Modern Male Condoms: Not Your Father's "Rubbers"
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Continuing Medical Education
Modern Male Condoms:
Not Your Father’s “Rubbers”
Anita L. Nelson, MD; Monica Hau Hien Le, MD
With sexy advertising and CONTINUING MEDICAL EDUCATION
eye-catching packaging, GOAL
condoms are dusting off their To promote condom use in women by updating information about effi-
cacy and design.
image for a younger generation.
OBJECTIVES
Manufacturers have responded
1. To emphasize the efficacy of condoms in protecting women against
to consumer complaints and pregnancy and sexually transmitted infections.
2. To explore the reasons why patients do not use condoms consistently.
needs with more variety and 3. To highlight changes in condom manufacture and design that address
many consumer complaints and needs.
features. Now, it is time for
ACCREDITATION
physicians to point out the
This activity has been planned and implemented in accordance with the
many benefits of condom use Essential Areas and Policies of the Accreditation Council for Continuing
Medical Education (ACCME) through the joint sponsorship of Albert Ein-
to patients as the fashionable stein College of Medicine and Quadrant HealthCom Inc. Albert Einstein
College of Medicine is accredited by the ACCME to provide continuing
choice for intimate protection. medical education for physicians.
This activity has been peer reviewed and approved by Brian Cohen, MD,
professor of clinical OB/GYN, Albert Einstein College of Medicine. Review
date: April 2007. It is designed for OB/GYNs, primary care physicians, and
M
ale condoms are the most pop- nurse practitioners.
ular method of male contra- Albert Einstein College of Medicine designates this educational activity
ception in the United States, for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should
with more than 450 million only claim credit commensurate with the extent of their participation in
the activity.
sold annually.1 Although they Participants who answer 70% or more of the questions correctly will
are unique in reducing the risks of both preg- obtain credit. To earn credit, see the instructions on page 65 and mail your
nancy and sexually transmitted infections answers according to the instructions on page 66.
(STIs), utilization of condoms is notoriously
CONFLICT OF INTEREST STATEMENT
inconsistent. This may be due to the mixed
messages patients are given about the efficacy The “Conflict of Interest Disclosure Policy” of Albert Einstein College of
Medicine requires that authors participating in any CME activity disclose
and safety of condoms, and also to the con- to the audience any relationship(s) with a pharmaceutical or equipment
doms’ intrinsic lack of appeal in the past. As company. Any author whose disclosed relationships prove to create a
this article will show, many such concerns are conflict of interest, with regard to their contribution to the activity, will
no longer valid. not be permitted to present.
The Albert Einstein College of Medicine also requires that faculty partici-
Condom use significantly reduces hetero- pating in any CME activity disclose to the audience when discussing any
sexual transmission of human immunode- unlabeled or investigational use of any commercial product, or device,
ficiency virus (HIV) by at least 85%, and not yet approved for use in the United States.
Dr Nelson reports that she is on the Advisory Board of Church &
Anita L. Nelson, MD, is professor; and Monica Hau Hien Dwight Co, Inc. Dr Hau Hien Le reports no conflict of interest. Dr Cohen
Le, MD, is Women’s Health fellow. Both are in the Depart- reports no conflict of interest.
ment of Obstetrics and Gynecology, Harbor-University of
California at Los Angeles Medical Center, Torrence.
The Female Patient VOL. 32 MAY 2007 59CME
Modern Male Condoms
decreases the rate of cervical cancer asso-
Clinical Pearls: Overcoming Patient ciated with human papillomavirus (HPV).
Resistance to Using Condoms However, there is not sufficient evidence to
support or refute claims of risk reductions for
“I don’t use condoms because...” other STIs.2 Nonetheless, there is a clear asso-
ciation between condom use and statistically
• “They don't work that well.” significant protection for men and women
Correct and consistent condom use confers against chlamydia, herpes simplex virus type 2
pregnancy rates of only 2%. (HSV-2), and syphilis. Condoms may be asso-
ciated with protection against trichomoniasis
• “I only have to use them when I‘m ovulating.” in women as well.3
Almost 80% of women significantly misjudge Until recently, the prevailing perception
the phases of their cycles. was that condoms could reduce the risk
of STI transmission by fluids but were less
• “They make me break out.” effective against infections spread by skin-
The patient may have a latex allergy and could to-skin contact. Therefore, it was somewhat
benefit from using polyurethane condoms. surprising to discover that condom use sig-
nificantly reduced HSV-2 transmission,4 and
• “They‘re too much trouble.” that correct, consistent use lowered the risk
Condoms can be incorporated into foreplay. of HPV acquisition by 70% and cervical
dysplasia by 100%. 5 Thus, condom usage
• ”It hurts to use them.” should be strongly encouraged to reduce the
Some condoms come with lubrication, and the spread of STIs.
