to check that the device remains in place.
The currently available IUDs are safe and effective. These devices include: Copper-containing IUDs prevent pregnancy by preventing sperm from reaching the fallopian tubes. Copper-containing IUDs remain effective for at least 10 years. Levonorgestrel-releasing IUDs, prevent pregnancy by thickening the cervical mucus and thinning the endometrium (the lining of the uterus). They also decrease menstrual bleeding by 40 to 90 percent and decrease pain associated with periods. They can be left in place for up to five years, and are highly effective in preventing pregnancy. Some women stop having menstrual periods entirely; this effect is reversed when the IUD is removed.
STERILIZATION — Sterilization is a procedure that permanently prevents a person from becoming pregnant or able to have children. Tubal ligation and vasectomy are the two most common sterilization procedures. Sterilization should be considered permanent, and should only be considered after a careful discussion of all available options with a healthcare provider. (See "Patient information: Surgical sterilization of women" and see "Patient information: Vasectomy").
Tubal ligation — Tubal ligation is a sterilization procedures for women that surgically cuts, blocks, or seals the fallopian tubes to prevent pregnancy. The procedure is usually done in an operating room as a day surgery. Women who have recently delivered a baby can undergo tubal ligation before going home. It may be done at other times as well. A separate topic review is available. (See "Patient information: Surgical sterilization of women").
Essure® — Essure® is a permanent birth control method that requires surgical placement of a tiny coil mechanism into each of the fallopian tubes. The coil blocks the fallopian tubes three months after placement in most women. Placement is done after the woman receives local anesthesia (numbing medicine is injected into the cervix to prevent pain). A back up method of contraception (eg, oral contraceptive or condom) is needed until testing confirms that the fallopian tubes are completed blocked; this is usually performed three months after coil placement.
Vasectomy — Vasectomy is a sterilization procedure for men that surgically cuts or blocks the vas deferens, the tubes that carry sperm from the testes. It is a safe, highly effective surgical procedure that can be performed in a doctor's office under local anesthesia. Following surgery, another contraceptive (eg, condoms) must be used for approximately three months, until a semen analysis confirms that there are no sperm present. A separate topic review is available. (See "Patient information: Vasectomy").
OTHER METHODS — Some women and their partners cannot or choose not to use the contraceptive methods mentioned above due to religious or cultural reasons. Alternate birth control options include periodic abstinence and withdrawal.
Periodic abstinence — Periodic abstinence involves trying to predict the time of the month when a woman is most fertile, and abstaining from sexual intercourse during that time. Different methods may be used to help determine the fertile period:
Rhythm or calendar method — This uses the date of the last menstrual period to determine a woman's most fertile period. The first day of the fertile period is calculated by subtracting 18 days from the shortest menstrual cycle. The menstrual cycle is defined as the number of days from the start of one period to the start of the next period. The last day of the fertile period is calculated by subtracting 11 days from the length of the longest cycle. For example, if a woman's menstrual cycle varies from 28 to 30 days, she should refrain from intercourse from days 10 to 19 of each cycle. Day 1 is the first day of bleeding. This method is not appropriate for a woman who has irregular menstrual cycles and women who have recently delivered a baby or who are breastfeeding.
Basal body temperature — This method is based upon changes in body temperature that occur during a woman's cycle. A woman takes her temperature before getting out of bed in the morning; this is called the basal body temperature. Basal temperature rise slightly (about 0.5ยบ F) after release of the egg. Intercourse should be avoided between the start of the menstrual cycle (day one) until three days after the temperature rises. For most women, this requires abstinence for two weeks. This method is not recommended for women who breastfeeding or nearing menopause.
Cervical mucus — This method uses the color, amount, and consistency of a woman's cervical mucus, which change through a woman's cycle. During ovulation, the mucus is typically watery and in larger amounts than at other times. Intercourse should be avoided when watery cervical mucus first appears until three to four days after the heaviest day of mucus production.
When used perfectly, basal body temperature plus cervical mucus monitoring methods are more effective than the calendar or rhythm method. The estimated failure rates are 3 and 9 percent, respectively (show table 1A-1B). However, failure rates may be as high as 86 percent (with a 28 percent risk of pregnancy per cycle) if used incorrectly.
Withdrawal — Also known as coitus interruptus, the withdrawal method requires the man to withdraw his penis from the vagina before ejaculation. Pregnancy may occur if withdrawal occurs too late or if sperm is released before orgasm (in preejaculatory fluid). With this method, contraceptive failure rates may be as high as 18 to 20 percent (show table 1A-1B).
Breastfeeding — Breastfeeding after childbirth has limited effectiveness in preventing pregnancy due to a delay in the return of ovulation. Approximately 88 percent of women who breastfeed exclusively (meaning that no formula is given and the baby is fed on demand) do not ovulate for six months. If the woman does not have a menstrual period, she is more than 98 percent protected from pregnancy for the first six months (show table 1A-1B). Women who use supplemental feeding (formula) and those who menstruate are more likely to ovulate.
It is probably safest to resume a contraceptive in the third month following childbirth for those who breastfeed exclusively and in the third week postpartum for those who do not breastfeed or do so infrequently. A healthcare provider can help to determine the best timing and form of contraception following childbirth.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Child Health and Human Development (NICHD)
Toll-free: (800) 370-2943
(www.nichd.nih.gov)
National Women's Health Resource Center (NWHRC)
Toll-free: (877) 986-9472
(www.healthywomen.org)
EngenderHealth
Phone: (212) 561-8000
(www.engenderhealth.org)
Planned Parenthood Federation of America
Phone: (212) 541-7800
(www.plannedparenthood.org)
The Hormone Foundation
(www.hormone.org)
[1-4]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Abma, JC, Chandra, A, Mosher, WD, et al. and the National Center for Health Statistics. Fertility, family planning, and women's health: New data from the 1995 Survey of Family Growth. Vital Statistics; Series 23 No.19.
2. Fu, H, Darroch, JE, Haas, T, Ranjit, N. Contraceptive failure rates: New estimates from the 1995 National Survey of Family Growth. Fam Plann Perspect 1999; 31:56.
3. Steiner, MJ. Contraceptive effectiveness: what should the counseling message be?. JAMA 1999; 282:1405.
4. Trussell, J, Vaughan, B. Contraceptive failure, method-related discontinuation and resumption of use: results from the 1995 National Survey of Family Growth. Fam Plann Perspect 1999; 31:64.
Sunday, October 14, 2007
Barrier methods of birth control
INTRODUCTION — Barrier methods of birth control physically block or otherwise prevent sperm from entering the uterus and reaching the egg for fertilization. Barrier contraceptives include the condom, diaphragm, and cervical cap. These methods: Have fewer side effects than hormonal contraceptives Offer effective protection against certain sexually transmitted diseases (STDs) Are available without a prescription (condom and spermicides)
Spermicides (contraceptive creams or gels) are chemical substances that destroy sperm. They are available over the counter and are typically recommended in combination with barrier contraceptives to maximize the contraceptive effect (see "Spermicide" below).
This topic discusses barrier methods of birth control, including the condom, diaphragm, cervical cap, Lea contraceptive, sponge, and spermicides. A discussion of hormonal and long-term birth control methods are available separately. (See "Patient information: Hormonal methods of birth control" and see "Patient information: Long-term methods of birth control"). An overview of all birth control methods is also available. (See "Patient information: Contraception").
CHOOSING A METHOD — It can be difficult to decide which birth control method is best due to the variety of options available. The best method is one that will be used consistently, is acceptable to the woman and her partner, and which does no cause bothersome side effects. Other factors to consider include: Efficacy Convenience Duration of action Reversibility and time to return of fertility Effect on uterine bleeding Frequency of side effects and adverse events Affordability Protection against sexually transmitted diseases
No method of contraception is perfect. Each woman must balance the advantages of each method against the disadvantages and decide which method she prefers. A list of questions that are useful for defining a person's preferences are provided in the table (show table 1).
EMERGENCY CONTRACEPTION — Emergency contraception (EC, also known as postcoital contraception or the morning-after pill) refers to the use of drugs to prevent pregnancy in women who have had recent unprotected intercourse (including sexual assault), or who have had a failure of another method of contraception (eg, broken condom). As many as 30 percent of women will become pregnant after a single unprotected act of sex that occurs near the time of ovulation. Use of EC significantly reduces the chance of pregnancy, although pregnancy may still occur.
Experts are uncertain about how EC prevents pregnancy. Since these drugs are taken within hours of intercourse and implantation does not occur until approximately five to seven days after ovulation, use of EC does not interrupt pregnancy (medically, a woman is considered pregnant once a conceptus has implanted; however, some consider pregnancy to begin at conception).
Several options are available for EC (show table 2 and show table 3). Plan B is a pill pack that contains two 0.75 mg tablets of levonorgestrel, both of which should be taken as soon as possible after unprotected sex. It is also acceptable to take one pill as soon as possible, followed by the second pill 12 hours later (this is the instruction given by the manufacturer). The cost is approximately $40. The Plan B regimen is more effective and better tolerated than regimens using oral contraceptive pills that contain estrogen (eg, Ovral two tablets twelve hours apart or Lo/Ovral four tablets 12 hours apart).
Nausea and vomiting are the major side effects of the estrogen-containing regimen. A medication to reduce nausea and vomiting can be taken one hour before the first dose. Nausea and vomiting is less common with the levonorgestrel method. However, if levonorgestrel is vomited within one hour of taking it, a medication to prevent nausea can be taken, followed by a repeat of the EC dose.
EC is most effective when taken as soon as possible after intercourse. However, studies have shown that it is somewhat effective for up to 120 hours (five days) after intercourse, and may be started up to that time if necessary. After five days, insertion of a copper intrauterine device is considered the best way to prevent pregnancy. (See "Patient information: Long-term methods of birth control").
A risk of pregnancy still exists if the woman has unprotected intercourse after EC pills have been taken. Therefore, another method of contraception (eg, condoms) should be used for the rest of the cycle. A second dose of EC may be used if a second episode of unprotected intercourse occurs anytime after the first dose.
A woman who is sexually active and does not want to become pregnant can consider purchasing EC before it is needed. This would eliminate any delay in taking the first dose. In the United States, EC is approved as an over the counter medication for individuals (men or women) age 18 and older; proof of age is required (a government issued ID). Younger patients still require a prescription. Plan B is only available at sites with a licensed pharmacist.
A woman should have a menstrual period within three weeks of taking EC; failure to have a period may indicate pregnancy. An evaluation with a healthcare provider is recommended in this situation.
CONDOMS
Male condom — Male condoms are a thin, flexible sheath or cover that is placed over the penis to prevent semen from entering the partner's body during sexual intercourse. To help ensure optimal effectiveness and protection, people who use condoms must carefully follow instructions for their use.
Condoms are most effective when used with a vaginally-applied spermicide (see "Spermicide" below); use of the male condom and a vaginal spermicide is as effective as a hormonal method of contraception, and is more effective to prevent pregnancy than a condom alone (show table 4A-4B). However, spermicidal condoms (those that are packaged with spermicide applied to the condom) are no more effective and expire faster than condoms without spermicide.
When used properly, condoms can also reduce the risk of sexually transmitted infections such as HIV. Studies have found the following: There is a decreased risk of gonorrhea, chlamydia, trichomonas, syphilis, HIV, and HPV (human papillomavirus, which can cause genital warts and cervical cancer) in women whose male partner consistently uses condoms. (See "Patient information: Condyloma (genital warts) in women" and see "Patient information: Screening for cervical cancer" and see "Patient information: Testing for HIV"). In a study of HIV-negative women whose only risk for infection was a stable relationship with an HIV-infected man, none of the women who consistently used condoms became infected. Regular use of latex condoms appears to decrease the risk of HIV infection by about 69 percent.
Oil-based lubricants (eg, suntan oil, petroleum jelly, whipped cream) should not be used with latex condoms because this can cause breakage of the condom. Water-based lubricants are safe (eg, K-Y gel®, Astroglide®).
Most condoms are made of latex, which can be a problem for people who have an allergy or sensitivity to latex. Polyurethane condoms are available as an alternative to latex. Animal skin condoms (eg, lambskin) are not recommended when there is a risk of infection because they do not effectively prevent transmission of HIV.
Female condom — The female condom is worn by a woman to prevent semen from entering the vagina. It is a sheath made of polyurethane which is prelubricated with a silicone-based lubricant. There is a soft, flexible ring at each end. The edges of the ring at the closed end of the sheath are squeezed together and then inserted as far as possible into the vagina; upon release, the ring will open to hold the condom in place. The ring at the open end of the sheath remains outside the vulva, resting against the labia. The patient should check to make sure the condom is not twisted.
DIAPHRAGM/CERVICAL CAP — The diaphragm or cervical cap are placed over the cervix before intercouse. Pregnancy is prevented by blocking sperm from entering the uterus and killing sperm with the spermicide (see "Spermicide" below). Both require fitting by a trained clinician, and the fit should be checked after childbirth and weight loss or gain of more than 10 pounds (4.5 kilograms).
Both devices can decrease the risk of certain sexually transmitted diseases and infections, including gonorrhea, chlamydia, and pelvic inflammatory disease. However, the diaphragm and cervical cap are less effective than condoms in preventing the spread of HIV infection. Diaphragms and cervical caps are not recommended for women at high risk for HIV, who are HIV infected, or who have AIDS as they do not appear to prevent transmission of the virus.
In most studies, the failure rate (number of pregnancies) was higher for users of the diaphragm or cervical cap compared to hormonal methods of birth control (eg, the birth control pill) (show table 4A-4B).
Diaphragm — The diaphragm is a soft dome-shaped cup made of latex rubber or silicone with a flexible rim. Before intercourse, the hollow of the dome is partially filled with a spermicidal cream or jelly and then the diaphragm is inserted deep into the vagina and positioned so that it fits over the cervix (show picture 1). It must be left in place for six to eight hours after sexual intercourse, and then should be removed. If the woman has sex more than once during this time, an additional dose of spermicide should be inserted into the vagina.
Precautions — Most women can use the diaphragm; however; it is not a good method for those who have an allergy/sensitivity to latex, silicone, or spermicides; significant pelvic relaxation (uterine prolapse, cystocele, rectocele, poor vaginal tone); frequent urinary tract infections; HIV infection or are at high risk for acquiring HIV; or have difficulty with the insertion process. Women with a history of toxic shock syndrome should not use a diaphragm.
Cervical cap — The cervical cap is available in latex (the Prentif cap) or silicone rubber (FemCap) in multiple sizes. Similar to the diaphragm, it is partially filled with spermicide and placed over the cervix. It can remain in place for up to 48 hours.
OTHER BARRIER METHODS — There are several other barrier methods, none of which require a prescription. The Lea contraceptive and contraceptive sponge block sperm from entering the uterus and contain a spermicide to kill sperm.
Lea contraceptive — The Lea contraceptive is a pliable, cup-shaped silicone bowl with a one-way valve that allows for the passage of cervical discharge, menses, and air trapped behind the device during insertion. The vaginal walls keep it in place, which helps to provide a better fit. A silicone loop on the bowl eases insertion and removal.
The Lea can be inserted hours before intercourse and is left in place for at least eight and up to 48 hours afterwards, when it is removed and washed. As with the diaphragm, a spermicide is used with the device.
The Lea does not need to be fitted by a clinician (one size fits all) and is available without a prescription from a healthcare provider. Its effectiveness is comparable to that of the diaphragm (show table 4A-4B). It does not provide reliable protection from sexually transmitted infections.
Sponge — The Today sponge is a 2-inch wide circular disk that is 3/4 of an inch thick and attached to a loop that is used for removal. It contains a spermicide, and is moistened with tap water before insertion deep in the vagina.
The sponge can be left in place and used repeatedly for up to 24 hours. When compared to the diaphragm, the sponge was less effective (show table 4A-4B).
SPERMICIDE — Spermicides are chemical substances that destroy sperm. They are available in most pharmacies without a prescription. Spermicides are available in a variety of forms including gel, foam, cream, film, suppository, and tablet.
Spermicides may be used alone, but are more effective when used in combination with a condom, diaphragm, or cervical cap. Effectiveness is reduced if the patient does not wait long enough for the spermicide to disperse before having intercourse, if intercourse is delayed for more than one hour after administration, or if a repeat dose is not applied before each additional act of intercourse (show table 4A-4B).
