S2k-Guideline Non-hormonal Contraception, Part 1: Natural Family Planning, Lactational Amenorrhea, Barrier Methods, Coitus Interruptus

Abstract

Aim This official guideline was published and coordinated by the DGGG, OEGGG and SGGG with the involvement of other medical societies. The aim was to provide a consensus-based overview of non-hormonal forms of contraception based on an evaluation of the relevant literature. The first part of these summarized statements and recommendations presents natural family planning methods such as lactational amenorrhea, barrier methods and coitus interruptus. The second part will focus on intrauterine devices and sterilization methods.

Methods This S2k-guideline was developed by representative members from different medical professions on behalf of the guidelines commission of the DGGG, OEGGG and SGGG using a structured consensus process.

Recommendations The guideline provides recommendations on the indications for, safety of use, benefits, and limitations of the different methods as well as recommendations on providing advice and other aspects of non-hormonal contraception. Natural family planning methods, lactational amenorrhea, barrier methods and coitus interruptus are discussed.

Keywords

guideline - side effects - alternative contraception - effectiveness - pregnancy - Pearl Index

I  Guideline Information

Guidelines programm of the DGGG, OEGGG and SGGG

For information on the guidelines program, please refer to the end of the guideline.

Citation format

S2k-Guideline Non-hormonal Contraception, Part 1: Natural Family Planning, Lactational Amenorrhea, Barrier Methods, Coitus Interruptus. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry No. 015-095, January 2024). Geburtsh Frauenheilk 2024; 84: 697–714

Guideline documents

The complete long version in German and a slide version of this guideline as well as a list of the conflicts of interest of all the authors are available on the homepage of the AWMF: http://www.awmf.org/leitlinien/detail/ll/015-095.html

Guideline authors

See [Tables 1] and [2].

Author	AWMF professional society
PD Dr. med. Bettina Böttcher	Austrian Society for Gynaecology and Obstetrics [Österreichische Gesellschaft für Gynäkologie und Geburtshilfe e. V.] (OEGGG)
Prof. Dr. med. Sabine Segerer	German Society for Gynaecology and Obstetrics [Deutsche Gesellschaft für Gynäkologie und Geburtshilfe e. V.] (DGGG)

