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Spermicides (Vaginal)

This monograph includes information on the following:

1) Benzalkonium Chloride  *
2) Nonoxynol 9
3) Octoxynol 9

VA CLASSIFICATION
Primary: GU400

Commonly used brand name(s): Advantage 242; Because2; Conceptrol Contraceptive Inserts2; Conceptrol Gel2; Delfen2; Emko2; Emko Pre-Fil2; Encare2; Gynol II Extra Strength Contraceptive Jelly2; Gynol II Original Formula Contraceptive Jelly2; K-Y Plus2; Koromex Cream3; Koromex Crystal Clear Gel2; Koromex Foam2; Koromex Jelly2; Ortho-Creme2; Ortho-Gynol3; Pharmatex1; Ramses Contraceptive Foam2; Ramses Crystal Clear Gel2; Semicid2; Shur-Seal2; VCF2.

Note: For a listing of dosage forms and brand names by country availability, see Dosage Forms section(s).

*Not commercially available in the U.S.



Category:


Contraceptive, vaginal—

Indications

Note: Bracketed information in the Indications section refers to uses that are not included in U.S. product labeling.

Accepted

Pregnancy (prophylaxis)—Vaginal spermicides are used in the prevention of pregnancy. {104} {105} {106} {107} {108} {109} {110} {111} {112} {113} {115} {120} {122} {123} {126} {128} {130} {132} {134} {144} {145} {149} Because of the high failure rate associated with these products when used alone, suppositories, soluble films, creams, foams, gels, and jellies are generally recommended for use in combination with mechanical barrier methods of contraception (condom, cervical cap, or diaphragm) or for patients with a low level of fertility or suspected infertility, or patients who have intercourse infrequently {04} {06} {08} {12} {17} {18} {19} {22} {51} {85} {98} {104} {107} {109} {110} {170} {196}.
—These preparations are also used in combination with mechanical barrier contraceptives to prevent pregnancy at times when oral contraceptives or intrauterine devices may not be effective or are contraindicated, or as an adjuvant to the periodic abstinence (rhythm) method of contraception. {05} {51} {154} {160} {243}
—Vaginal spermicides provide a back-up to the condom in case of leaking or spilling of ejaculate or rupture of the condom during coitus. {12} {22} {47} Cervical caps and diaphragms are designed to hold the spermicide near the cervical os, which is particularly important in the event that the cap or diaphragm is dislodged or does not form a complete seal around the cervix. {03} {04} {18} {61} {62} {98} {109} {189} {216} Jellies and gels also provide a high level of lubrication, which may ease insertion of a cervical cap or diaphragm, may decrease the risk of condom rupture during intercourse, or may decrease frictional trauma to the vaginal mucosa during intercourse {03} {04} {110} {134} {160}.

[Sexually transmitted diseases (prophylaxis)]1—The use of vaginal spermicides in combination with latex condoms may be partially effective in reducing the risk of acquiring many sexually transmitted diseases (STDs). {03} {05} {06} {17} {23} {24} {32} {33} {35} {40} {98} {186} {193} {194} {195} {196} {197} {199} {236} {238} However, the extent of this additional protection against acquiring STDs (especially viral) has not yet been determined {186} {195} {210} {238} {241}.
—Vaginal spermicides provide a backup to the condom in case of leaking or spilling of ejaculate or rupture of the condom during coitus {12} {22} {40} {46} {47} {193} {194}. They may be recommended for use by patients using non-barrier contraceptives such as the intrauterine device or oral contraceptives, ideally in combination with latex condoms, to reduce the risk of acquiring STDs. {05} {33} {194} {196} The use of spermicides in combination with latex condoms may also be considered for those patients at high risk of acquiring STDs (especially HIV infection) during pregnancy {215}.
—Nonoxynol 9 has been shown to inhibit the in vitro growth of the following STD pathogens: {152} {237} {238}

Chlamydia trachomatis{22} {23} {24} {25} {34} {40} {42} {46} {47} {48} {102} {172} {186} {193}


Gardnerella vaginalis{23} {172}


Mycoplasma hominis{23} {101} {172}


Neisseria gonorrhoeae{06} {17} {22} {23} {24} {26} {31} {33} {34} {40} {42} {47} {48} {51} {172} {186}


Trichomonas vaginalis{06} {17} {22} {23} {27} {33} {34} {48} {51} {102} {172} {186} {193}


Ureaplasma urealyticum{23} {172}

In vitro, nonoxynol 9 also decreases the infectivity of Treponema pallidum , the pathogenic agent of syphilis {03} {06} {22} {23} {26} {33} {34} {40} {42} {47} {48} {51} {172} {186}.
—Clinical studies have shown a reduction in the rate of occurrence of chlamydia {01} {05} {06} {17} {23} {24} {34} {35} {48} {172} {193}, gonorrhea {01} {03} {04} {05} {06} {17} {23} {24} {28} {29} {30} {31} {32} {33} {34} {35} {48} {98} {172} {186} {193} {194} {198}, trichomoniasis {35} {172} {193} {238}, and bacterial vaginosis {35} {172} {238} with the use of nonoxynol 9–containing preparations, especially in combination with mechanical barrier contraceptives. {01} {06} {23} {193}
In vitro, nonoxynol 9 has been shown to inactivate herpes simplex viruses (HSV) I and II {06} {17} {23} {33} {34} {40} {46} {47} {48} {49} {50} {51} {172} {186} {191} {193} {197} and human immunodeficiency virus (HIV or the AIDS virus) {06} {17} {22} {23} {33} {34} {36} {37} {38} {39} {40} {41} {42} {43} {46} {47} {48} {100} {172} {186} {193}. Benzalkonium chloride has also been shown to inactivate HIV in vitro . {44} {186} {203} {241}
—The use of vaginal spermicides in combination with latex condoms may afford some degree of protection against viral STDs. However, this recommendation is based on in vitro data and no appropriate clinical studies have been completed that document a reduction in the vaginal, rectal, or oropharyngeal transmission of these diseases by the use of spermicides alone or a further reduction when used in combination with mechanical barrier contraceptives {23} {33} {38} {39} {42} {45} {47} {48} {100} {153} {186} {194} {198} {201}. Because clinical studies have not been performed that document the safety and efficacy of spermicides in reducing STD transmission, the following points should be considered: it is not known whether subinhibitory concentrations of spermicides would result from application or use within the rectum {40} {193}; or whether spermicides may cause epithelial damage to the mucosa {56} {172} {186} {190} {198}, damage to cells of the immune system {87}, or Y-lymphocyte activation, resulting in an increased risk of transmission {42}. Also, because protection from pregnancy is frequently incomplete, the same possibility must be considered for the use of spermicides for STD prevention {172}.

[Pelvic inflammatory disease (prophylaxis)]1—Use of vaginal spermicides, especially in combination with mechanical barrier contraceptives, decreases the risk of development of pelvic inflammatory disease and subsequent tubal damage and infertility. {05} {06} {17} {33} {99} {172} One study showed a reduction in the incidence of tubal infertility among users of mechanical barrier contraceptives combined with a spermicide, which was greater than the reduction with either method alone. {99} {172} The use of spermicides in combination with latex condoms may also be considered for those patients at high risk of development of pelvic inflammatory disease (PID) during pregnancy {215}.

—A reduced incidence of cervical neoplasia has been observed in epidemiologic studies among users of vaginal spermicides, especially when used in combination with a mechanical barrier method of contraception {08} {17} {49} {98} {100} {230}. However, the nature and extent of this reduction in incidence has not yet been clearly documented {170} {197} {209} {230}. It has been proposed that spermicides may provide protection against cervical cancer by virtue of their antiviral actions, since there is some evidence that cervical neoplasia may be associated with sexual transmission of human papillomavirus. {23} {48} {49} {98} {100} {209} {230} {231}

Unaccepted
One study has shown nonoxynol 9 cream to be ineffective in the treatment of genital herpes (HSV II) infections. {50} {187} {188}

1 Not included in Canadian product labeling.



Pharmacology/Pharmacokinetics

Physicochemical characteristics:

Chemical group—
    Benzalkonium chloride: Cationic surfactant {21}.
    Nonoxynol 9 and octoxynol 9: Nonionic surfactants {08} {59} {90} {150}.

