For a variety of reasons, some women cannot use hormonal contraception. A gynecologist walks you through the alternate approaches.

Prescribing safe, effective birth control for reproductive-aged women who cannot or will not use hormonal contraceptives can be a challenge for primary-care clinicians because the needs of these patients are varied.

Women with a history of estrogen-dependent breast cancer, liver dysfunction, or deep venous thrombosis can’t use hormonal contraceptives. In addition, adverse side effects of hormonal medication and religious or personal beliefs that put birth control off-limits often prompt women to seek alternate approaches. The good news is that many nonhormonal contraceptive methods are safe, effective, and easy to use.

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Permanent solutions

Bilateral tubal ligation and tubal micro inserts (flexible coils placed in each fallopian tube) are very effective. Both methods should be considered nonreversible and may be the best choices for women who have ruled out future pregnancies.

Reversible contraception: All-natural methods

Withdrawal. Though seldom discussed as a reliable birth-control method, withdrawal works well in select couples. The perfect-use failure rate is only 4% per year.* However, the typical-use failure rate is 27%.

Fertility awareness-based method. This method relies on a woman’s awareness of the days on which she is fertile and the avoidance of coitus on those days. This is done by counting the days in the menstrual cycle and noting the days on which she observes changes in fertile signs, such as cervical mucus and basal body temperature. On days identified as fertile, the woman abstains from intercourse or uses a diaphragm, cervical cap, or condom.

This method is based on a menstrual cycle of 26-32 days; women who have two or more periods with durations outside this range in a single calendar year are not good candidates. When used consistently in women with regular cycles, fertility awareness has perfect and typical failure rates of 2%-5% and 12%-22%, respectively. To find out more about fertility-awareness contraception, go to Non-Hormonal Contraceptive Methods: A Quick Reference Guide for Clinicians on the Association of Reproductive Health Professionals Web site Accessed March 1, 2007).

Outercourse. Defined as any form of sexual pleasure or stimulation between partners that does not include insertion of the penis into the vagina, anus, or mouth, outercourse can, of course, be engaged in with no risk of pregnancy. Such ac-tivities typically include mutual masturbation, erotic massage, fantasy, and consensual frottage (the rubbing together of clothed or naked body parts).

OTC options

Female condom. The closed end of this 17-cm-long polyurethane sheath is inserted into the vagina, while the open end, shaped like a ring, lies outside the vaginal opening. The sheath prevents sperm and infectious agents from going up the vaginal canal and into the cervical opening. Following coitus, the sheath can be removed immediately. Although female condoms do protect against sexually transmitted diseases (STDs), they cannot be used discreetly and may interfere with genital sensation. The condoms are most useful for women at high risk of STDs and have perfect/typical failure rates of 5%/21%.

Vaginal sponge. This plastic, donut-shaped device is inserted into the vagina to cover the cervix. It contains a spermicide (nonoxynol-9) and can remain effective for up to 24 hours. It should be left in place for at least six hours after intercourse but should not be left for more than 30 hours because of the small but statistically significant risk of toxic shock syndrome. The sponge does not protect against STDs; it has a perfect/typical use effectiveness of 9%/16% in nulliparous women and 20%/32% in parous women. (Because parous women have proven fertility and nulliparous women do not, this demonstrated statistical difference may not be due to the effectiveness of the contraceptive method.)

Spermicides. Spermicides are widely used, either alone or with a diaphragm, and can be purchased in gel, foam, cream, and suppository formulations, depending on patient preference. Spermicides do not protect against STDs; they have perfect/typical failure rates of 18% and 29%, respectively.

Rx needed

The following contraceptives require a prescription and are covered by most health insurance plans.

Copper-T IUD. Although there are other intrauterine devices available on the market, the Copper-T contains no hormones.The device can be used for 10 years before it must be removed, and it has perfect/typical failure rates of just 0.6%/0.8%. For some women, side effects include heavier menses and cramping. The Copper-T IUD does not protect against STDs, and there is a 2%-10% risk of expulsion within the first year of use.

Diaphragm. Although diaphragms must be inserted with each act of coitus, most women find them easy to use; they also have few side effects and cause few complications. Perfect/typical use effectiveness is 6%/16%. Diaphragms do not protect against STDs.

Cervical cap. The cap prevents conception in the same way a diaphragm does; however, the cap fits snugly over the cervix rather than being positioned in the vaginal vault. Some women find the cap difficult to insert and remove. Moreover, it can increase the risk of vaginal infections and does not protect the user against STDs. It has a perfect/typical use effectiveness of 9%/16% in nulliparous women and 26%/32% in parous women.

A smart backup plan

It is worth noting that women who do opt for hormonal contraceptives may still benefit from a nonhormonal backup method, especially if they are not in a monogamous relationship. In addition to preventing pregnancy, female and male condoms effectively prevent the spread of STDs.

Dr. Bachmann is associate dean for women’s health as well as professor of medicine and obstetrics & gynecology at UMDNJ-Robert Wood Johnson Medical School in New Brunswick, N.J.