Contraceptive diaphragms provide effective, reversible, episodic contraception without hormonal influence. The device consists of a shallow, cup-shaped, latex or silicone sheet anchored to a circular outer spring that is contained in the rim. A diaphragm acts as a physical barrier that prevents sperm from entering the cervix and holds spermicide in place as an additional barrier. Diaphragms are always used in combination with spermicides, which usually contain nonoxynol-9 as their active ingredient, but preparations with octoxynol-9 also are available.
Diaphragms are available by prescription from most pharmacies. They range in size from 50 to 105 mm in diameter, with the 65- to 80-mm sizes most commonly prescribed. The diaphragm must be fitted by the practitioner in the office. Sizing must be rechecked 6 weeks after the birth of a child, after significant weight gain or loss, and yearly. Avoid devices that are too large (i.e., uncomfortable or press on the urethra excessively) or too small (i.e., easily displaced or expelled). When the diaphragm is pinched, the device folds into an arc. This allows the posterior edge to easily slip behind the cervix and facilitates insertion. Diaphragms require a high level of patient motivation and compliance to be effective, and they may be used in combination with condoms to help prevent transmission of human immunodeficiency virus (HIV). They remain popular because they do not use hormones, and most patients and their partners cannot feel them when they are properly fitted.
Diaphragms are latex-based appliances and therefore should be avoided in latex-allergic individuals. Patients should be educated that oil-based lubricants may dissolve the latex and cause contraceptive failure. The diaphragm should be cleaned after every use with mild soap and water, gently dried, and stored in a protective container. The user should never apply powders on the device and should always inspect for holes or damage before use. Urinary tract infections may be more common in diaphragm users, but voiding after intercourse may help avoid this complication.
The contraceptive diaphragm has a failure rate between 13% and 23%. Younger users (<25 years) and patients who have intercourse more than four times each week may have a higher failure rate. Diaphragms may be inserted up to 6 hours before intercourse, and they must be removed 6 to 24 hours after intercourse. Additional spermicide must be applied intravaginally with an applicator
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before any additional episodes of intercourse. When using these contraceptive methods, the possibility of system failure or patient noncompliance must be anticipated. Many patients can benefit from discussion about emergency contraception when a barrier method is decided on and periodically thereafter.
INDICATIONS
CONTRAINDICATIONS
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PROCEDURE
Explain the diaphragm-fitting procedure, and obtain informed consent. With the patient in the dorsal lithotomy position, perform a pelvic examination to rule out disease and identify atypical anatomy. During the bimanual examination, place the middle finger into the posterior cul-de-sac. Use the thumb to mark the point where the symphysis pubis abuts the index finger (Figure 1A). The distance from the tip of the middle finger to the point marked on the index finger is the approximate diameter of the diaphragm. The fitting ring or diaphragm is selected by measuring the marked length or by placing the ring against the measurement fingers (Figure 1B).
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(1) The distance between the tip of the middle finger to the point marked on the index finger is the approximate diameter of the diaphragm. |
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Besides the size measured, try inserting diaphragms that are one size larger and one size smaller, and prescribe the one that fits best. When properly fitted, there should be about a fingertip's width between the diaphragm and the symphysis pubis, a good seal with the lateral vaginal walls, and no sensation of tightness or pressure. The diaphragm is removed by hooking the index finger under the ring behind the symphysis and pulling.
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(2) The diaphragm is removed by hooking the index finger under the ring behind the symphysis and pulling. |
PITFALL: Have the patient perform a Valsalva maneuver (i.e., cough). If the diaphragm is displaced or comes out, select the next larger size, and try again.
PITFALL: Caution the patient not to puncture the diaphragm with a long or ragged fingernail.
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The woman should then practice inserting (with water-soluble lubricant), checking for placement, and removing the diaphragm in the office. A diaphragm that is difficult for the woman to remove may be too small. Have her walk around and make sure the diaphragm stays in place.
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(3) The patient should practice inserting, checking for placement, and removing the diaphragm in the office before heading home. |
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CODING INFORMATION
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INSTRUMENT AND MATERIALS ORDERING
Diaphragms (e.g., Ortho-flex) are dispensed by prescription from pharmacies. Fitting rings may be obtained from Ortho-McNeil Pharmaceuticals (http://www.ortho-mcneil.com/) or from your local Ortho-McNeil pharmaceutical representative.
BIBLIOGRAPHY
Bulut A, Ortayli N, Ringheim K, et al. Assessing the acceptability, service delivery requirements, and use-effectiveness of the diaphragm in Colombia, Philippines, and Turkey. Contraception 2001;63:267–275.
Craig S, Hepburn S. The effectiveness of barrier methods of contraception with and without spermicide. Contraception 1982;26:347–359.
Fihn SD, Latham RH, Roberts P, et al. Association between diaphragm use and urinary tract infections. JAMA 1986;25:240—245.
Grady MR, Haywood MD, Yagi J. Contraceptive failure in the United States. Estimates from the 1982 National Survey of Family Growth.Fam Plan Perspect 1986;18:200.
Graves WK. Contraception. In: Glass RH, Curtis MG, Hopkins MP, eds. Glass's office gynecology, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 1999:61–94.
Hatcher RA, Stewart F, Trussel J, et al. Contraceptive technology, 15th ed. New York: Iverting, 1992.
Hooton TM, Hillier S, Johnson C, et al. Escherichia coli bacteriuria and contraceptive method. JAMA 1991;265:64–69.
Hooton TM, Scholes D, Stapleton AE, et al. A prospective study of asymptomatic bacteriuria in sexually active young women. N Engl J Med 2000;343:992–997.
Mauck C, Callahan M, Weiner DH, et al. A comparative study of the safety and efficacy of FemCap, a new vaginal barrier contraceptive, and the Ortho All-Flex diaphragm. Contraception 1999;60:71–80.
Speroff L, Darney P. A clinical guide for contraception, 2nd ed. Baltimore: Williams & Wilkins, 1996.