Local irritation of the vagina is not uncommon with spermicide use, and spermicide-coated condoms are associated with an increased risk of urinary tract infection in the female partner. In the United States, the only spermicide available is nonoxynol-9; use of this spermicide alone is not effective in preventing transmission of sexually transmitted infections, including HIV.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Child Health and Human Development (NICHD)
Toll-free: (800) 370-2943
(www.nichd.nih.gov)
National Women's Health Resource Center (NWHRC)
Toll-free: (877) 986-9472
(www.healthywomen.org)
EngenderHealth
Phone: (212) 561-8000
(www.engenderhealth.org)
Planned Parenthood Federation of America
Phone: (212) 541-7800
(www.plannedparenthood.org)
The Hormone Foundation
(www.hormone.org)
[1-5]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Fu, H, Darroch, JE, Haas, T, Ranjit, N. Contraceptive failure rates: new estimates from the 1995 National Survey of Family Growth. Fam Plann Perspect 1999; 31:56.
2. Steiner, MJ, Dominik, R, Rountree, RW, et al. Contraceptive effectiveness of a polyurethane condom and a latex condom: A randomized controlled trial. Obstet Gynecol 2003; 101:539.
3. Gallo, MF, Grimes, DA, Schulz, KF. Non-latex versus latex male condoms for contraception. Cochrane Database Syst Rev 2003; :CD003550.
4. Gallo, MF, Grimes, DA, Schulz, KF. Cervical cap versus diaphragm for contraception. Cochrane Database Syst Rev 2002; :CD003551.
5. Kuyoh, MA, Toroitich-Ruto, C, Grimes, DA, et al. Sponge versus diaphragm for contraception. Cochrane Database Syst Rev 2002; :CD003172.
Spermicides (contraceptive creams or gels) are chemical substances that destroy sperm. They are available over the counter and are typically recommended in combination with barrier contraceptives to maximize the contraceptive effect (see "Spermicide" below).
This topic discusses barrier methods of birth control, including the condom, diaphragm, cervical cap, Lea contraceptive, sponge, and spermicides. A discussion of hormonal and long-term birth control methods are available separately. (See "Patient information: Hormonal methods of birth control" and see "Patient information: Long-term methods of birth control"). An overview of all birth control methods is also available. (See "Patient information: Contraception").
CHOOSING A METHOD — It can be difficult to decide which birth control method is best due to the variety of options available. The best method is one that will be used consistently, is acceptable to the woman and her partner, and which does no cause bothersome side effects. Other factors to consider include: Efficacy Convenience Duration of action Reversibility and time to return of fertility Effect on uterine bleeding Frequency of side effects and adverse events Affordability Protection against sexually transmitted diseases
No method of contraception is perfect. Each woman must balance the advantages of each method against the disadvantages and decide which method she prefers. A list of questions that are useful for defining a person's preferences are provided in the table (show table 1).
EMERGENCY CONTRACEPTION — Emergency contraception (EC, also known as postcoital contraception or the morning-after pill) refers to the use of drugs to prevent pregnancy in women who have had recent unprotected intercourse (including sexual assault), or who have had a failure of another method of contraception (eg, broken condom). As many as 30 percent of women will become pregnant after a single unprotected act of sex that occurs near the time of ovulation. Use of EC significantly reduces the chance of pregnancy, although pregnancy may still occur.
Experts are uncertain about how EC prevents pregnancy. Since these drugs are taken within hours of intercourse and implantation does not occur until approximately five to seven days after ovulation, use of EC does not interrupt pregnancy (medically, a woman is considered pregnant once a conceptus has implanted; however, some consider pregnancy to begin at conception).
Several options are available for EC (show table 2 and show table 3). Plan B is a pill pack that contains two 0.75 mg tablets of levonorgestrel, both of which should be taken as soon as possible after unprotected sex. It is also acceptable to take one pill as soon as possible, followed by the second pill 12 hours later (this is the instruction given by the manufacturer). The cost is approximately $40. The Plan B regimen is more effective and better tolerated than regimens using oral contraceptive pills that contain estrogen (eg, Ovral two tablets twelve hours apart or Lo/Ovral four tablets 12 hours apart).
Nausea and vomiting are the major side effects of the estrogen-containing regimen. A medication to reduce nausea and vomiting can be taken one hour before the first dose. Nausea and vomiting is less common with the levonorgestrel method. However, if levonorgestrel is vomited within one hour of taking it, a medication to prevent nausea can be taken, followed by a repeat of the EC dose.
EC is most effective when taken as soon as possible after intercourse. However, studies have shown that it is somewhat effective for up to 120 hours (five days) after intercourse, and may be started up to that time if necessary. After five days, insertion of a copper intrauterine device is considered the best way to prevent pregnancy. (See "Patient information: Long-term methods of birth control").
A risk of pregnancy still exists if the woman has unprotected intercourse after EC pills have been taken. Therefore, another method of contraception (eg, condoms) should be used for the rest of the cycle. A second dose of EC may be used if a second episode of unprotected intercourse occurs anytime after the first dose.
A woman who is sexually active and does not want to become pregnant can consider purchasing EC before it is needed. This would eliminate any delay in taking the first dose. In the United States, EC is approved as an over the counter medication for individuals (men or women) age 18 and older; proof of age is required (a government issued ID). Younger patients still require a prescription. Plan B is only available at sites with a licensed pharmacist.
A woman should have a menstrual period within three weeks of taking EC; failure to have a period may indicate pregnancy. An evaluation with a healthcare provider is recommended in this situation.
CONDOMS
Male condom — Male condoms are a thin, flexible sheath or cover that is placed over the penis to prevent semen from entering the partner's body during sexual intercourse. To help ensure optimal effectiveness and protection, people who use condoms must carefully follow instructions for their use.
Condoms are most effective when used with a vaginally-applied spermicide (see "Spermicide" below); use of the male condom and a vaginal spermicide is as effective as a hormonal method of contraception, and is more effective to prevent pregnancy than a condom alone (show table 4A-4B). However, spermicidal condoms (those that are packaged with spermicide applied to the condom) are no more effective and expire faster than condoms without spermicide.
When used properly, condoms can also reduce the risk of sexually transmitted infections such as HIV. Studies have found the following: There is a decreased risk of gonorrhea, chlamydia, trichomonas, syphilis, HIV, and HPV (human papillomavirus, which can cause genital warts and cervical cancer) in women whose male partner consistently uses condoms. (See "Patient information: Condyloma (genital warts) in women" and see "Patient information: Screening for cervical cancer" and see "Patient information: Testing for HIV"). In a study of HIV-negative women whose only risk for infection was a stable relationship with an HIV-infected man, none of the women who consistently used condoms became infected. Regular use of latex condoms appears to decrease the risk of HIV infection by about 69 percent.
Oil-based lubricants (eg, suntan oil, petroleum jelly, whipped cream) should not be used with latex condoms because this can cause breakage of the condom. Water-based lubricants are safe (eg, K-Y gel®, Astroglide®).
Most condoms are made of latex, which can be a problem for people who have an allergy or sensitivity to latex. Polyurethane condoms are available as an alternative to latex. Animal skin condoms (eg, lambskin) are not recommended when there is a risk of infection because they do not effectively prevent transmission of HIV.
Female condom — The female condom is worn by a woman to prevent semen from entering the vagina. It is a sheath made of polyurethane which is prelubricated with a silicone-based lubricant. There is a soft, flexible ring at each end. The edges of the ring at the closed end of the sheath are squeezed together and then inserted as far as possible into the vagina; upon release, the ring will open to hold the condom in place. The ring at the open end of the sheath remains outside the vulva, resting against the labia. The patient should check to make sure the condom is not twisted.
DIAPHRAGM/CERVICAL CAP — The diaphragm or cervical cap are placed over the cervix before intercouse. Pregnancy is prevented by blocking sperm from entering the uterus and killing sperm with the spermicide (see "Spermicide" below). Both require fitting by a trained clinician, and the fit should be checked after childbirth and weight loss or gain of more than 10 pounds (4.5 kilograms).
Both devices can decrease the risk of certain sexually transmitted diseases and infections, including gonorrhea, chlamydia, and pelvic inflammatory disease. However, the diaphragm and cervical cap are less effective than condoms in preventing the spread of HIV infection. Diaphragms and cervical caps are not recommended for women at high risk for HIV, who are HIV infected, or who have AIDS as they do not appear to prevent transmission of the virus.
In most studies, the failure rate (number of pregnancies) was higher for users of the diaphragm or cervical cap compared to hormonal methods of birth control (eg, the birth control pill) (show table 4A-4B).
Diaphragm — The diaphragm is a soft dome-shaped cup made of latex rubber or silicone with a flexible rim. Before intercourse, the hollow of the dome is partially filled with a spermicidal cream or jelly and then the diaphragm is inserted deep into the vagina and positioned so that it fits over the cervix (show picture 1). It must be left in place for six to eight hours after sexual intercourse, and then should be removed. If the woman has sex more than once during this time, an additional dose of spermicide should be inserted into the vagina.
Precautions — Most women can use the diaphragm; however; it is not a good method for those who have an allergy/sensitivity to latex, silicone, or spermicides; significant pelvic relaxation (uterine prolapse, cystocele, rectocele, poor vaginal tone); frequent urinary tract infections; HIV infection or are at high risk for acquiring HIV; or have difficulty with the insertion process. Women with a history of toxic shock syndrome should not use a diaphragm.
Cervical cap — The cervical cap is available in latex (the Prentif cap) or silicone rubber (FemCap) in multiple sizes. Similar to the diaphragm, it is partially filled with spermicide and placed over the cervix. It can remain in place for up to 48 hours.
OTHER BARRIER METHODS — There are several other barrier methods, none of which require a prescription. The Lea contraceptive and contraceptive sponge block sperm from entering the uterus and contain a spermicide to kill sperm.
Lea contraceptive — The Lea contraceptive is a pliable, cup-shaped silicone bowl with a one-way valve that allows for the passage of cervical discharge, menses, and air trapped behind the device during insertion. The vaginal walls keep it in place, which helps to provide a better fit. A silicone loop on the bowl eases insertion and removal.
The Lea can be inserted hours before intercourse and is left in place for at least eight and up to 48 hours afterwards, when it is removed and washed. As with the diaphragm, a spermicide is used with the device.
The Lea does not need to be fitted by a clinician (one size fits all) and is available without a prescription from a healthcare provider. Its effectiveness is comparable to that of the diaphragm (show table 4A-4B). It does not provide reliable protection from sexually transmitted infections.
Sponge — The Today sponge is a 2-inch wide circular disk that is 3/4 of an inch thick and attached to a loop that is used for removal. It contains a spermicide, and is moistened with tap water before insertion deep in the vagina.
The sponge can be left in place and used repeatedly for up to 24 hours. When compared to the diaphragm, the sponge was less effective (show table 4A-4B).
SPERMICIDE — Spermicides are chemical substances that destroy sperm. They are available in most pharmacies without a prescription. Spermicides are available in a variety of forms including gel, foam, cream, film, suppository, and tablet.
Spermicides may be used alone, but are more effective when used in combination with a condom, diaphragm, or cervical cap. Effectiveness is reduced if the patient does not wait long enough for the spermicide to disperse before having intercourse, if intercourse is delayed for more than one hour after administration, or if a repeat dose is not applied before each additional act of intercourse (show table 4A-4B).
Local irritation of the vagina is not uncommon with spermicide use, and spermicide-coated condoms are associated with an increased risk of urinary tract infection in the female partner. In the United States, the only spermicide available is nonoxynol-9; use of this spermicide alone is not effective in preventing transmission of sexually transmitted infections, including HIV.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Child Health and Human Development (NICHD)
Toll-free: (800) 370-2943
(www.nichd.nih.gov)
National Women's Health Resource Center (NWHRC)
Toll-free: (877) 986-9472
(www.healthywomen.org)
EngenderHealth
Phone: (212) 561-8000
(www.engenderhealth.org)
Planned Parenthood Federation of America
Phone: (212) 541-7800
(www.plannedparenthood.org)
The Hormone Foundation
(www.hormone.org)
[1-5]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Fu, H, Darroch, JE, Haas, T, Ranjit, N. Contraceptive failure rates: new estimates from the 1995 National Survey of Family Growth. Fam Plann Perspect 1999; 31:56.
2. Steiner, MJ, Dominik, R, Rountree, RW, et al. Contraceptive effectiveness of a polyurethane condom and a latex condom: A randomized controlled trial. Obstet Gynecol 2003; 101:539.
3. Gallo, MF, Grimes, DA, Schulz, KF. Non-latex versus latex male condoms for contraception. Cochrane Database Syst Rev 2003; :CD003550.
4. Gallo, MF, Grimes, DA, Schulz, KF. Cervical cap versus diaphragm for contraception. Cochrane Database Syst Rev 2002; :CD003551.
5. Kuyoh, MA, Toroitich-Ruto, C, Grimes, DA, et al. Sponge versus diaphragm for contraception. Cochrane Database Syst Rev 2002; :CD003172.
Barrier methods of birth control
INTRODUCTION — Barrier methods of birth control physically block or otherwise prevent sperm from entering the uterus and reaching the egg for fertilization. Barrier contraceptives include the condom, diaphragm, and cervical cap. These methods: Have fewer side effects than hormonal contraceptives Offer effective protection against certain sexually transmitted diseases (STDs) Are available without a prescription (condom and spermicides)
Spermicides (contraceptive creams or gels) are chemical substances that destroy sperm. They are available over the counter and are typically recommended in combination with barrier contraceptives to maximize the contraceptive effect (see "Spermicide" below).
This topic discusses barrier methods of birth control, including the condom, diaphragm, cervical cap, Lea contraceptive, sponge, and spermicides. A discussion of hormonal and long-term birth control methods are available separately. (See "Patient information: Hormonal methods of birth control" and see "Patient information: Long-term methods of birth control"). An overview of all birth control methods is also available. (See "Patient information: Contraception").
CHOOSING A METHOD — It can be difficult to decide which birth control method is best due to the variety of options available. The best method is one that will be used consistently, is acceptable to the woman and her partner, and which does no cause bothersome side effects. Other factors to consider include: Efficacy Convenience Duration of action Reversibility and time to return of fertility Effect on uterine bleeding Frequency of side effects and adverse events Affordability Protection against sexually transmitted diseases
No method of contraception is perfect. Each woman must balance the advantages of each method against the disadvantages and decide which method she prefers. A list of questions that are useful for defining a person's preferences are provided in the table (show table 1).
EMERGENCY CONTRACEPTION — Emergency contraception (EC, also known as postcoital contraception or the morning-after pill) refers to the use of drugs to prevent pregnancy in women who have had recent unprotected intercourse (including sexual assault), or who have had a failure of another method of contraception (eg, broken condom). As many as 30 percent of women will become pregnant after a single unprotected act of sex that occurs near the time of ovulation. Use of EC significantly reduces the chance of pregnancy, although pregnancy may still occur.
Experts are uncertain about how EC prevents pregnancy. Since these drugs are taken within hours of intercourse and implantation does not occur until approximately five to seven days after ovulation, use of EC does not interrupt pregnancy (medically, a woman is considered pregnant once a conceptus has implanted; however, some consider pregnancy to begin at conception).
Several options are available for EC (show table 2 and show table 3). Plan B is a pill pack that contains two 0.75 mg tablets of levonorgestrel, both of which should be taken as soon as possible after unprotected sex. It is also acceptable to take one pill as soon as possible, followed by the second pill 12 hours later (this is the instruction given by the manufacturer). The cost is approximately $40. The Plan B regimen is more effective and better tolerated than regimens using oral contraceptive pills that contain estrogen (eg, Ovral two tablets twelve hours apart or Lo/Ovral four tablets 12 hours apart).
Nausea and vomiting are the major side effects of the estrogen-containing regimen. A medication to reduce nausea and vomiting can be taken one hour before the first dose. Nausea and vomiting is less common with the levonorgestrel method. However, if levonorgestrel is vomited within one hour of taking it, a medication to prevent nausea can be taken, followed by a repeat of the EC dose.
EC is most effective when taken as soon as possible after intercourse. However, studies have shown that it is somewhat effective for up to 120 hours (five days) after intercourse, and may be started up to that time if necessary. After five days, insertion of a copper intrauterine device is considered the best way to prevent pregnancy. (See "Patient information: Long-term methods of birth control").
A risk of pregnancy still exists if the woman has unprotected intercourse after EC pills have been taken. Therefore, another method of contraception (eg, condoms) should be used for the rest of the cycle. A second dose of EC may be used if a second episode of unprotected intercourse occurs anytime after the first dose.
A woman who is sexually active and does not want to become pregnant can consider purchasing EC before it is needed. This would eliminate any delay in taking the first dose. In the United States, EC is approved as an over the counter medication for individuals (men or women) age 18 and older; proof of age is required (a government issued ID). Younger patients still require a prescription. Plan B is only available at sites with a licensed pharmacist.
