A diaphragm is a little rubber cup, between 2 and 3.5 inches in diameter, whose rim is stiffened with a metal spring. The various models on the market differ according to the kind of spring used in the rim. Some come with a special applicator for insertion.

The diaphragm fits across the upper end of the vagina and covers the cervix. It works by preventing sperm from entering the uterus and by holding a spermicidal cream or jelly in place close to the cervix. Before the advent of oral contraceptives, diaphragms were a major form of contraception; for some women they are still a reasonable way to prevent pregnancy.

Figure: When inserted correctly, the diaphragm completely covers the cervix and rests behind the pubic bone

Figure: When inserted correctly, the diaphragm completely covers the cervix and rests behind the pubic bone

How do you use a diaphragm?

Diaphragms come in different sizes, so your caregiver must fit you and give you a prescription for your personal size, which you can fill at your pharmacy. If you gain or lose more than twenty pounds or have a pregnancy, you will need to have the diaphragm refitted. You can use it during your period (it catches the menstrual blood). Before inserting your diaphragm, be sure it has no rips, tears, or pinholes. If it does, use another method of contraception until you get a new diaphragm.

Inserting a diaphragm takes a little practice, but most women learn without much difficulty Squeeze about a teaspoon of spermicidal cream or jelly into the dome of the diaphragm and smear a little more just inside or around the outside of the rim. Then pinch the rim together and slide the diaphragm into your vagina, making sure that the cup entirely covers the cervix. When you let go of the rim, the diaphragm springs open. It is easiest to insert lying on your back with your knees bent, sitting on the toilet, or squatting. When the diaphragm is in place, it should fit snugly against your cervix. The front rim should be anchored under your pubic bone. Properly positioned, the diaphragm cannot fall out. Neither you nor your partner should be aware of the diaphragm once it is in place; if it slips around or feels uncomfortable, your caregiver should check and possibly refit it.

You can insert your diaphragm as long as two hours before intercourse, and you must leave it in place six to eight hours afterward, giving the spermicide a chance to work. Do not leave it longer than twenty-four hours. If you have intercourse more than once, you should leave the diaphragm in place but add more spermicide, using the applicator to insert it high in your vagina.

To remove the diaphragm, simply hook your index finger over the front rim and pull the diaphragm out. The positions that made it easier to insert also make it easier to take out. After you have removed the diaphragm, wash it in soapy water, rinse it, and put it safely away in its case. Exposure to light can shorten the life of the rubber.

Some women have difficulty keeping a diaphragm in place. These include women who have certain anatomical problems — for example, a severely prolapsed uterus, which sometimes is the case after the birth of several children. Women who have frequent urinary tract infections might be better off with another form of contraception, since the diaphragm’s front edge can press against the urethra and make it difficult for the bladder to empty.

What happens if you forget to take out your diaphragm, or if it gets stuck?

Although you should not leave a diaphragm in place for more than twenty-four hours, nothing dire will happen if you do. There are no documented cases of toxic shock caused by a diaphragm left in too long. However, you may notice a strong or unpleasant odor when you do remove it.

If your diaphragm gets stuck (which happens rarely), ask your partner to help you remove it. If that doesn’t work, wait an hour and try again; sometimes waiting helps. Don’t be embarrassed to call your caregiver if necessary and ask to have it removed.

How reliable is a diaphragm?

If used faithfully and correctly along with a spermicidal cream or jelly, a diaphragm has a failure rate of about 4 percent. With actual use, which includes women who use the method incorrectly or inconsistently, the failure rate is probably around 18 percent. Diaphragms fail because sperm manage to sneak around the edge and enter the uterus, perhaps because the diaphragm gets dislodged or was incorrectly inserted or fitted, or because additional spermicide was not used for a subsequent intercourse. I have had patients who were themselves gynecologists who became pregnant while wearing a diaphragm, and I assume they inserted it correctly.

What are its advantages and disadvantages?

Properly inserted, a diaphragm has a relatively high effectiveness rate. It is quite easy to use. It has no significant side effects. It is under the woman’s control, though it certainly helps to have a partner committed to the method. Once it is in place, most couples are unaware of its presence. The spermicide used along with the diaphragm may lower (but not cancel) the risk of being infected with an sexually transmitted disease during vaginal intercourse.

On the negative side, diaphragms with their accompanying spermicides are messy. Some people object to the feel or taste of the spermicide. You have to insert your diaphragm each time you have intercourse and remove it after the appropriate interval. You cannot rely on it to protect you absolutely against sexually transmitted diseases or vaginal infections. Using a diaphragm may predispose you to urinary tract infections, though you can minimize this risk by using a soft-ring diaphragm in the smallest size that adequately covers the top of your vagina.

The up-front cost of a diaphragm is fairly high — around twenty-five dollars plus the cost of the visit to your doctor. If you get measured for a diaphragm at your annual visit, you do not incur the costs of an extra appointment. Spermicidal creams and jellies cost somewhere between seven and ten dollars for a 3.8-ounce tube, about twelve applications.

Is a diaphragm the right contraceptive for you?

Mary is 26, married with one child. She had trouble with blood clots in her legs during her pregnancy, so birth control pills are not appropriate for her. She wants another baby in a year or so, but certainly would not mind if she got pregnant sooner.

A diaphragm might be a reasonable choice for Mary; she and her husband feel comfortable with its effectiveness rate and the need to insert it each time before intercourse.

Carly is 21, a senior in college. Her boyfriend graduated last year and has taken a job in a city hundreds of miles away from her school. Oral contraceptives make Carly queasy, but she is very conscientious about using contraception.

Since she and her boyfriend see each other only occasionally and she is willing to put up with its inconveniences, a diaphragm used along with spermicide might be an acceptable option for her.

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