Mechanism of action/Effect:


For the prevention of pregnancy:

All products: Vaginal spermicides are considered chemical forms of barrier contraceptives because they form a chemical barrier between the mucous membranes and ejaculate. {23} {33} {61} {62} {99} {121} {172} Mechanical barrier contraceptives include the condom, diaphragm, and cervical cap {04} {61} {62} {121} {170} {216} {217} {218} {211}. The active chemicals in vaginal spermicides interact with the lipoproteins of the cell membrane to permanently disrupt the cell membranes of spermatozoa, resulting in severe damage to the acrosome (head), neck, midpiece, and tail of the sperm and rapid, irreversible loss of function and motility within the vagina and viability {03} {06} {08} {21} {22} {23} {31} {51} {52} {53} {54} {62} {104} {172} {186}. Cell permeability increases and the leaking of cellular components occurs. {51} Studies also indicate that carbohydrate-metabolizing enzymes and the mitochondriae are disturbed {08} {21} {54} {55}. Additionally, the inactive vehicle itself may form a mechanical barrier to the cervical os, inhibiting the passage of sperm. {03} {08} {49} {51} {104} {121}

Benzalkonium chloride may make the cervical mucus hostile to sperm by disrupting the electrolyte balance of the aqueous phase {02}. It also coagulates ovulatory cervical mucus, resulting in a mesh of less than 5 microns, which may inhibit sperm passage. {21} {155}

The following table presents the results of studies examining contraceptive failure rates calculated using the life-table method. The first column lists the contraceptive method used. The second column indicates the percentage of women experiencing an accidental pregnancy in the first year of use of a contraceptive method while using the method perfectly under clinical conditions. The range of failure rates in the clinical trials may be explained by interstudy variations in study design or patient population characteristics, such as motivation, fecundity, or socioeconomic factors (including education). The third column indicates contraceptive failure rates in the first year of contraceptive use under clinical conditions for typical couples who start using a method (not necessarily for the first time). Failure rates among adolescents may be higher than in other age groups due to poorer compliance by adolescents. {53} {54} {55}

Method used
 
Failure rate range (over 12 months) in clinical studies (%)
 
Typical first year failure rate (%)
 
None
78–94
85
Spermicides *
0.3–37
21
Periodic abstinence
13–35
20
Withdrawal
7–22
19
Cervical cap with spermicide
6–27
18
Diaphragm with spermicide
2–23
18
Condom without spermicide
2–14
12
IUD
   
  Progesterone-releasing
1.9–2
2
  Copper-T 200
3–3.6

 
  Copper-T 200Ag
0–1.2

 
  Copper-T 220C §
0.9–1.8

 
  Copper-T 380A
0.5–0.8
0.8
  Copper-T 380S {14} {15}
0.9

 
Oral contraceptive

 
3
  Estrogen and progestin
0–6

 
  Progestin only
1–10

 

 

 

 
Medroxyprogesterone injection (90-day)
0–0.3
0.3
Levonorgestrel implants

 
 
  Six capsules
0–0.09
0.09
  Two rods
0–0.2
0.3
Sterilization

 
 
  Female #
0–8
0.4
  Male
0–0.5
0.15
* Spermicides studied include creams, foams, gels, jellies, and suppositories {14} {15}.
 Methods studied include calendar, ovulation method, and symptothermal (cervical mucus method supplemented by basal body temperature postovulation) {14} {15}.
 Life-table method rate is unavailable for Copper-T 200Ag and the Pearl method rate at 12 months was reported; these methods at 12 months are considered comparable {09} {10} {11}.
§ Copper-T 220C is manufactured with copper sleeves instead of copper wire; often used as a control in clinical studies {16}.
# Methods studied include culdotomy, laparoscopy, minilaparotomy, electrocoagulation, laparotomy, tubal diathermy, and/or use of rings or clips {14} {15}.




For prevention of sexually transmitted diseases:

All products: The majority of studies conducted have concerned the most commonly used spermicide, nonoxynol 9. In vitro , nonoxynol 9 has been shown to produce bactericidal and virucidal effects by disrupting the cell membrane and the viral envelope. {06} {45} {49} {85} {90} {172} {186} The active chemicals in vaginal spermicides interact with the lipoproteins of the cell membrane to permanently disrupt the cell membranes {172} {186}. Nonoxynol 9 may also exert antimicrobial activity against Chlamydia trachomatis receptors on target cells {23} {172}. Low concentrations in vitro have been shown to block cellular attachment and/or penetration by C. trachomatis organisms {23}. In one study, nonoxynol 9 caused significant chemorepulsion of Trichomonas vaginalis in vitro {102}.

Any method covering the cervix may protect against gonorrhea and chlamydia because the causative organisms primarily infect cervical tissues {23} {24} {172}. Therefore, spermicides alone or in combination with a mechanical barrier contraceptive may protect against transmission of these infections. {23} {172} Spermicidal preparations that are well-distributed within the vagina, such as foams, may be best for those organisms that reside mostly in the vagina, such as T. vaginalis {23} {172}.


Other: Sperm acrosin is inactivated by nonoxynol 9. {55}



Absorption:

Radiolabeled nonoxynol 9 and octoxynol 9 have been shown to be rapidly and extensively absorbed into the systemic circulation from the vaginal mucosa of rats and rabbits. {08} {57} {58} {59} {60} The rate of absorption is dependent upon the product vehicle. {18} {57} {59} No direct information on the rate or extent of absorption of spermicides from human rectal or vaginal mucosa is available. {08} {18} {51} {57} {59} {212} {243} However, disruption of the vaginal epithelial cells occurs, with increased thinning of the epithelium occurring with continuing exposure {51}. Also, the vaginal mucosa is histologically similar to the buccal mucosa {51}. Therefore, it is feasible that these agents could be absorbed into the systemic circulation in humans as well. {51} {243}

Distribution:


Local:

By nature of their vehicles, certain preparations tend to be distributed more evenly and extensively within the vagina and better adhere to the vaginal mucosa. {51} {121} Foam spermicidal products have the highest degree of dispersion within the vagina and adherence to the mucosa, followed by creams, gels and jellies, and suppositories and films. {51} {121}



Systemic:

Studies have not been published regarding systemic distribution in humans {212}. However, in one study on the use of vaginal nonoxynol 9 in rabbits, the highest amounts of radiolabeled nonoxynol 9 were in the uterus and vaginal tissue {57}. The liver also contained a greater amount than most other body tissues {57} {58}.

In one study of vaginally administered radiolabeled nonoxynol 9 in gravid rats, at 6 hours the medication in the uterus and placenta was in equilibrium with that of the maternal plasma {58}. The concentration of nonoxynol 9 in the amniotic fluid was approximately one third that of the maternal plasma. {58}


Biotransformation:

In studies conducted in animals, there was little evidence that nonoxynol 9 is metabolized {60}.

Onset of action:

Film and suppositories—5 to 15 minutes, depending upon individual product, to allow for melting or effervescence and dispersion within the vagina. {12} {20} {30} {98} {104} {120} {149}

Foams, creams, gels, and jellies—Immediately effective {12} {115} {126} {128}.

Elimination:
    In one study in rabbits, a cumulative total of 40% of a dose of radiolabeled nonoxynol 9 was excreted in the urine and 10% in the feces in the 144 hours following vaginal administration. {57} {59} {60} Within 24 hours, 20% was excreted in the urine, and the daily fecal excretion rate was approximately 1 to 2%. {57} {60} In rats, approximately 95% of the dose was excreted within 72 hours, 23% of which was present in the urine and 70% in the feces {57} {59} {60}.


Precautions to Consider

Cross-sensitivity and/or related problems

Because of close similarities in composition, activity, and structure, patients allergic to nonoxynol 9 are likely to be allergic to octoxynol 9 also and should avoid further use of either product if sensitization occurs. {90}

Pregnancy/Reproduction

Pregnancy—
The majority of evidence indicates that the vaginal spermicides nonoxynol and octoxynol do not increase the risk of occurrence of spontaneous abortion or major congenital anomalies when used at or near the time of conception or during pregnancy. {03} {04} {05} {06} {17} {22} {52} {63} {64} {65} {66} {67} {68} {69} {70} {71} {72} {73} {74} {75} {76} {77} {78} {79} {80} {81} {82} {83} {84} {98} {134} {192} {208} {214} {244}

In a study of gravid rats, nonoxynol 9 appeared in the serum of the pups within 2 hours of vaginal administration of radiolabeled nonoxynol 9. {57}

Breast-feeding

It is not known whether spermicides are distributed into human breast milk. However, problems have not been documented.

In a study conducted in gravid rats, an amount of radiolabeled nonoxynol 9 corresponding to approximately 0.3% of the given dose was distributed into the breast milk in the 24 hours following vaginal administration. {57}


Adolescents

Consistent and careful use is critical in the employment of vaginal spermicide products to prevent pregnancy, a high failure rate is inherent with these agents when used alone, and their use requires a considerable amount of interruption in sexual spontaneity. {05} {06} For these reasons, vaginal spermicides are generally not recommended for use as a sole method of contraception for all sexually active adolescent patients. {05} {06} {156} They are primarily recommended for use in combination with latex condoms and reserved for highly motivated adolescents or when intercourse occurs infrequently. {05} {06} {196} However, there are some advantages to the use of vaginal spermicides with condoms in that it is a fairly effective, widely available, inexpensive, nonprescription contraceptive method. {06} {98} {196}


Drug interactions and/or related problems
The following drug interactions and/or related problems have been selected on the basis of their potential clinical significance (possible mechanism in parentheses where appropriate)—not necessarily inclusive (» = major clinical significance):


Note: Combinations containing any of the following medications, depending on the amount present, may also interact with this medication.

» Vaginal or topical medications, especially those containing:{104}
Aluminum or{02}
Citrate or{02}
Cotton dressings or{02}
Hydrogen peroxide or{02}
Iodides or{02}
Lanolin, hydrous or{02}
Nitrates or{02}
Permanganates or{02}
Salicylates or{02}
Silver salts or{02}
Soaps, surfactants, or detergents, ionic or{02}{21}{104}
Sulfonamides or{02}
Tartrates{02}    (benzalkonium chloride may be chemically inactivated by the above agents; contact between benzalkonium chloride spermicides and any product containing the above ingredients should be avoided {02} {21} {104})


» Vaginal douches and rectal or vaginal cleansing products{104}{111}{123}{130}    (vaginal douching is not recommended or necessary after use of these products, but, if performed, at least 8 hours [cervical cap] or 6 hours [most products] should pass following the last act of intercourse to allow for adequate contact of the spermicide with ejaculate, which ensures maximal contraceptive effect {98} {104} {105} {106} {107} {109} {110} {111} {123} {130} {145})


Medical considerations/Contraindications
The medical considerations/contraindications included have been selected on the basis of their potential clinical significance (reasons given in parentheses where appropriate)— not necessarily inclusive (» = major clinical significance).