patient can also use a water-based lubricant. Maximizing these benefits depends on
consistent condom use. Pregnancy rates for
• “It’s embarrassing/inconvenient to buy them.” typical use (15%) are significantly differ-
A wide variety of condoms can be compared ent compared with those for consistent use
and purchased on the Internet. (2%).6 In a clinical setting where patients
had unlimited access to free condoms, it was
• “I’m shy about bringing up the subject.” reported that only 56.2% of the women used
Condom choice and use can actually bring a condoms with every act of intercourse in the
couple closer together. 2 weeks prior to the survey.7 Often, couples
use condoms only during days of the cycle
• “My partner will think I don‘t trust him.” they deem to be “at risk.” However, only
The patient can remind her partner that con- 23% of women diagnosed by hormonal tests
doms protect the both of them. as periovulatory could correctly identify
their cycle phase. Most periovulatory women
• “My partner says it doesn‘t feel as good
thought they were in the luteal phase and not
with them.”
at risk.8 Even in the context of a clinical trial
Many condoms are designed to increase sexual where couples agreed to use condoms with
pleasure for both partners. every act of intercourse and log such use,
more than 33% of cycles had at least one
• “My partner complains they never fit right.”
episode of unprotected intercourse.9
Condoms now come in different sizes, so that Patients who do not use condoms report that
everyone can find the right fit. lack of access is a barrier to consistent utiliza-
• “We can’t be spontaneous, and it ruins the mood.” tion. However, even in settings with ready
access, women still complain that they do not
Condom use can enhance the sexual experi- like to use them.7 Men report that condoms
ence, promoting foreplay, encouraging sex play, reduce sensation, decrease spontaneity, inter-
and increasing intimacy.
fere with erection, imply a lack of trust, and
make intercourse uncomfortable.10,11 Recogniz-
ing these problems, there have been many new
60 The Female Patient VOL. 32 MAY 2007Nelson and Le
developments in condom manufacturing and
marketing. Condom features and testing results
are now reported periodically by consumer
organizations.12 Lists of available condoms
are available online (see “Online Condom
Information”). Clinicians should familiarize
themselves with these new products to generate
more enthusiasm for condom use.
MANUFACTURING INNOVATIONS
New Materials
In the 1940s, condoms were so tough and
blunted sensation so markedly that they were
actually useful in helping men who experi-
enced premature ejaculation. However, other
users complained that the experience was like
“trying to make love through a raincoat.” In clinical trials, the polyurethane con-
Modern latex condoms are thinner, enhancing dom provided pregnancy protection equal
sensation for both partners. to that of latex condoms, but had breakage
and spillage rates that were significantly
Polyurethane higher.14,15 Polyurethane condoms are odor-
Polyurethane condoms fill critical needs for less, transmit body heat, are smoother, have
some users. Up to 4% of the general US popu- a long shelf life, and are pre-
lation has a latex allergy.13 Women with latex ferred for those with latex
allergies may attribute postcoital irritation and allergies and women using
pruritus to candidiasis and may self-treat with
over-the-counter (OTC) antifungal agents.
This treatment does relieve symptoms, “buy-
ing time” for the contact dermatitis to resolve.
petroleum-based vaginal
creams. However, the higher
cost and the higher break-
age/slippage rates for poly-
I n clinical trials,
the polyurethane
More significantly, however, both clinicians urethane condoms preclude condom provided
who prescribe antifungals and women who routine recommendation as
self-medicate should be aware that all antifun- first-line barrier contracep-
pregnancy
gal therapies, all vaginal antibiotic therapies tion. Other materials are also protection equal
(except metronidazole gel), and all vaginal under investigation for use in to that of latex
estrogen creams are petroleum-based. Use condoms, such as those used
of these petroleum-based medications causes in surgical gloves.
condoms, but
rapid deterioration in the integrity of latex had breakage
condoms. Although there may be no visible New Condom Sizes and spillage
rupture of the latex, just 30 to 60 seconds of Surveys discovered that
exposure to these products can induce micro- more than 5% of US men
rates that were
scopic tears in the latex that are large enough to fi nd standard latex con- significantly
permit passage of pathogens, and larger tears doms constricting. There- higher.
may permit the passage of sperm. Whenever fore, new designs have been
clinicians prescribe these agents, they must introduced to provide extra
counsel condom users to switch to polyure- “headroom” and relax pres-
thane condoms during treatment and for 3 to sure on the glans, or with more room from
7 days after the last application. Women who the base through the tip. For more modestly
self-medicate with OTC antifungals or petro- endowed, mature men and younger men who
leum-based homeopathic compounds should may not have attained all their secondary
likewise use polyurethane condoms with every sexual changes,16 new condoms with a snug-
act of coitus. ger fit are particularly appropriate.