A woman should have a menstrual period within three weeks of taking EC; failure to have a period may indicate pregnancy. An evaluation with a healthcare provider is recommended in this situation.
CONDOMS
Male condom — Male condoms are a thin, flexible sheath or cover that is placed over the penis to prevent semen from entering the partner's body during sexual intercourse. To help ensure optimal effectiveness and protection, people who use condoms must carefully follow instructions for their use.
Condoms are most effective when used with a vaginally-applied spermicide (see "Spermicide" below); use of the male condom and a vaginal spermicide is as effective as a hormonal method of contraception, and is more effective to prevent pregnancy than a condom alone (show table 4A-4B). However, spermicidal condoms (those that are packaged with spermicide applied to the condom) are no more effective and expire faster than condoms without spermicide.
When used properly, condoms can also reduce the risk of sexually transmitted infections such as HIV. Studies have found the following: There is a decreased risk of gonorrhea, chlamydia, trichomonas, syphilis, HIV, and HPV (human papillomavirus, which can cause genital warts and cervical cancer) in women whose male partner consistently uses condoms. (See "Patient information: Condyloma (genital warts) in women" and see "Patient information: Screening for cervical cancer" and see "Patient information: Testing for HIV"). In a study of HIV-negative women whose only risk for infection was a stable relationship with an HIV-infected man, none of the women who consistently used condoms became infected. Regular use of latex condoms appears to decrease the risk of HIV infection by about 69 percent.
Oil-based lubricants (eg, suntan oil, petroleum jelly, whipped cream) should not be used with latex condoms because this can cause breakage of the condom. Water-based lubricants are safe (eg, K-Y gel®, Astroglide®).
Most condoms are made of latex, which can be a problem for people who have an allergy or sensitivity to latex. Polyurethane condoms are available as an alternative to latex. Animal skin condoms (eg, lambskin) are not recommended when there is a risk of infection because they do not effectively prevent transmission of HIV.
Female condom — The female condom is worn by a woman to prevent semen from entering the vagina. It is a sheath made of polyurethane which is prelubricated with a silicone-based lubricant. There is a soft, flexible ring at each end. The edges of the ring at the closed end of the sheath are squeezed together and then inserted as far as possible into the vagina; upon release, the ring will open to hold the condom in place. The ring at the open end of the sheath remains outside the vulva, resting against the labia. The patient should check to make sure the condom is not twisted.
DIAPHRAGM/CERVICAL CAP — The diaphragm or cervical cap are placed over the cervix before intercouse. Pregnancy is prevented by blocking sperm from entering the uterus and killing sperm with the spermicide (see "Spermicide" below). Both require fitting by a trained clinician, and the fit should be checked after childbirth and weight loss or gain of more than 10 pounds (4.5 kilograms).
Both devices can decrease the risk of certain sexually transmitted diseases and infections, including gonorrhea, chlamydia, and pelvic inflammatory disease. However, the diaphragm and cervical cap are less effective than condoms in preventing the spread of HIV infection. Diaphragms and cervical caps are not recommended for women at high risk for HIV, who are HIV infected, or who have AIDS as they do not appear to prevent transmission of the virus.
In most studies, the failure rate (number of pregnancies) was higher for users of the diaphragm or cervical cap compared to hormonal methods of birth control (eg, the birth control pill) (show table 4A-4B).
Diaphragm — The diaphragm is a soft dome-shaped cup made of latex rubber or silicone with a flexible rim. Before intercourse, the hollow of the dome is partially filled with a spermicidal cream or jelly and then the diaphragm is inserted deep into the vagina and positioned so that it fits over the cervix (show picture 1). It must be left in place for six to eight hours after sexual intercourse, and then should be removed. If the woman has sex more than once during this time, an additional dose of spermicide should be inserted into the vagina.
Precautions — Most women can use the diaphragm; however; it is not a good method for those who have an allergy/sensitivity to latex, silicone, or spermicides; significant pelvic relaxation (uterine prolapse, cystocele, rectocele, poor vaginal tone); frequent urinary tract infections; HIV infection or are at high risk for acquiring HIV; or have difficulty with the insertion process. Women with a history of toxic shock syndrome should not use a diaphragm.
Cervical cap — The cervical cap is available in latex (the Prentif cap) or silicone rubber (FemCap) in multiple sizes. Similar to the diaphragm, it is partially filled with spermicide and placed over the cervix. It can remain in place for up to 48 hours.
OTHER BARRIER METHODS — There are several other barrier methods, none of which require a prescription. The Lea contraceptive and contraceptive sponge block sperm from entering the uterus and contain a spermicide to kill sperm.
Lea contraceptive — The Lea contraceptive is a pliable, cup-shaped silicone bowl with a one-way valve that allows for the passage of cervical discharge, menses, and air trapped behind the device during insertion. The vaginal walls keep it in place, which helps to provide a better fit. A silicone loop on the bowl eases insertion and removal.
The Lea can be inserted hours before intercourse and is left in place for at least eight and up to 48 hours afterwards, when it is removed and washed. As with the diaphragm, a spermicide is used with the device.
The Lea does not need to be fitted by a clinician (one size fits all) and is available without a prescription from a healthcare provider. Its effectiveness is comparable to that of the diaphragm (show table 4A-4B). It does not provide reliable protection from sexually transmitted infections.
Sponge — The Today sponge is a 2-inch wide circular disk that is 3/4 of an inch thick and attached to a loop that is used for removal. It contains a spermicide, and is moistened with tap water before insertion deep in the vagina.
The sponge can be left in place and used repeatedly for up to 24 hours. When compared to the diaphragm, the sponge was less effective (show table 4A-4B).
SPERMICIDE — Spermicides are chemical substances that destroy sperm. They are available in most pharmacies without a prescription. Spermicides are available in a variety of forms including gel, foam, cream, film, suppository, and tablet.
Spermicides may be used alone, but are more effective when used in combination with a condom, diaphragm, or cervical cap. Effectiveness is reduced if the patient does not wait long enough for the spermicide to disperse before having intercourse, if intercourse is delayed for more than one hour after administration, or if a repeat dose is not applied before each additional act of intercourse (show table 4A-4B).
Local irritation of the vagina is not uncommon with spermicide use, and spermicide-coated condoms are associated with an increased risk of urinary tract infection in the female partner. In the United States, the only spermicide available is nonoxynol-9; use of this spermicide alone is not effective in preventing transmission of sexually transmitted infections, including HIV.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Child Health and Human Development (NICHD)
Toll-free: (800) 370-2943
(www.nichd.nih.gov)
National Women's Health Resource Center (NWHRC)
Toll-free: (877) 986-9472
(www.healthywomen.org)
EngenderHealth
Phone: (212) 561-8000
(www.engenderhealth.org)
Planned Parenthood Federation of America
Phone: (212) 541-7800
(www.plannedparenthood.org)
The Hormone Foundation
(www.hormone.org)
[1-5]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Fu, H, Darroch, JE, Haas, T, Ranjit, N. Contraceptive failure rates: new estimates from the 1995 National Survey of Family Growth. Fam Plann Perspect 1999; 31:56.
2. Steiner, MJ, Dominik, R, Rountree, RW, et al. Contraceptive effectiveness of a polyurethane condom and a latex condom: A randomized controlled trial. Obstet Gynecol 2003; 101:539.
3. Gallo, MF, Grimes, DA, Schulz, KF. Non-latex versus latex male condoms for contraception. Cochrane Database Syst Rev 2003; :CD003550.
4. Gallo, MF, Grimes, DA, Schulz, KF. Cervical cap versus diaphragm for contraception. Cochrane Database Syst Rev 2002; :CD003551.
5. Kuyoh, MA, Toroitich-Ruto, C, Grimes, DA, et al. Sponge versus diaphragm for contraception. Cochrane Database Syst Rev 2002; :CD003172.
Spermicides (contraceptive creams or gels) are chemical substances that destroy sperm. They are available over the counter and are typically recommended in combination with barrier contraceptives to maximize the contraceptive effect (see "Spermicide" below).
This topic discusses barrier methods of birth control, including the condom, diaphragm, cervical cap, Lea contraceptive, sponge, and spermicides. A discussion of hormonal and long-term birth control methods are available separately. (See "Patient information: Hormonal methods of birth control" and see "Patient information: Long-term methods of birth control"). An overview of all birth control methods is also available. (See "Patient information: Contraception").
CHOOSING A METHOD — It can be difficult to decide which birth control method is best due to the variety of options available. The best method is one that will be used consistently, is acceptable to the woman and her partner, and which does no cause bothersome side effects. Other factors to consider include: Efficacy Convenience Duration of action Reversibility and time to return of fertility Effect on uterine bleeding Frequency of side effects and adverse events Affordability Protection against sexually transmitted diseases
No method of contraception is perfect. Each woman must balance the advantages of each method against the disadvantages and decide which method she prefers. A list of questions that are useful for defining a person's preferences are provided in the table (show table 1).
EMERGENCY CONTRACEPTION — Emergency contraception (EC, also known as postcoital contraception or the morning-after pill) refers to the use of drugs to prevent pregnancy in women who have had recent unprotected intercourse (including sexual assault), or who have had a failure of another method of contraception (eg, broken condom). As many as 30 percent of women will become pregnant after a single unprotected act of sex that occurs near the time of ovulation. Use of EC significantly reduces the chance of pregnancy, although pregnancy may still occur.
Experts are uncertain about how EC prevents pregnancy. Since these drugs are taken within hours of intercourse and implantation does not occur until approximately five to seven days after ovulation, use of EC does not interrupt pregnancy (medically, a woman is considered pregnant once a conceptus has implanted; however, some consider pregnancy to begin at conception).
Several options are available for EC (show table 2 and show table 3). Plan B is a pill pack that contains two 0.75 mg tablets of levonorgestrel, both of which should be taken as soon as possible after unprotected sex. It is also acceptable to take one pill as soon as possible, followed by the second pill 12 hours later (this is the instruction given by the manufacturer). The cost is approximately $40. The Plan B regimen is more effective and better tolerated than regimens using oral contraceptive pills that contain estrogen (eg, Ovral two tablets twelve hours apart or Lo/Ovral four tablets 12 hours apart).
Nausea and vomiting are the major side effects of the estrogen-containing regimen. A medication to reduce nausea and vomiting can be taken one hour before the first dose. Nausea and vomiting is less common with the levonorgestrel method. However, if levonorgestrel is vomited within one hour of taking it, a medication to prevent nausea can be taken, followed by a repeat of the EC dose.
EC is most effective when taken as soon as possible after intercourse. However, studies have shown that it is somewhat effective for up to 120 hours (five days) after intercourse, and may be started up to that time if necessary. After five days, insertion of a copper intrauterine device is considered the best way to prevent pregnancy. (See "Patient information: Long-term methods of birth control").
A risk of pregnancy still exists if the woman has unprotected intercourse after EC pills have been taken. Therefore, another method of contraception (eg, condoms) should be used for the rest of the cycle. A second dose of EC may be used if a second episode of unprotected intercourse occurs anytime after the first dose.
A woman who is sexually active and does not want to become pregnant can consider purchasing EC before it is needed. This would eliminate any delay in taking the first dose. In the United States, EC is approved as an over the counter medication for individuals (men or women) age 18 and older; proof of age is required (a government issued ID). Younger patients still require a prescription. Plan B is only available at sites with a licensed pharmacist.
A woman should have a menstrual period within three weeks of taking EC; failure to have a period may indicate pregnancy. An evaluation with a healthcare provider is recommended in this situation.
CONDOMS
Male condom — Male condoms are a thin, flexible sheath or cover that is placed over the penis to prevent semen from entering the partner's body during sexual intercourse. To help ensure optimal effectiveness and protection, people who use condoms must carefully follow instructions for their use.
Condoms are most effective when used with a vaginally-applied spermicide (see "Spermicide" below); use of the male condom and a vaginal spermicide is as effective as a hormonal method of contraception, and is more effective to prevent pregnancy than a condom alone (show table 4A-4B). However, spermicidal condoms (those that are packaged with spermicide applied to the condom) are no more effective and expire faster than condoms without spermicide.
When used properly, condoms can also reduce the risk of sexually transmitted infections such as HIV. Studies have found the following: There is a decreased risk of gonorrhea, chlamydia, trichomonas, syphilis, HIV, and HPV (human papillomavirus, which can cause genital warts and cervical cancer) in women whose male partner consistently uses condoms. (See "Patient information: Condyloma (genital warts) in women" and see "Patient information: Screening for cervical cancer" and see "Patient information: Testing for HIV"). In a study of HIV-negative women whose only risk for infection was a stable relationship with an HIV-infected man, none of the women who consistently used condoms became infected. Regular use of latex condoms appears to decrease the risk of HIV infection by about 69 percent.
Oil-based lubricants (eg, suntan oil, petroleum jelly, whipped cream) should not be used with latex condoms because this can cause breakage of the condom. Water-based lubricants are safe (eg, K-Y gel®, Astroglide®).
Most condoms are made of latex, which can be a problem for people who have an allergy or sensitivity to latex. Polyurethane condoms are available as an alternative to latex. Animal skin condoms (eg, lambskin) are not recommended when there is a risk of infection because they do not effectively prevent transmission of HIV.
Female condom — The female condom is worn by a woman to prevent semen from entering the vagina. It is a sheath made of polyurethane which is prelubricated with a silicone-based lubricant. There is a soft, flexible ring at each end. The edges of the ring at the closed end of the sheath are squeezed together and then inserted as far as possible into the vagina; upon release, the ring will open to hold the condom in place. The ring at the open end of the sheath remains outside the vulva, resting against the labia. The patient should check to make sure the condom is not twisted.
DIAPHRAGM/CERVICAL CAP — The diaphragm or cervical cap are placed over the cervix before intercouse. Pregnancy is prevented by blocking sperm from entering the uterus and killing sperm with the spermicide (see "Spermicide" below). Both require fitting by a trained clinician, and the fit should be checked after childbirth and weight loss or gain of more than 10 pounds (4.5 kilograms).
Both devices can decrease the risk of certain sexually transmitted diseases and infections, including gonorrhea, chlamydia, and pelvic inflammatory disease. However, the diaphragm and cervical cap are less effective than condoms in preventing the spread of HIV infection. Diaphragms and cervical caps are not recommended for women at high risk for HIV, who are HIV infected, or who have AIDS as they do not appear to prevent transmission of the virus.
In most studies, the failure rate (number of pregnancies) was higher for users of the diaphragm or cervical cap compared to hormonal methods of birth control (eg, the birth control pill) (show table 4A-4B).
Diaphragm — The diaphragm is a soft dome-shaped cup made of latex rubber or silicone with a flexible rim. Before intercourse, the hollow of the dome is partially filled with a spermicidal cream or jelly and then the diaphragm is inserted deep into the vagina and positioned so that it fits over the cervix (show picture 1). It must be left in place for six to eight hours after sexual intercourse, and then should be removed. If the woman has sex more than once during this time, an additional dose of spermicide should be inserted into the vagina.
Precautions — Most women can use the diaphragm; however; it is not a good method for those who have an allergy/sensitivity to latex, silicone, or spermicides; significant pelvic relaxation (uterine prolapse, cystocele, rectocele, poor vaginal tone); frequent urinary tract infections; HIV infection or are at high risk for acquiring HIV; or have difficulty with the insertion process. Women with a history of toxic shock syndrome should not use a diaphragm.
Cervical cap — The cervical cap is available in latex (the Prentif cap) or silicone rubber (FemCap) in multiple sizes. Similar to the diaphragm, it is partially filled with spermicide and placed over the cervix. It can remain in place for up to 48 hours.
OTHER BARRIER METHODS — There are several other barrier methods, none of which require a prescription. The Lea contraceptive and contraceptive sponge block sperm from entering the uterus and contain a spermicide to kill sperm.
Lea contraceptive — The Lea contraceptive is a pliable, cup-shaped silicone bowl with a one-way valve that allows for the passage of cervical discharge, menses, and air trapped behind the device during insertion. The vaginal walls keep it in place, which helps to provide a better fit. A silicone loop on the bowl eases insertion and removal.
The Lea can be inserted hours before intercourse and is left in place for at least eight and up to 48 hours afterwards, when it is removed and washed. As with the diaphragm, a spermicide is used with the device.
The Lea does not need to be fitted by a clinician (one size fits all) and is available without a prescription from a healthcare provider. Its effectiveness is comparable to that of the diaphragm (show table 4A-4B). It does not provide reliable protection from sexually transmitted infections.