Except under special circumstances, this medication should not be used when the following medical problems exist:

For all products:
» Allergy to benzalkonium chloride, octoxynol, or nonoxynol{17}{51}{88}{104}{158}{230}
For cervical cap or diaphragm only:
» Toxic shock syndrome, history of, especially with prior use of cervical cap, diaphragm, or tampons{157}{170}{217}{230}{232}    (the cervical cap or diaphragm should not be used, since these patients may be at increased risk of recurrence {170} {213} {216} {217} {230})


Risk-benefit should be considered when the following medical problems exist

For all products:
Allergy, chronic, local or{51}{230}
Contact dermatitis, genital{51}{230}    (moderate to severe irritation may occur with the use of spermicides {230})


» Medical or psychosocial conditions where a critical need exists for highly effective contraception{51}{104}{110}{230}    (when spermicides are used alone, a high rate of failure occurs {51} {104} {230})


For benzalkonium chloride only:
Vaginal infection{104}{230}    (efficacy of benzalkonium chloride may be affected {104})


For cervical cap or diaphragm only:
Parturition or abortion, recent{216}{217}{230}    (a physician should be consulted prior to use or resumption of use of these products, as use in the postpartum or postabortal period is not recommended and may increase the risk of development of toxic shock syndrome {170} {216} {217} {230})


For prevention of sexually transmitted diseases only:
» Genital ulcers or{170}{230}{245}{246}{248}
» Vaginal epithelial irritation{170}{190}{230}{246}    (it is not known whether vaginal spermicides may cause further epithelial damage, resulting in an increased risk of transmission of STDs {42} {170} {190} {230} {246})




Side/Adverse Effects
The following side/adverse effects have been selected on the basis of their potential clinical significance (possible signs and symptoms in parentheses)—not necessarily inclusive:

Note: The safety of the use of spermicides on the rectal mucosa is unknown {33} {40}. However, no serious adverse effects have been reported {40} {42}.
In one study in rats and rabbits given high doses of nonoxynol 9 peritoneally or vaginally, some evidence of hepatotoxicity and nephrotoxicity was seen. {56} {57} {60} However, these effects or other serious systemic side effects have not been seen in humans {08} {18} {22} {121}.


Those indicating need for medical attention
Incidence rare
For all products
    
Allergic vaginitis {06}{21}{24}{85}{87}{88}{89}{98}(persistent vaginal redness, irritation, rash, dryness, or whitish discharge)
    
contact dermatitis (persistent skin rash, redness, irritation, or itching){90}{91}{190}{198}—in males or females
    
urinary tract infection {06}{249}{250}(increased frequency of urination; pain on urination; bladder pain; cloudy or bloody urine)—in females

Note: An increased risk of urinary tract infection may occur in females, independent of diaphragm use, possibly due to changes in vaginal flora. {06} {249} {250}


For cervical cap or diaphragm only
    
Candidiasis, vulvovaginal {06}{34}(thick, white, or curd-like vaginal discharge)
    
toxic shock syndrome {03}{05}{06}{17}{171}{205}{206}{213}(dizziness; fever; lightheadedness; chills; sunburn-like rash that is followed by peeling of the skin; muscle aches; hypotension; unusual redness of the mucous membranes inside of the mouth, nose, throat, vagina, or conjunctivae; confusion)

Note: An increased relative risk of acquiring nonmenstrual toxic shock syndrome has been reported with the use of cervical caps or diaphragms {170} {205} {206} {207} {213} {230}. However, its occurrence is rare and the absolute risk of nonmenstrual toxic shock syndrome is still very low with the correct use of any of these contraceptive methods {159} {170} {171} {213} {230}.





Those indicating need for medical attention only if they continue or are bothersome
Incidence less frequent
    
Burning, stinging, warmth, itching, or other irritation of the skin, penis, rectum, or vagina{19}{20}{21}{22}{24}{56}{60}{85}{86}{90}{98}{104}{109}{110}{111}{149}{190}{198}
    
vaginal discharge, transient —with suppositories, creams, or foams{12}{19}{20}{85}{104}
    
vaginal dryness or odor{85}

Note: Local irritation of the skin, penis, rectum, or vagina may require use of a product with a lower concentration of spermicide or different ingredients {08} {47} {56} {105} {106} or wetting of benzalkonium chloride suppository prior to insertion {104}.






Patient Consultation
As an aid to patient consultation, refer to Advice for the Patient, Spermicides (Vaginal).

In providing consultation, consider emphasizing the following selected information (» = major clinical significance):

Before using this medication
»   Conditions affecting use, especially:
Allergy to benzalkonium chloride, octoxynol 9, or nonoxynol 9
Other medications, especially:

• For all products—Vaginal douches and rectal or vaginal cleansing products


• For benzalkonium chloride only—Vaginal or topical medications, especially those containing aluminum, citrate, cotton dressings, hydrogen peroxide, iodides, lanolin, nitrates, permanganates, salicylates, silver salts, soaps, detergents, surfactants, sulfonamides, or tartrates

Medical problems, especially:

• For all products—Conditions for which highly effective contraception is critical; or, for users at special risk of STDs, genital ulcers or vaginal epithelial irritation


• For benzalkonium chloride only—Vaginal infection


• For cervical cap or diaphragm only—History of toxic shock syndrome


Proper use of this medication
Reading patient package insert carefully

» Following spermicide instructions carefully for each act of sexual intercourse

» Understanding that douching is neither needed nor recommended; however, if douching is desired, not using douches and rectal or vaginal cleansing products for 6 to 8 hours following intercourse (depending on spermicide product) to avoid reducing the spermicide's efficacy

» Not using cervical cap or diaphragm during menstruation; using condom with or without spermicide if protection is needed

Proper administration of spermicide
Understanding that application directions for spermicides vary widely, especially regarding how to administer, amount to use, waiting period before intercourse, and medication-retaining period after intercourse

Proper administration of spermicide with a cervical cap, condom, or diaphragm
Understanding that the female partner may need to apply more spermicide immediately if latex device leaks or condom breaks during sexual intercourse

» Understanding that only water-based spermicides or lubricants can be used with latex cervical caps, condoms, or diaphragms—not using oil-based products, which can cause condoms to break and cervical caps or diaphragms to weaken or wear out faster

» For cervical cap—Always using a spermicide with a cervical cap for maximum contraception protection; not removing cervical cap for at least 8 hours following intercourse, but not waiting longer than 48 hours; contacting physician if removal of device is troublesome

For condoms—Spermicides do not always have to be used with condoms but do provide backup protection if leakage or breakage occurs

» For diaphragm—Always using a spermicide with a diaphragm for maximum contraception protection; not removing diaphragm for at least 6 to 8 hours following intercourse (depending on spermicide used) but not waiting longer than 24 hours; contacting physician if removal of device is troublesome

» Proper dosing

» Proper storage

Precautions while using this medication
Using a weaker strength of the spermicide or switching to a different spermicide if a spermicide causes burning, stinging, warmth, itching, or other irritation of the skin, sex organs, anus, or rectum of either partner. If symptoms continue, contacting physician for clinical evaluation of possible infection or allergy.
Wetting of benzalkonium chloride suppositories before insertion may prevent local insertion irritation; contacting physician if symptoms continue for clinical evaluation of possible infection or allergy

Side/adverse effects
Signs of potential side effects, especially allergic vaginitis; contact dermatitis (males or females); or urinary tract infection (females); in addition, for cervical cap or diaphragm only—vulvovaginal candidiasis or toxic shock syndrome


General Dosing Information
Vaginal spermicides should be placed deep within the vagina, on the cervix, to allow for maximal contact and efficacy {104} {105} {115} {121} {126} {149}.

The cervical cap or diaphragm should not be used during menstruation, as the risk of toxic shock syndrome may be increased {216} {217} {218} {230}. It may be recommended that condoms with or without a spermicide be used instead during menses if protection is needed. {157} {159} {170} {216} {230}

The use of spermicides, especially gels and jellies, provides additional lubrication during intercourse or insertion of a diaphragm {184}. If additional lubrication is desired, only the appropriate water-based lubricants should be used, such as sterile surgical lubricant or a personal lubricant formulated for use with a diaphragm {193}. Oil-based products such as hand, body, or face cream; petroleum jelly; cooking oils or shortenings; or baby oil will weaken latex and increase the risk of condom rupture during intercourse {193} {200} {202} {204}. These oil-based products will also weaken latex diaphragms and cervical caps, requiring early replacement {216} {217}.

For use of spermicides with a cervical cap
Prior to insertion, the cervical cap should be filled one third full with spermicidal cream, foam, gel, or jelly {216} {217} {218}. The spermicide should not be applied to the rim of the cervical cap, because it may interfere with the suction seal against the cervix {216} {219}. The patient should check the cap for proper placement on the cervix before and after each act of intercourse {217} {218}. Additional spermicide may be applied vaginally prior to each repeat act of intercourse {162} {230}. The cervical cap must remain in the proper place for at least 8 hours after the last act of intercourse {216} {218}. The cervical cap may be worn up to 48 hours {216} {217} {218}.

For use of spermicides with a condom
Spermicide should be put on the outside of the condom after it is unrolled onto the penis. It is especially important that a female partner also use spermicide in the vagina {170} {193}. Such use is more likely to afford greater efficacy {170} {193}.