Author Mandate holder	DGGG working group (AG)/AWMF/non-AWMF professional society/organization/association
Dr. med. Maria Beckermann	Working Group on Womenʼs Health in Medicine, Psychotherapy and Society [Arbeitskreis Frauengesundheit in Medizin, Psychotherapie und Gesellschaft e. V.] (AKF)
Barbara Berger	Sexual Health Switzerland [Sexuelle Gesundheit Schweiz] (SGCH)
PD Dr. med. Bettina Böttcher	Austrian Society for Gynecology and Obstetrics (OEGGG)
Dr. med. Jann Frederik Cremers	German Society for Urology [Deutsche Gesellschaft für Urologie] (DGU)
Dr. med. univ. Elisabeth DʼCosta	Expert
Dr. med. Petra Frank-Herrmann	German Society for Gynecological Endocrinology and Reproductive Medicine [Deutsche Gesellschaft für Gynäkologische Endokrinologie und Fortpflanzungsmedizin] (DGGEF)
Dr. med. Tanja Freundl-Schütt	Expert
Dr. med. Cornelia Friedrich	German Society for Sexual Medicine, Sexual Therapy and Sexual Science [Deutsche Gesellschaft für Sexualmedizin, Sexualtherapie und Sexualwissenschaften] (DGSMTW)
Dr. med. Sören Funck	Professional Association of Gynecologists [Berufsverband der Frauenärzte] (BVF)
Dr. med. Christine Gathmann	Federal Association pro familia – German Society for Family Planning, Sexual Education and Sexual Counselling [Bundesverband pro familia – Deutsche Gesellschaft für Familienplanung, Sexualpädagogik und Sexualberatung e. V.]
Sabine Goette	Federal Center for Health Education [Bundeszentrale für gesundheitliche Aufklärung] (BZgA)
Dr. med. Maren Goeckenjan	Pediatric and Adolescent Gynecology Working Group [AG Kinder- und Jugendgynäkologie e. V.] of the DGGG
Prof. Dr. med. Katharina Hancke	German Society for Reproductive Medicine [Deutsche Gesellschaft für Reproduktionsmedizin] (DGRM)
Dr. med. Christian Leiber-Caspers	German Society for Andrology [Deutsche Gesellschaft für Andrologie] (DGA)
Dr. med. Jana Maeffert	German Society for Psychosomatic Gynecology and Obstetrics [Deutsche Gesellschaft für Psychosomatische Frauenheilkunde und Geburtshilfe] (DGPFG)
Prof. Dr. med. Gabriele Merki	Swiss Society for Gynecology and Obstetrics [Schweizerische Gesellschaft für Gynäkologie und Geburtshilfe] (SGGG)
Prof. Dr. med. Patricia G. Oppelt	Pediatric and Adolescent Gynecology Working Group of the DGGG
Stefanie Paschke	Federal Center for Health Education (BZgA)
Dr. med. Saira-Christine Renteria	Swiss Society for Gynecology and Obstetrics (SGGG)
Prof. Dr. med. Annette Richter-Unruh	German Society of Pediatrics and Adolescent Medicine [Deutsche Gesellschaft für Kinder- und Jugendmedizin] (DGKJ)
Dr. med. Sebastian Schäfer	Gynecological Endoscopy Working Group [AG Gynäkologische Endoskopie e. V.] (AGE) of the DGGG
Dr. med. Anne-Rose Schardt	Professional Association of Gynecologists (BVF)
Nina Schernus	Feminist Womenʼs Health Center Berlin [Feministisches Frauengesundheitszentrum Berlin e. V.] (FFGZ)
Dr. med. Claudia Schumann-Doermer	German Society for Psychosomatic Gynecology and Obstetrics (DGPFG)
Prof. Dr. med. Sabine Segerer	German Society for Gynecology and Obstetrics (DGGG)
Helga Seyler	Working Group on Womenʼs Health in Medicine, Psychotherapy and Society (AKF)
Christine Sieber	Sexual Health Switzerland (SGCH)
Prof. Dr. med. Barbara Sonntag	German Society for Reproductive Medicine (DGRM)
Gabrielle Stöcker	Federal Association pro familia – German Society for Family Planning, Sexual Education and Sexual Counselling
Prof. Dr. med. Bettina Toth	Austrian Society for Gynecology and Obstetrics (OEGGG)
Mag.a Angela Tunkel	Austrian Society for Family Planning [Österreichische Gesellschaft für Familienplanung] (ÖGF)
Dr. med. Lisa-Maria Wallwiener	German Society for Gynecological Endocrinology and Reproductive Medicine (DGGEF)

The following professional societies/working groups/organizations/associations stated that they wished to contribute to the guideline text and participate in the consensus conference and nominated representatives to attend the conference.

The guideline was moderated by Dr. Monika Nothacker (AWMF-certified guidelines adviser/moderator).

Abbreviations

Apps: applications

AWMF: Association of the Scientific Medical Societies in Germany [Arbeitsgemeinschaft der wissenschaftlichen medizinischen Fachgesellschaften e. V.]

BZgA: Federal Center for Health Education [Bundeszentrale für gesundheitliche Aufklärung]

CE: Conformité Européenne

DMPA: depot medroxyprogesterone acetate

HIV: human immunodeficiency virus

IUD: intrauterine device

IUP: intrauterine pessary

LNG-IUP: levonorgestrel intrauterine pessary

NFP: natural family planning

STI: sexually transmitted infection

TSS: toxic shock syndrome
 

II  Guideline Application

Purpose and objectives

The aim is to provide evidence-based recommendations for action to advise persons who wish to practice birth control using non-hormonal forms of contraception.