Sponge — The Today sponge is a 2-inch wide circular disk that is 3/4 of an inch thick and attached to a loop that is used for removal. It contains a spermicide, and is moistened with tap water before insertion deep in the vagina.
The sponge can be left in place and used repeatedly for up to 24 hours. When compared to the diaphragm, the sponge was less effective (show table 4A-4B).
SPERMICIDE — Spermicides are chemical substances that destroy sperm. They are available in most pharmacies without a prescription. Spermicides are available in a variety of forms including gel, foam, cream, film, suppository, and tablet.
Spermicides may be used alone, but are more effective when used in combination with a condom, diaphragm, or cervical cap. Effectiveness is reduced if the patient does not wait long enough for the spermicide to disperse before having intercourse, if intercourse is delayed for more than one hour after administration, or if a repeat dose is not applied before each additional act of intercourse (show table 4A-4B).
Local irritation of the vagina is not uncommon with spermicide use, and spermicide-coated condoms are associated with an increased risk of urinary tract infection in the female partner. In the United States, the only spermicide available is nonoxynol-9; use of this spermicide alone is not effective in preventing transmission of sexually transmitted infections, including HIV.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Child Health and Human Development (NICHD)
Toll-free: (800) 370-2943
(www.nichd.nih.gov)
National Women's Health Resource Center (NWHRC)
Toll-free: (877) 986-9472
(www.healthywomen.org)
EngenderHealth
Phone: (212) 561-8000
(www.engenderhealth.org)
Planned Parenthood Federation of America
Phone: (212) 541-7800
(www.plannedparenthood.org)
The Hormone Foundation
(www.hormone.org)
[1-5]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Fu, H, Darroch, JE, Haas, T, Ranjit, N. Contraceptive failure rates: new estimates from the 1995 National Survey of Family Growth. Fam Plann Perspect 1999; 31:56.
2. Steiner, MJ, Dominik, R, Rountree, RW, et al. Contraceptive effectiveness of a polyurethane condom and a latex condom: A randomized controlled trial. Obstet Gynecol 2003; 101:539.
3. Gallo, MF, Grimes, DA, Schulz, KF. Non-latex versus latex male condoms for contraception. Cochrane Database Syst Rev 2003; :CD003550.
4. Gallo, MF, Grimes, DA, Schulz, KF. Cervical cap versus diaphragm for contraception. Cochrane Database Syst Rev 2002; :CD003551.
5. Kuyoh, MA, Toroitich-Ruto, C, Grimes, DA, et al. Sponge versus diaphragm for contraception. Cochrane Database Syst Rev 2002; :CD003172.
Bacterial vaginosis
INTRODUCTION — Bacterial vaginosis (BV) is the most common cause of vaginal discharge in women of childbearing age. It can cause bothersome symptoms, and also increases the risk of acquiring serious sexually transmitted infections, such as HIV. It may be difficult to know if discharge is caused by BV or other common vaginal infections, thus a visit with a healthcare provider is recommended in most cases.
CAUSES — BV occurs when there is a complex change in the number and types of bacteria in the vagina. The concentration of lactobacilli, a type of bacteria that is normally predominant in the vagina, becomes reduced. The reasons for the reduction in lactobacilli and overgrowth of other bacteria are not clear. The role of sexual activity in this process is also not clear.
Risk factors — Risk factors for BV include multiple or new sexual partners, douching, and cigarette smoking. Although sexual activity is a risk factor for the condition, BV can occur in women who have never had vaginal intercourse. BV is not thought to be a sexually transmitted infection.
SIGNS AND SYMPTOMS — Approximately 50 to 75 percent of women with BV have no symptoms. Those with symptoms often note an unpleasant, "fishy smelling" vaginal discharge that is more noticeable after sexual intercourse. Vaginal discharge that is off-white and thin may also be present.
Pain during urination or sex, vulvar itching, redness, and swelling are not typical features of the disorder. Occasionally, BV causes an abnormal cervical discharge and easy bleeding (such as after sexual intercourse).
A woman with concerns about excessive or foul-smelling vaginal discharge, abnormal bleeding, or vulvar irritation is advised to see a healthcare provider. Self-treatment with over-the-counter products (eg, yeast creams, deodorants) is not recommended without a definite diagnosis.
DIAGNOSIS — The diagnosis of BV is based upon a physical examination and laboratory testing. The physical examination usually includes a pelvic examination, which allows the healthcare provider to observe and test vaginal secretions during or immediately after the examination. It can be difficult to know, without an examination and testing, if vaginal discharged is caused by BV or another vaginal infection.
COMPLICATIONS — BV itself is not harmful, although it has been associated with some health problems. Pregnant women with BV are at higher risk of preterm delivery Untreated BV in a woman who undergoes hysterectomy or abortion can lead to infection of the surgical site. BV increases the risk of acquiring and transmitting HIV. BV increases the risk that a woman will become infected with genital herpes, gonorrhea, or chlamydia. (See "Patient information: Genital herpes" and see "Patient information: Gonorrhea" and see "Patient information: Chlamydia").
TREATMENT — Treatment is usually recommended for women who have bothersome symptoms from the infection and those preparing for abortion or hysterectomy. Treatment of BV may also reduce the risk of acquiring other STDs, including HIV. For this reason, some experts now support the concept of treating all women with BV.
There are two prescription medications used for the treatment of BV: metronidazole and clindamycin. Both medications can be taken in pill form by mouth, or with a treatment inserted inside the vagina. Oral medication may be more convenient, but has a higher rate of side effects. Follow-up testing is not needed if symptoms resolve.
Metronidazole — The oral regimen for metronidazole is 500 mg twice daily for seven days. Topical vaginal therapy with 0.75 percent metronidazole gel (5 g in the vagina at bedtime for five days) is as effective as oral metronidazole. The choice of oral versus topical therapy depends upon the patient's preference. In general, there are fewer side effects with the topical treatment.
Side effects of oral metronidazole include a metallic taste, nausea, and a temporary lowered blood count. Alcohol should not be consumed during oral metronidazole treatment due to the risk of a serious interaction, which can cause flushing, nausea, thirst, palpitations, chest pain, vertigo, and low blood pressure. Oral metronidazole also interacts with warfarin (Coumadin®), potentially increasing the risk of bleeding. The vaginal gel does not cause these side effects.
Clindamycin — The standard treatment regimen for clindamycin is a 2 percent vaginal clindamycin cream for seven days; this should not be used with latex condoms due to the risk of condom breakage.
Alternate regimens for treatment of BV include oral clindamycin (300 mg twice daily by mouth for seven days) or clindamycin ovules (100 mg intravaginally once daily for three days). A one-day application of clindamycin is also available (Clindesse®).
Sexual partners — It is not necessary to treat the male sexual partner of a woman with BV; there is no evidence that the woman's symptoms or risk of relapse is improved if her sex partner(s) is treated.
Relapse and recurrent infection — Approximately 30 percent of women who initially improve with standard treatment have a recurrence of BV symptoms within three months, and more than 50 percent experience a recurrence within 12 months. The explanation for this high rate of recurrence is unclear. Recurrence is likely the result of failure to eliminate the offending bacteria or failure to reestablish the normal levels of protective lactobacilli.
Relapse can be treated with a prolonged course of oral or vaginal metronidazole or clindamycin for 10 to 14 days; the United States Center for Disease Control and Prevention suggests a treatment regimen different from the initial or previous treatment regimen (eg, oral treatment if vaginal treatment used previously).
Most women with recurrent BV benefit from suppressive therapy. A long-term maintenance regimen that includes vaginal metronidazole gel twice weekly may be of benefit, although secondary yeast infection can develop with this regimen. (See "Patient information: Vaginal yeast infection").
Pregnancy — Pregnant women with BV are at increased risk of preterm birth. However, there is no evidence that screening and treatment of pregnant women who have no signs or symptoms of infection reduces the risk of preterm birth. There may be benefits to screening and treating pregnant women who have symptoms of BV and a history of a previous preterm delivery.
Pregnant women with signs or symptoms of BV infection are usually treated to relieve symptoms. Oral treatment with seven days of metronidazole is preferred over shorter oral regimens or vaginal treatments.
PREVENTION — The best way to prevent BV is not known. However, a few basic recommendations can be made. Do not douche. Douching is the use of a solution to rinse the inside of the vagina. Some women douche to feel "clean", although there is no proven benefit of douching. The vagina is normally able to maintain a healthy balance of bacteria; douching can upset this balance and potentially flush harmful bacteria into the upper genital tracts (uterus, fallopian tubes). Limit the number of sexual partners. Women with multiple sexual partners are at higher risk of developing bacterial vaginosis, as well as sexually transmitted infections. Finish the entire course of treatment for BV, even if the symptoms resolve after a few doses.
SUMMARY Bacterial vaginosis (BV) is the most common cause of vaginal discharge in women of childbearing age. It occurs when there is a complex change in the number and types of bacteria in the vagina (see "Causes" above). Risk factors for BV include multiple or new sexual partners, douching, and cigarette smoking. Although sexual activity is a risk factor for the condition, BV can occur in women who have never had vaginal intercourse. BV is not thought to be a sexually transmitted infection. Approximately 50 to 75 percent of women with BV have no symptoms. Those with symptoms often note an unpleasant, "fishy smelling" vaginal discharge that is more noticeable after sexual intercourse. Vaginal discharge that is off-white and thin may also be present (see "Signs and symptoms" above). A woman with concerns about excessive or foul-smelling vaginal discharge, abnormal bleeding, or vulvar irritation is advised to see a healthcare provider. Self-treatment with over-the-counter products (eg, yeast creams, deodorants) is not recommended without a definite diagnosis (see "Diagnosis" above). BV is diagnosed with a physical examination and laboratory testing. The physical examination usually includes a pelvic examination, which allows the healthcare provider to observe and test vaginal secretions during or immediately after the examination. Treatment is usually recommended for women who have bothersome symptoms from the infection and those preparing for abortion or hysterectomy. Treatment of BV may also reduce the risk of acquiring other STDs, including HIV. For this reason, some experts now support the concept of treating all women with BV (see "Treatment" above). There are two prescription medications used for the treatment of BV: metronidazole and clindamycin. Both medications can be taken in pill form by mouth, or with a treatment inserted inside the vagina. Oral medication may be more convenient, but has a higher rate of side effects. Follow-up testing is not needed if symptoms resolve. It is not necessary to treat the male sexual partner of a woman with BV; there is no evidence that the woman's symptoms or risk of relapse is improved if her sex partner(s) is treated. Approximately 30 percent of women who initially improve with standard treatment have a recurrence of BV symptoms within three months, and more than 50 percent experience a recurrence within 12 months. Relapse can be treated with a prolonged course of oral or vaginal metronidazole or clindamycin for 10 to 14 days. Most women with recurrent BV benefit from suppressive therapy. A long-term maintenance regimen that includes vaginal metronidazole gel twice weekly may be of benefit, although secondary yeast infection can develop with this regimen (see "Relapse and recurrent infection" above). Pregnant women with signs or symptoms of BV infection are usually treated to relieve symptoms. Oral treatment with seven days of metronidazole is preferred over shorter oral regimens or vaginal treatments (see "Pregnancy" above).
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Allergy and Infectious Diseases
(www.niaid.nih.gov/factsheets/vaginitis.htm)
Centers for Disease Control and Prevention
(www.cdc.gov/STD/BV/default.htm)
American Social Health Association
(www.ashastd.org/learn/learn_vag_trich_bv.cfm)
[1-4]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Schwebke, JR, Desmond, RA, Oh, MK. Predictors of bacterial vaginosis in adolescent women who douche. Sex Transm Dis 2004; 31:433.
2. Gutman, RE, Peipert, JF, Weitzen, S, Blume, J. Evaluation of clinical methods for diagnosing bacterial vaginosis. Obstet Gynecol 2005; 105:551.
3. McDonald, H, Brocklehurst, P, Parsons, J. Antibiotics for treating bacterial vaginosis in pregnancy. Cochrane Database Syst Rev 2005; :CD000262.
4. Riggs, MA, Klebanoff, MA. Treatment of vaginal infections to prevent preterm birth: a meta-analysis. Clin Obstet Gynecol 2004; 47:796.
CAUSES — BV occurs when there is a complex change in the number and types of bacteria in the vagina. The concentration of lactobacilli, a type of bacteria that is normally predominant in the vagina, becomes reduced. The reasons for the reduction in lactobacilli and overgrowth of other bacteria are not clear. The role of sexual activity in this process is also not clear.
Risk factors — Risk factors for BV include multiple or new sexual partners, douching, and cigarette smoking. Although sexual activity is a risk factor for the condition, BV can occur in women who have never had vaginal intercourse. BV is not thought to be a sexually transmitted infection.
SIGNS AND SYMPTOMS — Approximately 50 to 75 percent of women with BV have no symptoms. Those with symptoms often note an unpleasant, "fishy smelling" vaginal discharge that is more noticeable after sexual intercourse. Vaginal discharge that is off-white and thin may also be present.
Pain during urination or sex, vulvar itching, redness, and swelling are not typical features of the disorder. Occasionally, BV causes an abnormal cervical discharge and easy bleeding (such as after sexual intercourse).
A woman with concerns about excessive or foul-smelling vaginal discharge, abnormal bleeding, or vulvar irritation is advised to see a healthcare provider. Self-treatment with over-the-counter products (eg, yeast creams, deodorants) is not recommended without a definite diagnosis.
DIAGNOSIS — The diagnosis of BV is based upon a physical examination and laboratory testing. The physical examination usually includes a pelvic examination, which allows the healthcare provider to observe and test vaginal secretions during or immediately after the examination. It can be difficult to know, without an examination and testing, if vaginal discharged is caused by BV or another vaginal infection.
COMPLICATIONS — BV itself is not harmful, although it has been associated with some health problems. Pregnant women with BV are at higher risk of preterm delivery Untreated BV in a woman who undergoes hysterectomy or abortion can lead to infection of the surgical site. BV increases the risk of acquiring and transmitting HIV. BV increases the risk that a woman will become infected with genital herpes, gonorrhea, or chlamydia. (See "Patient information: Genital herpes" and see "Patient information: Gonorrhea" and see "Patient information: Chlamydia").
TREATMENT — Treatment is usually recommended for women who have bothersome symptoms from the infection and those preparing for abortion or hysterectomy. Treatment of BV may also reduce the risk of acquiring other STDs, including HIV. For this reason, some experts now support the concept of treating all women with BV.
There are two prescription medications used for the treatment of BV: metronidazole and clindamycin. Both medications can be taken in pill form by mouth, or with a treatment inserted inside the vagina. Oral medication may be more convenient, but has a higher rate of side effects. Follow-up testing is not needed if symptoms resolve.
Metronidazole — The oral regimen for metronidazole is 500 mg twice daily for seven days. Topical vaginal therapy with 0.75 percent metronidazole gel (5 g in the vagina at bedtime for five days) is as effective as oral metronidazole. The choice of oral versus topical therapy depends upon the patient's preference. In general, there are fewer side effects with the topical treatment.
Side effects of oral metronidazole include a metallic taste, nausea, and a temporary lowered blood count. Alcohol should not be consumed during oral metronidazole treatment due to the risk of a serious interaction, which can cause flushing, nausea, thirst, palpitations, chest pain, vertigo, and low blood pressure. Oral metronidazole also interacts with warfarin (Coumadin®), potentially increasing the risk of bleeding. The vaginal gel does not cause these side effects.
Clindamycin — The standard treatment regimen for clindamycin is a 2 percent vaginal clindamycin cream for seven days; this should not be used with latex condoms due to the risk of condom breakage.
Alternate regimens for treatment of BV include oral clindamycin (300 mg twice daily by mouth for seven days) or clindamycin ovules (100 mg intravaginally once daily for three days). A one-day application of clindamycin is also available (Clindesse®).
Sexual partners — It is not necessary to treat the male sexual partner of a woman with BV; there is no evidence that the woman's symptoms or risk of relapse is improved if her sex partner(s) is treated.
Relapse and recurrent infection — Approximately 30 percent of women who initially improve with standard treatment have a recurrence of BV symptoms within three months, and more than 50 percent experience a recurrence within 12 months. The explanation for this high rate of recurrence is unclear. Recurrence is likely the result of failure to eliminate the offending bacteria or failure to reestablish the normal levels of protective lactobacilli.
Relapse can be treated with a prolonged course of oral or vaginal metronidazole or clindamycin for 10 to 14 days; the United States Center for Disease Control and Prevention suggests a treatment regimen different from the initial or previous treatment regimen (eg, oral treatment if vaginal treatment used previously).