For use of spermicides with a diaphragm
Prior to insertion of the diaphragm, a generous amount of cream, foam, gel, or jelly should be spread along the rim of the diaphragm that will be in contact with the cervix. {98} {109} {110} {134} {170} Then, manufacturer's instructions should be followed in placing spermicide in the cup of the diaphragm. {159} {160} Some physicians also recommend that a generous amount of spermicide be spread on the outer surface of the diaphragm {170}.

The diaphragm and spermicide should not be removed until at least 6 (most products) or 8 hours have passed after the last act of intercourse {98} {109} {110} {123} {130} {184} {233}. The diaphragm should not be removed when additional spermicide is applied during this time. After 6 or 8 hours, the diaphragm may be removed {98} {109} {110} {111} {123} {130} {162} {184}. A diaphragm should not be left in place for longer than 24 hours, since doing so may increase the risk of developing toxic shock syndrome. {17} {62} {98} {109} {110} {111} {123} {130}

To be maximally effective, diaphragms must be used in combination with a spermicide each time that intercourse occurs {113} {123} {130} {161}. Some women choose nightly insertion of the diaphragm to minimize the occurrence of unprotected intercourse. {113} {123} {234} {242} Additional spermicide should be applied each time that intercourse is repeated. {151} {162}

BENZALKONIUM CHLORIDE


Vaginal Dosage Forms

Note: Bracketed uses in the Dosage Forms section refer to categories of use and/or indications that are not included in U.S. product labeling.

BENZALKONIUM CHLORIDE VAGINAL SUPPOSITORIES

Usual adult and adolescent dose
Pregnancy, prophylaxis or
[Sexually transmitted diseases, prophylaxis]1 or
[Pelvic inflammatory disease, prophylaxis]1


For use alone:
Pharmatex—Intravaginal, 1 suppository inserted at least ten minutes, and not longer than four hours, prior to intercourse {104}. An additional suppository should be inserted into vagina at least ten minutes, and not longer than four hours, prior to each repeat act of intercourse {104}.



For use with a diaphragm:
Pharmatex—Intravaginal, one suppository inserted at least ten minutes, and not longer than four hours, prior to each act of intercourse after initial placement of diaphragm with spermicide or if intercourse takes place later than six hours after diaphragm placement. {104}



Strength(s) usually available
U.S.—
Not commercially available.

Canada—


18.9 mg (OTC) [Pharmatex{104}]

Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), in a well-closed container, unless otherwise specified by manufacturer. Do not refrigerate.

Auxiliary labeling:
   • Not to be taken by mouth.


NONOXYNOL 9


Vaginal Dosage Forms

Note: Bracketed uses in the Dosage Forms section refer to categories of use and/or indications that are not included in U.S. product labeling.

NONOXYNOL 9 VAGINAL CREAM

Usual adult and adolescent dose
Pregnancy, prophylaxis or
[Sexually transmitted diseases, prophylaxis]1 or
[Pelvic inflammatory disease, prophylaxis]1


For use alone:
Delfen—Intravaginal, 1 applicatorful of a 5% cream inserted just prior to intercourse {105}. An additional applicatorful should be inserted into vagina just prior to each repeat act of intercourse. {105}



For use with a diaphragm:
Delfen—Intravaginal, initially 1 applicatorful (approximately one teaspoonful) of a 5% cream placed into cup and additional spermicide spread along the rim of diaphragm just before insertion of diaphragm and not longer than six hours prior to intercourse. {01} {105} {109} {110} {160} An additional applicatorful should be inserted into the vagina just prior to each repeat act of intercourse or if intercourse occurs later than six hours after initial diaphragm placement {01} {109} {110}; or

Ortho-Creme—Intravaginal, initially 1 applicatorful (approximately one teaspoonful) of a 2% cream placed into cup and additional spermicide spread along the rim of diaphragm just before insertion of diaphragm and not longer than six hours prior to intercourse. {01} {105} {109} {110} {160} An additional applicatorful should be inserted into the vagina just prior to each repeat act of intercourse or if intercourse occurs later than six hours after initial diaphragm placement. {01} {109} {110}



Strength(s) usually available
U.S.—


2% (OTC) [Ortho-Creme{108}{109}{110}]

Canada—


5% (OTC) [Delfen{105}{163}{164}]

Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), in a well-closed container, unless otherwise specified by manufacturer. {109} Protect from freezing.

Auxiliary labeling:
   • Not to be taken by mouth.


NONOXYNOL 9 VAGINAL FILM

Usual adult and adolescent dose
Pregnancy, prophylaxis or
[Sexually transmitted diseases, prophylaxis]1 or
[Pelvic inflammatory disease, prophylaxis]1


For use alone:
VCF—Intravaginal, 1 film inserted at least five (preferably fifteen) minutes, and not longer than one and one-half hours, prior to each act of intercourse {149}.



Strength(s) usually available
U.S.—


28% (OTC) [VCF{01}{149}]

Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), in a well-closed container, unless otherwise specified by manufacturer.

Auxiliary labeling:
   • Not to be taken by mouth.


NONOXYNOL 9 VAGINAL FOAM

Usual adult and adolescent dose
Pregnancy, prophylaxis or
[Sexually transmitted diseases, prophylaxis]1 or
[Pelvic inflammatory disease, prophylaxis]1


For use alone:
Because; Delfen; Emko; Emko Pre-Fil; Koromex Foam; Ramses Contraceptive Foam—Intravaginal, 1 applicatorful inserted just prior to and not longer than one hour prior to each act of intercourse. {105} {106} {115} {122} {126} {128} {145} {182}



For use with a diaphragm:
Because; Emko; Emko Pre-Fil; Ramses Contraceptive Foam—Intravaginal, initially 1 applicatorful placed into vagina and additional spermicide spread along the rim of diaphragm just before insertion of diaphragm and not longer than one hour prior to intercourse. {105} {122} {126} {128} {145} {160} {182} An additional applicatorful should be inserted into vagina just prior to, and not longer than one hour before, each repeat act of intercourse {105} {122} {126} {128} {145} {182}; or

Koromex Foam—Intravaginal, initially 1 applicatorful placed into cup and additional spermicide spread along the rim of diaphragm just before insertion of diaphragm and not longer than one hour prior to intercourse. {122} An additional applicatorful should be inserted into vagina just prior to, and not longer than one hour before, each repeat act of intercourse. {122}



Strength(s) usually available
U.S.—


8% (OTC) [Because{145}] [Emko{01}{126}] [Emko Pre-Fil{01}{128}]


12.5% (OTC) [Delfen{01}{115}] [Koromex Foam{01}{122}]

Canada—


8% (OTC) [Emko{106}{164}]


12.5% (OTC) [Delfen{105}] [Ramses Contraceptive Foam{182}]

Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), unless otherwise specified by manufacturer. {115} Protect from freezing.

Auxiliary labeling:
   • Not to be taken by mouth.
   • Shake well before using. {105} {115} {122} {126}


NONOXYNOL 9 VAGINAL GEL

Usual adult and adolescent dose
Pregnancy, prophylaxis or
[Sexually transmitted diseases, prophylaxis]1 or
[Pelvic inflammatory disease, prophylaxis]1


For use alone:
Advantage 24—Intravaginal, 1 applicatorful of a 3.5% gel inserted just prior to or up to twenty-four hours prior to each act of intercourse {34} {93}; or

Conceptrol Gel—Intravaginal, 1 applicatorful of a 4% gel inserted just prior to and not longer than one hour prior to intercourse {222}; or

Ramses Crystal Clear Gel—Intravaginal, 1 applicatorful of a 5% gel inserted just prior to each act of intercourse. {132}



For use with diaphragm:
Koromex Crystal Clear Gel—Intravaginal, initially 2 teaspoonfuls of a 2% gel placed into cup and additional spermicide spread along the rim of diaphragm just before insertion of diaphragm and not longer than six hours prior to intercourse. {01} {130} {132} {160} An additional applicatorful should be inserted into vagina just prior to each repeat act of intercourse or if intercourse takes place later than six hours after initial diaphragm placement {01} {130} {132}; or

Ramses Crystal Clear Gel—Intravaginal, initially 1 teaspoonful of a 5% gel placed into cup and additional spermicide spread along the rim of diaphragm just before insertion of diaphragm and not longer than six hours prior to intercourse. {01} {132} {160} An additional applicatorful should be inserted into vagina just prior to each repeat act of intercourse or if intercourse takes place later than six hours after initial diaphragm placement {01} {132}; or

Shur-Seal—Intravaginal, initially contents of 1 packet of 2% gel placed into cup and spread along the rim of diaphragm just before insertion of diaphragm and intercourse {134} {160}. The contents of an additional packet should be inserted into vagina just prior to each repeat act of intercourse. {134} Applicator not provided for vaginal application; {134} contents of packet are to be inserted vaginally by placing contents on one or two fingers and deposited on the outer surface of diaphragm. {134}



Strength(s) usually available
U.S.—


2% (OTC) [Koromex Crystal Clear Gel{01}{130}] [Shur-Seal{01}{134}]


3.5% (OTC) [Advantage 24{93}]


4% (OTC) [Conceptrol Gel{01}{222}]


5% (OTC) [Ramses Crystal Clear Gel{01}{132}]

Canada—


3.5% (OTC) [Advantage 24{34}]

Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), in a well-closed container, unless otherwise specified by manufacturer. Protect from freezing.

Auxiliary labeling:
   • Not to be taken by mouth.


NONOXYNOL 9 VAGINAL JELLY

Usual adult and adolescent dose
Pregnancy, prophylaxis or
[Sexually transmitted diseases, prophylaxis]1 or
[Pelvic inflammatory disease, prophylaxis]1


For use alone:
Gynol II Extra Strength Contraceptive Jelly; Koromex Jelly; or K-Y Plus—Intravaginal, 1 applicatorful of a 2.2 or 3% jelly inserted just prior to, and not longer than one hour prior to, each act of intercourse {227}.