Targeted areas of care

• predominantly outpatient care/in special cases, also day-patient and in-patient care

• primary and specialist care

Target user groups/target audience

This guideline is aimed at the following groups of people:

• gynecologists, urologists and andrologists in private practice

• hospital-based gynecologists, urologists and andrologists

• pediatricians

The guideline also provides information for the following target audience:

• general practitioners

• nursing staff

• partners who work together with medical professionals (e.g., specialist healthcare occupations, funding agencies)

• counselling services (e.g., pro familia, Donum vitae, health authorities)

• the general public, to inform them about good medical approaches

Adoption and period of validity

The validity of this guideline was confirmed by the executive boards/representatives of the participating medical professional societies, working groups, organizations, and associations and the boards of the DGGG, SGGG, OEGGG and the DGGG/OEGGG/SGGG Guidelines Commission in December 2023 and was thereby approved in its entirety. This guideline is valid from 1 January 2024 through to 31 December 2028. Because of the contents of this guideline, this period of validity is only an estimate. The guideline can be reviewed and updated earlier if urgently necessary. If the guideline still reflects the current state of knowledge, its period of validity can be extended.

III  Methodology

Basic principles

The method used to prepare this guideline was determined by the class to which this guideline was assigned. The AWMF Guidance Manual (version 1.0) has set out the respective rules and requirements for different classes of guidelines. Guidelines are differentiated into lowest (S1), intermediate (S2), and highest (S3) class. The lowest class is defined as consisting of a set of recommendations for action compiled by a non-representative group of experts. In 2004, the S2 class was divided into two subclasses: a systematic evidence-based subclass (S2e) and a structural consensus-based subclass (S2k). The highest S3 class combines both approaches.

This guideline was classified as: S2k

Grading of recommendations

The grading of evidence based on the systematic search, selection, evaluation, and synthesis of an evidence base which is then used to grade the recommendations is not envisaged for S2k guidelines. The individual statements and recommendations are only differentiated by syntax, not by symbols ([Table 3]).

Description of binding character	Expression
Strong recommendation with highly binding character	must/must not
Regular recommendation with moderately binding character	should/should not
Open recommendation with limited binding character	may/may not

Statements

Expositions or explanations of specific facts, circumstances, or problems without any direct recommendations for action included in this guideline are referred to as “statements.” It is not possible to provide any information about the level of evidence for these statements.

Achieving consensus and level of consensus

At structured NIH-type consensus-based conferences (S2k/S3 level), authorized participants attending the session vote on draft statements and recommendations. The process is as follows. A recommendation is presented, its contents are discussed, proposed changes are put forward, and all proposed changes are voted on. If a consensus (> 75% of votes) is not achieved, there is another round of discussions, followed by a repeat vote. Finally, the level of consensus is determined, based on the number of participants ([Table 4]).

Symbol	Level of consensus	Extent of agreement in percent
+++	Strong consensus	> 95% of participants agree
++	Consensus	> 75 – 95% of participants agree
+	Majority agreement	> 50 – 75% of participants agree
–	No consensus	< 51% of participants agree

Expert consensus

As the term already indicates, this refers to consensus decisions taken which relate specifically to recommendations/statements issued without a prior systematic search of the literature (S2k) or where evidence is lacking (S2e/S3). The term “expert consensus” (EC) used here is synonymous with terms used in other guidelines such as “good clinical practice” (GCP) or “clinical consensus point” (CCP). The strength of the recommendation is graded as previously described in the chapter Grading of recommendations but without the use of symbols; it is only expressed semantically (“must”/“must not” or “should”/“should not” or “may”/“may not”).

IV  Guideline

1  Introduction

There has been a clear trend reversal with regards to the choice of contraception in recent years. For many decades, the pill was the most common contraceptive method used in Germany. However, since a number of years, hormone-based contraception has begun to be viewed more critically and is being rejected more often. Women are looking for alternatives, and men are now bearing more responsibility for family planning. Condoms are now being used for contraception as often as the pill [1].