Most women with recurrent BV benefit from suppressive therapy. A long-term maintenance regimen that includes vaginal metronidazole gel twice weekly may be of benefit, although secondary yeast infection can develop with this regimen. (See "Patient information: Vaginal yeast infection").
Pregnancy — Pregnant women with BV are at increased risk of preterm birth. However, there is no evidence that screening and treatment of pregnant women who have no signs or symptoms of infection reduces the risk of preterm birth. There may be benefits to screening and treating pregnant women who have symptoms of BV and a history of a previous preterm delivery.
Pregnant women with signs or symptoms of BV infection are usually treated to relieve symptoms. Oral treatment with seven days of metronidazole is preferred over shorter oral regimens or vaginal treatments.
PREVENTION — The best way to prevent BV is not known. However, a few basic recommendations can be made. Do not douche. Douching is the use of a solution to rinse the inside of the vagina. Some women douche to feel "clean", although there is no proven benefit of douching. The vagina is normally able to maintain a healthy balance of bacteria; douching can upset this balance and potentially flush harmful bacteria into the upper genital tracts (uterus, fallopian tubes). Limit the number of sexual partners. Women with multiple sexual partners are at higher risk of developing bacterial vaginosis, as well as sexually transmitted infections. Finish the entire course of treatment for BV, even if the symptoms resolve after a few doses.
SUMMARY Bacterial vaginosis (BV) is the most common cause of vaginal discharge in women of childbearing age. It occurs when there is a complex change in the number and types of bacteria in the vagina (see "Causes" above). Risk factors for BV include multiple or new sexual partners, douching, and cigarette smoking. Although sexual activity is a risk factor for the condition, BV can occur in women who have never had vaginal intercourse. BV is not thought to be a sexually transmitted infection. Approximately 50 to 75 percent of women with BV have no symptoms. Those with symptoms often note an unpleasant, "fishy smelling" vaginal discharge that is more noticeable after sexual intercourse. Vaginal discharge that is off-white and thin may also be present (see "Signs and symptoms" above). A woman with concerns about excessive or foul-smelling vaginal discharge, abnormal bleeding, or vulvar irritation is advised to see a healthcare provider. Self-treatment with over-the-counter products (eg, yeast creams, deodorants) is not recommended without a definite diagnosis (see "Diagnosis" above). BV is diagnosed with a physical examination and laboratory testing. The physical examination usually includes a pelvic examination, which allows the healthcare provider to observe and test vaginal secretions during or immediately after the examination. Treatment is usually recommended for women who have bothersome symptoms from the infection and those preparing for abortion or hysterectomy. Treatment of BV may also reduce the risk of acquiring other STDs, including HIV. For this reason, some experts now support the concept of treating all women with BV (see "Treatment" above). There are two prescription medications used for the treatment of BV: metronidazole and clindamycin. Both medications can be taken in pill form by mouth, or with a treatment inserted inside the vagina. Oral medication may be more convenient, but has a higher rate of side effects. Follow-up testing is not needed if symptoms resolve. It is not necessary to treat the male sexual partner of a woman with BV; there is no evidence that the woman's symptoms or risk of relapse is improved if her sex partner(s) is treated. Approximately 30 percent of women who initially improve with standard treatment have a recurrence of BV symptoms within three months, and more than 50 percent experience a recurrence within 12 months. Relapse can be treated with a prolonged course of oral or vaginal metronidazole or clindamycin for 10 to 14 days. Most women with recurrent BV benefit from suppressive therapy. A long-term maintenance regimen that includes vaginal metronidazole gel twice weekly may be of benefit, although secondary yeast infection can develop with this regimen (see "Relapse and recurrent infection" above). Pregnant women with signs or symptoms of BV infection are usually treated to relieve symptoms. Oral treatment with seven days of metronidazole is preferred over shorter oral regimens or vaginal treatments (see "Pregnancy" above).
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Allergy and Infectious Diseases
(www.niaid.nih.gov/factsheets/vaginitis.htm)
Centers for Disease Control and Prevention
(www.cdc.gov/STD/BV/default.htm)
American Social Health Association
(www.ashastd.org/learn/learn_vag_trich_bv.cfm)
[1-4]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Schwebke, JR, Desmond, RA, Oh, MK. Predictors of bacterial vaginosis in adolescent women who douche. Sex Transm Dis 2004; 31:433.
2. Gutman, RE, Peipert, JF, Weitzen, S, Blume, J. Evaluation of clinical methods for diagnosing bacterial vaginosis. Obstet Gynecol 2005; 105:551.
3. McDonald, H, Brocklehurst, P, Parsons, J. Antibiotics for treating bacterial vaginosis in pregnancy. Cochrane Database Syst Rev 2005; :CD000262.
4. Riggs, MA, Klebanoff, MA. Treatment of vaginal infections to prevent preterm birth: a meta-analysis. Clin Obstet Gynecol 2004; 47:796.
Bacterial vaginosis
INTRODUCTION — Bacterial vaginosis (BV) is the most common cause of vaginal discharge in women of childbearing age. It can cause bothersome symptoms, and also increases the risk of acquiring serious sexually transmitted infections, such as HIV. It may be difficult to know if discharge is caused by BV or other common vaginal infections, thus a visit with a healthcare provider is recommended in most cases.
CAUSES — BV occurs when there is a complex change in the number and types of bacteria in the vagina. The concentration of lactobacilli, a type of bacteria that is normally predominant in the vagina, becomes reduced. The reasons for the reduction in lactobacilli and overgrowth of other bacteria are not clear. The role of sexual activity in this process is also not clear.
Risk factors — Risk factors for BV include multiple or new sexual partners, douching, and cigarette smoking. Although sexual activity is a risk factor for the condition, BV can occur in women who have never had vaginal intercourse. BV is not thought to be a sexually transmitted infection.
SIGNS AND SYMPTOMS — Approximately 50 to 75 percent of women with BV have no symptoms. Those with symptoms often note an unpleasant, "fishy smelling" vaginal discharge that is more noticeable after sexual intercourse. Vaginal discharge that is off-white and thin may also be present.
Pain during urination or sex, vulvar itching, redness, and swelling are not typical features of the disorder. Occasionally, BV causes an abnormal cervical discharge and easy bleeding (such as after sexual intercourse).
A woman with concerns about excessive or foul-smelling vaginal discharge, abnormal bleeding, or vulvar irritation is advised to see a healthcare provider. Self-treatment with over-the-counter products (eg, yeast creams, deodorants) is not recommended without a definite diagnosis.
DIAGNOSIS — The diagnosis of BV is based upon a physical examination and laboratory testing. The physical examination usually includes a pelvic examination, which allows the healthcare provider to observe and test vaginal secretions during or immediately after the examination. It can be difficult to know, without an examination and testing, if vaginal discharged is caused by BV or another vaginal infection.
COMPLICATIONS — BV itself is not harmful, although it has been associated with some health problems. Pregnant women with BV are at higher risk of preterm delivery Untreated BV in a woman who undergoes hysterectomy or abortion can lead to infection of the surgical site. BV increases the risk of acquiring and transmitting HIV. BV increases the risk that a woman will become infected with genital herpes, gonorrhea, or chlamydia. (See "Patient information: Genital herpes" and see "Patient information: Gonorrhea" and see "Patient information: Chlamydia").
TREATMENT — Treatment is usually recommended for women who have bothersome symptoms from the infection and those preparing for abortion or hysterectomy. Treatment of BV may also reduce the risk of acquiring other STDs, including HIV. For this reason, some experts now support the concept of treating all women with BV.
There are two prescription medications used for the treatment of BV: metronidazole and clindamycin. Both medications can be taken in pill form by mouth, or with a treatment inserted inside the vagina. Oral medication may be more convenient, but has a higher rate of side effects. Follow-up testing is not needed if symptoms resolve.
Metronidazole — The oral regimen for metronidazole is 500 mg twice daily for seven days. Topical vaginal therapy with 0.75 percent metronidazole gel (5 g in the vagina at bedtime for five days) is as effective as oral metronidazole. The choice of oral versus topical therapy depends upon the patient's preference. In general, there are fewer side effects with the topical treatment.
Side effects of oral metronidazole include a metallic taste, nausea, and a temporary lowered blood count. Alcohol should not be consumed during oral metronidazole treatment due to the risk of a serious interaction, which can cause flushing, nausea, thirst, palpitations, chest pain, vertigo, and low blood pressure. Oral metronidazole also interacts with warfarin (Coumadin®), potentially increasing the risk of bleeding. The vaginal gel does not cause these side effects.
Clindamycin — The standard treatment regimen for clindamycin is a 2 percent vaginal clindamycin cream for seven days; this should not be used with latex condoms due to the risk of condom breakage.
Alternate regimens for treatment of BV include oral clindamycin (300 mg twice daily by mouth for seven days) or clindamycin ovules (100 mg intravaginally once daily for three days). A one-day application of clindamycin is also available (Clindesse®).
Sexual partners — It is not necessary to treat the male sexual partner of a woman with BV; there is no evidence that the woman's symptoms or risk of relapse is improved if her sex partner(s) is treated.
Relapse and recurrent infection — Approximately 30 percent of women who initially improve with standard treatment have a recurrence of BV symptoms within three months, and more than 50 percent experience a recurrence within 12 months. The explanation for this high rate of recurrence is unclear. Recurrence is likely the result of failure to eliminate the offending bacteria or failure to reestablish the normal levels of protective lactobacilli.
Relapse can be treated with a prolonged course of oral or vaginal metronidazole or clindamycin for 10 to 14 days; the United States Center for Disease Control and Prevention suggests a treatment regimen different from the initial or previous treatment regimen (eg, oral treatment if vaginal treatment used previously).
Most women with recurrent BV benefit from suppressive therapy. A long-term maintenance regimen that includes vaginal metronidazole gel twice weekly may be of benefit, although secondary yeast infection can develop with this regimen. (See "Patient information: Vaginal yeast infection").
Pregnancy — Pregnant women with BV are at increased risk of preterm birth. However, there is no evidence that screening and treatment of pregnant women who have no signs or symptoms of infection reduces the risk of preterm birth. There may be benefits to screening and treating pregnant women who have symptoms of BV and a history of a previous preterm delivery.
Pregnant women with signs or symptoms of BV infection are usually treated to relieve symptoms. Oral treatment with seven days of metronidazole is preferred over shorter oral regimens or vaginal treatments.
PREVENTION — The best way to prevent BV is not known. However, a few basic recommendations can be made. Do not douche. Douching is the use of a solution to rinse the inside of the vagina. Some women douche to feel "clean", although there is no proven benefit of douching. The vagina is normally able to maintain a healthy balance of bacteria; douching can upset this balance and potentially flush harmful bacteria into the upper genital tracts (uterus, fallopian tubes). Limit the number of sexual partners. Women with multiple sexual partners are at higher risk of developing bacterial vaginosis, as well as sexually transmitted infections. Finish the entire course of treatment for BV, even if the symptoms resolve after a few doses.
SUMMARY Bacterial vaginosis (BV) is the most common cause of vaginal discharge in women of childbearing age. It occurs when there is a complex change in the number and types of bacteria in the vagina (see "Causes" above). Risk factors for BV include multiple or new sexual partners, douching, and cigarette smoking. Although sexual activity is a risk factor for the condition, BV can occur in women who have never had vaginal intercourse. BV is not thought to be a sexually transmitted infection. Approximately 50 to 75 percent of women with BV have no symptoms. Those with symptoms often note an unpleasant, "fishy smelling" vaginal discharge that is more noticeable after sexual intercourse. Vaginal discharge that is off-white and thin may also be present (see "Signs and symptoms" above). A woman with concerns about excessive or foul-smelling vaginal discharge, abnormal bleeding, or vulvar irritation is advised to see a healthcare provider. Self-treatment with over-the-counter products (eg, yeast creams, deodorants) is not recommended without a definite diagnosis (see "Diagnosis" above). BV is diagnosed with a physical examination and laboratory testing. The physical examination usually includes a pelvic examination, which allows the healthcare provider to observe and test vaginal secretions during or immediately after the examination. Treatment is usually recommended for women who have bothersome symptoms from the infection and those preparing for abortion or hysterectomy. Treatment of BV may also reduce the risk of acquiring other STDs, including HIV. For this reason, some experts now support the concept of treating all women with BV (see "Treatment" above). There are two prescription medications used for the treatment of BV: metronidazole and clindamycin. Both medications can be taken in pill form by mouth, or with a treatment inserted inside the vagina. Oral medication may be more convenient, but has a higher rate of side effects. Follow-up testing is not needed if symptoms resolve. It is not necessary to treat the male sexual partner of a woman with BV; there is no evidence that the woman's symptoms or risk of relapse is improved if her sex partner(s) is treated. Approximately 30 percent of women who initially improve with standard treatment have a recurrence of BV symptoms within three months, and more than 50 percent experience a recurrence within 12 months. Relapse can be treated with a prolonged course of oral or vaginal metronidazole or clindamycin for 10 to 14 days. Most women with recurrent BV benefit from suppressive therapy. A long-term maintenance regimen that includes vaginal metronidazole gel twice weekly may be of benefit, although secondary yeast infection can develop with this regimen (see "Relapse and recurrent infection" above). Pregnant women with signs or symptoms of BV infection are usually treated to relieve symptoms. Oral treatment with seven days of metronidazole is preferred over shorter oral regimens or vaginal treatments (see "Pregnancy" above).
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Allergy and Infectious Diseases
(www.niaid.nih.gov/factsheets/vaginitis.htm)
Centers for Disease Control and Prevention
(www.cdc.gov/STD/BV/default.htm)
American Social Health Association
(www.ashastd.org/learn/learn_vag_trich_bv.cfm)
[1-4]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Schwebke, JR, Desmond, RA, Oh, MK. Predictors of bacterial vaginosis in adolescent women who douche. Sex Transm Dis 2004; 31:433.
2. Gutman, RE, Peipert, JF, Weitzen, S, Blume, J. Evaluation of clinical methods for diagnosing bacterial vaginosis. Obstet Gynecol 2005; 105:551.
3. McDonald, H, Brocklehurst, P, Parsons, J. Antibiotics for treating bacterial vaginosis in pregnancy. Cochrane Database Syst Rev 2005; :CD000262.
4. Riggs, MA, Klebanoff, MA. Treatment of vaginal infections to prevent preterm birth: a meta-analysis. Clin Obstet Gynecol 2004; 47:796.
CAUSES — BV occurs when there is a complex change in the number and types of bacteria in the vagina. The concentration of lactobacilli, a type of bacteria that is normally predominant in the vagina, becomes reduced. The reasons for the reduction in lactobacilli and overgrowth of other bacteria are not clear. The role of sexual activity in this process is also not clear.
Risk factors — Risk factors for BV include multiple or new sexual partners, douching, and cigarette smoking. Although sexual activity is a risk factor for the condition, BV can occur in women who have never had vaginal intercourse. BV is not thought to be a sexually transmitted infection.
SIGNS AND SYMPTOMS — Approximately 50 to 75 percent of women with BV have no symptoms. Those with symptoms often note an unpleasant, "fishy smelling" vaginal discharge that is more noticeable after sexual intercourse. Vaginal discharge that is off-white and thin may also be present.
Pain during urination or sex, vulvar itching, redness, and swelling are not typical features of the disorder. Occasionally, BV causes an abnormal cervical discharge and easy bleeding (such as after sexual intercourse).
A woman with concerns about excessive or foul-smelling vaginal discharge, abnormal bleeding, or vulvar irritation is advised to see a healthcare provider. Self-treatment with over-the-counter products (eg, yeast creams, deodorants) is not recommended without a definite diagnosis.
DIAGNOSIS — The diagnosis of BV is based upon a physical examination and laboratory testing. The physical examination usually includes a pelvic examination, which allows the healthcare provider to observe and test vaginal secretions during or immediately after the examination. It can be difficult to know, without an examination and testing, if vaginal discharged is caused by BV or another vaginal infection.
COMPLICATIONS — BV itself is not harmful, although it has been associated with some health problems. Pregnant women with BV are at higher risk of preterm delivery Untreated BV in a woman who undergoes hysterectomy or abortion can lead to infection of the surgical site. BV increases the risk of acquiring and transmitting HIV. BV increases the risk that a woman will become infected with genital herpes, gonorrhea, or chlamydia. (See "Patient information: Genital herpes" and see "Patient information: Gonorrhea" and see "Patient information: Chlamydia").
TREATMENT — Treatment is usually recommended for women who have bothersome symptoms from the infection and those preparing for abortion or hysterectomy. Treatment of BV may also reduce the risk of acquiring other STDs, including HIV. For this reason, some experts now support the concept of treating all women with BV.