For use with diaphragm:
Gynol II Extra Strength Contraceptive Jelly—Intravaginal, initially 1 applicatorful (one teaspoonful) of a 3% jelly placed into cup and additional spermicide spread along the rim of diaphragm just before insertion of diaphragm and not longer than six hours prior to intercourse {227}. An additional applicatorful should be inserted into vagina just prior to each repeat act of intercourse or if intercourse occurs later than six hours after initial diaphragm placement {227}; or

Gynol II Original Formula Contraceptive Jelly—Intravaginal, initially 1 applicatorful (approximately 1 teaspoonful) of a 2% jelly placed into cup and additional spermicide spread along the rim of diaphragm just before insertion of diaphragm and not longer than six hours prior to intercourse. {01} {113} {114} {160} An additional applicatorful should be inserted into vagina just prior to each repeat act of intercourse or if intercourse occurs later than six hours after initial diaphragm placement {01} {113} {114}; or

Koromex Jelly—Intravaginal, initially 2 teaspoonfuls of a 3% jelly placed into cup and additional spermicide spread along the rim of diaphragm just before insertion of diaphragm and not longer than six hours prior to intercourse. {01} {160} An additional applicatorful should be inserted into vagina just prior to each repeat act of intercourse or if intercourse occurs later than six hours after initial diaphragm placement. {01}



Strength(s) usually available
U.S.—


2% (OTC) [Gynol II Original Formula Contraceptive Jelly{01}{114}]


2.2% (OTC) [K-Y Plus{43}]


3% (OTC) [Gynol II Extra Strength Contraceptive Jelly{01}{227}] [Koromex Jelly{01}{137}]

Canada—
Not commercially available.

Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), in a well-closed container, unless otherwise specified by manufacturer. {114} Protect from freezing.

Auxiliary labeling:
   • Not to be taken by mouth.


NONOXYNOL 9 VAGINAL SUPPOSITORIES

Usual adult and adolescent dose
Pregnancy, prophylaxis or
[Sexually transmitted diseases, prophylaxis]1 or
[Pelvic inflammatory disease, prophylaxis]1


For use alone:
Conceptrol Contraceptive Inserts; Encare—Intravaginal, 1 suppository inserted at least ten minutes, and not longer than one hour, prior to each act of intercourse {20} {221} {226} {239}; or

Semicid—Intravaginal, 1 suppository inserted at least fifteen minutes, and not longer than one hour, prior to each act of intercourse. {120} {121}



For use with diaphragm:
Encare—Intravaginal, one suppository inserted at least ten minutes, and not longer than one hour, prior to each act of intercourse after initial insertion of diaphragm with spermicide or if intercourse takes place later than six hours after diaphragm placement {20} {120} {226}; or

Semicid—Intravaginal, one suppository inserted at least fifteen minutes, and not longer than one hour, prior to each act of intercourse after initial insertion of diaphragm with spermicide or if intercourse takes place later than six hours after diaphragm placement. {120}



Strength(s) usually available
U.S.—


2.27% (OTC) [Encare{01}{20}{226}]


100 mg (OTC) [Semicid{01}{120}{251}]


150 mg (OTC) [Conceptrol Contraceptive Inserts{221}{239}]

Canada—


10% (OTC) [Encare{92}]

Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), in a well-closed container, unless otherwise specified by manufacturer. Protect from freezing.

Auxiliary labeling:
   • Not to be taken by mouth.


OCTOXYNOL 9


Vaginal Dosage Forms

Note: Bracketed uses in the Dosage Forms section refer to categories of use and/or indications that are not included in U.S. product labeling.

OCTOXYNOL 9 VAGINAL CREAM

Usual adult and adolescent dose
Pregnancy, prophylaxis or
[Sexually transmitted diseases, prophylaxis]1 or
[Pelvic inflammatory disease, prophylaxis]1


For use with a diaphragm:
Koromex Cream—Intravaginal, initially 2 teaspoonfuls placed into cup and additional spermicide spread along the rim of diaphragm just before insertion of diaphragm and not longer than six hours prior to intercourse {112} {160}. An additional applicatorful should be inserted into vagina just prior to each repeat act of intercourse or if intercourse occurs later than six hours after initial diaphragm placement. {112}



Strength(s) usually available
U.S.—


3% (OTC) [Koromex Cream{01}{111}]

Canada—
Not commercially available.

Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), in a well-closed container, unless otherwise specified by manufacturer. Protect from freezing.

Auxiliary labeling:
   • Not to be taken by mouth.


OCTOXYNOL 9 VAGINAL JELLY

Usual adult and adolescent dose
Pregnancy, prophylaxis or
[Sexually transmitted diseases, prophylaxis]1 or
[Pelvic inflammatory disease, prophylaxis]1


For use with a diaphragm:
Ortho-Gynol—Intravaginal, initially 1 applicatorful (approximately 1 teaspoonful) placed into cup and additional spermicide spread along the rim of diaphragm just before insertion of diaphragm and not longer than six hours prior to intercourse. {01} {123} {144} {160} An additional applicatorful should be inserted into vagina just prior to each repeat act of intercourse or if intercourse occurs later than six hours after initial diaphragm placement. {107} {123} {144}



Strength(s) usually available
U.S.—


1% (OTC) [Ortho-Gynol{01}{144}]

Canada—


1% (OTC) [Ortho-Gynol{107}]

Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), in a well-closed container, unless otherwise specified by manufacturer. {144} Protect from freezing.

Auxiliary labeling:
   • Not to be taken by mouth.