The Female Patient VOL. 32 MAY 2007 61CME
Modern Male Condoms
TABLE. Hypothetical Relative Risk Model of Condom Use2
Event Semen Exposure Relative Risk
(Volume Averaged Over (Compared With Nonuse)
Event Probability)
Failure to use a condom 3.3 mL 1
Condom used, but it breaks 1 mL × 2/100 0.006
Condom used, but it has 10-2 mL × 1/400 0.000008
visibly detectable hole Table not available online
(by water leak test)
Condom used with no 6 × 10-6mL × 0.023 0.00000004
breaks/holes, but it still
passes virus
Condom used with no 0.0 mL 0
breaks or leaks
Spermicidal Coating are intended not only to eliminate vaginal
Studies have shown that the spermicidal coat- dryness and end-of-day buildup of secre-
ing on a condom does not provide additional tions, but also to provide a pleasant experi-
protection from pregnancy or STIs. In addi- ence during foreplay. A small vibrator that
tion, the spermicide-coated condoms have a fits on the rim of the condom has been intro-
much shorter shelf life. Some duced to provide stimulation during use. In
nonoxynol-9 (N-9) studies the same spirit, other condoms have been
To facilitate use
showed that frequent or daily
of N-9 might increase
the risk of genital ulceration
proper and/or HIV infection.17 As
designed to glow in the dark or have been
coated with a warming lubricant.
Special needs have also been addressed
by different condoms. To facilitate proper
application, there a result, some manufactur- application, there are condoms that can
are condoms ers have discontinued pro-
duction of spermicide-coated
only be applied in the correct fashion. For
men who experience early ejaculation, there
that can only be condoms, and women who are condoms with benzocaine at the tip to
applied in the relied on this spermicide help chemically blunt sensation and main-
correct fashion. to provide coital lubrica-
tion should be advised to use
tain erection.
other products. NEW MARKETING APPROACHES
Other Special Features At least 30% of male condoms are pur-
To transform the image of condoms from chased by women. Women may feel com-
something that couples “should” use into fortable browsing through various types of
something that they “want” to use, sev- condoms online, but are not as comfortable
eral new features have been added. Some with the traditional condom display in the
condoms are available now with a variety pharmacy. As a result, some brands of male
of flavors and scents to fit more tastefully condoms are now sold to women in “their”
into foreplay activities. Other condoms are section of the store⎯ie, near the feminine
available with ridges and ribs to enhance hygiene products. Many of these condoms
sensation. Condoms are being packaged or are being directly marketed to women, with
sold with other precoital stimulants such as images promoting beauty and sophistication
refreshing wipes or warming lubricants that on the packages.
62 The Female Patient VOL. 32 MAY 2007Nelson and Le
condoms may infrequently slip or break. To
Online Condom Information protect against unwanted pregnancy in such
occurrences, women who rely on condoms
American Social Health Association for contraception should be given emergency
(http://www.ashastd.org) contraception (EC) by advance prescription.
AVERT Those who decline such prescriptions should
(http://www.avert.org) be advised about the behind-the-counter
availability of levonorgestrel
Condomania EC products for all men and
(http://www.condomania.com) women aged 18 years or
CondomDepot
(http://www.condomdepot.com)
older. Emergency contracep-
tion is most effective if used
within 12 hours of exposure,
C
linicians
should remain
but has some clinical value if
At the other end of the marketing spectrum, started within 120 hours of vigilant and
some brands are being advertised to men with the accident. 20
counter the more
strong androgen appeal⎯eg, “the condom that subtle barriers
has captured a whopping 60% market share CONCLUSION
in Japan.” The names of many brands are also to use, such
clearly aimed at creating positive male images Male condoms have greatly as medically
for the user. improved in recent years. incorrect
Their quality and reliability
CONDOM ACCESS AND are quite good.12 Undeniable or biased
PATIENT EDUCATION evidence confi rms their effi- information about
cacy in reducing STI trans- condom safety
Barely 100 years ago, condoms were available mission. The need to develop
only “behind the counter” (by asking the phar- products that couples will and efficacy.
macist), and in some areas interstate transport use correctly and consis-
of condoms for birth control was illegal. Today, tently has been recognized
the easy access to condoms in vending machines, by the industry, and many new designs have
on the shelves of pharmacies and grocery stores, been introduced to meet more individual
and on the Internet is particularly gratifying. needs. Clinicians should encourage condom
Clinicians should remain vigilant and counter usage to maximize the contraceptive and STI
the more subtle barriers to use, such as medi- risk-reduction benefits for all sexually active
cally incorrect or biased information about people. Up-to-date information about con-
condom safety and efficacy.18 They need to pro- dom efficacy and specific education about
vide patient education about correct placement, correct use should be shared with patients
use, and disposal of condoms⎯preferably in who are not yet sexually active to help them
advance of use (Table). Bad advice (eg, recom- responsibly protect themselves and their
mending the use of lubricant beneath the con- partners when they initiate sexual activity.
dom to enhance sensation) should be replaced
with better information about current designs REFERENCES
that offer sensation without increasing the risk 1. Warner L, Hatcher RA, Steiner MK. Male con-
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using two condoms to enhance sensation and al, eds. Contraceptive Technology. 18th ed. New
York, NY: Ardent Media; 2004:331.
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to patients.19 eases. Workshop Summary: Scientific Evidence
on Condom Effectiveness for Sexually Trans-
ACCESSORY MEDICATION mitted Disease (STD) Prevention, 12-13 June
2000. Herndon, Va: National Institutes of Health,
Department of Health and Human Services; 2001.
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that even with correct and consistent use, condomreport.pdf. Accessed April 2, 2007.
The Female Patient VOL. 32 MAY 2007 63CME
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