There are two prescription medications used for the treatment of BV: metronidazole and clindamycin. Both medications can be taken in pill form by mouth, or with a treatment inserted inside the vagina. Oral medication may be more convenient, but has a higher rate of side effects. Follow-up testing is not needed if symptoms resolve.
Metronidazole — The oral regimen for metronidazole is 500 mg twice daily for seven days. Topical vaginal therapy with 0.75 percent metronidazole gel (5 g in the vagina at bedtime for five days) is as effective as oral metronidazole. The choice of oral versus topical therapy depends upon the patient's preference. In general, there are fewer side effects with the topical treatment.
Side effects of oral metronidazole include a metallic taste, nausea, and a temporary lowered blood count. Alcohol should not be consumed during oral metronidazole treatment due to the risk of a serious interaction, which can cause flushing, nausea, thirst, palpitations, chest pain, vertigo, and low blood pressure. Oral metronidazole also interacts with warfarin (Coumadin®), potentially increasing the risk of bleeding. The vaginal gel does not cause these side effects.
Clindamycin — The standard treatment regimen for clindamycin is a 2 percent vaginal clindamycin cream for seven days; this should not be used with latex condoms due to the risk of condom breakage.
Alternate regimens for treatment of BV include oral clindamycin (300 mg twice daily by mouth for seven days) or clindamycin ovules (100 mg intravaginally once daily for three days). A one-day application of clindamycin is also available (Clindesse®).
Sexual partners — It is not necessary to treat the male sexual partner of a woman with BV; there is no evidence that the woman's symptoms or risk of relapse is improved if her sex partner(s) is treated.
Relapse and recurrent infection — Approximately 30 percent of women who initially improve with standard treatment have a recurrence of BV symptoms within three months, and more than 50 percent experience a recurrence within 12 months. The explanation for this high rate of recurrence is unclear. Recurrence is likely the result of failure to eliminate the offending bacteria or failure to reestablish the normal levels of protective lactobacilli.
Relapse can be treated with a prolonged course of oral or vaginal metronidazole or clindamycin for 10 to 14 days; the United States Center for Disease Control and Prevention suggests a treatment regimen different from the initial or previous treatment regimen (eg, oral treatment if vaginal treatment used previously).
Most women with recurrent BV benefit from suppressive therapy. A long-term maintenance regimen that includes vaginal metronidazole gel twice weekly may be of benefit, although secondary yeast infection can develop with this regimen. (See "Patient information: Vaginal yeast infection").
Pregnancy — Pregnant women with BV are at increased risk of preterm birth. However, there is no evidence that screening and treatment of pregnant women who have no signs or symptoms of infection reduces the risk of preterm birth. There may be benefits to screening and treating pregnant women who have symptoms of BV and a history of a previous preterm delivery.
Pregnant women with signs or symptoms of BV infection are usually treated to relieve symptoms. Oral treatment with seven days of metronidazole is preferred over shorter oral regimens or vaginal treatments.
PREVENTION — The best way to prevent BV is not known. However, a few basic recommendations can be made. Do not douche. Douching is the use of a solution to rinse the inside of the vagina. Some women douche to feel "clean", although there is no proven benefit of douching. The vagina is normally able to maintain a healthy balance of bacteria; douching can upset this balance and potentially flush harmful bacteria into the upper genital tracts (uterus, fallopian tubes). Limit the number of sexual partners. Women with multiple sexual partners are at higher risk of developing bacterial vaginosis, as well as sexually transmitted infections. Finish the entire course of treatment for BV, even if the symptoms resolve after a few doses.
SUMMARY Bacterial vaginosis (BV) is the most common cause of vaginal discharge in women of childbearing age. It occurs when there is a complex change in the number and types of bacteria in the vagina (see "Causes" above). Risk factors for BV include multiple or new sexual partners, douching, and cigarette smoking. Although sexual activity is a risk factor for the condition, BV can occur in women who have never had vaginal intercourse. BV is not thought to be a sexually transmitted infection. Approximately 50 to 75 percent of women with BV have no symptoms. Those with symptoms often note an unpleasant, "fishy smelling" vaginal discharge that is more noticeable after sexual intercourse. Vaginal discharge that is off-white and thin may also be present (see "Signs and symptoms" above). A woman with concerns about excessive or foul-smelling vaginal discharge, abnormal bleeding, or vulvar irritation is advised to see a healthcare provider. Self-treatment with over-the-counter products (eg, yeast creams, deodorants) is not recommended without a definite diagnosis (see "Diagnosis" above). BV is diagnosed with a physical examination and laboratory testing. The physical examination usually includes a pelvic examination, which allows the healthcare provider to observe and test vaginal secretions during or immediately after the examination. Treatment is usually recommended for women who have bothersome symptoms from the infection and those preparing for abortion or hysterectomy. Treatment of BV may also reduce the risk of acquiring other STDs, including HIV. For this reason, some experts now support the concept of treating all women with BV (see "Treatment" above). There are two prescription medications used for the treatment of BV: metronidazole and clindamycin. Both medications can be taken in pill form by mouth, or with a treatment inserted inside the vagina. Oral medication may be more convenient, but has a higher rate of side effects. Follow-up testing is not needed if symptoms resolve. It is not necessary to treat the male sexual partner of a woman with BV; there is no evidence that the woman's symptoms or risk of relapse is improved if her sex partner(s) is treated. Approximately 30 percent of women who initially improve with standard treatment have a recurrence of BV symptoms within three months, and more than 50 percent experience a recurrence within 12 months. Relapse can be treated with a prolonged course of oral or vaginal metronidazole or clindamycin for 10 to 14 days. Most women with recurrent BV benefit from suppressive therapy. A long-term maintenance regimen that includes vaginal metronidazole gel twice weekly may be of benefit, although secondary yeast infection can develop with this regimen (see "Relapse and recurrent infection" above). Pregnant women with signs or symptoms of BV infection are usually treated to relieve symptoms. Oral treatment with seven days of metronidazole is preferred over shorter oral regimens or vaginal treatments (see "Pregnancy" above).
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Allergy and Infectious Diseases
(www.niaid.nih.gov/factsheets/vaginitis.htm)
Centers for Disease Control and Prevention
(www.cdc.gov/STD/BV/default.htm)
American Social Health Association
(www.ashastd.org/learn/learn_vag_trich_bv.cfm)
[1-4]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Schwebke, JR, Desmond, RA, Oh, MK. Predictors of bacterial vaginosis in adolescent women who douche. Sex Transm Dis 2004; 31:433.
2. Gutman, RE, Peipert, JF, Weitzen, S, Blume, J. Evaluation of clinical methods for diagnosing bacterial vaginosis. Obstet Gynecol 2005; 105:551.
3. McDonald, H, Brocklehurst, P, Parsons, J. Antibiotics for treating bacterial vaginosis in pregnancy. Cochrane Database Syst Rev 2005; :CD000262.
4. Riggs, MA, Klebanoff, MA. Treatment of vaginal infections to prevent preterm birth: a meta-analysis. Clin Obstet Gynecol 2004; 47:796.
Saturday, October 13, 2007
Testicular cancer
INTRODUCTION — Testicular cancer occurs when cancer cells develop in one or both of the testicles. Testicles are the male reproductive glands located within the scrotum (show figure 1). The scrotum is a sack of loose skin that contains the testicles and hangs directly below the penis.
Testicular cancer is the most common cancer arising in young men. Fortunately, it has become one of the most curable of all cancers, largely due to advances in medical treatment. More than 95 percent of all men diagnosed with testicular cancer survive their disease.
TYPES OF TESTICULAR CANCER — Approximately 95 percent of testicular cancers develop from a type of cell in the testicle called a germ cell. Thus, they are called testicular germ cell tumors.
Seminoma vs Nonseminomatous germ cell tumor (NSGCT) — There are two major types of testicular germ cell tumors: seminoma and nonseminomatous germ cell tumors (NSGCTs). Approximately one-third of all testicular germ cell tumors are seminomas; the remainder are NSGCGTs. Both seminoma and NSGCT primarily affect men between the ages of 15 and 35 years of age, although seminomas occur in a slightly older group of men (show table 1).
SYMPTOMS — For most men, the first symptom of testicular cancer is a painless lump or swelling in the scrotum. Some men may also experience a dull ache or heavy sensation in the lower abdomen, area around the anus, or scrotum. Pain is the first symptom in about 10 percent of men.
DIAGNOSIS — Men who detect a lump in their testicle should see a healthcare provider as soon as possible. The provider will perform a general examination, with special attention to the breasts (which can become enlarged in some men with testicular cancer), the abdomen (to evaluate the lymph nodes and abdominal organs) and the scrotum. Both testicles will be examined and compared. (See "Clinical manifestations, diagnosis, and staging of testicular germ cell tumors").
If testicular cancer is suspected, several tests may be ordered to support the diagnosis. However, the only way to be certain that the diagnosis is testicular cancer is to remove the testicle. Testicular ultrasound — Testicular ultrasound uses sound waves to measure the size and characteristics of the testicle and mass (lump), and can determine whether the mass is inside or outside of the testicle and whether it contains fluid or is a solid mass. Testicular cancers are solid and develop inside the testicle. Often, the ultrasound will strongly suggest the diagnosis of testicular cancer. Orchiectomy — The only way to confirm the diagnosis of testicular cancer is by surgically removing the testicle. This procedure is called a radical inguinal orchiectomy (see "Radical inguinal orchiectomy" below).
STAGING AND PROGNOSTIC CLASSIFICATION — Staging is used to determine if there is spread (metastasis) of the cancer beyond the testicle. Stage I testicular cancer is defined as cancer that is limited to the testis only. Stage II testicular cancer has spread (metastasized) to the retroperitoneal lymph nodes (located in the abdomen). Stage III testicular cancer has spread to other organs (show table 2 and show table 3).
Blood tests and imaging (eg, CT scan) are used in the process of staging.
Blood tests — Substances produced by a testicular cancer (called tumor markers) can be measured in the blood. The three most important markers are: Alpha fetoprotein (AFP) Beta human chorionic gonadotropin (beta-hCG) Lactate dehydrogenase (LDH)
High levels of these tumor markers are suggestive of testicular cancer, and can help determine the specific type of testicular cancer that is present. These markers are also used during and after treatment to monitor a patient's response.
CT scans — Most men with a suspected testicular cancer will undergo a CT scan (sometimes called a CAT scan) of the abdomen and pelvis. A chest x-ray or CT scan of the chest is also commonly done.
These tests are done to determine if the suspected cancer has spread beyond the testicle (metastasized). The most common site of metastasis in testicular cancer is the lymph nodes in the abdomen; metastasis to the lung, liver, bones, and brain is also possible.
Prognostic classification — Men with stage II or III testicular cancer (both seminomas and NSGCTs) can be classified as having a good, intermediate, or poor prognosis (chance of survival and recovery) based upon the stage of disease and particular type of testicular tumor. Men with stage I testicular cancer have an excellent prognosis, and are not included in this classification system.
Following radical inguinal orchiectomy, a physician treats testicular cancer according to the type of tumor (seminoma or nonseminomatous germ cell tumor), the stage of the disease, and the patient's prognosis.
All men with seminoma are classified as having a good or intermediate prognosis. Men with NSGCT may have a good, intermediate, or poor prognosis, depending upon the stage of their disease. Good prognosis — Men with seminoma have a good prognosis if the tumor has not metastasized to organs other than the lungs and if they have a normal AFP serum level.
Patients with NSGCTs have a good prognosis if the tumor is located only in the testicle or area outside or behind the abdominal wall, if the tumor has not metastasized to organs other than the lungs, and if their serum tumor markers are only slightly elevated. Intermediate prognosis — Patients with seminoma have an intermediate prognosis if the tumor has metastasized to organs other than the lungs and their AFP test is normal.
Patients with NSGCTs have an intermediate prognosis if the tumor is found in only one testicle or in the area outside or behind the abdominal wall, if the tumor has not spread to organs other than the lungs, and if serum tumor markers are not significantly elevated. Poor prognosis — Men with NSGCTs are classified as having a poor prognosis if the tumor develops in the center of the chest between the lungs (called the mediastinum), if it has spread to organs other than the lungs, or if any of the serum tumor markers are significantly elevated.
Even for patients with a poor prognosis, approximately one-half are cured with aggressive treatment.
TREATMENT — Treatment of both seminoma and NSGCT generally includes surgery to remove the affected testicle; this surgery is called radical inguinal orchiectomy (see "Radical inguinal orchiectomy" below). The need for further treatment is determined by the type of cancer, the stage of the cancer, and the prognosis. Advances in chemotherapy and radiation therapy, often used in combination with surgery, have improved the outcome for patients with testicular cancer, and approximately 95 percent of patients can be cured.
Radical inguinal orchiectomy — Radical inguinal orchiectomy is not only required for diagnosis, but is also the initial step in treatment for most patients.
Orchiectomy is usually done in an operating room after the patient receives general or epidural anesthesia. A small incision (cut) is made in the groin and the testicle is removed. The standard treatment is to remove the entire affected testicle to avoid the risk of spreading the tumor within the scrotum. Tissue from the testicle is then examined using a microscope.
Chemotherapy
What is chemotherapy? — Chemotherapy refers to the use of medicines to stop or slow the growth of cancer cells. Chemotherapy works by interfering with the ability of rapidly growing cells (like cancer cells) to divide or multiply. Because most of an adult's normal cells are not actively dividing or multiplying, they are not affected by chemotherapy. However, the bone marrow (where the blood cells are produced), the hair follicles, and the lining of the gastrointestinal (GI) tract are all growing. The side effects of chemotherapy drugs are related to effects on these and other normal tissues (see "Chemotherapy side effects" below).
Most drugs are given intravenously (IV) rather than by mouth. They are not usually taken daily, but periodically, in cycles. A cycle of chemotherapy refers to the time it takes to give the drugs and the time required for the body to recover. For example, a typical chemotherapy regimen could include a one hour IV infusion of two different chemotherapy medications given once every three weeks. This three week period is one cycle of therapy. If this regimen were repeated for a total of three months, four cycles of chemotherapy would be administered.
Adjuvant chemotherapy — The term adjuvant therapy refers to additional anticancer treatment that is given after surgery to eliminate any remaining tumor cells in the body (often termed micrometastases). Adjuvant therapy significantly decreases the chance that the cancer will return (or recur), and also improves the likelihood of surviving cancer. As a result, adjuvant therapy has become an important component of treatment. Modern adjuvant chemotherapy typically involves a combination of two or more drugs; these combinations are referred to as regimens.
Chemotherapy for testicular cancer — Chemotherapy is sometimes used as an adjuvant treatment for men with early stage testicular cancer, as well as for men with more advanced disease. Patients with more advanced stages of cancer and those who have a disease relapse after radiation therapy usually undergo multiple cycles of combination chemotherapy. A cycle of chemotherapy refers to the time it takes to give the drugs and the time required for the body to recover. Combination chemotherapy involves giving more than one drug, which improves the chance of a cure and reduces the chance that the tumor will develop resistance to one chemotherapy drug.
Lymph node removal — The most common sites of spread for testicular cancer are the lymph nodes in the back of the abdomen, called the retroperitoneal lymph nodes. Surgical removal (called retroperitoneal lymph node dissection or RPLND) of these nodes may be needed in the following situations: If the CT scan of the abdomen shows enlarged nodes, raising suspicion that the cancer has spread to this area. For men who have no evidence of enlargement of the retroperitoneal lymph nodes, RPLND may still be performed because a CT cannot determine lymph node involvement in as many as one-third of cases.
There are alternatives to RPLND, including periodic physical examination and CT scans (called surveillance or watchful waiting), the administration of a short course of chemotherapy, or, in the case of seminomas, low-dose radiation therapy directed at the retroperitoneal lymph nodes.
Men with stage II or III testicular cancer may not undergo RPLND at all, or may only have it if there is still cancer present after chemotherapy.
RPLND requires specialized knowledge and training; patients who require this procedure should seek care in a facility where the surgeon is experienced with RPLND. Risks of the procedure depend upon the amount of surgery needed to remove the lymph nodes and whether the patient has undergone chemotherapy; patients are more likely to have complications if they have received chemotherapy.
Radiation therapy — Radiation therapy (RT) refers to the exposure of a tumor to high-energy x-rays in order to slow or stop its growth. Exposure to x-rays damages cells. Unlike normal cells, cancer cells cannot repair the damage caused by exposure to x-rays, particularly when it is administered over several days. This prevents the cancer cells from growing further and causes them to eventually die.