Doctors should therefore be required to expand their knowledge of non-hormonal contraceptives. Individual counselling of couples/users is necessary to select the most suitable contraceptive method [2]. Important selection criteria include efficacy (reliability of the method), potential side effects including reversibility of the method, acceptance of the method, and availability of the method (access to a procedure, costs). Possible impacts on sexuality and libido play an important role and this is discussed in the individual chapters. Selection criteria as well as the assessment of what is important and acceptable with regards to preventing pregnancy can change over the course of a lifetime. The choice of method often changes accordingly.

If the aim is to reduce the risk of an unplanned pregnancy, especially if pregnancy would constitute an additional health risk, the efficacy of the method will be the most important selection criteria [3]. It is important to differentiate between typical use and perfect use [4]. Typical use refers to the methodʼs efficacy when it is used in actual life and includes typical user-related mistakes (i.e., inconsistent or incorrect use). Perfect use refers to the methodʼs efficacy when the method is always used correctly and consistently [4], [5]. Sometimes the information provided about the efficacy of a specific family planning method does not explicitly state whether the stated efficacy refers to typical use or perfect use.

When the contraceptive methods used are hormonal contraceptives, natural family planning methods or barrier methods, where efficacy depends on consistent and correct usage, there is a greater range between the figures reported for typical use and those reported for perfect use, compared to methods which are effective irrespective of how they are used. The latter methods include sterilization of the man or woman, placement of intrauterine devices (IUDs) and hormone-releasing implants. Factors that can affect the reliability of use are manifold: motivation, quality of the information provided, how complicated the method is to use, etc.

The efficacy rates of family planning methods are usually reported as rates of unplanned pregnancies per 100 women per year (both for typical use and for perfect use). Two methods are used to calculate efficacy: the Pearl Index and the Life Table. The Pearl Index corresponds to the number of unplanned pregnancies which occur when 100 women use a specific family planning method for one year [6]. The Pearl Index has been shown to have some significant inaccuracies and, from a scientific perspective, the Pearl Index should no longer be used. Nowadays, it is better to use the Life Table to obtain typical-use figures [7] and the perfect-use method of Trussell to calculate perfect use [8], [9]. The cumulative Life-Table figures after 13 cycles correspond to pregnancy rates per 100 women in one year.

Unfortunately, data on many non-hormonal methods, especially data on barrier methods used by women, is limited. Most of the data comes from the USA, and there are some indications that this data cannot be simply transferred to German-speaking countries. The data on diaphragm use are very heterogeneous, which is why the reported range for unplanned pregnancy rates is quite broad. The data on cervical caps and female condoms are based only on a small study of moderate quality and should be treated with caution. Some of the figures presented in international guidelines are only based on estimates, which is why they have not been included in [Table 5]. This particularly refers to the reliability of use of the withdrawal method (coitus interruptus) and of IUDs. Perfect-use data are lacking for currently available cervical caps.

	% of women with an unplanned pregnancy in the first year of use
	Typical use	Perfect use
No contraception [4]	85	85
Spermicide [4]	28	18
Natural family planning
Standard Days method [10]	12	5
symptothermal method, Sensiplan [4]	1.8 – 2.3	0.4
Lactational amenorrhea (refers only to a period of 6 months) [10]	0.45 – 2.45	0.97 – 1.5
Withdrawal method [11]	20	n. s.
Condom [4], [11]	13	2
Female condom [4]	21	5
Diaphragm [12], [13], [14], [15], [16], [17], [18], [19], [23]	12 – 18	4 or 14
Cervical cap (FDA 2003 [P020041b.pdf {fda.gov}])	Total 23 no previous vaginal birth 14 previous vaginal birth 29	n. s.
Copper IUD with a copper surface area of ≥ 300 mm2 [20], [21], [22]	0.1 – 1%	n. s.
LNG-IUP [20], [21], [22]	0.06 – 0.12	n. s.
Sterilization (woman) [4]	0.5	0.5
Sterilization (man) [4]	0.15	0.10

Sexual activity also includes the risk of sexually transmitted infections (STIs). In addition to the efficacy of the contraceptive method, potential protection against STIs also needs to be considered and users need appropriate information. This is where condoms have a significant advantage: consistent and correct use of condoms effectively reduces the risk of transmitting HIV or STIs such as chlamydia, gonorrhea or trichomoniasis [24].