Revised: 08/16/1997



References
  1. Spermicides. In: Drug facts and comparisons staff. Drug facts and comparisons. St. Louis: Facts and Comparisons Inc., 2/97: 535-6.
  1. Reynolds JEF, editor. Martindale, the extra pharmacopeia. 31st ed. London: Jarrold Printing, 1996: 1117-8.
  1. Pernoll ML, Benson RC, editors. Current obstetric and gynecologic diagnosis and management. 6th ed. Norwalk, CT: Appleton & Lange, 1987: 588-9.
  1. Tatum HJ, Connell-Tatum EB. Barrier contraception: a comprehensive overview. Fertil Steril 1981; 36(1): 1-12.
  1. Kulig JW. Adolescent contraception: an update. Pediatrics 1985; (Suppl 675): 80.
  1. Kulig JW. Adolescent contraception: nonhormonal methods. Ped Clin N Amer 1989; 36(3): 717-31.
  1. Wilborn WH, Hahn DW, McGuire JJ. Scanning electron microscopy of human spermatozoa after incubation with the spermicide nonoxynol 9. Fertil Steril 1983; 39(5): 717-9.
  1. Gossel TA, Wuest JR. Advising consumers on OTC contraceptive products. Maryland Pharmacist 1989 Nov: 4-8.
  1. Copper-T 200Ag package insert (Nova-T, Berlex—Canada), Rev 11/8/90, Rec 5/26/93.
  1. Chi I. The Nova-T IUD—A review of the literature. Contraception 1991; 44(4): 341-66.
  1. Panel comment, 1/94.
  1. Topical spermicides for contraception. Med Letter Drug Therap 1980; 22(1 issue 568): 90-1.
  1. Trussell J, Kost K. Contraceptive failure in the United States: a critical review of the literature. Stud Fam Plan 1987; 18(5): 237-83.
  1. Trussell J, Hatcher RA, Cates W Jr, Stewart FH, Kost K. Contraceptive failure in the United States: an update. Stud Fam Plann 1990; 21(1): 51-4.
  1. Trussell J, Kost K. Contraceptive failure in the United States: a critical review of the literature. Stud Fam Plann 1987 Sept/Oct; 18(5): 237-83.
  1. World Health Organ Tech Rep Ser 753. Mechanism of action, safety and efficacy of intrauterine devices. Geneva: World Health Organization; 1987.
  1. Heaton CJ, Smith MAS. The diaphragm. Am Fam Physician 1989; 39(5): 231-6.
  1. Koch JP. The Prentif contraceptive cervical cap: a contemporary study of its clinical safety and effectiveness. Contraception 1982: 25(2): 135-59.
  1. Squire JJ, Berger GS, Keith L. A retrospective clinical study of a vaginal contraceptive suppository. J Reprod Med 1979; 22(6): 319-21.
  1. The Encare Oval. Med Letter Drug Therap 1978; 20(6-Issue 501): 29-30.
  1. Mendez F, Castro A, Ortego A. Use effectiveness of a spermicidal suppository containing benzalkonium chloride. Contraception 1986; 34(4): 353-62.
  1. Rodgers-Neame N, Duncan SF, Bradley EL, et al. In vitro and in vivo evaluation of latex condoms using a two-phase nonoxynol 9 system. Fertil Steril 1985; 43(6): 931-6.
  1. North BB. Vaginal contraceptives: effective protection from sexually transmitted disease for women? J Reprod Med 1988; 33(3): 307-11.
  1. Louv WC, Austin H, Alexander WJ, et al. A clinical trial of nonoxynol 9 for preventing gonococcal and chlamydial infections. J Infect Dis 1988; 158(3): 518-23.
  1. Amortegui AJ, Meyer MP. In vitro effect of chemical intravaginal contraceptives on Chlamydia trachomatis. Contraception 1987; 36: 481-7.
  1. Singh B, Cutler JC, Utidjian HMD. Studies on the development of a vaginal preparation providing both prophylaxis against venereal disease and other genital infections and contraception II: effect in vitro of vaginal contraceptive and noncontraceptive preparation on Treponema pallidum and Neisseria gonorrhoea. Brit J Vener Dis 1972; 48: 57-64.
  1. Singh B, Cutler JC, Utidjian HMD. Studies on development of a vaginal preparation providing both prophylaxis against venereal disease, other genital infections and contraception III: in vitro effect of vaginal contraceptive and selected vaginal preparations on Candida albicans and Trichomonas vaginalis. Contraception 1972; 5(5): 401-11.
  1. Jick H, Hannan MT, Stergachis A, et al. Vaginal spermicides and gonorrhea. JAMA 1982; 248(13): 1619-21.
  1. Camisa C. Vaginal spermicides and gonorrhea [letter]. JAMA 1983; 249(9): 1149.
  1. Jick H. Vaginal spermicides and gonorrhea [letter]. JAMA 1983; 249(9): 1149.
  1. Austin H, Louv WC, Alexander J. A case-control study of spermicides and gonorrhea. JAMA 1984; 251(21): 2822-4.
  1. Quinn RW, O'Reilly KR. Contraceptive practices of women attending the sexually transmitted disease clinic in Nashville, Tennessee. Sex Trans Dis 1985; 12(3): 99-102.
  1. Stone KM, Grimes DA, Magder LS. Personal protection against sexually transmitted diseases. Am J Obstet Gynecol 1986; 155(1): 180-8.
  1. Nonoxynol 9 (Advantage 24, Roberts). In: Gillis MC, editor. CPS Compendium of pharmaceuticals and specialties. 32nd ed. Ottawa: Canadian Pharmaceutical Association; 1997. p. 37.
  1. Feldblum PJ, Bernardik E, Rosenberg MJ. Spermicide use and sexually transmitted disease [letter]. JAMA 1988; 259(19): 2851.
  1. Hicks DR, Martin LS, Getchell JP, et al. Inactivation of HTLV-III/LAV-infected cultures of normal human lymphocytes by nonoxynol 9 in vitro [letter]. Lancet Dec 21-28 1985: 2(8469-70): 1422-3.
  1. Voeller B. Nonoxynol-9 and HTLV-III [letter]. Lancet May 17, 1986: 1153.
  1. Wellings K. AIDS and the condom. Brit Med J 1986; 293: 1259-60.
  1. AIDS, condoms, and spermicides. WHO Drug Information 1987; 1(2): 66.
  1. Rietmeijer CA, Krebs JW, Feorino PM, et al. Condoms as physical and chemical barriers against human immunodeficiency virus. JAMA 1988; 259(12): 1851-3.
  1. Malkovsky M, Newell A, Dalgleish AG. Inactivation of HIV by nonoxynol 9 [letter]. Lancet 1988 Mar 19: 645.
  1. Jeffries DJ. Nonoxinol 9 and HIV infection [letter]. Brit Med J 1988; 296: 1798.
  1. Nonoxynol 9 package insert (Johnson & Johnson Consumer Products—US), Rev 1993, Rec 12/94.
  1. Spermicide kills AIDS virus. Can Pharm J 1988 Aug: 479.
  1. Pollner F. Experts hedge on condom value. Med World News 1988 Aug 22: 60.
  1. Judson FN, Ehret JM, Bodin GF, et al. In vitro evaluations of condoms with and without nonoxynol 9 as physical and chemical barriers against Chlamydia trachomatis, herpes simplex virus type 2, human immunodeficiency virus. Sex Transm Dis 1989; 16(2): 51-6.
  1. Can you rely on condoms? Consumer Reports 1989 Mar: 135-42.
  1. Chandler RF. More than you ever wanted to know about condoms. Can Pharm J 1989 Jan: 14-20.
  1. Celentano DD, Klassen AC, Weisman CS, et al. The role of contraceptive use in cervical cancer: the Maryland cervical cancer case-control study. Am J Epidemiol 1987; 126(4): 592-604.
  1. Vontver LA, Reeves WC, Rattray M, et al. Clinical course and diagnosis of genital herpes simplex virus infection and evaluation of topical surfactant therapy. Am J Obstet Gynecol 1979; 133(5): 548-54.
  1. Sobrero AJ. Spermicidal agents: effectiveness, use, and testing. Zatuchi GI, editor. Vaginal contraception. Hagerstown, MD: Harper & Row, 1979: 48-65.
  1. Drife JO. The effects of drugs on sperm. Drugs 1987; 33: 610-22.
  1. Wilborn WH, Hahn DW, McGuire JJ. Scanning electron microscopy of human spermatozoa after incubation with the spermicide nonoxynol 9. Fertil Steril 1983; 39(5): 717-9.
  1. Schill WB, Wolff HH. Ultrastructure of human spermatozoa in the presence of the spermicide nonoxinol-9 and a vaginal contraceptive containing nonoxinol-9 [abstract]. Andrologia 1981: 13(1): 42-9.
  1. Muller-Esterl W, Schill WB. Sperm acrosin: liberation from the acrosome and activity of the free proteinase in the presence of nonoxinol-9. Andrologia 1982: 14(4): 309-16.
  1. Chvapil M, Droegemueller W, Owen JA, et al. Studies of nonoxynol 9 I: the effect on the vaginas of rabbits and rats. Fertil Steril 1980; 33(4): 445-50.
  1. Chvapil M, Eskelson CD, Stiffel V, et al. Studies on nonoxynol 9 II: intravaginal absorption, distribution, metabolism and excretion in rats and rabbits. Contraception 1980: 22(3): 325-39.
  1. Buttar HS. Transvaginal absorption and disposition of nonoxynol 9 in gravid rats. Toxicol Letters 1982: 13: 211-6.
  1. Benziger DP, Jerome E. Absorption from the vagina. Drug Metab Rev 1983: 14(2): 137-68.
  1. Chvapil M, et al. New data on the pharmacokinetics of nonoxynol 9. In: Zatuchi GI, editor. Vaginal contraception. Hagerstown, MD: Harper & Row, 1979: 165-74.
  1. Slayton Leitch W. Longevity of Gynol II (R) and Ortho Creme (R) in the Prentif cervical cap. Contraception 1986; 34(4): 363-79.
  1. Slayton Leitch W. Longevity of Ortho Creme (R) and Gynol II (R) in the contraceptive diaphragm. Contraception 1986; 34(4): 381-93.
  1. Jick H, Walker AM, Rothman KJ, et al. Vaginal spermicides and congenital disorders. JAMA 1981; 245(13): 1329-32.
  1. Jick H, et al. Vaginal spermicides and miscarriage seen primarily in the emergency room. Teratogenesis Carcinog Mutagen 1982; 2(2): 205-10.
  1. Vaginal spermicides and congenital disorders [letters]. JAMA 1981; 246(23): 2677-8.
  1. Vaginal spermicides and congenital disorders: study reassessed, not retracted [letters]. JAMA 1987; 257(21): 2919.