RT for testicular cancer is given as external beam radiation therapy, meaning that the radiation beam is generated by a machine that is outside the patient. The radiation is delivered to the patient, who is usually lying on a table underneath or in front of the machine. The high energy beams are directed at the paraaortic lymph nodes, not the scrotum (show figure 2).
Exposure to the beam typically takes only a few seconds (similar to having an x-ray). In general, treatment is repeated five days per week for approximately five to six weeks. Treatment cannot be given over a shorter period because the higher daily doses would cause too many side effects.
Radiation therapy (RT) is often recommended after orchiectomy for men with seminoma. RT effectively prevents relapse in over 95 percent of patients with clinical stage I seminoma. RT may also be used after orchiectomy for men with non-bulky stage II seminoma. However, there are potential risks of RT, including impaired fertility, second malignancy, or late cardiac disease (see "Radiation therapy side effects" below). For these reasons, RT is usually reserved for older men, men who could not tolerate chemotherapy, and men who are not good candidates for surveillance.
Surveillance — In some cases, men with small stage I testicular cancers do not require additional treatment after orchiectomy. However, these men do need to follow up regularly with a healthcare provider to monitor for signs or symptoms of relapse. This approach is called surveillance.
Surveillance is only appropriate for men who are motivated to participate in their care and willing to have follow up over a period of years. Men who are not able or willing to undergo this active surveillance may require additional treatment with either radiation therapy or chemotherapy (see "Seminoma" below). During surveillance, men are usually seen every few months for a physical examination, blood tests, and imaging studies (eg, CT scan of the abdomen and pelvis, chest x-ray). This schedule is recommended for the first three to four years, and then visits may become less frequent (eg, twice per year for several years, and then once per year until at least 10 years after diagnosis).
Recommendations
Seminoma — In general, seminomas grow slowly and do not spread rapidly to other areas of the body. About 80 percent of men have an early stage of cancer that is only in the testicle, and about 15 percent have cancer that metastasizes to the retroperitoneal lymph nodes.
Surgery (radical inguinal orchiectomy) is recommended for all men with early stage seminoma. Following surgery, three treatment options are possible, all of which have a cure rate of approximately 98 percent. Treatment options include surveillance (watchful waiting), radiation therapy, and chemotherapy. Retroperitoneal lymph node dissection is used in some situations after chemotherapy, but is not usually performed initially (see "Lymph node removal" above). A short course of chemotherapy or radiation therapy is sometimes used to treat patients with stage I seminoma who are not candidates for active surveillance.
Not all treatments are suitable for all patients; a physician will work with the patient to determine the most appropriate option based upon the individual's situation.
Nonseminomatous germ cell tumors — Surgery (radical inguinal orchiectomy) is recommended for all men with NSGCT. NSGCTs are not as sensitive to radiation therapy as seminomas. NSGCTs are also more likely to spread through the bloodstream to other areas of the body, such as the liver, lungs, and brain. Treatment with one or two cycles of adjuvant chemotherapy, usually with cisplatin and another chemotherapy agent, has a lower initial relapse rate than RPLND. Overall cure rates are similar to that seen with either careful surveillance or RPLND. Although enthusiasm for chemotherapy has been tempered by concerns about its long-term efficacy and adverse effects, one or two cycles of adjuvant chemotherapy is a reasonable option and is not as toxic as longer course of chemotherapy.
Men with stage II and III NSGCT are generally treated with combination chemotherapy following orchiectomy. Men who have a mass remaining after chemotherapy may require surgery to remove it. Patients who require this type of surgical treatment are best treated at a cancer center that treats a high volume of testicular cancer patients.
TREATMENT SIDE EFFECTS AND COMPLICATIONS — Side effects and complications related to treatment depend upon the type of treatment used and the severity of the disease.
Fertility issues — Testicular cancer frequently occurs in younger men who have not begun or completed having children. Treatment with surgery, radiation, or chemotherapy can reduce or eliminate sperm production, causing infertility. For reasons that are not well understood, up to 50 percent of men with testicular cancer have a low number of sperm, even before treatment.
For these reasons, men preparing to have treatment for testicular cancer should consider storing their sperm for future use. The storage process is called semen cryopreservation, and involves storing semen at very low temperatures. Cryopreservation requires that a man give several samples of semen. Ideally, a semen sample should be collected in a clinician's office after masturbation; if this is not possible, the man may be allowed to collect a sample at home in a sterile laboratory container or chemical-free condom. (See "Patient information: Evaluation of the infertile couple"). If possible, collection should be started before surgical removal of the testicle and before chemotherapy or radiation therapy; this allows the greatest number and healthiest sperm to be stored.
Even men with very low sperm counts (before cancer treatment) should be encouraged to store their sperm. Intracytoplasmic sperm injection (ICSI) is a type of in vitro fertilization (IVF) that requires a very small number of sperm. Approximately 30 percent of ICSI procedures result in a viable pregnancy and delivery of an infant.
Men who are unable to store sperm before treatment may still be able to father a child after treatment, depending upon the type and amount of treatment used. Advances in infertility treatment allow 30 and 60 percent of all men who undergo testicular cancer treatment to father a child. (See "Patient information: Treatment of infertility in men").
Chemotherapy side effects — There are a number of side effects and complications that can develop as a result of chemotherapy. These can be divided into acute side effects (that occur during and shortly after treatment) and long-term risks.
Short-term side effects — Men who undergo chemotherapy can have side effects such as fatigue, hair loss, and nausea or vomiting. Nausea can be prevented or treated with oral or intravenous medications, and hair regrows after treatment is completed. Low blood cell counts can occur in the first few weeks of chemotherapy, which can increase the risk of infection. This generally does not require that the dose or schedule of treatment be changed.
Long-term complications — Chemotherapy can cause serious problems in a number of organ systems within the body, especially when given in combination and if multiple cycles of chemotherapy are required. The type and severity of these problems depends upon the type and dose of chemotherapy. A few of the most common include: Impaired kidney function Damage to nerves, causing pain in the arms and feet or hearing loss Damage to blood vessels in the heart, potentially increasing the risk of cardiovascular disease. This typically occurs many years after treatment is completed. Lung inflammation and scarring
Another serious long-term risk of testicular cancer treatment is the development of a second cancer. This is not a metastasis of the testicular cancer, but is a new cancer that develops in the blood or blood forming organs (leukemia), lung, colon, pancreas, bladder, stomach, or other organ system.
Retroperitoneal lymph node dissection — The most common side effect of RPLND is decreased or absent semen with ejaculation. Advances in surgical techniques with nerve-sparing retroperitoneal lymph node dissection have reduced the incidence of this problem. For those men who do have decreased or absent ejaculatory volume, infertility treatments are available.
Radiation therapy side effects — During radiation therapy, fatigue is common but usually not debilitating. Gastrointestinal effects, including nausea, vomiting, increased stool frequency, and rapid gastric emptying, have been described, but are not typical. Anti-nausea medications may be used for control of nausea and vomiting. Suppression of the bone marrow can occur (potentially causing anemia), but is usually mild. Mild tanning of the treated skin occurs in the weeks after radiation.
POST-TREATMENT MONITORING — Relapses of testicular germ cell tumors usually occur within two years of the end of treatment, although they can occur later. As a result, all patients who have been successfully treated for testicular cancer should be monitored for cancer recurrence with blood tests, x-rays, computed tomography (CT) scans, and other imaging tests. Monitoring is generally more frequent in the first few years after treatment is completed.
Blood tests such as the beta-hCG and the AFP are used to monitor for early signs of a relapse. In 30 to 50 percent of patients who relapse, increases in serum tumor markers are the first sign of cancer relapse. A patient who relapses may have no changes in their tumor markers, and for this reason, the combination of blood testing, CT, and x-ray is recommended.
Stage I follow up — The optimal schedule for posttreatment surveillance is controversial. Most experts recommend frequent monitoring with blood tests and imaging studies (eg, x-ray, CT scan) every few months for the first few years, decreasing to twice per year for several years then once per year for the man's lifetime.
After RPLND — For men who undergo retroperitoneal lymph node dissection (RPLND) for limited stage disease, most experts recommend blood testing for tumor markers and a chest x-ray every few months initially, decreasing to once per year after several years. CT scan of the abdomen and pelvis may be done less frequently because of the decreased risk of retroperitoneal relapse.
Advanced disease follow up — Follow up of men with advanced disease is similar to that of men with stage 1 disease. Follow up does not begin until after the man has a complete response to chemotherapy. More intensive surveillance may be recommended for men who undergo chemotherapy for advanced disease followed by an RPLND.
PROGNOSIS — Patients with stage I, good prognosis disease have an excellent chance for cure when treated appropriately (see "Staging and prognostic classification" above). Patients who have an intermediate or poor prognosis also generally respond well to treatment, and require a more aggressive treatment regimen. Even for those with a poor prognosis, approximately one-half can be cured.
CLINICAL TRIALS — Progress in treating cancer requires that better treatments be identified through clinical trials, which are conducted all over the world. A clinical trial is a carefully controlled way to study the effectiveness of new treatments or new combinations of known therapies. Ask for more information about clinical trials, or read about clinical trials at:
www.cancer.gov/clinical_trials/learning/
www.cancer.gov/clinical_trials/
http://clinicaltrials.gov/
SUMMARY Testicular cancer occurs when cancer cells develop in one or both of the testicles. Testicles are the male reproductive glands located within the scrotum (show figure 1). The scrotum is a sack of loose skin that hangs below the penis. There are two types of testicular cancer: seminoma and nonseminomatous germ cell tumors (NSGCTs). More than 95 percent of all men diagnosed with testicular cancer can be cured with treatment. Several tests are needed to diagnose testicular cancer. Testing is also needed to determine if cancer has spread to areas outside the testicle. The only way to know for sure if a man has testicular cancer is to remove the testicle. The tests used to diagnose cancer are also used to choose the best treatment. Treatment always requires surgery to remove the testicle that contains cancer. Some men also have lymph nodes (glands) removed at the same time. Some men require treatment with radiation (similar to an x-ray) or chemotherapy (medicine given into a vein) after surgery, depending upon the type of testicular cancer and whether the cancer has spread to other areas. Treatment for testicular cancer often has side effects, including difficulty with sex and infertility (being unable to father a child). Men should discuss these side effects with their doctor before treatment begins. After cancer treatment, men should see their doctor or nurse regularly. These visits are used to monitor for signs that the cancer has returned.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. American Cancer Society
(www.cancer.org)
Lance Armstrong Foundation
(www.laf.org)
National Cancer Institute
(www.cancer.gov)
National Institutes of Health: Clinical Trials
(www.clinicaltrials.gov)
National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
OncoLink
(www.oncolink.com/index.cfm)
Testicular Cancer Resource Center
(http://tcrc.acor.org)
Clinical Trials Links
(www.cancer.gov/clinicaltrials/ or http://clinicaltrials.gov/)
People Living With Cancer: The official patient information
website of the American Society of Clinical Oncology
(www.plwc.org/portal/site/PLWC)
[1-4]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Arai, Y, Kawakita, M, Okada, Y, Yoshida, O. Sexuality and fertility in long-term survivors of testicular cancer. J Clin Oncol 1997; 15:1444.
2. National Cancer Institute. Testicular Cancer (PDQ®): Treatment: Patient Version. December 21, 2004. Available online at www.nci.nih.gov/cancertopics/pdq/treatment/testicular/patient. (Accessed 4/23/07).
3. Amato, RJ, Ro, JY, et al. Risk-adapted treatment for patients with clinical stage I nonseminomatous germ cell tumor of the testis. Urology 2004; 63:144.
4. Kondagunta, GV, Bacik, J, Bajorin, D, et al. Etoposide and Cisplatin chemotherapy for metastatic good-risk germ cell tumors. J Clin Oncol 2005; 23:9290.
5. American Cancer Society. Testicular cancer. Available online at http://www.cancer.org/docroot/CRI/content/CRI_2_4_7x_CRC_Testicular_Cancer_PDF.asp (Accessed 4/23/07).
Testicular cancer is the most common cancer arising in young men. Fortunately, it has become one of the most curable of all cancers, largely due to advances in medical treatment. More than 95 percent of all men diagnosed with testicular cancer survive their disease.
TYPES OF TESTICULAR CANCER — Approximately 95 percent of testicular cancers develop from a type of cell in the testicle called a germ cell. Thus, they are called testicular germ cell tumors.
Seminoma vs Nonseminomatous germ cell tumor (NSGCT) — There are two major types of testicular germ cell tumors: seminoma and nonseminomatous germ cell tumors (NSGCTs). Approximately one-third of all testicular germ cell tumors are seminomas; the remainder are NSGCGTs. Both seminoma and NSGCT primarily affect men between the ages of 15 and 35 years of age, although seminomas occur in a slightly older group of men (show table 1).
SYMPTOMS — For most men, the first symptom of testicular cancer is a painless lump or swelling in the scrotum. Some men may also experience a dull ache or heavy sensation in the lower abdomen, area around the anus, or scrotum. Pain is the first symptom in about 10 percent of men.
DIAGNOSIS — Men who detect a lump in their testicle should see a healthcare provider as soon as possible. The provider will perform a general examination, with special attention to the breasts (which can become enlarged in some men with testicular cancer), the abdomen (to evaluate the lymph nodes and abdominal organs) and the scrotum. Both testicles will be examined and compared. (See "Clinical manifestations, diagnosis, and staging of testicular germ cell tumors").
If testicular cancer is suspected, several tests may be ordered to support the diagnosis. However, the only way to be certain that the diagnosis is testicular cancer is to remove the testicle. Testicular ultrasound — Testicular ultrasound uses sound waves to measure the size and characteristics of the testicle and mass (lump), and can determine whether the mass is inside or outside of the testicle and whether it contains fluid or is a solid mass. Testicular cancers are solid and develop inside the testicle. Often, the ultrasound will strongly suggest the diagnosis of testicular cancer. Orchiectomy — The only way to confirm the diagnosis of testicular cancer is by surgically removing the testicle. This procedure is called a radical inguinal orchiectomy (see "Radical inguinal orchiectomy" below).
STAGING AND PROGNOSTIC CLASSIFICATION — Staging is used to determine if there is spread (metastasis) of the cancer beyond the testicle. Stage I testicular cancer is defined as cancer that is limited to the testis only. Stage II testicular cancer has spread (metastasized) to the retroperitoneal lymph nodes (located in the abdomen). Stage III testicular cancer has spread to other organs (show table 2 and show table 3).
Blood tests and imaging (eg, CT scan) are used in the process of staging.
Blood tests — Substances produced by a testicular cancer (called tumor markers) can be measured in the blood. The three most important markers are: Alpha fetoprotein (AFP) Beta human chorionic gonadotropin (beta-hCG) Lactate dehydrogenase (LDH)
High levels of these tumor markers are suggestive of testicular cancer, and can help determine the specific type of testicular cancer that is present. These markers are also used during and after treatment to monitor a patient's response.
CT scans — Most men with a suspected testicular cancer will undergo a CT scan (sometimes called a CAT scan) of the abdomen and pelvis. A chest x-ray or CT scan of the chest is also commonly done.
These tests are done to determine if the suspected cancer has spread beyond the testicle (metastasized). The most common site of metastasis in testicular cancer is the lymph nodes in the abdomen; metastasis to the lung, liver, bones, and brain is also possible.
Prognostic classification — Men with stage II or III testicular cancer (both seminomas and NSGCTs) can be classified as having a good, intermediate, or poor prognosis (chance of survival and recovery) based upon the stage of disease and particular type of testicular tumor. Men with stage I testicular cancer have an excellent prognosis, and are not included in this classification system.
Following radical inguinal orchiectomy, a physician treats testicular cancer according to the type of tumor (seminoma or nonseminomatous germ cell tumor), the stage of the disease, and the patient's prognosis.
All men with seminoma are classified as having a good or intermediate prognosis. Men with NSGCT may have a good, intermediate, or poor prognosis, depending upon the stage of their disease. Good prognosis — Men with seminoma have a good prognosis if the tumor has not metastasized to organs other than the lungs and if they have a normal AFP serum level.
Patients with NSGCTs have a good prognosis if the tumor is located only in the testicle or area outside or behind the abdominal wall, if the tumor has not metastasized to organs other than the lungs, and if their serum tumor markers are only slightly elevated. Intermediate prognosis — Patients with seminoma have an intermediate prognosis if the tumor has metastasized to organs other than the lungs and their AFP test is normal.