2  Summary of Recommendations

1.  Natural family planning

Consensus-based statement 1.S1
Expert consensus	Level of consensus +++
NFP methods are based on the observation and interpretation of hormone-related menstrual cycle parameters which are used to determine the fertile window. This allows family planning to be carried out without intervening in the natural menstrual cycle.

Consensus-based statement 1.S2
Expert consensus	Level of consensus +++
The efficacy/reliability of a contraceptive method is one of its most important selection criteria for users. When considering the efficacy of a method, it is important to differentiate between typical use and perfect use.

Consensus-based statement 1.S3
Expert consensus	Level of consensus +++
For a more detailed presentation and evaluation of the NFP methods listed in this guideline, the following criteria must be met: 1. sufficient range and acceptance of the method in Europe, and 2. published controlled studies, especially on the contraceptive efficacy.

Consensus-based recommendation 1.E1
Expert consensus	Level of consensus +++
Based on the data and experience in Europe, if a user wishes to have highly reliable contraception, of all of the methods used for natural family planning, only symptothermal methods can currently be recommended as being highly effective.

Consensus-based recommendation 1.E2
Expert consensus	Level of consensus ++
To ensure the safe use of symptothermal methods, the user should be given introductory training or appropriate advice. This can be provided by the existing network of certified advisors.

Consensus-based statement 1.S4
Expert consensus	Level of consensus +++
Cycle apps track menstrual cycle parameters and show the presumed fertile window. This means that they are not only used as a menstrual calendar but also by users wanting to become pregnant or for contraceptive purposes. But most products have not been approved for use as a means of contraception.

Consensus-based recommendation 1.E3
Expert consensus	Level of consensus +++
Prognostic apps and apps or menstrual cycle computers, where the primary application is based on basal body temperature, must currently not be recommended as a reliable form of contraception.

Consensus-based statement 1.S5
Expert consensus	Level of consensus +++
Users of effective variants of the symptothermal method may make use of suitable NFP apps to support documentation.

Consensus-based recommendation 1.E4
Expert consensus	Level of consensus +++
Apps and measurement systems based on other parameters must currently be considered experimental and must not be recommended as a contraceptive method.

2.  Lactational amenorrhea

Consensus-based recommendation 2.E5
Expert consensus	Level of consensus ++
Lactational amenorrhea may be used as a contraceptive method provided the following conditions are met: amenorrhea is present it should only be used in the first six months postpartum the infant must be fed by breastfeeding alone without supplementary nutrition, with a maximum interval between breastfeeding sessions of between 4 and 6 hours

3.  Barrier methods

Consensus-based statement 3.S6
Expert consensus	Level of consensus ++
In parallel to the decrease in the use of hormonal contraceptive methods, in Germany-speaking countries condoms are increasingly being used for contraception. Condoms do not just offer protection against unplanned pregnancy but also against STIs.

Consensus-based recommendation 3.E6
Expert consensus	Level of consensus +++
Medical training and development should focus more on how to communicate information about barrier methods to men and women.

Consensus-based statement 3.S7
Expert consensus	Level of consensus ++
Condoms differ with regards to the material used, its thickness and the size. In Europe, the four-digit CE marking is considered an indication of compliance with safety standards.

Consensus-based statement 3.S8
Expert consensus	Level of consensus +++
Condoms that do not fit properly may lead to various problems such as tearing or sliding off and negatively affect the sexual experience.

Consensus-based statement 3.S9
Expert consensus	Level of consensus ++
Coating the condom with a lubricant containing nonoxynol-9 does not increase the protection against pregnancy or against the transmission of STIs. In women, it can increase the risk of bladder infections and the transmission of STIs.

Consensus-based recommendation 3.E7
Expert consensus	Level of consensus ++
Persons who have decided to use condoms as their contraceptive method must be informed that they must use a correctly sized condom, must check for the CE marking when buying condoms, check the expiration date, and must store the condom correctly. If the condom has a coating, the coating must not contain nonoxynol-9.