  1. The relation between vaginal spermicides and congenital disorders [letters]. JAMA 1987; 258(15): 2066.
  1. Rothman KJ. Spermicide use and Down's syndrome. Am J Public Health 1982; 72(4): 399-401.
  1. Buttar HS. Embryotoxicity of benzalkonium chloride in vaginally treated rats. J Applied Toxicol 1985; 5(6): 398-401.
  1. Tryphonas L, Buttar HS. Effects of the spermicide nonoxynol 9 on the pregnant uterus and the conceptus of rat. Toxicology 1986; 39: 177-86.
  1. Strobina B, Kline J, Warburton D. Spermicide use and pregnancy outcome. Am J Public Health 1988; 78(3): 260-3.
  1. Strobina B, Kline J, Warburton D. Spermicide use and pregnancy outcome. Am J Public Health 1988; 78(8): 918. [erratum to Am J Public Health 1988; 78(3): 260-3].
  1. Strobina B, Kline J, Lai A, et al. Vaginal spermicides and spontaneous abortion of known karyotype. Am J Epidemiol 1986; 123(3): 431-43.
  1. Louik C, Mitchell AA, Werler MM, et al. Maternal exposure to spermicides in relation to certain birth defects. N Engl J Med 1987; 317(8): 474-8.
  1. Warburton D, Neugut RH, Lustenberger A, et al. Lack of association between spermicide use and trisomy. N Engl J Med 1987; 317(8): 478-82.
  1. Maternal exposure to spermicides does not increase the risk of birth defects. WHO Drug Info 1987; 1(4): 214.
  1. FDA panel finds no association between spermicides, birth defects. FDA Consumer 1986 Sep: 3-4.
  1. Bracken MB, Vita K. Frequency of non-hormonal contraception around conception and association with congenital malformations in offspring. Am J Epidem 1983; 117(3): 281-91.
  1. Linn S, Schoenbaum SC, Monson RR, et al. Lack of association between contraceptive usage and congenital malformations in offspring. Am J Obstet Gynecol 1983; 147(8): 923-8.
  1. Scholl TO, Sobel E, Tanfer K, et al. Effects of vaginal spermicides on pregnancy outcome. Fam Plann Perspect 1983; 15(5): 248-50.
  1. Cordero JF, Layde PM. Vaginal spermicides, chromosomal abnormalities and limb reduction defects. Fam Plan Perspect 1983; 15(1): 16-8.
  1. Shapiro S, Slone D, Heinonen OP, et al. Birth defects and vaginal spermicides. JAMA 1982; 247(17): 2381-4.
  1. Huggins G, Vessey M, Flavel R, et al. Vaginal spermicides and outcome of pregnancy: findings in a large cohort study. Contraception 1982; 25(3): 219-30.
  1. Abrutyn D, McKenzie BE, Nadaskay N. Teratology study of intravaginally administered nonoxynol 9–containing contraceptive cream in rats. Fertil Steril 1982; 37(1): 113-7.
  1. Koch JP. The Prentif contraceptive cervical cap: acceptability aspects and their implications for future cap design. Contraception 1982; 25(2): 161-73.
  1. Youssef H, Crofton VA, Smith SC. Clinical trial of Neo Sampoon vaginal tablets and Emko foam in Alexandria, Egypt. Contraception 1987; 35: 101-10.
  1. Witkin SS. Immunology of recurrent vaginitis. Am J Reprod Immunol Microbiol 1987; 15(1): 34-7.
  1. Witkin SS, Jeremias J, Ledger WJ. A localized vaginal allergic response in women with recurrent vaginitis. J Allergy Clin Immunol 1988; 81(2): 412-6.
  1. Ricer R, Guthrie R. Allergic vaginitis, a possibly new syndrome: a case report. J Reprod Med 1988; 33: 781-3.
  1. Dooms-Goossens A, Deveylder H, de Alam AG, et al. Contact sensitivity to nonoxynols as a cause of intolerance to antiseptic preparations. J Am Acad Dermatol 1989; 21(4 part 1): 723-7.
  1. Kabasawa Y, Kanzaki T. Allergic contact dermatitis from the surfactant in Hibitane (R). Contact Dermatitis 1989; 20: 378.
  1. Nonoxynol 9 (Encare, Stella). In: Gillis MC, editor. CNP Compendium of nonprescription products. 2nd ed. Ottawa: Canadian Pharmaceutical Association; 1995. p. 63.
  1. Nonoxynol 9 package insert (Advantage 24, Lake Consumer Products—US), Rev 1996, Rec 6/97.
  1. Not used.
  1. Not used.
  1. Not used.
  1. Baehler EA, Dillon WP, Cumbo TJ, et al. The effects of prolonged retention of diaphragms on colonization by Staphylococcus aureus of the lower genital tract. Fertil Steril 1983; 39(2): 162-6.
  1. Grimes DA. Reversible contraception for the 1980s. JAMA 1986; 255(1): 69-75.
  1. Cramer DW, Wilson E, Stillman RJ, et al. The relationship of tubal infertility to barrier method and oral contraceptive use. JAMA 1987; 257(18): 2446-50.
  1. Feldblum PJ, Fortney JA. Condoms, spermicides, and the transmission of human immunodeficiency virus: a review of the literature. Am J Pub Health 1988; 78(1): 52-4.
  1. McCormack WM. Epidemiology of mycoplasma hominis. Sex Trans Dis 1983; 10(4 suppl): 261-2.
  1. Sugarman B, Mummaw N. Effects of antimicrobial agents on growth and chemotaxis of Trichomonas vaginalis. Antimicrob Agents Chemother 1988; 32(9): 1323-6.
  1. Fleeger, CA, editor. USAN 1991. USAN and the USP dictionary of drug names. Rockville, MD: The United States Pharmacopeial Convention, Inc., 1990.
  1. Benzalkonium chloride (Pharmatex, Interpharm). In: Krogh CME, editor. CPS Compendium of pharmaceuticals and specialties. 24th ed. Ottawa: Canadian Pharmaceutical Association; 1989. p. 800.
  1. Nonoxyl 9 (Delfen Ortho-McNeil). In: Gillis MC, editor. CNP Compendium of nonprescription products: Summer 95, 2nd ed. Ottawa: Canadian Pharmaceutical Association; 1995. p. 287.
  1. Nonoxyl 9 (Emko, Schering). In: Gillis MC, editor. CNP Compendium of nonprescription products: Summer 95, 2nd ed. Ottawa: Canadian Pharmaceutical Association; 1995. p. 287.
  1. Octoxynol 9 (Ortho-Gynol, Ortho-McNeil). In: Gillis MC, editor. CNP Compendium of nonprescription products: Summer 95, 2nd ed. Ottawa: Canadian Pharmaceutical Association; 1995. p. 287.
  1. Pharmindex September 1989. Conceptrol cream discontinued.
  1. Octoxynol 9 patient package insert and packaging (Ortho-Creme, Ortho—US), Rec 11/14/88.
  1. Octoxynol 9 (Ortho-Creme, Ortho). In: PDR Physicians' desk reference for nonprescription drugs, 10th ed. Oradell, NJ: Medical Economics Co., Inc.; 1989. p. 625.
  1. Octoxynol 9 packaging (Koromex cream, Schmid—US), Expires 12-89.
  1. Nonoxyl 9 package insert (Koromex crystal clear gel or cream, Schmid—US), Rec 11/20/87.
  1. Nonoxyl 9 patient package insert (Gynol II, Ortho—US), Rev 83, Rec 11/14/88.
  1. Not used.
  1. Nonoxynol 9 (Delfen foam, Advanced Care Products). In: PDR Physicians' desk reference for nonprescription drugs, 11th ed. Oradell, NJ: Medical Economics Co., Inc.; 1990. p. 621.
  1. Not used.
  1. Not used.
  1. Not used.
  1. Not used.
  1. Nonoxyl 9 (Semicid inserts, Whitehall). In: PDR Physicians' desk reference for nonprescription drugs, 11th ed. Oradell, NJ: Medical Economics Co., Inc.; 1990. p. 754.
  1. Nonoxyl 9 package insert—facts about birth control (Semicid inserts, Whitehall—US).
  1. Nonoxyl 9 patient package insert (Koromex, Schmid—US), Rec 11/20/87.
  1. Octoxynol 9 patient package insert (Ortho-Gynol, Advanced Care—US), Rec 11/14/88, Rev 1/78.
  1. Not used.
  1. Not used.
  1. Nonoxyl 9 (Emko foam, Schering). In: PDR Physicians' desk reference for nonprescription drugs, 11th ed. Oradell, NJ: Medical Economics Co., Inc.; 1990. p. 691-2.
  1. Not used.
  1. Nonoxyl 9 patient package insert (Emko Pre-Fil, Schering—US), Rec 12/11/87, Rev 80.
  1. Not used.
  1. Nonoxyl 9 patient package insert (Koromex crystal clear gel, Schmid—US), Rec 11/20/87.
  1. Not used.
  1. Nonoxyl 9 patient package insert (Ramses crystal clear gel, Schmid—US), Rec 11/20/87.
  1. Not used.
  1. Nonoxyl 9 patient package insert (Shur-seal gel, Milex—US), Rec 10/9/87, Rev 1986.
  1. Not used.
  1. Nonoxyl 9 patient package insert (Koromex jelly, Schmid—US), Rec 11/20/87.
  1. Nonoxyl 9 packaging (Koromex jelly, Schmid—US), Rec 11/20/87, Exp date 7/90.
  1. Not used.
  1. Not used.
  1. Not used.
  1. Not used.
  1. Not used.
  1. Not used.
  1. Octoxynol 9 (Ortho-Gynol, Ortho). In: PDR Physicians' desk reference for nonprescription drugs, 11th ed. Oradell, NJ: Medical Economics Co., Inc.; 1990. p. 625-6.
  1. Nonoxynol 9 vaginal foam (Because, Schering). In: PDR Physicians' desk reference for nonprescription drugs, 11th ed. Oradell, NJ: Medical Economics Co., Inc.; 1990. p. 690-1.
  1. Not used.
  1. Not used.
  1. Not used.
  1. Nonoxyl 9 package insert (VCF, Apothecus—US), Rec 2/20/90.
  1. Panel comment.
  1. Panel comments (various), Panel survey date 5/3/90.
  1. Panel comments, 5/3/90 survey date.
  1. Not used.
  1. Panel comment, Panel survey date 5/3/90.
  1. Panel comment Panel survey date 5/3/90.
  1. Panel comment, Panel survey date 5/3/90.
  1. Panel comment, Panel survey date 5/3/90.
  1. Panel comment, Panel survey date 5/3/90.
  1. Panel comment, Panel survey date 5/3/90.
  1. Panel comment, Panel survey date 5/3/90.
  1. Panel comment.
  1. Panel comment, Panel survey date 5/3/90.
  1. Call to manufacturer (Ortho—Canada), Only Delfen, OrthoGynol, and Gynol II in Canada.
  1. Ontario College of Pharmacists. New Drugs/Drug News: Drug information centre newsletter Mar/Apr 1990; 8(2): 1, 2, 4, 5.