Patients with NSGCTs have an intermediate prognosis if the tumor is found in only one testicle or in the area outside or behind the abdominal wall, if the tumor has not spread to organs other than the lungs, and if serum tumor markers are not significantly elevated. Poor prognosis — Men with NSGCTs are classified as having a poor prognosis if the tumor develops in the center of the chest between the lungs (called the mediastinum), if it has spread to organs other than the lungs, or if any of the serum tumor markers are significantly elevated.
Even for patients with a poor prognosis, approximately one-half are cured with aggressive treatment.
TREATMENT — Treatment of both seminoma and NSGCT generally includes surgery to remove the affected testicle; this surgery is called radical inguinal orchiectomy (see "Radical inguinal orchiectomy" below). The need for further treatment is determined by the type of cancer, the stage of the cancer, and the prognosis. Advances in chemotherapy and radiation therapy, often used in combination with surgery, have improved the outcome for patients with testicular cancer, and approximately 95 percent of patients can be cured.
Radical inguinal orchiectomy — Radical inguinal orchiectomy is not only required for diagnosis, but is also the initial step in treatment for most patients.
Orchiectomy is usually done in an operating room after the patient receives general or epidural anesthesia. A small incision (cut) is made in the groin and the testicle is removed. The standard treatment is to remove the entire affected testicle to avoid the risk of spreading the tumor within the scrotum. Tissue from the testicle is then examined using a microscope.
Chemotherapy
What is chemotherapy? — Chemotherapy refers to the use of medicines to stop or slow the growth of cancer cells. Chemotherapy works by interfering with the ability of rapidly growing cells (like cancer cells) to divide or multiply. Because most of an adult's normal cells are not actively dividing or multiplying, they are not affected by chemotherapy. However, the bone marrow (where the blood cells are produced), the hair follicles, and the lining of the gastrointestinal (GI) tract are all growing. The side effects of chemotherapy drugs are related to effects on these and other normal tissues (see "Chemotherapy side effects" below).
Most drugs are given intravenously (IV) rather than by mouth. They are not usually taken daily, but periodically, in cycles. A cycle of chemotherapy refers to the time it takes to give the drugs and the time required for the body to recover. For example, a typical chemotherapy regimen could include a one hour IV infusion of two different chemotherapy medications given once every three weeks. This three week period is one cycle of therapy. If this regimen were repeated for a total of three months, four cycles of chemotherapy would be administered.
Adjuvant chemotherapy — The term adjuvant therapy refers to additional anticancer treatment that is given after surgery to eliminate any remaining tumor cells in the body (often termed micrometastases). Adjuvant therapy significantly decreases the chance that the cancer will return (or recur), and also improves the likelihood of surviving cancer. As a result, adjuvant therapy has become an important component of treatment. Modern adjuvant chemotherapy typically involves a combination of two or more drugs; these combinations are referred to as regimens.
Chemotherapy for testicular cancer — Chemotherapy is sometimes used as an adjuvant treatment for men with early stage testicular cancer, as well as for men with more advanced disease. Patients with more advanced stages of cancer and those who have a disease relapse after radiation therapy usually undergo multiple cycles of combination chemotherapy. A cycle of chemotherapy refers to the time it takes to give the drugs and the time required for the body to recover. Combination chemotherapy involves giving more than one drug, which improves the chance of a cure and reduces the chance that the tumor will develop resistance to one chemotherapy drug.
Lymph node removal — The most common sites of spread for testicular cancer are the lymph nodes in the back of the abdomen, called the retroperitoneal lymph nodes. Surgical removal (called retroperitoneal lymph node dissection or RPLND) of these nodes may be needed in the following situations: If the CT scan of the abdomen shows enlarged nodes, raising suspicion that the cancer has spread to this area. For men who have no evidence of enlargement of the retroperitoneal lymph nodes, RPLND may still be performed because a CT cannot determine lymph node involvement in as many as one-third of cases.
There are alternatives to RPLND, including periodic physical examination and CT scans (called surveillance or watchful waiting), the administration of a short course of chemotherapy, or, in the case of seminomas, low-dose radiation therapy directed at the retroperitoneal lymph nodes.
Men with stage II or III testicular cancer may not undergo RPLND at all, or may only have it if there is still cancer present after chemotherapy.
RPLND requires specialized knowledge and training; patients who require this procedure should seek care in a facility where the surgeon is experienced with RPLND. Risks of the procedure depend upon the amount of surgery needed to remove the lymph nodes and whether the patient has undergone chemotherapy; patients are more likely to have complications if they have received chemotherapy.
Radiation therapy — Radiation therapy (RT) refers to the exposure of a tumor to high-energy x-rays in order to slow or stop its growth. Exposure to x-rays damages cells. Unlike normal cells, cancer cells cannot repair the damage caused by exposure to x-rays, particularly when it is administered over several days. This prevents the cancer cells from growing further and causes them to eventually die.
RT for testicular cancer is given as external beam radiation therapy, meaning that the radiation beam is generated by a machine that is outside the patient. The radiation is delivered to the patient, who is usually lying on a table underneath or in front of the machine. The high energy beams are directed at the paraaortic lymph nodes, not the scrotum (show figure 2).
Exposure to the beam typically takes only a few seconds (similar to having an x-ray). In general, treatment is repeated five days per week for approximately five to six weeks. Treatment cannot be given over a shorter period because the higher daily doses would cause too many side effects.
Radiation therapy (RT) is often recommended after orchiectomy for men with seminoma. RT effectively prevents relapse in over 95 percent of patients with clinical stage I seminoma. RT may also be used after orchiectomy for men with non-bulky stage II seminoma. However, there are potential risks of RT, including impaired fertility, second malignancy, or late cardiac disease (see "Radiation therapy side effects" below). For these reasons, RT is usually reserved for older men, men who could not tolerate chemotherapy, and men who are not good candidates for surveillance.
Surveillance — In some cases, men with small stage I testicular cancers do not require additional treatment after orchiectomy. However, these men do need to follow up regularly with a healthcare provider to monitor for signs or symptoms of relapse. This approach is called surveillance.
Surveillance is only appropriate for men who are motivated to participate in their care and willing to have follow up over a period of years. Men who are not able or willing to undergo this active surveillance may require additional treatment with either radiation therapy or chemotherapy (see "Seminoma" below). During surveillance, men are usually seen every few months for a physical examination, blood tests, and imaging studies (eg, CT scan of the abdomen and pelvis, chest x-ray). This schedule is recommended for the first three to four years, and then visits may become less frequent (eg, twice per year for several years, and then once per year until at least 10 years after diagnosis).
Recommendations
Seminoma — In general, seminomas grow slowly and do not spread rapidly to other areas of the body. About 80 percent of men have an early stage of cancer that is only in the testicle, and about 15 percent have cancer that metastasizes to the retroperitoneal lymph nodes.
Surgery (radical inguinal orchiectomy) is recommended for all men with early stage seminoma. Following surgery, three treatment options are possible, all of which have a cure rate of approximately 98 percent. Treatment options include surveillance (watchful waiting), radiation therapy, and chemotherapy. Retroperitoneal lymph node dissection is used in some situations after chemotherapy, but is not usually performed initially (see "Lymph node removal" above). A short course of chemotherapy or radiation therapy is sometimes used to treat patients with stage I seminoma who are not candidates for active surveillance.
Not all treatments are suitable for all patients; a physician will work with the patient to determine the most appropriate option based upon the individual's situation.
Nonseminomatous germ cell tumors — Surgery (radical inguinal orchiectomy) is recommended for all men with NSGCT. NSGCTs are not as sensitive to radiation therapy as seminomas. NSGCTs are also more likely to spread through the bloodstream to other areas of the body, such as the liver, lungs, and brain. Treatment with one or two cycles of adjuvant chemotherapy, usually with cisplatin and another chemotherapy agent, has a lower initial relapse rate than RPLND. Overall cure rates are similar to that seen with either careful surveillance or RPLND. Although enthusiasm for chemotherapy has been tempered by concerns about its long-term efficacy and adverse effects, one or two cycles of adjuvant chemotherapy is a reasonable option and is not as toxic as longer course of chemotherapy.
Men with stage II and III NSGCT are generally treated with combination chemotherapy following orchiectomy. Men who have a mass remaining after chemotherapy may require surgery to remove it. Patients who require this type of surgical treatment are best treated at a cancer center that treats a high volume of testicular cancer patients.
TREATMENT SIDE EFFECTS AND COMPLICATIONS — Side effects and complications related to treatment depend upon the type of treatment used and the severity of the disease.
Fertility issues — Testicular cancer frequently occurs in younger men who have not begun or completed having children. Treatment with surgery, radiation, or chemotherapy can reduce or eliminate sperm production, causing infertility. For reasons that are not well understood, up to 50 percent of men with testicular cancer have a low number of sperm, even before treatment.
For these reasons, men preparing to have treatment for testicular cancer should consider storing their sperm for future use. The storage process is called semen cryopreservation, and involves storing semen at very low temperatures. Cryopreservation requires that a man give several samples of semen. Ideally, a semen sample should be collected in a clinician's office after masturbation; if this is not possible, the man may be allowed to collect a sample at home in a sterile laboratory container or chemical-free condom. (See "Patient information: Evaluation of the infertile couple"). If possible, collection should be started before surgical removal of the testicle and before chemotherapy or radiation therapy; this allows the greatest number and healthiest sperm to be stored.
Even men with very low sperm counts (before cancer treatment) should be encouraged to store their sperm. Intracytoplasmic sperm injection (ICSI) is a type of in vitro fertilization (IVF) that requires a very small number of sperm. Approximately 30 percent of ICSI procedures result in a viable pregnancy and delivery of an infant.
Men who are unable to store sperm before treatment may still be able to father a child after treatment, depending upon the type and amount of treatment used. Advances in infertility treatment allow 30 and 60 percent of all men who undergo testicular cancer treatment to father a child. (See "Patient information: Treatment of infertility in men").
Chemotherapy side effects — There are a number of side effects and complications that can develop as a result of chemotherapy. These can be divided into acute side effects (that occur during and shortly after treatment) and long-term risks.
Short-term side effects — Men who undergo chemotherapy can have side effects such as fatigue, hair loss, and nausea or vomiting. Nausea can be prevented or treated with oral or intravenous medications, and hair regrows after treatment is completed. Low blood cell counts can occur in the first few weeks of chemotherapy, which can increase the risk of infection. This generally does not require that the dose or schedule of treatment be changed.
Long-term complications — Chemotherapy can cause serious problems in a number of organ systems within the body, especially when given in combination and if multiple cycles of chemotherapy are required. The type and severity of these problems depends upon the type and dose of chemotherapy. A few of the most common include: Impaired kidney function Damage to nerves, causing pain in the arms and feet or hearing loss Damage to blood vessels in the heart, potentially increasing the risk of cardiovascular disease. This typically occurs many years after treatment is completed. Lung inflammation and scarring
Another serious long-term risk of testicular cancer treatment is the development of a second cancer. This is not a metastasis of the testicular cancer, but is a new cancer that develops in the blood or blood forming organs (leukemia), lung, colon, pancreas, bladder, stomach, or other organ system.
Retroperitoneal lymph node dissection — The most common side effect of RPLND is decreased or absent semen with ejaculation. Advances in surgical techniques with nerve-sparing retroperitoneal lymph node dissection have reduced the incidence of this problem. For those men who do have decreased or absent ejaculatory volume, infertility treatments are available.
Radiation therapy side effects — During radiation therapy, fatigue is common but usually not debilitating. Gastrointestinal effects, including nausea, vomiting, increased stool frequency, and rapid gastric emptying, have been described, but are not typical. Anti-nausea medications may be used for control of nausea and vomiting. Suppression of the bone marrow can occur (potentially causing anemia), but is usually mild. Mild tanning of the treated skin occurs in the weeks after radiation.
POST-TREATMENT MONITORING — Relapses of testicular germ cell tumors usually occur within two years of the end of treatment, although they can occur later. As a result, all patients who have been successfully treated for testicular cancer should be monitored for cancer recurrence with blood tests, x-rays, computed tomography (CT) scans, and other imaging tests. Monitoring is generally more frequent in the first few years after treatment is completed.
Blood tests such as the beta-hCG and the AFP are used to monitor for early signs of a relapse. In 30 to 50 percent of patients who relapse, increases in serum tumor markers are the first sign of cancer relapse. A patient who relapses may have no changes in their tumor markers, and for this reason, the combination of blood testing, CT, and x-ray is recommended.
Stage I follow up — The optimal schedule for posttreatment surveillance is controversial. Most experts recommend frequent monitoring with blood tests and imaging studies (eg, x-ray, CT scan) every few months for the first few years, decreasing to twice per year for several years then once per year for the man's lifetime.
After RPLND — For men who undergo retroperitoneal lymph node dissection (RPLND) for limited stage disease, most experts recommend blood testing for tumor markers and a chest x-ray every few months initially, decreasing to once per year after several years. CT scan of the abdomen and pelvis may be done less frequently because of the decreased risk of retroperitoneal relapse.
Advanced disease follow up — Follow up of men with advanced disease is similar to that of men with stage 1 disease. Follow up does not begin until after the man has a complete response to chemotherapy. More intensive surveillance may be recommended for men who undergo chemotherapy for advanced disease followed by an RPLND.
PROGNOSIS — Patients with stage I, good prognosis disease have an excellent chance for cure when treated appropriately (see "Staging and prognostic classification" above). Patients who have an intermediate or poor prognosis also generally respond well to treatment, and require a more aggressive treatment regimen. Even for those with a poor prognosis, approximately one-half can be cured.
CLINICAL TRIALS — Progress in treating cancer requires that better treatments be identified through clinical trials, which are conducted all over the world. A clinical trial is a carefully controlled way to study the effectiveness of new treatments or new combinations of known therapies. Ask for more information about clinical trials, or read about clinical trials at:
www.cancer.gov/clinical_trials/learning/
www.cancer.gov/clinical_trials/
http://clinicaltrials.gov/
SUMMARY Testicular cancer occurs when cancer cells develop in one or both of the testicles. Testicles are the male reproductive glands located within the scrotum (show figure 1). The scrotum is a sack of loose skin that hangs below the penis. There are two types of testicular cancer: seminoma and nonseminomatous germ cell tumors (NSGCTs). More than 95 percent of all men diagnosed with testicular cancer can be cured with treatment. Several tests are needed to diagnose testicular cancer. Testing is also needed to determine if cancer has spread to areas outside the testicle. The only way to know for sure if a man has testicular cancer is to remove the testicle. The tests used to diagnose cancer are also used to choose the best treatment. Treatment always requires surgery to remove the testicle that contains cancer. Some men also have lymph nodes (glands) removed at the same time. Some men require treatment with radiation (similar to an x-ray) or chemotherapy (medicine given into a vein) after surgery, depending upon the type of testicular cancer and whether the cancer has spread to other areas. Treatment for testicular cancer often has side effects, including difficulty with sex and infertility (being unable to father a child). Men should discuss these side effects with their doctor before treatment begins. After cancer treatment, men should see their doctor or nurse regularly. These visits are used to monitor for signs that the cancer has returned.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. American Cancer Society
(www.cancer.org)
Lance Armstrong Foundation
(www.laf.org)
National Cancer Institute
(www.cancer.gov)
National Institutes of Health: Clinical Trials
(www.clinicaltrials.gov)
National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
OncoLink
(www.oncolink.com/index.cfm)
Testicular Cancer Resource Center
(http://tcrc.acor.org)
Clinical Trials Links
(www.cancer.gov/clinicaltrials/ or http://clinicaltrials.gov/)
People Living With Cancer: The official patient information
website of the American Society of Clinical Oncology
(www.plwc.org/portal/site/PLWC)
[1-4]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Arai, Y, Kawakita, M, Okada, Y, Yoshida, O. Sexuality and fertility in long-term survivors of testicular cancer. J Clin Oncol 1997; 15:1444.
2. National Cancer Institute. Testicular Cancer (PDQ®): Treatment: Patient Version. December 21, 2004. Available online at www.nci.nih.gov/cancertopics/pdq/treatment/testicular/patient. (Accessed 4/23/07).
3. Amato, RJ, Ro, JY, et al. Risk-adapted treatment for patients with clinical stage I nonseminomatous germ cell tumor of the testis. Urology 2004; 63:144.
4. Kondagunta, GV, Bacik, J, Bajorin, D, et al. Etoposide and Cisplatin chemotherapy for metastatic good-risk germ cell tumors. J Clin Oncol 2005; 23:9290.
5. American Cancer Society. Testicular cancer. Available online at http://www.cancer.org/docroot/CRI/content/CRI_2_4_7x_CRC_Testicular_Cancer_PDF.asp (Accessed 4/23/07).
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