Consensus-based statement 3.S10
Expert consensus	Level of consensus +++
When condoms are used correctly and consistently (perfect use), they have a high contraceptive efficacy of 98%. When condoms are used inconsistently/incorrectly (typical use), the failure rate may be as high as 13%. The data on the contraceptive reliability of non-latex condoms compared to latex condoms is inconsistent.

Consensus-based recommendation 3.E3
Expert consensus	Level of consensus +++
When advice on contraception is provided, the advice must also include information about condoms and their contraceptive reliability and the information that, in addition to the choice of condom, the contraceptive efficacy of condoms very much depends on their consistent and correct use.

Consensus-based recommendation 3.E4
Expert consensus	Level of consensus +++
If persons requiring contraception have a latex allergy or reject the use of latex condoms, they may be advised to use non-latex condoms as a viable alternative.

Consensus-based recommendation 3.E8
Expert consensus	Level of consensus ++
Condom users must be advised in detail about the correct application and use of condoms and additionally be made aware of suitable information materials. Such advisory services should increasingly also be offered in doctorsʼ surgeries.

Consensus-based recommendation 3.E9
Expert consensus	Level of consensus ++
Persons who have opted to use condoms must be advised about the options for emergency contraception if there should be a problem with the condom.

Consensus-based statement 3.S11
Expert consensus	Level of consensus ++
Persons who have opted to use condoms as their method of contraception do not always use them consistently, with correspondingly negative consequences for their contraceptive efficacy. The reasons for this inconsistent use appear to be a feared or experienced negative impact on sexual satisfaction.

Consensus-based recommendation 3.E10
Expert consensus	Level of consensus ++
When advising on condoms, the possible negative impact on the sexual experience and on sexual function should be actively addressed.

Consensus-based statement 3.S12
Expert consensus	Level of consensus ++
Condoms are very effective at preventing the transmission of HIV and of most other STIs. Achieving an efficacy of 100% is impossible.

Consensus-based statement 3.S13
Expert consensus	Level of consensus ++
Non-latex condoms have a higher risk of tearing and slipping off compared to latex condoms. This means that protection against STIs may be lower compared to latex condoms.

Consensus-based recommendation 3.E11
Expert consensus	Level of consensus ++
When providing advice about contraception, the topic of STIs should always be addressed, and it should be pointed out that condoms offer very good protection against the transmission of HIV and, to a varying extent, also against the transmission of other STIs.

Consensus-based recommendation 3.E12
Expert consensus	Level of consensus +++
If persons wish or need to have hormone-free contraception, they should also be advised about the option of using a diaphragm or a cervical cap for contraception.

Consensus-based statement 3.S14
Expert consensus	Level of consensus ++
A correctly sized diaphragm does not cause subjective complaints in users, is lodged securely in the retropubic recess, and does not become dislodged by physical activity. A properly fitted cervical cap encloses the cervix to create suction.

Consensus-based recommendation 3.E13
Expert consensus	Level of consensus ++
The diaphragm or cervical cap must remain in place in the vagina for at least 6 hours after intercourse; the diaphragm must not remain in place for more than 24 – 30 hours in total and the cap must not remain in place for more than 48 hours.

Consensus-based recommendation 3.E14
Expert consensus	Level of consensus ++
Before a diaphragm or cervical cap is used, a trained professional should provide instructions and verify the correct fit and size of the diaphragm or cap and identify possible restrictions on the use of the method. Users should be offered checkups.

Consensus-based recommendation 3.E15
Expert consensus	Level of consensus ++
The user or her partner must be able to insert the barrier method themselves, reliably monitor that the diaphragm or cervical cap is in its proper place at all times by palpating the cervix through the membrane and be able to correct the placement if necessary. They must also be able to remove the diaphragm or cervical cap by themselves.

Consensus-based statement 3.S15
Expert consensus	Level of consensus +++
There are no evidence-based standards on the proper fitting of diaphragms and cervical caps.