  1. Mfr. comment, Panel survey date 5/3/90.
  1. Not used.
  1. Not used.
  1. Mastroianni L, Donaldson PJ, Kane TK, editors. National Research Council and Institute of Medicine. Developing new contraceptives: obstacles and opportunities. Washington, D.C.: National Academy Press, 1990.
  1. Not used.
  1. Panel comment. Panel survey date 5/3/90.
  1. Wolf PH, Perlman J, Fortney J, et al. Toxic shock syndrome [letter]. JAMA 1987 Aug 21; 258(7): 906.
  1. North BB. Heterosexual transmission of AIDS: effectiveness of vaginal contraceptives in prevention of sexually transmitted diseases. Alan R. Liss, Inc., 1990: 273-90.
  1. Not used.
  1. Not used.
  1. Not used.
  1. Not used.
  1. Grady WR, Hayward MD, Yagi J. Contraceptive failure in the United States: estimates from the 1982 National Survey of Family Growth. Fam Plan Perspect 1986; 18(5): 200-9.
  1. Bernstein GS. Final report: use-effectiveness study of cervical caps [unpublished]. Period covered 7/1/81-3/31/86. Rec 6/6/90.
  1. Vessey M, Doll R, Peto R, et al. A long-term follow-up study of women using different methods of contraception—an interim report. J Biosoc Sci 1976; 8: 373-427.
  1. Not used.
  1. Not used.
  1. Nonoxyl 9 packaging (Ramses foam, Julius Schmid—Canada), Rec 7/26/90. Number 570400/0389.
  1. Nonoxyl 9 packaging (Ramses foam, Julius Schmid—Canada), Rec 7/26/90. Number 500400 0389.
  1. Nonoxyl 9 package insert (Ramses jelly, Julius Schmid—Canada), Rec 7/26/90. Number 002-269-01.
  1. Not used.
  1. Alexander NJ. Sexual transmission of human immunodeficiency virus: virus entry into the male and female genital tract. Fertil Steril 1990; 54(1): 1-18.
  1. Sacks SL, Varner TL, Davies KS, et al. Randomized, double-blind, placebo controlled patient initiated study of topical high- and low-dose interferon alpha with nonoxynol-9 in the treatment of recurrent genital herpes. J Infect Dis 1990; 161(4): 692-8.
  1. Friedman-Kien AE, Klein RJ, Glaser RD, et al. Treatment of recurrent genital herpes with topical alpha interferon gel combined with nonoxynol 9. J Am Acad Dermatol 1986; 15(5 part 1): 989-94.
  1. [Aut. anon.] Contraceptive care. Can Pharm J 1989 Dec; 644, 646.
  1. Rekart M, et al. Nonoxynol 9: its adverse effects. Sixth International Conference on AIDS. 1990 June 20-4, San Francisco, CA.
  1. Rapp F, Wrzos H. Synergistic effect of human leukocyte interferon and nonoxynol 9 against herpes simplex virus type 2. Antimicrob Agents Chemotherapy 1985; 28(3): 449-51.
  1. Einarson TR, Koren G, Mattice D, et al. Maternal spermicide use and adverse reproductive outcome: a meta-analysis. Am J Obstet Gynecol 1990; 162(3): 655-60.
  1. U.S. Preventative Services Task Force, Wash., D.C. Counseling to prevent HIV infection and other sexually transmitted diseases. Am Fam Phys 1990; 41(4): 1179-87.
  1. Stein ZA. HIV prevention: the need for methods women can use. Am J Pub Health 1990; 80: 460-2.
  1. Collier AC, Handsfield HH, Roberts PL, et al. Cytomegalovirus infection in women attending a sexually transmitted disease clinic. J Infect Dis 1990; 162(1): 46-51.
  1. American Academy of Pediatrics, Committee on Adolescence. Contraception and adolescents. Pediatrics 1990; 86(1): 134-8.
  1. Kjaer SK, Engholm G, Teisen C, et al. Risk factors for cervical human papillomavirus and herpes simplex virus infections in Greenland and Denmark: a population-based study. Am J Epidemiol 1990; 131(4): 669-82.
  1. Kreiss J, et al. Efficacy of nonoxynol-9 in preventing HIV transmission [abstract MAO 36]. Fifth International Conference on AIDS 1989 June 4-9, Montreal, Quebec, Canada.
  1. Hira SK, et al. Anti-HIV efficacy of barrier contraceptives in HIV-discordant couples [abstract MAO 37]. Fifth International Conference on AIDS 1989 June 4-9, Montreal, Quebec, Canada.
  1. Pugh B, Englert M. An evaluation of the effects of various lubricants on latex condoms [abstract WAP 95]. Fifth International Conference on AIDS 1989 June 4-9, Montreal, Quebec, Canada.
  1. Nzila N, et al. Evaluation of condom utilization and acceptability of spermicides among prostitutes in Kinshasa, Zaire [Abstract WAP 96]. Fifth International Conference on AIDS 1989 June 4-9, Montreal, Quebec, Canada.
  1. Voeller B. Persistent condom breakage [Abstract WAP 99]. Fifth International Conference on AIDS 1989 June 4-9, Montreal, Quebec, Canada.
  1. Wainberg MA, Thomas R. Inactivation of HIV-1 in vaginal and seminal secretions by the spermicide benzalkonium chloride. Fifth International Conference on AIDS 1989 June 4-9, Montreal, Quebec, Canada. [Abstract WAP 102].
  1. Voeller B, et al. Rapid condom damage by common sex lubricants [Abstract D685]. Fifth International Conference on AIDS 1989 June 4-9, Montreal, Quebec, Canada.
  1. Baehler EA, Dillon WP, Cumbo TJ, et al. Prolonged use of a diaphragm and toxic shock syndrome. Fertil Steril 1982; 38(2): 248-50.
  1. Broome CV. Epidemiology of toxic shock syndrome in the United States: overview. Rev Infect Disease 1989; 11(Suppl 1): S14-21.
  1. Resnick DS. Toxic shock syndrome: recent developments in pathogenesis. J Pediatrics 1990; 116(3): 321-8.
  1. Koren G, editor. Maternal-fetal toxicology: a clinician's guide. New York: Marcel Dekker, Inc., 1990: 304, 422.
  1. Panel comments, Panel survey date 5/3/90.
  1. Panel comment, Panel survey date 5/3/90.
  1. Panel comment, Panel survey date 5/3/90.
  1. Panel comment, Panel survey date 5/3/90.
  1. Schwartz, Gaventa S, Broome CV, et al. Nonmenstrual toxic shock syndrome associated with barrier contraceptives: report of a case-control study. Rev Infect Dis 1989; 11(Suppl 1): S43-9.
  1. Panel comment, Panel survey date 5/3/90.
  1. Panel comments, Panel survey date 5/3/90.
  1. Prentif cavity-rim cervical cap patient package insert (Lambert [Dalston] Ltd.—US), Rec 1989, Rev 1988.
  1. Prentif cavity-rim cervical cap fitting instructions (Lamber [Dalston] Ltd.—US), Rec 1989, Rev 1988.
  1. The cervical cap Med Letter Drugs Therap 1988 Oct 7; 30(Issue 776): 93-4.
  1. The cervical cap: an additional note. Med Letter Drugs Therap 1988 Dec 16; 30(Issue 781): 116.
  1. Not used.
  1. Nonoxyl 9 package insert (Conceptrol suppositories, Advanced Care Products—US), Rec 9/4-90, Rev 1989.
  1. Nonoxyl 9 (Conceptrol gel, Ortho). In: PDR Physicians' desk reference for nonprescription drugs, 11th ed. Oradell, NJ: Medical Economics Co., Inc.; 1990. p. 620.
  1. Not used.
  1. Not used.
  1. Not used.
  1. Nonoxyl 9 (Encare, Thompson Medical). In: PDR Physicians' desk reference for nonprescription drugs. 17th ed. 1996. Montvale, NJ: Medical Economics Company; 1996. p. 797.
  1. Nonoxyl 9 package insert (Gynol II Extra Strength, Advanced Care Products—US), Rec 9/4/90, Rev 1989.
  1. Not used.
  1. Not used.
  1. Panel comments, Panel survey date 9-28-90.
  1. Panel comment [8]. Panel survey date 9-28-90.
  1. Panel comment, Panel survey date 9-28-90.
  1. Panel comments, Panel survey date 9/28/90.
  1. Panel comments, Panel survey date 9/28/90.
  1. Panel comment. Panel survey date 9/28/90.
  1. U.S. Preventative Services Task Force. Counseling to prevent HIV infection and other sexually transmitted diseases. Am Fam Physician 1990 Apr; 41(4): 1179-87.
  1. Shubair M, Larsen B. Growth inhibition of Candida albicans and other medically important yeasts by vaginal contraceptive products. Gynecol Obstet Invest 1990; 29: 67-70.
  1. Barbone F, Austin H, Louv WC, et al. A follow-up study of methods of contraception, sexual activity, and rates of trichomoniasis, candidiasis, and bacterial vaginosis. Am J Obstet Gynecol 1990; 160(2): 510-4.
  1. Not used.
  1. Not used.
  1. Panel comments, Panel survey date 9/28/90.
  1. Panel comment, Panel survey date 9/28/90.
  1. Yang J, Zhao Z. Quantitative analysis of nonoxynol-9 in blood. Contraception 1991; 43(2): 161-6.
  1. Muggins GR, Cullins VE. Fertility after contraception or abortion [review]. Fertil Steril 1990; 54(4): 559-73.
  1. Keet IP, Lee FK, van Griensven GJ, et al. Herpes simplex virus type 2 and other genital ulcerative infections as a risk factor for HIV-1 acquisition. Genitourin Med 1990; 66(5): 330-3.
  1. Holmberg SD, Horsburgh CR Jr, Ward JW, et al. Biologic factors in the sexual transmission of human immunodeficiency virus [review]. J Infect Dis 1989; 160(1): 116-25.
  1. Green ST, Nathwani D, Goldberg DJ, et al. Intercourse during menstruation among prostitutes [letter]. JAMA 1990; 264(3): 333.
  1. Deodhar LP, Tendolkar UM. Genital ulcers and HIV antibody [letter]. Lancet 1990 Jul 14: 112.
  1. Hooten TM, et al. Escherichia coli bacteriuria and contraceptive method. JAMA 1991; 265(1): 64-9.
  1. Peddie BA, Gorrie SI, Bailey RR. Diaphragm use and urinary tract infection [letter]. JAMA 1986; 255(13): 1707.
  1. Manufacturer comment (Ortho—US), Panel survey date 9/28/90.
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