Consensus-based statement 3.S16
Expert consensus	Level of consensus ++
Different types of diaphragms have a comparable contraceptive efficacy. Currently available cervical caps have a lower contraceptive reliability compared to diaphragms, especially for women who have given birth.

Consensus-based recommendation 3.E16
Expert consensus	Level of consensus ++
Advice on contraception with a diaphragm or cervical cap must include information about the contraceptive reliability of the method, also compared to other available methods. Users must be informed about emergency contraception methods.

Consensus-based statement 3.S17
Expert consensus	Level of consensus ++
For diaphragms, studies have reported a comparable efficacy for nonoxynol-9-containing spermicide gels and lactic acid gels. There is no similar data available for cervical caps. The data on the efficacy of using barrier methods without a gel compared to using them with a gel is inadequate. Lactic acid-based gels are tolerated better than nonoxynol-9-containing gels. There are also some indications that the risk of transmitting STIs including HIV and the occurrence of bladder infections is higher when using nonoxynol-9-containing gel.

Consensus-based recommendation 3.E14
Expert consensus	Level of consensus +++
Diaphragms and cervical caps must be used together with a contraceptive gel, preferably a lactic acid-based gel.

Consensus-based statement 3.S18
Expert consensus	Level of consensus +++
The precondition for using a diaphragm or cervical cap for contraception is a willingness to carry out vaginal self-examinations and the ability to palpate the cervix.

Consensus-based statement 3.S19
Expert consensus	Level of consensus +++
Anatomical anomalies or changes to the pelvic floor such as prolapse may be the reason why for some women, a diaphragm or cervical cap will not be a suitable means of contraception.

Consensus-based recommendation 3.E17
Expert consensus	Level of consensus ++
Women with frequently recurring bladder infections or vaginal infections should be informed about the possible negative effect of diaphragm use (especially when combined with nonoxynol-9-containing gel). These women may be offered an alternative contraceptive method.

Consensus-based recommendation 3.E18
Expert consensus	Level of consensus +++
Women with a history of TSS should be informed about the potentially higher risk of TSS. They should not use a diaphragm or cervical cap during menstruation, and the diaphragm or cap should not remain in place longer than the time recommended by the manufacturer.

Consensus-based recommendation 3.E19
Expert consensus	Level of consensus +++
Users of diaphragms or cervical caps must be informed that there is insufficient evidence on whether diaphragms or cervical caps offer protection against HIV/STI transmission or whether they are associated with a lower risk of cervical intraepithelial neoplasia. Nonoxynol-9-containing contraceptive gels should not be used, as the frequent use of such gels may increase the risk of HIV transmission. Condoms should be used in addition or as the sole contraceptive method to protect against the transmission of STIs including HIV.

Consensus-based recommendation 3.E20
Expert consensus	Level of consensus +++
The size and fit of a diaphragm or cervical cap should be checked and adapted at the earliest 6 weeks after having given birth or after a late-term termination of pregnancy, miscarriage or stillbirth in the 2nd or 3rd trimester of pregnancy.

Consensus-based statement 3.S20
Expert consensus	Level of consensus +++
There is no reliable data on the impact of using a diaphragm or cervical cap on sexual satisfaction or the sexual experience.

Consensus-based recommendation 3.E21
Expert consensus	Level of consensus ++
Women who are looking for a method which they can use to prevent pregnancy as well as protecting themselves against STIs including HIV should be advised about female condoms. They should be informed that the contraceptive reliability of female condoms is lower compared to male condoms and that it is not clear whether protection against STIs is as high as reported for male condoms.

4.  Coitus interruptus

Consensus-based recommendation 4.E22
Expert consensus	Level of consensus +++
Coitus interruptus (withdrawal method) must not be recommended as a means of contraception.

Conflict of Interest/Interessenkonflikt

The conflicts of interest of all the authors are listed in the long German-language version of the guideline./Die Interessenkonflikte der Autor*innen sind in der Langfassung der Leitlinie aufgelistet.

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Publication History

Received: 27 April 2024

Accepted: 29 April 2024

Article published online:
06 August 2024